Virtual Reality for Preoperative Planning in Complex Surgical Oncology: A Single-Center Experience.

INTRODUCTION: Virtual reality models (VRM) are three-dimensional (3D) simulations of two-dimensional (2D) images, creating a more accurate mental representation of patient-specific anatomy. METHODS: Patients were retrospectively identified who underwent complex oncologic resections whose operations differed from preoperative plans between April 2018 and April 2019. Virtual reality modeling was performed based on preoperative 2D images to assess feasibility of use of this technology to create models. Preoperative plans made based upon 2D imaging versus VRM were compared to the final operations performed. Once the use of VRM to create preoperative plans was deemed feasible, individuals undergoing complex oncologic resections whose operative plans were difficult to define preoperatively were enrolled prospectively from July 2019 to December 2021. Preoperative plans made based upon 2D imaging and VRM by both the operating surgeon and a consulting surgeon were compared to the operation performed. Confidence in each operative plan was also measured. RESULTS: Twenty patients were identified, seven retrospective and 13 prospective, with tumors of the liver, pancreas, retroperitoneum, stomach, and soft tissue. Retrospectively, VRM were unable to be created in one patient due to a poor quality 2D image; the remainder (86%) were successfully able to be created and examined. Virtual reality modeling more clearly defined the extent of resection in 50% of successful cases. Prospectively, all VRM were successfully performed. The concordance of the operative plan with VRM was higher than with 2D imaging (92% versus 54% for the operating surgeon and 69% versus 23% for the consulting surgeon). Confidence in the operative plan after VRM compared to 2D imaging also increased for both surgeons (by 15% and 8% for the operating and consulting surgeons, respectively). CONCLUSIONS: Virtual reality modeling is feasible and may improve preoperative planning compared to 2D imaging. Further investigation is warranted.

Evaluating team decision-making as an emergent phenomenon.

BACKGROUND: The complexity of modern clinical practice has highlighted the fallibility of individual clinicians' decision-making, with effective teamwork emerging as a key to patient safety. Dual process theory is widely accepted as a framework for individual decision-making, with type 1 processes responsible for fast, intuitive and automatic decisions and type 2 processes for slow, analytical decisions. However, dual process theory does not explain cognition at the group level, when individuals act in teams. Team cognition resulting from dynamic interaction of individuals is said to be more resilient to decision-making error and greater than simply aggregated cognition. METHODS: Clinicians were paired as teams and asked to solve a cognitive puzzle constructed as a drug calculation. The frequency at which the teams made incorrect decisions was compared with that of individual clinicians answering the same question. RESULTS: When clinicians acted in pairs, 63% answered the cognitive puzzle correctly, compared with 33% of clinicians as individuals, showing a statistically significant difference in performance (χ2 (1, n=116)=24.329, P<0.001). Based on the predicted performance of teams made up of the random pairing of individuals who had the same propensity to answer as previously, there was no statistical difference in the actual and predicted teams' performance. CONCLUSIONS: Teams are less prone to making errors of decision-making than individuals. However, the improved performance is likely to be owing to the effect of aggregated cognition rather than any improved decision-making as a result of the interaction. There is no evidence of team cognition as an emergent and distinct entity.

Ergonomic assessment of robotic general surgeons: a pilot study.

Inadequacies exist in the ergonomics of upper body positioning of robotic surgeons; these deficits in biomechanical efficacy predispose surgeons to musculoskeletal injury. Ergonomics and biomechanics may be objectively measured using the Rapid Entire Body Assessment (REBA) and the Rapid Upper Limb Assessment (RULA) to quantify ergonomic efficacy. The purpose of this study is to use validated ergonomic tools to assess the posture of robotic surgeons to examine deficiencies. Four robotic surgeons using the da Vinci model were observed for a minimum of 30 min each. An Xbox connect camera was positioned 10 feet away from the surgeon console. Kinetisense software measured position of the head, shoulders, mid-spine, hips, and knees. One image was captured every 30 s. The software measured the positions in centimeters that deviated from an ideal central postural line (plumb line). RULA and REBA were also employed to assess posture using a still image at 15 min. The average RULA score for the four surgeons was 4.75 (range 3-6). The average REBA score for the four surgeons was 7 (range 5-8). The average RULA score of 4.5/7 and the average REBA of 7/15 qualify as medium risk with the recommendation that action is needed to improve ergonomics. While this pilot study is limited in size, it demonstrates the need for further investigation. With more than half of surgeons reporting musculoskeletal pain after robotic surgery (McDonald et al. in Gynecol Oncol 134:243-247, 2014), poor posture may offer an explanation.

A Standardized Robotic Training Curriculum in a General Surgery Program.

BACKGROUND AND OBJECTIVES: The general surgery residency at the University of Illinois College of Medicine at Peoria has a long tradition of integrating robotic surgery into training since 2002. The purpose of this paper is to investigate our curriculum and evaluation system, which was designed to achieve a standardized format for education in general robotic surgery. METHODS: The curriculum consists of two phases: phase 1 (PGY 1-2): Complete 4 robotic surgery training modules; read two assigned robotic surgery articles; and practice simulation modules on the robot. phase 2 (PGY 3-5): Refresh training modules, score >90% on the simulator modules every 6 months; bedside assist minimum of 4 robotic procedures; and act as console surgeon for a minimum of 10 procedures with 2 separate attending surgeons. The required simulator modules were specially selected to incorporate all of the skills categories documented in the simulator. The faculty evaluate the resident's operative performance using the Global Evaluative Assessment of Robotic Skills validated rubric. RESULTS: Since the curriculum was instituted in June 2017, 73 evaluations from 8 surgeons have been collected. We examined data from 6 residents who had at least 5 Global Evaluative Assessment of Robotic Skills assessments completed. Correlation coefficient scores showed a positive correlation ranging from 0.476 to 0.862 for average skills and 0.334 to 0.866 for overall performance scores. DISCUSSION: The preliminary results suggest an improvement of resident robotic surgical skills through tailored education. This curriculum is designed to enhance robotic general surgery education that could potentially produce general surgeons able to operate robotically without needing a robotic/MIS (Minimally Invasive Surgery) fellowship.

Evolution and literature review of robotic general surgery resident training 2002-2018.

The University of Illinois purchased their first da Vinci System in September of 2002. Within the first calendar year, their program began orienting trainees to the da Vinci Standard System to make its inclusion in their clinical training run more smoothly. During the ensuring 16 years, their program has evolved into more frequent resident orientations, lectures, and courses. The program has grown over the course of different versions of the da Vinci System. Currently, their program houses three Xi and two Si systems. Led by Dr. Crawford and Mr. Dwyer they have formalized their curriculum using a systematic progression of skill acquisition. The lecture will detail the program's organic development over the last 16 years. It will also explain the scientific measurement tools recently applied to the curriculum.

Review and update: robotic transanal surgery (RTAS).

As the field of surgery advances, new approaches have allowed surgeons additional flexibility to perform further interventions with minimal or no external incisions. For many years, single site access (SSA) has been used for transanal procedures, and platforms allowing modified endoscopic approaches have been available. These platforms have limitations related to access, visualization, dexterity, camera control, and instrumentation. Recently, surgical robotics companies have developed and introduced new technologies and platforms, which may help address some of these limitations. Comprehensive internet, open access, and medical and industry conference reviews of robotic surgery platforms and technology available for use in SSA surgery were conducted and 30 articles were found using keywords "robotic surgery, transanal, single site, robotic transanal surgery". A PubMed, Medline, Journals @OVID and open access search for data related to these platforms and technologies was also performed yielding 11 articles. Abstracts were reviewed for those written in the English language, leaving 40 articles which were then filtered for those pertaining to robotic surgery, transanal. 58 abstracts were found, duplicates were eliminated, and the remaining 35 articles were read in their entirety by two reviewers. Several new and existing platforms are identified for use in SSA surgery for transanal surgery as well as abdominal and transoral surgery. These are reviewed, including brand, features, approved and suggested uses, and potential limitations. New robotic technologies serve to enhance the ability of surgeons to perform SSA surgery. This next generation of robotic surgery technology overcomes some of the limitations of preceding endoscopic SSA surgery technology and will enhance the advancement of robotic transanal surgery, but outcomes and performance data are still limited.

Telemedicine and telerobotics: from science fiction to reality.

Advances in communication technologies have paved the way for telemedicine to transform the delivery of medical care throughout the world. Coinciding developments in minimally invasive surgery and in particular teleoperated robotic surgical systems will allow the surgeon to deliver expert care in remote locations. This study presents a systematic review of telemedicine, focusing on telerobotic surgical systems. A brief historical review of telemedicine and telerobotics is provided, including a description of the various subtypes of telemedicine. Currently available systems and recent experimental utilization, including long-distance remote telesurgery, are discussed. Experimental telerobotic surgical systems and future developments in the field are reviewed and the potential applications are considered. Future challenges to the implementation and opinions on the future direction of telerobotics are provided in this review.

Histologic characterization of acute spinal cord injury treated with intravenous methylprednisolone.

OBJECTIVE: Many substances have been investigated for attenuation of spinal cord injury after acute trauma; however, pharmacologically only steroid administration has shown clinical benefits. This study attempts to characterize local spinal cord histologic response to human dose equivalent (HDE) intravenous methylprednisolone (MP) administration in a rodent model of acute spinal cord injury. DESIGN: Forty-eight Sprague-Dawley rats were divided equally into control and experimental groups. Each group was subdivided into eight sets of three animals each, according to postinjury intervals. Paraplegia after lower thoracic laminectomy was achieved using a standardized weight drop technique. INTERVENTION: Within one hour, experimental animals were treated with HDE MP followed by 23-hour continuous infusion of HDE MP. Spinal cords were harvested at variable intervals postinjury and prepared for histologic/immunohistochemistry examination. MAIN OUTCOME MEASUREMENTS: Edema, necrosis, and glial fibrillary acidic protein (GFAP) positivity in the specimens from treated/control groups were graded by microscopy and immunohistochemistry staining and compared in a blinded manner by a qualified neuropathologist and senior authors. RESULTS: Minimal differences were observed between control and MP-treated animals at zero and four hours. At eight hours, increased white matter and medullary edema was evident in control versus MP-treated rats. This trend continued through twelve, sixteen, twenty-four, forty-eight, and seventy-two hours. No difference was observed in the astrocytic response to injury by GFAP immunohistochemistry between the groups. CONCLUSIONS: Histologically, MP reduces the development of severe edema and preserves spinal cord architecture adjacent to the site of injury. In contrast, MP does not alter the development of spinal cord necrosis or astrocytic response at the zone of injury.

High rectal injury during trans-1 axial lumbar interbody fusion L5-S1 fixation: a case report.

STUDY DESIGN: A case report. OBJECTIVE: To report a case of high rectal injury during trans-1 axial Lumbar Interbody Fusion (axiaLIF) L5-S1 fixation. SUMMARY OF BACKGROUND DATA: Trans-1 axiaLIF procedure is gaining in popularity for L5-S1 fusion due to the ease of access to the sacrum through the presacral space. Normally, the midline of the sacrum at S1-S2 is relatively free from neurovascular and intra-abdominal structures, making this level a safe entry point for the axiaLIF procedure. We report a case of high rectal injury during Trans-1 axiaLIF L5-S1 procedure due to altered intra-abdominal anatomy as a result of multifactorial adhesions formation. METHODS: A 44-year-old female patient with a history of previous anterior and posterior spinal surgeries, pelvic inflammatory disease, and non-disclosed previous diverticulitis, developed a high rectal injury during Trans-1 axiaLIF L5-S1 fixation. RESULTS: After Trans-1 axiaLIF L5-S1, the patient presented with an episode of melena and hypogastric pain with nausea and vomiting. A computed tomography (CT) scan of the abdomen with intravenous and oral contrast showed presacral soft tissue fluid density with fat stranding and extraluminal rectal contrast and gas with some areas of soft tissue enhancement compatible with probable high rectal perforation. Patient's symptoms gradually subsided during a period of 6 months with aid from a temporary diverting ileostomy and a course of i.v. antibiotics. No spine implants were removed. CONCLUSION: We report a case of high rectal injury during Trans-1 axiaLIF L5-S1 fixation and strongly advice that patients who are candidates for this surgery and have any risk factors for intra-abdominal adhesion formation, undergo a pelvic CT with rectal contrast before the surgery to evaluate for any signs of altered rectal-sacral anatomy.

Advocating "spine damage control" as a safe and effective treatment modality for unstable thoracolumbar fractures in polytrauma patients: a hypothesis.

BACKGROUND: The "ideal" timing and modality of fracture fixation for unstable thoracolumbar spine fractures in multiply injured patients remains controversial. The concept of "damage control orthopedics" (DCO), which has evolved globally in the past decade, provides a safe guidance for temporary external fixation of long bone or pelvic fractures in multisystem trauma. In contrast, "damage control" concepts for unstable spine injuries have not been widely implemented, and the scarce literature in the field remains largely anecdotal. The current practice standards are reflected by two distinct positions, either (1) immediate "early total care" or (2) delayed spine fixation after recovery from associated injuries. Both concepts have inherent risks which may contribute to adverse outcome. PRESENTATION OF HYPOTHESIS: We hypothesize that the concept of "spine damage control" - consisting of immediate posterior fracture reduction and instrumentation, followed by scheduled 360 degrees completion fusion during a physiological "time-window of opportunity" - will be associated with less complications and improved outcomes of polytrauma patients with unstable thoracolumbar fractures, compared to conventional treatment strategies. TESTING OF HYPOTHESIS: We propose a prospective multicenter trial on a large cohort of multiply injured patients with an associated unstable thoracolumbar fracture. Patients will be assigned to one of three distinct study arms: (1) Immediate definitive (anterior and/or posterior) fracture fixation within 24 hours of admission; (2) Delayed definitive (anterior and/or posterior) fracture fixation at > 3 days after admission; (3) "Spine damage control" procedure by posterior reduction and instrumentation within 24 hours of admission, followed by anterior 360 degrees completion fusion at > 3 days after admission, if indicated. The primary and secondary endpoints include length of ventilator-free days, length of ICU and hospital stay, mortality, incidence of complications, neurological status and functional recovery. IMPLICATIONS OF HYPOTHESIS: A "spine damage control" protocol may save lives and improve outcomes in severely injured patients with associated spine injuries.

Intraoperative 3-dimensional reconstructed multiplanar fluoroscopic imaging for immediate evaluation of spinal decompression.

Although thorough preoperative planning is the best method of achieving appropriate levels of lumbar spinal decompression, current methods for intraoperative assessment of the extent of spinal decompression are inadequate. Underdecompression leads to poor clinical outcomes and overdecompression can lead to instability. The purpose of this study is to evaluate the use of multiplanar, fluoroscopic images reconstructed in 3-dimensional format, combined with spinal myelography to intraoperatively assess lumbar spinal decompression. Patients scheduled for lumbar spinal decompression surgery were recruited for intraoperative evaluation using multiplanar imaging and myelography. After performing the minimal necessary decompression of the preoperatively planned areas of spinal stenosis, 13 mL of omnipaque contrast dye was injected into the subarachnoid space. Iso-C sequential fluoroscopic images were acquired and reconstructed into multiplanar images. Images were evaluated for quality, and spinal decompression was evaluated for completeness. The average time for this technique was 13 minutes 42 seconds (range, 9 min 59 s to 19 min 57 s). The average time for injecting the dye was 3 minutes 3 seconds and for assessing the images was 3 minutes 24 seconds. There was a notable decrease in the time required for the technique as the surgeon and staff became more proficient at the procedure. All patients had adequate visualization of the spinal canal and nerve roots. Three patients had additional decompression after review of the images. It is feasible to obtain multiplanar myelograph enhanced C-arm fluoroscopic images in the operating room setting and these are useful for the evaluation of decompression of lumbar spinal stenosis.

Unilateral cervical facet fractures with subluxation: injury patterns and treatment.

STUDY DESIGN: This is a retrospective study of patients with unilateral cervical facet fractures from a Level I academic trauma center. OBJECTIVE: We sought to examine fracture patterns involving only the facets, to examine the incidence of associated neurologic and vascular injuries, and to determine optimum management strategies for these injuries. SUMMARY OF BACKGROUND DATA: Most of the literature regarding unilateral cervical facet injuries has resulted from studies evaluating dislocated locked facets, "fracture-dislocations," or fractures of the lateral mass and pedicle. METHODS: We retrospectively reviewed our experience with unilateral fractures of the facets, identifying 25 cases over a 5-year period. Presenting history, neurologic examination, imaging findings, method of reduction, interval to surgery, type of surgery, and evaluation for vascular injuries were recorded. Fusion was assessed by plain radiographs and computed tomography scans at follow-up. RESULTS: All 25 patients were treated operatively. Ten of the fractures involved the superior articular process, 13 involved the inferior articular process, and 2 cases involved both. The most commonly affected level was at C6/7. Twenty-one of the 25 patients underwent anterior stabilization, 3 underwent posterior stabilization, and 1 underwent anterior-posterior stabilization. Eleven patients underwent diagnostic 4-vessel angiography, revealing 2 patients with vertebral artery injuries. Average follow-up was 11.5 months. There were no identifiable nonunions. CONCLUSIONS: We conclude the following: (a) anterior discectomy and fusion with a static (constrained) plating system is appropriate treatment for this type of injury, (b) in the absence of significant neurologic deficit with residual canal or foraminal stenosis, preoperative closed reduction is not necessary, (c) a small percentage of these patients will have vertebral artery injury, thus warranting screening with 16-slice computed tomographic angiography.

End organ effects of high-dose human equivalent methylprednisolone in a spinal cord injury rat model.

STUDY DESIGN: Interventional study. OBJECTIVE: To analyze the histologic effects of high-dose human equivalent methylprednisolone on the pulmonary, cardiac, intestinal, renal, hepatic, and splenic tissues in a spinal cord injury rat model. SUMMARY OF BACKGROUND DATA: There are numerous investigations of various medical interventions for the treatment of acute spinal cord trauma. Currently, the only generally accepted medical intervention in an acute spinal cord trauma is the intravenous administration of high doses of methylprednisolone. Although it has been nearly 2 decades since the first National Acute Spinal Cord Injury Study investigated the role high-dose steroids might play in the treatment of acute spinal cord trauma, controversy still exists regarding the efficacy of this treatment. To our knowledge, no study has examined the role of high-dose methylprednisolone in organ systems other than the spinal cord in an acute spinal cord injury model at the histologic level. This study attempts to characterize end organ histologic response to human dose equivalent (HDE) intravenous methylprednisolone administration in a rodent model of acute spinal cord injury. METHODS: A total of 48 Sprague-Dawley rats were divided equally into control and experimental groups. Each group was subdivided into 6 sets of 4 animals each, according to intervals after injury. Groups 1-6 consisted of animals euthanized at 0, 4, 8, 16, 24, and 48 hours after spinal cord injury. Paraplegia after lower thoracic laminectomy was achieved using a standardized Allen weight drop technique. Within 1 hour of injury, experimental animals were treated with HDE methylprednisolone, infused for 23 hours continuously. Liver, kidney, lung, intestine, spleen, and heart were harvested at variable intervals after injury and prepared for histologic examination. These slides were analyzed with microscopic staining techniques and compared in a blinded manner by a qualified pathologist. RESULTS: Of all the end organs analyzed, the spleens were most affected. Lymphocytic depletion was seen in as little as 4 hours after methylprednisolone infusion and continued until 48 hours. Pulmonary tissues variably showed interstitial congestion and eosinophilic alveolar collections. Intestinal mucosal tissues showed edema and autolyzed mucosa from 16 hours onwards. Cardiac, kidney, and hepatic tissue did not differ significantly from controls. CONCLUSIONS: Histologically, HDE methylprednisolone caused significant splenic lymphocytic depletion changes in as little as 4 hours. This trend of end organ lymphocytopenia continued to progress until 48 hours. Pulmonary eosinophilic infiltrates were seen from 8 until 24 hours. Intestinal mucosal edema and necrosis were seen in samples at 16 hours throughout 48 hours. This study was designed to evaluate end organ changes seen in an animal model of an acute spinal cord injury treated with HDE methylprednisolone. Study animals were infused with HDE methylprednisolone given according to the National Acute Spinal Cord Injury Study II protocol. The kidney, lung, cardiac, intestinal, splenic, and hepatic tissues from the aforementioned animals were then sectioned and analyzed using histologic staining techniques by a qualified pathologist.