1,721,128 research outputs found
Alternative uses of virtual simulators for laparoscopy and robot-assisted surgery for medical students
No full textLetter to the edito
Use of 3D models for planning, simulation, and training in vascular surgery
No full textDear Editor,
We read with great interest the article by Pugliese et al. entitled “The clinical use of 3D printing in surgery” recently published by Updates in Surgery.
In the past years, 3D printing has seen an almost exponential growth in several fields, including medicine and surgery, as testified by the increasing number of published articles. This success was fostered by technological progresses on manufacturing processes allowing to build layer by layer 3D objects at higher resolution
Should we use virtual simulators for surgical resident selection?
No full textTo the Editor:
we read with great interest the article by Gardner et al. entitled “How Much Are We Spending on Resident Selection?” recently published by Journal of Surgical Education [1].
Gardner et al. put the attention on the importance of a rigorous selection process to identify applicants who will be the best fit for training programs. In this analysis authors revealed the significant time and resources spent for the current resident selection process, with the average program spending approximately $100,000 annually. Moreover, examining the amount of time and efforts dedicated to applicant screening activities, they observed that residency coordinators were shouldering much of the burden, spending over 132 hours on the process.
Gardner et al., rightly, stressed the importance for program leaders to assess the efficacy and efficiency of their current selection procedures and identify additional methodologies to make the process more efficient. A key point of the high costs is the large number of interviews conducted. For these reason, Gardner et al. highlighted the importance of reducing the number of on-site interviews, administering customized assessments to eligible applicants early in the process to help the identification of candidate's potential, fit, and alignment with the program’s values and expectations.
Moreover, according to a survey, 30% of program directors from Fellowship Council in North America believe that graduates entering fellowships cannot independently and safely perform routine operations [2]. Therefore, it is important to adopt more efficient screening tools, such as online assessments, phone or video interviews, or assessment centers, to decrease the burden for both applicants and programs, but also to choose candidates with higher possibilities to become competent surgeons. In this context, the use of simulators could represent a valid option. The use of simulators for the training of surgical resident is increasingly widespread nowadays. However, in our opinion a possible alternative use of surgical simulators could be as tests for resident selection during their initial assessment. Indeed, there is an increasing interest for a reliable test as an objective assessment of the innate ability for psychomotor manipulative skills for surgery and as an integral component of the selection process for the many interns or house officers’ intent on a surgical career. Moreover, the restrictions on working hours in the USA and even more extremely in EU member states has increased the importance of such innate aptitudes for surgery because surgical resident should acquire technical skills quickly, or at least efficiently.
As pointed out by Gardner the selection procedure of surgical residents students is currently very complex because it includes many phases. But it is very important to ensure a high probability of selecting the most promising candidates in view of such high costs.. Unfortunately, at present the selection process does not consider manual dexterity among the determining factors, an increasingly important aspect after the advent of minimally invasive surgery that requires psychomotor skills (hand-eye coordination, lack or reduction of tactile feedback,...). Since virtual simulators are able to objectively evaluate psychomotor competences, an aptitude test based on a virtual simulator may complement the evaluation process. For example, two studies were done using virtual simulators for robotic surgery to evaluate the innate ability for surgery among medical students. [2,3]. Although the two studies differ in design, participants and used simulators, they have found very similar results. In fact the two studies showed almost the same distribution of the three groups with 6.6% and 5.8% exhibiting outstanding performance, and 11.6% and 11.0% with low level ability for manipulative skills compared to their peers. [3]. These data are in agreement with data reported by a study on medical students using a simulator for laparoscopic appendectomy that revealed a 15% of medical students with low aptitude to reach proficiency [4]. Furthermore, the value of simulators as an aptitude test on technical skills has been demonstrated in the Republic of Ireland by a study on candidates entering a higher surgical residency training program (equivalent to a Fellowship in the USA), which confirmed a high correlation between score at surgical simulators and overall assessment, based on education and academic records, progress in clinical surgical performance, research output, and interview assessment [5].
In conclusion, the use of virtual simulators for objective testing could be included to complement the selection process of residents. However, if in the future the simulators were added among the tools for the resident selection, the costs of the purchase of the simulators and of the dedicated personnel should be considered in the total costs. However, thanks to the increasing diffusion of laparoscopy and robotic surgery, the number of simulators for these surgical approaches is constantly growing and this could reduce purchasing costs. Moreover, their use could save on training costs during the residency because it would give the possibility to invest on the most promising candidates and not to invest on those with less potentia
Comment on: ‘Money for nothing’. The role of robotic-assisted laparoscopy for the treatment of endometriosis
No full textTo the Editor:
We read with great interest the published article by Berlanda et al. entitled “Money for nothing”. The role of robotic-assisted laparoscopy for the treatment of endometriosis [1].
Deep infiltrating endometriosis (DIE) with colorectal involvement is one of the most aggressive forms of endometriosis. At present, a minimally invasive surgery (MIS) and in particular the direct manual laparoscopy (DML), is considered the gold standard for radical treatment of DIE with colorectal involvement, as it results in faster recovery, reduced in-hospital stay, improved cosmesis, and lower postoperative morbidity compared to laparotomy. Robot-assisted surgery (RAS), is a technological advancement of DML, introduced with the aim to overcome its kinematics limitations.
In recent years, the diffusion of the da Vinci System has created much enthusiasm has grown between surgeons of different specialties, with a constantly growing application of RAS, and several studies have been published to describe safety and efficacy of RAS, as well as to compare RAS to DML. In particular, colorectal surgeons and gynecologists have explored RAS and have also applied it to the treatment of DIE [2].
In the article, Berlanda et al. describe a very well structured critical review of the literature about the role of RAS for the treatment of endometriosis. In particular, they reported that RAS treatment of endometriosis did not provide clear benefits over standard laparoscopy, in the face of a longer operative time and higher costs. They, therefore, express concern for economic sustainability in the face of increasing use of the widely diffusion of da Vinci system, and they made conclusions against the use of robot for the treatment of DIE.
However, we have noticed that in all of the article the authors uses generically the terms of “robotic-assisted laparoscopy”, without specifying which system they refer to and in truth, the whole study is based on the da Vinci Si system, the most widespread version to date until recently. Indeed, only in the last 2–3 years, in many centers it has been gradually replaced by the most recent version, the da Vinci Xi. Therefore, we can agree with the conclusions reached by the authors only if applied to a specific robotic system, namely the da Vinci Si, but not if generalized to the broader concept of “RAS”.
In fact, recent works have shown that many of the conclusions reached to date, in the comparison between DML and RAS, unfavorable to the latter because of the longer operating times and higher costs, without clear evidence of clinical benefits, are referred to results obtained by comparing expert laparoscopists with novice robotic surgeons, using a now almost obsolete robotic system, the da Vinci Si.
Indeed, recently data published by our group on rectal resections performed with the two different da Vinci systems, showed that with the new robot, and with the increase of the surgeon’s experience, the results improve, and the costs are significantly reduced [3, 4, 5].
In conclusion, the article by Berlanda et al. deals with a very interesting topic using objective and critical methods. However, today the use of da Vinci Xi with case series being performed by expert robotic surgeons, and the use of new robotic system that will enter in the market, represents a totally different proposition from what is reported in this study, requiring careful objective re-evaluation of cost–benefit of RAS, also in the surgical treatment of DIE
Augmented reality in open surgery
Full text linkAugmented reality (AR) has been successfully providing surgeons an extensive visual information of surgical anatomy to assist them throughout the procedure. AR allows surgeons to view surgical field through the superimposed 3D virtual model of anatomical details. However, open surgery presents new challenges. This study provides a comprehensive overview of the available literature regarding the use of AR in open surgery, both in clinical and simulated settings. In this way, we aim to analyze the current trends and solutions to help developers and end/users discuss and understand benefits and shortcomings of these systems in open surgery. We performed a PubMed search of the available literature updated to January 2018 using the terms (1) “augmented reality” AND “open surgery”, (2) “augmented reality” AND “surgery” NOT “laparoscopic” NOT “laparoscope” NOT “robotic”, (3) “mixed reality” AND “open surgery”, (4) “mixed reality” AND “surgery” NOT “laparoscopic” NOT “laparoscope” NOT “robotic”. The aspects evaluated were the following: real data source, virtual data source, visualization processing modality, tracking modality, registration technique, and AR display type. The initial search yielded 502 studies. After removing the duplicates and by reading abstracts, a total of 13 relevant studies were chosen. In 1 out of 13 studies, in vitro experiments were performed, while the rest of the studies were carried out in a clinical setting including pancreatic, hepatobiliary, and urogenital surgeries. AR system in open surgery appears as a versatile and reliable tool in the operating room. However, some technological limitations need to be addressed before implementing it into the routine practice
Is there a role of robotic surgery in abdominal organs transplantations?
No full textAbdominal organs transplantations represent the only poten-tially curative treatment in several end stage-diseases, but despite the improvement of the surgical techniques and the overall good outcomes, the invasiveness of these procedures is still very high. Therefore, the possible application of mini-mally invasive surgery in this field would be of great interest.Until a few years ago this application was not even con-sidered because of the kinematic limitations of laparoscopy which makes very challenging to carry out the reconstruc-tive phases of the transplant. Instead, more recently, since the successful introduction of the da Vinci Surgical System, the possible application of robot-assisted Surgery (RAS) in organ transplantation has become a reality [1].Indeed, with RAS, several limitations of laparoscopic technique for minimally invasive surgical procedures have been overcome, particularly with its latest version, the da Vinci Xi, capable to ensure an easy docking, a wide range of motion with its small, thin arms, the ability to attach the endoscope to any arm, and a highly flexible access to differ-ent anatomical regions [2]. Thus, thanks to these features, the execution of vascular anastomoses has become feasible, offering a new impetus in proposing a minimally invasive approach to patients suitable for an abdominal solid organ transplantation.However, although the technical feasibility of RAS to certain abdominal transplantations procedures has been recently demonstrated by several groups [1], we think that its use in this field is still affected by some main limita-tions that prevent its wide diffusion. In fact, the first critical issue is related to the donor organ’s insertion and manipula-tion through a narrow incision, with the associated risk of organ damage and/or difficult positioning. Furthermore, this limitation together with the longer execution time of vascu-lar anastomoses, could negatively impact on the ischemia time, the reduction of which is instead crucial, especially nowadays that organs procurement from deceased marginal donors is becoming more and more frequent to shorten the continuously growing waiting lists [3, 4].For all these reasons, although dedicated clinical postop-erative follow-up strategies [5, 6] and optimized immuno-suppressant therapies [7, 8] have contributed today to very good outcomes in abdominal solid organs transplantations even with marginal donors, the reduction of operative time for the reconstructive phase is still a major critical factor, and can represent a major limitation for a wide application of RAS.Finally, the use of RAS for organ transplantations on a wider scale could clash with two other non-clinical funda-mental matters, such as the necessity of a continuous avail-ability of the robotic system for a non-elective surgery and the economical sustainability of this approach [9].In conclusion, we think that RAS in transplant surgery is an appealing and promising technique, and without any doubt it represents an open window out to the future, but today it is still far to become the new standard approach, particularly for deceased donor organs transplantation
Impact of COVID-19 on vascular patients worldwide: analysis of the COVIDSurg data
No full textBACKGROUND: The COVIDSurg collaborative was an international multicenter prospective analysis of perioperative data from 235 hospitals in 24 countries. It found that perioperative COVID-19 infection was associated with a mortality rate of 24%. At the same time, the COVER study demonstrated similarly high perioperative mortality rates in vascular surgical patients undergoing vascular interventions even without COVID-19, likely associated with the high burden of comorbidity associated with vascular patients. This is a vascular subgroup analysis of the COVIDSurg cohort. METHODS: All patients with a suspected or confirmed diagnosis of COVID-19 in the 7 days prior to, or in the 30 days following a vascular procedure were included. The primary outcome was 30-day mortality. Secondary outcomes were pulmonary complications (adult respiratory distress syndrome, pulmonary embolism, pneumonia and respiratory failure). Logistic regression was undertaken for dichotomous outcomes. RESULTS: Overall, 602 patients were included in this subgroup analysis, of which 88.4% were emergencies. The most common operations performed were for vascular-related dialysis access procedures (20.1%, N.=121). The combined 30-day mortality rate was 27.2%. Composite secondary pulmonary outcomes occurred in half of the vascular patients (N.=275, 45.7%). CONCLUSIONS: Mortality following vascular surgery in COVID positive patients was significantly higher than levels reported pre-pandemic, and similar to that seen in other specialties in the COVIDSurg cohort. Initiatives and surgical pathways that ensure vascular patients are protected from exposure to COVID-19 in the peri-operative period are vital to protect against excess mortality. (Cite this article as: Hitchman L, Machin M; The COVIDSurg Collaborative and Vascular and Endovascular Research Network. Impact of COVID-19 on vascular patients worldwide: analysis of the COVIDSurg data. J Cardiovasc Surg 2021;62:558-70. DOI: 10.23736/S0021-9509.21.12024-5
Comment on “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-center experience from southern India”
No full textTo the Editor:
We read with great interest the article by Shajahan et al. entitled “Lessons learnt from living donor liver transplantation with ABO-incompatibility: A single-centre experience from southern India” [1] recently published on Indian Journal of Gastroenterology.
ABO-incompatible living donors liver transplantation (ABO-I LDLT) represents a precious opportunity to shorten the waiting time for surgery, avoiding the disease progression that might occur waiting for an ABO-compatible living or deceased donor. However, ABO-I LDLT is still associated with a high risk of antibody-mediated rejection (AMR), lower patient and graft survival and a high risk of vascular thrombosis and ischemic bile duct complications if compared to ABO-compatible LT.
The study of Shajahan et al. represents the largest report of ABO-I LDLT from India, even if the sample size is still small. The authors retrospectively analyzed data of 12 patients undergone ABO-I LDLT using Rituximab and preoperative plasmapheresis for desensitisation, adjusting doses after facing a very high mortality rate in the first 7 patients (5 deaths), mostly due to septic complications.
Rituximab, a murine/human monoclonal chimeric antibody against CD20 depleting B-lymphocytes, has traditionally been used to treat haematological malignancies and autoimmune diseases. More recently, it has been gained interest as an immunomodulatory agent in solid organ transplantations. [2] Although if current literature is more and more supporting the effectiveness of Rituximab in antibody-mediated rejection (AMR) as a desensitizing regimen, several reports have shown that concerns still remain in the high incidence of complication rates, such as biliary strictures, ischemic-type biliary lesions and postoperative infections. [3,4,5]
Particularly this latter complication afflicted the study of Shajahan et al. who faced a dramatically high rate of postoperative infections involving 9 out of 12 patients, of whom 5 died due to overwhelming sepsis from multidrug-resistant pathogens. Several works such as a Japanese multicenter study have demonstrated that multiple or large Rituximab doses significantly increase the incidence of infection [3], advocating for a “minimization” of the desensitizing protocols. Even if authors have reduced the Rituximab doses after the first 7 cases, the overall septic complications and morality rates still remain very high (75% and 50% respectively), raising the issue of the desensitizing regimen’s adequacy.
Actually, different modalities of Rituximab free immunosuppressive regimens to prevent AMR have been successfully reported in literature, such as the use of high-dose polyclonal intravenous immunoglobulin associated with plasmapheresis without the use of steroid pulses or monoclonal antibodies, or even of everolimus-based immunosuppressive regimen under a strict monitoring of anti-A/B antibodies titres [6,7].
In conclusion, we strongly believe that more and more efforts should be make to minimize the desensitization regimen in ABO-I LDLT in order to reduce the rates of septic complications and improve patients’ and grafts’ survival.
Moreover, prospective studies with bigger sample sizes are required to validate the Indian ABO-I LDLT experience
Le lesioni del tenue e del mesentere nel trauma addominale chiuso. Esperienza monocentrica.
No full textle lesioni del tenue e del mesentere sono difficili da riconoscere precocemente se non associate ad emoperitoneo importante. Tuttavia un trattamento tardico non impatta negativamente sulla prognosi
- …
