Cognitive ergonomics and robotic surgery.

Cognitive ergonomics refer to mental resources and is associated with memory, sensory motor response, and perception. Cognitive workload (CWL) involves use of working memory (mental strain and effort) to complete a task. The three types of cognitive loads have been divided into intrinsic (dependent on complexity and expertise), extraneous (the presentation of tasks) and germane (the learning process) components. The effect of robotic surgery on CWL is complex because the postural, visualisation, and manipulation ergonomic benefits for the surgeon may be offset by the disadvantages associated with team separation and reduced situation awareness. Physical fatigue and workflow disruptions have a negative impact on CWL. Intraoperative CWL can be measured subjectively post hoc with the use of self-reported instruments or objectively with real-time physiological response metrics. Cognitive training can play a crucial role in the process of skill acquisition during the three stages of motor learning: from cognitive to integrative and then to autonomous. Mentorship, technical practice and watching videos are the most common traditional cognitive training methods in surgery. Cognitive training can also occur with computer-based cognitive simulation, mental rehearsal, and cognitive task analysis. Assessment of cognitive skills may offer a more effective way to differentiate robotic expertise level than automated performance (tool-based) metrics.

Ergonomic hand positioning overcomes visual perception mismatch in nonsimulated robotic colorectal surgery.

The aim of the study was to compare the internal instrument and external surgeon hand positions to determine whether visual perception mismatch (VPM) is a factor during robotic colorectal surgery. Continuous video footage of 24 consecutive robotic colorectal surgery cases were analysed concurrently with sagittal video recordings of surgeon hand positions. Separated sagittal hand positions would indicate nonergonomic positioning without clutching of the robotic controls, either matching the on-screen up/down instrument tip positions (no VPM) or in the opposite direction (true VPM). Variables (30-min surgery time blocks, anatomic target, and task performed), which resulted in hand separation or VPM, were analysed. Operating with the presence of VPM for more than one duration occurred 51 times and nonergonomic sagittal hand positioning occurred 22 times. For an experienced robotic surgeon, ergonomic positioning of the hands is favoured over adjustment for VPM despite the potential higher mental workload.

Factors affecting upper limb ergonomics in robotic colorectal surgery.

The aim of the study was to examine the factors which may influence suboptimal ergonomic surgeon hand positioning during robotic colorectal surgery (RCS). An observational study of 11 consecutive RCS cases from June 2022 to August 2022 was performed. Continuous video footage of RCS cases was analysed concurrently with video recordings of surgeon's hand positions at the console. The outcome studied was the frequency with which either hand remained in a suboptimal ergonomic position outside the predetermined double box outlines, as marked on the surgeon's video, for >1 min. Situations which resulted in poor upper limb ergonomics were dissection in the peripheral operating field location, left-hand use, use of the stapler, dissection of the main mesenteric blood vessels, and multi-quadrant surgery. Being aware of situations when suboptimal ergonomic positions occur can allow surgeons to consciously compensate by using the clutch or pausing to take a rest break. What does this paper add to the literature?: The study is important because it is the first to look at factors which may influence poor upper limb ergonomics during non-simulated RCS. By recognizing these factors and compensating for them, it may improve surgeon ergonomics with resultant better performance.

Automated performance metrics, learning curve and robotic colorectal surgery.

BACKGROUND: The aim of this study was to evaluate the usefulness of Automated Performance Metrics (APMs) in assessing the learning curve. METHODS: A retrospective review of 85 consecutive patients who underwent total robotic colorectal surgery at a single institution between August 2020 and October 2022 was performed. Patient demographics, operation type, and APMs were collected and analysed. Cumulative summation technique (CUSUM) was used to construct learning curves of surgeon console time (SCT), use of the fourth arm, clutch activation, instrument off screen (number and duration), and cut electrocautery activation. RESULTS: Two phases with 50 and 35 cases were identified from the CUSUM graph for SCT. The SCT was significantly different between the two phases (176 and 251 min, p < 0.002). After adjustment for SCT, the APMs were not significantly different between the two phases. CONCLUSIONS: Most APMs do not offer additional learning curve information when compared with SCT analysis alone.

Workflow disruptions in robot-assisted surgery.

Surgical flow disruptions are unexpected deviations from the natural progression which can potentially compromise the safety of the operation. Separation of the surgeon from the patient and team members is the main contributor for flow disruptions (FDs) in robot-assisted surgery (RAS). FDs have been categorised as communication, coordination, surgeon task considerations, training, equipment/ technology, external factors, instrument changes, and environmental factors. There may be an association between FDs and task error rate. Intervention to counter FDs include training, operating room adjustments, checklists, teamwork, communication improvement, ergonomics, technology, guidelines, workflow optimisation, and team briefing. Future studies should focus on identifying the significant disruptive FDs and the impact of interventions on surgical flow during RAS.

Visualisation ergonomics and robotic surgery.

Stereopsis may be an advantage of robotic surgery. Perceived robotic ergonomic advantages in visualisation include better exposure, three-dimensional vision, surgeon camera control, and line of sight screen location. Other ergonomic factors relating to visualisation include stereo-acuity, vergence-accommodation mismatch, visual-perception mismatch, visual-vestibular mismatch, visuospatial ability, visual fatigue, and visual feedback to compensate for lack of haptic feedback. Visual fatigue symptoms may be related to dry eye or accommodative/binocular vision stress. Digital eye strain can be measured by questionnaires and objective tests. Management options include treatment of dry eye, correction of refractive error, and management of accommodation and vergence anomalies. Experienced robotic surgeons can use visual cues like tissue deformation and surgical tool information as surrogates for haptic feedback.

The impact of additional pathology analysis on the diagnosis and management of soft tissue tumours: a 10-year retrospective study.

In order to characterise soft tissue tumours, pathologists often utilise specialised additional tests, or may seek opinions from subspecialist pathologists due to rarity or complex morphology. Additionally, further review may be sought by subspecialist sarcoma pathologists, such as those at our tertiary referral centre in Sydney, Australia. The aim of this study was to examine the impact on diagnosis and management of this external review, following diagnosis at a specialised sarcoma unit. We collated the results of all additional external ancillary tests and specialist reviews over a 10-year period and characterised the impact on the preliminary diagnosis as 'confirmed', 'new' or 'no clear diagnosis'. We subsequently noted whether the additional findings resulted in a clinically significant change in management. Of the 136 cases sent away, 103 patients had their initial diagnosis confirmed, 29 patients received a new diagnosis and, for four patients, the diagnosis remained uncertain. Nine of the 29 patients receiving a new diagnosis had their management altered. This study demonstrated that within our specialised sarcoma unit, the majority of diagnoses provided by our specialist pathologists are confirmed on additional external testing and review, but external review does provide additional assurance and benefit to the patient.

Improving ergonomics for the bedside assistant in robotic colorectal surgery.

The aim of the study was to document when significant bedside assistant (BA) and robotic arm collisions occurred during robotic colorectal surgery (RCS). An observational study of 10 consecutive RCS cases, from May 2022 to September 2022, was performed. Situations when there was significant collision between BA arm and robotic arm (to cause inadvertent movement of the assistant instrument) were documented. The assistant port was randomly placed to the right or the left side of the camera port. Situations which led to detrimental BA ergonomics include dissection at the most peripheral working field, proximity of the target (mesenteric vessels), small bowel retraction, placement of the assistant port in the medial position (on the left side of the camera port), during intra-corporeal suturing and robotic stapler use. The robotic console surgeon can predictably identify and avoid situations when injury to the BA may occur.

Mesenchymal chondrosarcoma: An Australian multi-centre cohort study.

BACKGROUND: Mesenchymal chondrosarcoma (MCS) is an ultra-rare sarcoma that follows a more aggressive course than conventional chondrosarcoma. This study evaluates prognostic factors, treatments (surgery, chemotherapy, and radiation), and outcomes in an Australian setting. METHODS: We collected demographics, clinicopathological variables, treatment characteristics, and survival status from patients with MCS registered on the national ACCORD sarcoma database. Outcomes include overall survival (OS) and progression-free survival (PFS). RESULTS: We identified 22 patients with MCS between 2001-2022. Median age was 28 (range 10-59) years, 19 (86%) had localised disease at diagnosis of whom 16 had surgery (84%), 11 received radiation (58%), and 10 chemotherapy (53%). Ten (52%) developed recurrence and/or metastases on follow-up and three patients with initial metastatic disease received surgery, radiation, and chemotherapy. At a median follow-up of 50.9  (range 0.4-210) months nine patients had died. The median OS was 104.1 months (95% CI 25.8-182.3). There was improved OS for patients with localised disease who had surgical resection of the primary (p = 0.003) and those with ECOG 0-1 compared to 2-3 (p = 0.023) on univariate analysis. CONCLUSIONS: This study demonstrates contemporary Australian treatment patterns of MCS. The role of chemotherapy for localised disease remains uncertain. Understanding treatment patterns and outcomes help support treatment decisions and design of trials for novel therapeutic strategies.

CCNE1 and survival of patients with tubo-ovarian high-grade serous carcinoma: An Ovarian Tumor Tissue Analysis consortium study.

BACKGROUND: Cyclin E1 (CCNE1) is a potential predictive marker and therapeutic target in tubo-ovarian high-grade serous carcinoma (HGSC). Smaller studies have revealed unfavorable associations for CCNE1 amplification and CCNE1 overexpression with survival, but to date no large-scale, histotype-specific validation has been performed. The hypothesis was that high-level amplification of CCNE1 and CCNE1 overexpression, as well as a combination of the two, are linked to shorter overall survival in HGSC. METHODS: Within the Ovarian Tumor Tissue Analysis consortium, amplification status and protein level in 3029 HGSC cases and mRNA expression in 2419 samples were investigated. RESULTS: High-level amplification (>8 copies by chromogenic in situ hybridization) was found in 8.6% of HGSC and overexpression (>60% with at least 5% demonstrating strong intensity by immunohistochemistry) was found in 22.4%. CCNE1 high-level amplification and overexpression both were linked to shorter overall survival in multivariate survival analysis adjusted for age and stage, with hazard stratification by study (hazard ratio [HR], 1.26; 95% CI, 1.08-1.47, p = .034, and HR, 1.18; 95% CI, 1.05-1.32, p = .015, respectively). This was also true for cases with combined high-level amplification/overexpression (HR, 1.26; 95% CI, 1.09-1.47, p = .033). CCNE1 mRNA expression was not associated with overall survival (HR, 1.00 per 1-SD increase; 95% CI, 0.94-1.06; p = .58). CCNE1 high-level amplification is mutually exclusive with the presence of germline BRCA1/2 pathogenic variants and shows an inverse association to RB1 loss. CONCLUSION: This study provides large-scale validation that CCNE1 high-level amplification is associated with shorter survival, supporting its utility as a prognostic biomarker in HGSC.

Factors affecting the learning curve in robotic colorectal surgery.

Learning related to robotic colorectal surgery can be measured by surgical process (such as time or adequacy of resection) or patient outcome (such as morbidity or quality of life). Time based metrics are the most commonly used variables to assess the learning curve because of ease of analysis. With analysis of the learning curve, there are factors which need to be considered because they may have a direct impact on operative times or may be surrogate markers of clinical effectiveness (unrelated to times). Variables which may impact on operation time include surgery case mix, hybrid technique, laparoscopic and open colorectal surgery experience, robotic surgical simulator training, technology, operating room team, and case complexity. Multidimensional analysis can address multiple indicators of surgical performance and include variables such as conversion rate, complications, oncological outcome and functional outcome. Analysis of patient outcome and/or global assessment of robotic skills may be the most reliable methods to assess the learning curve.

The learning curve to attain surgical competency in robotic colorectal surgery.

INTRODUCTION: The aim of the study was to assess the robotic colorectal surgery (RCS) learning curve of an experienced surgeon. METHODS: A retrospective review of 117 consecutive patients who underwent total RCS at a single institution between October 2018 and July 2021 was performed. Patient demographics, surgery indications, operation type, intraoperative data, histopathology, morbidity and mortality, and length of stay were analysed. Cumulative summation technique (CUSUM) was used to construct a learning curve of surgeon console and total operation times (SCT and TOT). RESULTS: There was no open conversion, positive resection margin and mortality in the study population. There were four Clavien-DIndo grade III complications and one local recurrence. The range for SCT was 18-855 min (mean 214, median 211) and TOT was 68-937 min (mean 302, median 291). The SCT CUSUM graph identified change in slope at cases 44 and 88, which divided the learning curve into three distinct phases. Patient demographics were similar through the three phases. There was proportionally more cancer cases performed in the first phase (P = 0.001). The mean SCT was significantly higher in Phase 2 when compared with Phases 1 and 3 (P = 0.03). The failure rate was similar through the three phases. There was a non-significant steady decline in LOS over the three phases, from 6.9 to 6.1 days. CONCLUSION: Experienced colorectal surgeons can perform robotic surgery safely, even on patients with high complexity early in the learning curve. Audit of patient outcome should be an important component of learning curve assessment.

Managing patients with advanced soft tissue sarcoma: Evolving landscape from an Australian perspective.

AIM: Despite lack of advances in the first-line systemic therapy, the overall survival (OS) has continued to improve in patients with advanced soft tissue sarcoma (STS) with the recent estimation of median OS at 20 months. Several systemic therapy options are available now for the second-line and beyond, with more treatment tailored to histology and molecular subtype. The aim of this retrospective study was to characterize current patterns of care in managing patients with advanced STS (aSTS) in Australia. METHODS: Sarcoma databases from 7 Australian sarcoma services were accessed to identify patients diagnosed with locally advanced inoperable and/or metastatic STS between January 1, 2010 and December 31, 2015. Baseline clinicopathological factors and initial treatment patterns were descriptively analyzed. For the Victorian cohort where treatment of aSTS and follow-up details were available, further exploratory analysis was conducted to determine the impact of patient and tumor characteristics and the use of palliative-intent treatment OS. RESULTS: Of 2261 cases of STS, 671 were deemed as aSTS. Two thirds were relapsed disease with a mean 1.9 years from initial diagnosis. Median age at diagnosis of aSTS was 59 years (18-95 years) and 56.3% was male. Histology classification revealed four main subtypes: undifferentiated pleomorphic sarcoma (UPS) (23.1%), leiomyosarcoma (18.2%), liposarcoma (12.8%), synovial sarcoma (8.2%), and other comprising 14 STS subtypes. For the Victorian cohort (N = 361), approximately 80% of patients accessed palliative-intent treatment of various modalities. Nearly 40% of patients underwent tumor-debulking surgery or metastasectomy, of which lung wedge resection was the most common (N = 83, 47.7%). A total of 438 palliative-intent radiotherapy treatments were delivered to 259 patients (71.7%), with the majority in the form of external beam radiotherapy. Palliative-intent systemic therapy was delivered to 51.5% of patients (N = 186), mostly (73%). Anthracycline-based therapy was the most commonly delivered therapy (N = 135, 72.6%). Approximately half of the patients in each line of therapy failed to proceed to the subsequent line of systemic therapy with 29.4% receiving three or more lines of therapy (N = 55). A total of 18.3% of patient (N = 34) participated in clinical trials or accessed off-label drugs. The median OS for the Victoria cohort was 15.4 months (95% confidence interval: 12.1, 18.2). The UPS histology subtype was associated with poorer OS, whereas receiving any modality of palliative-intent treatment conferred survival benefit. CONCLUSION: In Australia, aSTS is managed with diverse treatment approaches comprising various therapy modalities. Further work is planned in describing healthcare resource utilization and estimating costs by this patient cohort.

Robotic colorectal surgery and ergonomics.

Improved ergonomics for the operating surgeon may be an advantage of robotic colorectal surgery. Perceived robotic ergonomic advantages in visualisation include better exposure, three-dimensional vision, surgeon camera control, and line of sight screen location. Postural advantages include seated position and freedom from the constraints of the sterile operating field. Manipulation benefits include articulated instruments with seven degrees of freedom movement, elimination of fulcrum effect, tremor filtration, and scaling of movement. Potential ergonomic detriments of robotic surgery include lack of haptic feedback, visual, and mental strain from increased operating time and interruptions to workflow from crowding.

Ergonomic port placement in robotic colorectal surgery.

AIM: The aim of the study was to determine how spacing between ports and alignment of ports (oblique or vertical) influences manipulation angles in robotic colorectal surgery. METHOD: Abdominal CT scans of 10 consecutive robotic right hemicolectomy and 10 consecutive robotic high anterior resection patients were analysed. The manipulation angles were calculated using fixed points on the preoperative abdominal coronal CT scan. Port placements were marked on the CT scan. The fixed points used to measure the manipulation angles were from the most lateral part of the caecum, hepatic flexure, splenic flexure, the descending colon/sigmoid colon junction and the sigmoid colon/rectum junction. RESULTS: For right hemicolectomy and high anterior resection surgery, a port spacing of 8 cm compared with 6 cm resulted in greater manipulation angles. With 6-cm port spacing, wider manipulation angles were not achieved with vertical port alignment compared with oblique alignment except for dissection at the splenic flexure. CONCLUSIONS: The greatest manipulation angles were achieved with the oblique 8-cm port spacing, which should be used in most cases.

Efficacy of MEK inhibition in a recurrent malignant peripheral nerve sheath tumor.

The prognosis of recurrent malignant peripheral nerve sheath tumors (MPNST) is dismal, with surgical resection being the only definitive salvage therapy. Treatment with chemoradiation approaches has not significantly improved patient outcomes. Similarly, trials of therapies targeting MPNST genomic drivers have thus far been unsuccessful. Improved understanding of the molecular pathogenesis of MPNST indicates frequent activation of the mitogen-activated protein kinase (MAPK) cell signaling pathway. MEK inhibitors have shown activity in preclinical studies; however, their clinical efficacy has not been reported to date. We describe here a case of sustained complete response to MEK inhibition in an adolescent patient with a recurrent metastatic MPNST with multiple alterations in the MAPK pathway, guided by a precision oncology approach.

A Cross-Sectional Study of Sub-Basal Corneal Nerve Reduction Following Neurotoxic Chemotherapy.

Purpose: Sub-basal corneal nerves have been shown to change during neurotoxic chemotherapy treatment. This cross-sectional study investigated corneal nerve morphology in patients who have completed neurotoxic chemotherapy well after treatment cessation and its association with peripheral nerve function. Methods: Central corneal nerve fiber length (CNFL) and inferior whorl length (IWL), average nerve fiber length (ANFL), corneal nerve fiber density (CNFD) and corneal nerve branch density (CNBD), and nerve fiber area (CNFA) were examined using in vivo corneal confocal microscopy in patients with cancer who had completed treatment with either paclitaxel or oxaliplatin between 3 and 24 months prior to assessment in comparison with 2 separate groups of healthy controls. Neurological assessments were conducted including clinician- and patient-reported outcomes, and neurological grading scales. Results: Both paclitaxel- (n = 40) and oxaliplatin-treated (n = 30) groups had reduced IWL and ANFL compared to the respective healthy control groups (n = 15 in each group) (paclitaxel: IWL = P = 0.02, ANFL = P = 0.009; and oxaliplatin: IWL = P = 0.008, ANFL P = 0.02). CNFL and CNFD reduction were observed only in the paclitaxel-treated group compared with healthy controls (P = 0.008 and P = 0.02, respectively), whereas CNFA was reduced in the oxaliplatin-treated group (P = 0.04). IWL reduction correlated with worse fine hand dexterity in chemotherapy-treated patients (r = -0.33, P = 0.007). Conclusions: There is evidence of corneal nerve loss in patients with cancer who have been treated with paclitaxel and oxaliplatin well after treatment cessation associated with worse upper limb function. Translational Relevance: Sub-basal corneal nerve reduction is evident even after cessation of neurotoxic treatment. In vivo corneal confocal microscopy may be useful in the monitoring of nerve function in patients receiving chemotherapy.

Outcomes of patients with metastatic cutaneous squamous cell carcinoma to the axilla: a multicentre cohort study.

BACKGROUND: Metastatic cutaneous squamous cell carcinoma to the axilla is uncommon, with limited data to guide management. We sought to assess the outcomes of patients with this condition after surgery and radiotherapy. METHODS: A retrospective cohort study of patients treated at two Australian hospitals from 1994 through 2016 was performed. RESULTS: A total of 74 patients were identified, including 48 treated curatively with surgery-plus-radiotherapy and 15 with surgery alone. Compared with patients treated with surgery alone, a higher proportion of patients treated with surgery-plus-radiotherapy had lymph nodes larger than 6 cm (53% versus 8%, P = 0.012) and multiple adverse histopathological features (75% versus 47%, P = 0.04). The groups had similar 5-year disease-free survival (45% versus 46%) and overall survival (51% versus 48%). Presence of multiple positive lymph nodes was associated with reduced disease-free survival (hazard ratio 4.57, P = 0.01) and overall survival (hazard ratio 3.53, P = 0.02). Regional recurrence was higher in patients treated with surgery alone (38% versus 22%, P = 0.22) and patients with lymph nodes larger than 6 cm (34% versus 10%, P = 0.03). All recurrences occurred within 2 years following treatment. CONCLUSION: Combined-modality therapy for metastatic cutaneous squamous cell carcinoma to the axilla is recommended for high-risk patients, although outcomes remain modest. The key period for recurrence is within 2 years following treatment.

Moving with the Times: The Health Science Alliance (HSA) Biobank, Pathway to Sustainability.

Human biobanks are recognised as vital components of translational research infrastructure. With the growth in personalised and precision medicine, and the associated expansion of biomarkers and novel therapeutics under development, it is critical that researchers can access a strong collection of patient biospecimens, annotated with clinical data. Biobanks globally are undertaking transformation of their operating models in response to changing research needs; transition from a 'classic' model representing a largely retrospective collection of pre-defined specimens to a more targeted, prospective collection model, although there remains a research need for both models to co-exist. Here we introduce the Health Science Alliance (HSA) Biobank, established in 2012 as a classic biobank, now transitioning to a hybrid operational model. Some of the past and current challenges encountered are discussed including clinical annotation, specimen utilisation and biobank sustainability, along with the measures the HSA Biobank is taking to address these challenges. We describe new directions being explored, going beyond traditional specimen collection into areas involving bioimages, microbiota and live cell culture. The HSA Biobank is working in collaboration with clinicians, pathologists and researchers, piloting a sustainable, robust platform with the potential to integrate future needs.