FOREWORD by Volkmar Falk, MD, Director of the Department of Cardiothoracic Surgery, Charité, Universitätsmedizin Berlin, Berlin, Germany
Mechatronic Support System for NOTES and Monoport Surgery – A New Approach
Hubertus Feussner, MD, Founder, MITI Research Group, Professor, Yannick Krieger, MSc, Scientific Head of Medical Robotics & Mechanisms, Dirk Wilhelm, MD, Medical/Clinical Head of MITI, Stephan Brunner, Student, Daniel Ostler, MSc, Scientific Head of MITI, Tim Lueth, MD, Institute of Micro Technology and , Medical Device Technology, Alexander Meining, MD, Chair of InExEn (Interventional &, Experimental Endoscopy), Clinic for Internal Medicine I, Center for Internal Medicine, Ulm University Hospital, Ulm, Germany
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To circumvent the drawbacks of currently available platforms for natural orifice transluminal endoscopic surgery (NOTES) and monoport surgery (MPS), we developed a patient-specific, disposable, surgical soft robotic system. The system (Single-Port Overtube; SPOT) is designed as an overtube for standard surgical equipment. The platform body and the manipulators can be quickly adapted to transmural (monoport), NOTES and endoluminal (endoscopic) applications, and 3D-printed overnight as an individualized system. In addition, practical considerations, such as the predicted “ideal” dimensions of the platform, were evaluated. As a result, we found that preoperatively available biometric data currently provide little support for tailored instrument design. Further work is required to provide engineers / developers with more useful preoperative information.
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Estimating the Incidence of Stray Energy Burns during Laparoscopic Surgery based on Two Statewide Databases and Retrospective Rates: An Opportunity to Improve Patient Safety
Carlos Guzman, MD, Clinical Assistant Instructor, School of Medicine, Stony Brook Medical Center, Stony Brook, NY, Jared A. Forrester, MD, Resident Physician, General Surgery , School of Medicine, Stanford University, Stanford, CA, Pascal R. Fuchshuber, MD, General and Oncologic Surgery, Wound Care Specialist, Vohra Physicians Associate Professor of Surgery, Walnut Creek, CA, Jeffery L Eakin, MD, Trauma and Hernia Center Director, Jordan Valley Medical Center, Minimally Invasive and Bariatric Surgeons, Salt Lake City, UT
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Background: The growth of laparoscopic surgery has increased the use of laparoscopic electrosurgical devices based on radiofrequency current. Despite an improvement in most post-operative outcomes, the use of these devices can be associated with inadvertent thermal or mechanical injuries, also called accidental punctures and lacerations (APLs). APLs can occur through either operator error or system error, including insulation failure or capacitive coupling resulting in stray energy burns. Our aim was to estimate the incidence and—as a result—the impact of laparoscopic APLs.
Methods: A retrospective analysis of the Healthcare Cost and Utilization Project (HCUP) State Inpatient Database (SID) was performed for 2009 in California (CA) and Florida (FL). ICD-9 codes and current procedural terminology were used to query for five common general surgery procedures: appendectomy, cholecystectomy, fundoplication, gastric bypass, and gastroplasty with these procedures cross-referenced for any secondary procedure at the time of the initial surgery indicative of APLs. The c2 test was used for comparisons where appropriate.
Results: Overall, 192,794 primary laparoscopic procedures were identified in the HCUP database in CA and FL in 2009, with a similar procedure frequency distribution between CA and FL. Six hundred ninety-four procedures were complicated by APL. Gastric bypass and fundoplication were more commonly associated with APLs.
Conclusion: In this retrospective analysis of procedures performed in CA and FL, the estimated incidence of APL was 3.6 per 1000 cases. Patient morbidity and mortality were likely related to both pilot-error injuries and stray energy burns during laparoscopy. Possible solutions to reduce surgical complications from APL include educational programs to reduce pilot error and the incorporation of fail-safe technologies to eliminate stray energy burns, such as active electrode monitoring and use of non-radiofrequency current (true cautery).
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Comparative Thermal Effects of J-Plasma®, Monopolar, Argon, and Laser Electrosurgery in a Porcine Tissue Model
Salome Masghati, MD, Fellow, University of Nevada, Las Vegas, School of Medicine, Las Vegas, Nevada, Jasmine Pedroso, MD, MPH, Associate Fellowship Director, Medical Director, Melissa Gutierrez, MD, Director of Robotic Surgery, Erica Stockwell, DO, MBA, Director of Innovation and Business Education, K. Warren Volker, MD, PhD, Fellowship Program Director, David L. Howard, MD, PHD, Director of Research, WellHealth QualityCare, a DaVita Medical Group, University of Nevada, Las Vegas, School of Medicine, Las Vegas, Nevada
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Introduction: The objective of this study was to understand how J-Plasma® (Bovie Medical Corporation, Clearwater, Florida) surgical energy compares to monopolar, argon beam, and CO2 laser devices in terms of depth of penetration and lateral thermal spread in a porcine tissue model.
Materials and methods: Using a porcine animal model, we applied the thermal energy of the J-Plasma® laser, Bovie Monopolar Pencil™ (Bovie Medical Corporation, Clearwater, Florida), argon beam coagulator, and CO2 laser to porcine small bowel, bladder, and peritoneal tissues at equivalent settings. Tissue was excised and sent to pathology for histologic evaluation. Primary outcome was depth of penetration and lateral thermal spread.
Results: When applied to peritoneum tissue, CO2 laser had the greatest lateral thermal spread at 2.99mm, while the argon beam had the lowest at just under 1.5mm. With regard to depth of penetration, the monopolar pencil had the highest while J-Plasma® had the lowest. When applied to bladder tissue, the argon beam was associated with the greatest lateral thermal spread (3.1mm) as compared to the other three devices (all less than 1mm). In terms of depth of penetration of bladder tissue, J-Plasma® again had the lowest value, while the monopolar pencil had the highest. When applied to small intestine tissue, the argon beam had the greatest lateral spread (3.51mm), while J-Plasma® had the lowest (less than 1mm). Regarding depth of penetration of small intestine tissue, argon beam had the highest value at 1.8mm compared to the other three devices (all below 0.6mm).
Conclusion: Consistent with our previous study, J-Plasma® had minimal lateral and depth spread when applied to various tissue types. J-Plasma® performed better or similar when compared to monopolar, argon beam, and laser electrosurgical devices. Further studies in-vivo are needed to evaluate safety and surgical application of the J-Plasma® device.
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Normothermia is Best Achieved by Warming Above and Below with Pre-warming Adjunct: A Comparison of Conductive Fabric Versus Forced-air and Water
Kenji Ohki, MD, Manager, Mitsuyoshi Yoshida, MD, Anesthesiologist, Kuyo Kanosue, MD, Anesthesiologist, Saiseikai Shimonoseki General Hospital, Shimonoseki, Japan, Kohki Yamamoto, MD, Research Associate, Anesthesiologist, Rumi Kawano, MD, Research Associate, Anesthesiologist, Yamaguchi University Graduate School, of Medicine, Yamaguchi, Japan
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Background: Although forced-air warming is the most commonly used method for perioperative patient warming, it is fundamentally problematic because it disturbs the carefully designed airflow in the operating room. Because unintended hypothermia has significant consequences, there is a need for more effective warming strategies. The effectiveness of warming technologies that apply heat through the skin is based on surface-area contact with the heat source and the duration of pre-warming. Therefore, we sought to test the therapeutic effectiveness of combined above- and below-warming therapies. Our hospital prohibits forced-air warming before the patient is draped, so a secondary goal was to determine the effect of preoperative warming using a system that does not interfere with airflow in the operating room.
Methods: We prospectively randomized 35 patients undergoing total knee arthroplasty into two groups: 1) forced-air warming/water mattress, using both WarmTouch® upper-body forced-air warming (Medtronic/Covidien Inc., Dublin, Ireland) and a Norm-O-Temp® underbody water mattress (CSZ/Gentherm Inc., Cincinnati, OH, USA), and 2) conductive fabric warming, using a HotDog® electric upper-body blanket (Augustine Temperature Management LLC, Eden Prairie, MN, USA) and a HotDog® underbody mattress.
Results: Throughout the surgical procedure, group 2 patients had significantly higher temperatures; this group experienced superior pre-warming during preoperative preparations and thus the redistribution temperature drop following the induction of anesthesia was reduced. Both groups achieved 100% normothermia by the end of surgery.
Conclusion: Based solely on the temperatures at the end of surgery, these data indicate that forced-air warming in conjunction with a water mattress warming system is as effective as a conductive fabric electric warming system alone.
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Medical Applications of Drones for Disaster Relief: A Review of the Literature
James “Butch” Rosser, Jr, MD, FACS, Director of the Center for the Advanced Treatment of Heartburn, Grant Regional Healthcare Center, Lancaster, WI, Clinical Professor of Surgery, University at Buffalo, Buffalo, NY, Brett C. Parker, MD, Resident Physician, University at Buffalo, Buffalo, NY, Vudatha Vignesh, BSE, University of Central Florida College of Medicine, Orlando, FL
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Introduction: Rapid progress has been made with unmanned aerial systems (UAS), which are now used in a wide variety of different fields, including media, agriculture, wildlife, and infrastructure. However, the application of UAS for medical purposes, and in particular disaster relief efforts, has been slower to develop. This paper will review and present pertinent studies in the literature.
Methodology: Studies related to drones and medical applications for disaster relief were identified as part of a larger search regarding the civilian application of drones. A search for civilian drone applications was performed in the EBSCO (Elton B. Stephens Company) database. Non-civilian applications as well as redundant sources were excluded.
Results: The search identified 711 sources pertaining to civilian drone applications. Of these, 117 involved drone applications in disaster relief, and 28 articles specifically addressed medical uses.
Conclusion: Drones can be useful during immediate and non-immediate medical disaster relief efforts. They can provide an instant telecommunications infrastructure, assist in telemedicine-enabled clinical services, perform equipment/drug/patient delivery, enhance search and rescue efforts, assess damage and map disaster zones. Rapid processing of permission for emergency operations, promotion of industry expansion, public awareness, and public participation must be emphasized for these to become routine applications. There is a major concern about the organizational umbrella that would promote this initiative. Creation of an organization such as a Drone Civil Air Patrol Wing (DCAPW) could improve our ability to provide post-disaster healthcare delivery services.
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Translational Study to Standardize the Safe Use of Bipolar Forceps, LigaSure™, Sonicision™ and PlasmaBlade™ Around the Recurrent Laryngeal Nerve in Thyroid Surgery
Yishen Zhao, MD, Changlin Li, MD, Tie Wang, MD, Le Zhou, MD, PhD, Clinical Assistant Professor, Xiaoli Liu, MD, PhD, Clinical Assistant Professor, Jingwei Xin, MD, PhD, Clinical Assistant Professor, Shijie Li, MD, PhD, Hui Sun, MD, PhD, Professor, Division of Thyroid Surgery, China–Japan Union Hospital of Jilin University, Jilin Provincial Key Laboratory of Surgical Translational Medicine, Changchun, China, Gianlorenzo Dionigi, MD, FACS, Professor, Division for Endocrine and Minimally Invasive Surgery, Department of Human Pathology in Adulthood and Childhood ''G. Barresi'', University Hospital G. Martino, University of Messina, Messina, Italy
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Purpose: We investigated the function of the recurrent laryngeal nerve (RLN) in a live porcine model during adjacent activation with bipolar forceps (BF), LigaSure™ small jaw (LSJ), Sonicision™ and PlasmaBlade™ (PB) devices.
Methods: Each of the energy-based devices (EBD) was activated for 3 seconds at different power settings at 5, 3, 2, and 1 mm from the RLN. Nerve root function and thermal spread were measured by continuous intraoperative neuromonitoring and infrared thermal imaging.
Results: BF: The EMG amplitude decreased to 87% of baseline at a standardized distance. The highest thermal reading was 120°C at 1 mm (average 80.7°C). LSJ: EMG amplitudes were 99% (5mm), 90% (3mm) and 66% (2mm) of the baseline amplitude. At 1mm, the temperatures of the RLN surface and the LSJ tip reached 80.6°C and 100.8°C, respectively. Sonicision™: Under both the minimum and maximum settings, EMG amplitudes remained above 80% of the baseline amplitude. The highest temperatures of the device tip and RLN surface were 135°C and 117.3°C, respectively, at 1 mm. PB: The temperatures of the device tip and RLN surface increased gradually with an increase in the setting (tip 38.3°C to 163.8°C; nerve 34.8°C to 46.2°C). Loss of nerve function occurred at settings 9 and 10. There were no changes in the latency profile under any of the applications.
Conclusions: RLN roots were exposed to increased temperatures when EBDs were applied at close spacing. The results suggest that these 4 EBDs are unsafe when applied at a distance of 1-3 mm from the RLN due to their effects on both EMG and temperature.
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Blended Learning Methods for Surgical Education
Roger Smith, PhD, Chief Technology Officer, Danielle Julian, MS, Research Scientist, Nicholson Center, Florida Hospital, Celebration, Florida, Alyssa Tanaka, PhD, Principal Investigator, Intelligent Training Division, SoarTech Inc., Orlando, Florida
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The emergence and maturation of the concept of blended learning in public and military education may prove equally valuable in CME surgical education and training. Creating a learner-centric environment in which multiple modes of education are encouraged, available, integrated, and accredited can increase the level of competence achieved in CME courses. This paper defines a framework for blended surgical training using principles developed for the military and it is applied in courses at a major post-graduate surgical education center.
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A Retrospective Comparative Analysis of 2D Versus 3D Laparoscopy in Total Laparoscopic Hysterectomy for Large Uteri (≥ 500g)
Rakesh Sinha, MD, Senior Gynecological Endoscopic Surgeon, and Founder, Latika Chawla, DNB, MRCOG, Gynecological Endoscopic Surgeon, Shweta Raje, MD, DNB, Senior Gynecological Endoscopic Surgeon, Gayatri Rao, DGO, DNB, Senior Obstetrician and, Gynecological Endoscopic Surgeon, Women’s Hospital, Mumbai, Maharashtra, India
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Study objective: To evaluate the outcomes of total laparoscopic hysterectomy using 3D vision in comparison with 2D vision in women with large uteri (³500g).
Design: Retrospective analytical study
Design Classification: Canadian Task Force II-1
Setting: Tertiary referral center for advanced gynecological surgery.
Patients: Five hundred forty six women who underwent total laparoscopic hysterectomy over a period of 13 years were studied: 301 under 2D vision and 245 under 3D vision.
Interventions: Total laparoscopic hysterectomy
Measurements: Surgical time, blood loss and complications were recorded for every case in both groups.
Main Results: The duration of surgery for hysterectomy in the 3D laparoscopy group (88.01±36.95 min) was significantly shorter than that in the 2D group (112.61±42.59 min, p=.0001). Blood loss in the 500-1000g group was significantly less in the 3D group (p=.005). The total complication rates for 3D surgery (3.37 %) and 2D surgery (6.64%) were comparable (p=.25).
Conclusion: Three-dimensional laparoscopy provides stereoscopic vision and increases precision and safety. The availability of depth perception adds to the ease of surgery, especially in cases of large uteri, leading to reductions in both the duration of surgery and blood loss, which improves patient outcomes.
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Virtual Reality Simulator Systems in Robotic Surgical Training
Alberto Mangano, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Federico Gheza, MD, Robotic Surgery Research Specialist, Division of General, Minimally Invasive, and Robotic Surgery, University of Illinois at Chicago, Chicago, IL, Pier Cristoforo Giulianotti, MD, FACS, Vice Head, Department of Surgery, Head, Division of General, Minimally Invasive and Robotic Surgery, Professor of Surgery, Distinguished Lloyd M. Nyhus Chair in Surgery, University of Illinois at Chicago, Chicago, IL
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The number of robotic surgical procedures has been increasing worldwide. It is important to maximize the cost-effectiveness of robotic surgical training and safely reduce the time needed for trainees to reach proficiency. The use of preliminary lab training in robotic skills is a good strategy for the rapid acquisition of further, standardized robotic skills. Such training can be done either by using a simulator or by exercises in a dry or wet lab. While the use of an actual robotic surgical system for training may be problematic (high cost, lack of availability), virtual reality (VR) simulators can overcome many of these obstacles. However, there is still a lack of standardization. Although VR training systems have improved, they cannot yet replace experience in a wet lab. In particular, simulated scenarios are not yet close enough to a real operative experience. Indeed, there is a difference between technical skills (i.e., mechanical ability to perform a simulated task) and surgical competence (i.e., ability to perform a real surgical operation). Thus, while a VR simulator can replace a dry lab, it cannot yet replace training in a wet lab or operative training in actual patients. However, in the near future, it is expected that VR surgical simulators will be able to provide total reality simulation and replace training in a wet lab. More research is needed to produce more wide-ranging, trans-specialty robotic curricula.
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Closing the Gap: Novel Abdominal Wound Closure Techniques
James Dana Kondrup, MD,
Assistant Clinical Professor,
Department of Obstetrics/Gynecology,
Our Lady of Lourdes, Memorial Hospital,
Binghamton, New York, Alaina M. Qayyum
Medical Student 4th Year,
Lake Erie College of Osteopathic Medicine,
Erie, Pennsylvania
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Traditionally, surgical procedures within the realm of both general and gynecological surgery employ the use of staples and interrupted sutures that run continuously with knot tying or subcuticular sutures to ensure closure of large wound incisions, subcuticular incisions, and fascial repair. However, these methods may not always be cosmetically favorable and, thus, result in an unpleasant outcome for the patient, adding to their surgery-related stress. It is, therefore, imperative that surgeons and gynecologists are aware of alternative methods of wound closure that are not only cosmetically favorable, but also ensure rapid wound recovery and infection control. Two such products available include DERMABOND™ PRINEO™ Skin Closure System (Ethicon Inc., Somerville New Jersey) and STRATAFIX™ Symmetric PDS™ Plus Knotless Tissue Control Device (Ethicon Inc., Somerville New Jersey). The DERMABOND™ PRINEO™ Skin Closure System is a topical mesh and skin adhesive that creates a strong polymeric bond across wound edges. This permits natural healing to occur, but with a synthetic flexible microbial barrier providing in vitro protection against organisms. The STRATAFIX™ Symmetric PDS™ Plus, on the other hand, is a knotless tissue control device that permits soft tissue approximation in appropriate situations where such absorbable sutures are permitted. This can be used for large fascial closure as well as on the skin. The purpose of this article is to review and share our experience with two alternative methods of wound closure (one for fascia and one for skin) with a review of their composition and benefits and to illustrate their common applications in gynecologic or general surgery when laparotomy is necessary.
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A Prospective Clinical and Instrumental Study on the Effects of a Transcutaneous Cosmeceutical Gel that is Claimed to Produce CO2
Gustavo H Leibaschoff, MD, Gynecologist, President of International Consulting in Aesthetic Medicine (ICAM), President of the International Union of Lipoplasty, Dallas, TX, Luis Coll, MD, Dermatologist, Director of the Center of Research in Video Capillaroscopy, Buenos Aires, Argentina, Wendy E. Roberts, MD, FAAD, Generational and Cosmetic Dermatology, Rancho Mirage, CA
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Carboxytherapy is the therapeutic use of carbon dioxide (CO2) in its gaseous state. Since 1933, carboxytherapy has referred to either the subcutaneous injection of CO2 or percutaneous application in a warm bath. The present clinical study was performed to determine if there were any changes in the dermis after the application of a transcutaneous gel, which is claimed to produce CO2, and, if so, how these changes compared to those with CO2 injection. Ten patients received transcutaneous treatment with the gel on one side of the face and the other side without any product was used as a control. We used videocapillaroscopy with an optic probe (VCSO) to evaluate the changes in the microcirculation of the skin. VCSO was performed for the treated right and untreated left ear lobes in each patient. VCSO was performed before treatment was started (VCSO1) and after 7 days of treatment (VCSO2).A comparison of VCSO1 to VCSO2 showed an increase in the microcirculation, an increase in vertical and horizontal capillaries, and a reduction in the area of ischemia. These results are similar to those observed in other studies with CO2 injection. In conclusion, use of this transcutaneous CO2 gel produced changes in the dermis similar to those observed with subcutaneous injection of CO2.
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Microbial Load of Trocars: Potential Source of Contamination and Surgical Site Infection
Vanessa Aparecida Vilas-Boas, PhD, MSN, RN, Infection Control Nurse, Women's Health Hospital "Prof Dr José Aristodemo Pinotti" (CAISM), University of Campinas (UNICAMP), Campinas/SP - Brazil, Carlos Emílio Levy, PhD, MD, Professor, Clinical Pathology Department, School of Medical Sciences, University of Campinas (UNICAMP), Campinas/SP – Brazil, Maria Isabel Pedreira de Freitas, PhD, RN, Associate Professor, School of Nursing, University of Campinas (UNICAMP), Campinas/SP – Brazil, Kevin Woo, PhD, RN, Associate Professor, Queen’s University, Kingston, ON, Canada
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Surgical site infection (SSI) is a common complication that is associated with delayed recovery, prolonged length of hospital stay, exorbitant cost, and mortality. The present prospective longitudinal study aimed to evaluate the relationships between the microbial load of trocars used in laparoscopic gynecological surgery, microbiota in surgical sites, and SSI. The final sample consisted of 24 patients, including 68 swab samples and 48 trocars. Microorganisms were recovered in 100.0% of the swabs collected from the umbilicus and vaginal fornix and in 58.3% (14/24) of the swabs collected from skin at the left McBurney’s point. Most of the samples collected from trocars (87.5%) did not exhibit bacterial growth, suggesting proper disinfection. In addition, antisepsis was effective for decolonization of the skin to create an aseptic surgical field.
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The Development of Augmented Reality to Enhance Minimally Invasive Surgery
Keith Dodd, BS, Research Assistant, Nathaniel P. Brooks, MD, Associate Professor/Director, University of Wisconsin, Madison, Wisconsin
Minimally invasive surgery (MIS) reduces unnecessary tissue damage to the patient but obscures the natural surgical interface that is provided by open surgical procedures. Multiple feedback mechanisms, mainly visual and tactile, are greatly reduced in MIS. Microscopes, endoscopes, and image-guided navigation traditionally provide enough visual information for successful minimally invasive procedures, although the limited feedback makes these procedures more difficult to learn. Research has been performed to develop alternative solutions that regain additional feedback. Augmented reality (AR), a more recent guidance innovation that overlays digital visual data physically, has begun to be implemented in various applications to improve the safety and efficacy of minimally invasive procedures. This review focuses on the recent implementation of augmented display and direct visual overlay and discusses how these innovations address common feedback concerns associated with minimally invasive surgeries.
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7-09-2017
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Surgical Skills Improvement Using a Low-Cost Laparoscopic Simulator for Ventral Incisional Hernia
Vincenzo Consalvo, MD, General Surgeon Assistant, Clinique Clementville,
Montpellier, France, Vincenzo Salsano, MD, Director, Clinique du Parc Montpellier,
Clinique Clementville, Montpellier, France
Introduction: Ventral incisional hernia is one of the most common procedures in laparoscopic surgery, however, it requires proper training before doing it in the operating room. We propose a low-cost mechanical simulator with a new optical system to learn the basic steps of the procedure and improve surgical laparoscopic skill.
Materials and Methods: From November 3, 2014 to January 4, 2015, five residents and five surgeons with no prior laparoscopic experience, as well as two laparoscopic expert surgeons, participated in our study. They repeated the procedure three times per day for seven days. From January 10, 2015 to April 21, 2015, the five trained and five non-trained residents performed (each) five real laparoscopic ventral or median incisional hernia repairs under senior supervision. Operative time, decision making capabilities, number of errors, laparoscopic skill, and depth perception were compared between the two groups.
Results: A multiple regression (R) model was calculated and F-test showed a significant relation between operative time and numbers of procedures with the laparoscopic simulator (p<0.001) for the resident and non-laparoscopic surgeons groups and a multiple R-squared = 0.9974 (highly significant) of the model. No statistical difference was found between residents and non-laparoscopic surgeons (p<0.001), but both groups reached the same level as the expert surgeons after intensive training. Kruskal-Wallis was used to show an increased operative time for non-trained group. Pearson test and t-test showed a lower number of errors and failure in the trained group.
Conclusions: These results indicate that this new model of simulator could shorten the learning curve of surgical trainees for laparoscopic incisional hernia.
879
24-06-2017
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Fluorescent Imaging Evaluation of Lidocaine Distribution Following Bier Block in the Upper Extremity
Andrea L. Gale, MD, Fellow in Orthopedic Surgery, Shari R. Liberman, MD, Board-Certified Orthopedic Surgeon, Suzanne Berry, MD, Board-Certified Anesthesiologist, Dmitry Zavlin, MD, Postdoctoral Research Fellow in Plastic Surgery, Anthony Echo, MD, Board-Certified Plastic Surgeon, Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, Texas
Introduction: Bier block regional anesthesia has been used as an alternative to general anesthesia for years. Despite multiple theories and multiple techniques to delineate the location of the action of lidocaine during Bier block anesthesia, there has not been a consensus on the location of action. The purpose of this study was to use fluorescent imaging to further investigate the site of action of lidocaine during Bier block.
Materials and Methods: Three patients with carpal tunnel syndrome underwent open carpal tunnel release with Bier block anesthesia performed in the standard fashion with 1cc of Indocyanine green (IcG) mixed with lidocaine. Fluorescent images were obtained at the time of injection and after 10 minutes to allow patients to reach the level of surgical anesthesia. Repeated imaging was obtained at the time of completion of the procedure or at 30 minutes of tourniquet time.
Results: At time 0, IcG was distributed along the superficial venous system of the hand and forearm. At 10 minutes, the distribution of IcG was within the capillary system and infiltrating the dermis. The distribution later saturated the capillary beds and remained present until release of the tourniquet.
Conclusions: The authors demonstrate that some lidocaine action occurs at the cutaneous level during the administration of a Bier block. Due to limited field depth of view provided by the SPY® Elite System (Novadaq Technologies Inc., Mississauga, Canada), we are unable to draw any conclusions as to the distribution of the IcG or lidocaine at the level of the larger nerves at the site of the tourniquet.
884
21-06-2017
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Reproducibility and Reliability of Repeated Quantitative Fluorescence Angiography
Nikolaj Nerup, MD, PhD, PHD-Fellow, Senior Resident, Kristine Bach Korsholm Knudsen, MD, PhD, PHD-Fellow, Resident, Rikard Ambrus, MD, PhD, Resident, Morten Bo Søndergaard Svendsen, MScEng, PhD, Engineer, Inge Botker Rasmussen Ifaoui, MD, PhD, Consultant, Lars Bo Svendsen, MD, DMSc, Consultant, Professor, Michael Patrick Achiam, MD, PHD, DMSc, Consultant, Associate Professor, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark, Thomas Thymann, DVM, PhD, Veterinarian, Associate Professor, Copenhagen University, Frederiksberg, Denmark
Introduction: When using fluorescence angiography (FA) in perioperative perfusion assessment, repeated measures with re-injections of fluorescent dye (ICG) may be required. However, repeated injections may cause saturation of dye in the tissue, exceeding the limit of fluorescence intensity that the camera can detect. As the emission of fluorescence is dependent of the excitatory light intensity, reduction of this may solve the problem. The aim of the present study was to investigate the reproducibility and reliability of repeated quantitative FA during a reduction of excitatory light.
Materials and Methods: Six preterm piglets were used as a model of humans with compromised liver function and slow ICG clearance, as well as mimicking a situation with close camera tissue distance. In three piglets, FA was performed laparoscopically and in another three, FA was performed after laparotomy. Measurements were performed in the same three regions of interest in each measurement with excitatory light intensities of 100%, 60%, and 20%.
Results: We found an excellent agreement of the normalized slope with an intraclass correlation coefficient of 0.940 (95% CI: 0.870–0.976), and a Cronbach’s alpha of 0.944 indicating high consistency. In addition, Bland Altmann plots found acceptable levels of agreement with minimal proportion bias.
Conclusions: This study indicates that problems with hyper saturation of ICG, when performing repetitive perfusion assessment with FA, may be overcome by using the normalized slope and a reduction of the excitatory light intensity. This may especially be relevant in patients with compromised liver function or when a close camera tissue distance is necessary.
892
27-07-2017
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Design and Development of a Novel Distance Learning Telementoring System Using Off-the-Shelf Materials and Software
James C. Rosser, MD, FACS, Clinical Professor of Surgery, University of Central Florida College of Medicine, Orlando, Florida, Director of the Center for the Advanced Treatment of Heartburn, Grant Medical Center, Lancaster, Wisconsin, Jeffrey P. Fleming, BS, Timothy B. Legare, MS, Katherine M. Choi, BS, Jamie Nakagiri, BS, Elliot Griffith, MS, Medical Student, University of Central Florida College of Medicine, Orlando, Florida
Objective: To design and develop a distance learning (DL) system for the transference of laparoscopic surgery knowledge and skill constructed from off-the-shelf materials and commercially available software.
Introduction: Minimally invasive surgery offers significant benefits over traditional surgical procedures, but adoption rates for many procedures are low. Skill and confidence deficits are two of the culprits. DL combined with simulation training and telementoring may address these issues with scale.
Materials and Methods: The system must be built to meet the instruction requirements of a proven laparoscopic skills course (Top Gun). Thus, the rapid sharing of multimedia educational materials, secure two-way audio/visual communications, and annotation and recording capabilities are requirements for success. These requirements are more in line with telementoring missions than standard distance learning efforts.
Results: A DL system with telementor, classroom, and laboratory stations was created. The telementor station consists of a desktop computer and headset with microphone. For the classroom station, a laptop is connected to a digital projector that displays the remote instructor and content. A tripod-mounted webcam provides classroom visualization and a Bluetooth® wireless speaker establishes audio. For the laboratory station, a laptop with universal serial bus (USB) expander is combined with a tabletop laparoscopic skills trainer, a headset with microphone, two webcams and a Bluetooth® speaker. The cameras are mounted on a standard tripod and an adjustable gooseneck camera mount clamp to provide an internal and external view of the training area. Internet meeting software provides audio/visual communications including transmission of educational materials.
Conclusion: A DL system was created using off-the-shelf materials and commercially available software. It will allow investigations to evaluate the effectiveness of laparoscopic surgery knowledge and skill transfer utilizing DL techniques.
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17-08-2017
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