Use of artificial intelligence for decision-support to avoid high-risk behaviors during laparoscopic cholecystectomy.

INTRODUCTION: Bile duct injuries (BDIs) are a significant source of morbidity among patients undergoing laparoscopic cholecystectomy (LC). GoNoGoNet is an artificial intelligence (AI) algorithm that has been developed and validated to identify safe ("Go") and dangerous ("No-Go") zones of dissection during LC, with the potential to prevent BDIs through real-time intraoperative decision-support. This study evaluates GoNoGoNet's ability to predict Go/No-Go zones during LCs with BDIs. METHODS AND PROCEDURES: Eleven LC videos with BDI (BDI group) were annotated by GoNoGoNet. All tool-tissue interactions, including the one that caused the BDI, were characterized in relation to the algorithm's predicted location of Go/No-Go zones. These were compared to another 11 LC videos with cholecystitis (control group) deemed to represent "safe cholecystectomy" by experts. The probability threshold of GoNoGoNet annotations were then modulated to determine its relationship to Go/No-Go predictions. Data is shown as % difference [99% confidence interval]. RESULTS: Compared to control, the BDI group showed significantly greater proportion of sharp dissection (+ 23.5% [20.0-27.0]), blunt dissection (+ 32.1% [27.2-37.0]), and total interactions (+ 33.6% [31.0-36.2]) outside of the Go zone. Among injury-causing interactions, 4 (36%) were in the No-Go zone, 2 (18%) were in the Go zone, and 5 (45%) were outside both zones, after maximizing the probability threshold of the Go algorithm. CONCLUSION: AI has potential to detect unsafe dissection and prevent BDIs through real-time intraoperative decision-support. More work is needed to determine how to optimize integration of this technology into the operating room workflow and adoption by end-users.

What is the educational value and clinical utility of artificial intelligence for intraoperative and postoperative video analysis? A survey of surgeons and trainees.

INTRODUCTION: Surgical complications often occur due to lapses in judgment and decision-making. Advances in artificial intelligence (AI) have made it possible to train algorithms that identify anatomy and interpret the surgical field. These algorithms can potentially be used for intraoperative decision-support and postoperative video analysis and feedback. Despite the very early success of proof-of-concept algorithms, it remains unknown whether this innovation meets the needs of end-users or how best to deploy it. This study explores users' opinion on the value, usability and design for adapting AI in operating rooms. METHODS: A device-agnostic web-accessible software was developed to provide AI inference either (1) intraoperatively on a live video stream (synchronous mode), or (2) on an uploaded video or image file (asynchronous mode) postoperatively for feedback. A validated AI model (GoNoGoNet), which identifies safe and dangerous zones of dissection during laparoscopic cholecystectomy, was used as the use case. Surgeons and trainees performing laparoscopic cholecystectomy interacted with the AI platform and completed a 5-point Likert scale survey to evaluate the educational value, usability and design of the platform. RESULTS: Twenty participants (11 surgeons and 9 trainees) evaluated the platform intraoperatively (n = 10) and postoperatively (n = 11). The majority agreed or strongly agreed that AI is an effective adjunct to surgical training (81%; neutral = 10%), effective for providing real-time feedback (70%; neutral = 20%), postoperative feedback (73%; neutral = 27%), and capable of improving surgeon confidence (67%; neutral = 29%). Only 40% (neutral = 50%) and 57% (neutral = 43%) believe that the tool is effective in improving intraoperative decisions and performance, or beneficial for patient care, respectively. Overall, 38% (neutral = 43%) reported they would use this platform consistently if available. The majority agreed or strongly agreed that the platform was easy to use (81%; neutral = 14%) and has acceptable resolution (62%; neutral = 24%), while 30% (neutral = 20%) reported that it disrupted the OR workflow, and 20% (neutral = 0%) reported significant time lag. All respondents reported that such a system should be available "on-demand" to turn on/off at their discretion. CONCLUSIONS: Most found AI to be a useful tool for providing support and feedback to surgeons, despite several implementation obstacles. The study findings will inform the future design and usability of this technology in order to optimize its clinical impact and adoption by end-users.

Partnering to build surgical capacity in low-resource settings: a qualitative study of Canadian global surgeons.

OBJECTIVES: This qualitative study aimed to explore the perspectives of Canadian global surgeons with experience developing surgical education partnerships with low- and middle-income countries (LMICs) for the purpose of identifying factors for success. DESIGN: A purposive sample of leaders from global surgery programmes at Canadian Faculties of Medicine participated in virtual semi-structured interviews. A six-phase thematic analysis was performed using a constructivist lens on verbatim transcripts by three independent researchers. Key factors for success were thematically collated with constant comparison and inter-investigator triangulation in NVivo software until theoretical saturation was reached. PARTICIPANTS: Fifteen surgeons, representing 11 subspecialties at 6 Canadian academic institutions and a combined experience across 6 continents, were interviewed between January and June 2022. RESULTS: Four facilitators for success of global surgery training programmes were identified, with a strong undertone of relationship-building permeating all subthemes: (1) facilitative skill sets and infrastructure, (2) longitudinal engagement, (3) local ownership and (4) interpersonal humility. Participants defined facilitative skill sets to include demonstrated surgical competence and facilitative infrastructure to include pre-existing local networks, language congruency, sustainable funding and support from external organisations. They perceived longitudinal engagement as spanning multiple trips, enabled by strong personal motivation and arrangements at their home institutions. Ownership of projects by local champions, including in research output, was noted as key to preventing brain drain and catalysing a ripple effect of surgical trainees. Finally, interviewees emphasised interpersonal humility as being crucial to decolonising the institution of global surgery with cultural competence, reflexivity and sustainability. CONCLUSIONS: The interviewed surgeons perceived strong cross-cultural relationships as fundamental to all other dimensions of success when working in low-resource capacity-building. While this study presents a comprehensive Canadian perspective informed by high-profile leadership in global surgery, a parallel study highlighting LMIC-partners' perspectives will be critical to a more complete understanding of programme success.

Integrating Public Health Into Undergraduate Medicine in North America: A Systematic Review.

The coronavirus disease 2019 (COVID-19) pandemic has served as a stark reminder of the importance of foundational public health training for all physicians. However, the most effective way to incorporate these concepts into undergraduate medical education remains unclear. Here, we characterize the literature regarding the effectiveness of public health integration into undergraduate medical education in North America. We systematically searched MEDLINE, Embase, Cochrane Central, and Education Resources Information Center (ERIC) in accordance with preferred reporting items for systematic review and meta-analysis (PRISMA) guidelines for North American peer-reviewed literature, published from 01/01/2000 to 30/08/2021, that described outcomes of integrating public health training within an undergraduate medical curriculum. Results were qualitatively synthesized into key themes. A total of 38 studies, involving interventions across 43 medical schools, were included. Studies reported on a combination of public (n=13), global (n=9), population (n=9), community (n=6), and epidemiological (n=1) health interventions, and either implemented one-off workshops, electives, or international experiences (n=19); a longitudinal theme or long-term enrichment pathway (n=14); or a case-based learning curriculum (n=8). The majority (81.5%, 31/38) of integrations were self-described as successful and, of studies reporting on feasibility, most (94.1%, 16/17) were indicated as feasible. The definition of what constituted such success, however, was unclear. Innovative examples included the use of simulation workshops and mobile-optimized media content. Key challenges were noted, however, in securing adequate funding and buy-in from administrative leadership. Robust community partnerships and iterative cycles of implementation of the intervention were critical factors to success. In summary, foundational public health components can be effectively integrated into medical school curricula and would benefit from adequate resourcing, innovation, community partnerships, and continuous improvement.