Robotic Heller's myotomy using the new Hugo™ RAS system: first worldwide report.

BACKGROUND: Achalasia is a rare disorder of the esophagus characterized by motor dysfunction in the esophagus and relaxation failure of the lower esophageal sphincter (LES). Currently, surgical myotomy procedures are considered the standard of care. Robotic Heller's myotomy (RHM) with fundoplication has been gaining popularity due to documented advantages in the precision of myotomy as well as avoiding the potential reflux following per-oral endoscopic myotomy (POEM). To the best of our knowledge, RHM has thus far has been performed exclusively by the da Vinci surgical system. The new Hugo RAS™ system offers a unique modular design and an open console which offers better maneuverability and docking options. In this study, we present the first worldwide series of patients undergoing RHM using the new Hugo RAS™ platform. Our objective is to propose optimal operating configuration and setup to fully harness the advantages of the unique modular design of this system. METHODS: Ten consecutive achalasia patients underwent Robotic Heller's myotomy (RHM) with the Hugo RAS™ system. We prospectively collected patient data, including demographics, comorbidities, ASA class, Eckardt scores, pre-operative manometric data, and EndoFlip parameters. Additionally, we recorded the docking and total operative times. RESULTS: Between December 2022 and August 2023, 10 patients underwent RHM with the Hugo™ RAS system. Patients had a median age of 42.5 years, 60% were female, and mean BMI was 23.2. Fifty percent had achalasia type 2 and 50% type 1. The median pre-operative integrated relaxation pressure (IRP) was 24.9. Median docking time was 10 min and overall operative time was 129.5 min. All patients, except one with acute coronary syndrome, had an uneventful peri-operative course and were discharged on post-operative day 2. CONCLUSION: The Hugo™ RAS system is well designed for robotic Heller myotomy. The operative and clinical results are similar to the currently used robotic system; however, the modular design of the system has some differences. These translate to better docking angles and maneuverability as well as console surgeon's ergonomics. Further experience is needed to explore the advantages of the system's modular design and function.

An international Delphi consensus for surgical quality assessment of lymphadenectomy and anastomosis in minimally invasive total gastrectomy for gastric cancer.

BACKGROUND: Minimally invasive total gastrectomy (MITG) is a mainstay for curative treatment of patients with gastric cancer. To define and standardize optimal surgical techniques and further improve clinical outcomes through the enhanced MITG surgical quality, there must be consensus on the key technical steps of lymphadenectomy and anastomosis creation, which is currently lacking. This study aimed to determine an expert consensus from an international panel regarding the technical aspects of the performance of MITG for oncological indications using the Delphi method. METHODS: A 100-point scoping survey was created based on the deconstruction of MITG into its key technical steps through local and international expert opinion and literature evidence. An international expert panel comprising upper gastrointestinal and general surgeons participated in multiple rounds of a Delphi consensus. The panelists voted on the issues concerning importance, difficulty, or agreement using an online questionnaire. A priori consensus standard was set at > 80% for agreement to a statement. Internal consistency and reliability were evaluated using Cronbach's α. RESULTS: Thirty expert upper gastrointestinal and general surgeons participated in three online Delphi rounds, generating a final consensus of 41 statements regarding MITG for gastric cancer. The consensus was gained from 22, 12, and 7 questions from Delphi rounds 1, 2, and 3, which were rephrased into the 41 statetments respectively. For lymphadenectomy and aspects of anastomosis creation, Cronbach's α for round 1 was 0.896 and 0.886, and for round 2 was 0.848 and 0.779, regarding difficulty or importance. CONCLUSIONS: The Delphi consensus defined 41 steps as crucial for performing a high-quality MITG for oncological indications based on the standards of an international panel. The results of this consensus provide a platform for creating and validating surgical quality assessment tools designed to improve clinical outcomes and standardize surgical quality in MITG.

The influence of prolonged instrument manipulation on gas leakage through trocars.

BACKGROUND: During laparoscopic surgery, CO2 insufflation gas could leak from the intra-abdominal cavity into the operating theater. Medical staff could therefore be exposed to hazardous substances present in leaked gas. Although previous studies have shown that leakage through trocars is a contributing factor, trocar performance over longer periods remains unclear. This study investigates the influence of prolonged instrument manipulation on gas leakage through trocars. METHODS: Twenty-five trocars with diameters ranging from 10 to 15 mm were included in the study. An experimental model was developed to facilitate instrument manipulation in a trocar under loading. The trocar was mounted to a custom airtight container insufflated with CO2 to a pressure of 15 mmHg, similar to clinical practice. A linear stage was used for prolonged instrument manipulation. At the same time, a fixed load was applied radially to the trocar cannula to mimic the reaction force of the abdominal wall. Gas leakage was measured before, after, and during instrument manipulation. RESULTS: After instrument manipulation, leakage rates per trocar varied between 0.0 and 5.58 L/min. No large differences were found between leakage rates before and after prolonged manipulation in static and dynamic measurements. However, the prolonged instrument manipulation did cause visible damage to two trocars and revealed unintended leakage pathways in others that can be related to production flaws. CONCLUSION: Prolonged instrument manipulation did not increase gas leakage rates through trocars, despite damage to some individual trocars. Nevertheless, gas leakage through trocars occurs and is caused by different trocar-specific mechanisms and design issues.

Escape of surgical smoke particles, comparing conventional and valveless trocar systems.

BACKGROUND: During minimal access surgery, surgical smoke is produced which can potentially be inhaled by the surgical team, leading to several health risks. This smoke can escape from the abdominal cavity into the operating room due to trocar leakage. The trocars and insufflator that are used during surgery influence gas leakage. Therefore, this study compares particle escape from a valveless (Conmed AirSeal iFS), and a conventional (Karl Storz Endoflator) system. MATERIALS AND METHODS: Using an in vitro model, a conventional and a valveless trocar system were compared. A protocol that simulated various surgical phases was defined to assess the surgical conditions and particle leakage. Insufflation pressures and instrument diameters were varied as these are known to affect gas leakage. RESULTS: The conventional trocar leaked during two distinct phases. Removal of the obturator caused a sudden release of particles. During instrument insertion, an average of 211 (IQR 111) particles per second escaped when using the 5 mm diameter instrument. With the 10 mm instrument, 50 (IQR 13) particles per second were measured. With the conventional trocar, a higher abdominal pressure increased particle leakage. The valveless trocar demonstrated a continuously high particle release during all phases. After the obturator was removed, particle escape increased sharply. Particle escape decreased to 1276 (IQR 580) particles per second for the 5 mm instrument insertion, and 1084 (IQR 630) particles per second for 10 mm instrument insertion. With the valveless trocar system, a higher insufflation pressure lowered particle escape. CONCLUSIONS: This study shows that a valveless trocar system releases more particles into the operating room environment than a conventional trocar. During instrument insertion, the leakage through the valveless system is 6 to 20 times higher than the conventional system. With a valveless trocar, leakage decreases with increasing pressure. With both trocar types leakage depends on instrument diameter.

Robotic inguinal hernia repair with the new Hugo RASTM system: first worldwide case series report.

INTRODUCTION: Robotic-assisted surgery has been a part of surgical procedures for more than two decades. Recently new robotic platforms with a different design entered the market. The modular design with independent arms enables increased flexibility of arm docking to increase the range of motion and instrument maneuverability. We herein present the first case series of robotic inguinal hernia repair using the Hugo RAS system (Medtronic, Minneapolis, MN, USA). MATERIAL AND METHODS: Thirteen inguinal hernia repairs were performed on ten patients. A description of the Hugo RAS system as well as the new concept of modular design is presented along with the description of the operation setup. RESULTS: Mean docking time was 9.5 min and mean console time was 50.3 min and 74.7 min for unilateral and bilateral inguinal hernia repair, respectively. No intraoperative or postoperative complications occurred. There was one conversion to laparoscopic surgery due to a technical issue with the robot. Conclusions: The modular design of independent arms seems to enhance maneuverability of the instruments and contribute to fewer arm collisions. Further clinical data and experience with this new surgical system are necessary to understand if this new design has advantages over the standard robotic platforms.

The EAES intellectual property awareness survey.

INTRODUCTION: The protection of intellectual property (IP) is one of the fundamental elements in the process of medical device development. The significance of IP, however, is not well understood among clinicians and researchers. The purpose of this study was to evaluate the current status of IP awareness and IP-related behaviors among EAES members. METHODS: A web-based survey was conducted via questionnaires sent to EAES members. Data collected included participant demographics, level of understanding the need, new ideas and solutions, basic IP knowledge, e.g., employees' inventions and public disclosure, behaviors before and after idea disclosures. RESULTS: One hundred and seventy-nine completed forms were obtained through an email campaign conducted twice in 2019 (response rate = 4.8%). There was a dominancy in male, formally-trained gastrointestinal surgeons, working at teaching hospitals in European countries. Of the respondents, 71% demonstrated a high level of understanding the needs (frustration with current medical devices), with 66% developing specific solutions by themselves. Active discussion with others was done by 53%. Twenty-one percent of respondents presented their ideas at medical congresses, and 12% published in scientific journals. Only 20% took specific precautions or appropriate actions to protect their IPs before these disclosures. CONCLUSIONS: The current level of awareness of IP and IP-related issues is relatively low among EAES members. A structured IP training program to gain basic IP knowledge and skill should be considered a necessity for clinicians. These skills would serve to prevent the loss of legitimate IP rights and avoid failure in the clinical implementation of innovative devices for the benefit of patients.

Characterisation of trocar associated gas leaks during laparoscopic surgery.

BACKGROUND: During laparoscopy, the abdominal cavity is insufflated with carbon dioxide (CO2) that could become contaminated with viruses and surgical smoke. Medical staff is potentially exposed when this gas leaks into the operating room through the instruments and past trocar valves. No detailed studies currently exist that have quantified these leakage pathways. Therefore, the goal of this study was to quantify the gas leakages through trocars and instruments, during minimally invasive procedures. METHODS: A model of the surgical environment was created, consisting of a rigid container with an interface for airtight clamping of laparoscopic equipment such as trocars and surgical instruments. The model was insufflated to 15 mm Hg using a pressure generator and a pneumotachograph measured the equipment gas leak. A protocol of several use cases was designed to simulate the motions and forces the surgeon exerts on the trocar during surgery. RESULTS: Twenty-three individual trocars and twenty-six laparoscopic instruments were measured for leakage under the different conditions of the protocol. Trocar leakages varied between 0 L/min and more than 30 L/min, the instruments revealed a range of leakages between 0 L/min and 5.5 L/min. The results showed that leakage performance varied widely between trocars and instruments and that the performance and location of the valves influenced trocar leakage. CONCLUSIONS: We propose trocar redesigns to overcome specific causes of gas leaks. Moreover, an international testing standard for CO2 leakage for all new trocars and instruments is needed so surgical teams can avoid this potential health hazard when selecting new equipment.

Is it possible to continue academic teaching in surgery during the COVID pandemic era?

In the era of the novel coronavirus (COVID-19) pandemic, we critically appraised the literature by means of a systematic review on surgical education and propose an educational curriculum with the aid of available technologies. We performed a literature search on 10 May 2020 of Medline/PubMed, Embase, Google Scholar and major journals with specific COVID-19 sections. Articles eligible for inclusion contained the topic of education in surgery in the context of COVID-19. Specific questions we aimed to answer were: Is there any difference in surgical education from pre-COVID-19 to now? How does technology assist us in teaching? Can we better harness technology to augment resident training? Two-hundred and twenty-six articles were identified, 21 relevant for our aim: 14 case studies, three survey analyses, three reviews and one commentary. The collapse of the traditional educational system due to social distancing caused a fragmentation of knowledge, a reduced acquisition of skills and a decreased employment of surgical trainees. These problems can be partially overcome by using new technologies and arranging 2-weeks rotation shifts, alternating clinical activities with learning. While medical care will remain largely based on the interaction with patients, students' adaptability to innovation will be a characteristic of post-COVID classes.

Complete vs partial fundoplication: a laboratory measurement of functionality and effectiveness.

BACKGROUND: Complete or partial fundoplication remains controversial for the surgical treatment of GERD. While partial fundoplication is considered less effective, it is associated with less post-operative dysphagia and gas bloating compared with complete fundoplication. AIM: To compare the mechanical efficiency of the three different types of fundoplication. MATERIAL AND METHOD: Two studies of the LES were performed on explanted stomachs: distensibility and failure point. Measurements were taken before and after fundoplication. RESULTS: There was no difference in distensibility between Nissen and Toupet fundoplication, however, the EGJ was more distensible following Dor fundoplication. According to failure point measurements, Nissen fundoplication was significantly more effective than Toupet, Toupet was significantly more effective than Dor (p = .016, p = .017, respectively). CONCLUSIONS: There were significant differences in distensibility between Dor and both Nissen and Toupet, however no statistical difference between Toupet and Nissen. There was a significant difference in effectiveness between all three types of fundoplication according to the failure point. These laboratory findings demonstrate that the mechanical orientation of Nissen and Toupet have similar functionality suggesting that Toupet is as good as Nissen. While in clinical studies Toupet has fewer post-operative complications these findings support the proponents of Toupet for GERD. Abbreviation: GERD: Gastroesophageal reflux disease.

Sutureless energy-based wound closure: a step in the quest for trocar site hernia prevention.

OBJECTIVE: Easy and safe methods of fascia closure are needed in order to reduce the risk for trocar site hernias without affecting procedure time significantly. Here we present a method for port site closure using heat induced collagen denaturation. MATERIAL AND METHODS: Controlled heat-induced collagen denaturation was applied to laparoscopic trocar sites in living porcine animal models. These were compared to control trocar sites which were left open. Port sites were evaluated visually at days 14 and 28 after the procedure, and both visually and pathologically at post-procedural day 42. RESULTS: A total of 12 port sites were evaluated in three pigs. No incisional hernias were noted at any of the trocar sites in both groups. Histological evaluation revealed that one of the six control ports appeared to have a complete transfascial defect, whereas none of the study group trocars showed this finding. Furthermore, the study port sites showed a more robust scarring pattern. CONCLUSIONS: Heat-induced collagen denaturation in this preliminary study was found to be safe and allowed better scarring of the healing port sites. We believe that this technology may offer a safe and efficient closure of laparoscopic trocar sites. More studies are needed to further evaluate the true effectiveness of this technology.

Targeting tumor cells using magnetic nanoparticles - a feasibility study in animal models.

INTRODUCTION: In non-resectable tumors, chemotherapy is crucial to improve patient survival. However, it is often accompanied by considerable side effects. Targeted delivery of chemotherapy by coupling with iron oxide superparamagnetic nanoparticles (IONP) could potentially increase efficacy while decreasing adverse systemic side effects. We aimed to evaluate the feasibility of targeting nontoxic, biodegradable-IONP into tumors in-vivo by applying an external magnetic field. MATERIAL AND METHODS: Subcutaneous colon carcinoma tumors were induced in 35 mice. IONP was injected systemically, followed by suturing of a magnet on top of the tumors for 2-24 h. Tumors and livers were excised and stained for iron to explore IONP localization. RESULTS: Iron staining was evident in 43% and 20% of tumors exposed to magnets for 4 h or 24 h, respectively. No iron was present following 2 h exposure, nor in the control group; however, iron stain in the livers indicates most of the IONP were cleared by the liver 24 h later. CONCLUSION: We demonstrated the targeting feasibility of IONP to tumor tissue by an external magnetic field. Our data shows successful targeting; however, with low efficacy following systemic injection of the IONP. As such, a paradigm shift is strongly recommended from systemic to locoregional IONP injection to increase targeting efficacy.

The rapid development of AmboVent: a simple yet sustainable ventilation solution for use in a pandemic.

INTRODUCTION: COVID-19 (SARS-CoV-2) emerged at the end of 2019, generating a rapidly evolving pandemic, raising serious global health implications. Among them was the fear of a mechanical ventilator shortage due to COVID-19's high contagion rate and pathophysiology. Fears of a ventilator shortage unleashed a wave of innovations. MATERIAL AND METHOD: This manuscript describes the AmboVent, a ventilator, rapidly developed with a sense of urgency, by a group of Israeli volunteers. RESULTS: Using a decentralized approach, we worked extensively and managed within ten days to create a working ventilator. It utilizes a 64-year-old technological concept, the bag valve mask (BVM), sometimes known by the proprietary name Ambu bag, which we transformed into an automatic, controlled, and feature-rich ventilator by endowing it with contemporary computing technology. CONCLUSIONS: Applying a functional rather than a commercial-oriented approach can result in the ad hoc development of lifesaving solutions during a rapidly spreading pandemic.

The impact of preoperative vitamin administration on skeletal status following sleeve gastrectomy in young and middle-aged women: a randomized controlled trial.

BACKGROUND: The appropriate strategies to minimize skeletal deterioration following bariatric surgeries are inconclusive. This randomized controlled trial evaluated the effect of preoperative vitamin supplementation on bone mineral density (BMD) and biochemical parameters in females post-sleeve gastrectomy (SG). METHODS: Participants were randomized to a 2-month preoperative treatment with a multivitamin and vitamin D 4000 IU/d (intervention arm) or 1200 IU/d (control arm). Preoperative and 12-month postoperative follow-up evaluations included anthropometrics, biochemical parameters, and dual energy X-ray absorptiometry (DEXA). RESULTS: Sixty-two females (median age 29.7 years and median BMI 43.4 kg/m2) were recruited, 87% completed the 12-month follow-up. For the intervention and control arms, significant and similar reductions at 12-months post-surgery were observed in BMD of the hip (-6.8 ± 3.7% vs. -6.0 ± 3.6%; P = 0.646) and of the femoral neck (-7.1 ± 5.8% vs. -7.2 ± 5.5%; P = 0.973). For the intervention compared to the control arm, the 25 hydroxyvitamin D (25(OH)D) increment was greater after 2 months treatment, and vitamin D deficiency rates were lower at 3 and 6-months follow-up (P < 0.016). However, at 12-months postoperative, 25(OH)D values and vitamin D deficiency were comparable between the arms (P > 0.339). Predictors for BMD decline in the total hip were the percentage of excess weight-loss, age>50 years, and lower initial BMI (P ≤ 0.003). CONCLUSIONS: SG was associated with a significant decline in BMD of the hip and femoral neck in young and middle-aged women, and was unaffected by preoperative vitamin D supplementation. Females who are peri-menopausal or with greater postoperative weight-loss should be particularly followed for BMD decline.

The POEM bottom-up technique for achalasia.

BACKGROUND: POEM (Per Oral Endoscopic Myotomy) is rapidly becoming a valid option for surgical myotomy in achalasia patients. Several techniques to perform POEM are described, but all concentrate on the division of the circular muscle fibers in a proximal-to-distal fashion. Our aim is to present the distal-to-proximal, or the bottom-up technique using the Flush/Dual knife, which overcomes the disadvantages of the standard technique. METHODS: A retrospective study on a prospectively maintained database was performed on all patients treated by POEM in our institution. Clinical presentation, operating time, adverse events, and outcomes were studied. RESULTS: POEM was performed on 105 achalasia patients. The first 15 cases were performed using the standard technique and were compared to the next 90 cases performed using the bottom-up technique. The average preop Eckardt scores in the standard and bottom-up groups were 9.5 and 8.8, respectively, declining to 1.4 and 0.5, 3 months post myotomy (p < 0.001). The average procedure time was 111.2 min for the standard technique and 74.3 for the bottom-up technique. (p = 0.002). Perioperative adverse events included 14 instances of pneumoperitoneum, 3 tunnel leaks, and 4 patients with fever on postoperative day one. Pneumoperitoneum needing decompression and postoperative fever were more prevalent in the standard technique group. CONCLUSIONS: As POEM is becoming more common for the treatment of achalasia, refinements of the technique and instruments used are valuable. We compared our experience of the standard technique to our bottom-up technique and found the latter to be equally effective as well as safer, faster, and easier. We, therefore, suggest considering performing POEM in this technique.

EAES Recommendations for Recovery Plan in Minimally Invasive Surgery Amid COVID-19 Pandemic.

BACKGROUND: COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts' opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. METHODS: Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. RESULTS: A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. CONCLUSION: The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems.

Novel self-fixation chest drain device tested in a swine model of pneumo-hemothorax.

INTRODUCTION: Thoracic injuries account for 20-25% of trauma-related deaths. In cases of pneumothorax the insertion of a chest tube is mandatory but associated with high complication rates particularly when inserted under difficult conditions. The C-Lant is a novel chest-tube insertion device that provides integrated double fixation capabilities and can be used by responders with minimal experience. The aim of the study was to test the device in a large animal model. MATERIAL AND METHODS: Pneumothorax, tension pneumothorax, and hemothorax were induced in four white domestic female pigs. The C-Lant device (Vigor Medical Technologies, Haifa, Israel) was inserted as any chest-drain to decompress the thorax. Pull test was applied to test the strength of device fixation. RESULTS: The insertion of the device was simple and effective without detectable negative physiological effects. Reliable fixation was achieved without difficulty. Air and liquid were promptly drained from the chest cavity. Minimal tissue laceration occurred when applying the device in a scenario of erroneous pneumothorax diagnosis with fully expanded lungs. Interconnection with other surgical accessories was smooth. CONCLUSION: The C-Lant is a novel device that facilitates easy insertion and fixation of chest-tubes by minimally experienced medical providers and reduces the likelihood of unwanted expulsion. Clinical studies are planned.

The risk of COVID-19 transmission by laparoscopic smoke may be lower than for laparotomy: a narrative review.

BACKGROUND: Surgical smoke is a well-recognized hazard in the operating room. At the beginning of the COVID-19 pandemic, surgical societies quickly published guidelines recommending avoiding laparoscopy or to consider open surgery because of the fear of transmission of SARS-CoV-2 through surgical smoke or aerosol. This narrative review of the literature aimed to determine whether there are any differences in the creation of surgical smoke/aerosol between laparoscopy and laparotomy and if laparoscopy may be safer than laparotomy. METHODS: A literature search was performed using the Pubmed, Embase and Google scholar search engines, as well as manual search of the major journals with specific COVID-19 sections for ahead-of-print publications. RESULTS: Of 1098 identified articles, we critically appraised 50. Surgical smoke created by electrosurgical and ultrasonic devices has the same composition both in laparoscopy and laparotomy. SARS-CoV-2 has never been found in surgical smoke and there is currently no data to support its virulence if ever it could be transmitted through surgical smoke/aerosol. CONCLUSION: If laparoscopy is performed in a closed cavity enabling containment of surgical smoke/aerosol, and proper evacuation of smoke with simple measures is respected, and as long as laparoscopy is not contraindicated, we believe that this surgical approach may be safer for the operating team while the patient has the benefits of minimally invasive surgery. Evidence-based research in this field is needed for definitive determination of safety.

The use of 3D laparoscopic imaging systems in surgery: EAES consensus development conference 2018.

BACKGROUND: The use of 3D laparoscopic systems is expanding. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference with the aim of creating evidence-based statements and recommendations for the surgical community. METHODS: Systematic reviews of the PubMed and Embase libraries were performed to identify evidence on potential benefits of 3D on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by an international surgical and engineering expert panel which were presented and voted at the EAES annual congress, London, May 2018. RESULTS: 9967 abstracts were screened with 138 articles included. 18 statements and two recommendations were generated and approved. 3D significantly shortened operative time (mean difference 11 min (8% [95% CI 20.29-1.72], I2 96%)). A significant reduction in complications was observed when 3D systems were used (RR 0.75, [95 CI% 0.60-0.94], I2 0%) particularly for cases involving laparoscopic suturing (RR 0.57 [95% CI 0.35-0.90], I2 0%). In 69 box trainer or simulator studies, 64% concluded trainees were significant faster and 62% performed fewer errors when using 3D. CONCLUSION: We recommend the use of 3D vision in laparoscopy to reduce the operative time (grade of recommendation: low). Future robust clinical research is required to specifically investigate the potential benefit of 3D laparoscopy system on complication rates (grade of recommendation: high).

Introduction to artificial intelligence in medicine.

The term Artificial Intelligence (AI) was coined by John McCarthy in 1956 during a conference held on this subject. However, the possibility of machines being able to simulate human behavior and actually think was raised earlier by Alan Turing who developed the Turing test in order to differentiate humans from machines. Since then, computational power has grown to the point of instant calculations and the ability evaluate new data, according to previously assessed data, in real time. Today, AI is integrated into our daily lives in many forms, such as personal assistants (Siri, Alexa, Google assistant etc.), automated mass transportation, aviation and computer gaming. More recently, AI has also begun to be incorporated into medicine to improve patient care by speeding up processes and achieving greater accuracy, opening the path to providing better healthcare overall. Radiological images, pathology slides, and patients' electronic medical records (EMR) are being evaluated by machine learning, aiding in the process of diagnosis and treatment of patients and augmenting physicians' capabilities. Herein we describe the current status of AI in medicine, the way it is used in the different disciplines and future trends.

[FLEXIBLE ENDOSCOPY IN THE HANDS OF THE SURGEON - THE ISRAELI SURGEON'S POINT OF VIEW].

INTRODUCTION: The flexible endoscope was developed over 50 years ago as a diagnostic tool for the gastrointestinal (GI) tract. Since then, many therapeutic interventions were developed using the endoscope, mostly by surgeons. In the past decade, following technological developments and improvements made in light sources and video, more advanced procedures were developed, and the flexible endoscope is slowly becoming a powerful surgical tool that enables performing advanced procedures that replace traditional surgery, such as intra-operative endoscopy for exact localization of pathologies, active guidance of the surgical acts during surgery, treatment of common diseases of the GI tract and interventions to treat post-operative complications. The use of the flexible endoscope by surgeons varies between regions. Whereas it is a mandatory part of surgical residency in North America, Australia and parts of Asia, in other parts of the world, including Israel, flexible endoscopy is not accessible to surgeons. In this review we chart the reasons for this phenomenon and define the needs for change so that flexible endoscopy will become a common surgical tool in Israel.