Computer vision in surgery: from potential to clinical value

Hundreds of millions of operations are performed worldwide each year, and the rising uptake in minimally invasive surgery has enabled fiber optic cameras and robots to become both important tools to conduct surgery and sensors from which to capture information about surgery. Computer vision (CV), the application of algorithms to analyze and interpret visual data, has become a critical technology through which to study the intraoperative phase of care with the goals of augmenting surgeons' decision-making processes, supporting safer surgery, and expanding access to surgical care. While much work has been performed on potential use cases, there are currently no CV tools widely used for diagnostic or therapeutic applications in surgery. Using laparoscopic cholecystectomy as an example, we reviewed current CV techniques that have been applied to minimally invasive surgery and their clinical applications. Finally, we discuss the challenges and obstacles that remain to be overcome for broader implementation and adoption of CV in surgery.

Perceptions of the multidisciplinary operative team on intraoperative telecoaching among surgeons

Telecoaching, intraoperative coaching through videoconference, has been suggested as a tool to overcome logistical barriers with in-person coaching. However, little is known about the operative team's perception of telecoaching and its unique set of challenges. This qualitative study explores the perceptions of the multidisciplinary operative team on surgical telecoaching. A telecoaching program between peer surgeons was implemented using the Karl Storz Visitor1 remote presence system (Karl Storz, Germany). Semistructured interviews were conducted with the 12 operative team members present during 2 telecoaching sessions completed during the study period. Twelve participants were interviewed. The 4 central themes that emerged from the data were effective communication and collaboration, improving performance, operating room workflow, and culture and optics. Participating surgeon mentees reported that the session met expectations and learning goals and revealed concerns about negative perception of their autonomy and expertise by colleagues and patients. Conversely, team members unanimously reported a positive impression of surgeon mentees for taking additional measures to improve their performance and for patient outcomes. The operative team members reported that telecoaching was conducive to their own learning and relevant for complex cases. Considerations for future implementation of telecoaching include robust privacy standards for patients and staff, strong internet connectivity, coordinating with the operative team, and space constraints. Operative team participants viewed the intervention favorably and identified practical considerations for its continued use in an operating room environment. However, more work is needed on surgical culture as a contributor to low adoption and its impact on coaching programming activity.

Jejunal intussusception on jejunostomy tube: A rare cause of occlusion in adults

INTRODUCTION

Acute intestinal intussusception (AI) in adults secondary to jejunostomy is a rare complication and a surgical emergency requiring early diagnosis and treatment.

PRESENTATION OF CASE

We report the case of a 44-year-old patient, without medical history, who presented dysphagia after caustic ingestion. The patient underwent a Witzel feeding jejunostomy. The evolution was marked by the installation of abdominal distension with vomiting and alteration of the general state, the diagnosis of an intussusception in the jejunostomy tube was made in the abdominal CT scan, which required a surgical intervention, and reduction of intussusception, with simple after effects.

DISCUSSION

Acute intestinal intussusception (IIA) secondary to jejunostomy tube placement is a rare abdominal emergency. It manifests with signs of upper gastrointestinal obstruction. Diagnosis is based on abdominal imaging by ultrasound or CT scan. Treatment is most often surgical (Chavrier et al., 1992) [1].

CONCLUSION

We present a very rare example of acute intestinal intussusception in adults, complicating jejunostomy, with non-specific clinical signs, which needed an early radiological diagnosis for adequate management.

Development and evaluation of a virtual knowledge assessment tool for transanal total mesorectal excision

BACKGROUND

Transanal total mesorectal excision (TATME) is difficult to learn and can result in serious complications. Current paradigms for assessing performance and competency may be insufficient. This study aims to develop and provide preliminary validity evidence for a TATME virtual assessment tool (TATME-VAT) to assess the cognitive skills necessary to safely complete TATME dissection.

METHODS

Participants from North America, Europe, Japan and China completed the test via an interactive online platform between 11/2019 and 05/2020. They were grouped into expert, experienced and novice surgeons depending on the number of independently performed TATMEs. TATME-VAT is a 24-item web-based assessment evaluating advanced cognitive skills, designed according to a blueprint from consensus guidelines. Eight items were multiple choice questions. Sixteen items required making annotations on still frames of TATME videos (VCT) and were scored using a validated algorithm derived from experts' responses. Annotation (range 0-100), multiple choice (range 0-100), and overall scores (sum of annotation and multiple-choice scores, normalized to μ = 50 and σ = 10) were reported.

RESULTS

There were significant differences between the expert, experienced, and novice groups for the annotation (p < 0.001), multiple-choice (p < 0.001), and overall scores (p < 0.001). The annotation (p = 0.439) and overall (p = 0.152) scores were similar between the experienced and novice groups. Annotation scores were higher in participants with 51 or more vs. 30-50 vs. less than 30 cases. Scores were also lower in users with a self-reported recent complication vs. those without.

CONCLUSIONS

This study describes the development of an interactive video-based virtual assessment tool for TATME dissection and provides initial validity evidence for its use.

Surgical data science - from concepts toward clinical translation

Recent developments in data science in general and machine learning in particular have transformed the way experts envision the future of surgery. Surgical Data Science (SDS) is a new research field that aims to improve the quality of interventional healthcare through the capture, organization, analysis and modeling of data. While an increasing number of data-driven approaches and clinical applications have been studied in the fields of radiological and clinical data science, translational success stories are still lacking in surgery. In this publication, we shed light on the underlying reasons and provide a roadmap for future advances in the field. Based on an international workshop involving leading researchers in the field of SDS, we review current practice, key achievements and initiatives as well as available standards and tools for a number of topics relevant to the field, namely (1) infrastructure for data acquisition, storage and access in the presence of regulatory constraints, (2) data annotation and sharing and (3) data analytics. We further complement this technical perspective with (4) a review of currently available SDS products and the translational progress from academia and (5) a roadmap for faster clinical translation and exploitation of the full potential of SDS, based on an international multi-round Delphi process.

Quality Indicators for the Diagnosis and Management of Primary Hyperparathyroidism

Importance

Primary hyperparathyroidism (pHPT) is a common endocrine disorder with many diagnostic and treatment challenges. Despite high-quality guidelines, care is variable, and there is low adherence to evidence-based treatment pathways.

Objective

To develop quality indicators (QIs) to evaluate the diagnosis and treatment of pHPT that could measure, improve, and optimize quality of care and outcomes for patients with this disease.

Design, Setting, and Participants

This quality improvement study used a guideline-based approach to develop QIs that were ranked by a Canadian 9-member expert panel of 3 endocrinologists, 3 otolaryngologists, and 3 endocrine surgeons. Data were analyzed between September 2020 and May 2021.

Main Outcomes and Measures

Candidate indicators (CIs) were extracted from published primary hyperparathyroidism guidelines and summarized with supporting evidence. The 9-member expert panel rated each CI on the validity, reliability, and feasibility of measurement. Final QIs were selected from CIs using the modified RAND-University of California, Los Angeles appropriateness methodology. All panelists were then asked to rank the top 5 QIs for primary, endocrine, and surgical care.

Results

Forty QIs were identified and evaluated by the expert panel. After 2 rounds of evaluations and discussion, a total of 18 QIs were selected as appropriate measures of high-quality care. The top 5 QIs for primary, endocrine, and surgical care were selected following panelist rankings.

Conclusions and Relevance

This quality improvement study proposes 18 QIs for the diagnosis and management of pHPT. Furthermore, the top 5 QIs applicable to physicians commonly treating pHPT, including general physicians, internists, endocrinologists, otolaryngologists, and surgeons, are included. These QIs not only assess the quality of care to guide the process of improvement, but also can assess the implementation of evidence-based guideline recommendations. Using these indicators in clinical practice and health system registries can improve quality and cost-effectiveness of care for patients with pHPT.

Gender disparities among leadership in academic surgical publishing over the past decade

BACKGROUND

Women account for 19 % of practicing surgeons in the United States, with representation decreasing with higher academic rank. Less is known about the proportion of women in editorial leadership positions at surgical journals. The objective of this study was to examine gender representation among editorial leadership at high-impact surgical journals.

METHODS

The five journals with the highest impact factors in general, cardiothoracic, plastics, otolaryngology, orthopedics, urology, vascular, and neurosurgery were identified. Data were abstracted on the proportion of women editors-in-chief (EIC) and editorial board members between 2010 and 2020 to determine how these demographics changed over time.

RESULTS

Multiple fields had no women EIC over the past decade (orthopedics, urology, cardiothoracic, neurosurgery). In all other fields, women were a minority of EIC. In 2020, women made up 7.9 % of EIC and 11.1 % of editorial boards in surgical journals.

CONCLUSIONS

Women remain under-represented among leadership at high-impact surgical journals, with varying improvement over the past decade among different subspecialties.

Surgical data science and artificial intelligence for surgical education

Surgical data science (SDS) aims to improve the quality of interventional healthcare and its value through the capture, organization, analysis, and modeling of procedural data. As data capture has increased and artificial intelligence (AI) has advanced, SDS can help to unlock augmented and automated coaching, feedback, assessment, and decision support in surgery. We review major concepts in SDS and AI as applied to surgical education and surgical oncology.

SAGES consensus recommendations on an annotation framework for surgical video

BACKGROUND

The growing interest in analysis of surgical video through machine learning has led to increased research efforts; however, common methods of annotating video data are lacking. There is a need to establish recommendations on the annotation of surgical video data to enable assessment of algorithms and multi-institutional collaboration.

METHODS

Four working groups were formed from a pool of participants that included clinicians, engineers, and data scientists. The working groups were focused on four themes: (1) temporal models, (2) actions and tasks, (3) tissue characteristics and general anatomy, and (4) software and data structure. A modified Delphi process was utilized to create a consensus survey based on suggested recommendations from each of the working groups.

RESULTS

After three Delphi rounds, consensus was reached on recommendations for annotation within each of these domains. A hierarchy for annotation of temporal events in surgery was established.

CONCLUSIONS

While additional work remains to achieve accepted standards for video annotation in surgery, the consensus recommendations on a general framework for annotation presented here lay the foundation for standardization. This type of framework is critical to enabling diverse datasets, performance benchmarks, and collaboration.

Evaluating readmissions following laparoscopic cholecystectomy in the state of New York

INTRODUCTION

Hospital readmissions constitute an important component of associated costs of a disease and can contribute a significant burden to healthcare. The majority of studies evaluating readmissions following laparoscopic cholecystectomy (LC) comprise of single center studies and thus can underestimate the actual incidence of readmission. We sought to examine the rate and causes of readmissions following LC using a large longitudinal database.

METHODS

The New York SPARCS database was used to identify all adult patients undergoing laparoscopic cholecystectomy for benign biliary disease between 2000 and 2016. Due to the presence of a unique identifier, patients with readmission to any New York hospital were evaluated. Planned versus unplanned readmission rates were compared. Following univariate analysis, multivariable logistic regression model was used to identify risk factors for unplanned readmissions after accounting for baseline characteristics, comorbidities and complications.

RESULTS

There were 591,627 patients who underwent LC during the studied time period. Overall 30-day readmission rate was 4.94% (n = 29,245) and unplanned 30-days readmission rate was 4.58% (n = 27,084). Female patients were less likely to have 30-day unplanned readmissions. Patients with age older than 65 or younger than 29 were more likely to have 30-day unplanned readmissions compared to patients with age 30-44 or 45-64. Insurance status was also significant, as patients with Medicaid/Medicare were more likely to have unplanned readmissions compared to commercial insurance. In addition, variables such as Black race, presence of any comorbidity, postoperative complication, and prolonged initial hospital length of stay were associated with subsequent readmission.

CONCLUSION

This data show that readmissions rates following LC are relatively low; however, majority of readmissions are unplanned. Most common reason for unplanned readmissions was associated with complications of the procedure or medical care. By identifying certain risk groups, unplanned readmissions may be prevented.

International Nosocomial Infection Control Consortium (INICC) report, data summary of 45 countries for 2012-2017: Device-associated module

BACKGROUND

We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2012 to December 2017 in 523 intensive care units (ICUs) in 45 countries from Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific.

METHODS

During the 6-year study period, prospective data from 532,483 ICU patients hospitalized in 242 hospitals, for an aggregate of 2,197,304 patient days, were collected through the INICC Surveillance Online System (ISOS). The Centers for Disease Control and Prevention-National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI) were applied.

RESULTS

Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the medical-surgical ICUs, the pooled central line-associated bloodstream infection rate was higher (5.05 vs 0.8 per 1,000 central line-days); the ventilator-associated pneumonia rate was also higher (14.1 vs 0.9 per 1,000 ventilator-days,), as well as the rate of catheter-associated urinary tract infection (5.1 vs 1.7 per 1,000 catheter-days). From blood cultures samples, frequencies of resistance, such as of Pseudomonas aeruginosa to piperacillin-tazobactam (33.0% vs 18.3%), were also higher.

CONCLUSIONS

Despite a significant trend toward the reduction in INICC ICUs, DA-HAI rates are still much higher compared with CDC-NHSN's ICUs representing the developed world. It is INICC's main goal to provide basic and cost-effective resources, through the INICC Surveillance Online System to tackle the burden of DA-HAIs effectively.

An Unmodulated Very-Low-Voltage Electrosurgical Technology Creates Predictable and Ultimate Tissue Coagulation: From Experimental Data to Clinical Use

Objective. We analyzed the underlying principles of an unmodulated very-low-voltage (VLV) mode, designated as “soft coagulation” in hemostasis, and demonstrate its clinical applications. Summary Background Data. While the advantage of the VLV mode has been reported across surgical specialties, the basic principle has not been well described and remains ambiguous. Methods. Characteristics of major electrosurgical modes were measured in different settings. For the VLV mode, the tissue effect and electrical parameters were assessed in simulated environments. Results. The VLV mode achieved tissue coagulation with the lowest voltage compared with the other modes in any settings. With increasing impedance, the voltage of the VLV mode stayed very low at under 200 V compared with other modes. The VLV mode constantly produced effective tissue coagulation without carbonization. We have demonstrated the clinical applications of the method. Conclusions. The voltage of the VLV mode consistently stays under 200 V, resulting in tissue coagulation with minimal vaporization or carbonization. Therefore, the VLV mode produces more predictable tissue coagulation and minimizes undesirable collateral thermal tissue effects, enabling nerve- and function-preserving surgery. The use of VLV mode through better understanding of minimally invasive way of using electrosurgery may lead to better surgical outcomes.