Surgical Box Research Articles

Ablation of Atrial Fibrillation With PulsedElectric Fields: An Ultra-Rapid, Tissue-Selective Modality for Cardiac Ablation.

The authors report the first acute clinical experience of atrial fibrillation ablation with PEF-both epicardial box lesions during cardiac surgery, and catheter-based PV isolation. Standard energy sources rely on time-dependent conductive heating/cooling and ablate all tissue types indiscriminately. Pulsed electric field (PEF) energy ablates nonthermally by creating nanoscale pores in cell membranes. Potential advantages for atrial fibrillation ablation include: 1) cardiomyocytes have among the lowest sensitivity of any tissue to PEF-allowing tissue selectivity, thereby minimizing ablation of nontarget collateral tissue; 2) PEF is delivered rapidly over a few seconds; and 3) the absence of coagulative necrosis obviates the risk of pulmonary vein (PV) stenosis. PEF ablation was performed using a custom over-the-wire endocardial catheter for percutaneous transseptal PV isolation, and a linear catheter for encircling the PVs and posterior left atrium during concomitant cardiac surgery. Endocardial voltage maps were created pre- and post-ablation. Continuous and categorical data are summarized and presented as mean ± SD and frequencies. At 2 centers, 22 patients underwent ablation under general anesthesia: 15 endocardial and 7 epicardial. Catheter PV isolation was successful in all 57 PVs in 15 patients (100%) using 3.26 ± 0.5 lesions/PV: procedure time 67±10.5 min, catheter time (PEF catheter entry to exit) 19 ± 2.5 min, total PEF energy delivery time<60 s/patient, and fluoroscopy time 12 ± 4.0 min. Surgical box lesions were successful in 6 of 7 patients (86%) using 2 lesions/patient. The catheter time for epicardial ablation was 50.7 ± 19.5 min. There were no complications. These data usher in a new era of tissue-specific, ultrarapid ablation of atrial fibrillation.

Avaliação e controle de instrumentais utilizados em sala operatória durante cirurgias torácicas

Objetivo: Avaliar o número de instrumentais cirúrgicos não utilizados durante as cirurgias torácicas realizadas em um hospital universitário.Métodos: Trata-se de um estudo exploratório, descritivo, transversal com abordagem quantitativa, realizado a partir do levantamento de dados sobrea utilização ou não de instrumentais cirúrgicos presentes nas caixas cirúrgicas. Resultados: Foram observadas 30 cirurgias torácicas, sendo a média deinstrumentais utilizados por cirurgia de 84,53% e a média de instrumentais não utilizados de 15,48%. Conclusão: São necessárias reformulações na composiçãodas caixas cirúrgicas dessa especialidade a fim de otimizar a utilização e o processamento dos instrumentais.

Avaliação da utilização de instrumentais cirúrgicos em um centro cirúrgico ambulatorial

Objetivo: Avaliar o número de instrumentais cirúrgicos utilizados e não utilizados durante cirurgias realizadas em um centro cirúrgico ambulatorialde um hospital universitário. Método: Trata-se de um estudo transversal, quantitativo e descritivo, realizado a partir do levantamento de dados com aobservação da utilização ou não dos instrumentais cirúrgicos presentes nas caixas cirúrgicas. Resultados: Foram observadas 176 cirurgias, dentre as especialidades:oftalmologia 132 (75%), otorrinolaringologia 16 (9,09%), plástica 12 (6,81%) e outras especialidades 16 (9,09%). Verificou-se 49,10% de desperdíciodos instrumentais, por estes não terem sido utilizados nas cirurgias ambulatoriais. Conclusão: Este estudo traz uma nova perspectiva sobre a atuaçãoda enfermagem no Centro Cirúrgico Ambulatorial e sua responsabilidade perante o gerenciamento e controle de custos de uma instituição de saúde.

The impact of the centrifuge characteristics and centrifugation protocols on the cells, growth factors, and fibrin architecture of a leukocyte- and platelet-rich fibrin (L-PRF) clot and membrane

AbstractL-PRF (leukocyte- and platelet-rich fibrin) is one of the four families of platelet concentrates for surgical use and is widely used in oral and maxillofacial regenerative therapies. The first objective of this article was to evaluate the mechanical vibrations appearing during centrifugation in four models of commercially available table-top centrifuges used to produce L-PRF and the impact of the centrifuge characteristics on the cell and fibrin architecture of a L-PRF clot and membrane. The second objective of this article was to evaluate how changing some parameters of the L-PRF protocol may influence its biological signature, independently from the characteristics of the centrifuge.In the first part, four different commercially available centrifuges were used to produce L-PRF, following the original L-PRF production method (glass-coated plastic tubes, 400 g force, 12 minutes). The tested systems were the original L-PRF centrifuge (Intra-Spin, Intra-Lock, the only CE and FDA cleared system for t...

Design and Evaluation of a Portable Laparoscopic Training System Using Virtual Reality

The ubiquitous nature of laparoscopic surgery and the decreased training time available for surgeons are driving an increased need for effective training systems to help surgeons learn different procedures. A cost-effective and user-friendly simulator has been designed to imitate specific training tasks for laparoscopic surgery in virtual environments via image processing and computer vision. The capability of using various actual surgical instruments suited for these specific procedures gives heightened fidelity to the simulator. Image processing via matlab software provides real-time mapping of the graspers in the workspace to the virtual reality (VR) environment (vizard software). Two different tasks (peg transfer and needle passing) were designed to evaluate trainees and compare their performance with characteristics of expert surgeons. Pilot testing of the system was carried out with 11 subjects to validate the similarity of this device with an existing surgical box trainer. Task completion time and muscle activity have been used as metrics for evaluation. The decrease in completion time for all subjects suggests similarity of skills transfer for both simulators. In addition, the p-value of muscle activity showed no significant differences for most muscles in the peg transfer task when using either the VR or physical analog environment and no significant differences for about half of the muscles in the needle passing task. Based on the results, the new proposed VR simulator appears to be a viable alternative to help trainees gain laparoscopic skills.

96-14: Peri-atrial Fat Volume as a Predictor of Outcome in Hybrid Atrial Fibrillation Ablation

Introduction: Recently epicardial adipose tissue volume (EAT-V) has been linked to atrial fibrillation (AF) recurrence after catheter ablation. We have explored the relation between periatrial EAT-V and outcome after a hybrid AF ablation (simultaneous epicardial surgical and endocardial catheter ablation). Methods: Fifty patients, 26 paroxysmal (PAF), 22 persistent and 2 long-standing persistent AF (persAF), referred for a hybrid ablation were studied. On preoperative CT-scans, left atrial (LA) and right atrial (RA) EAT-V were quantified with custom-made software (imageJ). EAT was defined as any tissue located directly around the atria within a window of -30 to -190 Hounsfield Units. Also myocardial mass volumes (10 to 120 Hounsfield Units) and LA volumes (LAV) were assessed. Follow-up in 49 patients (1 lost to follow-up) at 1 year was according to the HRS/EHRA/ECAS expert consensus statement on catheter and surgical ablation of AF. Results: Detailed results are depicted in the Table 1. EAT-V was not significantly different between PAF and persAF patients. EAT-V was not predictive of acute conduction block in the epicardial surgical box lesion. EAT-V neither was predictive of AF recurrence at 1 year. EAT-V in the RA was consistently higher compared to the LA, with significant differences in the PAF (P = 0.009) and persAF groups (P < 0.001). LA EAT-V correlated with LAV determined on CT (r = 0.42, P < 0.01), but not with LAV determined on echocardiography (r = 0.22, P = ns). Overall, LAV determined on CT correlated to but was systematically smaller than LAV determined on echocardiography (r = 0.40, P < 0.01). LA myocardial mass volume positively correlated with LA EAT-V (r = 0.42, P < 0.01). EAT-V = Epicardial Adipose Tissue, LA = Left Atrium, RA = Right Atrium, AF = Atrial Fibrillation, PAF = Paroxysmal AF, persAF = persistent + long-standing persistent AF, SR = Sinus Rhythm. EAT-V = Epicardial Adipose Tissue, LA = Left Atrium, RA = Right Atrium, AF = Atrial Fibrillation, PAF = Paroxysmal AF, persAF = persistent + long-standing persistent AF, SR = Sinus Rhythm. Conclusion: In patients undergoing hybrid AF ablation, total EAT-V is not predictive of recurrence at 1 year. However, LA EAT-V does increase with LAV. As such, fatty infiltration might play a role in early substrate development, and less in AF domestication. Furthermore, acute conduction block of the epicardial box lesion was not influenced by the total amount of left atrial fat.

Does monitor position influence visual-motor performance during minimally invasive surgery?

Background: In minimally invasive surgery (MIS), the natural relationship between hand and eye is disrupted, i.e. surgeons typically control tools inserted through the patient’s abdomen while viewing the workspace on a remote monitor, which can be located in a variety of positions. This separates the location of visual feedback from the area in which a motor action is executed. Previous studies suggest that the visual display should be placed directly ahead of the surgeon (i.e. to preserve visual-motor mapping). However, the extent of the impact of this rotation on surgical performance is unknown. Methods: Eighteen participants completed an aiming task on a tablet PC within a surgical box trainer using a laparoscopic tool in a controlled simulated environment. Visual feedback was presented on a remote monitor located at 0°, ±45° and ±90°, with order randomised using the Latin Square method. Results: Movements were significantly slower when the monitor was 90° relative to midline, but spatial accuracy was unaffected by monitor position. Interestingly, the effect of reduced speed in the 90° condition was transient, decreasing over time, suggesting rapid adaptation to the rotation. Conclusions: We conclude that the angle of the visual display in the context of MIS may require a surgeon to adapt to a changed mapping between visual inputs and motor outputs. While this adaptation occurs relatively quickly, it may interfere with skilled actions (e.g. intracorporeal suturing) in complex surgical procedures.

PWE-417 Incentivising laparoscopic deliberate practice in core surgical training

<h3>Introduction</h3> Frequent practice using a laparoscopic simulator is known to improve subsequent live operating skills. Achieving automation of motor movements prior to live training frees the trainee’s attention for higher skills. Despite this, trainees don’t avail themselves of opportunity for practice. We incentivised frequent laparoscopic practise within two Core Surgical Training (CST) programmes. <h3>Method</h3> 27 CST’s in their first general/urology/paediatric post were given a take-home laparoscopic simulator with instrument tracking software and assigned 6 online modules. Support was provided via social media and a helpdesk. Achievement of metric targets and uploading specified data merited an eCertificate. On production of this certificate, supervisors progressed trainees from camera-holding to operating (the incentive). Trainee views of the intervention and laparoscopic practice were assessed by questionnaires. <h3>Results</h3> Metric results show improvement across all domains for those who completed 1 or more modules (presented graphically). Trainee self-rated anxiety of laparoscopic operating was reduced post-study. 94% of participants thought simulator practise was worthwhile, 76% would recommend the programme. 88% reported improved confidence and motor skills. 41% of participants completed &gt;1 modules. 19% completed all. Comments indicated reasons for this, including the need to integrate simulation into curricular structures. Metric results showed improvement in 5 domains Motion smoothness, acceleration, speed, distance between instruments,% time off screen + time to completion. <h3>Conclusion</h3> The message from this feasibility study, the first to “incentivise” laparoscopic practice, indicates that simply incentivising practice with 24/7 access to simulators and targets, doesn9t result in frequent deliberate practice by trainees, though performance improves in those who do engage. Trainee feedback provides clear indicators of what to address to maximise uptake. It would suggest that to fully engage trainees, laparoscopic practice must be fully integrated into training and progress assessed within training. <h3>Disclosure of interest</h3> L. Nicol: None Declared, R. Partridge Conflict with: Founder of E-O surgical, J. Cleland: None Declared, S. Moug: None Declared, A. Paisley: None Declared, I. Ahmed: None Declared, K. Walker: None Declared. <h3>References</h3> Nagendran M, <i>et al</i>. Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience. Cochrane Database Syst Rev. 2014;1 Dawe SR, <i>et al</i>. A Systematic Review of Surgical Skills Transfer After Simulation-Based Training Laparoscopic Cholecystectomy and Endoscopy. Ann Surg. 2014;259(2) Zapf MA, Ujiki MB. Surgical resident evaluations of portable laparoscopic box trainers incorporated into a simulation-based minimally invasive surgery curriculum. Surg Innov. 2015;22(1):83–7

Instrumentais nas caixas cirúrgicas: avaliação de custo

Objective: To evaluate the number of instruments in surgical boxes, which are not used during a surgery in a hospital in the state of Sao Paulo. Method: Data collection resulted from the direct observation of the instruments used in surgery, recording the actual number of instruments in the box, the number of instruments used in surgery, and the number of unused ones. Results: On an average, about 52% of existing materials in surgical boxes are not used, generating high costs for the institution. Calculating the losses, we obtained an average worth US$ 2.90 (R$ 8.00) per surgical box used, mounting up to the value of U$ 566 (R$ 1,584.17) per month. Conclusions: We conclude that there is a waste of materials, which are sterilized and not used in surgical procedures, directly reflecting the quality and the cost management of the sterilized material center. Keywords: Surgical instruments. Costs and cost analysis. Surgical procedures, operative

The Medical Vestment and Surgical Instruments of Saint Cosmas and Damian on Sinai Icons From the Seventh to the Eighteenth Century.

The iconography of the doctor saints Cosmas and Damian and the artistic representations of their miracles are important sources for the history of medicine. Within the sphere of physician-saints, Cosmas and Damian have the greatest number of iconographic depictions in Byzantine and Post-Byzantine art. In most of their representations, they wear long robes as a sort of professional mantles and carry surgical instruments and boxes indicating their status as doctors. The progress of Byzantine surgery could be attested by these objects, some of them mentioned in collections of miracle stories and documented in medical sources.

Laparoscopic surgical box model training for surgical trainees with limited prior laparoscopic experience.

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown. To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training. We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013. We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training. Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible. We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training. There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Laparoscopic surgical box model training for surgical trainees with no prior laparoscopic experience.

Surgical training has traditionally been one of apprenticeship, where the surgical trainee learns to perform surgery under the supervision of a trained surgeon. This is time consuming, costly, and of variable effectiveness. Training using a box model physical simulator is an option to supplement standard training. However, the value of this modality on trainees with limited prior laparoscopic experience is unknown.To compare the benefits and harms of box model training for surgical trainees with limited prior laparoscopic experience versus standard surgical training or supplementary animal model training.We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Science Citation Index Expanded to May 2013.We planned to include all randomised clinical trials comparing box model trainers versus other forms of training including standard laparoscopic training and supplementary animal model training in surgical trainees with limited prior laparoscopic experience. We also planned to include trials comparing different methods of box model training.Two authors independently identified trials and collected data. We analysed the data with both the fixed-effect and the random-effects models using Review Manager 5. For each outcome, we calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis whenever possible.We identified eight trials that met the inclusion criteria. One trial including 17 surgical trainees did not contribute to the meta-analysis. We included seven trials (249 surgical trainees belonging to various postgraduate years ranging from year one to four) in which the participants were randomised to supplementary box model training (122 trainees) versus standard training (127 trainees). Only one trial (50 trainees) was at low risk of bias. The box trainers used in all the seven trials were video trainers. Six trials were conducted in USA and one trial in Canada. The surgeries in which the final assessments were made included laparoscopic total extraperitoneal hernia repairs, laparoscopic cholecystectomy, laparoscopic tubal ligation, laparoscopic partial salpingectomy, and laparoscopic bilateral mid-segment salpingectomy. The final assessments were made on a single operative procedure.There were no deaths in three trials (0/82 (0%) supplementary box model training versus 0/86 (0%) standard training; RR not estimable; very low quality evidence). The other trials did not report mortality. The estimated effect on serious adverse events was compatible with benefit and harm (three trials; 168 patients; 0/82 (0%) supplementary box model training versus 1/86 (1.1%) standard training; RR 0.36; 95% CI 0.02 to 8.43; very low quality evidence). None of the trials reported patient quality of life. The operating time was significantly shorter in the supplementary box model training group versus the standard training group (1 trial; 50 patients; MD -6.50 minutes; 95% CI -10.85 to -2.15). The proportion of patients who were discharged as day-surgery was significantly higher in the supplementary box model training group versus the standard training group (1 trial; 50 patients; 24/24 (100%) supplementary box model training versus 15/26 (57.7%) standard training; RR 1.71; 95% CI 1.23 to 2.37). None of the trials reported trainee satisfaction. The operating performance was significantly better in the supplementary box model training group versus the standard training group (seven trials; 249 trainees; SMD 0.84; 95% CI 0.57 to 1.10).None of the trials compared box model training versus animal model training or versus different methods of box model training.There is insufficient evidence to determine whether laparoscopic box model training reduces mortality or morbidity. There is very low quality evidence that it improves technical skills compared with standard surgical training in trainees with limited previous laparoscopic experience. It may also decrease operating time and increase the proportion of patients who were discharged as day-surgery in the first total extraperitoneal hernia repair after box model training. However, the duration of the benefit of box model training is unknown. Further well-designed trials of low risk of bias and random errors are necessary. Such trials should assess the long-term impact of box model training on clinical outcomes and compare box training with other forms of training.

Chapter 1: Sinonasal anatomy and function.

An understanding of paranasal sinus anatomy based on important fixed landmarks rather than variable anatomy is critical to ensure safe and complete surgery. The concept of the paranasal surgical box defines the anatomic limits of dissection. The boundaries of the surgical box include the middle turbinate medially, orbital wall laterally, and skull base superiorly. The "vertical component" of the surgical box defines the boundaries of the frontal recess and includes the middle turbinate and intersinus septum medially, medial orbital wall and orbital roof laterally, nasofrontal beak anteriorly, and skull base and posterior table of frontal sinus posteriorly. The paranasal sinuses are divided into anterior, posterior, and sphenoidal functional cavities based on their distinct drainage pathways into the nose. The ultimate goal of surgery is to create a functional sinus cavity. Application of the paranasal surgical box and its vertical component enables the surgeon to view the limits of dissection with a single position of the endoscope. This will ensure complete dissection of the functional sinonasal compartments and effectively avoid leaving behind disconnected cells from the surgical cavity, mucocele formation, mucous recirculation, overcome obstructive phenomenon and enable maximal delivery of topical therapy in the post-operative setting. This article reviews the structure and function of the nasal cartilages and turbinates. It also describes the concept of the paranasal surgical box, key anatomical landmarks and limits of dissection. Normal anatomy and common variants of normal anatomy are discussed.

Full-Arch Vertical Reconstruction of an Extremely Atrophic Mandible With “Box Technique.” A Novel Surgical Procedure

To describe a new augmentation procedure named "box technique" for bone reconstruction in a severely atrophic jaw with mandibular and mental nerve dehiscence. The first surgical box technique procedure was performed to augment the atrophic posterior area. Simultaneously, 2 implants were inserted into the interforaminal zone to stabilize the denture. After 6 months, 2 implants were positioned in the regenerated bone, and a second box technique procedure was performed to reconstruct the ridge in the area of fixture exposition. Six months after the second surgery, the patient was rehabilitated with a removable prosthesis retained on 4 implants. The clinical and histologic analyses highlighted outstanding healing resulting from this vertical and horizontal allografting and included complete resorption of poly D,L-lactide meshes and substitution of the mineralized human bone allograft with an excellent quality new bone formation. Results confirm the effectiveness of the technique, which needs a further case series study endorsing its reliability.

Durable staged hybrid ablation with thoracoscopic and percutaneous approach for treatment of long-standing atrial fibrillation: A 30-month assessment with continuous monitoring

Electrophysiologic and surgical procedures to treat stand-alone atrial fibrillation (AF) have recently evolved, but disappointing results in patients with long-standing persistent (LSP) AF have challenged the durability of these procedures. Lone AF patients (n=36) with either LSP-AF (n=28) or persistent AF (n=8) were prospectively enrolled in the study and consecutively treated by thoracoscopic ablation followed by electrophysiologic evaluation 30 days afterward. Mean left atrial dimension was 50.3±5.5 mm, and average AF duration was 72.8 months (range, 7-240 months). The thoracoscopic procedure was a right monolateral approach to create a box lesion using a temperature-controlled radiofrequency device with suction adherence. A continuous rhythm monitoring device was implanted at the end of the operation. Thoracoscopic ablation was successfully completed without morbidity or mortality and without any intensive care unit stay. Intraoperative exit and entrance block was achieved in 100% and 88.8% (32/36) of patients, respectively. At 33±2 days after the operation, an electrophysiologic study confirmed entry-exit block in 83.3% (30/36) whereas pulmonary vein reconnections were observed in 16.7% (6/36) of patients. Additional transcatheter lesions were performed in 61.1% (22/36) of patients. At a mean follow-up of 30 months (range, 1-58 months), 91.6% (33/36) of patients are in sinus rhythm with 77.7% (28/36) of these patients off antiarrhythmic drugs and 88.8% (32/36) free of warfarin. Long-term incidence of left atrial flutter was 0%. The combination of a surgical box lesion and transcatheter ablation in a hybrid approach provided excellent durable clinical outcomes in patients with LSP-AF.

“Blowing up the Barriers” in Surgical Training

To explore face, content and construct validity of Distributed Simulation (DS), an innovative approach to low-cost, high-fidelity surgical simulation and compare technical performance in the DS with that on a standard surgical box trainer. Immersive simulation is widely accepted as an important modality for surgical education. However, access and cost limit the uptake of full-scale simulation training. DS is a portable, simulated clinical environment aiming at widening access to immersive simulation. Ten novice and 10 expert surgeons performed a laparoscopic cholecystectomy on a porcine model in the DS and on a box trainer. Face and content validity were measured using 6-point Likert-type questionnaires. Construct validity was rated using the Objective Structured Assessment of Technical Skills (OSATS). Comparison of technical performance between DS and box trainer was measured using the Wilcoxon test. Face validity was rated as 5.1 (SD = 0.54) by novices and 4.8 (SD = 0.64) by experts.Content validity was rated as 5.2 (SD = 0.40) by novices and 5.1 (SD = 0.56) by experts. Experts performed significantly better than novices in the DS (16.3 vs. 27.3, P < 0.001) demonstrating construct validity. Experts' technical performance did not differ between DS and box trainer (26.5 vs. 27.3, P > 0.84) whereas novices performed better on the box trainer (19.8 vs. 16.3, P < 0.01). Qualitative data analysis demonstrated that surgeons felt able to behave as if in a real operating room (OR). DS offers a valid, low-cost, accessible environment for training and assessing surgeons. This approach has major implications for surgical education and for the widespread implementation of immersive simulation at a time of increasing financial austerity.

Midterm Results of Surgical Box Line Ablation for Atrial Fibrillation by Bipolar Radiofrequency

The surgical box lesion isolation of pulmonary veins and left atrium is recently reported to be superior to the conventional Cox maze IV procedure. The aim of this study is to investigate the midterm results of surgical box lesion ablation with the use of the bipolar radiofrequency energy performed at our institution. From April 2004 to December 2008, 35 patients underwent the surgical box lesion ablation using bipolar radiofrequency and were followed for mean 31 months ranging from 3 to 58 months. There was no operative mortality. One patient (2.86%) needed electric cardioversion before discharge. One patient (2.86%) needed pacemaker implantation. At discharge, all patients were in normal sinus rhythm. During the follow-up period, the rate of sinus rhythm maintenance was 100%, the rate of freedom from antiarrhythmic medication was 42.9%, and the rate of freedom from thromboembolic episodes was 100%. The surgical box lesion ablation was a safe and effective procedure to terminate atrial fibrillation and restore sinus rhythm.

Sterility Maintenance Assessment of Moist/Wet Material After Steam Sterilization and 30-day Storage

Moist/wet materials stored after autoclaving are considered contaminated and not recommended for use. This study evaluates the maintenance of sterility in moist/wet material after being submitted to steam sterilization and stored for a period of 30 days. Aiming to support decision-making in emergency situations, 40 surgical boxes packed in nonwoven cloth covering Spunbound, Metblouwn, Spunbound (SMS): half (the experimental group) were placed in an autoclave but the drying phase was interrupted, yielding moist/wet materials and the other half (the negative control group) underwent the complete cycle. The external parts of each surgical box were deliberately contaminated with Serratia marcescens and subsequently stored for 30 days. After this period, the boxes' contents were submitted to sterility tests and no growth was observed. The presence of moisture inside the surgical boxes did not interfere with maintaining their sterility.

Robot‐assisted minimally invasive lung brachytherapy

This paper presents a novel alternative for the treatment of lung cancer. The method consists of accessing the lung through small incisions in a minimally invasive manner in order to insert radioactive seeds directly into the lung using a robotic surgical system. An experimental test-bed to evaluate the feasibility of this approach has been developed. It consists of two surgical robotic systems, a device specifically designed to robotically implant radioactive seeds, needle tracking software, ultrasound imaging, electromagnetic tracking, and a surgical box that mimics a patient's thorax. A detailed comparison has been performed between currently available access options and robot-assisted minimally invasive access. The results show insignificant differences in accuracy between the methods, with the exception of a significant improvement when electromagnetic (EM) guidance was added to the non-robotic techniques. The navigation system reduced the number of attempts for all seed delivery methods. Significant reductions in time were achieved in the minimally invasive procedures by the addition of EM guidance. The performance achieved when using robotic systems and image guidance for minimally-invasive brachytherapy is clinically comparable to that achieved in an open surgery procedure, while reducing the invasiveness of the procedure, improving ergonomic conditions for the clinician and reducing radiation exposure.