Is Precision Surgery Applicable to Colorectal Liver Metastases? A Systematic Review and Meta-analysis of Studies that Investigate the Association of Surgical Technique with Outcomes in the Context of Distinct Tumor Biology.

BACKGROUND: Although some data suggest that patients with mutRAS colorectal liver metastases (CRLM) may benefit from anatomic hepatectomy, this topic remains controversial. We performed a systematic review and meta-analysis to determine whether RAS mutation status was associated with prognosis relative to surgical technique [anatomic resection (AR) vs. nonanatomic resection (NAR)] among patients with CRLM. PATIENTS AND METHODS: A systematic review and meta-analysis of studies were performed to investigate the association of AR versus NAR with overall and liver-specific disease-free survival (DFS and liver-specific DFS, respectively) in the context of RAS mutation status. RESULTS: Overall, 2018 patients (831 mutRAS vs. 1187 wtRAS) were included from five eligible studies. AR was associated with a 40% improvement in liver-specific DFS [hazard ratio (HR) = 0.6, 95% confidence interval (CI) 0.44-0.81, p = 0.01] and a 28% improvement in overall DFS (HR = 0.72, 95% CI 0.54-0.95, p = 0.02) among patients with mutRAS tumors; in contrast, AR was not associated with any improvement in liver-specific DFS or overall DFS among wtRAS patients. These differences may have been mediated by the 40% decreased incidence in R1 resection among patients with mutRAS tumors who underwent AR versus NAR [relative risk (RR): 0.6, 95% CI 0.40-0.91, p = 0.02]. In contrast, the probability of an R1 resection was not decreased among wtRAS patients who underwent AR versus NAR (RR: 0.93, 95% CI 0.69-1.25, p = 0.62). CONCLUSIONS: The data suggest that precision surgery may be relevant to CRLM. Specifically, rather than a parenchymal sparing dogma for all patients, AR may have a role in individuals with mutRAS tumors.

Identification of Pediatric Tumors Intraoperatively Using Indocyanine Green (ICG).

BACKGROUND: Fluorescence-guided surgery (FGS) with indocyanine green (ICG) is increasingly applied in pediatric surgical oncology. However, FGS has been mostly reported in case studies of liver or renal tumors. Applying novel technologies in pediatric surgical oncology is more challenging than in adult surgical oncology due to differences in tumor histology, biology, and fewer cases. No consensus exists on ICG-guided FGS for surgically managing pediatric solid tumors. Therefore, we reviewed the literature and discuss the limitations and prospects of FGS. METHODS: Using PRISMA guidelines, we analyzed articles on ICG-guided FGS for childhood solid tumors. Case reports, opinion articles, and narrative reviews were excluded. RESULTS: Of the 108 articles analyzed, 17 (14 retrospective and 3 prospective) met the inclusion criteria. Most (70.6%) studies used ICG to identify liver tumors, but the timing and dose of ICG administered varied. Intraoperative outcomes, sensitivity and specificity, were reported in 23.5% of studies. Fluorescence-guided liver resections resulted in negative margins in 90-100% of cases; lung metastasis was detected in 33% of the studies. In otolaryngologic malignancies, positive margins without fluorescence signal were reported in 25% of cases. Overall, ICG appeared effective and safe for lymph node sampling and nephron-sparing procedures. CONCLUSIONS: Despite promising results from FGS, ICG use varies across the international pediatric surgical oncology community. Underreported intraoperative imaging outcomes and the diversity and rarity of childhood solid tumors hinder conclusive scientific evidence supporting adoption of ICG in pediatric surgical oncology. Further international collaborations are needed to study the applications and limitations of ICG in pediatric surgical oncology.

High-definition 3D exoscope-assisted tonsillectomy.

Tonsillectomy is one of the most frequent surgical procedures performed by ENT surgeons. The high-definition 3D exoscope showed to be a promising tool to substitute the operating microscope in performing microsurgical procedures. However, transoral surgery might represent an innovative application of this visualization and magnification tool. In this video, a bilateral tonsillectomy was performed entirely under exoscopic visualization by an ENT resident. The high-definition 3D exoscope allowed to conduct the procedure with higher precision, with potential benefits in terms of complications and postoperative pain. Moreover, the use of the exoscope demonstrated important benefit from the educational perspective, allowing the senior surgeon to continuously monitor the resident without interruptions and position changes. The exoscopic-assisted tonsillectomy is a valuable alternative to conventional transoral procedures, and the superiority of this technique should be further investigated in cohort studies.

[The development of laser technologies in vitreoretinal surgery (publications review)].

The article presents review of scientific publications on development of laser treatment methods in vitreoretinal surgery. The use of photo-therapy in medicine dates back to ancient times, when people began to use sunlight as treatment of various diseases. The heyday of photo-therapy falls on the second half of the XIX century, which was associated with the invention of first electric lamps. In 1960, T. Maiman developed the world's first laser, revolutionizing precision and control of light delivery. This was the beginning of heyday of laser surgery primarily in ophthalmology, where potential of lasers was instantly recognized. The subsequent discovery of argon laser in 1964 by W. Bridges (USA) marked new era in retinal photo-coagulation. Then new types of lasers with various systems of delivering laser radiation appeared that significantly expanded range of application of laser technologies in ophthalmology and vitreoretinal surgery. Currently, the lasers are applied in oculoplasty, refractive and corneal surgery, in laser support of phacoemulsification of cataract, in treatment of glaucoma, in laser coagulation of retina and thermotherapy. In vitreoretinal surgery laser technologies remain at the level of the XX century. Thus, they are still applied only for endolaser coagulation of retina. And this despite the fact that there is immense potential for applying lasers as "laser scalpel" to remove vitreous humor, epiretinal fibrosis, retinotomy and choroidotomy.

Intraoperative fluorescence molecular imaging accelerates the coming of precision surgery in China.

PURPOSE: China has the largest cancer population globally. Surgery is the main choice for most solid cancer patients. Intraoperative fluorescence molecular imaging (FMI) has shown its great potential in assisting surgeons in achieving precise resection. We summarized the typical applications of intraoperative FMI and several new trends to promote the development of precision surgery. METHODS: The academic database and NIH clinical trial platform were systematically evaluated. We focused on the clinical application of intraoperative FMI in China. Special emphasis was placed on a series of typical studies with new technologies or high-level evidence. The emerging strategy of combining FMI with other modalities was also discussed. RESULTS: The clinical applications of clinically approved indocyanine green (ICG), methylene blue (MB), or fluorescein are on the rise in different surgical departments. Intraoperative FMI has achieved precise lesion detection, sentinel lymph node mapping, and lymphangiography for many cancers. Nerve imaging is also exploring to reduce iatrogenic injuries. Through different administration routes, these fluorescent imaging agents provided encouraging results in surgical navigation. Meanwhile, designing new cancer-specific fluorescent tracers is expected to be a promising trend to further improve the surgical outcome. CONCLUSIONS: Intraoperative FMI is in a rapid development in China. In-depth understanding of cancer-related molecular mechanisms is necessary to achieve precision surgery. Molecular-targeted fluorescent agents and multi-modal imaging techniques might play crucial roles in the era of precision surgery.

Sex and Gender-Related Differences in the Outcome of Total Hip Arthroplasty: A Current Concepts Review.

Background and Objectives: Sex and gender-related differences may influence the outcome of patients undergoing total hip arthroplasty (THA). The present paper aims to depict the importance of sex and gender-related issues in the perioperative management of patients undergoing THA to improve clinical outcomes and prevent postoperative complications. Materials and Methods: From January 2002 to August 2022, OVID-MEDLINE, EMBASE, SCOPU S, Web of Science, Google Scholar, and PubMed were searched to identify relevant studies for further analysis. The search strategy included the following terms: (("gender-related differences" [MeSH Terms] OR "sex-related differences" [All Fields]) OR ("gender indicators" [MeSH Terms] OR "sex" [All Fields])) AND ("total hip arthroplasty" [MeSH Terms] OR (total hip replacement [All Fields])). Results: Twenty-eight papers were included in this current concepts review. Sex and gender-related differences were analyzed with regard to the following points: (1) surgical approach, robotic surgery, scar cosmesis, and implant choice; (2) postoperative clinical outcome and complications; (3) sexual activity after THA; and (4) psychological status and daily functional requirements. The data analysis showed that female patients need more specific attention in the preoperative, intraoperative, and postoperative phases to improve clinical and functional outcomes, reduce complications risk, and manage patient satisfaction. Conclusions: THA outcomes may be influenced by sex and gender-related factors which should be carefully assessed and addressed in patients undergoing surgery to improve the postoperative outcomes of patients' satisfaction and reduce postoperative complications that can differ between the two sexes.

Clinical translation and implementation of optical imaging agents for precision image-guided cancer surgery.

INTRODUCTION: The field of tumor-specific fluorescence-guided surgery has seen a significant increase in the development of novel tumor-targeted imaging agents. Studying patient benefit using intraoperative fluorescence-guided imaging for cancer surgery is the final step needed for implementation in standard treatment protocols. Translation into phase III clinical trials can be challenging and time consuming. Recent studies have helped to identify certain waypoints in this transition phase between studying imaging agent efficacy (phase I-II) and proving patient benefit (phase III). TRIAL INITIATION: Performing these trials outside centers of expertise, thus involving motivated clinicians, training them, and providing feedback on data quality, increases the translatability of imaging agents and the surgical technique. Furthermore, timely formation of a trial team which oversees the translational process is vital. They are responsible for establishing an imaging framework (camera system, imaging protocol, surgical workflow) and clinical framework (disease stage, procedure type, clinical research question) in which the trial is executed. Providing participating clinicians with well-defined protocols with the aim to answer clinically relevant research questions within the context of care is the pinnacle in gathering reliable trial data. OUTLOOK: If all these aspects are taken into consideration, tumor-specific fluorescence-guided surgery is expected be of significant value when integrated into the diagnostic work-up, surgical procedure, and follow-up of cancer patients. It is only by involving and collaborating with all stakeholders involved in this process that successful clinical translation can occur. AIM: Here, we discuss the challenges faced during this important translational phase and present potential solutions to enable final clinical translation and implementation of imaging agents for image-guided cancer surgery.

How molecular imaging will enable robotic precision surgery : The role of artificial intelligence, augmented reality, and navigation.

Molecular imaging is one of the pillars of precision surgery. Its applications range from early diagnostics to therapy planning, execution, and the accurate assessment of outcomes. In particular, molecular imaging solutions are in high demand in minimally invasive surgical strategies, such as the substantially increasing field of robotic surgery. This review aims at connecting the molecular imaging and nuclear medicine community to the rapidly expanding armory of surgical medical devices. Such devices entail technologies ranging from artificial intelligence and computer-aided visualization technologies (software) to innovative molecular imaging modalities and surgical navigation (hardware). We discuss technologies based on their role at different steps of the surgical workflow, i.e., from surgical decision and planning, over to target localization and excision guidance, all the way to (back table) surgical verification. This provides a glimpse of how innovations from the technology fields can realize an exciting future for the molecular imaging and surgery communities.

The Click-On gamma probe, a second-generation tethered robotic gamma probe that improves dexterity and surgical decision-making.

PURPOSE: Decision-making and dexterity, features that become increasingly relevant in (robot-assisted) minimally invasive surgery, are considered key components in improving the surgical accuracy. Recently, DROP-IN gamma probes were introduced to facilitate radioguided robotic surgery. We now studied if robotic DROP-IN radioguidance can be further improved using tethered Click-On designs that integrate gamma detection onto the robotic instruments themselves. METHODS: Using computer-assisted drawing software, 3D printing and precision machining, we created a Click-On probe containing two press-fit connections and an additional grasping moiety for a ProGrasp instrument combined with fiducials that could be video tracked using the Firefly laparoscope. Using a dexterity phantom, the duration of the specific tasks and the path traveled could be compared between use of the Click-On or DROP-IN probe. To study the impact on surgical decision-making, we performed a blinded study, in porcine models, wherein surgeons had to identify a hidden 57Co-source using either palpation or Click-On radioguidance. RESULTS: When assembled onto a ProGrasp instrument, while preserving grasping function and rotational freedom, the fully functional prototype could be inserted through a 12-mm trocar. In dexterity assessments, the Click-On provided a 40% reduction in movements compared to the DROP-IN, which converted into a reduction in time, path length, and increase in straightness index. Radioguidance also improved decision-making; task-completion rate increased by 60%, procedural time was reduced, and movements became more focused. CONCLUSION: The Click-On gamma probe provides a step toward full integration of radioguidance in minimal invasive surgery. The value of this concept was underlined by its impact on surgical dexterity and decision-making.

[Research frontiers in precision therapy for liver cancer].

Hepatocellular carcinoma (HCC), a fatal malignancy, is highly prevalent in China. Recently, tremendous achievements have been made in HCC, both in the clinical management and the understanding of cancer biology. The discovery and application of novel serum biomarkers, such as proteins, miRNAs, and cfDNA (cell-free circulating DNA) methylation will facilitate the early management of HCC. Improvements in radiological and computational technology have made the practice of precision liver surgery a true reality. The emergence of novel molecular targeted therapies, immunotherapy and their combinations has significantly prolonged patient survival rate, but the therapeutic breakthroughs are still needed. Integrated multi-omics analysis has broadened our understanding of HCC pathogenesis, providing an unprecedented molecular characterization of HCC and revealing new therapeutic opportunities. Technological innovations and revolutions such as single-cell sequencing, genome editing, and innovative drug research and development will greatly accelerate our understanding of HCC biology and bring new therapeutic opportunities. Nevertheless, HCC is a highly heterogeneous and treatment-refractory malignancy, therefore deep insights into the biology of the disease and novel therapies for HCC remain an unmet medical need.

Development and validation of 3D printed virtual models for robot-assisted radical prostatectomy and partial nephrectomy: urologists' and patients' perception.

PURPOSE: To test the face and content validity of 3D virtual-rendered printed models used before robot-assisted prostate cancer and nephron-sparing surgery. METHODS: Patients who underwent live surgery during an international urological meeting organized in January 2017 were enrolled. Those with organ-confined prostate cancer underwent robot-assisted radical prostatectomy. Patients with a single renal tumor underwent minimally invasive nephron-sparing surgery. High-resolution (HR) imaging was obtained for all patients. Those with kidney tumors received contrast-enhanced CT scan with angiography; those with prostate cancer underwent mp-MRI. Images in DICOM format were processed by dedicated software. The first step was the rendering of a 3D virtual model. The models were then printed. They were presented during the live surgery of the urological meeting. All the participants and the operated patients were asked to fill a questionnaire about their opinion expressed in Likert scale (1-10) about the use and application of the 3D printed models. RESULTS: 18 patients were enrolled, including 8 undergoing robot-assisted radical prostatectomy and 10 undergoing minimally invasive partial nephrectomy. For each patient, a virtual 3D printed model was created. The attendants rated the utility of printed models in surgical planning, anatomical representation and the role of technology in surgical training as 8/10, 10/10 and 9/10, respectively. All patients reported favorable feedbacks (from 9 to 10/10) about the use of the technology during the case discussion with the surgeon. CONCLUSIONS: In our experience, 3D printing technology has been perceived as a useful tool for the purpose of surgical planning, physician education/training and patient counseling. Further researches are expected to increase the level of evidence.

Furthering Precision in Sentinel Node Navigational Surgery for Oral Cancer: a Novel Triple Targeting System.

To describe an innovative sentinel lymph node (SLN) guidance approach using a radionuclide tracer, 3D augmented reality-guided imaging, and near infrared (NIR) fluorescence over-lay imaging with hand-held probes to optimize accuracy, efficiency, and precise navigation for sentinel node (SN) localization in head and neck cancer. In a cT1N0M0 squamous cell carcinoma of the tongue, pre-operative radionuclide lymphoscintigraphy was performed with a sentinel node-specific radiolabeled tracer. Intraoperatively, a 3D hand-held augmented reality (AR) scanning SPECT probe assessed concordance of the SN with pre-operative SPECT-CT images. The real-time optical video was linked to the SPECT-CT images for added precision. Final guidance to the SN was performed using ICG fluorescence imaging. Dynamic and SPECT-CT showed bilateral lymphatic drainage from the tumor. The 3D hand-held AR SPECT probe SN localization was concordant with pre-operative imaging. The optical video successfully demonstrated the lymphatic drainage in real-time through a unique overlay fluorescence image. The ICG localized to the same nodes identified by both the SPECT-CT and hand-held SPECT images. The use of dual radiation and fluorescence tracers improved SN detection, especially for SN close to the injection site. The hand-held probes allowed the surgeon to dissect continuously, without needing to change tools. The combination of augmented reality, nuclear medicine, and over-lay fluorescence imaging allowed greater accuracy for matching the preoperative imaging with intraoperative identification and precisely guiding the dissection. This method uniquely permitted the surgeon to efficiently dissect the SN with accurate visualization and optimal precision.

Potential Risk of Intelligent Technologies in Clinical Orthopedics.

Nowadays, the intelligent technologies are getting more and more attention, and the surgical robot is one of the most typical representatives. Orthopedic robots have revolutionized orthopedic surgery, but there are also risks. The risks can be categorized into those directly related to the use of the robotic system and the general risks of the operative procedure. This paper analyzes the potential risks of intelligent technologies in clinical orthopedics from three aspects, including surgical planning and strategies, spatial registration, and robotic guidance and navigation. Through these summaries, we hope to help clinical doctors better understand intelligent orthopedic techniques and promote a wide range of clinical applications of intelligent orthopedics. Besides, we also indicate the future research direction of intelligent orthopedic techniques, such as risk analysis, safety assessment, and risk management system.

[Application of perihilar surgical techniques in perihilar biliary tract tumours].

Perihilar biliary tract tumours include hilar cholangiocarcinoma, gallbladder cancer invading the hepatic hilum and intrahepatic cholangiocarcioma invading the hepatic hilum.The tumours have the special characteristics such as strong invasion capability, the anatomic variant, the pathophysiological complexity, the biological behavior diversity and the difficulty of preoperative evaluation which result in low R0 resection rate, more postoperative complications, more mortality and poor prognosis.The perihilar surgical techniques system aims to set a reasonable and individual operation procedure on the principle of precision surgery by taking the key technique of hilar dissection and exposing, evaluting the hilar anatomy by the means of three-dimensional digital medical image evaluation system, evaluting the relationship between the tumour and hepatic artery and portal vein under the condition of hepatic hilum complete exposure by combining anterograde and retrograde route from intra and extra-hepatic direction to hepatic hilum.The perihilar surgical techniques system is applied to improve the accuracy of resectable evaluation, the R0 radical resection rate, the safety of operation and the accuracy of cholangiojejunostomy through the accurate preoperative evaluation, the detailed operation plan, the accurate intraoperative reassessment, the perfect operative procedure and the excellent postoperative management, eventually for the purpose of reducing the postoperative complications rate and perioperative mortality and improving the prognosis of perihilar biliary tract tumours.

The Perfect Total Mesorectal Excision Obviates the Need for Anything Else in the Management of Most Rectal Cancers.

This article discusses the local control of primary rectal cancer and its locoregional spread in the light of modern advances. In recent years, the use of neoadjuvant chemoradiation has spread widely. However, its true benefit is not always balanced with its morbidities. Often total mesorectal excision (TME) is the best option. We will discuss the indications for immediate surgery for chemoradiation in advance and the importance of a delay in the management plan. To understand this selection, it is mandatory to know the true extent of tissue at risk for tumor dissemination and spread. Considering that TME may be enough for many patients and that most local recurrences are failures of surgical technique we introduce a new concept of total mesorectal irradiation. This exploits the new reality that precise, focused neoadjuvant therapy can offer a better response with fewer complications. Together these important changes in cancer board (multidisciplinary team) planning can also offer selected patients complete control of their cancer with no need for surgery.

3D-4K Exoscope-Assisted CO2 Laser Supraglottoplasty for Severe Laryngomalacia in a Pediatric Patient.

Laryngomalacia is the most frequent congenital laryngeal anomaly. Surgery is possible by means of cold knife, carbon dioxide (CO2 ) laser, microdebrider and coblation, traditionally under microscopic view. We here describe the use of the 3D-4K exoscope assisted CO2 laser supraglottoplasty in tubeless general anesthesia in spontaneous breathing in a 5 month-old patient with severe laryngomalacia. Laryngoscope, 134:1359-1362, 2024.

Challenges and Opportunities for Precision Surgery for Colorectal Liver Metastases.

The incidence of colorectal cancer and colorectal liver metastases (CRLM) is increasing globally due to an interaction of environmental and genetic factors. A minority of patients with CRLM have surgically resectable disease, but for those who have resection as part of multimodal therapy for their disease, long-term survival has been shown. Precision surgery-the idea of careful patient selection and targeting of surgical intervention, such that treatments shown to be proven to benefit on a population level are the optimal treatment for each individual patient-is the new paradigm of care. Key to this is the understanding of tumour molecular biology and clinically relevant mutations, such as KRAS, BRAF, and microsatellite instability (MSI), which can predict poorer overall outcomes and a poorer response to systemic therapy. The emergence of immunotherapy and hepatic artery infusion (HAI) pumps show potential to convert previously unresectable disease to resectable disease, in addition to established systemic and locoregional therapies, but the surgeon must be wary of poor-quality livers and the spectre of post-hepatectomy liver failure (PHLF). Volume modulation, a cornerstone of hepatic surgery for a generation, has been given a shot in the arm with the advent of liver venous depletion (LVD) ensuring significantly more hypertrophy of the future liver remnant (FLR). The optimal timing of liver resection for those patients with synchronous disease is yet to be truly established, but evidence would suggest that those patients requiring complex colorectal surgery and major liver resection are best served with a staged approach. In the operating room, parenchyma-preserving minimally invasive surgery (MIS) can dramatically reduce the surgical insult to the patient and lead to better perioperative outcomes, with quicker return to function.

Textbook outcome of laparoscopic hepatectomy in the context of precision surgery: A single center experience.

OBJECTIVE: Laparoscopic hepatectomy (LH) has become a common surgery for the treatment of liver tumor. To evaluate the surgical quality of laparoscopic hepatectomy under the context of precision surgery with Textbook outcome (TO), a comprehensive and holistic assessment approach. METHODS: A total of 1056 patients who underwent laparoscopic hepatectomy from May 2016 and December 2022 were enrolled in the study. All the patients were performed hepatectomy. The rate of TO and factors associated with achieving TO were examined. RESULTS: Among the 1056 patients, 75 % patients achieved TO. The main reason limited patients achieving textbook outcomes was prolonged length of hospital stay (LOS). The univariate analysis indicated that age>65, ASA classification ≥3, liver cirrhosis, tumor size > 3 cm, tumor number ≥2, type of primary cancer, and IWATE DSS were significantly associated with non-achievement of TO. The multivariate analysis indicated that the ASA classification ≥3 and advanced difficulty level in IWATE DSS independent factors associated with achieving TO. Reaching TO can significantly prolong the postoperative recurrence time and overall survival time of hepatocellular carcinoma patients. CONCLUSION: In the context of precision surgery, 75 % patients undergoing laparoscopic hepatectomy achieved a TO. Patients who achieved TO had significantly improved survival.