Impaired robotic surgical visualization: archaic issues in a modern operating room.

While robotic-assisted surgery (RAS) has been revolutionizing surgical procedures, it has various areas needing improvement, specifically in the visualization sector. Suboptimal vision due to lens occlusions has been a topic of concern in laparoscopic surgery but has not received much attention in robotic surgery. This study is one of the first to explore and quantify the degree of disruption encountered due to poor robotic visualization at a major academic center. In case observations across 28 RAS procedures in various specialties, any lens occlusions or "debris" events that appeared on the monitor displays and clinicians' reactions, the cause, and the location across the monitor for these events were recorded. Data were then assessed for any trends using analysis as described below. From around 44.33 h of RAS observation time, 163 debris events were recorded. 52.53% of case observation time was spent under a compromised visual field. In a subset of 15 cases, about 2.24% of the average observation time was spent cleaning the lens. Additionally, cautery was found to be the primary cause of lens occlusions and little variation was found within the spread of the debris across the monitor display. This study illustrates that in 6 (21.43%) of the cases, 90% of the observation time was spent under compromised visualization while only 2 (7.14%) of the cases had no debris or cleaning events. Additionally, we observed that cleaning the lens can be troublesome during the procedure, interrupting the operating room flow.

Adrenal Ganglioneuroma: Diagnosis, Presentation, and Management of a Rare Tumor.

Adrenal ganglioneuromas are rare tumors arising from sympathetic ganglion cells that may present similarly to other adrenal tumors, making preoperative diagnosis challenging. We present a case of a young woman with a history of Hashimoto's thyroiditis who presented with hypertension and headaches. An abdominal CT scan revealed a large left adrenal mass, and while laboratory tests for catecholamines and metanephrines were normal, the suspicion for pheochromocytoma remained high given the size of the mass and persistent hypertension. The patient was started on alpha-blockers and beta-blockers in preparation for surgical removal. Pathology revealed a mature ganglioneuroma without evidence of malignancy, and postoperative blood pressure was normalized. We hypothesize that vessel compression from the large mass created functional stenosis, resulting in persistent hypertension. This case highlights the importance of a thorough workup for hypertension in young adults and routine preventative care visits to avoid delayed management. Adrenalectomy with histopathological examination remains the gold standard for treatment and diagnosis, and patients have a good prognosis following resection, with minimal need for recurrent therapy.

Assessing visualization in robotic-assisted surgery: demystifying a misty lens.

Despite major technological advancements in robotic-assisted laparoscopic surgery (RAS), there remain shortcomings yet to be addressed. This study assesses the prevalence of suboptimal vision in minimally invasive RAS and corresponding factors regarding related surgical conditions. 45 minimally invasive robotic surgeries, performed using Da Vinci XI, were observed across three surgical subspecialties: general, urology, and OB/GYN. Lens occlusion events were monitored and defined as the presence of a visual distortion caused by debris deposition on the scope lens. Lens occlusions and cleanings, and "active instrumentation" were recorded. Descriptive statistics summarized duration-based variables, and one-factor ANOVA compared the presence of active instrumentation. Cases averaged 127 ± 76 min. Active instrumentation ANOVA during lens occlusions demonstrated significant variation between categories (F7, 256 = 11.63, p = 2.558e-13). Post hoc Tukey HSD found electrocautery devices were active significantly more during occlusion events (37.9%) than other instruments. On average, lens cleaning occurred every 36.5 ± 39.8 min despite lens occlusion occurring every 24.5 ± 15.7 min. Of the operative time observed, 41.4% ± 28.1% was conducted with visual distortion. 1.16% ± 0.97% of time observed was spent cleaning. Although only 1.16% of operative time was spent cleaning, surgeons experienced suboptimal conditions for nearly 35× the time it would take the clear lens, potentially indicating a tendency to avoid cleaning the lens to disrupt surgery. Future research may examine the impact of occluded visualization and lens cleaning on other aspects of surgery.

A Clean Sweep: Initial Experience with a Novel Intracavity Laparoscopic Cleaning Device.

Background: A frequently encountered problem in laparoscopic surgery is an impaired visual field. The Novel Intracavitary Laparoscopic Cleaning Device (NILCD) is designed to adequately clean a laparoscopic lens quickly and efficiently without requiring removal from the surgical cavity. Animal and cadaver studies showed good efficacy and a short learning curve. This study aims to describe the efficacy and initial human experience with the device during laparoscopic operations. Methods: Since 2020, NILCD was used in 167 cases with surgeons at 12 different institutions in Texas, California, and Massachusetts. The rate of scope removal in each case was examined. Following each trial, users were asked to rank the NILCD on ease of set up, insertion, adjustment, and cleaning efficacy. A survey was then used to evaluate surgeon satisfaction. Results: The NILCD was tested in a variety of cases, including colorectal, gynecological, general, pediatric, hepatobiliary, thoracic, bariatric and foregut surgery. NILCD usage eliminated the need for scope removal in 90.14% of debris events, with only 97 removals in 984 events. Eighty-six percent of users reported that the NILCD improved their visual field. When asked to rate specific qualities of the device using a 5-point Likert scale, surgeons gave an average score of 4.56 for ease of setup, 4.10 for ease of insertion, and 4.12 for ease of adjusting and cleaning efficacy. Conclusion: In an initial analysis of 167 cases, the NILCD proved to be an effective and convenient method of cleaning the laparoscopic lens in-vivo. It was associated with good surgeon satisfaction.

Stop the leak!: Mitigating potential exposure of aerosolized COVID-19 during laparoscopic surgery.

BACKGROUND: Viral particles have been shown to aerosolize into insufflated gas during laparoscopic surgery. In the operating room, this potentially exposes personnel to aerosolized viruses as well as carcinogens. In light of circumstances surrounding COVID-19 and a concern for the safety of healthcare professionals, our study seeks to quantify the volumes of gas leaked from dynamic interactions between laparoscopic instruments and the trocar port to better understand potential exposure to surgically aerosolized particles. METHODS: A custom setup was constructed to simulate an insufflated laparoscopic surgical cavity. Two surgical instrument use scenarios were examined to observe and quantify opportunities for insufflation gas leakage. Both scenarios considered multiple configurations of instrument and trocar port sizes/dimensions: (1) the full insertion and full removal of a laparoscopic instrument from the port and (2) the movement of the scope within the port, recognized as "dynamic interaction", which occurs nearly 100% of the time over the course of any procedure. RESULTS: For a 5 mm instrument in a 5 mm trocar, the average volume of gas leaked during dynamic interaction and full insertion/removal scenarios were 43.67 and 25.97 mL of gas, respectively. Volume of gas leaked for a 5 mm instrument in a 12 mm port averaged 41.32 mL and 29.47 for dynamic interaction vs. instrument insertion and removal. Similar patterns were shown with a 10 mm instrument in 12 mm port, with 55.68 mL for the dynamic interaction and 58.59 for the instrument insertion/removal. CONCLUSIONS: Dynamic interactions and insertion/removal events between laparoscopic instruments and ports appear to contribute to consistent leakage of insufflated gas into the OR. Any measures possible taken to reduce OR gas leakage should be considered in light of the current COVID-19 pandemic. Minimizing laparoscope and instrument removal and replacement would be one strategy to mitigate gas leakage during laparoscopic surgery.

Case logging habits among general surgery residents are discordant and inconsistent.

BACKGROUND: General surgery residents log operative case experience as "first assist" (FA) or "primary surgeon" (PS). This study will evaluate their quantitative and qualitative case log practices. METHODS: Modified Delphi technique was used to create a questionnaire and distributed online to institutions via the APDS. Descriptive analyses and example operative scenarios for resident case logging habits were ascertained. RESULTS: There were 363 residents from university (60%) and non-university (40%) programs; 94% did not know the definition of primary surgeon. Over 50% stated they had been encouraged to log a case as surgeon that they did not feel was warranted. Only 4% felt the current logging system is "very accurate." Given an operative scenario, residents varied how they chose to log the case. CONCLUSION: General surgery residents do not know the current definition of PS. Case logging should be an objective measure of resident operative exposure, but may actually be more complex than previously recognized.

Demonstrating Higher Incidence of Advanced Breast Malignancies in Our Young Hispanic Population.

Historically, the Hispanic population in the United States has had a lower incidence of cancer than the matched non-Hispanic population, despite disparities in access to health care, screening, and prevention. Our experience in Austin, Texas, directly contradicts this. We have seen a disproportionate amount of young Hispanic patients with advanced malignancies, particularly of the breast. The aim of this study was to compare the incidence of advanced breast malignancies. We performed a retrospective review over a 10-year period (2003-2013) of all newly diagnosed breast cancer patients. Data were collected from the cancer registry. Patients were divided into two groups: Hispanic versus non-Hispanic descent, with a subgroup of those aged less than 50 years. Primary outcome was the incidence of advanced cancers (stage 3 or 4). There were a total of 3968 breast cancer patients seen in our Shivers Cancer Center from 2003 to 2013, with an overall incidence of advanced breast cancer of 11.5 per cent. Of the patients aged less than 50 years, 14.2 per cent had advanced breast cancer. However, the rate among Hispanic patients was 21.3 per cent, whereas in non-Hispanic patients it was 13.5 per cent, P = 0.002. Being Hispanic was found to be an independent predictor of having advanced malignancies at a young age (odds ratio 1.7, confidence interval 1.1-2.5, P = 0.01). Here in Austin, Texas, we have found a higher overall incidence of breast cancer among young Hispanic women. This is important to recognize because more efforts may be required to increase screening and health-care access to this population.

Is current surgery resident and GI fellow training adequate to pass FES?

BACKGROUND: The purpose of this study was to assess the adequacy of current surgical residency and gastroenterology (GI) fellowship flexible endoscopy training as measured by performance on the FES examination. METHODS: Fifth-year general surgery residents and GI fellows across six institutions were invited to participate. All general surgery residents had met ACGME/ABS case volume requirements as well as additional institution-specific requirements for endoscopy. All participants completed FES testing at the end of their respective academic year. Procedure volumes were obtained from ACGME case logs. Curricular components for each specialty and institution were recorded. RESULTS: Forty-eight (28 surgery and 20 GI) trainees completed the examination. Average case numbers for residents were 76 ± 26 colonoscopies and 45 ± 12 EGDs. Among GI fellows, PGY4 s (N = 10) reported 99 ± 64 colonoscopies and 147 ± 79 EGDs. PGY5 s (N = 3) reported 462 ± 307 colonoscopies and 411 ± 260 EGDs. PGY6 GI fellows (N = 7) reported 515 ± 111 colonoscopies and 418 ± 146 EGDs. The overall pass rate for all participants was 75 %, with 68 % of residents and 85 % of fellows passing both the cognitive and skills components. For surgery residents, pass rates were 75 % for manual skills and 85.7 % for cognitive. On the skills examination, Task 2 (loop reduction) was associated with the lowest performance. Skills scores correlated with both colonoscopy (r = 0.46, p < 0.001) and EGD experience (r = 0.46, p < 0.001). Receiver operating characteristics curves were examined among the resident cohort. The minimum number of total cases associated with passing the FES skills component was 103. Significant variability existed in curricular components across institutions. DISCUSSION: These data suggest that current flexible endoscopy training may not be sufficient for all trainees to pass the examination. Implementing additional components of the FEC may prove beneficial in achieving more uniform pass rates on the FES examination.

Restrictive Transfusion in Geriatric Trauma Patients.

To determine whether a restrictive strategy of red cell transfusion was safe in elderly trauma patients, we compared those treated with a restrictive transfusion strategy versus those who were liberally transfused. We performed a retrospective study of elderly (age ≥ 70 years) trauma patients admitted to our Level I trauma center from 2005 to 2013. Patients with a hemoglobin (Hg) < 10 g/dL after 48 hours were included. We excluded patients with an Injury Severity Score > 25 or active cardiac ischemia. Patients who were transfused for an Hg < 10 g/dL (liberal group) were compared to those who were transfused for an Hg< 7 g/dL (restrictive group). There were 382 patients included, 229 and 153 in the liberal and restrictive transfusion groups, respectively. All patients in the liberal group and 20 per cent of patients in the restrictive group received a transfusion (P < 0.0001). Patients in the liberal group had more overall complications (52 vs 32%, P = 0.0001). On multivariate analysis, receiving a transfusion was an independent risk factor to develop a complication [odds ratio = 2.3 (1.5-3.6), P < 0.0001]. For survivors, patients in the liberal group spent more days in the hospital (nine versus seven days, P = 0.007) and intensive care unit (two versus one day, P = 0.01). There was no difference in mortality (3 vs 4%, P = 0.82). In conclusion, restrictive transfusion appears to be safe in elderly trauma patients and may be associated with decreased complications and shortened length of stay.

What do residents need to be competent laparoscopic and endoscopic surgeons?

BACKGROUND: Despite numerous efforts to ensure that surgery residents are adequately trained in the areas of laparoscopy and flexible endoscopy, there remain significant concerns that graduates are not comfortable performing many of these procedures. METHODS: Online surveys were sent to surgery residents (98 items, PGY1-5 Categorical) and faculty (78 items, general surgery, and gastrointestinal specialties) at seven institutions. De-identified data were analyzed under an IRB-approved protocol. RESULTS: Ninety-five faculty and 121 residents responded, with response rates of 65 and 52 %, respectively. Seventy-three percent of faculty indicated that competency of their graduating residents were dramatically or slightly worse than previous graduates. Only 29 % of graduating residents felt very comfortable performing advanced laparoscopic (AL) cases and 5 % performing therapeutic endoscopy (TE) cases immediately after graduation. Over half of interns expressed a need for fellowship to feel comfortable performing AL and TE procedures, and this need did not decrease as residents neared graduation. For these procedures, residents receive only "little to some" autonomy, as reported by both faculty and PGY5s. Residents reported that current curricula for laparoscopy and endoscopy consist primarily of clinical experience. Both residents and faculty, though, reported considerable value in other training modalities, including simulations, live animal laboratories, cadavers, and additional didactics. CONCLUSIONS: These data indicate that both residents and faculty perceive significant competency gaps for both laparoscopy and flexible endoscopy, with the most notable shortcomings for advanced and therapeutic cases, respectively. Improvement in resident training methods in these areas is warranted.

Predicting and enhancing American Board of Surgery In-Training Examination performance: does writing questions really help?

BACKGROUND: The generative learning model posits that individuals remember content they have generated better than materials created by others. The goals of this study were to evaluate question generation as a study method for the American Board of Surgery In-Training Examination (ABSITE) and determine whether practice test scores and other data predict ABSITE performance. METHODS: Residents (n = 206) from 6 general surgery programs were randomly assigned to one of the two study conditions. One group wrote questions for practice examinations. All residents took 2 practice examinations. RESULTS: There was not a significant effect of writing questions on ABSITE score. Practice test scores, United States Medical Licensing Examination Step 1 scores, and previous ABSITE scores were significantly correlated with ABSITE performance. CONCLUSIONS: The generative learning model was not supported. Performance on practice tests and other data can be used for early identification of residents at risk of performing poorly on the ABSITE.

Use of Magnetic Resonance Cholangiopancreatography in Clinical Practice: Not as Good as We Once Thought.

BACKGROUND: Magnetic resonance cholangiopancreatography (MRCP) is believed to be a useful tool to evaluate the biliary tree and pancreas for stones, tumors, or injuries to the ductile system. The purpose of this study was to compare the accuracy of MRCP to the gold standard, endoscopic retrograde cholangiopancreatography (ERCP), in our institution. STUDY DESIGN: We performed a retrospective review of all MRCP followed by ERCP (follow-on ERCP) at a single institution over a 6-year period. Exam findings from MRCP were compared with findings on the follow-on ERCP and compared. Studies were grouped into 2 main classifications: tests being performed for patients with suspected choledocholithiasis (stone disease) and tests being performed for concerns of malignant strictures or duct injuries (non-stone disease). RESULTS: A total of 81 patients had MRCPs and follow-on ERCPs in this time period. Thirty-six patients had positive findings on MRCP and ERCP for stones in the common duct system, and 14 patients had positive findings on MRCP and subsequent ERCP for masses and strictures of the common duct. Three patients had positive MRCP and ERCP findings for pancreatic duct abnormalities. The specificity and positive predictive value of MRCP were 94% and 98%, respectively. However, 13 of 28 patients had lesions identified on ERCP after a normal MRCP. The sensitivity and negative predictive value were 80% and 54%, respectively. CONCLUSIONS: Magnetic resonance cholangiopancreatography was not useful in the management algorithm of either stone or non-stone disease of the biliary tree or pancreas. It should be abandoned as a diagnostic tool for work-up of biliary duct pathology.

Comparable operative times with and without surgery resident participation.

BACKGROUND: Both physicians and patients may perceive that having surgical residents participate in operative procedures may prolong operations and worsen outcomes. We hypothesized that resident participation would prolong operative times and potentially adversely affect postoperative outcomes. OBJECTIVE: To evaluate the effect of general surgery resident participation in surgical procedures on operative times and postoperative patient outcomes. DESIGN: Retrospective study of general surgery procedures performed during two 1-year time periods, 2007 without residents and 2011 with residents. Procedures included laparoscopic appendectomy and cholecystectomy, thyroidectomy, breast procedure, hernia repair, lower extremity amputation, tunneled venous catheter, and percutaneous endoscopic gastrostomy. The primary outcome was operative time and secondary outcomes included length of stay (LOS) and mortality. SETTING: Academic general surgery residency program. RESULTS: There were 2280 operative procedures performed during the 2 periods: 1150 with resident involvement (RES group) and 1130 without residents (NORES group). The RES and NORES groups were similar for patient age (42 vs 41, p = 0.14) and male gender (46% vs 45%, p = 0.68), and there was no difference in overall operative time (68min vs 66min, p = 0.58). More specifically there was no difference in operative time (minutes) for specific procedures including laparoscopic appendectomy (67 vs 71, p = 0.8), thyroidectomy (125 vs 109, p = 0.16), breast procedure (38 vs 26, p = 0.79), hernia repair (61 vs 60, p = 0.74), lower extremity amputation (65 vs 77, p = 0.16), tunneled venous catheter (49 vs 47, p = 0.75), and percutaneous endoscopic gastrostomy (49 vs 46, p = 0.76). However, laparoscopic cholecystectomy took slightly longer in the RES group (71 vs 66, p = 0.02). LOS was shorter during the year with resident involvement (2.6 days vs 3.7 days, p = 0.0004) and there was no difference in mortality (0.17% vs 0.35%, p = 0.45). CONCLUSIONS: There is no difference in operative time for common general surgery procedures with or without resident involvement. In addition, resident involvement is associated with a decrease in LOS. This information should be used to change physician and patient negative perceptions regarding resident involvement while performing surgical procedures.

Intraoperative assessment of breast cancer specimens decreases cost and number of reoperations.

It is the aim of our study to determine if the assessment of intraoperative breast cancer margins leads to decreased incidence of repeat operations and decreased cost. We collected data prospectively from two hospitals in Austin, TX, University Medical Center at Brackenridge (UMCB) and Seton Northwest Hospital (SNW), over a 2-year period. Comparison was made to see if intraoperative margin assessment affected total surgical costs and need for reoperation. One hundred and seven cases met criteria for inclusion in the study (UMCB = 45, SNW = 62). Intraoperative margin assessment was used in zero cases at SNW (0%) and in 17 at UMCB (38%). Intraoperative assessment was used in 16 per cent of total cases. Sixty per cent of cases at SNW required subsequent return to the operating room. Twenty-four per cent of cases at UMCB required subsequent reoperation (P < 0.05). The average number of surgical interventions required was 1 ± 0.3 with intraoperative assessment, 2 ± 0.6 without, (P < 0.05). Total surgical costs were $15,341 ± $4,328 with intraoperative assessment and $22,013 ± $13,821 without (P < 0.05). Use of intraoperative margin assessment for breast cancer operations leads to both a decrease in reoperations as well as a decrease in total operative costs.

Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: one unit's experience.

BACKGROUND: Rapidly restoring perfusion to injured extremities is one of the primary missions of forward military surgical teams. The austere setting, limited resources, and grossly contaminated nature of wounds encountered complicates early definitive repair of complex combat vascular injuries. Temporary vascular shunting of these injuries in the forward area facilitates rapid restoration of perfusion while allowing for deferment of definitive repair until after transport to units with greater resources and expertise. METHODS: Standard Javid or Sundt shunts were placed to temporarily bypass complex peripheral vascular injuries encountered by a forward US Navy surgical unit during a six month interval of Operation Iraqi Freedom. Data from the time of injury through transfer out of Iraq were prospectively recorded. Each patient's subsequent course at Continental US medical centers was retrospectively reviewed once the operating surgeons had returned from deployment. RESULTS: Twenty-seven vascular shunts were used to bypass complex vascular injuries in twenty combat casualties with a mean injury severity score of 18 (range 9-34) and mean mangled extremity severity score of 9 (range 6-11). All patients survived although three (15%) ultimately required amputation for nonvascular complications. Six (22%) shunts clotted during transport but an effective perfusion window was provided even in these cases. CONCLUSION: Temporary vascular shunting appears to provide simple and effective means of restoring limb perfusion to combat casualties at the forward level.

A case of Cushing syndrome secondary to ectopic adrenocorticotropic hormone producing carcinoid of the duodenum.

Cushing syndrome caused by adrenocorticotropic hormone (ACTH) production from solid tumors can result in life-threatening hypercortisolemia. Ectopic ACTH production is most commonly associated with bronchial carcinoids and squamous cell carcinoma of the lung. We report a case of Cushing syndrome caused by ectopic ACTH production from a carcinoid of the duodenum. The patient presented to an outside hospital in hypertensive crisis and diabetic ketoacidosis. After stabilization, diagnostic studies including a serum cortisol level, and computed tomography (CT) scans of the head, chest, abdomen, and pelvis revealed hypercortisolemia and a large mass in the head of the pancreas. Pancreaticoduodenectomy was performed. Pathologic investigation revealed a 1-cm carcinoid of the duodenum with two large metastatic lymph nodes near the head of the pancreas. This is the first reported case in the English literature of Cushing syndrome caused by ectopic ACTH production from a carcinoid of the duodenum.