Defining digital surgery: a SAGES white paper.

BACKGROUND: Digital surgery is a new paradigm within the surgical innovation space that is rapidly advancing and encompasses multiple areas. METHODS: This white paper from the SAGES Digital Surgery Working Group outlines the scope of digital surgery, defines key terms, and analyzes the challenges and opportunities surrounding this disruptive technology. RESULTS: In its simplest form, digital surgery inserts a computer interface between surgeon and patient. We divide the digital surgery space into the following elements: advanced visualization, enhanced instrumentation, data capture, data analytics with artificial intelligence/machine learning, connectivity via telepresence, and robotic surgical platforms. We will define each area, describe specific terminology, review current advances as well as discuss limitations and opportunities for future growth. CONCLUSION: Digital Surgery will continue to evolve and has great potential to bring value to all levels of the healthcare system. The surgical community has an essential role in understanding, developing, and guiding this emerging field.

A steady stream of knowledge: decreased urinary retention after implementation of ERAS protocols in ambulatory minimally invasive inguinal hernia repair.

BACKGROUND: Potential complications after inguinal hernia repair include uncontrolled post-operative pain and post-operative urinary retention (POUR). Enhanced Recovery After Surgery (ERAS) protocols aim to mitigate post-operative morbidity. We study the impact of ERAS measures alongside discharge without a narcotic prescription on post-operative pain and POUR after minimally invasive inguinal hernia repair. METHODS: A retrospective review of a prospectively maintained database identified patients that underwent minimally invasive inguinal hernia repair at a single institution. Intra-operative data included operative time, narcotic usage, non-narcotic adjunct medication, and fluid administration. Primary outcomes included rates of POUR and uncontrolled post-operative pain. Operations performed after 2018 were included in the ERAS cohort. Uncontrolled post-operative pain was defined as needing additional narcotic prescriptions, admission, or ER visits for post-operative pain. POUR was defined as requiring an indwelling urethral catheter at discharge, admission for retention, or returning to the ER for urinary retention. RESULTS: Between January 2008 and March 2021, 1097 patients who underwent minimally invasive inguinal hernia repair were identified. 91.3% of these procedures were laparoscopic and 8.7% were robotic. Average patient age was 57.4 years, 93% were male. Patients receiving care after initiation of the ERAS protocol were significantly less likely to experience POUR when compared to their prior counterparts (1.4% vs. 4.2% p = 0.01); there was no difference in post-operative pain complications (1.4% vs. 2.9% p = 0.15). Patients who were discharged without a narcotic prescription had 0% incidence of POUR. Significant differences were found between the ERAS and non-ERAS cohort regarding narcotic usage and fluid administration. Age, higher fluid volume, and higher narcotic usage were found to be risk factors for POUR while ERAS, sugammadex, and dexamethasone were found to be protective. CONCLUSION: Implementation of an ambulatory ERAS protocol can significantly decrease urinary retention and narcotic usage rates after minimally invasive inguinal hernia repair.

Rupture of a previously thrombosed hepatic artery aneurysm.

Hepatic artery aneurysm (HAA) is a rare form of visceral artery aneurysm. Historically, most HAAs were ruptured at presentation, but advances in imaging have led to an increase in the diagnosis of asymptomatic HAAs. Description of the natural history of patent HAAs has been difficult because of their rarity, even more so for less common thrombosed HAAs. We report the case of a 74-year-old man who experienced the rupture of a previously thrombosed HAA. He was successfully surgically treated with ligation of the aneurysm. Our case provides insight into the progression and management of thrombosed HAAs.

Validation of a virtual intracorporeal suturing simulator.

BACKGROUND: Intracorporeal suturing is one of the most important and difficult procedures in laparoscopic surgery. Practicing on a FLS trainer box is effective but requires large number of consumables, and the scoring is somewhat subjective and not immediate. A virtualbasic laparoscopic skill trainer (VBLaST©) was developed to simulate the five tasks of the FLS Trainer Box. The purpose of this study is to evaluate the face and content validity of the VBLaST suturing simulator (VBLaST-SS©). METHODS: Twenty-five medical students and residents completed an evaluation of the simulator. The participants were asked to perform the standard intracorporeal suturing task on both VBLaST-SS© and the traditional FLS box trainer. The performance scores on each system were calculated based on time (s), deviations to the black dots (mm), and incision gap (mm). The participants were then asked to finish a 13-item questionnaire with ratings from 1 (not realistic/useful) to 5 (very realistic/useful) regarding the face validity of the simulator. A Wilcoxon signed rank test was performed to identify differences in performance on the VBLaST-SS© compared to that of the traditional FLS box trainer. RESULTS: Three questions from the face validity questionnaire were excluded due to lack of response. Ratings to 8 of the remaining 10 questions (80%) averaged above 3.0 out of 5. Average intracorporeal suturing completion time on the VBLaST-SS© was 421 (SD = 168 s) seconds compared to 406 (175 s) seconds on the box trainer (p = 0.620). There was a significant difference between systems for the incision gap (p = 0.048). Deviation in needle insertion from the black dot was smaller for the box trainer than the virtual simulator (1.68 vs. 7.12, p < 0.001). CONCLUSION: Participants showed comparable performance on the VBLaST-SS© and traditional box trainer. Overall, the VBLaST-SS© system showed face validity and has the potential to support training for the suturing skills.

Correction to: Validation of a virtual intracorporeal suturing simulator.

The surname of Sreekanth Arikatla incorrectly appeared as Sreekanth Artikala.

Self-assembly of core-shell structures driven by low doping limit of Ti in LiCoO2: first-principles thermodynamic and experimental investigation.

Introducing additives is a general method of performance improvement in materials engineering, but details regarding whether the additive is doped in the host crystal or present as a secondary phase are usually examined from experimental experience, with a systematic theoretical prediction lacking, which sometimes causes controversy on the role of additives. In this study, the dopability of Ti in crystalline LiCoO2 (LCO) is investigated by a first-principles simulation method, and the doping limit is quantitatively calculated. The probability of Ti substitution for Co is examined and related to point-defect formation in LCO as a function of the general experimental variables of temperature and gas-phase partial pressures, enabling practical use of the theoretical model for real experiments. It was found that Ti substitution for Co, accompanied by the formation of a Li vacancy, is the most probable Ti doping form in LCO, but the doping limit is very low and most Ti would segregate into secondary phases. The theoretical prediction showed good agreement with the experimental results. Based on theoretical predictions, particles having LCO cores and Ti-rich shells are obtained from a simple sol-gel route followed by one-step firing without additional surface treatment. The high-voltage cyclability of LCO is greatly improved. The method demonstrated in this study may be a useful tool for screening suitable coating or doping elements for various material systems and provide a guide for designing simple spontaneous coating processes, as in this study.

One-shot skill assessment in high-stakes domains with limited data via meta learning.

Deep Learning (DL) has achieved robust competency assessment in various high-stakes fields. However, the applicability of DL models is often hampered by their substantial data requirements and confinement to specific training domains. This prevents them from transitioning to new tasks where data is scarce. Therefore, domain adaptation emerges as a critical element for the practical implementation of DL in real-world scenarios. Herein, we introduce A-VBANet, a novel meta-learning model capable of delivering domain-agnostic skill assessment via one-shot learning. Our methodology has been tested by assessing surgical skills on five laparoscopic and robotic simulators and real-life laparoscopic cholecystectomy. Our model successfully adapted with accuracies up to 99.5 % in one-shot and 99.9 % in few-shot settings for simulated tasks and 89.7 % for laparoscopic cholecystectomy. This study marks the first instance of a domain-agnostic methodology for skill assessment in critical fields setting a precedent for the broad application of DL across diverse real-life domains with limited data.

Achieving Fast Oxygen Reduction on Oxide Electrodes by Creating 3D Multiscale Micro-Nano Structures for Low-Temperature Solid Oxide Fuel Cells.

Fast oxygen reduction reaction (ORR) at the cathode is a key requirement for the realization of low-temperature solid oxide fuel cells (SOFCs). While the design of three-dimensional (3D) structures has emerged as a new and promising approach to improving the electrochemical performance of SOFC cathodes, achieving versatile structures and structural stability is still challenging. In this study, we demonstrate a novel architectural design for a superior cathode with fast ORR activity. By employing a completely new fabrication process comprising a 3D printing technique and pulsed laser deposition (PLD), we design 3D La0.8Sr0.2CoO3-δ (LSC) micro-nano structures with the desired shape. 3D-printed yttria-stabilized ZrO2 (YSZ) microstructures significantly increase the ratio of surface area to volume while maintaining suitable ionic conductivity comparable to that of single-crystalline YSZ substrates. Scanning electron microscopy and energy dispersive X-ray microanalysis reveal the formation of crack- or void-free YSZ microstructures and the uniform deposition of LSC films by PLD on the YSZ microstructures. The 3D LSC micro-nano structures show significantly enhanced oxygen surface exchange coefficients (kchem) extracted from electrical conductivity relaxation (ECR) measurements by up to 3 orders of magnitude relative to the bulk LSC. Furthermore, electrochemical impedance spectroscopy measurements verify the kchem values from ECR and no directional difference in the measured ORR activity depending on the shape of 3D microstructures. The dramatic enhancement of the ORR activity of LSC is attributed to the increased film surface areas resulting from the 3D YSZ microstructures.

Tuning Ionic Conductivity in Fluorite Gd-Doped CeO2-Bixbyite RE2O3 (RE = Y and Sm) Multilayer Thin Films by Controlling Interfacial Strain.

Interfacial strain in heteroepitaxial oxide thin films is a powerful tool for discovering properties and recognizing the potential of materials performance. Particularly, facilitating ion conduction by interfacial strain in oxide multilayer thin films has always been seen to be a highly promising route to this goal. However, the effect of interfacial strain on ion transport properties is still controversial due to the difficulty in deconvoluting the strain contribution from other interfacial phenomena, such as space charge effects. Here, we show that interfacial strain can effectively tune the ionic conductivity by successfully growing multilayer thin films composed of an ionic conductor Gd-doped CeO2 (GDC) and an insulator RE2O3 (RE = Y and Sm). In contrast to compressively strained GDC-Y2O3 multilayer films, tensile strained GDC-Sm2O3 multilayer films demonstrate the enhanced ionic conductivity of GDC, which is attributed to the increased concentration of oxygen vacancies. In addition, we demonstrate that increasing the number of interfaces has no impact on the further enhancement of the ionic conductivity in GDC-Sm2O3 multilayer films. Our findings demonstrate the unambiguous role of interfacial strain on ion conduction of oxides and provide insights into the rational design of fast ion conductors through interface engineering.

Quality of laparoscopic camera navigation in robot-assisted versus conventional laparoscopic surgery for rectal cancer: An analysis of surgical videos through a video processing computer software.

BACKGROUND: To compare laparoscopic camera navigation (LCN) quality between robot-assisted laparoscopic surgery (RALS) and conventional laparoscopic surgery (CLS). METHODS: 20 recordings were selected by propensity score matching and subjected to Python® software to generate single frames at one second intervals. For each frame, the pixel where the camera should be centred, based on instrument position, current action (dissection/haemostasis/traction) in the frame, was detected. LCN quality was reviewed by two independent surgeons to evaluate erroneous LCN. RESULTS: RALS had higher incidence of centred views (83.1 ± 4.02% vs. 76.0 ± 2.38%, p < 0.05) and a shorter distance between actual and optimal frame centres (123.3 ± 9.8 vs. 144.8 ± 13.9, p < 0.05) compared to CLS. Erroneous camera navigations were more frequent in CLS regarding total time of horizontal alignment failure (2.1 ± 2.2 vs. 6.0 ± 5.4 min, p = 0.063) and number of excessive zoom-in visualization (0.1 ± 0.3 vs. 1.9 ± 1.4, p = 0.003). CONCLUSIONS: RALS provided higher LCN quality than did CLS, emphasising the benefits of a surgeon-controlled view.