Training Of Surgeons Research Articles

FIGO position statement on opportunistic salpingectomy as an ovarian cancer prevention strategy.

Epithelial ovarian cancer, with the highest mortality rate among gynecologic malignancies, often goes undetected until advanced stages due to non-specific symptoms. Traditional prevention strategies such as bilateral salpingo-oophorectomy (BSO) are limited to high-risk women and induce surgical menopause, often leading to significant health concerns. Recent findings suggest that many serous epithelial ovarian cancers originate in the fallopian tubes rather than the ovaries. This has led to the hypothesis that salpingectomy, with preservation of the ovaries, may reduce the risk of ovarian cancer while avoiding the adverse effects of early menopause. Studies show that bilateral salpingectomy (BS) significantly reduces ovarian cancer incidence even in average-risk women. Bilateral salpingectomy has been demonstrated to be safe with minimal added operative time, no adverse effects on ovarian function and is also cost effective. Opportunistic salpingectomy (OS), at the time of non-gynecologic surgeries, is a promising strategy for reducing ovarian cancer risk, especially among average-risk women who have completed childbearing. It offers a safe and cost-effective alternative to traditional methods. Emerging data supports incorporating OS into standard surgical practices for benign gynecologic conditions and considering it during unrelated abdominal/pelvic surgeries after adequate patient counseling and informed consent. Further training of non-gynecologic surgeons in OS is recommended to expand its preventive benefits.

The Importance of Virtual Reality in Training Surgeons in Simulated Environments: Innovations and Applications in Medical Practice

The Importance of Virtual Reality in Training Surgeons in Simulated Environments: Innovations and Applications in Medical Practice

Evaluation of Optical Tracking to Distinguish Surgeon Experience During Endoscopic Stone Surgery.

Introduction and Objectives: Optical tracking (OT) has shown potential in assessing surgical skill but has yet to be evaluated for endoscopic urologic surgery. We sought to evaluate the potential for OT to distinguish expert and trainee surgeons during flexible ureteroscopy (fURS) for kidney stone treatment in both simulated and live surgical settings. Methods: We performed OT analysis of six surgeons performing stone localization during fURS in two settings. In the first setting, surgeons were tasked with fiducial localization in three separate kidney phantoms during fURS. In the second setting, surgeons performed stone localization via fURS in five separate patients. Surgeons were categorized as "expert" (n = 3, endourologist, average case volume of >100 fURS per year) or trainee (n = 3, trainee, <100 fURS per year). OT metrics were recorded for both settings using the Microsoft HoloLens 2© as the surgeons viewed the surgical monitor during fURS. Standard OT metrics of experts and trainees were compared, and included: area of eye gaze movement, gaze distance traveled, number of gaze fixation points, percentage of gaze fixation dwell time, and number of saccades. Results: In the simulated setting, the average time for stone localization was greater for trainees compared to experts (318 seconds vs 52 seconds, p < 0.01). Additionally, the mean area of eye gaze movements with area of interest (AOI) was greater for trainees compared to experts (1430 cm2 vs 1060 cm2, p < 0.01). The total gaze distance traveled was also greater for trainees compared to experts (1480 cm vs 730 cm, p < 0.01). In the live surgical setting, average time for stone localization was similar for trainees and experts (74 seconds vs 51 seconds, p = 0.05). The total area of eye gaze movements in AOI was greater for trainees compared to experts (700 cm2 vs 30 cm2, p < 0.01). Additionally, the total gaze distance traveled was greater for trainees compared to experts (14,000 cm vs 680 cm, p < 0.01). This suggests more varied and less point specific concentration on the surgical screen by trainees. There was no difference in percentage of gaze fixation dwell time and number of saccades between experts and trainees in either setting. Conclusions: OT analysis can objectively distinguish surgical experience between experts and trainee surgeons performing fURS in both simulated and live surgical settings. These findings may play a role in future surgical training and skills assessment.

Abstracts of the Italian Society of Thoracic Endoscopy (SIET) 2024 Annual Congress

We are pleased to introduce the abstracts of the XXIII National Congress of the Italian Society of Thoracic Endoscopy (SIET), which will be held in Florence from 17 to 19 October 2024. The principal objectives of SIET are to (1) Promote research and innovation in the fields of thoracic surgery and endoscopy, facilitating the development and implementation of innovative techniques and technologies; (2) Provide education and training for surgeons, endoscopists, pulmonologists and other related specialties; and (3) Facilitate the exchange of knowledge with the aim of creating a cohesive and active scientific community. The Congress will address the integration of traditional surgical and endoscopic techniques with emerging technologies, with the goal of promoting innovation and education among professionals. The theme of integration will be explored throughout the programme, with a particular focus on the collaborative efforts of different medical specialties to improve patient outcomes. This event will host a multidisciplinary cohort comprising thoracic surgeons, endoscopists, pulmonologists, oncologists, pathologists, radiologists and anaesthetists, who will assume a pivotal role in the multidisciplinary sessions of the scientific programme. The Congress will include several core areas of expertise, including lung cancer, interventional endoscopy, pathology, and upper airway reconstruction. Emphasis will be placed on both the theoretical aspects of these subjects and their practical applications in patient care. The theme of integration will be explored throughout the programme, with particular attention on the impact of recent technological developments in the fields of thoracic surgery and endoscopy. Additionally, the Congress will examine the contributions of allied health professionals, including nurses, physiotherapists, and speech pathologists, to patient care.

Evaluation and Improvement of the Quality of Surgical Operative Notes in the Department of General Surgery at Dongola Teaching Hospital, Sudan.

Background Surgical operative notes are essential for patient care and legal documentation. However, inconsistencies in the quality of these notes at Dongola Teaching Hospital, Sudan, highlighted the need for improvement. In line with guidelines from the Royal College of Surgeons of England (RCSEng), this study aimed to enhance the documentation practices in the hospital by implementing a standardized format. Methods A retrospective audit was conducted over three months at the General Surgery Department of Dongola Training Hospital. In the first audit cycle, 81 surgical notes were assessed, revealing significant deficiencies in adherence to RCSEng standards. An intervention was introduced, including a standardized template, training for surgeons, and widespread dissemination of the new format. A second audit cycle followed to assess improvements. Results In the first audit cycle, adherence to documentation standards was 50.3%, with missing or incomplete information in key areas. After the intervention, adherence improved to 71.9%. Notable improvements included documentation of extra procedures (18% to 100%), prosthesis details (0% to 100%), and antibiotic prophylaxis (71% to 97%). However, a slight decline was observed in postoperative care instructions, dropping from 100% to 90%. Conclusion The introduction of a standardized template and training significantly improved the quality of surgical documentation. Continuous efforts are necessary to maintain these improvements, particularly in areas where adherence remains suboptimal, such as postoperative care instructions.

Preserving Essential Skills: The Future of Vaginal Hysterectomy Training in Urogynaecology.

This study aimed to evaluate the training and self-assessed proficiency of surgeons in the surgical management of pelvic organ prolapse (POP). We focused on the factors that influence decision-making, the surgical techniques employed, the training received, and the management of complications. A cross-sectional survey. An electronic questionnaire. European Urogynaecological Association (EUGA) and International Urogynecological Association (IUGA) members. A total of 33 questions evaluating surgeon preference regarding vaginal surgeries. Demographics, surgical selection, proficiency and technique, and training methods. There were 471 respondents, of which 273 (58%) dedicated more than 50% of their week to urogynaecology. 250 (53%) had completed a fellowship, with 215 (86%) of those fellowships being in urogynaecology and pelvic floor reconstruction. A preference for hysterectomy in cases of uterine descent was noted by 297 (63%) respondents, influenced mainly by patient preference, age, and prolapse anatomical score. A total of 443 (94%) were proficient in vaginal hysterectomy, with two-thirds performing 30 or fewer procedures annually; 212 (45%) reporting a decrease in the number of procedures over the last decade. Additionally, 373 (79%) respondents believed that 10-30 cases were needed to achieve and maintain proficiency. Vaginal hysterectomy remains a key component in uterine prolapse repair. However, with the rise of uterine-sparing prolapse repairs, the decision-making process may be influenced by multiple factors, including surgical training. Emphasis should be placed on training and maintaining proficiency in both traditional and novel techniques.

Healthcare professionals beliefs and priorities for the rehabilitation of patients after ankle fracture surgery: A qualitative study

ObjectiveThe study aims to understand healthcare professionals’ (HCPs) beliefs and practices in the treatment and rehabilitation of patients after ankle fracture surgery, with the goal of informing new rehabilitation interventions based on these insights. BackgroundThere is considerable variation in postoperative rehabilitation advice given to patients with ankle fractures, leading to inconsistent care. Prior studies have primarily focused on patients' experiences, making it crucial to explore HCPs' perspectives to identify areas for intervention. MethodsThe study utilised semi-structured interviews with HCPs involved in the multicentre randomised controlled Weightbearing in Ankle Fractures (WAX) trial. Interviewees included physiotherapists, consultant trauma and orthopaedic surgeons, and trainee surgeons. Interviews were conducted between February 2020 and December 2021. Data were analysed using a mixed deductive and inductive approach, aligning with the Behavioural Change Wheel framework to translate findings into potential intervention strategies. Results18 Interviews were conducted, revealing discrepancies between patient and HCP beliefs about recovery, particularly regarding weight-bearing and managing physical symptoms like swelling and numbness. HCPs expressed varying beliefs on the safety of early weight-bearing and recognised historical practice and medicolegal concerns influencing rehabilitation advice. Themes highlighted the need for clearer communication, standardised advice, and the impact of HCPs' remarks on patients' recovery confidence. ConclusionsFindings underscore the mismatch between patient expectations and HCP guidance, emphasising the need for consensus on rehabilitation protocols. The study advocates for tailored rehabilitation pathways that address individual patient recovery trajectories, reduce dependency on HCPs, and encourage patient self-management.

Virtual Reality Surgical Planning of a Complex Two-Jaw Defect

Head and neck reconstruction poses challenges requiring stable coverage and optimal appearance and functionality. In complex cases, and beyond the right choice of flap, Virtual Reality (VR) surgical software and preoperative planning, are needed to optimize outcomes. Our patient is a 16-year-old with a history of rhabdomyosarcoma necessitating maxillary-mandibular defect reconstruction. VR-based preoperative planning facilitated the intervention by creating 3D-VR models of facial anatomy and fibula, simulating resection margins, and creating surgical guides for intraoperative use. Our 2-team surgeons opted for a single-staged reconstruction using a vascularized fibula free flap. This case demonstrates successful single-flap reconstruction of a maxillary-mandibular defect, addressing challenges of recipient vessel scarcity, fibrotic scarring, and poor tissue quality. It also underscores the efficacy of a 2-team approach and VR-based preoperative planning in achieving successful outcomes in complex maxillary-mandibular reconstruction. The use of a single fibula flap minimized possible complications and operative time, and the 2-team approach helped by combining the expertise and training of craniofacial and microsurgical trained surgeons. Acknowledging limitations in imaging quality and real-time adaptability, we advocate for continued exploration of VR technologies in enhancing surgical precision in challenging cases.

Lower Limb Comprehensive Reconstructive Surgery: Experiences from an Orthopedic Teaching Unit

Abstract Introduction: The burden of open extremity fractures is well recognized in placing a burgeoning demand on an already exhausted medical facility in low- and middle-income countries. This study aims to evaluate the functional outcome following “orthoplastic management” by orthopedic surgeons trained in limb reconstruction surgery. Methodology: Adult patients with open lower limb injuries treated from January 1, 2022, to December 30, 2022, who underwent single or staged fixation and reconstruction procedures were identified. Patients with Gustilo–Anderson type IIIB fractures requiring skeletal stabilization with soft-tissue cover were included. Polytrauma patients requiring multidisciplinary surgical attention were excluded. A team of orthopedic surgeons trained in limb reconstruction was involved in the management. Inpatient and outpatient department follow-up by the treating team was done to document complications (infections, reoperations, and graft failures) and functional outcomes using the Lower Extremity Function Score. The duration of mean follow-up was 1 year since index surgery. Results: A total of 24 adult patients with open lower limb injuries with preoperative Ganga Hospital Score (GHS) were included. Decision toward fixation with primary closure or further reconstruction was made collectively. The gray zone (GHS score of 15–16) of patients was more aggressively managed with emphasis on salvage. Additional reconstructive procedures were carried out based on the assessment at consequent follow-up. Three patients had a suboptimal joint function (less than functional range of motion for the involved joint) due to the resultant loss of compartment(s) and joint contracture. Five patients were retaken to the theater for further supplementary or corrective procedures following the index, definitive surgical procedure (bone grafting, partial flap loss, and fixator readjustment). Conclusion: Good-to-excellent functional outcome was demonstrated with the “orthoplastic approach” where skeletal stabilization as well as soft-tissue reconstruction was performed by trained orthopedic surgeons. This study demonstrated that orthoplastic surgery is a safe and effective method of limb salvage.

Pediatric orthopedic surgeons may perform better in terms of surgical outcomes in type 3 supracondylar humerus fractures: a comparative analysis

Supracondylar fractures of the humerus represent the most common surgical fractures in pediatric patients. There is a discourse regarding the influence of the surgeon training on treatment. Different studies show equivocal effect of subspecialty training. We conducted a single center case control study to evaluate the outcomes of type 3 fractures (fully displaced) comparing pediatric-trained orthopedic surgeons (PTOS) and non-pediatric trained orthopedic surgeons (NTOS). In this retrospective study, we investigated the surgical outcomes of type 3 supracondylar fractures of the humerus in children treated between the years 2012 and 2019, divided by surgeon type. During the research, a policy reform at our department was established and PTOS became the only surgeons for those injuries starting from September 2017. Patients’ demographics, perioperative details, and postoperative course were recorded. Primary outcome was reoperations, and secondary outcomes were open reductions, infections, length of surgery, and neurological deficits. 1175 patients were diagnosed with supracondylar fractures at our Level I trauma center, and 346 cases were diagnosed with radiologically confirmed type 3. Overall, 312 cases were analyzed; 113 cases were diagnosed before 1 September 2017 and treated by NTOS, and 199 cases were treated by PTOS until 31 December 2019; 7.1% (8) of the patients treated by NTOS had to be reoperated compared to 1.5% (3) of the patients treated by PTOS (P = 0.014). There was significant difference looking at postsurgical complications and surgery length. This study’s findings suggest that PTOS achieve superior outcomes when treating patients with type 3 supracondylar humerus fractures. Level of evidence: Level III.

Transoral snare removal of subepiglottic cysts.

The objective of this demonstration was to describe and simulate a surgical technique for removing subepiglottic cysts in horses via an oral approach under endoscopic guidance using a cadaver model for simulation and clinical data. The technique aims to provide a minimally invasive method for the removal of these cysts. 2 clinical case images from the Washington State University Teaching Hospital were used in the video. In a third horse euthanized for reasons unrelated to the study, the procedure was simulated after the head was frozen and transected transversally. Files from 2 horses were reviewed, and the relevant parts were selected. The horse head was set on a stand, and a simulated cyst was implanted under the mucosa, made of the fingertip from a glove filled with carboxymethyl cellulose gel, and sutured. The procedure was performed by one of the authors (CAR) and recorded. A bronchoesophageal grasping forceps and cautery snare were used to simulate a clinical situation in dorsal recumbency. The cyst was successfully removed as in the real procedure, and the demonstration was recorded for educational use. The review of the videos shows that the simulated procedure is also achievable in a real clinical environment. This technique provides a minimally invasive method for the removal of subepiglottic cysts in horses. The demonstration of this procedure is crucial for the training of surgeons, as it allows the visualization of the procedure in a controlled setting, free from the complications of real clinical situations.

HYPERBILIRUBINEMIA: A NEW DIAGNOSTIC MARKER FOR ACUTE APPENDICITIS AND ITS PART IN PREDICTING APPENDICULAR PERFORATION

Introduction:Acuteappendicitis is the commonest cause of Acute Surgical abdomen.Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training. Aims&amp;Objectives:The objectives of the study were-To study the relationship between hyperbilirubinemia and acute appendicitis and to evaluate its credibility as a diagnostic marker for acute appendicitis. Materials&amp;Methods:The study was conducted in the Department of General Surgery, HKEs Basaveshwar Teaching and General Hospital, kalaburagi attached to MahadevappaRampure Medical College, kalaburagi during the period of August 2022 to August 2023. A one year cross sectional study. Results:A total of 100 patients with clinical diagnosis of acute appendicitis or appendicular perforation admitted in the Department of General surgery, HKEs Basaveshwar Teaching &amp; General Hospital, kalaburagi attached to MahadevappaRampure Medical College, kalaburagi were studied. Discussion:Acute appendicitis is the most common cause of acute abdomen in young adults. Appendicectomy is the most frequently performed urgent abdominal operation and is often the first major procedure performed by a surgeon in training.PPAbout 8% of people in Westerncountries have appendicitis at some time in their lifetime. Conclusion: The present study suggests-Serum bilirubin levels appears to be a promising new laboratory marker for diagnosing acute appendicitis, however diagnosis of appendicitis remains essentially still - clinical. Its level come out tobe a credible aid in diagnosis of acute appendicitis and would be helpful investigation in decision making.

Performance of OpenAI’s GPT-4 in a mock MRCS Part A Examination

Introduction: OpenAI’s latest iteration of a Large Language Model (LLM); GPT-4 (Generative Pre-trained Transformer 4) has demonstrated its proficiency against various professional examination standards like the USMLE (United States Medical Licensing Examination), FRCS (Fellowship of the Royal Colleges of Surgeons) and the United States Bar. However, GPT-4’s capability with the MRCS (Membership of the Royal College of Surgeons) Part A has not yet been investigated. Methodology: A representative MRCS Part A examination that was prepared and provided by “TeachMeSurgery” based on the MRCS Intercollegiate Curriculum was used to assess GPT-4's performance. Each question was processed via the web-based interface of ChatGPT (Chat Generative Pre-trained Transformer) Plus. Results: GPT-4 scored 87.2% on Applied Basic Sciences (157/180) and 86.7% on Principles of Surgery in General (104/120 questions), achieving an overall score of 261/300 (87%), which is above the typical passing threshold. GPT-4 scored 100% in four out of the eleven predefined curriculum areas, which included: Pharmacology, Microbiology, Data Interpretation and Audit, and The Surgical Care of Children. GPT-4’s weakest performance was in the Medico-Legal Aspects of Surgical Practice, in which it scored 33.3%. Conclusion: GPT-4 successfully passed the mock MRCS Part A without any specialised preparatory training, however further research could look at integrating the GPT-4 model to enhance a trainee surgeon’s learning and use it as an effective tool to deliver high quality &amp; efficient patient care.

Impact of Resident and Attending Surgeon Training Level on Free Tissue Transfer Ischemia Time and Complications.

Microsurgical free tissue transfer has become an essential method for reconstruction of complex surgical defects, making the level of training an important factor to consider. There is little published regarding the impact of training level on microsurgical outcomes. This study investigates microsurgical free tissue transfer ischemia time and postoperative complications based on resident and attending surgeon experience level. A retrospective review of all free flaps at a single institution from January 1, 2013, to December 31, 2021 was performed. Linear regression was performed analyzing ischemia time of 497 free flaps and attending surgeon experience defined by years in practice and resident level defined as postgraduate year (PGY). Logistic regression model was used to analyze complications based on attending experience and resident level. The average resident PGY was 3.5 ± 0.8; the average attending has been practicing for 6.4 ± 5.1 years. There was no statistically significant difference in ischemia time or complication rates based on resident PGY or attending surgeon experience level. Lower PGY residents were not found to increase ischemia time or increase complication rates. Lower attending surgeon year was not found to increase ischemia time or increase complication rates compared with surgeons who had been practicing for longer. Microsurgical free tissue transfer is considered a safe procedure in residency training and trainee involvement should be encouraged to improve resident education and enhance technical skills.

Objective performance indicators versus GEARS: an opportunity for more accurate assessment of surgical skill.

Surgical skill evaluation that relies on subjective scoring of surgical videos can be time-consuming and inconsistent across raters. We demonstrate differentiated opportunities for objective evaluation to improve surgeon training and performance. Subjective evaluation was performed using the Global evaluative assessment of robotic skills (GEARS) from both expert and crowd raters; whereas, objective evaluation used objective performance indicators (OPIs) derived from da Vinci surgical systems. Classifiers were trained for each evaluation method to distinguish between surgical expertise levels. This study includes one clinical task from a case series of robotic-assisted sleeve gastrectomy procedures performed by a single surgeon, and two training tasks performed by novice and expert surgeons, i.e., surgeons with no experience in robotic-assisted surgery (RAS) and those with more than 500 RAS procedures. When comparing expert and novice skill levels, OPI-based classifier showed significantly higher accuracy than GEARS-based classifier on the more complex dissection task (OPI 0.93 ± 0.08 vs. GEARS 0.67 ± 0.18; 95% CI, 0.16-0.37; p = 0.02), but no significant difference was shown on the simpler suturing task. For the single-surgeon case series, both classifiers performed well when differentiating between early and late group cases with smaller group sizes and larger intervals between groups (OPI 0.9 ± 0.08; GEARS 0.87 ± 0.12; 95% CI, 0.02-0.04; p = 0.67). When increasing the group size to include more cases, thereby having smaller intervals between groups, OPIs demonstrated significantly higher accuracy (OPI 0.97 ± 0.06; GEARS 0.76 ± 0.07; 95% CI, 0.12-0.28; p = 0.004) in differentiating between the early/late cases. Objective methods for skill evaluation in RAS outperform subjective methods when (1) differentiating expertise in a technically challenging training task, and (2) identifying more granular differences along early versus late phases of a surgeon learning curve within a clinical task. Objective methods offer an opportunity for more accessible and scalable skill evaluation in RAS.

The impact of COVID-19 on Australian plastic and reconstructive surgery trainees: a survey study

Introduction: The COVID-19 pandemic had a significant impact on the training of plastic and reconstructive surgeons and the wellbeing of surgical trainees internationally. The aim of this study was to evaluate the impact of the COVID-19 pandemic on Australian plastic and reconstructive surgery trainees. Method: A web-based self-administered survey was distributed by the Australian Society of Plastic Surgeons to all Australian plastic and reconstructive surgery registrars in October 2021. A questionnaire developed to assess the impact of the COVID-19 pandemic on plastic and reconstructive surgery trainees in the United States of America was adapted for the Australian context. Subgroup analysis evaluated differences in responses between early and late Surgical Education and Training trainees and between Australian states. ​Results: Of 103 Australian plastic and reconstructive surgery trainees invited to participate, 24 responded (23%). Of these, 52 per cent were in their first two years of training. Total working hours were reduced for 61 per cent of respondents, 54 per cent reported less direct operative supervision, and 75 per cent reported missing out on critical operative learning experiences due to elective operating changes. Overall impact on trainee education was reported to be negative by 71 per cent of respondents. Self-assessed overall wellbeing was negatively impacted in 92 per cent of respondents: all reported feeling isolated from colleagues and 67 per cent reported burnout due to changes during the pandemic. Positive innovation in plastic and reconstructive surgery unit management was reported by 29 per cent of respondents. There were no statistically significant differences in responses between early and late Surgical Education and Training trainees. There were some differences identified in senior supervision and frequency of organised teaching between states. Conclusion: Australian plastic and reconstructive surgery trainees in our cohort reported that the COVID-19 pandemic had a negative impact on their clinical training opportunities, formal education and wellbeing. These findings should be considered in planning for future periods of significant disruption to try to mitigate the negative impacts on trainees.

Reliability and validity of the Paprosky classification for acetabular bone loss based on level of orthopedic training.

Reliability and validity of the Paprosky classification for acetabular bone loss have been debated. Additionally, the relationship between surgeon training level and Paprosky classification accuracy/treatment selection is poorly defined. This study aimed to: (1) evaluate the validity of preoperative Paprosky classification/treatment selection compared to intraoperative classification/treatment selection and (2) evaluate the relationship between training level and intra-rater and inter-rater reliability of preoperative classification and treatment choice. Seventy-four patients with intraoperative Paprosky types [I (N = 24), II (N = 27), III (N = 23)] were selected. Six raters (Residents (N = 2), Fellows (N = 2), Attendings (N = 2)) independently provided Paprosky classification and treatment using preoperative radiographs. Graders reviewed images twice, 14 days apart. Cohen's Kappa was calculated for (1) inter-rater agreement of Paprosky classification/treatment by training level (2), intra-rater reliability, (3) preoperative and intraoperative classification agreement, and (4) preoperative treatment selection and actual treatment performed. Inter-rater agreement between raters of the same training level was moderate (K range = 0.42-0.50), and mostly poor for treatment selection (K range = 0.02-0.44). Intra-rater agreement ranged from fair to good (K range = 0.40-0.73). Agreement between preoperative and intraoperative classifications was fair (K range = 0.25-0.36). Agreement between preoperative treatment selections and actual treatments was fair (K range = 0.21-0.39). Inter-rater reliability of Paprosky classification was poor to moderate for all training levels. Preoperative Paprosky classification showed fair agreement with intraoperative Paprosky grading. Treatment selections based on preoperative radiographs had fair agreement with actual treatments. Further research should investigate the role of advanced imaging and alternative classifications in evaluation of acetabular bone loss.

Validation of a dynamic 4D microsurgical bypass simulator for training and teaching microvascular anastomosis techniques with blood flow and fluorescence imaging

ObjectiveMicrovascular anastomosis is challenging, and training surgeons to develop and maintain skills is imperative. Current training models either miss the simulation of the surgical workflow, lack 3D key-hole space, need ethical approval, require special preparation, or lack realism. To circumvent these issues, this study describes the use of a mixed reality 3D printed model with integrated blood flow for training cerebral anastomosis and assesses its validity. MethodsDifferent-sized 3D-printed artificial micro artery models in a 3D brain space with a keyhole opening were used. The model was connected to a 4D simulator to induce pulsatile blood flow. Neurosurgical microscopes and exoscopes were used for visualization. Nine participants (n = 6 board-certified cerebrovascular neurosurgeons; n = 3 in-training) participated in the study and practiced anastomosis techniques with the simulator. Two senior, experienced vascular neurosurgeons mentored live teaching activity on the simulator. Participants completed a survey to score the face and content validity of the simulation on a 5-point Likert scale. Simulation time and anastomosis score differences between in-training and board-certified participants were compared for construct validity. ResultsParticipants scored the simulation difficulty similar to actual surgery, proving face validity. All participants agreed that practice on the provided simulator models would improve bypass techniques (μ = 4.67/5 ± 0.47) and instrument handling (μ = 4.56/5 ± 0.68). Board-certified participants had better anastomosis scores than in-training participants (non-significant difference). ConclusionsThe 4D simulator and the high-fidelity artificial 3D printed model effectively simulated actual bypass surgery in a key-hole fashion with blood flow abilities. Limited resources and preparation time are needed for the training setup. The model provides benefits in learning and maintaining anastomosis skills and allows for easy adaptation to different microanatomical scenarios.

The Royal College of Ophthalmologists' National Ophthalmology Database study of cataract surgery: Report 17, a risk factor model for posterior capsule rupture.

To create a risk factor model for posterior capsule rupture (PCR) during cataract surgery. Eligible operations between 01/04/2016 and 31/03/2022 from centres supplying data to the UK national cataract audit with complete data including patients' gender and age at surgery, anterior chamber depth (ACD) measurement and preoperative visual acuity (VA) were included. A logistic regression model was fitted to identify risk factors and calculate their odds ratios (OR) and 95% confidence intervals (CI) for PCR. This analysis included 961,208 cataract operations performed on 682,381 patients from 136 participating centres by 3198 surgeons. 9730 (1.01%) of surgeries were complicated by PCR. The median age was 75.7 and 76.7 years for first and second eye surgery respectively, and 5154 (53.0%) were female. The highest risk factors for PCR were less experienced trainee surgeon (OR 3.75, 95% CI 3.33-4.24, p < 0.001), pseudoexfoliation/phacodonesis (OR 3.47, 95% CI 3.05-3.94, p < 0.001), younger males (OR 3.05, 95% CI 2.23-4.16, p < 0.001) and brunescent/white/mature cataract (OR 2.41, 95% CI 2.24-2.60, p < 0.001). Other risk factors identified were glaucoma, worse preoperative VA, previous intravitreal therapy, high myopia, previous vitrectomy, systemic diabetes, diabetic retinopathy, amblyopia, older age, shallower ACD and inability to lie flat and cooperate. Various surgical, patient and ocular factors increase the risk of PCR during cataract surgery. This risk factor model permits estimation of individualised risks for patients and allows risk-adjustment for surgeons to evaluate their PCR rates based on case complexity.

Sociopolitical, clinical, and ethical challenges of sustainable fracture care in Haiti.

In low- and middle-income countries such as Haiti, musculoskeletal injuries are the leading cause of morbidity and mortality. Untreated injuries can contribute to decreased mobility, leading to disability and reduced productivity for individuals. The accessibility of timely fracture care poses a substantial challenge in Haiti, where socioeconomic instability and recent surges in gang violence exacerbate an already strained healthcare infrastructure. This manuscript delves into the intricate barriers to sustainable fracture care in Haiti, shedding light on the sociopolitical landscape and clinical challenges that influence the delivery of orthopedic services. The ethical considerations in providing fracture care in Haiti are multifaceted, including classic medical principles, self-preservation in the face of violence, issues of justice in resource and service allocation, and concerns of nonmaleficence in the context of international volunteers. These ethical dilemmas arise from the complex interplay of limited resources, the dangers posed by the current sociopolitical climate, and the involvement of international aid in a vulnerable healthcare system. To address the clinical and ethical conflicts of providing fracture care in Haiti, solutions include education and training of Haitian orthopedic surgeons, capacity building of healthcare facilities, and establishing ethical standards for international volunteers. This comprehensive approach is vital for advancing sustainable fracture care in Haiti and other resource-limited settings.