Training and credentialing in Robotic Surgery in India: Current perspectives.

Robotic surgery has changed the landscape of surgery and ushered in a new era of technology-assisted minimally invasive surgery. There is a paradigm shift from traditional open surgeries to minimal access surgery, with robotic surgery being the new standard of care in some surgical fields. This change comes with an unprecedented influx of innovations in technology related to minimal access surgery, robotics and artificial intelligence. Despite the exponential advances in technology, there is a lacuna in the training and credentialling of robotic surgeons. In India, no dedicated training curriculum exists for trainees in robotic surgery. Thus, as robotic surgery continues to develop in India, it is imperative that robust training and credentialing systems are in place to ensure that patient safety and surgical outcomes are not compromised.

Role of 99m Tc-Mebrofenin Hepatobiliary Scintigraphy in the Diagnosis of Post Cholecystectomy Syndrome.

Background Huge variation in the prevalence of post cholecystectomy syndrome (PCS) is because PCS can include a wide variety of disorders that can be both related and unrelated to cholecystectomy. Hepatobiliary scintigraphy (HBS) is a noninvasive nuclear medicine scan that can evaluate a delay in the transit of bile from the hepatic hilum to the duodenum using a radiotracer 99m Tc-Mebrofenin that can be associated with a functional ampullary obstruction. The aim of this study was to assess the role of 99m Tc-Mebrofenin HBS in the detection of the cause of PCS among the patients undergoing cholecystectomy. Methods Twenty-one patients who presented with PCS from September 2018 to February 2020 were included in the study. These patients were characterized based on history, examination, liver function test, and abdominal ultrasound. Sphincter of Oddi dysfunction (SOD) was diagnosed using the Rome 3 criteria and the Milwaukee classification. Magnetic resonance cholangiopancreatography (MRCP) and upper gastrointestinal endoscopy and biopsy were done when indicated, to establish the diagnosis. These patients were further subjected to 99m Tc-Mebrofenin HBS, and the findings were analyzed. Results The most common symptom in PCS was biliary pain occurring in 85.7% of the patients. The average time of presentation since surgery was 1.9 years. The most common cause of PCS was SOD, occurring in 52.3% of the patients, followed by benign biliary stricture occurring in 23.8% of the patients. The mean bile duct (common bile duct) visualization time in patients with PCS was 25.2 minutes, the mean duodenal visualization time was 38.2 minutes, and the mean jejunal visualization time was 60.5 minutes. The mean bile duct to duodenum transit time was 12.7 minutes, while the mean bile duct to jejunum transit time was 30.1 minutes. HBS showed consistent findings with the final diagnosis made by other diagnostic modalities (clinical criteria/MRCP/intraoperative findings) in 80.9% of the patients. Conclusion 99m Tc-Mebrofenin HBS has a significant role in the evaluation of PCS.

Artificial intelligence: A new tool in surgeon's hand.

Artificial intelligence (AI) is the future of surgery. Technological advancements are taking place at an incredible pace, largely due to AI or AI-backed systems. It is likely that there will be a massive explosion or "Cambrian explosion" of AI in our everyday life, largely aided by increased funding and resources spent on research and development. AI has also significantly revolutionized the medical field. The concept of machine learning and deep learning in AI is the crux of its success. In surgical practice, AI has numerous applications in the diagnosis of disease, preoperative planning, intraoperative assistance, surgical training and assessment, and robotics. The potential automation of surgery is also a possibility in the next few decades. However, at present, augmentation rather than automation should be the priority. In spite of the allure of AI, it comes with its own price. A robot lacks the "sixth sense" or intuition that is crucial in the practice of surgery and medicine. Empathy and human touch are also inimitable characteristics that cannot be replaced by an AI system. Other limitations include the financial burden and the feasibility of using such technology on a wide scale. Ethical and legal dilemmas such as those involving privacy laws are other issues that should be taken under consideration. Despite all these limitations, with the way technology is progressing, it is inevitable that AI and automation will completely change the way we practice surgery in the near future. Thus, this narrative review article aims to highlight the various applications and pitfalls of AI in the field of surgery.

Expression and clinicopathological correlation of Ki-67 in gallbladder carcinoma.

INTRODUCTION: Gallbladder cancer is an aggressive cancer with short median survival from the time of diagnosis. Improved understanding of the pathological molecular mechanisms of gallbladder carcinogenesis is important to refine the diagnosis, prognosis, and also to develop novel targeted therapies for patients with advanced Gallbladder cancer (GBC) malignancy. Ki-67 is a marker of cell proliferation and its detection by immunohistochemistry is considered to be an effective method for the detection of prognosis in several tumors. In the present study, we have analyzed expression of immunohistochemical marker Ki-67 in gallbladder carcinoma and its correlation with clinicopathological and radiological parameters. MATERIALS AND METHODS: This prospective observational study was conducted from December 2017 to July 2020. The patients of newly diagnosed gallbladder cancer were enrolled as per the inclusion and exclusion criteria defined in the study protocol. Contrast-enhanced computer tomography of the chest and abdomen and serum tumor markers such as carbohydrate antigen (CA)-19.9, carcinoembryonic antigen, and CA 125 were done. Immunohistochemical expression of Ki-67 was evaluated on biopsy tissue from the gallbladder mass. RESULTS: Fifty newly diagnosed patients of carcinoma gallbladder were included in the present study. The correlation was studied between clinicodemographic parameters and Ki-67, but no association was found with age, gender, and symptoms. There was a weak positive correlation between Ki-67 and direct bilirubin, serum glutamic pyruvic transaminase, serum glutamic oxaloacetic transaminase, and alkaline phosphatase (P = 0.094; 0.126; 0.542; and 0.328, respectively). There was a weak positive correlation between body mass index (Kg/m2) and Ki-67, but this correlation was not statistically significant (P = 0.304). CONCLUSIONS: Ki-67 is a marker of proliferation and it correlated with histological differentiation, jaundice and liver function tests, presence of stones, and location of metastases but did not correlate with stage and extent of disease.

Demographic and clinicopathological Profile of Gall Bladder Cancer Patients: Study from a tertiary care center of the Sub-Himalayan region in Indo-Gangetic Belt.

INTRODUCTION: Gall bladder cancer (GBC) accounts for 80%-95% of biliary tract malignancies in the world. There is however striking variability in the global incidence of gallbladder cancer, reaching epidemic levels for some regions and ethnicities. The aim of this study was to evaluate the demographic and clinicopathological profile of the gallbladder cancer patients. MATERIALS AND METHODS: All patients of carcinoma gall bladder presenting to department of surgery in hepatopancreaticobiliary unit from July 2017 to November 2020 were included in this study. A proforma containing all the relevant details including history, examination, blood, radiology, and pathological investigations was filled. RESULTS: A total of 326 patients of GBC were analyzed. The majority (75%) were found to be females with a mean age of 55 years. Pain abdomen was the most common presenting symptom in 81% of patients. The most common stage of presentation was stage IV and only 6 were in stage I. Two hundred and thirty three (71.4%) patients had metastatic disease at presentation. Liver infiltration at the time of diagnosis was present in 89% of patients. The most common site of metastasis was found in the liver (23.3%). GBC was more common in patients with A blood group. Baseline serum albumin levels were found to be significantly associated with the staging of GBC. CONCLUSIONS: Due to the non specific symptoms patients of GBC present at very advanced stages, high index of suspicion and health education seems to play an important role in early detection and improvement of survival.

The Surgeon and the Smartphone - is the Association Really Smart?

The aim of this literature review is to encompass the importance of integrating smartphones in the life of a surgeon especially in the era of the COVID-19 pandemic. With the progression of technology, telesurgery, remote pre and postoperative care, smartphone-assisted intraoperative navigation and transcontinental education can be made a reality. Nonetheless, rates of nosocomial infections have been raised and the increased use of a smartphone can compound this issue. Similarly, there is a greater potential for operator distraction, medical equipment interference and increased radiation exposure for the user. All the above create a new set of problems for the surgeon. We hereby attempt a review of the advantages and harmful effects from the usage of smartphones.