Introduction Of New Surgical Techniques Research Articles

OGC SO45 - Effect of anastomotic technique on leak rates in two-stage robotic-assisted subtotal oesophagectomy

Abstract Background Introduction of new surgical techniques requires constant monitoring and real time audit. In our unit the introduction of the thoracic component of our robotic oesophagectomy program resulted in an increase in the anastomotic leak rate which was recognised in real time. This prompted a decision to change from a circular to a linear stapled technique. The aim of this study was to evaluate the impact of this change in technique on the anastomotic leak rate. Method A database was used to identify all cases of patients undergoing two stage subtotal oesophagectomy where the thoracic phase was performed robotically-assisted. Demographic, operative, pathological and complications data were extracted. An anastomotic leak was defined as radiological or endoscopic disruption of the oesophagogastric anastomosis or where a clinician had documented the presence of a leak in the clinical notes. Leaks were then graded by severity according to the classification by Low et al into type 1: localised defect treated with medical therapy or observation; Type 2: localised defect requiring intervention but not surgery, and; Type 3: localised defects requiring surgery. Results Fifty-seven patients were identified. The first 25 cases were reconstructed with a circular-stapled and the subsequent 32 with a linear-stapled anastomosis. There were no differences in baseline demographics. There were no differences in thoracic operating time nor blood loss, intraoperative complications and pathological variables such as lymph node yield. Overall, 11/57 patients (19%) had an anastomotic leak, of which 7 (28%) had a circular stapled anastomosis and 4 (12%) had a linear stapled anastomosis. This difference was not statistically significant (p=0.2384). However, CUSUM analysis after the change in anastomotic technique showed an ongoing and diminished anastomotic leak rate. Conclusion In our unit changing from a circular to a linear stapled anastomotic technique resulted in a reduction in the anastomotic leak rate from 24% to 12%. While this was not statistically significant, this is a clinically appreciable result and this benefit was confirmed on CUSUM analysis.

Contemporary Perioperative Nutritional Care.

Over the last decades, surgical complication rates have fallen drastically. With the introduction of new surgical techniques coupled with specific evidence-based perioperative care protocols, patients today run half the risk of complications compared with traditional care. Many patients who in previous years needed weeks of hospital care now recover and can leave in days. These remarkable improvements are achieved by using nutritional stress-reducing care elements for the surgical patient that reduce metabolic stress and allow for the return of gut function. This new approach to nutritional care and how it is delivered as an integral part of enhancing recovery after surgery are outlined in this review. We also summarize the new and increased understanding of the effects of the routes of delivering nutrition and the role of the gut, as well as the current recommendations for artificial nutritional support.

MANDIBULAR POST-SURGICAL ANALYSIS WITH USE OF FIBULAR GRAFT

The objective of this study is to highlight some reports that were previously published in serial publications, also known as journals, that explain the reason for using fibular grafts in facial anatomical regions. These grafts are considered safe alternatives, but, on the other hand, they have resulted in some complications. Routinely, several surgical options are introduced as viable predilections in surgical centers, thus ensuring hopeful results. During the research, several clinical cases were found, the vast majority of which were patients affected by neoplastic lesions. In a smaller minority, polytrauma patients were observed who suffered large extensions of anatomical damage and who, unfortunately, required the application of grafts to replace the lost areas. These studies highlight the importance of carefully choosing reconstructive techniques to minimize risks and maximize benefits. The introduction of new surgical techniques and the continuous evolution of medical practices have enabled significant improvements in patient outcomes, providing a better quality of life after surgery.

Prepectoral Breast Reconstruction with Prosthesis and Acellular Dermal Matrix: A New Technique of ADM Implantation and Fixation.

Direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique and linked to better overall results. The introduction of new surgical techniques has prompted us to develop an acellular dermal matrix fixation technique that reduces the rate of complications and implant loss. We retrospectively analyzed data from patients who underwent DTI prepectoral breast reconstruction with two different techniques of acellular dermal matrix fixation to the chest wall. Descriptive statistics were reported using frequencies and percentages for categorical variables, and means and SDs for continuous variables. Pearson chi-square test was used to compare differences in categorical variables. Univariable and multivariable logistic regression models were fitted to investigate the predictors of complications. From October 2019 to March 2023, 90 DTI breast reconstructions were performed, 43 using the standard technique and 47 using the new technique. The new technique demonstrated a significant reduction of major complications (P = 0.010), namely seroma (13.9% versus 2.3%), skin necrosis (9.3% versus 2.3%), implant loss (7% versus 0%), wound dehiscence (9.3% versus 0%), and infection (4.7% versus 0%). Compared with the standard technique, the new one reduced the risk of complications by 76% (OR 0.24; 95% confidence interval 0.09-0.68; P = 0.007) and 73% (aOR 0.27; 95% confidence interval 0.08-0.92; P = 0.037), at univariable and multivariable regression models. No other significant predictor of complications was identified. The procedure performed with the proposed modality proved to be advantageous. Careful fixation of the prosthetic implant and the placement of two drains, were the keys to a drastic reduction in complications.

Comparative evaluation using PRO of an algorithm of one-stage immediate alloplastic breast reconstruction versus two-stage reconstruction

One-stage direct-to-implant (DTI) immediate breast reconstruction has proven to be an oncologically safe technique, but there are some conditions that do not allow its performance. The introduction of new surgical techniques and the recent COVID-19 pandemic have pushed us to introduce a breast reconstruction algorithm in our clinical practice. This allows a one-stage immediate reconstruction for all patients, regardless of their anatomical characteristics, the type of implants used, and the need for postoperative radiotherapy. A total of 40 patients were recruited and divided into two cohorts, 20 patients underwent immediate one-stage breast reconstruction in the period between October 2019 and January 2021, and 20 patients completed the two-stage reconstructive process in the period prior to October 2019. During the follow-up at 6 months, all patients who had completed the reconstructive process filled out the Breast-Q Reconstruction Module Pre and Postoperative scales questionnaire. The outcomes of the questionnaires were compared between the two cohorts, and statistical analysis was carried out using SPSS Statistics 20 (IBM Corporation, Armonk, NY, USA). The analysis of patient-reported outcomes showed that patients from the one-stage group reported better outcomes in all items evaluated. We did not find statistically significant differences concerning the rate of complications and length of hospital stay between the two groups. The analysis of the results shows that the outcomes reported by patients who completed breast reconstruction according to our algorithm are statistically better than those with the two-stage technique.

Modern intracranial electroencephalography for epilepsy localization with combined subdural grid and depth electrodes with low and improved hemorrhagic complication rates.

Recent trends have moved from subdural grid electrocorticography (ECoG) recordings toward stereo-electroencephalography (SEEG) depth electrodes for intracranial localization of seizures, in part because of perceived morbidity from subdural grid and strip electrodes. For invasive epilepsy monitoring, the authors describe the outcomes of a hybrid approach, whereby patients receive a combination of subdural grids, strips, and frameless stereotactic depth electrode implantations through a craniotomy. Evolution of surgical techniques was employed to reduce complications. In this study, the authors review the surgical hemorrhage and functional outcomes of this hybrid approach. A retrospective review was performed of consecutive patients who underwent hybrid implantation from July 2012 to May 2022 at an academic epilepsy center by a single surgeon. Outcomes included hemorrhagic and nonhemorrhagic complications, neurological deficits, length of monitoring, and number of electrodes. A total of 137 consecutive procedures were performed; 113 procedures included both subdural and depth electrodes. The number of depth electrodes and electrode contacts did not increase the risk of hemorrhage. A mean of 1.9 ± 0.8 grid, 4.9 ± 2.1 strip, and 3.0 ± 1.9 depth electrodes were implanted, for a mean of 125.1 ± 32 electrode contacts per patient. The overall incidence of hematomas over the study period was 5.1% (7 patients) and decreased significantly with experience and the introduction of new surgical techniques. The incidence of hematomas in the last 4 years of the study period was 0% (55 patients). Symptomatic hematomas were all delayed and extra-axial. These patients required surgical evacuation, and there were no cases of hematoma recurrence. All neurological deficits related to hematomas were temporary and were resolved at hospital discharge. There were 2 nonhemorrhagic complications. The mean duration of monitoring was 7.3 ± 3.2 days. Seizures were localized in 95% of patients, with 77% of patients eventually undergoing resection and 17% undergoing responsive neurostimulation device implantation. In the authors' institutional experience, craniotomy-based subdural and depth electrode implantation was associated with low hemorrhage rates and no permanent morbidity. The rate of hemorrhage can be nearly eliminated with surgical experience and specific techniques. The decision to use subdural electrodes or SEEG should be tailored to the patient's unique pathology and surgeon experience.

Approach to the Pan-brachial Plexus Injury: Variation in Surgical Strategies among Surgeons

Background:Treatment of pan-brachial plexus injuries has evolved significantly over the past 2 decades, with refinement and introduction of new surgical techniques, particularly free functional muscle transfer. The extent to which contemporary brachial plexus surgeons utilize various techniques as part of their treatment algorithm for pan-plexus injuries and the rationale underlying these choices remain largely unknown.Methods:A case scenario was posed to 12 brachial plexus surgeons during semi-structured qualitative interviews. The case involved a young patient presenting 6 weeks after a pan-plexus injury from a motorcycle accident. Surgeons were asked to formulate a treatment plan. Inductive thematic analysis was used to identify commonalities and variation in approach to treatment.Results:For shoulder function, the majority of surgeons would graft from a viable C5 nerve root, if possible, though the chosen target varied. Two-thirds of the surgeons would address elbow flexion with nerve transfers, though half would combine this with a free functional muscle transfer to increase elbow flexion strength. Free functional muscle transfer was the technique of choice to restore finger flexion. Finger extension, intrinsic function, and sensation were not prioritized.Conclusions:Our study sheds light on current trends in the approach to pan-plexus injuries in the U.S. and identifies areas of variability that would benefit from future study. The optimal shoulder target and the role for grafting to the MCN for elbow flexion merit further investigation. The role of FFMT plays an increasingly prominent role in treatment algorithms.

A Systematic Review of Minimally Invasive Trans-thoracic Liver Resection to Examine Intervention Description, Governance, and Outcome Reporting of an Innovative Technique.

The number of laparoscopic liver resections undertaken has increased. However, lesions located postero-superiorly are difficult to access. This may be overcome by the novel use of trans-thoracic port(s). Methods for the safe and transparent introduction of new and modified surgical procedures are limited and a summary of these issues, for minimally invasive trans-thoracic liver resections (MITTLR), is lacking. This study aims to understand and summarize technique description, governance procedures, and reporting of outcomes for MITTLR. A systematic literature search to identify primary studies of all designs describing MITTLR was undertaken. How patients were selected for the new technique was examined. The technical components of MITTLR were identified and summarized to understand technique development over time. Governance arrangements (eg, Institutional Review Board approval) and steps taken to mitigate harm were recorded. Finally, specific outcomes reported across studies were documented. Of 2067 screened articles, 16 were included reporting data from 145 patients and 6 countries. Selection criteria for patients was explicitly stated in 2 papers. No studies fully described the technique. Five papers reported ethical approval and 3 gave details of patient consent. No study reported on steps taken to mitigate harm.Technical outcomes were commonly reported, for example, blood loss (15/16 studies), operative time (15/16), and margin status (11/16). Information on patient-reported outcomes and costs were lacking. Technical details and governance procedures were poorly described. Outcomes focussed on short term details alone. Transparency is needed for reporting the introduction of new surgical techniques to allow their safe dissemination.

Introduction of new techniques and technologies in surgery: Where is transanal total mesorectal excision today?

The introduction of new surgical techniques and technologies has traditionally been unregulated. In many settings surgeons frequently adopt novel procedures without following a structured program of implementation or supervision. The appearance of innovative technology played a pivotal role in the advancement of new surgical techniques during the industrial revolution. Innovation has been an essential component of surgical development, which led to contemporary surgical techniques such as minimally invasive surgery. Different initiatives have been developed to guide the safe introduction of new surgical techniques and other procedures. Those include comprehensive concepts such as the Idea, Development, Exploration, Assessment, Long-term study framework, which could be particularly relevant when reflecting on the novel transanal total mesorectal excision (taTME), introduced a decade ago. This relatively novel and complex procedure promised to overcome some of the major limitations of traditional surgical approaches for rectal cancer. According to the Idea, Development, Exploration, Assessment, Long-term study framework, taTME is in the phase of exploration, where there is an existing and increasing number of reports being published as the experience grows. The current management of rectal cancer is in a state of radical evolution, with multiple options that were not previously available. TaTME is only one technique amongst many which could be part of a rectal cancer surgeon’s armamentarium; however, it requires further rigorous study and evaluation.

Impact of preoperative portal vein thrombosis on the outcome of living donor liver transplantation

Abstract Background Portal vein thrombosis (PVT) is a common complication in terminal-stage liver disease. Its incidence in liver transplantation (LT) ranges from 2.1% to 26%. In the past, PVT was considered an absolute contraindication for LT, especially due to the technical difficulty involved. Nonetheless, since the mid-1980s, with the introduction of new surgical techniques, PVT is no longer considered an absolute contraindication in a larger percentage of patients. Aim of the Work to show the effect of preoperative portal vein thrombosis with its different extension degree on both patient and graft survival post living donor liver transplantation. Patients and Methods This retrospective cohort study was conducted on all the patients who performed living donor liver transplantation during the period from January 2010 till June 2017 at Ain Shams centre for organ transplantation (ASCOT). Our study included 240 cases who performed right lobe LDLT in that time interval and fulfilled the required data and time interval follow up. Those 240 cases were classified into 2 groups: group A Patients without preoprative PVT (200); group B Patients with pre-operative PVT. (40). Results 1-year patients survival rates of patients with and without PVT were 75% vs. 85%. t 2-year patients survival rates of patients with and without PVT 75% vs. 84%. 1-year graft survival rates of patients with and without PVT were 75% vs. 84%; that 2-year graft survival rates of patients with and without PVT: 65% vs. 77%. Conclusion P.V.T not only makes the surgery more difficult and complex but it also affects the outcome of LT. However Further studies should be done taking in consideration different degree of extension of the thrombus as it has crucial effect on the outcome of the liver transplantation.

Radiofrequency thermocoagulation for high transphincteric fistulae, Merlini l'Héritier et al.

Obliteration of the internal opening has long been held as the key resolution of high transsphincteric fistulae. This month's Editor's Choice by Merlini l'Héritier et al. evaluated ablation of the tract by applying radiofrequency thermocoagulation 1. They used a control group, selected from a prospective database consisting of patients who underwent occlusion of the fistula tract by a rectal advancement flap, paired-matched for sex, age and the presence of Crohn's disease. The healing rate was only 26% at 5 months after radiofrequency thermocoagulation, vs 68% after flap repair, and dropped further to 10% after 21 months. These findings suggest that obliteration of the fistula tract is not enough to accomplish healing of perianal fistulae in most cases. The authors must be congratulated on publishing these findings. Negative findings provide much needed feedback on the effectiveness of treatment after introducing a new technique or pursuing new indications for a known technique. Radiofrequency thermocoagulation has become common practice as the primary treatment of varicose veins. Recently, new indications for the radiofrequency technique have been defined. For example, obliteration of the sinus in simple pilonidal disease with radiofrequency has been shown to be highly successful 2. We now know that pilonidal disease is caused by loose hairs entering the pits in the intergluteal cleft by their root ends, where a foreign body reaction creates the pilonidal sinus. Consequently, it is understandable that after removing the hairs from the pilonidal cavity, obliteration of the pits by thermocoagulation in order to avoid future potential ports of hair re-entry is a sound treatment principle. The pathophysiology of cryptoglandular and Crohn's fistulae has not been conclusively established. Crohn's disease is thought to be caused by a failure of the intestinal mucosal immune system to tolerate commensal bacteria. The highest healing rates in the featured study were achieved in patients with Crohn's disease (overall success 64 percent) 1. All these patients were on anti-tumour necrosis factor alpha therapy. There is now growing evidence that in patients with Crohn's fistulae, it is essential to combine surgery with biologic agents 2, 3. When managing Crohn's fistulae, combining a surgical procedure, which prevents entry of bacteria to the fistula, with immunotherapy seems to be the logical approach. The overall healing rate in patients with cryptoglandular fistulae was only 41% at 5 months follow-up 1. The persistent inflammation in the anal crypt is nowadays believed to occur as a result of a defective local immune system. Hence, before introduction of new surgical techniques, a better understanding of what process drives this ongoing perianal sepsis is recommended.

Introduction of new surgical techniques and technologies

ANZ Journal of SurgeryVolume 89, Issue 6 p. 625-626 EDITORIAL Introduction of new surgical techniques and technologies Guy J. Maddern PhD, FRACS, Guy J. Maddern PhD, FRACS guy.maddern@adelaide.edu.au orcid.org/0000-0003-2064-181X The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, AustraliaSearch for more papers by this author Guy J. Maddern PhD, FRACS, Guy J. Maddern PhD, FRACS guy.maddern@adelaide.edu.au orcid.org/0000-0003-2064-181X The University of Adelaide Discipline of Surgery, The Queen Elizabeth Hospital, Adelaide, South Australia, AustraliaSearch for more papers by this author First published: 09 June 2019 https://doi.org/10.1111/ans.15225Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume89, Issue6June 2019Pages 625-626 RelatedInformation

Addressing the ethical grey zone in surgery: a framework for identification and safe introduction of novel surgical techniques and procedures.

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as 'the biggest unaudited free-for-all in the history of surgery' due to 'a lack of effective centralised control'. Whether a new surgical intervention is considered an acceptable 'minor' variation of an established procedure, or is sufficiently 'novel' to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first-in-human setting. In phase I (first-in-human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the 'first in human' stage.

Application of modified Weerda laryngoscopes in the ear, nose, and throat practice

Microscope-assisted direct endoscopy of the airways and the upper gastrointestinal tract in general anesthesia is an essential diagnostic and therapeutic method of otorhinolaryngology. The quality of surgical exploration is a key for the good visibility and maneuverability of microsurgical tools. Beside the most commonly used Kleinsasser laryngoscope, the distending Weerda laryngoscope is a more favorable option for the exploration of the retrocricoid region. Narrow anatomical situation, examination and manipulation of lesions involving several sub-regions of the hypopharynx or larynx may be problematic in some cases even with this endoscope. The authors present the application of modified Weerda laryngoscopes with asymmetric spatula length in addition with four cases. The retrocricoid region, the distal part of the posterior hypopharyngeal wall and the proximal part of the esophagus can be easily visualized with this device. The modifications allow the introduction of new surgical techniques by increasing the number of applied microsurgical devices and their maneuverability. Orv Hetil. 2019; 160(7): 264-269.

Pancreatic cancer: A review of clinical diagnosis, epidemiology, treatment and outcomes.

This review aims to outline the most up-to-date knowledge of pancreatic adenocarcinoma risk, diagnostics, treatment and outcomes, while identifying gaps that aim to stimulate further research in this understudied malignancy. Pancreatic adenocarcinoma is a lethal condition with a rising incidence, predicted to become the second leading cause of cancer death in some regions. It often presents at an advanced stage, which contributes to poor five-year survival rates of 2%-9%, ranking firmly last amongst all cancer sites in terms of prognostic outcomes for patients. Better understanding of the risk factors and symptoms associated with this disease is essential to inform both health professionals and the general population of potential preventive and/or early detection measures. The identification of high-risk patients who could benefit from screening to detect pre-malignant conditions such as pancreatic intraepithelial neoplasia, intraductal papillary mucinous neoplasms and mucinous cystic neoplasms is urgently required, however an acceptable screening test has yet to be identified. The management of pancreatic adenocarcinoma is evolving, with the introduction of new surgical techniques and medical therapies such as laparoscopic techniques and neo-adjuvant chemoradiotherapy, however this has only led to modest improvements in outcomes. The identification of novel biomarkers is desirable to move towards a precision medicine era, where pancreatic cancer therapy can be tailored to the individual patient, while unnecessary treatments that have negative consequences on quality of life could be prevented for others. Research efforts must also focus on the development of new agents and delivery systems. Overall, considerable progress is required to reduce the burden associated with pancreatic cancer. Recent, renewed efforts to fund large consortia and research into pancreatic adenocarcinoma are welcomed, but further streams will be necessary to facilitate the momentum needed to bring breakthroughs seen for other cancer sites.

The direct anterior minimal invasive approach in total hip replacement: a prospective departmental study on the learning curve.

Introduction of new surgical techniques is normal, but seldom monitored in real time. The purpose of this study was to monitor the learning curve when introducing a new surgical technique to a department. We did a prospective evaluation of the learning curve when introducing the minimally invasive direct anterior approach in total hip arthroplasty. We wish to investigate whether there is a learning curve for the direct anterior minimal invasive approach in total hip replacement and what are the early complications to this approach. The department changed from the direct lateral approach to the minimally invasive direct anterior approach. We monitored the first 522 patients operated using this approach with regards to patient outcome scores and complications 6 months postoperatively. The last 250 patients operated all had significantly better results with regard to patient outcome scores and cup placement. We investigated 100 patients at a time and compared them with the rest of the patient and found the same pattern. This pattern ends when we reach patients somewhere between 200-300. We established the learning curve on a departmental level with regards to introduction of the minimal invasive direct anterior approach. We see a steady improvement in scores with regards to patient outcome scores and cup positioning until we reach a steady-state. The learning curve here flattens out. Departments must understand that one should expect early complications and somewhat less than optimal results at first when introducing this new surgical technique.

Technology assessment and cost-effectiveness in orthopedics: how to measure outcomes and deliver value in a constantly changing healthcare environment.

The purpose of this study is to review the basic concepts of healthcare value, patient outcome measurement, and cost-effectiveness analyses as they relate to the introduction of new surgical techniques and technologies in the field of orthopedic surgery. An increased focus on financial stewardship in healthcare has resulted in a plethora of cost-effectiveness and patient outcome research. Recent research has made great progress in identifying orthopedic technologies that provide exceptional value and those that do not meet adequate standards for widespread adoption. As the pace of technological innovation advances in lockstep with an increased focus on value, orthopedic surgeons will need to have a working knowledge of value-based healthcare decision-making. Value-based healthcare and cost-effectiveness analyses can aid orthopedic surgeons in making ethical and fiscally responsible treatment choices for their patients.

The Role of Simulation in Surgical Training: An Analysis of Controversies

The technologies applied to surgery cause urologists to use modified anatomic approaches, different surgical steps, and new instruments. In parallel, patients themselves require novel techniques and expect improved outcomes. It has been suggested that the introduction of new surgical techniques, even in high-volume centers with experienced surgeons, leads to impaired outcomes, at least initially, compared with the standard [1]. In contrast, the traditional volume-based apprenticeship is associated with higher rates of complications until the initial part of the learning curve is reached [2]. Performing surgery on animal models and on human fresh cadavers has historically been the only available option. Animals provide a system with living tissues and reactions to tissue damage (eg, active bleeding), but they have different anatomy, even if somehow close, and do not represent a realistic pathologic model. Alternatively, cadavers offer the best anatomic experience, but the tissues are passive and generally healthy. Finally, both are limited by ethics and costs. For all of these reasons, surgical simulators are now considered possible learning tools for trainees to better perform surgery. Beyond these reasonable considerations, some questions should be raised. First, we must definitively distinguish basic tasks (eg, suturing, knot tying, cutting, tissue handling and manipulation, or dissection) from surgery, that is, a much more complex process that combines understanding of the disease and a permanent technical adaptation to local conditions. The ideal patient, if one exists, is certainly not representative of the daily, yearly, or even career experience of the surgeon.

Progress in anesthesia and management of the newborn surgical patient

Ongoing advances in the perioperative management of the newborn have undoubtedly decreased the incidence of morbidity and mortality of this vulnerable patient group. The introduction of new surgical techniques and more comprehensive understanding of the effects of varied anesthetic drugs and techniques on the surgical newborn present many challenges for pediatric surgeons and anesthesiologists. Thorough preoperative evaluation and open communication between members of the health care team are important. A basic understanding of age-dependent variables and the interaction of anesthetic and surgical procedures is essential in minimizing perioperative morbidity and mortality.

Robotic Kidney Transplantation with Regional Hypothermia: Evolution of a Novel Procedure Utilizing the IDEAL Guidelines (IDEAL Phase 0 and 1)

BackgroundSurgical innovation is essential for progress of surgical science, but its implementation comes with potential harms during the learning phase. The Balliol Collaboration has recommended a set of guidelines (Innovation, Development, Exploration, Assessment, Long-term study [IDEAL]) that permit innovation while minimizing complications. ObjectiveTo utilize the IDEAL model of surgical innovation in the development of a novel surgical technique, robotic kidney transplantation (RKT) with regional hypothermia, and describe the process of discovery and development. Design, setting, and participantsPhase 0 (simulation) studies included the establishment of techniques for pelvic cooling, graft placement in a robotic prostatectomy model, and simulation of the RKT procedure in a cadaveric model. Phase 1 (innovation) studies began in January 2013 and involved treatment of a highly selective small group of patients (n=7), using the principles utilized in the phase 0 studies, at a tertiary referral center. InterventionIDEAL model implementation in the development of RKT with regional hypothermia. Outcome measurements and statistical analysisFor phase 0 studies, the outcomes evaluated included pelvic and body temperature measurements, and technical feasibility assessment. The primary outcome during phase 1 was post-transplant graft function. Other outcomes measured were operative and ischemic times, perioperative complications, and intracorporeal graft surface temperature. Results and limitationsPhase 0 (simulation phase): Pelvic cooling to 15–20oC was achieved reproducibly. Using the surgical approach developed for robotic radical prostatectomy, vascular and ureterovesical anastomoses could be done without redocking the robot. Phase 1 (innovation phase): All patients underwent live-donor RKT in the lithotomy position. All grafts functioned immediately. Mean console, anastomotic, and warm ischemia times were 154min, 29min, and 2min, respectively. One patient was re-explored on postoperative day 1. ConclusionsAdherence to the IDEAL guidelines put forth by the Balliol Collaboration provided a practical framework for the establishment of a novel surgical procedure, RKT with regional hypothermia, without exposing the initial patients to unacceptable risk. Patient summaryThe IDEAL model allows safe introduction of new surgical techniques without compromising patient outcomes.