Operative Surgeon Research Articles

Clinical capability of Iranian operating room nurses and surgeons regarding radiation protection protocols in radiation-exposed operating rooms

Background: Considering the daily increasing use of radiation in operating rooms and the existing problems in the field of radiation protection, the present study aimed to evaluate the clinical capability of operating room nurses and surgeons regarding radiation protection protocols in radiation-exposed operating rooms in Shiraz. Methods: This descriptive, cross-sectional study was carried out in 2019–2020 by conducting a census of radiation-exposed nurses and surgeons in the operating rooms of private and public hospitals in Shiraz. The study data were collected using a demographic and professional information form and a questionnaire on the radiation protection capability of operating room personnel. Then, the data were entered into the SPSS 25 software and were analyzed via descriptive and inferential statistics. Results: Totally, 200 questionnaires were completely filled out. The mean age of the participants with complete questionnaires was 33.34 ± 8.09 years. The mean scores of clinical capability, knowledge, attitude, performance, and personal commitment were 111.7 ± 21.09, 39.05 ± 12.8, 44.2 ± 7.2, 14.6 ± 6.2, and 13.98 ± 5.8, respectively. Accordingly, the participants’ knowledge, attitude, personal commitment, and clinical capability were at good levels, while they showed a weak performance. Conclusion: It seems that educational as well as managerial measures in terms of radiation protection protocols are needed to increase the clinical capability of radiation-exposed operating room nurses and surgeons. The present study results can be used to improve clinical capability regarding radiation protection, provide related strategies, and solve problems.

The impact of surgeon's experience and sex on the incidence of cystoid macular edema after uneventful cataract surgery.

To assess the rate of pseudophakic cystoid macular edema (pCME) in uneventful cataract surgery in surgeons in training vs experienced surgeons and to analyze the rate of pCME according to surgeon's sex. Medical reports post phacoemulsification between 2010 and 2018 at the Department of Ophthalmology, Medical University of Graz, Austria, were reviewed for pCME. A running lifetime number of preceding cataract surgeries was used to express hands-on experience. A cut-off number of 300 surgeries was defined to distinguish between surgeons in training and experienced surgeons. Outcome parameters were incidence of pCME, patient's sex and age, laterality of eye, coexistence of pseudoexfoliation syndrome (PEX), duration of surgery and surgeon's sex. 25.422 surgeries on 18.266 patients were included. The majority was performed by experienced surgeons (23.139, 91.0%) vs 2.283 (9.0%) by surgeons in training (25 surgeons, 9 (36%) female and 16 (64%) male). pCME occurred in 32 eyes (1.4%) following surgery by surgeons in training and in 152 eyes (0.7%) following surgery by experienced surgeons. Chance for pCME was 1.57 higher in training surgeries (95% CI 1.03-2.41, p = 0.034) and longer duration (OR = 1.04; 95% CI 1.02-1.07, p = 0.001). After excluding the first 100 surgeries for every surgeon in training similar results were observed. No difference in risk for pCME was found between female and male surgeons in both groups (training and experienced surgeons). In conclusion, the rate for pCME after uneventful cataract surgery is significantly higher for surgeons in training but steadily decreasing and associated to surgical time. No difference in the risk for pCME was found between female and male surgeons.

What Is Next in Computer-Assisted Spine Surgery? Advances in Image-Guided Robotics and Extended Reality

Background: This article provides a scoping review on the current status of Image-Guided Navigation with various forms of digital technologies, including Extended Reality, Augmented Reality Head-Mounted Displays (AR–HMDs) and Robot-Assisted Surgery (RAS) for Pedicle Screw Placement in orthopedics and spine surgery. Methods: A scoping literature review was performed in the PubMed, Scopus, Embase, Web of Science, Google Scholar and IEEE Xplore databases to collect clinical and user satisfaction data on AR–HMDs and compare those with RAS outcomes. In vivo patient, cadaver and phantom trial accuracy data reports were identified and grouped through the analysis. Over the past two years, 14 publications were retrieved and analyzed. Pedicle screw placement accuracy was described with Linear Tip Error (LTE), Angular Trajectory Error (ATE) and Gertzbein–Robbins Scale (GRS) outcomes. Results: The Pedicle Screw Placement accuracy was seen to increase in the in vivo, cadaver and phantom model groups using AR-HMD compared to the Free-Hand insertion technique. User experience and satisfaction data were limited; however, a clear advantage for the operative results was described when it was added. RAS screwing showed similar accuracy outcomes. The need for benchmarking and quantified situation awareness for AR–HMDs is recognizable. The authors present a method for standardized scoring and visualization of surgical navigation technologies, based on measurements of the surgeon (as the end-users) user satisfaction, clinical accuracy and operation time. Conclusions: computer-technology driven support for spine surgery is well-established and efficient for certain procedures. As a more affordable option next to RAS, AR–HMD navigation has reached technological readiness for surgical use. Ergonomics and usability improvements are needed to match the potential of RAS/XR in human surgeries.

Design of a Novel Tendon-Sheath-Driven Upper Limb Exoskeleton for Assisting Surgeon Performing Microlaryngoscopic Surgery

Abstract Microlaryngoscopic surgery is a type of laryngeal surgery performed by surgeons using microsurgical instruments under the observation of a specially designed laryngoscope. While performing a microlaryngoscopic operation, the surgeons must maintain their arms' position for a long time, which can cause arms' soreness and affect the accuracy of the operation. In this study, a tendon-sheath-driven upper limb auxiliary exoskeleton (TULAE) is proposed and developed. The flexible cables are compressed by a wave-shaped pressing mechanism to fix the TULAE's rotating joints. The TULAE can assist surgeons in laryngoscopy operations by providing suitable support for their arms to reduce the surgical risks caused by muscle fatigue. The TULAE has four degrees-of-freedom (DOFs) on each arm. The shoulder flexion/extension, shoulder abduction/adduction, and elbow internal rotation/external rotation can be fixed by the control box. The shoulder internal rotation/external rotation is a passive DOF obtained using hinges. The TULAE's shoulder, upper arm and forearm links are designed with lengths adjustable to accommodate wearers of different heights and weights. A large-scale but risk-free workspace is analyzed through rigid body kinematics using the spinor method. The control hardware of the TULAE is developed based on the open-source Arduino board. Finally, the experimental results show that this TULAE can significantly reduce the range of wrists shaking and assist surgeons in laryngoscopy surgery.

A Surgical Technique for Percutaneous Intraoperative Monitoring of Proximal Femur Epiphyseal Perfusion

A Surgical Technique for Percutaneous Intraoperative Monitoring of Proximal Femur Epiphyseal Perfusion

Periprosthetic acetabular fractures and defects : Trauma meets ortho

Periprosthetic acetabular fractures are considered to be asevere and challenging complication in total hip arthroplasty. To date, there are no internationally applicable standardized recommendations which can assist orthopedic surgeons and trauma surgeons in the treatment of patients. The aim of this article is to report on the current state of knowledge on periprosthetic acetabular fractures, to present the commonly used classification systems and to demonstrate appropriate treatment algorithms together with personal experiences. Aselective search of the existing literature was carried out and the commonly used classification systems and treatment options for periprosthetic acetabular fractures were compiled and are discussed in relation to the in-house cases. The comparison of the classification systems showed that frequently only fractures which have a purely traumatic origin are included among periprosthetic acetabular fractures. Insufficiency fractures within the framework of acetabular defects, which also belong to the group of acetabular fractures, are frequently included in revision arthroplasty. The management of defects with appropriate implants represents a challenge. By the combination of osteosynthesis and implant replacement, the selection of implants can often be de-escalated. Periprosthetic acetabular fractures represent a complex operation for both trauma surgeons and for specially trained orthopedic surgeons, which necessitate a high level of expertise. By the cooperation between trauma surgeons and orthopedic surgeons good treatment results can be achieved and recommendations for the selection of implants can be made.

Combining time-driven activity-based costing and lean methodology: an initial study of single-level lumbar fusion surgery to assess value-based healthcare in patients undergoing spine surgery.

Measuring costs across entire episodes of care, time-driven activity-based costing (TDABC) has recently been described as a novel cost accounting arm of value-based care organizations. Lean methodology is a system used to understand pathways of care at a granular level, allowing for standardization. The current work presents an attempt at combining the 2 methodologies to detect meaningful variation in a patient's care following single-level spine fusion. The objective of this study was to evaluate the combination of TDABC and lean methodologies in detecting meaningful variability in time-based care in patients undergoing single-level spine fusion surgery. This study is a consecutive case series of patients who underwent single-level spine fusion performed by 1 of 5 fellowship-trained spine surgeons. Patients were diagnosed with either lumbar stenosis or spondylolisthesis. Additional inclusion criteria included inpatient stays from 1 to 3 days, discharge to home, and no readmission within 30 days of surgery. Patient demographic data were obtained. Time spent on activities for each personnel role was aggregated in 15-minute increments occurring preoperatively, intraoperatively, and postoperatively. Patients were analyzed in 3 groups based on the duration of their in-hospital stay. Patients discharged on postoperative day (POD) 3 had statistically significantly more total time spent than those discharged on POD 2. Patients discharged on POD 1 had less total time than those in the former 2 groups. The amount of time spent with patients did not differ for personnel in either preoperative or postanesthesia care unit phases of care. There was a statistically significant difference in time spent in surgery for surgeons, anesthesia attendings, circulators, and scrub technicians. In a healthcare setting run by lean methodology, TDABC may detect meaningful variability in an episode of care for single-level spine fusion. Clinicians and administrators can use this combination to allocate costs appropriately, optimize value care streams, and help improve patient care.

Analysis of fixed and variable operating room (or) time point efficiency in partial nephrectomies: open versus robotic-assisted.

To analyze operating room (OR) efficiency by evaluating fixed and variable OR times for open (OPN) and robotic-assisted partial nephrectomies (RAPN). We analyzed consecutive OPN and RAPN performed by one surgeon over a 24-month period. All patients were placed in the lateral decubitus position and secured with a beanbag regardless of approach. Fixed (non-procedural) OR times were prospectively collected and defined as: in-room to anesthesia-release time (IRAT), anesthesia release to cut time (ARCT), and close to wheels-out time (CTWO). Variable OR time was procedural cut to close time (CTCT). Comparisons of fixed and variable OR time points between OPN and RAPN were performed using the Wilcoxon rank-sum test. 146 RAPN and 31 OPN were evaluated from 2019-2020. Median IRAT was similar for RAPN versus OPN [20min (IQR: 16-25) vs. 20min (IQR: 16-26), P = 0.57]. Median ARCT was longer for RAPN than it was for OPN [40min (IQR: 36-46) vs. 34min (IQR: 30-39), P < 0.001]. Median CTWO was similar for OPN (12min, IQR: 9-14) and RAPN (11min, IQR: 7-15) (P = 0.89). Median CTCT was longer for RAPN (202min, IQR: 170-236) compared to OPN (164min, IQR: 154-184) (P < 0.001). In a single surgeon, partial nephrectomy series with the same patient positioning, utilization of robotic technology was associated with longer surgeon operating time as well as less efficient fixed OR times, specifically ARCT.

Modeling and design optimization of master manipulator for robot-assisted minimally invasive surgery

In the minimally invasive surgical robot system, the surgeon controls the movement of instruments with master manipulators, which is a typical physical human-robot interaction system. In this paper, the surgeon is fully taken into consideration for structural design optimization. The kinematics model of the surgeon’s arm was established to describe the irregular shape of surgeon’s operation space; The surgeon console model was established to describe the relative position between the master manipulators and the surgeon’s arm. To make master manipulator could behavior great dexterity in surgery, the dexterity index of surgeon operation space was proposed. Combined with the minimum gravity torque index and the redundancy index, this multi-objective optimization problem was solved by Salp Swarm optimization algorithm. Compared with the pre-optimization master manipulator, the performances of the optimized manipulator are overall improved by 10.3%, 23.0%, and 41.2% respectively in animal experiment.

Impact of a new teaching model on the fine cosmetic suturing operation and quantitative assessment of the training effect on plastic surgeons

BackgroundTraditional lecture-based teaching (TLT) has long been the primary method of teaching plastic suturing techniques and even surgical education. It has been challenging to adapt this approach to fit the educational objectives of plastic surgery, which is a very practical science. Additionally, it is mainly teacher-led, and the course content is teacher-driven, which has disadvantages such as difficulty in motivating students and disconnection from clinical practice. Therefore, we developed a video point-to-point teaching (VPT) method and teamwork-based teaching (TBT) to study the effect of the new teaching model on fine cosmetic suturing operation (FCSO) and training outcomes for plastic surgeons. MethodsWe selected 30 junior doctors from the Department of Plastic and Reconstructive Surgery of the Chinese PLA General Hospital. All trainees were randomly assigned to three groups: TLT, VPT, and TBT. All trainees had their performances photographed, and a senior attending physician was appointed as a rater. We rated the process and results of FCSO according to a uniform rubric following the double-blind principle to compare the effects of different teaching modes on the trainees’ FCSO and differences in training outcomes. ResultsThere was no significant effect of video recording on trainees’ FCSO (P>0.05). The total scores of the first suturing in the three groups were as follows: TLT group (13.18 ​± ​1.66), VPT group (13.63 ​± ​1.97), and TBT group (13.50 ​± ​2.26), with no significant difference among the groups (P>0.05), indicating that the starting level of the trainees in the three groups was basically the same. There was no significant difference (P>0.05) between the VPT (20.30 ​± ​2.17) and TBT (20.38 ​± ​2.29) groups, but both of these groups were significantly better than the TLT group (16.43 ​± ​1.86, P<0.01). ConclusionThe TBT and VPT methods are significantly better than TLT. However, the TBT method is more economical and optimal for teachers and better utilizes students’ initiative in learning and operation, which improves the teaching level and training efficiency.

Systematic error compensation for improving accuracy of the electrosurgical unit.

This paper presents an approach to systematic error correction for improving the accuracy of the electrosurgical unit (ESU), through a method that enables safer operation for both surgeons and patients. The equations for systematic errors encountered during the calibration of the eight ESUs were obtained using regression analysis. The ESU calibration was performed using a power analyzer and the reference power value was selected on the ESU panel; the power value indicated by the ESU was noted from the power analyzer and recorded. The fitted regression models were suitable for predicting systematic errors associated with ESU output power values, as a reduction of about 84 % was noted in cutting power (CuP) and about 74 % for coagulation power (CoP). After correction, systematic error values remained below 1.9 W and 0.4 W in cutting and coagulation power, respectively. The maximum error values obtained were less than those specified for the IEC 60601-2-2 standard for all evaluated ESUs.

Locally advanced pancreatic cancer: a reliable contraindication to resection in the modern era?

The aim of this study is to present radiologically designated LAPC found to be resectable upon surgical exploration and evaluate the outcomes of such resections. Sequential LAPC patients between 2013 and 2019 were staged and underwent resection were included in the analysis of both perioperative and long-term outcomes. Twenty-eight patients with radiologically-designated LAPC underwent surgical resection after chemotherapy with a median follow-up of 31.7m,75% underwent pancreaticoduodenectomy. The margin positivity and local recurrence rates were 21.4% and 35.7%, respectively. When compared to the 30 BRPC controls, the LAPC group had a higher rates of an arterial resection (11vs.1; p=0.002), but the groups were similar with regard to all other preoperative and intraoperative variables (p<0.05). Perioperative morbidity rates were similar (25.9%vs21.4%; p=0.53). The LAPC and BRPC groups were also equivalent with respect to median recurrence-free survival (9.0mo; 95%CI 6.3, 11.7vs.8.3mo; 95%CI 5.4, 11.2) and median overall survival (19.9mo; 95%CI 17.0, 22.7 vs. 19.9mo; 95%CI 14.8, 25.1), respectively. Despite a radiologic designation of locally advanced pancreatic cancer, certain subtypes of LAPC warrant surgical exploration provided the operative surgeon is prepared for major arterial and/or venous resection. Pancreatectomy in these patients has acceptable morbidity and oncologic outcomes, similar to patients who are radiologically borderline resectable.

Feasibility and comparison of laparoscopic laser speckle contrast imaging to near-infrared display of indocyanine green in intraoperative tissue blood flow/tissue perfusion in preclinical porcine models.

To determine if laser speckle contrast imaging (LSCI) mitigates variations and subjectivity in the use and interpretation of indocyanine green (ICG) fluorescence in the current visualization paradigm of real-time intraoperative tissue blood flow/perfusion in clinically relevant scenarios. De novo laparoscopic imaging form-factor detecting real-time blood flow using LSCI and blood volume by near-infrared fluorescence (NIRF) of ICG was compared to ICG NIRF alone, for dye-less real-time visualization of tissue blood flow/perfusion. Experienced surgeons examined LSCI and ICG in segmentally devascularized intestine, partial gastrectomy, and the renal hilum across six porcine models. Precision and accuracy of identifying demarcating lines of ischemia/perfusion in tissues were determined in blinded subjects with varying levels of surgical experience. Unlike ICG, LSCI perfusion detection was real time (latency < 150ms: p < 0.01), repeatable and on-demand without fluorophore injection. Operating surgeons (n = 6) precisely and accurately identified concordant demarcating lines in white light, LSCI, and ICG modes immediately. Blinded subjects (n = 21) demonstrated similar spatial-temporal precision and accuracy with all three modes ≤ 2min after ICG injection, and discordance in ICG mode at ≥ 5min in devascularized small intestine (p < 0.0001) and in partial gastrectomy (p < 0.0001). Combining LSCI for near real-time blood flow detection with ICG fluorescence for blood volume detection significantly improves precision and accuracy of perfusion detection in tissue locations over time, in real time, and repeatably on-demand than ICG alone.

Spanish-Speaking Status: A Protective Factor in Colorectal Cancer Presentation at a Safety-Net Hospital

IntroductionLower screening rates and poorer outcomes for colorectal cancer have been associated with Hispanic ethnicity and Spanish-speaking status, respectively. MethodsWe reviewed sequential colorectal cancer patients evaluated by the surgical service at a safety-net hospital (SNH) (2016-2019). Insurance type, stage, cancer type, surgery class (elective/urgent), initial surgeon contact setting (outpatient clinic/inpatient consult), operation (resection/diversion), and follow-up were compared by patient-reported primary spoken language. ResultsOf 157 patients, 85 (54.1%) were men, 91 (58.0%) had colon cancer, 67 (42.7%) primarily spoke Spanish, and late stage (III or IV) presentations occurred in 83 (52.9%) patients. The median age was 58 y, cancer resection was completed in 48 (30.6%) patients, and 51 (32.5%) patients were initially seen as inpatient consults. On univariate analysis, Spanish-speaking status was significantly associated with female sex, Medicaid insurance, being seen as an outpatient consult, and undergoing elective and resection surgery. On multivariable logistic regression, Spanish-speaking patients had higher odds of having Medicaid insurance (AOR 2.28, P = 0.019), receiving a resection (AOR 3.96, P = 0.006), and undergoing an elective surgery (AOR 3.24, P = 0.025). Spanish-speaking patients also had lower odds of undergoing an initial inpatient consult (AOR 0.34, P = 0.046). ConclusionsSpanish-speaking status was associated with a lower likelihood of emergent presentation and need for palliative surgery among SNH colorectal cancer patients. Further research is needed to determine if culturally competent infrastructure in the SNH setting translates into Spanish-speaking status as a potentially protective factor.

Minimally Invasive Resection of Intraventricular Pilocytic Astrocytoma Using the Aurora Surgiscope in an Adult Patient: Technical Note

Pilocytic astrocytomas account for approximately 5%-6% of all gliomas and are most commonly diagnosed between the ages of 8 and 13 years. Although they may occur throughout the neuraxis, approximately two thirds arise from the cerebellum and optic pathway. Other locations of origin include midline structures such as thalamus, hypothalamus, and periventricular regions. Surgical approaches to lateral or third ventricular tumors include anterior transcallosal, subfrontal translamina terminalis, and anterior transcortical approaches. The Aurora Surgiscope is a single-use, disposable minimally invasive neurological endoscope designed for intraparenchymal hemorrhage evacuation. We present the successful use of this system to aid resection of a large intraventricular pilocytic astrocytoma. A 29-year-old man presented with signs of developing hydrocephalus and was found to have a large intraventricular tumor, which was later identified to be a rare intraventricular pilocytic astrocytoma. A ventriculostomy was performed as a temporizing measure, and he was transferred to our tertiary care facility for surgical management. Sulcal dissection was performed, and the endoscope was inserted to create a minimally invasive corridor to the lateral ventricle. Using the endoscope, bimanual surgery using multiple instruments simultaneously was possible and enabled gross total resection of the tumor. The patient tolerated the procedure well and was discharged at his neurological baseline level. Extensive sulcal dissection preceding placement of the endoscope allowed access to the intraventricular space with minimal passage of parenchymal tissue. High-definition visualization was provided and allowed the operating surgeon to freely use both hands during surgery.

207 Accuracy of Reviewing NELA Operation Data Entry in Emergency Laparotomy

Abstract Aim The National Emergency Laparotomy Audit (NELA) is part of the National Clinical Audit and data can often be submitted by a non-surgical clinician who do not perform the procedure, whereas operating notes are written mostly by the primary surgeon. A concern for possible discrepancies prompted a comparison between the operation notes and the NELA audit data, to assess for accuracy and understanding of the NELA inclusion/exclusion criteria. Method Operation data was collected retrospectively from the NELA database from January to December 2020. The surgeon's operation notes were reviewed and compared. Main parameters compared included ‘indication of surgery’, ‘main operation procedure’, ‘operative findings', ‘peritoneal contamination’ and ‘level of contamination’. The inclusion and exclusion criteria for NELA audit was also assessed and compared. A further questionnaire survey was performed to review the understanding of the procedure Results Total of 171 data was retrieved from the NELA database from the selected time-period. Out of these, 4.6% fulfilled the exclusion criteria. ‘Indication of operation’ were not consistent in 14 entries while in Operation procedure 4.9%. ‘Main operative findings’ were inconsistent in 11% cases. The Survey showed surgical difference in reviewing the operation notes. Conclusions There were significant portion of discrepancies between the surgical operating notes and NELA data entry when compared, due to retrospective entry and two different clinicians. There is a lack of clear understanding for the inclusion/exclusion criteria. We would like to recommend that the primary surgeon who performs the procedure records both the operating notes and the NELA data entry.

SP8.2.7 Is “Hot” Laparoscopic Cholecystectomy in patients with high BMI a safe option? - Outcomes of Emergency Laparoscopic Cholecystectomy in obese vs non-obese patients

Abstract Aim NICE guidelines currently recommend offering patients presenting with acute cholecystitis a laparoscopic cholecystectomy within 1 week of diagnosis. We compared peri-operative outcomes for patients undergoing emergency laparoscopic cholecystectomy with a BMI of &amp;lt;30 kg/m2 (Group 1) and ≥30 kg/m2 (Group 2). Methods A retrospective review of patients undergoing an emergency laparoscopic cholecystectomy at a District General Hospital between January 2018 and November 2020. Results 159 patients were included. Group 1 had 97 patients (BMI range 18.8–29.9 kg/m2, age range 27–82 years, 56 females: 41 males). Group 2 had 62 patients (BMI range 30–56.3 kg/m2, age range 19–88 years, 38 females: 24 males). ASA breakdown was 1(25.8%), 2(64.9%) and 3(9.3%) for Group 1 and 2(71%) and 3(29%) for Group 2. Indications for surgery included biliary colic, acute cholecystitis and gallstone pancreatitis. Operating surgeons had training in both Upper GI and Bariatric surgery. There were no significant differences between Group 1 and Group 2 for anaesthetic time (minutes, 32.74 vs 32.50 p=0.91), operative time (minutes, 95.82 vs 93.67 p=0.75), total length of stay (days, 6.15 vs 5.17 p=0.30) or readmission rate within 30 days (22.68% vs 19.35% p=0.62). 4 patients in each group had acute complications during the index admission. Conclusion Emergency laparoscopic cholecystectomy for patients with a BMI ≥30 kg/m2 has similar peri-operative outcomes when compared to patients with a BMI &amp;lt;30 kg/ m2 and is safe to be performed in a District General Hospital by operating surgeons with an interest in Upper GI and Bariatric surgery.

The impact of a multispecialty operative team on colorectal cancer surgery: A retrospective study from a would-be medical center in Taiwan.

Some studies showed that when distant metastasis or locally advanced tumors were observed, the participation of 2 or more operating surgeons (combined surgery) in the operation could improve the prognosis of patients. The multispecialty operative team would perform combined surgery in colon cancer patients with some complications since 2015.The goal of this study is to confirm performing combined surgery would improve the outcomes of colon cancer patients.A retrospective observational study was conducted, which involved all colon cancer patients between November 2015 and December 2019 at one would-be medical center. Patients were divided into 3 cohorts: those with complicated cases and had combined surgery (C_2S), those with complicated cases and had surgery performed by a single surgeon (C_1S), and those with uncomplicated cases and had surgery performed by a single surgeon (NC_1S). Overall survival and disease-free survival were compared among the 3 groups.A total of 296 colon cancer patients during the study period. Among them, 35 were C_2S, 87 were C_1S, and 174 were NC_1S. Patients in the NC_1S group had significantly higher 12-, 24-, and 36-month OS rates compared to those in the C_1S group (P < .01). In contrast, there was no significant difference in overall survival among patients in the NC_1S and C_2S group (P =.15).The quality of surgery must be impact the prognosis, especially in the individual who was complicated case, the survival in patients who had surgery performed by multispecialty operative team would be improved.

Surgesture: a novel instrument based on surgical actions for objective skill assessment

Due to varied surgical skills and the lack of an efficient rating system, we developed Surgesture based on elementary functional surgical gestures performed by surgeons, which could serve as objective metrics to evaluate surgical performance in laparoscopic cholecystectomy (LC). We defined 14 LC basic Surgestures. Four surgeons annotated Surgestures among LC videos performed by experts and novices. The counts, durations, average action time, and dissection/exposure ratio (D/E ratio) of LC Surgestures were compared. The phase of mobilizing hepatocystic triangle (MHT) was extracted for skill assessment by three professors using a modified Global Operative Assessment of Laparoscopic Skills (mGOALS). The novice operation time was significantly longer than the expert operation time (58.12 ± 19.23min vs. 26.66 ± 8.00min, P < 0.001), particularly during MHT phase. Novices had significantly more Surgestures than experts in both hands (P < 0.05). The left hand and inefficient Surgesture of novices were dramatically more than those of experts (P < 0.05). The experts demonstrated a significantly higher D/E ratio of duration than novices (0.79 ± 0.37 vs. 2.84 ± 1.98, P < 0.001). The counts and time pattern map of LC Surgestures during MHT demonstrated that novices tended to complete LC with more types of Surgestures and spent more time exposing the surgical scene. The performance metrics of LC Surgesture had significant but weak associations with each aspect of mGOALS. The newly constructed Surgestures could serve as accessible and quantifiable metrics for demonstrating the operative pattern and distinguishing surgeons with various skills. The association between Surgestures and Global Rating Scale laid the foundation for establishing a bridge to automated objective surgical skill evaluation.

Transoral thyroid surgery vestibular approach.

Transoral thyroid surgery vestibular approach (TOETVA) is a novel and feasible surgical technique that allows for cervical surgery without visible incisions. TOETVA represents a new frontier in endocrine surgery since aesthetic results play a more and more decisive role in elective surgery. However, acceptance is different around the world with widespread prevalence in Asian countries and some high-volume centres in the US. While inclusion criteria for TOETVA are limited regarding size and volume a combination with other extracervical techniques like the retroauricular endoscopic cephalic access thyroid surgery (EndoCATS) approach or transaxillary access is an option. TOETVA is carried out through a three-port technique placed at the oral vestibule. Originally one 10-mm port for a 30° endoscope and two additional 5-mm ports for dissecting and coagulating instruments are used. Alternatively, one 5-mm and one or two 3mm ports can be used. CO2 insufflation pressure is set at 6mmHg. An additional device to optimize gas outflow for optimum view might be helpful. An anterior cervical subplatysmal space is created by hydrodissection from the oral vestibule to the sternal notch, laterally to the sternocleidomastoid muscle. Conventional endoscopic instruments are used. Combination of TOETVA with a modified retroauricular access includes insertion of a 10-12mm trocar placed subcutaneously via a skin incision on the scalp, behind the ear by blunt dissection. Since Anuwong published the first case series of 60 patients who underwent scarless thyroidectomy via the lower vestibule of the mouth with excellent results in 2016almost 1,000 cases are reported in literature to date with comparable results especially regarding traditional complications. In contrast to other extracervical approaches, areolar or axillary for example, the transoral access route is short and the dissection planes are rather like transcervical surgery. Surgical indications and contraindications have been modified since its first description and are partly institution specific to date. To amend indications combination with other extracervical techniques is an option. In addition, patients must carefully be selected for and surgeons` candidacy is of utmost importance in transoral surgery. Transoral surgery will likely continue to gain attraction as surgeons become more experienced with the technique. With increased operative use and surgeon experience the gap in conventional outcomes between transoral surgery and the transcervical approach will narrow, with both operative time and the incidence of specific complications diminishing. Experience in thyroid and endoscopic surgery is required to achieve excellent results with low complication rates. However, the new transoral technique is related to novel complications that must be evaluated.