The Reconstructive Metaverse - Collaboration in Real-Time Shared Mixed Reality Environments for Microsurgical Reconstruction.

Plastic surgeons routinely use 3D-models in their clinical practice, from 3D-photography and surface imaging to 3D-segmentations from radiological scans. However, these models continue to be viewed on flattened 2D screens that do not enable an intuitive understanding of 3D-relationships and cause challenges regarding collaboration with colleagues. The Metaverse has been proposed as a new age of applications building on modern Mixed Reality headset technology that allows remote collaboration on virtual 3D-models in a shared physical-virtual space in real-time. We demonstrate the first use of the Metaverse in the context of reconstructive surgery, focusing on preoperative planning discussions and trainee education. Using a HoloLens headset with the Microsoft Mesh application, we performed planning sessions for 4 DIEP-flaps in our reconstructive metaverse on virtual patient-models segmented from routine CT angiography. In these sessions, surgeons discuss perforator anatomy and perforator selection strategies whilst comprehensively assessing the respective models. We demonstrate the workflow for a one-on-one interaction between an attending surgeon and a trainee in a video featuring both viewpoints as seen through the headset. We believe the Metaverse will provide novel opportunities to use the 3D-models that are already created in everyday plastic surgery practice in a more collaborative, immersive, accessible, and educational manner.

HoloDIEP-Faster and More Accurate Intraoperative DIEA Perforator Mapping Using a Novel Mixed Reality Tool.

BACKGROUND: Microsurgical breast reconstruction using abdominal tissue is a complex procedure, in part, due to variable vascular/perforator anatomy. Preoperative computed tomography angiography (CTA) has mitigated this challenge to some degree; yet it continues to pose certain challenges. The ability to map perforators with Mixed Reality has been demonstrated in case studies, but its accuracy has not been studied intraoperatively. Here, we compare the accuracy of "HoloDIEP" in identifying perforator location (vs. Doppler ultrasound) by using holographic 3D models derived from preoperative CTA. METHODS: Using a custom application on HoloLens, the deep inferior epigastric artery vascular tree was traced in 15 patients who underwent microsurgical breast reconstruction. Perforator markings were compared against the 3D model in a coordinate system centered on the umbilicus. Holographic- and Doppler-identified markings were compared using a perspective-corrected photo technique against the 3D model along with measurement of duration of perforator mapping for each technique. RESULTS: Vascular points in HoloDIEP skin markings were -0.97 ± 6.2 mm (perforators: -0.62 ± 6.13 mm) away from 3D-model ground-truth in radial length from the umbilicus at a true distance of 10.81 ± 6.14 mm (perforators: 11.40 ± 6.15 mm). Absolute difference in radial distance was twice as high for Doppler markings compared with Holo-markings (9.71 ± 6.16 and 4.02 ± 3.20 mm, respectively). Only in half of all cases (7/14), more than 50% of the Doppler-identified points were reasonably close (<30 mm) to 3D-model ground-truth. HoloDIEP was twice as fast as Doppler ultrasound (76.9s vs. 150.4 s per abdomen). CONCLUSION: HoloDIEP allows for faster and more accurate intraoperative perforator mapping than Doppler ultrasound.

Semi-simultaneous hand-assisted laparoscopic (HAL) bilateral nephrectomy and kidney transplantation from the same incision in ADPKD, first case report in Saudi Arabia.

This case report discusses the management of a 46-year-old male patient with autosomal dominant polycystic kidney disease and a high body mass index, who underwent a semi-simultaneous procedure involving hand-assisted laparoscopic bilateral nephrectomy to alleviate severe abdominal symptoms and prepare for a kidney transplantation, all using the same incision. This is the first reported occurrence of such a procedure in Saudi Arabia. Post-operatively, the patient made a successful recovery with excellent kidney function and no complications.

Beyond the Signature: Informed Consent from a Legal Perspective and its Implications for Plastic Surgery.

SUMMARY: Informed consent is the principal tool that bridges the gap between clinical practice and our society's ethical ideals. The intricacies of informed consent, however, are frequently misunderstood and its effective implementation can be challenging in practice. The continuous stream of innovations, wide array of procedures, and other characteristics inherent to the practice of plastic surgery compound the challenges of implementing informed consent. Unfortunately, there remains a dearth of literature to provide a comprehensive overview of informed consent as it relates to plastic surgery. In this article, we highlight the history, legal components, and challenges of informed consent within plastic surgery and offer recommendations on how to approach them. A deeper understanding of informed consent helps enhance patient care, mitigates unnecessary malpractice risk, and leads to better physician-patient relationships.

An unusual hernia postkidney transplantation led to intermittent ureteric obstruction.

A 53-year-old man underwent a living donor kidney transplantation in the right iliac fossa 25 years prior to presentation. He had been noting an inguinal bugle that became more prominent as the day progressed, and it regressed at night. Upon further investigations, an ultrasound of the allograft revealed moderate-to-severe hydronephrosis. A computed tomography scan revealed herniation of the bladder and part of the transplanted ureter within the supravesical/direct inguinal space. Lichtenstein-like fashion of repair was performed, and the patient continues to enjoy satisfactory graft function with no recurrence. The case illustrates a rare hernia as a late complication of the kidney transplant incision leading to ureteric obstruction and a successful attempt at operative repair.

Enhancing Transplant Awareness and Acceptance Through Targeting Knowledge Gaps and Common Misconceptions.

Introduction Organ transplantation is a critical intervention for patients with end-stage organ failure, but misconceptions and knowledge gaps often hinder organ donation. This study evaluates the acceptability and effectiveness of an organ donation campaign focusing on addressing knowledge gaps and misconceptions in Riyadh, Saudi Arabia. Methods A two-day awareness campaign was conducted in a shopping mall, featuring four stations providing information on various aspects of organ donation. Participants completed a self-administered, researcher-developed, questionnaire before and after the tour. Results Of the 201 participants, 167 completed the questionnaire (83% response rate). The majority (92.9%) reported learning new information and indicated that the knowledge improved their perspective on organ donation. A high percentage (93.5%) felt the campaign answered their questions, with 90.9% deciding to register as organ donors. Conclusion A knowledge-enhancing campaign can effectively improve public perception and promote awareness of organ donation and transplantation. However, the study is limited by its short timeframe, location, and subjective data. Future research should explore the impact of such campaigns on donor registrations and evaluate their effectiveness in different cultural contexts.

Satisfaction and wellbeing of general surgery trainees in the Saudi Arabian residency educational environment: A mixed-methods study.

Background: Surgical residency training is prominently demanding and stressful. This can affect the residents' wellbeing, work-life balance and increase the rates of burnout. We aimed to assess rates of satisfaction and burn-out among GS residents in the national training programs and provide a subsequent in-depth analysis of the potential reasons. Method: A sequential explanatory mixed-methods study was conducted using an online survey and virtual interviews. The validated abbreviated Maslach Burnout Inventory (aMBI) was used to assess burnout while satisfaction was assessed via 5-points Likert scale. Results: After excluding incomplete responses from the total 74 received, 53 were analyzed. The average participant age was 27.4 ± 2 years, with females comprising 52 % of the sample. Junior residents made up 58.5 %, and nearly half -45 %- considered quitting GS training. Moderate to high burnout rates were noted on each aMBI subscale, ranging from 41.7 % to 62.5 %. The majority of residents expressed dissatisfaction with the level of research engagement (81.1 %), supervision, and mentorship. However, operative exposure was a source of satisfaction. Dissatisfaction rates with intra-operative learning, academia, teaching, and clinical exposure were 62.3 %, 52.8 %, 50.9 %, and 35.8 %, respectively. Interviews revealed surgical case flow and a friendly work environment as major satisfaction sources. Conversely, lack of academic supervision and suboptimal hands-on training were major dissatisfaction sources. Conclusion: Dissatisfaction and burn-out is prevalent among national GS training programs. Sub-optimal educational delivery and low-quality hands-on operative exposure -rather than lack of exposure to cases- seem to be the culprit.

Leveraging the Apple Ecosystem: Easy Viewing and Sharing of Three-dimensional Perforator Visualizations via iPad/iPhone-based Augmented Reality.

We introduce a novel technique using augmented reality (AR) on smartphones and tablets, making it possible for surgeons to review perforator anatomy in three dimensions on the go. Autologous breast reconstruction with abdominal flaps remains challenging due to the highly variable anatomy of the deep inferior epigastric artery. Computed tomography angiography has mitigated some but not all challenges. Previously, volume rendering and different headsets were used to enable better three-dimensional (3D) review for surgeons. However, surgeons have been dependent on others to provide 3D imaging data. Leveraging the ubiquity of Apple devices, our approach permits surgeons to review 3D models of deep inferior epigastric artery anatomy segmented from abdominal computed tomography angiography directly on their iPhone/iPad. Segmentation can be performed in common radiology software. The models are converted to the universal scene description zipped format, which allows immediate use on Apple devices without third-party software. They can be easily shared using secure, Health Insurance Portability and Accountability Act-compliant sharing services already provided by most hospitals. Surgeons can simply open the file on their mobile device to explore the images in 3D using "object mode" natively without additional applications or can switch to AR mode to pin the model in their real-world surroundings for intuitive exploration. We believe patient-specific 3D anatomy models are a powerful tool for intuitive understanding and communication of complex perforator anatomy and would be a valuable addition in routine clinical practice and education. Using this one-click solution on existing devices that is simple to implement, we hope to streamline the adoption of AR models by plastic surgeons.

Increasing DIEA Perforator Detail in 3D Photorealistic Volume Rendering Visualizations with Skin-masking and Cinematic Anatomy.

Preoperative CT angiography (CTA) is increasingly performed prior to perforator flap-based reconstruction. However, radiological 2D thin-slices do not allow for intuitive interpretation and translation to intraoperative findings. 3D volume rendering has been used to alleviate the need for mental 2D-to-3D abstraction. Even though volume rendering allows for a much easier understanding of anatomy, it currently has limited utility as the skin obstructs the view of critical structures. Using free, open-source software, we introduce a new skin-masking technique that allows surgeons to easily create a segmentation mask of the skin that can later be used to toggle the skin on and off. Additionally, the mask can be used in other rendering applications. We use Cinematic Anatomy for photorealistic volume rendering and interactive exploration of the CTA with and without skin. We present results from using this technique to investigate perforator anatomy in deep inferior epigastric perforator flaps and demonstrate that the skin-masking workflow is performed in less than 5 minutes. In Cinematic Anatomy, the view onto the abdominal wall and especially onto perforators becomes significantly sharper and more detailed when no longer obstructed by the skin. We perform a virtual, partial muscle dissection to show the intramuscular and submuscular course of the perforators. The skin-masking workflow allows surgeons to improve arterial and perforator detail in volume renderings easily and quickly by removing skin and could alternatively also be performed solely using open-source and free software. The workflow can be easily expanded to other perforator flaps without the need for modification.

Suture Packaging as a Marker for Intraoperative Image Alignment in Augmented Reality on Mobile Devices.

Preoperative vascular imaging has become standard practice in the planning of microsurgical breast reconstruction. Currently, translating perforator locations from radiological findings to a patient's abdomen is often not easy or intuitive. Techniques using three-dimensional printing or patient-specific guides have been introduced to superimpose anatomy onto the abdomen for reference. Augmented and mixed reality is currently actively investigated for perforator mapping by superimposing virtual models directly onto the patient. Most techniques have found only limited adoption due to complexity and price. Additionally, a critical step is aligning virtual models to patients. We propose repurposing suture packaging as an image tracking marker. Tracking markers allow quick and easy alignment of virtual models to the individual patient's anatomy. Current techniques are often complicated or expensive and limit intraoperative use of augmented reality models. Suture packs are sterile, readily available, and can be used to align abdominal models on the patients. Using an iPad, the augmented reality models automatically align in the correct position by using a suture pack as a tracking marker. Given the ubiquity of iPads, the combination of these devices with readily available suture packs will predictably lower the barrier to entry and utilization of this technology. Here, our workflow is presented along with its intraoperative utilization. Additionally, we investigated the accuracy of this technology.

Health risk behaviours of Palestinian youth: findings from a representative survey

Background: There is little systematic information about health risk behaviours among youth in Middle Eastern countries, leaving public health authorities unprepared to deal with emerging public health threats at a time of major social change. Aim: The Palestinian Youth Health Risk study investigates patterns of risk behaviours among Palestinian youth, their perceptions of the risks and benefits of such behaviours, and the relationship of exposure to violence with mental health and engagement in risk behaviours. Methods: We conducted a representative survey among 2500 individuals aged 15–24 years in the West Bank and East Jerusalem, permitting reliable comparison across sex and rural–urban divisions. A stratified 2-stage random sample was drawn from the 2007 population census, with strata formed by crossing the 12 governorates with urban, rural and refugee camp locations. Within strata, 208 survey clusters were sampled with probability proportional to size. Within each cluster, 14 households with youth of the appropriate age were sampled. Results: Among youth aged 20–24 years, 22.4% of males and 11.6% of females reported trying alcohol; 10.5% of males and 4.3% of females reported trying drugs. Almost one quarter of unmarried youth aged 20–24 years reported any sexual experience. Tobacco use is high, even among younger youth [45.4% of males and 21.2% of females aged 15–19 smoke]. Risk behaviours are higher among males, older youth and in urban areas and refugee camps. Conclusion: While smoking is of particular concern, prevention outreach for all behaviours should be directed at subgroups and areas identified as highest risk

Contexte : Il existe peu de données systématiques sur les comportements à risque pour la santé chez les jeunes au Moyen-Orient. Les autorités de santé publique ne sont donc pas préparées aux menaces de santé publique émergentes en période de changement social majeur. Objectif : L'Étude des risques sanitaires chez les jeunes palestiniens examine les schémas comportementaux à risque parmi les jeunes palestiniens, leurs perceptions des risques et des bénéfices tirés de tels comportements, la relation entre l'exposition à la violence et la santé mentale, et l'adoption de comportements à risque. Méthodes : Nous avons réalisé une enquête représentative auprès de 2500 individus âgés de 15 à 24 ans en Cisjordanie et à Jérusalem-Est, ce qui nous a permis de procéder à une comparaison fiable en fonction du sexe ainsi qu'entre zones rurale et zones urbaines. Un échantillon aléatoire stratifié à deux niveaux a été prélevé dans le recensement de population de 2007, avec des strates formées en sélectionnant les zones urbaines, rurales, et les camps de réfugiés au sein des 12 gouvernorats. Dans les strates, 208 foyers d'étude ont été échantillonnés, avec une probabilité proportionnelle à la taille. Au sein de chaque foyer, 14 ménages comptant des jeunes ayant l'âge approprié ont été échantillonnés. Résultats : Parmi les jeunes âgés de 20 à 24 ans, 22,4 % des garçons et 11,6 % des filles ont rapporté avoir déjà essayé l'alcool, et 10,5 % des garçons et 4,3 % des filles ont signalé avoir déjà essayé les drogues. Près d'un quart des jeunes célibataires âgés de 20 à 24 ans ont rapporté n'avoir eu aucune expérience sexuelle. Le tabagisme est très élevé, même chez les plus jeunes [45,4 % des garçons et 21,2 % des jeunes filles âgés de 15 à 19 ans fument]. Les comportements à risque sont plus élevés parmi les garçons, chez les jeunes plus âgés, dans les zones urbaines et dans les camps de réfugiés. Conclusion : Si le tabagisme est particulièrement préoccupant, des activités de prévention pour l'ensemble des comportements devraient être menées dans les sous-groupes et les zones identifiés à haut risque

الخلفية: لا تتوفر سوى معلومات منهجية ضئيلة عن كثير من السلوكيات التي تنطوي على مخاطر صحية بين شباب الشرق الأوسط. الهدف: توفير هذه الدراسة تقديرات لمستويات وأنماط السلوكيات الخطرة بين الشباب الفلسطينيين استناداّ إلى مسح ذو طابع تمثيلي واسع النطاق. طرق البحث: استُهدفت عينة من 2500 فرداً في الفئة العمرية 15-24 عاماً في الضفة الغربية والقدس الشرقية لإجراء مسح ذي طابع تمثيلي.النتائج: أفاد 22.4 % من الشبان الذكور في الفئة العمرية20-24 عاما و 11.6% من الشابات بتجربة المشروبات الكحولية - 8.1% و 3.6% - بالنسبة للشبان و الشابات فى الفئة العمرية 15-19 عاماوافاد 10.5% من الشبان فى الفئة العمرية 20-24 عاما 4.3% من الشابات بتجربة المخدرات 3.8% و 1.6% بالنسبة للشبان و الشابات فى الفئة 15-19 عاما كما افاد 9.3% من الشبان غير المتزوجين و 6.7% من الشابات غير المتزوجات فى الفئة العمرية 20-24 عاما بممارسة الجنس و لئن افاد نحو ربع هذه النسبة من كلا الجنسين بعدم وجود خبرة جنسية لديهموتبين ارتفاع مستوى تعاطي التبغ بصورة بالغة، حتى بين الشباب الأصغر سناً ) 45.5 % من الذكور و 21.2 % من الإناث في الفئة العمرية19-15 عاماً هم من المدخنين(، كما تبيّ انتشار العنف المتبادل بين الأفراد )الشجار( بصورة كبيرة. وتبيّ ارتفاع مستوى السلوكيات الخطرة فيما بينالشبان والشباب الأكبر سناً وفي المناطق الحضرية )لا سيَّما القدس( وفي مخيمات اللاجئين مقارنة بالمناطق الريفية. كما تبدو مستويات انخراط الشبابالفلسطينيين من المناطق الأخرى في تعاطي الكحوليات والمخدرات وممارسة الأنشطة الجنسية، بما في ذلك الجماع، أقل من غيرهم في جميع النتائج،ولكن ينقلب الوضع فيما يتعلق بالتدخين والعنف المتبادل بين الأفراد.الاستنتاجات: يمثل التدخين شاغلاً مهماً، إلا أنه ينبغي توجيه أنشطة التوعية على الوقاية من جميع السلوكيات الخطرة إلى المجموعات الفرعيةوالمناطق التي يتم تحديدها باعتبارها عالية المخاطر