Placement Of Instrumentation Research Articles

Fluoroscopy-guided robotic biopsy intervention system

Abstract Fluoroscopy-guided percutaneous biopsy interventions are mostly performed with traditional free-hand technique. The practical experience of the surgeon influences the duration of the intervention and the radiation exposure for patients and him-/herself. Especially when the placement of heavy and long instruments in double oblique angles is required, manual techniques reach their technical limitations very fast. The system presented herein automatizes the needle positioning using only two 2D scans while the robotic platform guides the intervention. These two images were used to plan the needle pathway and to estimate the pose of the robot using a custom-made end-effector with embedded registration fiducials. The estimated pose was subsequently used to transfer the planed needle path to the robot’s coordinate system and finally to compute the movement parameters in order to align the robot with this plan. To evaluate the system, two phantoms with 11 different targets on it were developed. The targets were punctured, and the application accuracy was measured quantitatively. The solution achieved sub-millimetric accuracy for needle placement (min. 0.23, max. 1.04 in mm). Our approach combines the advantages of fluoroscopic imaging and ensures automatic needle alignment with highly reduced X-ray radiation. The proposed system shows promising potential to be a guidance platform that is easy to combine with available fluoroscopic imaging systems and provides valuable help to the physician in more difficult interventions.

The effect of simulation training on resident proficiency in thoracolumbar pedicle screw placement using computer-assisted navigation.

Residency work-hour restrictions necessitate efficient, reproducible training. Simulation training for spinal instrumentation placement shows significant benefit to learners' subjective and objective proficiency. Cadaveric laboratories are most effective but have high cost and low availability. The authors' goal was to create a low-cost, efficient, reproducible spinal instrumentation placement simulation curriculum for neurosurgery and orthopedic surgery residents using synthetic models and 3D computer-assisted navigation, assessing subjective and objective proficiency with placement of thoracolumbar pedicle screws. Fifteen neurosurgery and orthopedic surgery residents participated in a standardized curriculum with lecture followed by two separate sessions of thoracolumbar pedicle screw placement in a synthetic spine model utilizing 3D computer-assisted navigation. Data were collected on premodule experience, time and accuracy of screw placement, and both subjective and objective ratings of proficiency. Fifteen of 15 residents demonstrated improvement in subjective (Physician Performance Diagnostic Inventory Scale [PPDIS]) and 14 in objective (Objective Structured Assessment of Technical Skills [OSATS]) measures of proficiency in navigated screw placement with utilization of this curriculum (p < 0.001 for both), regardless of the number of cases of previous experience using thoracolumbar spinal instrumentation. Fourteen of 15 residents demonstrated decreased time per screw placement from session 1 to session 2 (p = 0.006). There was no significant difference in pedicle screw accuracy between session 1 and session 2. A standardized curriculum using synthetic simulation training for navigated thoracolumbar pedicle screw placement results in significantly improved resident subjective and objective proficiency. Development of a nationwide competency curriculum using simulation training for spinal instrumentation placement should be considered for safe, efficient resident training.

Stereotactic navigation in anterior cervical spine surgery: surgical setup and technique.

Intraoperative stereotactic navigation in spine surgery is quickly becoming popularized for accurate placement of spinal instrumentation as well as assisting in the verification of anatomic landmarks. Navigation is less commonly utilized in anterior cervical spine surgery due to instrumentation being able to be placed under direct visualization. The utility of navigation in anterior cervical spine surgery is its ability to aid in the verification of anatomic location, particularly when anatomy is distorted or pathology comes close to critical neurovascular structures. We present a technique guide for anterior cervical spine navigation that we have applied at our institution and have found to be very beneficial in select patients, particularly those with complex anatomy, large body mass index, undergoing revision surgery, sustained spinal trauma and those patients with severe anterior ossification where depth or medial-lateral landmarks are difficult to visualize. We describe utilization of the technique using a case examples and specifically in a patient with significant ossification of the posterior longitudinal ligament and severe spinal cord compression that underwent multilevel cervical corpectomy. The described technique was found to be reproducible and effective, allowing cervical spine surgeons to perform more complex or minimally invasive procedures with safety and accuracy. We emphasize that navigation does not replace knowledge of anatomy or technical aspects of the procedure.

Preoperative Computer-Assisted Laparoscopy Planning for the Minimally Invasive Surgical Repair of Hiatal Hernia.

Minimal invasive surgical procedures such as laparoscopy are preferred over open surgery due to faster postoperative recovery, less trauma and inflammatory response, and less scarring. Laparoscopic repairs of hiatal hernias require pre-procedure planning to ensure appropriate exposure and positioning of the surgical ports for triangulation, ergonomics, instrument length and operational angles to avoid the fulcrum effect of the long and rigid instruments. We developed a novel surgical planning and navigation software, iMTECH to determine the optimal location of the skin incision and surgical instrument placement depth and angles during laparoscopic surgery. We tested the software on five cases of human hiatal hernia to assess the feasibility of the stereotactic reconstruction of anatomy and surgical planning. A whole-body CT investigation was performed for each patient, and abdominal 3D virtual models were reconstructed from the CT scans. The optical trocar access point was placed on the xipho-umbilical line. The distance on the skin between the insertion point of the optical trocar and the xiphoid process was 159.6, 155.7, 143.1, 158.3, and 149.1 mm, respectively, at a 40° elevation angle. Following the pre-procedure planning, all patients underwent successful surgical laparoscopic procedures. The user feedback was that planning software significantly improved the ergonomics, was easy to use, and particularly useful in obese patients with large hiatal defects where the insertion points could not be placed in the traditional positions. Future studies will assess the benefits of the planning system over the conventional, empirical trocar positioning method in more patients with other surgical challenges.

Droplet and Aerosol Generation With Endonasal Surgery: Methods to Mitigate Risk During the COVID-19 Pandemic.

ObjectiveTo define the aerosol and droplet risks associated with endonasal drilling and to identify mitigation strategies.Study DesignSimulation series with fluorescent 3-dimensional (3D) printed sinonasal models and deidentified cadaveric heads.SettingsDedicated surgical laboratory.Subjects and MethodsCadaveric specimens irrigated with fluorescent tracer and fluorescent 3D-printed models were drilled. A cascade impactor was used to collect aerosols and small droplets of various aerodynamic diameters under 15 µm. Large droplet generation was measured by evaluating the field for fluorescent debris. Aerosol plumes through the nares were generated via nebulizer, and mitigation measures, including suction and SPIWay devices, nasal sheaths, were evaluated regarding reduction of aerosol escape from the nose.ResultsThe drilling of cadaveric specimens without flexible suction generated aerosols ≤3.30 µm, and drilling of 3D sinonasal models consistently produced aerosols ≤14.1 µm. Mitigation with SPIWay or diameter-restricted SPIWay produced same results. There was minimal field contamination in the cadaveric models, 0% to 2.77% field tarp area, regardless of drill burr type or drilling location; cutting burr drilling without suction in the 3D model yielded the worst contamination field (36.1%), followed by coarse diamond drilling without suction (19.4%). The simple placement of a flexible suction instrument in the nasal cavity or nasopharynx led to complete elimination of all aerosols ≤14.1 µm, as evaluated by a cascade impactor positioned immediately at the nares.ConclusionGiven the findings regarding aerosol risk reduction, we strongly recommend that physicians use a suction instrument in the nasal cavity or nasopharynx during endonasal surgery in the COVID-19 era.

Evaluation of a Single-Use Flexible Cystoscope: A Multi-Institutional International Study.

Introduction: Acquisition costs and prohibitively expensive technical support for endoscope maintenance, repair, and reprocessing have deterred adoption of flexible cystoscopes by many urologists internationally. This study evaluated the performance of a novel single-use digital cystoscope that can directly connect to a laptop or computer monitor for visualization, obviating the need for a tower. Materials and Methods: The performance characteristics of flexible single-use cystoscopes (NeoScope) were prospectively evaluated vs a reusable flexible cystoscope (Olympus) in three clinical cases and two independent benchtop testing episodes in Canada. Cystoscope maneuverability, imaging, deflection, irrigation, and ease of use of instrumentation were investigated. Additional investigations were performed during clinical use in Zimbabwe (7 patients), Egypt (10 patients), and Dominica (5 patients). Results: Bench testing revealed smaller tip diameter (4.06 vs 6.09 mm) and shorter (35.4 vs 38 cm) single-use cystoscopes vs reusable cystoscopes. Deflection of the single-use scope was superior with an empty working channel (230 up/220 down) vs the reusable (195 up/95 down) but showed a more substantial decrease in deflection on placement of instruments including a grasper. Clinical use revealed satisfactory maneuverability, ease of use of instruments, deflection, and visualization. Conclusions: Benchtop testing performance of the single-use digital flexible cystoscopes was inferior compared with reusable digital cystoscopes. However, these single-use endoscopes offer adequate illumination, imaging, and maneuverability. Direct connection to any computer monitor allowed truly portable use, allowing for treatment of patients in a variety of clinical settings without the need for ancillary equipment.

Designing an optimized diagnostic network to improve access to TB diagnosis and treatment in Lesotho

BackgroundTo reach WHO End tuberculosis (TB) targets, countries need a quality-assured laboratory network equipped with rapid diagnostics for tuberculosis diagnosis and drug susceptibility testing. Diagnostic network analysis aims to inform instrument placement, sample referral, staffing, geographical prioritization, integration of testing enabling targeted investments and programming to meet priority needs.MethodsSupply chain modelling and optimization software was used to map Lesotho’s TB diagnostic network using available data sources, including laboratory and programme reports and health and demographic surveys. Various scenarios were analysed, including current network configuration and inclusion of additional GeneXpert and/or point of care instruments. Different levels of estimated demand for testing services were modelled (current [30,000 tests/year], intermediate [41,000 tests/year] and total demand needed to find all TB cases [88,000 tests/year]).ResultsLesotho’s GeneXpert capacity is largely well-located but under-utilized (19/24 sites use under 50% capacity). The network has sufficient capacity to meet current and near-future demand and 70% of estimated total demand. Relocation of 13 existing instruments would deliver equivalent access to services, maintain turnaround time and reduce costs compared with planned procurement of 7 more instruments. Gaps exist in linking people with positive symptom screens to testing; closing this gap would require extra 11,000 tests per year and result in 1000 additional TB patients being treated. Closing the gap in linking diagnosed patients to treatment would result in a further 629 patients being treated. Scale up of capacity to meet total demand will be best achieved using a point-of-care platform in addition to the existing GeneXpert footprint.ConclusionsAnalysis of TB diagnostic networks highlighted key gaps and opportunities to optimize services. Network mapping and optimization should be considered an integral part of strategic planning. By building efficient and patient-centred diagnostic networks, countries will be better equipped to meet End TB targets.

Prediction of clinical height gain from surgical posterior correction of idiopathic scoliosis.

The best predictors of height gain due to surgical correction are the number of fused vertebrae and the degrees of the corrected Cobb angle. Existing studies of predictive models measured the radiographic spinal height and did not report the clinical height gain. The aims of this study were to determine the best predictive factors of clinical height gain before surgical correction, construct a predictive model using patient population data for machine learning, and test the performance of this model on a validation population. The authors reviewed 145 medical records of consecutive patients who underwent surgery that included placement of posterior spinal instrumentation and fusion for idiopathic scoliosis between 2012 and 2016. Standing and sitting clinical heights were measured before and after surgery in patients who had been surgically treated under similar conditions. Multivariate analysis was then performed and the results were used to develop a predictive model for height gain after surgery. The data from the included patients were randomly assigned to a learning set or a test set. In total, 116 patients were included in the analysis, for whom the average postoperative clinical height gain in a standing position was 4.2 ± 1.8 cm (range 0-11 cm). The best prediction model was calculated as follows: standing clinical height gain (cm) = 1 - 0.023 × sitting clinical height (cm) - 0.19 × Risser stage + 0.058 × Cobb preoperative angle (°) + 0.021 × T5-12 kyphosis (°) + 0.14 × number of levels fused. In the validation cohort, 91% of the predicted values had an error of less than one-half of the actual height gain. This predictive model formula for calculating the potential postoperative height gain after surgical treatment can be used preoperatively to inform idiopathic scoliosis patients of what outcomes they may expect from posterior spinal instrumentation and fusion (taking into account the model's uncertainty).

Three-dimensional assessment of robot-assisted pedicle screw placement accuracy and instrumentation reliability based on a preplanned trajectory.

Robotic spine surgery systems are increasingly used in the US market. As this technology gains traction, however, it is necessary to identify mechanisms that assess its effectiveness and allow for its continued improvement. One such mechanism is the development of a new 3D grading system that can serve as the foundation for error-based learning in robot systems. Herein the authors attempted 1) to define a system of providing accuracy data along all three pedicle screw placement axes, that is, cephalocaudal, mediolateral, and screw long axes; and 2) to use the grading system to evaluate the mean accuracy of thoracolumbar pedicle screws placed using a single commercially available robotic system. The authors retrospectively reviewed a prospectively maintained, IRB-approved database of patients at a single tertiary care center who had undergone instrumented fusion of the thoracic or lumbosacral spine using robotic assistance. Patients with preoperatively planned screw trajectories and postoperative CT studies were included in the final analysis. Screw accuracy was measured as the net deviation of the planned trajectory from the actual screw trajectory in the mediolateral, cephalocaudal, and screw long axes. The authors identified 47 patients, 51% male, whose pedicles had been instrumented with a total of 254 screws (63 thoracic, 191 lumbosacral). The patients had a mean age of 61.1 years and a mean BMI of 30.0 kg/m2. The mean screw tip accuracies were 1.3 ± 1.3 mm, 1.2 ± 1.1 mm, and 2.6 ± 2.2 mm in the mediolateral, cephalocaudal, and screw long axes, respectively, for a net linear deviation of 3.6 ± 2.3 mm and net angular deviation of 3.6° ± 2.8°. According to the Gertzbein-Robbins grading system, 184 screws (72%) were classified as grade A and 70 screws (28%) as grade B. Placement of 100% of the screws was clinically acceptable. The accuracy of the discussed robotic spine system is similar to that described for other surgical systems. Additionally, the authors outline a new method of grading screw placement accuracy that measures deviation in all three relevant axes. This grading system could provide the error signal necessary for unsupervised machine learning by robotic systems, which would in turn support continued improvement in instrumentation placement accuracy.

Novel use of intraoperative cone-beam imaging with on-table angiography for excision of an occipitocervical tumour: A technical note and its feasibility

IntroductionIntraoperative imaging and stereotactic navigation in spinal surgery to guide instrumentation placement and tumour resection is well documented. However, image depiction is restricted to high attenuation structures such as osseous tissue and metal objects. Vascular anatomy like major arteries or vascular neoplasm cannot be depicted. We reported angiographically enhancing intraoperative cone-beam imaging (O-arm) to facilitate resection of a craniocervical junction neoplasm that distorted the course of vertebral artery, and discussed the feasibility of this technique. MethodsWe performed intraoperative angiography employing the O-arm for image acquisition, and applied the images in S7 Stealth Station to guide tumour resection in an occipitocervical osseous tumour in which the course of the vertebral artery was heavily distorted. ResultsIntraoperative findings matched the 3D navigation images demonstrating the V3 and upper V2 segments of the vertebral artery in close proximity to the tumour. Complete en bloc tumour removal was achieved without injury to the adjacent vertebral artery. No intra- or postoperative complications occurred. ConclusionIt is feasible intraoperatively to acquire angiographically enhancing cone-beam imaging of spinal tumour in close proximity to the V3 and upper V2 segments of vertebral artery. It appears to facilitate safe tumour resection by mapping critical vascular structures in the surgical field that is initially occult to direct vision. Such novel use of technique warrants further validation.

Hearing damage caused by noise in classical musicians

In this paper we discuss the issue of hearing damage caused by noise in classical musicians. Long-term exposure to high intensity sounds leads to degenerative changes at the level of the cochlea and then in the higher parts of the auditory canal. This is particularly unfavorable for musicians, because an efficient hearing organ is necessary for them to perform their daily work. The risk of hearing damage depends on noise parameters and intrinsic factors called individual noise sensitivity. Not all musicians are exposed to sounds that exceed the acceptable level. However, most of them work in noise levels that are close to the acceptable safety limit or above, thus posing a threat. In addition to elevated hearing threshold, tinnitus, auditory hypersensitivity and diploacousis may result from many years of exposure to high intensity acoustic stimuli. Although the differences between the hearing thresholds for instrumentalists and members of the unexposed population are not large, researchers emphasize the need to recognize musicians as a risk group and to apply appropriate prevention. One of the methods to prevent hearing damage is to use ear protectors, which, although effectively reduce exposure, are not widely used by instrumentalists because they impede auditory control over the sounds produced by the instrument. In addition, multifaceted prevention programs and various techniques to minimize exposure are used, such as the proper placement of loud instruments in an orchestra.

V02-02 SINGLE PORT ROBOTIC PYELOPLASTY

INTRODUCTION AND OBJECTIVE: Single Port Robotic Assisted Laparoscopic Surgery is a new technology released by Intuitive in 2018. This technology further advances minimally invasive surgery. It enables multiple instruments with fully wristed motions through one 25mm port. As with all new technologies, there is an associated learning curve and this video aims to demonstrate appropriate use of this technology for pyeloplasty. METHODS: 33 year old female with no significant past medical history presented with right flank pain. Workup demonstrated right ureteropelvic junction obstruction. RESULTS: Patient underwent single port robotic assisted laparoscopic right pyeloplasty. A single 25mm incision was placed in the umbilicus for the robotic instruments. A 5mm assistant port was placed in the ipsilateral lower quadrant within the pant line for the assistant port. The procedure mostly mimicked the multiport approach. Adjustments were made to instrument placement and traction to accommodate the different mobility of the single port system. CONCLUSIONS: The single port enables excellent mobility and control. It is similarly safe and effective as the multiport. In our unpublished data we have found no significant difference between our multiport and single port outcomes.Source of Funding: None

Novel In Situ Open Reduction and Fixation of a Displaced Type II Odontoid Fracture

Surgical intervention for type II odontoid fractures is a common treatment strategy when conservative management is not appropriate, such as in significantly displaced fractures. However, displaced fractures may not be easily reduced with instrumentation alone. We present a novel technique, using a "bucket-handle" construct to manually reduce a dorsally displaced type II odontoid fracture, in a patient with failure of previously placed dorsal instrumentation. A 63-year-old woman underwent posterior sublaminar wiring and fixation of a type II odontoid fracture at an outside institution. Several weeks later, she presented with graft dislodgement and increased dorsal displacement and angulation of her fractured dens. After removal of her prior instrumentation and placement of segmental instrumentation, a novel construct was created using components from the instrumentation system and was attached to her cervical 2 (C2) screws. Dorsal traction on the C2 pars interarticularis screws allowed for manual reduction of her fracture via a 3-point bending moment. This reduction was secured with an occiput to C6 fixation and fusion. She is clinically and radiographically stable at 3-months follow-up. This novel "bucket-handle" construct, used in conjunction with occipitocervical fusion, allowed safe and durable manual reduction of a dorsally displaced and angulated type II odontoid fracture.

A Patient-Specific Mixed-Reality Visualization Tool for Thoracic Surgical Planning

Identifying small lung lesions during minimally invasive thoracic surgery can be challenging. We describe 3-dimensional mixed-reality visualization technology that may facilitate noninvasive nodule localization. A software application and medical image processing pipeline were developed for the Microsoft HoloLens to incorporate patient-specific data and provide a mixed-reality tool to explore and manipulate chest anatomy with a custom-designed user interface featuring gesture and voice recognition. A needs assessment between engineering and clinical disciplines identified the potential utility of mixed-reality technology in facilitating safe and effective resection of small lung nodules. Through an iterative process, we developed a prototype employing a wearable headset that allows the user to (1) view a patient's original preoperative imaging; (2) manipulate a 3-dimensional rendering of that patient's chest anatomy including the bronchial, osseus, and vascular structures; and (3) simulate lung deflation and surgical instrument placement. Mixed-reality visualization during surgical planning may facilitate accurate and rapid identification of small lung lesions during minimally invasive surgeries and reduce the need for additional invasive preoperative localization procedures.

Computer-assisted navigation in complex cervical spine surgery: tips and tricks.

Stereotactic navigation is quickly establishing itself as the gold standard for accurate placement of spinal instrumentation and providing real-time anatomic referencing. There have been substantial improvements in computer-aided navigation over the last decade producing improved accuracy with intraoperative scanning while shortening registration time. The newest iterations of modeling software create robust maps of the anatomy while tracking software localizes instruments in multiple display modes. As a result, stereotactic navigation has become an effective adjunct to spine surgery, particularly improving instrumentation accuracy in the setting of atypical anatomy. This article provides an overview of stereotactic navigation applied to complex cervical spine surgery, details the means for registration and direct referencing, and shares our preferred methods to implement this promising technology.

The clinical utility of the Spinal Instability Neoplastic Score (SINS) system in spinal epidural metastases: a retrospective study.

A retrospective study. This study assessed the clinical utility of the Spinal Instability Neoplastic Score (SINS) in relation to the surgical treatment of spinal epidural metastasis and factors important for surgical decision-making. These factors include epidural spinal cord compression (ESCC), patient prognosis and neurologic status. Queen Elizabeth II Health Sciences Centre, Halifax, Canada. We identified 285 patients with spinal metastatic disease. Data were extracted through a retrospective review. SINS and ESCC were scored based on CT and MRI, respectively. Patients were grouped into stable (35%), potentially unstable (52%), and unstable (13%) groups. The overall incidence of metastatic spinal deformity was 9%. Surgical interventions were performed in 21% of patients, including decompression and instrumented fusion (70%), decompression alone (17%), percutaneous vertebral augmentation (9%), and instrumented vertebral augmentation (5%). The use of spinal instrumentation was significantly associated with unstable SINS (p = 0.005). Grade 3 ESCC was also significantly associated with unstable SINS (p < 0.001). Kaplan-Meier analysis revealed that SINS was not a predictor of survival (p = 0.98). In the radiotherapy-alone group, a significant proportion of patients with potentially unstable SINS (30%) progressed into unstable SINS category at an average 364 ± 244 days (p < 0.001). This study demonstrated that more severe categories of SINS were associated with higher degrees of ESCC, and surgical interventions were more often utilized in this group with more frequent placement of spinal instrumentation. Although SINS did not predict patient prognosis, it correlates with the progression of metastatic instability in patients treated with radiotherapy.

Single-Surgeon Direct Comparison of O-arm Neuronavigation versus Mazor X Robotic-Guided Posterior Spinal Instrumentation

We sought to compare intraoperative surgical instrumentation techniques with image-guidance versus robotic-guided procedures for posterior spinal fusion. A retrospective review of institutional data collected from a single surgeon was used to compare surgical outcomes between O-arm neuronavigation and the Mazor X robotic-assistance system for placement of posterior spinal instrumentation in a consecutive series of patients. Univariate statistical significance testing compared time spent in the operating room, blood loss, screw accuracy, and wound healing. Between January 2017 and February 2019, 46 O-arm cases (mean age 59.6 years ± 13.7 years) and 39 Mazor X cases (mean age 59.5 years ± 12.4 years) were conducted. Cases were classified as degenerative, infectious, oncologic, and trauma with a mean of 4.57 and 5.43 levels operated on using O-arm neuronavigation and Mazor X, respectively. Mean operative times (P= 0.124), estimated blood loss (P= 0.212), wound revision rates (P=0.560), and clinically acceptable instrumentation placement (P= 0.076) did not demonstrate significance between the 2 groups. However, screw placement was significantly more accurate and precise (P= 1× 10-9) with robotic assistance when considering Gertzbein-Robbins A placement. Although a trend toward greater accuracy was noticed with robotic technology when determining clinically acceptable screws, there was not a significant difference when compared with O-arm neuronavigation. However, robotic technology has a significant effect on both precision and accuracy in Gertzbein-Robbins A screw placement. Robotics does not have a clear advantage when discussing infection rates, intraoperative blood loss, or operative time.

Robot-Assisted versus Freehand Instrumentation in Short-Segment Lumbar Fusion: Experience with Real-Time Image-Guided Spinal Robot

Increasing patient demand for minimally invasive surgery and increased payer emphasis on quality-based payment schema have created a need for technologies that provide consistent, high-quality outcomes for patients undergoing spine surgery. Robotic assistance is one such technology. We report our early experience with a novel real-time, image-guided robot system for use in short-segment lumbar fusion in patients diagnosed with degenerative disease. A consecutive series of patients undergoing robot-assisted 1-level or 2-level lumbar fusion procedures were compared with matched controls who underwent freehand surgery. Screw accuracy, intraoperative outcomes, and 30-day outcomes were compared. We identified 56 patients who underwent 1-level or 2-level lumbar fusion during the study period: 28 who underwent robot-assisted procedures and 28 matched controls who underwent freehand instrumentation placement. No significant differences were found between the robot-assisted surgery cohort and the freehand surgery cohort with respect to matched variables. Patients who underwent robot-assisted surgery had less intraoperative blood loss (266.1 ± 236.8 mL vs. 598.8 ± 360.2 mL; P < 0.001) and shorter hospitalizations (3.5 ± 1.8 days vs. 4.5 ± 2.0 days; P= 0.01). No differences were noted in complication rates, 30-day outcomes, or screw accuracy. Profiling of our initial series showed an average reduction in operation duration of 4.6 minutes with each additional case. Patients undergoing robot-assisted fusion experienced less intraoperative blood loss and shorter hospitalizations. The results of this initial experience suggest that an image-guided robotic system may provide similar short-term outcomes compared with freehand instrumentation placement.

A Surgical Simulator for Tympanostomy Tube Insertion Incorporating Capacitive Sensing Technology to Track Instrument Placement.

We describe a device engineered for realistic simulation of myringotomy and tympanostomy tube insertion that tracks instrument placement and objectively measures operator proficiency. A 3-dimensional computer model of the external ear and cartilaginous external auditory canal was created from a normal maxillofacial computed tomography scan, and models for the bony external auditory canal and tympanic cavity were created with computer-aided design software. Physical models were 3-dimensionally printed from the computer reconstructions. The external auditory canal and tympanic cavity surfaces were coated with conductive material and wired to a capacitive sensor interface. A programmable microcontroller with custom embedded software completed the system. Construct validation was completed by comparing the run times and total sensor contact times of otolaryngology faculty and residents.

Передумови формування парадигми фінансового забезпечення сталого розвитку суб’єктів господарювання

Globalization trends in the world economy lead to changes in the economic conditions of enterprises activity and the distribution of financial resources to ensure their sustainable development. Sustainable development of enterprises largely depends on the state of their financial support and the choice of financing instruments. Therefore, the priority task is to study the financial nature of capital transformations under the influence of economic processes and revise approaches to the formation of a paradigm for financial support for business entities sustainable development. The purpose of the article is to substantiate the prerequisites of the paradigm of financial support for business entities sustainable development and directions of its implementation. The steady recovery of capital is required to ensure the sustainable development of business entities. Therefore, businesses should apply different modern instruments of raising financial resources: self-financing, bank lending, budget financing and crediting, redistribution of funds, and placement of financial instruments. The article presents the process of optimizing the ratio of forms and volumes of financial resources of economic activity, aimed at improving the efficiency of financing sustainable development of business entities. Based on a systematic analysis of the use of the set of concepts, the indicators of financial support for sustainable development of business entities have been determined. The results of the critical analysis of the fundamental theoretical bases of sustainable development and their development with the help of new postulates have allowed to develop the initial theoretical provisions of the paradigm of financial support for sustainable development. The main idea of this paradigm is to formulate adequate financial support for maximizing the value of a sustainable development-oriented company. It was proved that the value of the company reflects a complex system of economic relations and is the effective indicator of the potential for sustainable development.