The Creation of a Pediatric Surgical Checklist for Adult Providers.

Purpose: To address the need for a pediatric surgical checklist for adult providers. Background: Pediatric surgery is unique due to the specific needs and many tasks that are employed in the care of adults require accommodations for children. There are some resources for adult surgeons to perform safe pediatric surgery and to assist such surgeons in pediatric emergencies, we created a straightforward checklist based on current literature. We propose a surgical checklist as the value of surgical checklists has been validated through research in a variety of applications. Methods: Literature review on PubMed to gather information on current resources for pediatric surgery, all papers on surgical checklists describing their outcomes as of October 2022 were included to prevent a biased overview of the existing literature. Interviews with multiple pediatric surgeons were conducted for the creation of a checklist that is relevant to the field and has limited bias. Results: 42 papers with 8529061 total participants were included. The positive impact of checklists was highlighted throughout the literature in terms of outcomes, financial cost and team relationship. Certain care checkpoints emerged as vital checklist items: antibiotic administration, anesthetic considerations, intraoperative hemodynamics and postoperative resuscitation. The result was the creation of a checklist that is not substitutive for existing WHO surgery checklists but additive for adult surgeons who must operate on children in emergencies. Conclusion: The outcomes measured throughout the literature are varied and thus provide both a nuanced view of a variety of factors that must be taken into account and are limited in the amount of evidence for each outcome. We hope to implement the checklist developed to create a standard of care for pediatric surgery performed in low resource settings by adult surgeons and further evaluate its impact on emergency pediatric surgery outcomes. Funding: Fulbright Fogarty Fellowship, GHES NIH FIC D43 TW010540.

New generation evaluations: video-based surgical assessments : A technology update.

BACKGROUND: Surgical skill training, assessment, and feedback are the backbone of surgical training. High-quality skills require expert supervision and evaluation throughout a resource-intensive multi-year training process. As technological barriers to internet access and the ability to save and upload surgical videos continue to improve, video-based assessment technology is emerging as a tool that could reshape surgical training for the next generation of surgeons. Video-based assessment platforms have the potential to allow surgeons from across the globe to upload their surgical videos online and receive high-quality, standardized, and unbiased feedback. They combine visual recordings of a surgeon's operative technique, with standardized grading tools that have the potential to significantly impact surgical training and technical skill acquisition across the world. METHOD: The platforms included in this review are in various stages of development after a thorough discussion with national experts on the SAGES TAVAC (Technology and Value Assessments) Committee. For each VBA program, a description of its platform was given and a literature review was obtained using a PubMed search performed from inception until December 2021. RESULTS: The study reviewed all video-based assessment programs currently available in the market, identified their strengths and weaknesses, and how they can be optimized in future. CONCLUSION: The technological platforms will play a key role in the training and technical skill acquisition of the next generation of surgeons and can have an immense impact on patient care across the world. There is immense potential for all these platforms to grow and become incorporated within the framework of an effective surgical training program.

Senhance Robotic Platform in Pediatrics: Early US Experience.

INTRODUCTION: Different robotic systems have been used widely in human surgery since 2000, but pediatric patients require some features that are lacking in the most frequently used robotic systems. HYPOTHESIS: The Senhance® robotic system is a safe and an effective device for use in infants and children that has some advantages over other robotic systems. METHODS: All patients between 0 and 18 years of age whose surgery was amenable to laparoscopy were offered enrollment in this IRB-approved study. We assessed the feasibility, ease and safety of using this robotic platform in pediatric patients including: set-up time, operative time, conversions, complications and outcomes. RESULTS: Eight patients, ranging from 4 months to 17 years of age and weighing between 8 and 130 kg underwent a variety of procedures including: cholecystectomy (3), inguinal herniorrhaphy (3), orchidopexy for undescended testes (1) and exploration for a suspected enteric duplication cyst (1). All robotic procedures were successfully performed. The 4-month-old (mo), 8 kg patient underwent an uneventful robotic exploration in an attempt to locate a cyst that was hidden in the mesentery at the junction of the terminal ileum and cecum, but ultimately the patient required an anticipated laparotomy to palpate the cyst definitively and to excise it completely. There was no blood loss and no complications. Robotic manipulation with the reusable 3 mm instruments proved successful in all cases. CONCLUSIONS: Our initial experience with the Senhance® robotic platform suggests that this is a safe and effective device for pediatric surgery that is easy to use, and which warrants continued evaluation. Most importantly, there appears to be no lower age or weight restrictions to its use.

Cannabinoid Hyperemesis Syndrome Complicated by Pneumomediastinum: Implications for Pediatric Surgeons.

BACKGROUND: Cannabinoid Hyperemesis Syndrome (CHS) is a form of cyclic vomiting syndrome characterized by episodic vomiting occurring every few weeks or months and is associated with prolonged and frequent use of high-dose cannabis. CHS in the pediatric population has been increasingly reported over the last decade and can lead to life-threatening complications such as pneumomediastinum, which warrant careful consideration for surgical intervention. CASE PRESENTATION: A 17-year-old female with no significant past medical history presented to the emergency department with abdominal pain, nausea, and vomiting for 24 hours. She had four episodes of green-yellow emesis followed by dry heaves. She also complained of chest and back pain, worse with deep inspiration. Upon further history, the patient reported a similar episode of abdominal pain and repetitive vomiting six months prior to the current episode. She smoked cannabis at least once daily and has done so for the past two years. Chest X-ray revealed a subtle abnormal lucency along the anteroposterior window and anterior mediastinum, consistent with a small amount of pneumomediastinum without any other acute intrathoracic abnormalities. Follow-up chest computed tomography with contrast showed multiple foci of air within the anterior and posterior mediastinum tracking up to the thoracic inlet. There was no evidence of contrast extravasation; however, small esophageal perforation could not be excluded. Given uncomplicated pneumomediastinum without frank contrast extravasation, the patient was treated medically with piperacillin-tazobactam, metronidazole, and micafungin for microbial prophylaxis; hydromorphone for pain control; as well as with pantoprazole, ondansetron, and promethazine. Nutrition was provided via total parenteral nutrition. The patient was intensely monitored for signs of occult esophageal perforation, but none were detected. She was advanced to a soft diet on hospital day eight, solid food diet on day nine, at which point antibiotics were discontinued, and the patient was subsequently discharged. CONCLUSION: CHS in an increasingly common disorder encountered in the pediatric setting due to rising prevalence of cannabis use. The management of CHS and potentially life-threatening complications such as pneumomediastinum should be given careful consideration. Pneumomediastinum can be a harbinger of more sinister pathology such as esophageal perforation, which may warrant urgent surgical intervention.

A SAGES technology and value assessment and pediatric committee evaluation of mini-laparoscopic instrumentation.

BACKGROUND: The TAVAC and Pediatric Committees of SAGES evaluated the current use of mini-laparoscopic instrumentation to better understand the role this category of devices plays in the delivery of minimally invasive surgery today. METHODS: The role of mini-laparoscopic instrumentation, defined as minimally invasive instruments of between 1 and 4 mm in diameter, was assessed by an exhaustive review of the peer reviewed literature on the subject between 1990 and 2021. The instruments, their use, and their perceived value were tabulated and described. RESULTS: Several reported studies propose a value to using mini-laparoscopic instrumentation over the use of larger instruments or as minimally invasive additions to commonly performed procedures. Additionally, specifically developed smaller-diameter instruments appear to be beneficial additions to our minimally invasive toolbox. CONCLUSIONS: The development of small instrumentation for the effective performance of minimally invasive surgery, while perhaps best suited to pediatric populations, proves useful as adjuncts to a wide variety of adult surgical procedures. Mini-laparoscopic instrumentation thus proves valuable in selected cases.

Assessment of the da Vinci Single Port Robotic Platform on Cholecystectomy in Adolescents.

Background: The new da Vinci single port (SP) robotic platform has great appeal for pediatric surgery. To assess its efficacy and identify potential challenges, 7 adolescents underwent SP cholecystectomy. Materials and Methods: The surgeon controls three fully wristed elbowed instruments, and the first fully wristed da Vinci endoscope through a single 2.5 cm cannula. Instruments can reach 24 cm deep and triangulate distally. Instruments can also reach anatomy anywhere within 360° of port placement. A vertical incision was made through the umbilicus for port access. The cystic duct and cystic artery were dissected, clipped, divided, and hook cautery was used to remove the gallbladder. Patient characteristics and outcomes were collected and analyzed. Results: Patients were American Society of Anesthesiologists (ASA) classes I, II, and III; mean age was 17 years; mean weight was 72 kg; and 6 of 7 patients were female. There were no fatalities, and there were no returns to the operating room. Mean estimated blood loss was 2 mL and mean case duration was 126 minutes. Five out of seven patients were treated as outpatients, and none of them required narcotics on discharge. One patient reported bilateral shoulder pain 1 day postoperatively and was taking hydrocodone/acetaminophen at the time of 13-day follow-up. Conclusions: SP robotic platform cholecystectomy in adolescents appears to be safe and effective. The wristed movement of the robotic instruments improves surgeon dexterity, and the single incision hidden in the contour of the umbilicus provides good cosmesis. This series sets an exciting precedent and provides a glimpse of what is possible in pediatric robotic surgery. Clinical Trial Registration number 2014-0396.

Single port robotic splenectomy for pyruvate kinase deficiency in a five-year-old patient, a case report of a surgical first.

INTRODUCTION: Adoption of robotic surgery in pediatrics has been slow. Robotic surgery within spatially-constrained workspaces in children makes traditional platforms less translatable. Da Vinci's newest single port (SP) robotic platform provides narrow, and deep access, making pediatric robotic surgery more feasible. CASE PRESENTATION: A five-year old female presented with hepatosplenomegaly due to hemolytic anemia from pyruvate kinase deficiency (PKD). When she progressed to requiring monthly transfusions, a splenectomy was performed to avoid the complications associated with frequent blood transfusions. The robotic approach was used to remove the intact spleen because traditional minimally invasive surgery can result in post-operative splenosis. DISCUSSION: The patient successfully underwent single-port, robotic splenectomy - the first known splenectomy in a child using this approach. Furthermore, during the operation an accessory spleen was encountered in the omentum and was also successfully removed robotically. The patient tolerated the procedure well. CONCLUSION: This case demonstrates that the SP robot can be used for splenectomy to eliminate the risk of splenosis and achieve a superior cosmetic result.

Evaluating mental workload of two-dimensional and three-dimensional visualization for anatomical structure localization.

Visualization of medical data in three-dimensional (3D) or two-dimensional (2D) views is a complex area of research. In many fields 3D views are used to understand the shape of an object, and 2D views are used to understand spatial relationships. It is unclear how 2D/3D views play a role in the medical field. Using 3D views can potentially decrease the learning curve experienced with traditional 2D views by providing a whole representation of the patient's anatomy. However, there are challenges with 3D views compared with 2D. This current study expands on a previous study to evaluate the mental workload associated with both 2D and 3D views. Twenty-five first-year medical students were asked to localize three anatomical structures--gallbladder, celiac trunk, and superior mesenteric artery--in either 2D or 3D environments. Accuracy and time were taken as the objective measures for mental workload. The NASA Task Load Index (NASA-TLX) was used as a subjective measure for mental workload. Results showed that participants viewing in 3D had higher localization accuracy and a lower subjective measure of mental workload, specifically, the mental demand component of the NASA-TLX. Results from this study may prove useful for designing curricula in anatomy education and improving training procedures for surgeons.

The transaxillary, totally endoscopic approach for head and neck endocrine surgery in children.

PURPOSE: The purpose of this study was to assess the safety, efficacy, and learning curve for transaxillary, totally endoscopic (TATE) head and neck endocrine surgery in children. MATERIALS AND METHODS: Between June 2005 and October 2009, 31 children with head and neck endocrine problems were subjected to the TATE approach. Safety, efficacy, complications, and time of operation were assessed. DATA: Thirty-one children (mean age, 12.7 years; F:M, 5:1) underwent a TATE approach. Glands ranged in size from 10 g (in a small 5-year-old) to 63 g (in one 16-year-old). No cervical incisions were required and there were no conversions to open surgery. Three patients in our early experience underwent a robot-assisted procedure. Two patients suffered from hyperparathyroidism and had adenomas removed, using rapid PTH in the operating room to confirm immediate success. Of the remaining 29 children, 2 girls had an adenoma of the right thyroid lobe removed uneventfully, and the reminder all had Graves disease, which was treated successfully. Complications included transient hypocalcemia in 3 patients who were also on steroids for unrelated medical problems; transient neuropraxia in 3 patients with very large glands; 1 postoperative, lateral, subcutaneous hematoma that resolved uneventfully; and 1 asthmatic with a spontaneous apical pneumothorax that presented as subcutaneous gas in the neck, 6 hours after the surgery and which resolved with chest tube placement. Average operative time for the first 10 patients was 288 minutes and for the subsequent patients was 155 minutes (range, 92-210 minutes). CONCLUSIONS: The TATE approach appears to be as safe and effective as open surgery for cervical endocrinopathies in children. Only transient, minor complications were observed. Operative time significantly decreases with experience, making the length of surgery comparable to its open counterpart.

Tumor segmentation from computed tomography image data using a probabilistic pixel selection approach.

Automatic segmentation of tumors is a complicated and difficult process as most tumors are rarely clearly delineated from healthy tissues. A new method for probabilistic segmentation to efficiently segment tumors within CT data and to improve the use of digital medical data in diagnosis has been developed. Image data are first enhanced by manually setting the appropriate window center and width, and if needed a sharpening or noise removal filter is applied. To initialize the segmentation process, a user places a seed point within the object of interest and defines a search region for segmentation. Based on the pixels' spatial and intensity properties, a probabilistic selection criterion is used to extract pixels with a high probability of belonging to the object. To facilitate the segmentation of multiple slices, an automatic seed selection algorithm was developed to keep the seeds in the object as its shape and/or location changes between consecutive slices. The seed selection algorithm performs a greedy search by searching for pixels with matching intensity close to the location of the original seed point. A total of ten CT datasets were used as test cases, each with varying difficulty in terms of automatic segmentation. Five test cases had mean false positive error rates less than 10%, and four test cases had mean false negative error rates less than 10% when compared to manual segmentation of those tumors by radiologists.

Endosurgery of the future, today: lessons on how to be an innovator.

This lecture summarizes the elements of innovation and demonstrates how one can apply the principles every day to be an effective surgical innovator.

Our initial experience of the transaxillary totally endoscopic approach for hemithyroidectomy.

OBJECTIVE: To report our initial experience with the transaxillary totally endoscopic (TATE) approach to the thyroid gland. STUDY DESIGN: A historic cohort study of patients undergoing TATE procedures compared with open procedures for hemithyroidectomy with isthmusectomy. SETTING: Private-practice otolaryngology group. SUBJECT AND METHODS: Patients selected for benign thyroid disease confirmed by fine-needle aspiration and requiring hemithyroidectomy with isthmusectomy. A historic cohort study of 24 patients who underwent TATE procedures for hemithyroidectomy with isthmusectomy. Comparison of the first 10 TATE approaches to a control group of 10 consecutive open approaches by the senior author's group. RESULTS: All 24 TATE patients were successful without the need to convert to an open procedure. The TATE approach had longer operative times than the open group (142 vs 105), but these operative times decreased as the number of procedures increased (first five TATE = 170, last five TATE = 114, n = 24, average = 114). No patients had peri- or postoperative complications. CONCLUSIONS: The TATE approach to the thyroid gland is safe and effective. Operative time is longer but decreases with experience. The TATE approach is one option to treat young patients with unilateral benign thyroid disease who are seeking to avoid visible scars and limit morbidity.

Three-dimensional segmentation of tumors from CT image data using an adaptive fuzzy system.

A new segmentation method using a fuzzy rule based system to segment tumors in a three-dimensional CT data was developed. To initialize the segmentation process, the user selects a region of interest (ROI) within the tumor in the first image of the CT study set. Using the ROI's spatial and intensity properties, fuzzy inputs are generated for use in the fuzzy rules inference system. With a set of predefined fuzzy rules, the system generates a defuzzified output for every pixel in terms of similarity to the object. Pixels with the highest similarity values are selected as tumor. This process is automatically repeated for every subsequent slice in the CT set without further user input, as the segmented region from the previous slice is used as the ROI for the current slice. This creates a propagation of information from the previous slices, used to segment the current slice. The membership functions used during the fuzzification and defuzzification processes are adaptive to the changes in the size and pixel intensities of the current ROI. The method is highly customizable to suit different needs of a user, requiring information from only a single two-dimensional image. Test cases success in segmenting the tumor from seven of the 10 CT datasets with <10% false positive errors and five test cases with <10% false negative errors. The consistency of the segmentation results statistics also showed a high repeatability factor, with low values of inter- and intra-user variability for both methods.

A collaborative interaction and visualization multi-modal environment for surgical planning.

The proliferation of virtual reality visualization and interaction technologies has changed the way medical image data is analyzed and processed. This paper presents a multi-modal environment that combines a virtual reality application with a desktop application for collaborative surgical planning. Both visualization applications can function independently but can also be synced over a network connection for collaborative work. Any changes to either application is immediately synced and updated to the other. This is an efficient collaboration tool that allows multiple teams of doctors with only an internet connection to visualize and interact with the same patient data simultaneously. With this multi-modal environment framework, one team working in the VR environment and another team from a remote location working on a desktop machine can both collaborate in the examination and discussion for procedures such as diagnosis, surgical planning, teaching and tele-mentoring.

Transaxillary totally endoscopic robot-assisted ansa cervicalis to recurrent laryngeal nerve reinnervation for repair of unilateral vocal fold paralysis.

Pediatric unilateral vocal-fold paralysis represents a source of significant morbidity, for which treatment options are quite limited. Conventional management strategies suitable for adults are not appropriate for the developing larynx. In this study, we report the first experience with minimally invasive laryngeal reinnervation. While open techniques for pediatric recurrent laryngeal nerve reinnervation have been performed, these require large, visible incisions, which limit the appeal of this technique. The transaxillary endoscopic approach to the neck significantly reduces pain and recovery time from cervical surgery. In this study, we report the feasibility of transaxillary totally endoscopic robot-assisted laryngeal reinnervation for unilateral vocal-fold paralysis. Operative time was less than 3 hours, and patients were discharged the day of surgery. No postoperative narcotics were required. Initial results are favorable.

A virtual reality environment for patient data visualization and endoscopic surgical planning.

Visualizing patient data in a three-dimensional (3D) representation can be an effective surgical planning tool.As medical imaging technologies improve with faster and higher resolution scans, the use of virtual reality for interacting with medical images adds another level of realism to a 3D representation. The software framework presented in this paper is designed to load and display any DICOM/PACS-compatible 3D image data for visualization and interaction in an immersive virtual environment. In "examiner" mode, the surgeon can interact with a 3D virtual model of the patient by using an intuitive set of controls designed to allow slicing, coloring,and windowing of the image to show different tissue densities and enhance important structures. In the simulated"endoscopic camera" mode, the surgeon can see through the point of view of a virtual endoscopic camera to navigate inside the patient. These tools allow the surgeon to perform virtual endoscopy on any suitable structure.The software is highly scalable, as it can be used on a single desktop computer to a cluster of computers in an immersive multiprojection virtual environment. By wearing a pair of stereo glasses, a surgeon becomes immersed within the model itself, thus providing a sense of realism, as if the surgeon is "inside" the patient.

A framework for interactive visualization of digital medical images.

The visualization of medical images obtained from scanning techniques such as computed tomography and magnetic resonance imaging is a well-researched field. However, advanced tools and methods to manipulate these data for surgical planning and other tasks have not seen widespread use among medical professionals. Radiologists have begun using more advanced visualization packages on desktop computer systems, but most physicians continue to work with basic two-dimensional grayscale images or not work directly with the data at all. In addition, new display technologies that are in use in other fields have yet to be fully applied in medicine. It is our estimation that usability is the key aspect in keeping this new technology from being more widely used by the medical community at large. Therefore, we have a software and hardware framework that not only make use of advanced visualization techniques, but also feature powerful, yet simple-to-use, interfaces. A virtual reality system was created to display volume-rendered medical models in three dimensions. It was designed to run in many configurations, from a large cluster of machines powering a multiwalled display down to a single desktop computer. An augmented reality system was also created for, literally, hands-on interaction when viewing models of medical data. Last, a desktop application was designed to provide a simple visualization tool, which can be run on nearly any computer at a user's disposal. This research is directed toward improving the capabilities of medical professionals in the tasks of preoperative planning, surgical training, diagnostic assistance, and patient education.

A framework for interactive examination of automatic segmented tumors in a virtual environment.

An immersive virtual environment for viewing and interacting with three-dimensional representations of medical image data is presented. Using a newly developed automatic segmentation method, a segmented object (e.g., tumor or organ) can also be viewed in the context of the original patient data. Real time interaction is established using joystick movements and button presses on a wireless gamepad. Several open-source platforms have been utilized, such as DCMTK for processing of DICOM formatted data, Coin3D for scenegraph management, SimVoleon for volume rendering, and VRJuggler to handle the immersive visualization. The application allows the user to manipulate representations with features such as fast pseudo-coloring to highlight details of the patient data, windowing to select a range of tissue densities for display, and multiple clipping planes to allow the user to slice into the patient.

Bilateral transaxillary endoscopic total thyroidectomy.

BACKGROUND/PURPOSE: Minimal-access thyroid surgery using various techniques is well described. The present study reviews our initial experience with total thyroidectomy using a robotic-assisted bilateral transaxillary endoscopic approach (R-BAEA) and a non-robotic-assisted bilateral transaxillary endoscopic approach (BAEA) to assess it's safety and feasibility. PATIENTS AND METHODS: The study group was 13 consecutive patients who were candidates for total thyroidectomy with benign thyroid disease. Two young adult patients who were older than 20 years and 2 teenage patients who underwent a transaxillary endoscopic thyroid lobectomy were excluded from this study that was composed of 9 children. A detailed description of the surgical technique is provided. RESULTS: Eight patients were female and one was male. The mean age was 13.5 +/- 3.0 years. Two R-BAEAs and 7 BAEAs were performed. The initial diagnosis was Graves disease in all 9 cases. The mean operating time was 385 minutes (range, 364-407 minutes) for R-BAEA and 259 minutes (range, 135-385 minutes) for BAEA. The mean diameter of the resected specimens was 5.9 cm (range, 4.5-8.3 cm); the mean intraoperative blood loss was 15.0 mL (range, 10-30 mL). The recurrent laryngeal nerve and parathyroid glands were identified and preserved intact in all cases. No patients required conversion. There was one instance of postoperative wound erythema, and 2 patients experienced hypocalcemia that resolved spontaneously. Two patients with large glands experienced a transient postoperative hoarseness. The mean total postoperative morphine dose administered in the first 24 hours was 1.5 mg (range, 0-4 mg). Postoperative pain was minimal, and cosmetic results were considered excellent by all patients. All except one were discharged the day after surgery and returned immediately to normal activities. CONCLUSIONS: Total thyroidectomy using BAEA with or without robotic assistance is feasible and safe. The advantages of this approach are no cervical scar, no significant morbidity, less postoperative pain, and early return to normal activity compared with other published techniques.