Anatomic Accuracy Is the Keynote of Surgical Technic.

Cricothyroidotomy is a life-saving medical procedure that allows for tracheal intubation. Most current cricothyroidotomy simulation models are either expensive or not anatomically accurate and provide the learner with an unrealistic simulation experience. The goal of this project is to improve current simulation techniques by utilizing rapid prototyping using 3D printing technology and expert opinions to develop inexpensive and anatomically accurate trachea simulators. In doing so, emergency cricothyroidotomy simulation can be made accessible, accurate, cost-effective and reproducible.Three-dimensional modelling software was used in conjunction with a desktop three-dimensional (3D) printer to design and manufacture an anatomically accurate model of the cartilage within the trachea (thyroid cartilage, cricoid cartilage, and the tracheal rings). The initial design was based on dimensions found in studies of tracheal anatomical configuration. This ensured that the landmarking necessary for emergency cricothyroidotomies was designed appropriately. Several revisions of the original model were made based on informal opinion from medical professionals to establish appropriate anatomical accuracy of the model for use in rural/remote cricothyroidotomy simulation.Using an entry-level desktop 3D printer, a low cost tracheal model was successfully designed that can be printed in less than three hours for only $1.70 Canadian dollars (CAD). Due to its anatomical accuracy, flexibility and durability, this model is great for use in emergency medicine simulation training. Additionally, the model can be assembled in conjunction with a membrane to simulate tracheal ligaments. Skin has been simulated as well to enhance the realism of the model. The result is an accurate simulation that will provide users with an anatomically correct model to practice important skills used in emergency airway surgery, specifically landmarking, incision and intubation. This design is a novel and easy to manufacture and reproduce, high fidelity trachea model that can be used by educators with limited resources.

Use of small intestinal submucosa for corporal body grafting in cases of epispadias and epispadias/exstrophy complex

Transnasal endoscopic (TNE) procedures are gaining clinical importance in both diagnostic and therapeutic laryngology. Despite this growing relevance, there is currently no dedicated simulation model available for training these techniques, which require high anatomical accuracy and realistic scope maneuverability. We designed a 3D-printed anatomical framework based on a publicly available CT dataset, modified to allow realistic transnasal access and secure integration of excised cadaveric larynges. The model supports repeated use with interchangeable specimens and includes features for precise anatomical positioning. The setup was evaluated in 8 cadaveric larynges for anatomical realism and endoscope maneuverability by 2 experienced laryngologists. Key laryngeal landmarks, such as the vocal folds, arytenoid cartilages, and aryepiglottic folds, were clearly identifiable in all specimens during flexible endoscopy, closely resembling the view in awake patients. Scope navigation through the nasal cavity and hypopharynx was described as smooth and realistic. The total production cost of $388.25 makes the model a cost-efficient alternative to commercial simulators. Its design allows for repeated use and adaptation to different specimen types. We present the first simulation model specifically designed for training transnasal endoscopic laryngeal procedures. The hybrid model combines anatomical accuracy, realistic handling, and affordability, making it a valuable tool for surgical education and technique development. Its potential applications extend beyond laryngology, including anesthesiology and pulmonology, where transnasal access is also required.

Augmented Reality during Open Liver Surgery Using a Markerless Non-rigid Registration System

Enhanced anatomical accuracy in arthroscopic all-inside lateral ligament repair using ultrasound-guided anchor placement.

Computed-tomography modeled polyether ether ketone (PEEK) implants in revision cranioplasty

The authors assessed the feasibility, anatomical accuracy, and cost effectiveness of frameless electromagnetic (EM) neuronavigation in conjunction with portable intraoperative CT (iCT) registration for transsphenoidal adenomectomy (TSA). A prospective database was established for data obtained in 208 consecutive patients who underwent TSA in which the iCT/EM navigation technique was used. Data were compared with those acquired in a retrospective cohort of 65 consecutive patients in whom fluoroscope-assisted TSA had been performed by the same surgeon. All patients in both groups underwent transnasal removal of pituitary adenomas or neuroepithelial cysts, using identical surgical techniques with an operating microscope. In the iCT/EM technique-treated cases, a portable iCT scan was obtained immediately prior to surgery for registration to the EM navigation system, which did not require rigid head fixation. Preexisting (nonnavigation protocol) MR imaging studies were fused with the iCT scans to enable 3D navigation based on MR imaging data. The accuracy of the navigation system was determined in the first 50 iCT/EM cases by visual concordance of the navigation probe location to 5 preselected bony landmarks. For all patients in both cohorts, total operating room time, incision-to-closure time, and relative costs of imaging and surgical procedures were determined from hospital records. In every case, iCT registration was successful and preoperative MR images were fused to iCT scans without affecting navigation accuracy. There was 100% concordance between probe tip location and predetermined bony loci in the first 50 cases involving the iCT/EM technique. Total operating room time was significantly less in the iCT/EM cases (mean 108.9 ± 24.3 minutes [208 patients]) compared with the fluoroscopy group (mean 121.1 ± 30.7 minutes [65 patients]; p < 0.001). Similarly, incision-to-closure time was significantly less for the iCT/EM cases (mean 61.3 ± 18.2 minutes) than for the fluoroscopy cases (mean 71.75 ± 19.0 minutes; p < 0.001). Relative overall costs for iCT/EM technique and intraoperative C-arm fluoroscopy were comparable; increased costs for navigation equipment were offset by savings in operating room costs for shorter procedures. The use of iCT/MR imaging-guided neuronavigation for transsphenoidal surgery is a time-effective, cost-efficient, safe, and technically beneficial technique.

Editorial

Neuronavigation, a computer-assisted surgical technique, enhances the accuracy of spinal surgery by using medical imaging to guide the surgeon's instruments. This method mitigates the serious complications of screw misplacement, such as dural tears, nerve damage, vascular injuries, and internal organ damage, by integrating pre-operative imaging data with real-time intraoperative sensor readings. Because of this integration, it is possible to visualize the spine in three dimensions, guaranteeing accurate instrument placement and greatly lowering the risk of complications. Despite its growing popularity, the benefits of neuronavigation in spinal instrumentation are debated. While some studies report improved accuracy in pedicle screw placement, others find no significant difference compared to conventional freehand techniques. Further research is required to determine the long-term benefits of neuronavigation, including its impact on patient outcomes, like reduced pain and improved function. This systematic review will evaluate the evidence on the risks and benefits of neuronavigation in spinal instrumentation surgery, compared to conventional techniques.

Rhinoplasty is a challenging procedure with a steep learning curve. Surgical simulators provide a safe platform to gain hands-on experience without compromising patient outcomes. Therefore, rhinoplasty is an ideal procedure to benefit from an effective surgical simulator. A high-fidelity rhinoplasty simulator was developed using three-dimensional computer modeling, three-dimensional printing, and polymer techniques. The simulator was tested by six surgeons with experience in rhinoplasty to assess realism, anatomic accuracy, and value as a training tool. The surgeons performed common rhinoplasty techniques and were provided a Likert-type questionnaire assessing the anatomic features of the simulator. A variety of surgical techniques were performed successfully using the simulator, including open and closed approaches. Bony techniques performed included endonasal osteotomies and rasping. Submucous resection with harvest of septal cartilage, cephalic trim, and tip suturing, as well as grafting techniques including alar rim, columellar strut, spreader, and shield grafts, were performed successfully. Overall, there was agreement on the simulator's anatomic accuracy of bony and soft-tissue features. There was strong agreement on the simulator's overall realism and value as a training tool. The simulator provides a high-fidelity, comprehensive training platform to learn rhinoplasty techniques to augment real operating experience without compromising patient outcomes.

Anatomically and mechanically accurate scala tympani model for electrode insertion studies

OBJECTIVE Recent advances in optics and miniaturization have enabled the development of a growing number of minimally invasive procedures, yet innovative training methods for the use of these techniques remain lacking. Conventional teaching models, including cadavers and physical trainers as well as virtual reality platforms, are often expensive and ineffective. Newly developed 3D printing technologies can recreate patient-specific anatomy, but the stiffness of the materials limits fidelity to real-life surgical situations. Hollywood special effects techniques can create ultrarealistic features, including lifelike tactile properties, to enhance accuracy and effectiveness of the surgical models. The authors created a highly realistic model of a pediatric patient with hydrocephalus via a unique combination of 3D printing and special effects techniques and validated the use of this model in training neurosurgery fellows and residents to perform endoscopic third ventriculostomy (ETV), an effective minimally invasive method increasingly used in treating hydrocephalus. METHODS A full-scale reproduction of the head of a 14-year-old adolescent patient with hydrocephalus, including external physical details and internal neuroanatomy, was developed via a unique collaboration of neurosurgeons, simulation engineers, and a group of special effects experts. The model contains "plug-and-play" replaceable components for repetitive practice. The appearance of the training model (face validity) and the reproducibility of the ETV training procedure (content validity) were assessed by neurosurgery fellows and residents of different experience levels based on a 14-item Likert-like questionnaire. The usefulness of the training model for evaluating the performance of the trainees at different levels of experience (construct validity) was measured by blinded observers using the Objective Structured Assessment of Technical Skills (OSATS) scale for the performance of ETV. RESULTS A combination of 3D printing technology and casting processes led to the creation of realistic surgical models that include high-fidelity reproductions of the anatomical features of hydrocephalus and allow for the performance of ETV for training purposes. The models reproduced the pulsations of the basilar artery, ventricles, and cerebrospinal fluid (CSF), thus simulating the experience of performing ETV on an actual patient. The results of the 14-item questionnaire showed limited variability among participants' scores, and the neurosurgery fellows and residents gave the models consistently high ratings for face and content validity. The mean score for the content validity questions (4.88) was higher than the mean score for face validity (4.69) (p = 0.03). On construct validity scores, the blinded observers rated performance of fellows significantly higher than that of residents, indicating that the model provided a means to distinguish between novice and expert surgical skills. CONCLUSIONS A plug-and-play lifelike ETV training model was developed through a combination of 3D printing and special effects techniques, providing both anatomical and haptic accuracy. Such simulators offer opportunities to accelerate the development of expertise with respect to new and novel procedures as well as iterate new surgical approaches and innovations, thus allowing novice neurosurgeons to gain valuable experience in surgical techniques without exposing patients to risk of harm.

Neoadjuvant chemo-radiotherapy (nCRT) of locally advanced rectal cancer is associated with challenging surgical treatment and increased postoperative morbidity. Robotic technology overcomes laparoscopy limitations by enlarged 3D view, improved anatomical transection accuracy, and physiologic tremor reduction. Patients with UICC stage II-III rectal cancer, consecutively referred to our institution between March 2015 and June 2020 (n = 102) were treated with robotic (Rob-G, n = 38) or laparoscopic (Lap-G, n = 64) low anterior resection (LAR) for total meso-rectal excision (TME) following highly standardized and successful nCRT treatment. Feasibility, conversion rates, stoma creation, morbidity and clinical/pathological outcome were comparatively analysed. Sex, age, BMI, ASA scores, cTN stages and tumour distance from dentate line were comparable in the two groups. Robotic resection was always feasible without conversion to open surgery, which was necessary in 11/64 (17%) Lap-G operations (p = 0.006). Primary or secondary stomata were created in 17/38 (45%) Rob-G and 52/64 (81%) Lap-G patients (p < 0.001). Major morbidity occurred in 7/38 (18.4%) Rob-G and 6/64 (9.3%) Lap-G patients (p = 0.225). Although median operation time was longer in Rob-G compared with Lap-G (376; IQR: 330-417min vs. 300; IQR: 270-358min; p < 0.001), the difference was not significant in patients (Rob-G, n = 6; Lap-G, n = 10) with ≥30 BMI (p = 0.106). Number of resected lymph nodes, ypTN staging and circumferential resection margins (CRM) were comparable. Resection was complete in 87% of Rob-G and 89% of Lap-G patients (p = 0.750). Robotic LAR is not inferior to laparoscopic LAR following nCRT. Larger, randomized studies are needed to confirm lower conversion in robotic, compared to laparoscopic resection.

Background: Occipital neuromodulation is a promising treatment modality for refractory headache, but lead migration remains a frequent surgical complication. Objectives: The primary objective was to identify surgical techniques that may minimize adverse events, particularly lead migration. We hypothesized that a surgical technique employing 2-point anchoring of stimulator leads designed to provide a tension-relief loop and the use of ultrasound for lead placement would decrease the complication rate. Study Design and Setting: A retrospective analysis was performed through electronic medical record chart review in a tertiary referral center. Methods: Institutional Review Board (IRB) approval was obtained. Eighteen patients had a trial and subsequent permanent occipital nerve stimulator (ONS) implantation between 2004 and 2011 and were included. Adverse events were recorded and efficacy outcome variables analyzed for significance. Results: The cohort was a median (IQR) 45 (37 – 58) in age and 9 (50%) were women. Tension-relief loops placed via a 2-point anchoring technique and ultrasound use for occipital lead placement were evident in 16 (89%) and 13 (72%), respectively. There was one (6%) clinically insignificant lead position change, not definitively a lead migration, which could have been an artifact of fluoroscope positioning. Adverse events included one (6%) battery malfunction, one (6%) lead malfunction, and 2 (12%) post-implantation infections. Following ONS, there were significant reductions in numeric rating scale (NRS) pain scores from a median (IQR) of 9.5 (8.25 – 10) to 2.5 (1 – 4.75) (P &lt; 0.0001), headache days per week from 7 (7 – 7) to 1.5 (0.375 – 1.75) (P = 0.0005), and the number of daily headache medication from 3 (2.25 – 4) to 2.5 (2 – 3.75) (P = 0.0112). Limitations: Limitations include retrospective study design, investigator bias, and nonstandardized intervals of headache burden assessment. Conclusions: In ONS, utilization of a 2-point anchoring technique with a tension-relief loop may significantly minimize the risk of lead migration, based on the absence of definitive lead migration in our series. Ultrasound use may improve the anatomic accuracy of lead placement with the possibility of improved efficacy. ONS was associated with significantly decreased headache pain, frequency, and medication use. Key words: Occipital neuromodulation, occipital nerve stimulation, surgical technique, lead migration, tension-relief loop

BackgroundReconstructive surgery following head and neck cancer resection is inherently complex and technically demanding. Procedures such as osteotomy and flap inset involve a steep learning curve, yet opportunities for hands-on training are increasingly limited. Physical simulation using cost-effective, anatomically realistic models offers a promising solution. This study aimed to evaluate the educational value of 3D-printed training models and custom-made fibula models in enhancing surgical skills, supported by structured assessments and feedback.MethodsA hands-on workshop was conducted for 30 plastic surgery residents utilizing in-house 3D-printed models, created via fused deposition modeling (FDM), and acrylic-based fibula models. Participants performed simulated osteotomies and flap insets. Their performance was assessed using the 4-point Zwisch scale by two independent, blinded consultants. Additionally, a 6-item questionnaire was administered to capture self-reported improvements in anatomical understanding, surgical technique, and procedural planning. Pre- and post-training questionnaire scores were compared using Wilcoxon signed-rank test.ResultsPost-training, the average questionnaire scores significantly improved from 12.03 ± 2.20 to 20.30 ± 1.56 (p < 0.01). The greatest improvement was noted in the participants’ comprehension of surgical planning. Zwisch scale evaluations demonstrated a clear progression toward greater technical independence. Participants also expressed high satisfaction with the anatomical realism, durability, and affordability of the training models.ConclusionLow-cost 3D-printed training models and custom-made fibula models represent an effective and reproducible training tool for developing technical skills in head and neck reconstructive surgery. Their ease of fabrication, affordability, and anatomical accuracy make them particularly valuable in resource-limited settings. These models offer significant educational utility and warrant integration into structured surgical training curriculum.