Assistant Surgeon Research Articles

A new hybrid robotic surgery by minimally invasive laparoscopic and robotic (MILAR) system using da Vinci single-port (SP) in distal gastrectomy for gastric cancer.

The da Vinci SP (SP) has only 1 robotic arm, containing 4 channels. It provides a wide space for assistant surgeons using laparoscopic forceps. We performed a new type of minimally invasive surgery using laparoscopy and a robot (MILAR) utilizing the SP in distal gastrectomy for gastric cancer. An incision at the umbilicus was made for the SP, and 2 ports were inserted from the right abdomen for laparoscopic surgery. In the above view, where surgeons look down at the surgical field, the scope was inserted from the channel at 12 o'clock, and the round tooth retractor was inserted from 6 o'clock. In the below view, where surgeons look up at the surgical field, the scope and retractor were inserted from opposite directions. The robotic operator uses 3 forceps and a scope. The laparoscopic operator uses 2 forceps. On the greater curvature side, the left or right epiploic artery pedicles was retracted by the robot operator under the below view. The suprapancreatic area was dissected with the pedicle of the left gastric artery retracted by the laparoscopic operator under the above view. By setting the scope and the retractor in a diagonal direction of 12-6 o'clock, robotic surgeons have a wide space bilaterally for using forceps for nodal dissection under the co-axial setting. Laparoscopic surgeons can use this space easily. Gastrectomy by MILAR using SP could provide quality surgery within a short operative time.

Machine learning approaches in non-contact autofluorescence spectrum classification.

Manual surgical resection of soft tissue sarcoma tissue can involve many challenges, including the critical need for precise determination of tumor boundary with normal tissue and limitations of current surgical instrumentation, in addition to standard risks of infection or tissue healing difficulty. Substantial research has been conducted in the biomedical sensing landscape for development of non-human contact sensing devices. One such point-of-care platform, previously devised by our group, utilizes autofluorescence-based spectroscopic signatures to highlight important physiological differences in tumorous and healthy tissue. The following study builds on this work, implementing classification algorithms, including Artificial Neural Network, Support Vector Machine, Logistic Regression, and K-Nearest Neighbors, to diagnose freshly resected murine tissue as sarcoma or healthy. Classification accuracies of over 93% are achieved with Logistic Regression, and Area Under the Curve scores over 94% are achieved with Support Vector Machines, delineating a clear way to automate photonic diagnosis of ambiguous tissue in assistance of surgeons. These interpretable algorithms can also be linked to important physiological diagnostic indicators, unlike the black-box ANN architecture. This is the first known study to use machine learning to interpret data from a non-contact autofluorescence sensing device on sarcoma tissue, and has direct applications in rapid intraoperative sensing.

Development of a novel system for measuring femoroacetabular contact forces in hip arthroscopy

Purpose Arthroscopic osteochondroplasty is a minimally invasive procedure that has been used to treat femoroacetabular impingement syndrome, leading to significant improvements in patients’ clinical outcomes and quality of life. However, some studies suggest that inadequate bone resection can substantially alter hip biomechanics. These modifications may generate different contact profiles and higher contact forces, increasing the risk of developing premature joint degeneration. To improve control over bone resection and biomechanical outcomes during arthroscopic osteochondroplasty surgery, this study aims to present a novel system for measuring femoroacetabular contact forces. Design/methodology/approach Following a structured design process for the development of medical devices, the steps required for its production using additive manufacturing with material extrusion and easily accessible sensors are described. The system comprises two main devices, one for measuring femoroacetabular contact forces and the other for quantifying the force applied by the assistant surgeon during lower limb manipulation. The hip device was designed for use within an arthroscopic environment, eliminating the need for additional portals. Findings To evaluate its performance, the system was first tested in a laboratory setup and later under in-service conditions. The 3D printing parameters were tuned to ensure the watertighness of the device and sustain the intraoperative fluid pressures. The final prototype allowed for the controlled measurement of the hip contact forces in real-time. Originality/value Using additive manufacturing and readily available sensors, the present work presents the first device to quantify joint contact forces during arthroscopic surgeries, serving as an additional tool to support the surgeon’s decision-making process regarding bone resection.

Research on Surgical Gesture Recognition in Open Surgery Based on Fusion of R3D and Multi-Head Attention Mechanism

Surgical gesture recognition is an important research direction in the field of computer-assisted intervention. Currently, research on surgical gesture recognition primarily focuses on robotic surgery, with a lack of studies in traditional surgery, particularly open surgery. Therefore, this study established a dataset simulating open surgery for research on surgical gesture recognition in the field of open surgery. With the assistance of professional surgeons, we defined a vocabulary of 10 surgical gestures based on suturing tasks in open procedures. In addition, this paper proposes a surgical gesture recognition method that integrates the R3D network with a multi-head attention mechanism (R3D-MHA). This method uses the R3D network to extract spatiotemporal features and combines it with the multi-head attention mechanism for relational learning of these features. The effectiveness of the R3D-MHA method in the field of open surgery gesture recognition was validated through two experiments: offline recognition and online recognition. The accuracy at the gesture instance level for offline recognition was 92.3%, and the frame accuracy for online recognition was 73.4%. Finally, its performance was further validated on the publicly available JIGSAWS dataset. Compared to other online recognition methods, the accuracy improved without using additional data. This work lays the foundation for research on surgical gesture recognition in open surgery and has significant applications in process monitoring, surgeon skill assessment and educational training for open surgeries.

Effect of simulating training of the fundamentals of laparoscopic surgery on the attitude of operating room nurses students: an intervention study

Abstract Objective Clinical education plays a key role in preparing students for patient care. Laparoscopy is one of the most important minimally invasive surgeries (MISs) wherein surgical technologists are responsible for camera navigation and assistant surgeons are responsible for peg transfer. Therefore, it is necessary to improve the attitude of the operating room students toward these skills during their study period. The present study was conducted to determine the effect of simulating training in the fundamentals of laparoscopic surgery (FLS) on the attitude of the operating room students. Methods This interventional study was conducted on 28 operating room students of Iran University of Medical Sciences in 2019. The census sampling method was used. The data-collection tool included the “Intrinsic motivation inventory (IMI) questionnaire.” The educational intervention was carried out in theoretical (booklet design) and practical (simulation) sections. Data analysis was carried out using descriptive and inferential analyses including the paired t-test, Mann–Whitney U test, and independent t-test. The collected data were analyzed using R and SPSS software. P-value <0.05 was considered as the significant level. Results The mean ± SD of the participants’ age was 22.93 ± 2.14 years, and the majority of them were women (67.9%). There was a significant difference in the mean scores of students’ attitudes toward the FLS before and after the educational intervention (P < 0.001) in all dimensions (interest, perceived competence, perceived choice, and tension). There was also a significant correlation between gender and interest dimension (P = 0.005). Conclusions The results of the present study showed that simulating the training FLS curriculum positively affects students’ attitudes. Therefore, the researchers suggest that for creating a positive attitude, increasing students’ interest in laparoscopic surgery, and ensuring a more effective presence in the operating room, this training should be considered in the operating room curriculum.

EVALUATION OF NEEDLE STICK INJURY AND ASSOCIATED FACTORS AMONG HEALTHCARE WORKERS IN AL NAJAF CITY/ IRAQ

Introduction:In healthcare-related situations, needle sticks represent a substantial work-related health risk. Healthcare professionals face the danger of contracting blood-borne infections as well as the psychological impact of these wounds. The study aimedtoevaluate the prevalence of needle stick injuries and the associated socio-demographic determinants among healthcare workers.Methods: The research employed a cross-sectional design, with data collection occurring from February 1st, 2023 to February 1st, 2024. 380participants were conveniently selected from different Al-Najaf City/Iraq healthcare institutions. The study sample included a variety of specialists, including anesthetics, surgeons, dentists, surgeon assistants, anesthetics assistants, nurses, physicians, and laboratory workers. A self-administered questionnaire from previously published articles was used for data collection. It covers socio-demographic information, a history of previous exposure to, and the reasons for needle stick injuries.Quantitative variables were summarized with means and standard deviations; descriptive statistics for categorical variables included frequencies and percentages. P ≤ 0.05 indicated statistical significance.Results: Most healthcare workers (85%) were previously exposed to needle sticks. Job category was significantly associated with a history of needle stick exposure (p < 0.001). The anesthetics represent the highest job class exposed to needle sticks (100%). More than one-fifth of participants (21.85%) reported recapping needles followed by bending needles in 16.84% of them as a cause of needle stick injuries. Conclusion: Most healthcare workers are exposed to needle stick injuries; job category is an important risk factor

Intraoperative laparoscopic ultrasound during laparoscopic myomectomy: a narrative review.

Intraoperative laparoscopic ultrasound (IOLUS), a dynamic imaging technique, has emerged as a valuable instrument for guiding surgery in various medical specialties. As IOLUS provides accuracy, improved visualization, and real-time guidance, the integration of IOLUS into many surgical procedures has occurred and IOLUS assists surgeons during advanced procedures. Today, laparoscopic myomectomy has become a prominent surgical procedure in gynecology. Despite its benefits, laparoscopic myomectomy presents certain challenges. The risk of residual fibroids is higher in laparoscopic myomectomy compared to abdominal surgery. The limited depth perception and restricted range of motion can also be obstacles for surgeons, especially when dealing with deeply embedded fibroids. IOLUS has the potential to overcome these limitations. In this study, our aim was to conduct a review of the literature concerning the use of IOLUS during laparoscopic myomectomy.

Exoscope and Supermicrosurgery: Pros and Cons of 3D Innovation in Lymphatic Surgery.

Background: The surgical treatment of lymphedema has seen advancements in recent years, with supramicrosurgical lymphaticovenular anastomosis (sLVA) gaining global acceptance. The integration of 3D exoscopes into microsurgery offers potential ergonomic and educational benefits. However, systematic evaluation of their efficacy in sLVA remains limited. Methods: A retrospective cross-sectional study was conducted comparing the use of 3D exoscopes to conventional operating microscopes (OM) in sLVA surgeries. Patient data from January 2019 to January 2024 were reviewed, with demographic, clinical, and surgical outcome variables analyzed. Ergonomic assessments were performed using Rapid Entire Body Assessment (REBA) and Rapid Upper Limb Assessment (RULA), while surgeon satisfaction was evaluated through the Microsurgical Intraoperative Satisfaction and Comfort questionnaire (MISCq). Results: An analysis of 25 patients (OM group: n = 14; exoscope group: n = 11) revealed no significant differences in age, sex, etiology, or surgical site between the two groups. Surgical time, number of incisions, and number of anastomoses showed nonsignificant variations between the OM and exoscope groups. Ergonomic assessments indicated potential benefits with exoscope use, particularly for the assistant surgeon. Survey results demonstrated comparable levels of surgeon satisfaction with both instruments, with no significant differences in image quality, contrast, illumination, magnification, visual field, ergonomic maintenance, or stereoscopic orientation. Conclusions: The study suggests that 3D exoscopes are a valuable tool for sLVA supermicrosurgery, offering comparable outcomes to traditional microscopes with potential ergonomic advantages. Their integration into microsurgical practice may contribute to improved surgical comfort and team performance. Further research is warranted to confirm these findings and explore additional factors such as cost-effectiveness and long-term patient outcomes.

Robotic gastrectomy using hinotori™ Surgical Robot System: Initial case series.

This study aims to prove the feasibility and safety of robotic gastrectomy using the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan). We retrospectively enrolled the 16 patients who underwent gastrectomy by the hinotori™ Surgical Robot System for gastric cancer at our hospital between June 2023 and January 2024. Console surgeons performed almost all lymphadenectomies, including the clipping of vessels. Assistant surgeons supported the lymphadenectomy using vessel sealing devices and during reconstruction. Thirteen patients were cStage I, one patient was cStage II, and two patients were cStage III. Distal gastrectomy, proximal gastrectomy, and total gastrectomy were performed in 11, 1, and 4 patients, respectively. D1+ and D2 lymphadenectomies were performed in 11 and 5 patients, respectively. Billroth-I, Billroth-II, Roux-en-Y, and esophagogastrostomy were performed in three, six, six, and one patients, respectively. The median operation time was 282 (245-338) min, and the median console time was 226 (185-266) min. The median blood loss was 28 (12-50) mL, and the median amylase levels in drainage fluid were 280 (148-377) U/L on postoperative day 1 and 74 (42-148) U/L on postoperative day 3. There was anastomotic leakage (Clavien-Dindo [CD] IIIa) in one patient who underwent proximal gastrectomy. The median postoperative hospital stay was 12.5 (12-14) days. In this initial case series, the hinotori™ Surgical Robot System was found to be safe and feasible for patients with gastric cancer and is suggested to be appropriate for gastrectomy, including distal gastrectomy and total gastrectomy.

Robot-assisted approach using a laparoscopic articulating vessel-sealing device versus pure-robotic approach during distal pancreatectomy.

Robotic distal pancreatectomy (RDP) has emerged as a minimally invasive approach to left-sided pancreatic tumors. This study aimed to evaluate the efficacy of the robot-assisted approach (RAA) using a laparoscopic articulating vessel-sealing device (LAVSD) during RDP by comparing it with the pure-robotic approach (PRA). Among 62 patients who underwent RDP between April 2020 and December 2023 at Fujita Health University, 22 underwent RAA (the RAA group). In RAA, console surgeons mainly prepared the surgical fields, and assistant surgeons actively dissected the adipose and connective tissues using LAVSD. The surgical outcomes of these patients were compared with those of 40 consecutive patients who underwent RDP with PRA. In total, 28 males and 34 females with a median age of 71years were analyzed. The console surgeon's prior experience of performing RDP was similar between the groups (RAA; median, 6 [range, 0-36], PRA; median, 5.5 [range, 0-34] cases). The operation time was significantly shorter in the TST group (median, 300.5 [range, 202-557] vs. 363.5 [range, 230-556]min, p = 0.015). Major complications (Clavien-Dindo ≥ grade 3a) occurred less frequently in the RAA group (4.6% vs. 25.0%, p = 0.028). Although the median postoperative hospital stay was slightly shorter in the RAA group (median, 12 [range, 8-38] vs. 14.5 [8-44]days, p = 0.095), no statistically significant difference was observed. Compared with PRA, RAA using LAVSD is found to be safe and feasible in introducing RDP for operators with little experience.

SURG-03. VIRTUAL REALITY ASSISTANCE IN THE MANAGEMENT OF PEDIATRIC BRAIN TUMORS

Abstract BACKGROUND Virtual reality (VR) solutions are emerging as a useful adjunct to the armamentarium of the neurosurgeon. Surprisingly, little data is available in the literature regarding its utility in pediatric neurosurgical oncology. We hereby report our preliminary Institutional experience on the application of VR to surgical rehearsal in a series of pediatric brain tumors. METHODS Virtual models were obtained by the Surgical Planner (Surgical Theatre, Inc) in a series of 50 consecutive brain tumor cases treated at Bambino Gesù Children’s Hospital. Utility of VR was scored based on operators’ perception. Explored items included: planning, execution, resection, sparing of eloquent tissue, and overall surgical management. Scoring was performed using a customized Likert scale. RESULTS We prospectively collected 100 consecutive questionnaires from surgeons participating to brain tumor resection procedures. In a multivariate analysis VR was found to be significantly more beneficial in specific surgical settings. Leading surgeons (LS) judged VR significantly more useful in supratentorial tumors, in children younger than 10 years, and in planned partial resections. Assistant surgeons (AS) found VR more useful in supratentorial lesions, particularly in deep seated tumors. Both LS and AS perceived VR to be less useful for in embryonal tumors and epilepsy-associated gliomas (LEAT). CONCLUSIONS Our data suggest that VR technology is useful in the surgical management of children with brain tumors. There might be specific clinical scenarios in which the advantage of VR availability might have a significant clinical impact in planning and performing surgical resection.

РОБОТ-АССИСТИРОВАННЫЕ ОПЕРАЦИИ В ДЕТСКОЙ АБДОМИНАЛЬНОЙ ХИРУРГИИ: ПЕРВОНАЧАЛЬНЫЙ ОПЫТ

Purpose of this research was to apply the possibilities of robot-assisted surgery technology in children with abdominal pathology in terms of assessing feasibility and evaluating postoperative results. Material and methods used: the scientific study was carried out at the Irkutsk Oblast Regional Children's Clinical Hospital (Irkutsk, Russia) in Dec. 2022-June 2023. During this period, 11 robot-assisted procedures were performed on the abdominal organs. The study was conducted within the framework of the Clinical Trials Program for Medical Products approved by the Federal Service for Surveillance in Healthcare of the Russian Federation. All surgical procedures were implemented according to the same principles and patterns that the Authors have gathered previously with the Versius Surgical Robot. In all cases, the three robotic ports were used: a single 12-mm trocar for optics (intervened at the umbilicus) and two 5-mm trocars for robotic arms. Additionally, another 5-mm laparoport was installed for the assistant surgeon to work during the robotic intervention. During the study, patients' perioperative parameters related to data charts, surgical details and both early and long-term outcomes were recorded. Results: the total number of patients involved in robotic interventions on the abdominal organs was 11, 4 (36,4%) boys/7 (63,6%) girls. The mean age at the time of surgery was 10,9±5.1 y/o (Me 12.0 [7.0; 15.0] y/o), mean weight at the time of surgery was 39.7±18.0 kg (Me 43.0 [24.0; 53.8] kg). The distribution of reasons for surgical interventions was as follows: 3 (27,3%) patients with Nissen fundoplication, 3 (27,3%) patients with cholecystectomy, 2 (18,2%) patients with Heller esophagomyotomy with Dor fundoplication, 2 (18,2%) patients with splenic cyst fenestration and a single (9%) patient with enucleation of ovarian teratoma. The mean duration was 100±52.4 min (Me 70.0 [65.0; 122.5] min). None of the operations were accompanied by any intraoperative complications. There were also no conversions into laparoscopic and/or open surgeries. In the long-term period after the operations, the number of significant complications in the form of recurrence of symptoms of the initial disease did not increase, patients showed no digestive problems during the entire follow-up period as well. Conclusion: Russia’s initial experience with robotic-assisted abdominal surgery confirmed that robotics can be safely and effectively used in children. Fundoplication, esophagomyotomy and cholecystectomy are by far the most commonly performed basic interventions in pediatric surgery. Obviously, this is the first stage in the development of robotic abdominal surgery in children hence it would further involve a more complex procedure.

Postoperative Infection Following Hip Arthroscopy in Patients Receiving Preoperative Intra-articular Injections: A Systematic Review and Meta-Analysis.

Intra-articular injections prior to hip arthroscopy are often used to diagnose and conservatively manage hip pathologies, such as femoroacetabular impingement, labral tears, and chondral lesions. As a diagnostic tool, the relief of hip pain following an intra-articular injection helps pinpoint the primary source of pain and assists surgeons in recommending arthroscopic intervention for underlying intra-articular pathologies. However, when injections are not sufficiently spaced apart in time prior to hip arthroscopy, there is an elevated risk of postoperative infection. This systematic review aims to assess whether preoperative intra-articular injections prior to hip arthroscopy are associated with an increased risk of postoperative infection and to determine the safety timeframe for administering such injections prior to the procedure. A comprehensive search was conducted in the PubMed, Embase, and Cochrane Library databases to identify studies examining the relationship between preoperative intra-articular injections and postoperative infection following hip arthroscopy. A meta-analysis was conducted to compare the risk of infection between patients who received injections prior to hip arthroscopy at varying intervals and those who did not receive any preoperative injections. Five studies were included (four level III and one level IV), which consisted of 58,576 patients (58.4% female). Injections administered anytime prior to hip arthroscopy posed a significantly higher risk of infection compared to no history of prior injections (risk ratio: 1.45, 95% confidence interval: 1.14-1.85, P = 0.003). However, upon subanalysis, the risk of infection was significantly higher among patients who received injections within three months prior to hip arthroscopy compared to those who did not receive injections (risk ratio: 1.55, 95% confidence interval: 1.19-2.01, P = 0.001). Additionally, no significant difference in infection risk was observed when injections were administered more than three months before hip arthroscopy compared to no injections (risk ratio: 1.05, 95% confidence interval: 0.56-1.99, P = 0.87). The findings suggest that patients undergoing hip arthroscopy who have previously received intra-articular injections may face a statistically higher risk of postoperative infection, particularly when the injection is administered within three months prior to hip arthroscopy. Consequently, surgeons should exercise caution and avoid administering intra-articular injections to patients scheduled for hip arthroscopy within the subsequent three months to mitigate the increased risk of infection.

Enhancing neonatal thoracoscopic surgical training with rabbit model

BackgroundThoracoscopy, which has an increasing role in the treatment of indexed neonatal surgical conditions, requires adequate training. To support this, the current study aimed to evaluate the feasibility and effectiveness of using live rabbit models in neonatal thoracoscopic skills training among paediatric surgeons. MethodsFollowing didactic lectures and demonstrations, the participants were given hands-on opportunities to perform thoracoscopic procedures. The feasibility and effectiveness of using live rabbit models in neonatal thoracoscopic skills training among paediatric surgeons were evaluated with pre-/post-course procedural confidence scores and a questionnaire. ResultsThis study included 13 paediatric surgeons—2 (15 %) males and 11 (85 %) females—who were evenly distributed. There were four basic surgical trainees, five higher surgical trainees and four fellows in paediatric surgery (mean surgical practice experience: 4.5 ± 3.7 years). Most had experience assisting paediatric (70 %) and neonatal (62 %) thoracoscopic surgery. Only 30 % had experience as the chief surgeon of paediatric thoracoscopic surgery, with none on neonates. Significant improvement was seen in procedural confidence as the assistant and chief surgeon of all procedures post-workshop. The surgeons rated the model positively. ConclusionThe procedural confidence level of paediatric surgeons improved significantly after workshop participation. This realistic and easily reproducible model can help perfect thoracoscopic skills. Therefore, its integration into paediatric surgical training would promote surgical skill proficiency and could improve surgeons’ confidence in neonate operations.

Enhancing the Extent of Resection in Glioma Surgery Through the Integration of Intraoperative Contrast-Enhanced Ultrasound and Fluorescein Sodium

Due to the infiltrative nature and high local recurrence of gliomas, particularly high-grade gliomas, gross total resection (GTR) of a tumor is the first critical step in treatment. This study aimed to determine whether the integration of intraoperative contrast-enhanced ultrasound (CEUS) and fluorescein sodium can improve the identification of tumor boundaries and residuals, and increasethe extent of resection (EOR) to better protect neurological function. We retrospectively analysed clinical data from 87 glioma surgeries and categorised the patients into 3 groups: CEUS plus fluorescein sodium, fluorescein sodium alone and microsurgery alone. In terms of EOR, GTR was achieved in 22 (91.7%) patients in the CEUS plus fluorescein sodium group, which was significantly higher than that in other groups. In the subgroup analysis of tumors with lobulated or satellite lesions and WHO grade III or IV gliomas, CEUS plus fluorescein sodium group showed the highest GTR (86.7% and 88.9% respectively) among the groups. Logistic regression analysis of factors that may affect the GTR of tumors showed that the functional areas involvement and the presence of lobulated or satellite lesions were risk factors, whereas CEUS plus fluorescein sodium group was a protective factor. However, CEUS plus fluorescein sodium group had the longest surgery time. Intraoperative CEUS with fluorescein sodium is a real-time, straightforward, safe, and effective approach to perform surgical resection of gliomas. This approach assists surgeons in identifying tumor boundaries, residual tumors, and normal brain parenchyma, which increases the EOR.

Close Reduction of Supracondylar fracture of humerus in children by Gravity Method

Objective: To evaluate the outcomes of employing a new technique, the gravity method, for the closed reduction of supracondylar humerus fractures (Gartland’s type II and III) in pediatric patients treated at the Trauma Center of Aziz Bhatti Shaheed Hospital Gujrat. Methodology: This descriptive cross-sectional study was conducted at Aziz Bhatti Shaheed Hospital's Trauma Center from August 2022 to April 2023. Children under 12 years old, presenting within 48 hours of injury with closed supracondylar humerus fractures (Gartland’s Extension type II and III), were included. All patients underwent closed reduction and percutaneous pinning. Data analysis was performed using SPSS, employing means and standard deviations for quantitative variables, and frequency and percentage for qualitative variables. Results: The mean age was 5.5 years (±1.5). Among 65 patients, there were 45 males and 20 females, with a male-to-female ratio of 1:0.4. The right humerus was affected in 28 patients (43%), while the left humerus was affected in 37 patients (57%). The gravity method successfully reduced 90% of fractures without the need for an assistant surgeon, resulting in a zero percent incidence of iatrogenic neurovascular injury. The average surgical duration was 20 minutes (ranging from 16 to 24 minutes), with an average of 7 images captured using the image intensifier. In cases where the gravity method failed, alternative closed reduction methods were employed for 10% of fractures; no open reduction was necessary. Conclusion: The gravity method demonstrates safety and efficacy by providing accurate traction for reducing displaced supracondylar fractures without causing damage to the overlying skin or neurovascular structures around the elbow. Its applicability is particularly noteworthy in settings with a shortage of trained medical personnel and limited expertise in managing neurovascular complications.

Bilateral Flexion-Type Supracondylar Humerus Fracture.

Supracondylar humerus fractures are common in the pediatric population, but flexion fractures are very rare in this population. The need for open reduction in these fractures is high and can be challenging for orthopaedic surgeons. In this article, we report a 9-year-old patient with bilateral flexion-type humeral fracture treated with closed reduction, which, to our knowledge, is the first report in the literature. We concluded that the first step in the treatment of flexion-type supracondylar fractures should be closed reduction with the help of an experienced assistant surgeon and that successful results can be obtained even in bilateral flexion-type fractures with appropriate treatment and follow-up.

The role of the vascular surgeon in transcatheter aortic valve implantation.

Transcatheter aortic valve implantation (TAVI) has become the standard treatment for severe aortic valve stenosis in patients at increased surgical risk. Percutaneous transfemoral (TF) is the access of choice due to its reduced invasiveness and perioperative morbidity/mortality compared with the trans-axillary, aortic, and apical routes. On the other hand, vascular access complications (VACs) of the TF access are associated with prolonged hospitalization, 30-day, and 1-year mortality. In addition, the concomitance of peripheral arterial disease may require associated endovascular management. A multidisciplinary team with Interventional Cardiologists and Vascular Surgeons may minimize the rate of VACs in patients with challenging femoral-iliac access or concomitant disease of other vascular districts, thus optimizing the outcome of TF-TAVI. The aim of this study was to evaluate the role of Vascular Surgeons in TF TAVI procedures. We conducted a retrospective single-center review of all TF-TAVI procedures assisted by Vascular Surgeons between January 2016 and December 2020 in a high-volume tertiary hospital. Pre, intra, and postoperative data were analyzed by a dedicated group of Interventional Cardiologists and Vascular Surgeons. VACs were defined according with the Valve Academic Research Consortium (VARC) three guidelines. The outcomes of TF-TAVI procedures with Vascular Surgeons involvement were assessed as study's endpoints. Overall, 937 TAVI procedures were performed with a TF approach ranging between 78% (2016) and 98% (2020). Vascular Surgeons were involved in 67 (7%) procedures with the following indications: concomitant abdominal aortic aneurysm (EVAR + TAVI) - 3 (4%), carotid stenosis (TAVI + CAS) - 2 (3%), hostile femoral/iliac access, or VACs - 62 (93%). Balloon angioplasty of iliac artery pre-TAVI implantation was performed in 51 cases (conventional PTA: 38/51%-75%; conventional PTA + intravascular lithotripsy: 13/51%-25%; stenting: 5/51%-10%). TAVI procedure was successfully completed by percutaneous TF approach in all 62 cases with challenging femoral/iliac access. VACs necessitating interventions were 18/937 (2%) cases, localized to the common femoral or common/external iliac artery in 15/18 (83%) and 3/18 (17%) cases, respectively. They were managed by surgical or endovascular maneuvers in 3/18 (17%) and 15/18 (83%) cases, respectively. Fifteen/18 (83%) VACs were treated during the index procedure. There was no procedure-related mortality or 30-day readmission. In our experience, Vascular Surgeon assistance in TAVI procedures was not infrequent and allowed safe and effective device introduction through challenging TF access. Similarly, the concomitant significant disease of other vascular districts could be safely addressed, potentially reducing postoperative related mortality and morbidity. The implementation of multidisciplinary team with interventional cardiologists and vascular surgeons should be encouraged whenever possible.

Should Pediatric Surgical Oncologists Receive Training in Vascular Surgery ? A Practice Survey Report From the International Society of Paediatric Surgical Oncology (IPSO)

BackgroundIs vascular training in paediatric surgical oncology considered desirable ? MethodsA voluntary survey of work practice was undertaken with the surgeon membership of The International Society Of Paediatric Surgical Oncology (IPSO) using a structured designed questionnaire. ResultsA total of 149 IPSO surgeon members completed the survey. 57% (N = 84) of surgeons surveyed had no specific training in vascular surgery. 43% surgeons (N = 63) stated they had acquired some skills in residency training and/or with transplantation surgery. 65% (N = 96) of respondent surgeons stated that vascular surgical training must be incorporated into pediatric surgical oncology training and 27% (N = 40) agreed that it was considered desirable. 89% (N = 133) of surgeon respondents had encountered major vascular injury during work practice while operating on pediatric solid tumors. Vascular injury repairs were undertaken and attempted by pediatric surgeons though expert assistance of vascular surgeons proved crucially essential in many instances. Emergent operations included patch repairs, vessel ligation techniques and insertion of vascular graft prostheses. Interventional radiology services to arrest life-threatening hemorrhage were also reportedly utilized by respondents. ConclusionVascular injuries have significant potential for devastating patient outcomes including never event ‘mortality’. The IPSO surgeon survey highlights that there are visible ‘gaps’ in skills training. Training to be a pediatric oncology surgeon must incorporate acquisition of skill sets proficiency in vascular surgery.

Robotic spleen-preserving distal pancreatectomy using the first domestic surgical robot platform (the hinotori™ Surgical Robot System): a case report

BackgroundRobotic pancreatectomy has been performed worldwide mainly using the da Vinci® Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA, USA). Recently, because of the death of some patents related to the da Vinci® system, new surgical robot systems have been introduced that are characterized by unique technical refinements. In Japan, the hinotori™ Surgical Robot System (Medicaroid Corporation, Kobe, Japan) was approved for use in gastroenterological surgery in October 2022. Since then, we have attempted complicated procedures using this robot. In this report, we report our first experience performing spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein using this first Japanese domestic surgical robot.Case presentationThe patient was a 58-year-old woman with a mass in the pancreatic tail identified during medical screening. Further examinations resulted in a diagnosis of a pancreatic neuroendocrine tumor. The patient consented to surgical resection, and we planned robotic spleen-preserving distal pancreatectomy with conservation of the splenic artery and vein, using the hinotori™. Five trocars, including one port for the assistant surgeon, were placed in the upper abdomen. The operating unit was rolled in from the patient’s right side. The pivot position was set for each robotic arm, and this setting was specific to the hinotori™. The cockpit surgeon performed all surgical procedures, excluding port placement and pancreatic transection. There were no unrecoverable device errors during the operation. The operation time was 531 min, and blood loss was 192 ml. The postoperative course was uneventful. We were able to safely perform this highly complicated surgery for a pancreatic tumor using the first Japanese domestic surgical robot platform.ConclusionsThe first Japanese domestic surgical robot platform, hinotori™, has different features from those of the da Vinci® and performed sufficiently as a surgical robot system in highly advanced pancreatic surgery.