Perioperative Considerations for Tracheostomies in the Era of COVID-19.

The morbidity, mortality, and blistering pace of transmission of infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to an unprecedented worldwide health crisis. Coronavirus disease 2019 (COVID-19), the disease produced by SARS-CoV-2 infection, is remarkable for persistent, severe respiratory failure requiring mechanical ventilation that places considerable strain on critical care resources. Because recovery from COVID-19-associated respiratory failure can be prolonged, tracheostomy may facilitate patient management and optimize the use of mechanical ventilators. Several important considerations apply to plan tracheostomies for COVID-19-infected patients. After performing a literature review of tracheostomies during the severe acute respiratory syndrome (SARS) and Middle East Respiratory Syndrome (MERS) outbreaks, we synthesized important learning points from these experiences and suggested an approach for perioperative teams involved in these procedures during the COVID-19 pandemic. Multidisciplinary teams should be involved in decisions regarding timing and appropriateness of the procedure. As the theoretical risk of disease transmission is increased during aerosol-generating procedures (AGPs), stringent infectious precautions are warranted. Personal protective equipment (PPE) should be available and worn by all personnel present during tracheostomy. The number of people in the room should be limited to those absolutely necessary. Using the most experienced available operators will minimize the total time that staff is exposed to an infectious aerosolized environment. An approach that secures the airway in the safest and quickest manner will minimize the time any part of the airway is open to the environment. Deep neuromuscular blockade (train-of-four ratio = 0) will facilitate surgical exposure and prevent aerosolization due to patient movement or coughing. For percutaneous tracheostomies, the bronchoscopist should be able to reintubate if needed. Closed-loop communication must occur at all times among members of the team. If possible, after tracheostomy is performed, waiting until the patient is virus-free before changing the cannula or downsizing may reduce the chances of health care worker infection. Tracheostomies in COVID-19 patients present themselves as extremely high risk for all members of the procedural team. To mitigate risk, systematic meticulous planning of each procedural step is warranted along with strict adherence to local/institutional protocols.

Objective assessment of robotic surgical skill using instrument contact vibrations.

BACKGROUND: Surgical skill evaluation ordinarily requires tedious video review and survey completion, while new automatic approaches focus on evaluating the quality of the surgeon's movements in free space. Robotic surgical instrument vibrations are simple to measure and physically correspond to how roughly instruments are handled, but they have yet to be studied as a measure of technical surgical skill. METHODS: Thirteen surgeons used a robotic surgery system (da Vinci S by Intuitive Surgical) to perform four trials each of peg transfer (PT), needle pass (NP), and intracorporeal suturing (IS). Completion time, instrument vibrations, and applied forces were measured for each trial; root mean square (RMS) and total sum of squares (TSS) were calculated from both the vibration and force recordings. Four experienced surgeons blindly assessed the task videos using a Global Rating Scale (GRS), and skill metrics were compared between the eight novices and five experienced participants. Stepwise regression was performed to predict GRS score from objective skill metrics. The concurrent validity of each metric was evaluated using receiver operating characteristic (ROC) analysis. RESULTS: The GRS demonstrated excellent internal consistency (Cronbach's α = 0.91) and strong inter-rater reliability (ICC = 0.84). Compared to novices, experienced surgeons earned higher GRS scores and performed tasks with lower vibration magnitudes, lower forces, and shorter completion times in 15 of 18 task-metric combinations (p values ranging from 0.042 to <0.001). ROC analysis demonstrated that including vibration and force magnitudes along with completion time in skill prediction models improves the objective classification of subjects as novice or experienced for all tasks studied (PT: 90% sensitivity, 75% specificity; NP: 85% sensitivity, 84% specificity; suturing: 100% sensitivity, 100% specificity). CONCLUSIONS: RMS and TSS instrument vibrations are novel construct-valid measures of robotic surgical skill that enable the development of objective skill assessment models comparable to observer-based ratings.

Deliberate practice enhances quality of laparoscopic surgical performance in a randomized controlled trial: from arrested development to expert performance.

BACKGROUND: This study investigated whether deliberate practice leads to an increase in surgical quality in virtual reality (VR) laparoscopic cholecystectomies (LC). Previous research has suggested that sustained DP is effective in surgical training. METHODS: Fourteen residents were randomized into deliberate practice (n = 7) or control training (n = 7). Both groups performed ten sessions of two VR LCs. Each session, the DP group was assigned 30 min of DP activities in between LCs while the control group viewed educational videos or read journal articles. Performance was assessed on speed and dexterity; quality was rated with global (GRS) and procedure-specific (PSRS) rating scales. All participants then performed five porcine LCs. RESULTS: Both groups improved over 20 VR LCs in time, dexterity, and global rating scales (all p < 0.05). After 20 LCs, there were no differences in speed or dexterity between groups. The DP group achieved higher quality of VR surgical performance than control for GRS (26 vs. 20, p = 0.001) and PSRS (18 vs. 15, p = 0.001). For VR cases, DP subjects plateaued at GRS = 25 after ten cases and control group at GRS = 20 after five cases. At completion of VR training, 100 % of the DP group reached target quality of performance (GRS ≥ 21) compared with 30 % in the control group. There were no significant differences for improvements in time or dexterity over five porcine LCs. CONCLUSION: This study suggests that DP leads to higher quality performance in VR LC than standard training alone. Standard training may leave individuals in a state of "arrested development" compared with DP.

The relationship between safety-net hospital status and outcomes among elderly head and neck cancer patients.

BACKGROUND: The impact of safety-net status, case volume, and outcomes among geriatric head and neck cancer patients is unknown. METHODS: Chi-square tests and Student's t tests to compare head and neck surgery outcomes of elderly patients between safety-net and non-safety-net hospitals. Multivariable linear regressions to determine predictors of outcome variables including mortality index, ICU stays, 30-day readmission, total direct cost, and direct cost index. RESULTS: Compared with non-safety-net hospitals, safety-net hospitals had a higher average mortality index (1.04 vs. 0.32, p = 0.001), higher mortality rate (1% vs. 0.5%, p = 0.002), and higher direct cost index (p = 0.001). A multivariable model of mortality index found the interaction between safety-net status and medium case volume was predictive of higher mortality index (p = 0.006). CONCLUSION: Safety-net status is correlated with higher mortality index and cost in geriatric head and neck cancer patients. The interaction between medium volume and safety-net status is independently predictive of higher mortality index.

Comparing outcomes of radial forearm free flaps and anterolateral thigh free flaps in oral cavity reconstruction: A systematic review and meta-analysis.

OBJECTIVES: To compare surgical morbidity, functional and aesthetic restoration, and health-related quality of life among patients receiving anterolateral thigh (ALT) or radial forearm (RFF) free flaps for intra-oral reconstruction. MATERIALS AND METHODS: PubMed, Medline, EMBASE, CINAHL, and CDSR databases were searched from 2000 to 2022. Primary outcomes included flap survival, recipient site complications, donor site morbidity, recovery of oral function, and quality of life among patients after oncologic resection and reconstruction of oral cavity defects with ALT or RFF. RESULTS: A total of 23 criteria-meeting studies with 685 ALT and 723 RFF patients were included. There were no differences between the two groups in flap survival or the likelihood of flap-related complications. There was a significantly lower likelihood of donor site morbidity among ALT patients, specifically hypertrophic scarring (OR 0.24, 95 % CI: 0.06-0.96), tendon exposure (OR 0.13, 95 % CI: 0.03-0.60), paresthesia (OR: 0.06, 95 % CI: 0.01-0.25), movement impairment (OR: 0.12, 95 % CI: 0.04-0.38), and social stigma (OR: 0.10, 95 % CI: 0.03-0.28). ALT patients were significantly more likely to be satisfied with the donor site appearance (OR: 8.75, 95 % CI: 1.11-68.73). There were no significant differences in recovery of regular diet and speech or quality of life. CONCLUSION: The findings suggest that the ALT achieves equivalent flap survival rates and oral function with less donor site morbidity compared to the RFF for intra-oral reconstruction. Nonetheless, choice of free flap should incorporate surgeon- and patient-specific factors that may not be reflected in the studies included in this meta-analysis.

Design of interactive augmented reality functions for robotic surgery and evaluation in dry-lab lymphadenectomy.

BACKGROUND: Augmented reality (AR) has been widely researched for use in healthcare. Prior AR for robot-assisted minimally invasive surgery has mainly focussed on superimposing preoperative three-dimensional (3D) images onto patient anatomy. This article presents alternative interactive AR tools for robotic surgery. METHODS: We designed, built and evaluated four voice-controlled functions: viewing a live video of the operating room, viewing two-dimensional preoperative images, measuring 3D distances and warning about out-of-view instruments. This low-cost system was developed on a da Vinci Si, and it can be integrated into surgical robots equipped with a stereo camera and a stereo viewer. RESULTS: Eight experienced surgeons performed dry-lab lymphadenectomies and reported that the functions improved the procedure. They particularly appreciated the possibility of accessing the patient's medical records on demand, measuring distances intraoperatively and interacting with the functions using voice commands. CONCLUSIONS: The positive evaluations garnered by these alternative AR functions and interaction methods provide support for further exploration.

A Review of Otolaryngology Malpractice Cases with Associated Court Proceedings from 2010 to 2019.

OBJECTIVES/HYPOTHESIS: To report key characteristics of the landscape of malpractice litigation with associated court proceedings in otolaryngology over the previous decade. STUDY DESIGN: Retrospective database review. METHODS: The LexisNexis database was queried to identify otolaryngology-related malpractices cases that yielded court opinions, jury verdicts, and settlements from federal and state courts across the United States from 2010 to 2019. Cases settled outside of court were not identifiable. Provider subspecialty, procedures, error type, legal allegations, and case outcomes were recorded. Frequency of error type was compared between otolaryngology subspecialties using Fisher exact tests. RESULTS: Ninety-four medical malpractice cases related to otolaryngology with evidence of court proceedings were identified for the period between 2010 and 2019. An otolaryngologist was named as the sole defendant in 39 cases (41%). Rhinology was the most frequently implicated subspecialty (28% of all cases), followed by head and neck surgery (17%) and facial plastics (7%). Improper surgical performance was cited in nearly half of the identified cases (49%), followed by failure to diagnose/refer/treat (32%). Outcome and liability data were available for 56 cases (60%). Of these 56 cases, 50 (89%) were ruled in favor of the defendant otolaryngologist. Of the cases ruled in favor of the plaintiff, the average indemnity was $4.24 M (range, $150,000 M-$10.25 M). Fisher exact tests demonstrated statistically significant differences in consent issues (P = .040), failure to diagnose/refer/treat (P = .024), and improper surgical performance (P = .026) between subspecialties. CONCLUSIONS: In a limited, database-derived sample of medical malpractice cases involving otolaryngologists, trends in error type by subspecialty may warrant further investigation to identify specialty-wide and subspecialty-specific areas of practice improvement and education. LEVEL OF EVIDENCE: N/A Laryngoscope, 131:E1081-E1085, 2021.

A Novel Cough Simulation Device for Education of Risk Mitigation Techniques During Aerosol-Generating Medical Procedures.

The COVID-19 pandemic has drawn attention to aerosol-generating medical procedures (AGMPs) in health care environments as a potential mode of transmission. Many organizations and institutions have published AGMP safety guidelines, and several mention the use of simulation in informing their recommendations; however, current methods used to simulate aerosol generation are heterogenous. Creation of a high-fidelity, easily producible aerosol-generating cough simulator would meet a high-priority educational need across all medical specialties. In this communication, we describe the design, construction, and user study of a novel cough simulator, which demonstrates the utility of simulation in raising AGMP safety awareness for providers of all roles, specialties, and training levels.

A Multidisciplinary Approach and Review of Safety Recommendations for Plastic Surgeons during the COVID-19 Pandemic: Are N95 Masks Enough?

SUMMARY: The novel coronavirus disease of 2019 pandemic presents a unique challenge to the field of plastic and reconstructive surgery. Although plastic surgeons may be postponing elective operations, there are still a number of emergent or urgent procedures that may need to be performed, and surgeons may be facing the reality of returning to a new normalcy of operating with coronavirus disease of 2019. These procedures, consisting of those such as head and neck reconstruction or maxillofacial trauma, largely require a multidisciplinary approach and may be considered of higher risk to health care workers because of the involvement of areas of the body identified as sources for viral transmission. Moreover, viral transmission may potentially extend beyond respiratory secretions, which has been the main focus of most safety precautions. The authors aim to present the scope of these procedures and the means of viral transmission, and to provide safety precaution recommendations for plastic surgery and its related disciplines.

National Database Research in Head and Neck Reconstructive Surgery: A Call for Increased Transparency and Reproducibility.

OBJECTIVE: To reproduce a published study comparing outcomes of patients who underwent microvascular reconstruction by plastic surgeons and otolaryngologists and to examine how case selection and methodology using the National Surgical Quality Improvement Program (NSQIP) data set can affect results and conclusions. STUDY DESIGN: Cross-sectional analysis of US national database. SETTING: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) from 2005 to 2017. SUBJECTS AND METHODS: A recently published study that used the NSQIP database to compare outcomes after head and neck free tissue transfer between plastic surgeons and otolaryngologists was reproduced. Different approaches to case selection and statistical analysis were evaluated and their effects on statistical significance and study conclusions were compared. RESULTS: When all cases of free tissue transfer, captured in NSQIP between 2005 and 2017, were compared between plastic surgery and otolaryngology, plastic surgery patients appeared to have lower rates of complications and length of stay. However, a more in-depth analysis demonstrated that these results were confounded by older and sicker otolaryngology patients. A second analysis of the same NSQIP data, limited to only head and neck oncologic reconstructions, demonstrated that otolaryngology patients had fewer complications on univariate and multivariable analysis. CONCLUSION: We demonstrated how case selection and analysis can significantly affect results. It is incumbent upon researchers who use NSQIP and other publicly available data sets to fully detail their methodology to allow other researchers to reproduce and evaluate their work and for the journal editorial process to carefully evaluate the methodology and conclusions of their contributing authors.

Impact of Lymph Node Yield on Survival in Surgically Treated Oropharyngeal Squamous Cell Carcinoma.

OBJECTIVES: (1) To estimate the association between neck dissection lymph node yield (LNY) and survival among patients with surgically treated human papilloma virus (HPV)-associated oropharyngeal squamous cell carcinoma (OPSCC). (2) To identify a clinically relevant quality metric for surgical treatment of HPV-related OPSCC. STUDY DESIGN: Retrospective cohort study. SETTING: National Cancer Database. SUBJECTS AND METHODS: From the National Cancer Database, 4130 patients were identified with HPV-associated OPSCC treated with primary surgery from 2010 to 2016. Based on prior literature, an adequate neck dissection LNY was defined as ≥18 lymph nodes. To determine whether LNY is associated with survival, univariable and multivariable Cox proportional hazards regression was performed. Analysis was stratified by adjuvant therapy regimen. RESULTS: A total of 2113 patients (51.2%) underwent surgery with or without adjuvant radiation (S ± RT), and 2017 patients (48.8%) underwent surgery with adjuvant chemoradiation. LNY ≥18 was associated with a 5-year survival benefit of 7.15% (91.7% for LNY ≥18, 84.5% for LNY <18, P = .004) for the S ± RT cohort on unadjusted survival analysis. For the S ± RT group, LNY ≥18 was associated with decreased hazard of death (hazard ratio, 0.45; 95% CI, 0.29-0.70; P < .001) after adjustment for patient characteristics, TNM staging, surgical margins, extranodal extension, and treating facility characteristics. For surgery with adjuvant chemoradiation, the adjusted hazard ratio estimate for LNY ≥18 was 0.64 (95% CI, 0.41-1.00), but the result was not statistically significant (P = .052). CONCLUSION: An adequate LNY from a neck dissection may affect survival when HPV-related OPSCC is treated with up-front surgery.

Targeted loss of Arx results in a developmental epilepsy mouse model and recapitulates the human phenotype in heterozygous females.

Mutations in the X-linked aristaless-related homeobox gene (ARX) have been linked to structural brain anomalies as well as multiple neurocognitive deficits. The generation of Arx-deficient mice revealed several morphological anomalies, resembling those observed in patients and an interneuron migration defect but perinatal lethality precluded analyses of later phenotypes. Interestingly, many of the neurological phenotypes observed in patients with various ARX mutations can be attributed, in part, to interneuron dysfunction. To directly test this possibility, mice carrying a floxed Arx allele were generated and crossed to Dlx5/6(CRE-IRES-GFP)(Dlx5/6(CIG)) mice, conditionally deleting Arx from ganglionic eminence derived neurons including cortical interneurons. We now report that Arx(-/y);Dlx5/6(CIG) (male) mice exhibit a variety of seizure types beginning in early-life, including seizures that behaviourally and electroencephalographically resembles infantile spasms, and show evolution through development. Thus, this represents a new genetic model of a malignant form of paediatric epilepsy, with some characteristics resembling infantile spasms, caused by mutations in a known infantile spasms gene. Unexpectedly, approximately half of the female mice carrying a single mutant Arx allele (Arx(-/+);Dlx5/6(CIG)) also developed seizures. We also found that a subset of human female carriers have seizures and neurocognitive deficits. In summary, we have identified a previously unrecognized patient population with neurological deficits attributed to ARX mutations that are recapitulated in our mouse model. Furthermore, we show that perturbation of interneuron subpopulations is an important mechanism underling the pathogenesis of developmental epilepsy in both hemizygous males and carrier females. Given the frequency of ARX mutations in patients with infantile spasms and related disorders, our data unveil a new model for further understanding the pathogenesis of these disorders.

Incidence of inadequate perforators and salvage options for the anterior lateral thigh free flap.

OBJECTIVE: The anterolateral thigh (ALT) free flap is a soft tissue flap used in head and neck reconstruction. Occasionally, its perforators to the skin paddle are absent or too small to support the flap. Salvage options in this scenario have not been well described for head and neck reconstruction. METHODS: Multicenter review of 1,079 cases of planned ALT flaps where 28 initial flaps (2.6%) were discarded for nonviable skin paddle or lack of cutaneous perforators. Iatrogenic perforator injury was calculated separately. The total flap loss rate was 3.2%. RESULTS: In 12 cases, no perforators were noted after performing the anterior incision (early). Sixteen ALT flaps were discarded immediately before pedicle ligation (late). Reconstruction was salvaged by seven anteromedial thigh (AMT), six radial forearm, five contralateral ALT, four rectus abdominus myocutaneous, three vastus lateralis, three profunda artery perforator, two tensor fascia lata, one rectus femoris, two pectoralis major, one cervicofacial rotational, and one fibula flap. Of the 28 cases, 12 salvage cases did not involve an additional wound for the patient. Five of the seven AMT flaps were harvested after the ALT was identified as nonviable in the early time point. Two patients had no viable ALT flaps on bilateral lower extremities. CONCLUSION: The ALT flap is a reliable soft tissue flap, and rarely cutaneous perforators are not adequate to support the skin paddle. Multiple options exist to salvage the reconstruction without significant additional morbidity to the patient if said inadequacy is identified early. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:343-346, 2020.

Techniques for developing and viewing stereoscopic three-dimensional teaching videos for transoral robotic surgery (TORS).

Advances in three-dimensional (3D) video recording and playback have expanded the availability of stereoscopic videos for consumption with specialized televisions, computer monitors, and virtual reality (VR) headsets. The built-in stereoscopic vision of the da vinci surgical system (Intuitive Surgical, Sunnyvale, CA) enables the recording of both camera views. However, medical-grade devices for direct stereoscopic video recording can be cost-prohibitive. We describe methods of producing and viewing 3D videos in transoral robotic surgery (TORS) without acquisition of dedicated 3D recording equipment. The video output from the left and right cameras of the da Vinci Si endoscope were recorded during a TORS radical tonsillectomy using non-stereoscopic media devices. Raw video was processed using commercially available video-editing software to create stereoscopic videos clips. 3D videos were successfully observed using a low-cost mobile phone VR headset. 3D stereoscopic surgical videos were successfully developed using widely available software, applications, computer peripherals, and mobile devices. The methods described confer significant cost savings when compared to the purchase of specialized recording equipment despite the requirements of time and intermediate computer skills. Future studies will investigate the utility of stereoscopic videos in medical student and resident education.

Evaluation of high-fidelity simulation as a training tool in transoral robotic surgery.

OBJECTIVES/HYPOTHESIS: To develop and evaluate a high-fidelity training simulator for transoral robotic posterior hemiglossectomy. STUDY DESIGN: Prospective observational study. METHODS: We constructed a transoral robotic surgery (TORS) simulator using porcine tongue in a modified airway mannequin. Twenty-nine surgeons performed transoral robotic posterior hemiglossectomy on the simulator. The 20 resident subjects completed six trials each, and the five fellows and four attending surgeons completed two trials each. In addition to instrument vibrations, surgical video was recorded for each trial and was blindly rated using the Global Evaluative Assessment of Robotic Skill (GEARS), a validated instrument for assessing robotic surgical skill. RESULTS: Attending surgeons were faster (P = .004) and demonstrated greater technical skill than fellows or residents (P < .001). Resident completion time generally decreased over the study, becoming significantly faster by the fifth trial (P = .02). A similar trend was seen in resident GEARS scores, which generally increased and were significantly improved by the fourth trial (P = .008). Instrument vibrations were not significantly different between subject groups. Finally, subjects highly rated the realism and training value of the TORS simulator (mean 4.4 and 4.7 out of 5, respectively). CONCLUSIONS: The reported findings support using the described simulator as a training tool for TORS. Residents significantly improved in speed and technical skill over the course of six trials but did not achieve the performance levels of attending surgeons. These results demonstrate that high-fidelity simulation is a valuable tool for training novice surgeons in transoral robotic surgery. LEVEL OF EVIDENCE: NA. Laryngoscope, 127:2790-2795, 2017.

Anesthetic Management for Laser Excision of Ball-Valving Laryngeal Masses.

A 47-year-old obese woman with GERD and COPD presents for CO2-laser excision of bilateral vocal fold masses. She had a history of progressive hoarseness and difficulty in breathing. Nasopharyngeal laryngoscopy revealed large, mobile, bilateral vocal cord polyps that demonstrated dynamic occlusion of the glottis. We describe the airway and anesthetic management of this patient with a topicalized C-MAC video laryngoscopic intubation using a 4.5 mm Xomed Laser Shield II endotracheal tube. We examine the challenges of anesthetic management unique to the combined circumstances of a ball-valve lesion and the need for a narrow-bore laser compatible endotracheal tube.

A Randomized Controlled Trial to Assess the Effects of Competition on the Development of Laparoscopic Surgical Skills.

BACKGROUND: Serious games have demonstrated efficacy in improving participation in surgical training activities, but studies have not yet demonstrated the effect of serious gaming on performance. This study investigated whether competitive training (CT) affects laparoscopic surgical performance. METHODS: A total of 20 novices were recruited, and 18 (2 dropouts) were randomized into control or CT groups to perform 10 virtual reality laparoscopic cholecystectomies (LCs). Competitiveness of each participant was assessed. The CT group members were informed they were competing to outperform one another for a prize; performance ranking was shown before each session. The control group did not compete. Performance was assessed on time, movements, and instrument path length. Quality of performance was assessed with a global rating scale score. RESULTS: There were no significant intergroup differences in baseline skill or measured competitiveness. Time and global rating scale score, at final LC, were not significantly different between groups; however, the CT group was significantly more dexterous than control and had significantly lower variance in number of movements and instrument path length at the final LC (p = 0.019). Contentiousness was inversely related to time in the CT group. CONCLUSION: This was the first randomized controlled trial to investigate if CT can enhance performance in laparoscopic surgery. CT may lead to improved dexterity in laparoscopic surgery but yields otherwise similar performance to that of standard training in novices. Competition may have different effects on novices vs experienced surgeons, and subsequent research should investigate CT in experienced surgeons as well.

A practical system for recording instrument interactions during live robotic surgery.

We have developed a system for measuring and recording the high-frequency vibrations that characterize instrument interactions during minimally invasive robotic surgery. Consisting of simple circuitry and a DVD recorder, this system is low-cost and easily implementable, requires no sterilization, and enables measurement of a validated, objective technical skill metric in both the simulated setting and the operating room. The vibration recordings of fourteen sleeve gastrectomies were processed by segmenting the operation into seven phases and calculating the root mean square (RMS) vibration within each phase. Statistical analysis showed that the observed differences match expectations drawn from knowledge of the operation, substantiating the premise that RMS vibration provides a good measure of the intensity of instrument interactions during live robotic surgery.