Surgical Technology International
39th Edition
November 2021 - ISSN:1090-3941
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Development of Endoscopic Surgery Navigated by Artificial Intelligence
Masafumi Inomata, MD, PhD, Professor, Atsuro Fujinaga, MD, Hiroaki Nakanuma, MD, Yuichi Endo, MD, PhD, Assistant Professor, Tsuyoshi Etoh, MD, PhD, Associate Professor, Oita University Faculty of Medicine, Oita, Japan, Tatsushi Tokuyasu, PhD, Professor, Fukuoka Institute of Technology Faculty of Information Engineering, Fukuoka, Japan, Seigo Kitano, MD, PhD, President, Oita University, Oita, Japan
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Endoscopic surgery, which was first introduced in the late 1980s, has rapidly become widespread. However, despite its popularity, the occurrence of intraoperative organ damage has not necessarily decreased. To avoid intraoperative bile duct injury in laparoscopic cholecystectomy, which is one of the most popular procedures in endoscopic surgery, we are developing a laparoscopic surgical system that uses Artificial Intelligence (AI) to identify four anatomical landmarks (cystic duct of the gallbladder, common bile duct, lower surface of hepatic S4, and Rouviere’s sulcus, related to “Calot’s triangle") in real time during surgery. The development process consists of 5 steps: 1) identification of anatomical landmarks, 2) collection and creation of teaching data, 3) annotation and deep learning, 4) validation of development model, and 5) actual clinical performance evaluation. At present, anatomical landmarks can be identified with high accuracy in an actual clinical performance test in laparoscopic cholecystectomy, whereas issues for practical clinical use, such as a need to recognize the scene of surgical steps and surgical difficulties related to inflammation of the gallbladder, have also been clarified. The development of an AI-navigation system for endoscopic surgery, which could identify anatomical landmarks in real time during surgery, could be expected to support surgeons' decisions, reduce surgical complications, and contribute to improving the quality of surgical treatments.
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Evaluation of Indocyanine Green Fluorescence Imaging for Intraoperative Identification of Liver Malignancy
Jorge G. Zarate Rodriguez, MD, Chet W. Hammill, MD, MCR, FACS, Associate Professor, Washington University School of Medicine, St. Louis, Missouri, Jan Grendar, MD, MSc, Zeljka Jutric, MD, Assistant Professor, Portland Providence Cancer Center, Portland, Oregon, Paul D. Hansen, MD, The Oregon Clinic, Portland, Oregon, Maria A. Cassera, MD, University of Washington, Seattle, Washington, Ronald F. Wolf, MD, Professor of Surgery, UC Irvine Medical Center, Orange, California
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Introduction: There is early evidence that indocyanine green (ICG) fluorescence imaging has the ability to detect metastatic and primary malignancies in the liver that are too small to be identified by other methods. However, the rate of false positives and false negatives remains unknown.
Materials and Methods: This is a single institution prospective single-arm study. Patients with suspected hepatic or pancreatic malignancies were intravenously injected with ICG one to three days prior to their scheduled surgical therapy. At the beginning of the procedure, the liver was assessed with fluorescence imaging and all identified lesions were biopsied and evaluated.
Results: Twenty-three patients were enrolled from April 2015 through February 2016. Fifteen patients with confirmed malignancy had adequate fluorescence imaging evaluation of the liver; 10 with pancreatic primary malignancies and five with hepatic primaries. Fluorescence imaging was the only modality that identified nine concerning hepatic lesions, all of which were benign on pathology examination. Out of 11 malignant hepatic masses, six were visible on fluorescence imaging. Out of nine benign hepatic lesions, five were visible. No side effects or complications of the fluorescence imaging were encountered. The sensitivity for ICG fluorescence was 45.5%, the specificity 21.2%, the positive predictive value 25%, and the negative predictive value 40%.
Conclusion: Intraoperative hepatic assessment with ICG fluorescence imaging to identify malignancy in the liver is feasible and safe. However, in this study the significant number of false positives limit the utility of the technique. Our preliminary data do not support its routine use for detection of malignancies in the liver.
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Safety of Laser and Thermal Therapy During Rigid Bronchoscopy Using Manual Hand Jet Ventilation
Amit K. Mahajan, MD, FCCP, DAABIP, Priya P. Patel, MD, DAABIP, Inova Fairfax Hospital, Falls Church, Virginia, Radhika Garg, MD, Fairfax Anesthesiology Associates, Falls Church, Virginia, Christopher Manley, MD, DAABIP, Fox Chase Cancer Center, Philadelphia, Pennsylvania, Omar Ibrahim MD, DAABIP, University of Connecticut Health, Farmington, Connecticut, Atul C. Mehta, MD, Professor of Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
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Introduction: Thermal ablative therapies (laser, radiofrequency ablation, electrocautery, argon plasma coagulation) are often used during rigid bronchoscopy for the treatment of central airway obstructions (CAO). An airway fire is a feared complication that can occur during endobronchial thermal ablation.
Materials and Methods: This was a single-center, retrospective, observational study. A total of 175 patients were reviewed undergoing rigid bronchoscopy in the operating room and bronchoscopy suite requiring manual hand jet ventilation and thermal therapy between September 2014 and September 2018. The study objective was to determine the safety of manual hand jet ventilation during endobronchial thermal therapies with rigid bronchoscopy.
Results: Over a five-year period, 175 patients underwent endobronchial thermal therapy during rigid bronchoscopy with manual hand jet ventilation for the treatment CAOs. Immediately prior to thermal therapy activation, jet ventilation was paused. No incidences (0/175) of airway fires occurred despite immediate delivery of thermal energy following a jet ventilation hold.
Conclusions: Results of our study show that performing thermal ablative therapy during rigid bronchoscopy with jet ventilation using a breath-hold technique is safe.
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Status of Alternative Approaches for Thyroidectomy: Is There Any Evidence to Substitute in Place of Conventional Surgery?
Antonella Pino, MD, Carmelo Mazzeo, MD, University Hospital G. Martino, Messina, Italy, Francesco Frattini, MD, ASST Settelaghi, Varese, Italy, Daqi Zhang, MD, PhD, Professor, Jilin Provincial Precision Medicine Laboratory of Molecular Biology and Translational Medicine on Differentiated Thyroid Carcinoma, Changchun, People's Republic of China, Che Wei Wu, MD, PhD, Full Professor, Kaohsiung Medical University, Kaohsiung, Taiwan, Guido Zanghi, MD, Professor of General Surgery, Vittorio Emanuele Hospital, Catania, Italy, Ozer Makay, MD, PhD, Full Professor, Ege University Hospital, Izmir, Turkey, Hoon Yub Kim, MD, PhD, Full Professor, University College of Medicine, Seoul, Korea, Ralph P. Tufano, MD, PhD, Johns Hopkins University School of Medicine, Baltimore, MD, USA, Young Jun Chai, MD, Seoul National University Boramae Medical Center, Seoul, Korea, Gianlorenzo Dionigi, MD, PhD, FACS, Full Professor, Istituto Auxologico Italiano IRCCS, Milano, Italy
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Over the past 20 years, various alternative cervical minimally invasive (partly endoscopically assisted) and extracervical endoscopic (partly robot-assisted) approaches have been developed. All of these alternative access methods aim at optimizing the cosmetic results. In principle, the indication for the use of alternative access procedures does not differ from that for conventional surgery. Nonetheless, appropriate experience in traditional thyroid surgery and suitable patient selection, taking into account thyroid volumes and the underlying pathology, are important prerequisites. General contraindications for an alternative approach are large goiter with symptoms of compression, advanced thyroid carcinoma, recurrent interventions or previous radiotherapy in the operating area. The alternative surgical approaches to the thyroid can be divided into cervical minimally invasive, extracervical endoscopic (robot-assisted) and transoral procedures. This article gives an overview of the clinically used alternative approaches in thyroid surgery. The desire for an optimal cosmetic result should not be prioritized over patient safety. Only a few alternative procedures (minimally invasive video-assisted thyroidectomy, transaxillary robot-assisted thyroidectomy) can currently be viewed as a useful addition to conventional thyroid surgery, even when in responsible, experienced hands for a selected group of patients.
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Surgical Technique of Diverted One-Anastomosis Gastric Bypass
Daniel M. Felsenreich, MD, PhD, Felix B. Langer, MD, Associate Professor, Christoph Bichler, MDm Jakob Eichelter, MD, Julia Jedamzik, MD, Magdalena Mairinger, MD, PhD, Paula Richwien, MD, Prof. Gerhard Prager, MD, Medical University of Vienna, Vienna, Austria, Mahir Gachabayov, MD, New York Medical College, Valhalla, New York
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Laparoscopic diverted one-anastomosis gastric bypass (D-OAGB) is a bariatric procedure combining the principles of restriction, malabsorption, and other factors to induce weight loss. It is achieved by creating a narrow, long gastric pouch and bypassing a part of the small bowel (biliopancreatic limb). D-OAGB was first described by Dr. Ribero in 2013 and is technically a variation of the very heterogeneous group of Roux-en-Y gastric bypass operations. There are different technical variants to perform D-OAGB and to organize pre- and postoperative care. The following article is based on the approach to bariatric surgery as taken at the Department of General Surgery at the Medical University of Vienna. This article focuses on patient preparation before bariatric/metabolic surgery with mandatory and optional preoperative examinations to find the surgical procedure best suited for each individual patient and to decrease the patient’s risk. The surgical technique of D-OAGB itself, including positioning of the patient and related technical highlights, as well as the specifics of the postoperative course, are described. D-OAGB is an effective procedure for patients with symptomatic gastroesophageal reflux for adequate weight loss and remission of comorbidities with a low risk of malnutrition. For D-OAGB to be successful, important technical steps, such as creating a narrow, long pouch, exact length of the biliopancreatic and alimentary limb, and additional hiatoplasty (if necessary), should be taken. In terms of the postoperative course, regular checkups are vital to ensure desirable outcome in the long-term follow up and early detection of adverse developments.
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Energy-Based Devices Affect the Aesthetic Outcome of Cervical Thyroidectomy and Parathyroidectomy. A Retrospective Study
Antonella Pino, MD, Pietro Micieli, MD, Gabriele Delia, MD, PhD, Francesco Stagno d’Alcontres, MD, PhD, Professor, University Hospital G. Martino, University of Messina, Italy Lorenzo Gasco, MD, Daqi Zhang, MD, PhD, China Japan Union Hospital of Jilin University, Division of Thyroid Surgery, Changchun city, Jilin Province, China Paolo Carcoforo, MD, Professor, University of Ferrara, Ferrara, Italy, Francesco Frattini, MD, Division of Surgery, AST Varese, Varese, Italy, Gianlorenzo Dionigi, MD, PhD, FACS, Professor, Division of Surgery, Istituto Auxologico Italiano IRCCS, Milan, Italy
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Introduction: Thyroid and parathyroid diseases are very common. Most of these cases are in women and may be amenable to surgery. The patient’s perception that these are not life-threatening diseases leads them to expect an excellent aesthetic result, since the surgical incision area is clearly visible.
Objective: To evaluate different scarring outcomes using three different energy-based devices (Harmonic Focus®, Johnson & Johnson, New Brunswick, NJ; Thunderbeat Open Fine Jaw®, Olympus Medical, Tokyo, Japan; LigaSure Small Jaw®, Medtronic, Dublin, Ireland) and to determine the impact of post-thyroidectomy/parathyroidectomy scars on the patient’s quality of life.
Methods: One hundred female patients who underwent thyroidectomy or parathyroidectomy between September 2017 and September 2019 at the Endocrine and Minimally Invasive Surgery Department of Messina University Hospital were recruited. A retrospective analysis assessed the thickness of the cervical scar via ultrasound imaging, and the patient’s degree of satisfaction through the Patient and Observer Scar Assessment Scale (POSAS) and the Body Dysmorphic Disorder Questionnaire (BDDQ).
Results: The patients were divided into three groups according to the energy-device used: group A (LigaSure SJ (n=38), group B (Harmonic F, n=32) and group C (Thunderbeat OFJ, n=30). The three groups were homogeneous with respect to number of patients, age and surgical procedures. The best aesthetic result, which correlated with the lowest scar thickness, was observed in group A; these patients were more satisfied than those in the other two groups. Moreover, correlations between scar thickness and quantitative variables (such as age or BMI) were not found in any of the groups.
Conclusions: Based on the data collected and our experience, the LigaSure Small Jaw® (Medtronic) seems to offer the best aesthetic outcome in patients who undergo transverse cervicotomy for thyroid and parathyroid diseases. However, further prospective studies involving a greater number of cases are needed.
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Outcomes of Emergency Gastrointestinal Surgery Done on Post-Cardiac Surgery Patients—Analysis From a Tertiary Care Center
Shekhar Gogna, MD, FICS (Jr), MS, MBBS, Abbas Smiley, MD, PhD, Katherine French, BS, Syian Srikumar, BS, David Spielvogel, MD, FACS, Professor , Steven Lansman, MD, PhD, FACS , Professor, Rifat Latifi, MD, FACS, FICS, The Felicien Steichen Professor, Westchester Medical Center Health, Valhalla, New York
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Introduction: Abdominal complications following cardiac surgery have high mortality rates. This study analyzes the outcomes of patients who have undergone emergency general surgery (EGS) procedures after cardiothoracic surgery (CTS) at the same hospitalization.
Materials and Methods: This was a retrospective analysis of all patients who underwent emergent abdominal surgery after CTS surgery between 2010–2018. The CTS procedures included coronary artery bypass graft (CABG), valve replacement, cardiac transplant, aortic replacement, ventricular assist device, and pericardial procedures. The records were reviewed to obtain demographics, frequency distribution of EGS procedures, complications, outcomes, and the risk factors of mortality.
Results: Of 4826 patients who had CTS, 57 (1.2%) underwent EGS procedures during the period of 2010–2018. This cohort of patients had 113 CTS and 85 EGS procedures during the same hospitalization. The mean age was 62 years, and 49% were elderly (40% were females). CABG with or without valve replacement was the most common surgery (28%). After surgical consultation for “acute abdomen” in the post-CTS phase, the three most common findings on exploratory laparotomy were bowel perforation (23%), massive free fluid leading to abdominal compartment syndrome (19%), and acute cholecystitis (16%). Respiratory failure (46%), acute kidney injury (32%), and multiple organ dysfunction (18%) were the most common hospital-acquired complications. Regarding dispositions, 47% were discharged to an acute rehabilitation center, 10% were discharged to a sub-acute rehabilitation center, and a similar proportion of patients went home (10%). On multivariable logistic regression analysis with backward elimination, age (OR=1.10, 95% CI: 1.02–1.18) and serum proteins (OR=0.99, 95% CI: 0.98-0.998) were independently associated with the odds of mortality after EGS in the immediate CTS phase.
Conclusions: Respiratory failure is the most common complication of EGS immediately after CTS. The older the patient and the lower the serum proteins, the higher the odds of mortality in patients who undergo EGS after ETS.
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