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Kurauchi N, Mori Y, Nakamura Y, Tokumura H. Gallbladder and common bile duct. Asian J Endosc Surg 2024; 17:e13369. [PMID: 39278638 DOI: 10.1111/ases.13369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 07/20/2024] [Indexed: 09/18/2024]
Affiliation(s)
- Nobuaki Kurauchi
- Department of Surgery, Kutchan-Kosei General Hospital, Hokkaido, Japan
| | - Yasuhisa Mori
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyusyu, Japan
| | - Yoshiharu Nakamura
- Department of Surgery, Nippon Medical School, Chiba Hokusoh Hospital, Chiba, Japan
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Protserov S, Hunter J, Zhang H, Mashouri P, Masino C, Brudno M, Madani A. Development, deployment and scaling of operating room-ready artificial intelligence for real-time surgical decision support. NPJ Digit Med 2024; 7:231. [PMID: 39227660 PMCID: PMC11372100 DOI: 10.1038/s41746-024-01225-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 08/14/2024] [Indexed: 09/05/2024] Open
Abstract
Deep learning for computer vision can be leveraged for interpreting surgical scenes and providing surgeons with real-time guidance to avoid complications. However, neither generalizability nor scalability of computer-vision-based surgical guidance systems have been demonstrated, especially to geographic locations that lack hardware and infrastructure necessary for real-time inference. We propose a new equipment-agnostic framework for real-time use in operating suites. Using laparoscopic cholecystectomy and semantic segmentation models for predicting safe/dangerous ("Go"/"No-Go") zones of dissection as an example use case, this study aimed to develop and test the performance of a novel data pipeline linked to a web-platform that enables real-time deployment from any edge device. To test this infrastructure and demonstrate its scalability and generalizability, lightweight U-Net and SegFormer models were trained on annotated frames from a large and diverse multicenter dataset from 136 institutions, and then tested on a separate prospectively collected dataset. A web-platform was created to enable real-time inference on any surgical video stream, and performance was tested on and optimized for a range of network speeds. The U-Net and SegFormer models respectively achieved mean Dice scores of 57% and 60%, precision 45% and 53%, and recall 82% and 75% for predicting the Go zone, and mean Dice scores of 76% and 76%, precision 68% and 68%, and recall 92% and 92% for predicting the No-Go zone. After optimization of the client-server interaction over the network, we deliver a prediction stream of at least 60 fps and with a maximum round-trip delay of 70 ms for speeds above 8 Mbps. Clinical deployment of machine learning models for surgical guidance is feasible and cost-effective using a generalizable, scalable and equipment-agnostic framework that lacks dependency on hardware with high computing performance or ultra-fast internet connection speed.
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Affiliation(s)
- Sergey Protserov
- DATA Team, University Health Network, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada
| | - Jaryd Hunter
- DATA Team, University Health Network, Toronto, ON, Canada
| | - Haochi Zhang
- DATA Team, University Health Network, Toronto, ON, Canada
| | | | - Caterina Masino
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
| | - Michael Brudno
- DATA Team, University Health Network, Toronto, ON, Canada.
- Department of Computer Science, University of Toronto, Toronto, ON, Canada.
- Vector Institute for Artificial Intelligence, Toronto, ON, Canada.
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
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3
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Wightkin SP, Velasco J, Schimpke S, Kremer MJ. Enhancing Intraoperative Cholangiography Interpretation Skills: A Perceptual Learning Approach for Surgical Residents. JOURNAL OF SURGICAL EDUCATION 2024; 81:1267-1275. [PMID: 38960773 DOI: 10.1016/j.jsurg.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 05/27/2024] [Accepted: 06/01/2024] [Indexed: 07/05/2024]
Abstract
OBJECTIVE Laparoscopic cholecystectomy is a commonly performed surgery with risk of serious complications. Intraoperative cholangiography (IOC) can mitigate these risks by clarifying the anatomy of the biliary tree and detecting common bile duct injuries. However, mastering IOC interpretation is largely through experience, and studies have shown that even expert surgeons often struggle with this skill. Since no formal curriculum exists for surgical residents to learn IOC interpretation, we developed a perceptual learning (PL)-based training module aimed at improving surgical residents' IOC interpretation skills. DESIGN Surgical residents were assessed on their ability to identify IOC characteristics and provide clinical recommendations using an online training module based on PL principles. This research had 2 phases. The first phase involved pre/post assessments of residents trained via the online IOC interpretation module, measuring their IOC image recognition and clinical management accuracy (percentage of correct responses), response time and confidence. During the second phase, we explored the impact of combining simulator-based IOC training with the online interpretation module on same measures as used in the first phase (accuracy, response time, and confidence). SETTING The study was conducted at Rush University Medical College in Chicago. The participants consisted of surgical residents from each postgraduate year (PGY). Residents participated in this study during their scheduled monthly rotation through Rush's surgical simulation center. RESULTS Total 23 surgical residents participated in the first phase. A majority (95.7%) found the module helpful. Residents significantly increased confidence levels in various aspects of IOC interpretation, such as identifying complete IOCs and detecting abnormal findings. Their accuracy in making clinical management decisions significantly improved from pretraining (mean accuracy 68.1 +/- 17.3%) to post-training (mean accuracy 82.3 +/- 10.4%, p < 0.001). Furthermore, their response time per question decreased significantly from 25 +/- 12 seconds to 17 +/- 12 seconds (p < 0.001). In the second phase, we combined procedural simulator training with the online interpretation module. The 20, first year residents participated and 88% found the training helpful. The training group exhibited significant confidence improvements compared to the control group in various aspects of IOC interpretation with observed nonsignificant accuracy improvements related to clinical management questions. Both groups demonstrated reduced response times, with the training group showing a more substantial, though nonsignificant, reduction. CONCLUSION This study demonstrated the effectiveness of a PL-based training module for improving aspects of surgical residents' IOC interpretation skills. The module, found helpful by a majority of participants, led to significant enhancements in clinical management accuracy, confidence levels, and decreased response time. Incorporating simulator-based training further reinforced these improvements, highlighting the potential of our approach to address the lack of formal curriculum for IOC interpretation in surgical education.
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Affiliation(s)
| | - Jose Velasco
- Department of Surgery, Rush University Medical Center, Chicago, Illinois
| | - Scott Schimpke
- Department of Surgery, Rush University Medical Center, Chicago, Illinois; Rush Center for Clinical Skills and Simulation, Rush University Medical Center, Chicago, Illinois
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St John A, Khalid MU, Masino C, Noroozi M, Alseidi A, Hashimoto DA, Altieri M, Serrot F, Kersten-Oertel M, Madani A. LapBot-Safe Chole: validation of an artificial intelligence-powered mobile game app to teach safe cholecystectomy. Surg Endosc 2024; 38:5274-5284. [PMID: 39009730 DOI: 10.1007/s00464-024-11068-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 07/06/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND Gaming can serve as an educational tool to allow trainees to practice surgical decision-making in a low-stakes environment. LapBot is a novel free interactive mobile game application that uses artificial intelligence (AI) to provide players with feedback on safe dissection during laparoscopic cholecystectomy (LC). This study aims to provide validity evidence for this mobile game. METHODS Trainees and surgeons participated by downloading and playing LapBot on their smartphone. Players were presented with intraoperative LC scenes and required to locate their preferred location of dissection of the hepatocystic triangle. They received immediate accuracy scores and personalized feedback using an AI algorithm ("GoNoGoNet") that identifies safe/dangerous zones of dissection. Player scores were assessed globally and across training experience using non-parametric ANOVA. Three-month questionnaires were administered to assess the educational value of LapBot. RESULTS A total of 903 participants from 64 countries played LapBot. As game difficulty increased, average scores (p < 0.0001) and confidence levels (p < 0.0001) decreased significantly. Scores were significantly positively correlated with players' case volume (p = 0.0002) and training level (p = 0.0003). Most agreed that LapBot should be incorporated as an adjunct into training programs (64.1%), as it improved their ability to reflect critically on feedback they receive during LC (47.5%) or while watching others perform LC (57.5%). CONCLUSIONS Serious games, such as LapBot, can be effective educational tools for deliberate practice and surgical coaching by promoting learner engagement and experiential learning. Our study demonstrates that players' scores were correlated to their level of expertise, and that after playing the game, most players perceived a significant educational value.
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Affiliation(s)
- Ace St John
- Department of Surgery, University of Maryland Medical Center, Baltimore, MD, USA
- Surgical Artificial Intelligence Research Academy, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Muhammad Uzair Khalid
- Surgical Artificial Intelligence Research Academy, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Caterina Masino
- Surgical Artificial Intelligence Research Academy, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Mohammad Noroozi
- Gina Cody School of Engineering and Computer Science, Concordia University, Montreal, QC, Canada
| | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Daniel A Hashimoto
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maria Altieri
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | | | - Marta Kersten-Oertel
- Gina Cody School of Engineering and Computer Science, Concordia University, Montreal, QC, Canada
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy, University Health Network, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
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Nardone V, Marmorino F, Germani MM, Cichowska-Cwalińska N, Menditti VS, Gallo P, Studiale V, Taravella A, Landi M, Reginelli A, Cappabianca S, Girnyi S, Cwalinski T, Boccardi V, Goyal A, Skokowski J, Oviedo RJ, Abou-Mrad A, Marano L. The Role of Artificial Intelligence on Tumor Boards: Perspectives from Surgeons, Medical Oncologists and Radiation Oncologists. Curr Oncol 2024; 31:4984-5007. [PMID: 39329997 PMCID: PMC11431448 DOI: 10.3390/curroncol31090369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2024] [Revised: 08/24/2024] [Accepted: 08/26/2024] [Indexed: 09/28/2024] Open
Abstract
The integration of multidisciplinary tumor boards (MTBs) is fundamental in delivering state-of-the-art cancer treatment, facilitating collaborative diagnosis and management by a diverse team of specialists. Despite the clear benefits in personalized patient care and improved outcomes, the increasing burden on MTBs due to rising cancer incidence and financial constraints necessitates innovative solutions. The advent of artificial intelligence (AI) in the medical field offers a promising avenue to support clinical decision-making. This review explores the perspectives of clinicians dedicated to the care of cancer patients-surgeons, medical oncologists, and radiation oncologists-on the application of AI within MTBs. Additionally, it examines the role of AI across various clinical specialties involved in cancer diagnosis and treatment. By analyzing both the potential and the challenges, this study underscores how AI can enhance multidisciplinary discussions and optimize treatment plans. The findings highlight the transformative role that AI may play in refining oncology care and sustaining the efficacy of MTBs amidst growing clinical demands.
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Affiliation(s)
- Valerio Nardone
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80131 Naples, Italy
| | - Federica Marmorino
- Unit of Medical Oncology 2, Azienda Ospedaliera Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Marco Maria Germani
- Unit of Medical Oncology 2, Azienda Ospedaliera Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | | | | | - Paolo Gallo
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80131 Naples, Italy
| | - Vittorio Studiale
- Unit of Medical Oncology 2, Azienda Ospedaliera Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Ada Taravella
- Unit of Medical Oncology 2, Azienda Ospedaliera Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Matteo Landi
- Unit of Medical Oncology 2, Azienda Ospedaliera Universitaria Pisana, 56126 Pisa, Italy
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56126 Pisa, Italy
| | - Alfonso Reginelli
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80131 Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "L. Vanvitelli", 80131 Naples, Italy
| | - Sergii Girnyi
- Department of General Surgery and Surgical Oncology, "Saint Wojciech" Hospital, "Nicolaus Copernicus" Health Center, 80-462 Gdańsk, Poland
| | - Tomasz Cwalinski
- Department of General Surgery and Surgical Oncology, "Saint Wojciech" Hospital, "Nicolaus Copernicus" Health Center, 80-462 Gdańsk, Poland
| | - Virginia Boccardi
- Division of Gerontology and Geriatrics, Department of Medicine and Surgery, University of Perugia, 06123 Perugia, Italy
| | - Aman Goyal
- Adesh Institute of Medical Sciences and Research, Bathinda 151109, Punjab, India
| | - Jaroslaw Skokowski
- Department of General Surgery and Surgical Oncology, "Saint Wojciech" Hospital, "Nicolaus Copernicus" Health Center, 80-462 Gdańsk, Poland
- Department of Medicine, Academy of Applied Medical and Social Sciences-AMiSNS: Akademia Medycznych I Spolecznych Nauk Stosowanych, 82-300 Elbląg, Poland
| | - Rodolfo J Oviedo
- Nacogdoches Medical Center, Nacogdoches, TX 75965, USA
- Tilman J. Fertitta Family College of Medicine, University of Houston, Houston, TX 77021, USA
- College of Osteopathic Medicine, Sam Houston State University, Conroe, TX 77304, USA
| | - Adel Abou-Mrad
- Centre Hospitalier Universitaire d'Orléans, 45100 Orléans, France
| | - Luigi Marano
- Department of General Surgery and Surgical Oncology, "Saint Wojciech" Hospital, "Nicolaus Copernicus" Health Center, 80-462 Gdańsk, Poland
- Department of Medicine, Academy of Applied Medical and Social Sciences-AMiSNS: Akademia Medycznych I Spolecznych Nauk Stosowanych, 82-300 Elbląg, Poland
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Aoyama Y, Matsunobu Y, Etoh T, Suzuki K, Fujita S, Aiba T, Fujishima H, Empuku S, Kono Y, Endo Y, Ueda Y, Shiroshita H, Kamiyama T, Sugita T, Morishima K, Ebe K, Tokuyasu T, Inomata M. Artificial intelligence for surgical safety during laparoscopic gastrectomy for gastric cancer: Indication of anatomical landmarks related to postoperative pancreatic fistula using deep learning. Surg Endosc 2024:10.1007/s00464-024-11117-x. [PMID: 39093411 DOI: 10.1007/s00464-024-11117-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 07/23/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Postoperative pancreatic fistula (POPF) is a critical complication of laparoscopic gastrectomy (LG). However, there are no widely recognized anatomical landmarks to prevent POPF during LG. This study aimed to identify anatomical landmarks related to POPF occurrence during LG for gastric cancer and to develop an artificial intelligence (AI) navigation system for indicating these landmarks. METHODS Dimpling lines (DLs)-depressions formed between the pancreas and surrounding organs-were defined as anatomical landmarks related to POPF. The DLs for the mesogastrium, intestine, and transverse mesocolon were named DMP, DIP, and DTP, respectively. We included 50 LG cases to develop the AI system (45/50 were used for training and 5/50 for adjusting the hyperparameters of the employed system). Regarding the validation of the AI system, DLs were assessed by an external evaluation committee using a Likert scale, and the pancreas was assessed using the Dice coefficient, with 10 prospectively registered cases. RESULTS Six expert surgeons confirmed the efficacy of DLs as anatomical landmarks related to POPF in LG. An AI system was developed using a semantic segmentation model that indicated DLs in real-time when this system was synchronized during surgery. Additionally, the distribution of scores for DMP was significantly higher than that of the other DLs (p < 0.001), indicating the relatively high accuracy of this landmark. In addition, the Dice coefficient of the pancreas was 0.70. CONCLUSIONS The DLs may be used as anatomical landmarks related to POPF occurrence. The developed AI navigation system can help visualize the DLs in real-time during LG.
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Affiliation(s)
- Yoshimasa Aoyama
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Yusuke Matsunobu
- Department of Information Systems and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
- Department of Healthcare AI Data Science, Faculty of Medicine, Oita University, Oita, Japan
| | - Tsuyoshi Etoh
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan.
- Research Center for GLOBAL and LOCAL Infectious Diseases, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, Oita, 879-5593, Japan.
| | - Kosuke Suzuki
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Shunsuke Fujita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Takayuki Aiba
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Hajime Fujishima
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Shinichiro Empuku
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Yohei Kono
- Department of Advanced Medical Research and Development for Cancer and Hair [Aderans], Faculty of Medicine, Oita University, Oita, Japan
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Yoshitake Ueda
- Department of Comprehensive Surgery for Community Medicine, Faculty of Medicine, Oita University, Oita, Japan
| | - Hidefumi Shiroshita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Toshiya Kamiyama
- Advanced AI Technology Research, Advanced Software Technology Research, Olympus Corporation, Tokyo, Japan
| | - Takemasa Sugita
- Advanced AI Technology Research, Advanced Software Technology Research, Olympus Corporation, Tokyo, Japan
| | - Kenichi Morishima
- Advanced AI Technology Research, Advanced Software Technology Research, Olympus Corporation, Tokyo, Japan
| | - Kohei Ebe
- Information Aided Medical Solutions Development, Application Software Engineering, Olympus Medical Systems Corporation, Tokyo, Japan
| | - Tatsushi Tokuyasu
- Department of Information Systems and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
- Clinical Engineering Research Center, Faculty of Medicine, Oita University, Oita, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
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7
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Noroozi M, St John A, Masino C, Laplante S, Hunter J, Brudno M, Madani A, Kersten-Oertel M. Education in Laparoscopic Cholecystectomy: Design and Feasibility Study of the LapBot Safe Chole Mobile Game. JMIR Form Res 2024; 8:e52878. [PMID: 39052314 PMCID: PMC11310638 DOI: 10.2196/52878] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/04/2023] [Accepted: 05/14/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Major bile duct injuries during laparoscopic cholecystectomy (LC), often stemming from errors in surgical judgment and visual misperception of critical anatomy, significantly impact morbidity, mortality, disability, and health care costs. OBJECTIVE To enhance safe LC learning, we developed an educational mobile game, LapBot Safe Chole, which uses an artificial intelligence (AI) model to provide real-time coaching and feedback, improving intraoperative decision-making. METHODS LapBot Safe Chole offers a free, accessible simulated learning experience with real-time AI feedback. Players engage with intraoperative LC scenarios (short video clips) and identify ideal dissection zones. After the response, users receive an accuracy score from a validated AI algorithm. The game consists of 5 levels of increasing difficulty based on the Parkland grading scale for cholecystitis. RESULTS Beta testing (n=29) showed score improvements with each round, with attendings and senior trainees achieving top scores faster than junior residents. Learning curves and progression distinguished candidates, with a significant association between user level and scores (P=.003). Players found LapBot enjoyable and educational. CONCLUSIONS LapBot Safe Chole effectively integrates safe LC principles into a fun, accessible, and educational game using AI-generated feedback. Initial beta testing supports the validity of the assessment scores and suggests high adoption and engagement potential among surgical trainees.
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Affiliation(s)
- Mohammad Noroozi
- Applied Perception Lab, Department of Computer Science and Software Engineering, Concordia University, Montreal, QC, Canada
| | - Ace St John
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Caterina Masino
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
| | - Simon Laplante
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jaryd Hunter
- DATA Team, University Health Network, Toronto, ON, Canada
| | - Michael Brudno
- DATA Team, University Health Network, Toronto, ON, Canada
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Marta Kersten-Oertel
- Applied Perception Lab, Department of Computer Science and Software Engineering, Concordia University, Montreal, QC, Canada
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Fernicola A, Palomba G, Capuano M, De Palma GD, Aprea G. Artificial intelligence applied to laparoscopic cholecystectomy: what is the next step? A narrative review. Updates Surg 2024:10.1007/s13304-024-01892-6. [PMID: 38839723 DOI: 10.1007/s13304-024-01892-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/18/2024] [Indexed: 06/07/2024]
Abstract
Artificial Intelligence (AI) is playing an increasing role in several fields of medicine. AI is also used during laparoscopic cholecystectomy (LC) surgeries. In the literature, there is no review that groups together the various fields of application of AI applied to LC. The aim of this review is to describe the use of AI in these contexts. We performed a narrative literature review by searching PubMed, Web of Science, Scopus and Embase for all studies on AI applied to LC, published from January 01, 2010, to December 30, 2023. Our focus was on randomized controlled trials (RCTs), meta-analysis, systematic reviews, and observational studies, dealing with large cohorts of patients. We then gathered further relevant studies from the reference list of the selected publications. Based on the studies reviewed, it emerges that AI could strongly improve surgical efficiency and accuracy during LC. Future prospects include speeding up, implementing, and improving the automaticity with which AI recognizes, differentiates and classifies the phases of the surgical intervention and the anatomic structures that are safe and those at risk.
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Affiliation(s)
- Agostino Fernicola
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Pansini 5, 80131, Naples, Italy.
| | - Giuseppe Palomba
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Marianna Capuano
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Giovanni Domenico De Palma
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Pansini 5, 80131, Naples, Italy
| | - Giovanni Aprea
- Division of Endoscopic Surgery, Department of Clinical Medicine and Surgery, "Federico II" University of Naples, Via Pansini 5, 80131, Naples, Italy
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9
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Cizmic A, Häberle F, Wise PA, Müller F, Gabel F, Mascagni P, Namazi B, Wagner M, Hashimoto DA, Madani A, Alseidi A, Hackert T, Müller-Stich BP, Nickel F. Structured feedback and operative video debriefing with critical view of safety annotation in training of laparoscopic cholecystectomy: a randomized controlled study. Surg Endosc 2024; 38:3241-3252. [PMID: 38653899 PMCID: PMC11133174 DOI: 10.1007/s00464-024-10843-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 04/02/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND The learning curve in minimally invasive surgery (MIS) is lengthened compared to open surgery. It has been reported that structured feedback and training in teams of two trainees improves MIS training and MIS performance. Annotation of surgical images and videos may prove beneficial for surgical training. This study investigated whether structured feedback and video debriefing, including annotation of critical view of safety (CVS), have beneficial learning effects in a predefined, multi-modal MIS training curriculum in teams of two trainees. METHODS This randomized-controlled single-center study included medical students without MIS experience (n = 80). The participants first completed a standardized and structured multi-modal MIS training curriculum. They were then randomly divided into two groups (n = 40 each), and four laparoscopic cholecystectomies (LCs) were performed on ex-vivo porcine livers each. Students in the intervention group received structured feedback after each LC, consisting of LC performance evaluations through tutor-trainee joint video debriefing and CVS video annotation. Performance was evaluated using global and LC-specific Objective Structured Assessments of Technical Skills (OSATS) and Global Operative Assessment of Laparoscopic Skills (GOALS) scores. RESULTS The participants in the intervention group had higher global and LC-specific OSATS as well as global and LC-specific GOALS scores than the participants in the control group (25.5 ± 7.3 vs. 23.4 ± 5.1, p = 0.003; 47.6 ± 12.9 vs. 36 ± 12.8, p < 0.001; 17.5 ± 4.4 vs. 16 ± 3.8, p < 0.001; 6.6 ± 2.3 vs. 5.9 ± 2.1, p = 0.005). The intervention group achieved CVS more often than the control group (1. LC: 20 vs. 10 participants, p = 0.037, 2. LC: 24 vs. 8, p = 0.001, 3. LC: 31 vs. 8, p < 0.001, 4. LC: 31 vs. 10, p < 0.001). CONCLUSIONS Structured feedback and video debriefing with CVS annotation improves CVS achievement and ex-vivo porcine LC training performance based on OSATS and GOALS scores.
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Affiliation(s)
- Amila Cizmic
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Frida Häberle
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Philipp A Wise
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Müller
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Felix Gabel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Pietro Mascagni
- Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Institute of Image-Guided Surgery, IHU-Strasbourg, Strasbourg, France
| | - Babak Namazi
- Center for Evidence-Based Simulation, Baylor University Medical Center, Dallas, USA
| | - Martin Wagner
- Department of Visceral, Thoracic and Vascular Surgery, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniel A Hashimoto
- Penn Computer Assisted Surgery and Outcomes (PCASO) Laboratory, Department of Surgery, Department of Computer and Information Science, University of Pennsylvania, Philadelphia, USA
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy (SARA), Department of Surgery, University Health Network, Toronto, Canada
| | - Adnan Alseidi
- Department of Surgery, University of California - San Francisco, San Francisco, USA
| | - Thilo Hackert
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Beat P Müller-Stich
- Department of Surgery, Clarunis - University Centre for Gastrointestinal and Liver Diseases, Basel, Switzerland
| | - Felix Nickel
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
- Department of General, Visceral and Transplantation Surgery, Heidelberg University Hospital, Heidelberg, Germany.
- HIDSS4Health - Helmholtz Information and Data Science School for Health, Karlsruhe, Heidelberg, Germany.
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10
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Amiri R, Zwart MJW, Jones LR, Abu Hilal M, Beerlage HP, van Berge Henegouwen MI, Lameris WW, Bemelman WA, Besselink MG. Surgeon Preference and Clinical Outcome of 3D Vision Compared to 2D Vision in Laparoscopic Surgery: Systematic Review and Meta-Analysis of Randomized Trials. ANNALS OF SURGERY OPEN 2024; 5:e415. [PMID: 38911624 PMCID: PMC11191999 DOI: 10.1097/as9.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 03/11/2024] [Indexed: 06/25/2024] Open
Abstract
Objective To assess the added value of 3-dimensional (3D) vision, including high definition (HD) technology, in laparoscopic surgery in terms of surgeon preference and clinical outcome. Background The use of 3D vision in laparoscopic surgery has been suggested to improve surgical performance. However, the added value of 3D vision remains unclear as a systematic review of randomized controlled trials (RCTs) comparing 3D vision including HD technology in laparoscopic surgery is currently lacking. Methods A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines with a literature search up to May 2023 using PubMed and Embase (PROSPERO, CRD42021290426). We included RCTs comparing 3D versus 2-dimensional (2D) vision in laparoscopic surgery. The primary outcome was operative time. Meta-analyses were performed using the random effects model to estimate the pooled effect size expressed in standard mean difference (SMD) with corresponding 95% confidence intervals (CIs). The level of evidence and quality was assessed according to the Cochrane risk of bias tool. Results Overall, 25 RCTs with 3003 patients were included. Operative time was reduced by 3D vision (-8.0%; SMD, -0.22; 95% CI, -0.37 to -0.06; P = 0.007; n = 3003; 24 studies; I 2 = 75%) compared to 2D vision. This benefit was mostly seen in bariatric surgery (-16.3%; 95% CI, -1.28 to -0.21; P = 0.006; 2 studies; n = 58; I 2 = 0%) and general surgery (-6.7%; 95% CI, -0.34 to -0.01; P = 0.036; 9 studies; n = 1056; I 2 = 41%). Blood loss was nonsignificantly reduced by 3D vision (SMD, -0.33; 95% CI, -0.68 to 0.017; P = 0.060; n = 1830; I 2 = 92%). No differences in the rates of morbidity (14.9% vs 13.5%, P = 0.644), mortality (0% vs 0%), conversion (0.8% vs 0.9%, P = 0.898), and hospital stay (9.6 vs 10.5 days, P = 0.078) were found between 3D and 2D vision. In 15 RCTs that reported on surgeon preference, 13 (87%) reported that the majority of surgeons favored 3D vision. Conclusions Across 25 RCTs, this systematic review and meta-analysis demonstrated shorter operative time with 3D vision in laparoscopic surgery, without differences in other outcomes. The majority of surgeons participating in the RCTs reported in favor of 3D vision.
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Affiliation(s)
- Rawin Amiri
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
| | - Maurice J. W. Zwart
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
| | - Leia R. Jones
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Mohammad Abu Hilal
- Department of Surgery, Istituto Fondazione Poliambulanza, Brescia, Italy
| | - Harrie P. Beerlage
- Cancer Center Amsterdam, Netherlands
- Department of Urology, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
| | - Mark I. van Berge Henegouwen
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
| | - Wytze W. Lameris
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
| | - Willem A. Bemelman
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
| | - Marc G. Besselink
- From the Department of Surgery, Amsterdam UMC, Location University of Amsterdam, Amsterdam, Netherlands
- Cancer Center Amsterdam, Netherlands
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11
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Wang S, Yuan W, Yu A, Gu W, Wang T, Zhang C, Zhang C. Efficacy of different indocyanine green doses in fluorescent laparoscopic cholecystectomy: A prospective, randomized, double-blind trial. J Surg Oncol 2024; 129:1534-1541. [PMID: 38736301 DOI: 10.1002/jso.27684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND AND OBJECTIVES Intraoperative bile duct injury is a significant complication in laparoscopic cholecystectomy (LC). Near-infrared fluorescence cholangiography (NIFC) can reduce this complication. Therefore, determining the optimal indocyanine green (ICG) dosage for effective NIFC is crucial. This study aimed to determine the optimal ICG dosage for NIFC. METHODS This was a prospective, randomized, double-blind clinical trial at a single tertiary referral center, including 195 patients randomly assigned to three groups: lower dose (0.01 mg/BMI) ICG (n = 63), medium dose (0.02 mg/BMI) ICG (n = 68), and higher dose (0.04 mg/BMI) ICG (n = 64). Surgeon satisfaction and detection rates for seven biliary structures were compared among the three dose groups. RESULTS Demographic parameters did not significantly differ among the groups. The medium dose (72.1%) and higher dose ICG groups (70.3%) exhibited superior visualization of the common hepatic duct compared to the lower dose group (41.3%) (p < 0.001). No differences existed between the medium and higher dose groups. Similar trends were observed for the common bile duct and cystic common bile duct junction. CONCLUSIONS In patients undergoing fluorescent laparoscopic cholecystectomy, the 0.02 mg/BMI dose of indocyanine green demonstrated better biliary structure detection rates than the 0.01 mg/BMI dose and was non-inferior to the 0.04 mg/BMI dose.
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Affiliation(s)
- Siyu Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wenkang Yuan
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Anhai Yu
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wang Gu
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Tianqi Wang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chong Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Chao Zhang
- Department of General Surgery, the First Affiliated Hospital of Anhui Medical University, Hefei, China
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12
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Jang SI, Do MY, Lee SY, Cho JH, Joo SM, Lee KH, Chung MJ, Lee DK. Magnetic compression anastomosis for the treatment of complete biliary obstruction after cholecystectomy. Gastrointest Endosc 2024:S0016-5107(24)03206-1. [PMID: 38762041 DOI: 10.1016/j.gie.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 04/02/2024] [Accepted: 05/13/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND AND AIMS Post-cholecystectomy biliary strictures can be treated surgically or nonsurgically. Although endoscopic or percutaneous treatments are the preferred approaches, these methods are not feasible in cases in which complete stricture occlusion prevents the successful passage of a guidewire. The utility of magnetic compression anastomosis (MCA) in patients with post-cholecystectomy complete biliary obstruction that cannot be treated conventionally was evaluated. METHODS MCA was performed in 10 patients with post-cholecystectomy biliary strictures that did not resolve with conventional endoscopic or percutaneous treatment. One magnet was delivered through the percutaneous transhepatic biliary drainage tract, and another was advanced via ERCP of the common bile duct. After magnet approximation and recanalization, a fully covered self-expandable metal stent (FCSEMS) was placed for 3 months and then replaced for an additional 3 months. Stricture resolution was evaluated after FCSEMS removal. RESULTS Among the 10 patients who underwent MCA for post-cholecystectomy biliary stricture, the biliary injury was Strasberg type B in 2, type C in 3, and type E in 5. Recanalization was successful in all patients (technical success rate, 100%). The mean follow-up period after recanalization was 50.2 months (range, 13.2-116.8 months). Partial restenosis after MCA occurred in 2 patients at 24.1 and 1.6 months after stent removal. ERCP with FCSEMS placement resolved the recurrent stenosis in both patients. CONCLUSIONS MCA is a useful nonsurgical alternative treatment for complete biliary obstruction after cholecystectomy that cannot be resolved by use of conventional methods.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Young Do
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea; Department of Medicine, Graduate School of Yonsei University College of Medicine, Seoul, Republic of Korea
| | - See Young Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jae Hee Cho
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung-Moon Joo
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kwang-Hun Lee
- Department of Radiology, Ewha Womans University Medical Center, Ewha Womans University College of Medicine, Seoul, Republic of Korea
| | - Moon Jae Chung
- Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Dong Ki Lee
- Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
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13
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Richter A, Steinmann T, Rosenthal JC, Rupitsch SJ. Advances in Real-Time 3D Reconstruction for Medical Endoscopy. J Imaging 2024; 10:120. [PMID: 38786574 PMCID: PMC11122342 DOI: 10.3390/jimaging10050120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 04/23/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
This contribution is intended to provide researchers with a comprehensive overview of the current state-of-the-art concerning real-time 3D reconstruction methods suitable for medical endoscopy. Over the past decade, there have been various technological advancements in computational power and an increased research effort in many computer vision fields such as autonomous driving, robotics, and unmanned aerial vehicles. Some of these advancements can also be adapted to the field of medical endoscopy while coping with challenges such as featureless surfaces, varying lighting conditions, and deformable structures. To provide a comprehensive overview, a logical division of monocular, binocular, trinocular, and multiocular methods is performed and also active and passive methods are distinguished. Within these categories, we consider both flexible and non-flexible endoscopes to cover the state-of-the-art as fully as possible. The relevant error metrics to compare the publications presented here are discussed, and the choice of when to choose a GPU rather than an FPGA for camera-based 3D reconstruction is debated. We elaborate on the good practice of using datasets and provide a direct comparison of the presented work. It is important to note that in addition to medical publications, publications evaluated on the KITTI and Middlebury datasets are also considered to include related methods that may be suited for medical 3D reconstruction.
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Affiliation(s)
- Alexander Richter
- Fraunhofer Institute for High-Speed Dynamics, Ernst–Mach–Institut (EMI), Ernst-Zermelo-Straße 4, 79104 Freiburg, Germany
- Electrical Instrumentation and Embedded Systems, Albert–Ludwigs–Universität Freiburg, Goerges-Köhler-Allee 106, 79110 Freiburg, Germany; (T.S.); (S.J.R.)
| | - Till Steinmann
- Electrical Instrumentation and Embedded Systems, Albert–Ludwigs–Universität Freiburg, Goerges-Köhler-Allee 106, 79110 Freiburg, Germany; (T.S.); (S.J.R.)
| | - Jean-Claude Rosenthal
- Fraunhofer Institute for Telecommunications, Heinrich–Hertz–Institut (HHI), Einsteinufer 37, 10587 Berlin, Germany
| | - Stefan J. Rupitsch
- Electrical Instrumentation and Embedded Systems, Albert–Ludwigs–Universität Freiburg, Goerges-Köhler-Allee 106, 79110 Freiburg, Germany; (T.S.); (S.J.R.)
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14
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Alexander P, Marcucci V, Torres P, Cassidy J, Kipnis S, Arumugam D. Enhancing biliary structure identification using percutaneous cholecystostomy drain delivery of indocyanine green: a glowing two case review. J Surg Case Rep 2024; 2024:rjae275. [PMID: 38706473 PMCID: PMC11066793 DOI: 10.1093/jscr/rjae275] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/10/2024] [Indexed: 05/07/2024] Open
Abstract
The use of indocyanine green for fluorescent cholangiography in patients with cholecystitis initially treated with percutaneous cholecystostomy drainage catheters was described in this two case series. Two patients underwent robotic assisted cholecystectomy with fluorescent cholangiography and indocyanine green through percutaneous cholecystostomy drainage catheters. The patients were diagnosed with acute cholecystitis. Directed injection of indocyanine green allowed for direct visualization of the biliary system allowing for a safe identification of the critical view of safety. Injection of indocyanine green for fluorescent cholangiography through percutaneous cholecystostomy drainage catheters is reliable to assess the critical view of safety and allows for improved identification of the biliary tree anatomy. Administration of indocyanine green through the percutaneous cholecystostomy drainage catheters avoided background hepatic fluorescence and increased contrast between biliary structures.
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Affiliation(s)
- Peter Alexander
- Department of Surgery, St. George’s University, School of Medicine, St. George’sGrenada
| | - Vincent Marcucci
- Department of Surgery, Jersey Shore University Medical Center, 1945 New Jersey 33, Neptune, NJ, United States
| | - Patricia Torres
- Department of Surgery, Jersey Shore University Medical Center, 1945 New Jersey 33, Neptune, NJ, United States
| | - Jillian Cassidy
- Department of Surgery, Jersey Shore University Medical Center, 1945 New Jersey 33, Neptune, NJ, United States
| | - Seth Kipnis
- Department of Surgery, St. George’s University, School of Medicine, St. George’sGrenada
- Department of Surgery, Jersey Shore University Medical Center, 1945 New Jersey 33, Neptune, NJ, United States
| | - Dena Arumugam
- Department of Surgery, St. George’s University, School of Medicine, St. George’sGrenada
- Department of Surgery, Jersey Shore University Medical Center, 1945 New Jersey 33, Neptune, NJ, United States
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15
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Mann DR, Thomas CS, Parrado RH, Rives GT, Talley CL. Future Surgical Leaders: Resident Perception Of Longitudinal Leadership And Non-Technical Skills Curriculum. JOURNAL OF SURGICAL EDUCATION 2024; 81:696-701. [PMID: 38402094 DOI: 10.1016/j.jsurg.2024.01.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 01/15/2024] [Accepted: 01/15/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVE A paucity of formal leadership training programs exists for residents, and outcomes of those are limited in reporting. Based on a robust needs assessment, our program created a longitudinal cohort curriculum, Future Surgical Leaders, for residents and fellows of all levels to provide training in nontechnical skills. Our objective was to evaluate surgical resident short-term outcomes and satisfaction with the Future Surgical Leaders (FSL) curriculum. DESIGN Participants were sent a brief survey after each session of the curriculum from October 2020 to February 2022. The data was compiled after seventeen months of delivery. Likert Scale responses and text comments were analyzed with a 2-sample t-test and 2-way analysis of variance. SETTING Academic tertiary institution. PARTICIPANTS General surgery residents. RESULTS Survey response rate from 54 sessions among all postgraduate year levels was 73%. Overall, 96% of residents/fellows either "agreed" or "strongly agreed" that the topics of the FSL curriculum were important to learn during surgical training. Only 24% of learners knew "a lot" or "a great deal" about the topics prior to the session which rose to 73% afterwards (p < 0.01). Each postgraduate year class showed statistically significant increase in knowledge. About 80% of learners wanted to investigate these topics further. Open comment questions identified themes requesting delivery of specific sessions earlier in residency training and positive overall attitudes toward the FSL curriculum. CONCLUSIONS FSL is a satisfactory means of teaching leadership skills to surgical residents. Residents recognize the need to develop leadership skills prior to entering practice and want to learn more. The FSL curriculum may be considered for application at other surgical training programs.
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Affiliation(s)
- David R Mann
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Christopher S Thomas
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Raphael H Parrado
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - G Tyler Rives
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Cynthia L Talley
- Department of Surgery, Medical University of South Carolina, Charleston, South Carolina.
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16
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Muñoz Campaña A, Farre-Alins P, Gracia-Roman R, Campos-Serra A, Llaquet-Bayo H, Vitiello G, Lucas-Guerrero V, Marrano E, Gonzalez-Castillo AM, Vila-Tura M, García-Borobia FJ, Mora Lopez L. INDURG TRIAL Protocol: A Randomized Controlled Trial Using Indocyanine Green during Cholecystectomy in Acute Cholecystitis. Dig Surg 2024; 41:141-146. [PMID: 38657579 DOI: 10.1159/000538371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 03/01/2024] [Indexed: 04/26/2024]
Abstract
INTRODUCTION Laparoscopic cholecystectomy is one of the most common gastrointestinal surgeries, and bile duct injury is one of its main complications. The use of real-time indocyanine green fluorescence cholangiography allows the identification of extrahepatic biliary structures, facilitating the procedure and reducing the risk of bile duct lesions. A better visualization of the bile duct may help to reduce the need for conversion to open surgery, and may also shorten operating time. The main objective of this study was to determine whether the use of indocyanine green is associated with a reduction in operating time in emergency cholecystectomies. Secondary outcomes are the postoperative hospital stay, the correct intraoperative visualization of the Calot's Triangle structures with the administration of indocyanine green, and the intraoperative complications, postoperative complications and morbidity according to the Clavien-Dindo classification. METHODS This is a randomized, prospective, controlled, multicenter trial with patients diagnosed with acute cholecystitis requiring emergency cholecystectomy. The control group will comprise 220 patients undergoing emergency laparoscopic cholecystectomy applying the standard technique. The intervention group will comprise 220 patients also undergoing emergency laparoscopic cholecystectomy for acute cholecystitis with prior administration of indocyanine green. CONCLUSION Due to the lack of published studies on ICG in emergency laparoscopic cholecystectomy, this study may help to establish procedures for its use in the emergency setting.
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Affiliation(s)
- Anna Muñoz Campaña
- General and Digestive Surgery Department, Emergency Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Pau Farre-Alins
- General and Digestive Surgery Department, Emergency Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Raquel Gracia-Roman
- General and Digestive Surgery Department, Emergency Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Andrea Campos-Serra
- General and Digestive Surgery Department, Emergency Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Heura Llaquet-Bayo
- General and Digestive Surgery Department, Emergency Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Giulia Vitiello
- General and Digestive Surgery Department, Emergency Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Victoria Lucas-Guerrero
- General and Digestive Surgery Department, University Hospital of Vic, Vic (Barcelona), Spain
| | - Enrico Marrano
- General and Digestive Surgery Department, Emergency Surgery Unit, University Hospital Germans Trias I Pujol, Badalona (Barcelona), Spain
| | | | - Marina Vila-Tura
- General and Digestive Surgery Department, Emergency Surgery Unit, Mataró Hospital, Mataró, Spain
| | - Francisco-Javier García-Borobia
- General and Digestive Surgery Department, Hepatobiliary Surgery Unit, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
| | - Laura Mora Lopez
- General and Digestive Surgery Department, Parc Taulí University Hospital, Sabadell (Barcelona), Spain
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17
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Lusty A, Alexanian J, Kitto S, Wood T, Lavallée LT, Morash C, Cagiannos I, Breau RH, Raîche I. How Surgeons Think to Avoid Error: A Case Study of the Neurovascular Bundle Sparing During a Robotic Prostatectomy. JOURNAL OF SURGICAL EDUCATION 2024; 81:570-577. [PMID: 38490802 DOI: 10.1016/j.jsurg.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Revised: 01/06/2024] [Accepted: 01/15/2024] [Indexed: 03/17/2024]
Abstract
OBJECTIVE To illustrate how experts efficiently navigate a "slowing down moment" to obtain optimal surgical outcomes using the neurovascular bundle sparing during a robotic prostatectomy as a case study. DESIGN A series of semistructured interviews with four expert uro-oncologists were completed using a cognitive task analysis methodology. Cognitive task analysis, CTA, refers to the interview and extraction of a general body of knowledge. Each interview participant completed four 1 to 2-hour semistructured CTA interviews. The interview data were then deconstructed, coded, and analyzed using a grounded theory analysis to produce a CTA-grid for a robotic prostatectomy for each surgeon, with headings of: surgical steps, simplification maneuvers, visual cues, error/complication recognition, and error/complication management and avoidance. SETTING The study took place at an academic teaching hospital located in an urban center in Canada. PARTICIPANTS Four expert uro-oncologists participated in the study. RESULTS Visual cues, landmarks, common pitfalls, and technique were identified as the 4 key components of the decision-making happening during a slowing down moment in the neurovascular bundle sparing during a robotic prostatectomy. CONCLUSION The data obtained from the CTA is novel information identifying patterns and cues that expert surgeons use to inform their surgical decision-making and avoid errors. This decision-making knowledge of visual cues, landmarks, common pitfalls and techniques is also generalizable for other surgical subspecialties. Surgeon educators, surgical teaching programs and trainees looking to improve their decision-making skills could use these components to guide their educational strategies.
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Affiliation(s)
- Avril Lusty
- University of Ottawa, Queen's University, Ottawa, Ontario, Canada.
| | - Janet Alexanian
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Simon Kitto
- Department of Innovation in Medical Education, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Tim Wood
- Department of Medical Education, Director, Assessment and Evaluation, Faculty of Medicine, University of Ottawa, Ontario, Canada
| | - Luke T Lavallée
- Division of Urology, Department of Surgery, University of Ottawa, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Chris Morash
- Division of Urology, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Ilias Cagiannos
- Division of Urology, Department of Surgery, University of Ottawa, Ontario, Canada
| | - Rodney H Breau
- Clinical Epidemiology Program, Ottawa Hospital Research Institute/University of Ottawa, Ontario, Canada
| | - Isabelle Raîche
- Department of Surgery, University of Ottawa, Ontario, Canada
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18
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Li A, Javidan AP, Namazi B, Madani A, Forbes TL. Development of an Artificial Intelligence Tool for Intraoperative Guidance During Endovascular Abdominal Aortic Aneurysm Repair. Ann Vasc Surg 2024; 99:96-104. [PMID: 37914075 DOI: 10.1016/j.avsg.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 08/02/2023] [Accepted: 08/15/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Adverse events during surgery can occur in part due to errors in visual perception and judgment. Deep learning is a branch of artificial intelligence (AI) that has shown promise in providing real-time intraoperative guidance. This study aims to train and test the performance of a deep learning model that can identify inappropriate landing zones during endovascular aneurysm repair (EVAR). METHODS A deep learning model was trained to identify a "No-Go" landing zone during EVAR, defined by coverage of the lowest renal artery by the stent graft. Fluoroscopic images from elective EVAR procedures performed at a single institution and from open-access sources were selected. Annotations of the "No-Go" zone were performed by trained annotators. A 10-fold cross-validation technique was used to evaluate the performance of the model against human annotations. Primary outcomes were intersection-over-union (IoU) and F1 score and secondary outcomes were pixel-wise accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV). RESULTS The AI model was trained using 369 images procured from 110 different patients/videos, including 18 patients/videos (44 images) from open-access sources. For the primary outcomes, IoU and F1 were 0.43 (standard deviation ± 0.29) and 0.53 (±0.32), respectively. For the secondary outcomes, accuracy, sensitivity, specificity, NPV, and PPV were 0.97 (±0.002), 0.51 (±0.34), 0.99 (±0.001). 0.99 (±0.002), and 0.62 (±0.34), respectively. CONCLUSIONS AI can effectively identify suboptimal areas of stent deployment during EVAR. Further directions include validating the model on datasets from other institutions and assessing its ability to predict optimal stent graft placement and clinical outcomes.
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Affiliation(s)
- Allen Li
- Faculty of Medicine & The Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | - Arshia P Javidan
- Division of Vascular Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Babak Namazi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX
| | - Amin Madani
- Department of Surgery, University Health Network & University of Toronto, Toronto, Ontario, Canada; Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, Ontario, Canada
| | - Thomas L Forbes
- Department of Surgery, University Health Network & University of Toronto, Toronto, Ontario, Canada.
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19
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Sincavage J, Gulack BC, Zamora IJ. Indocyanine green (ICG) fluorescence-enhanced applications in pediatric surgery. Semin Pediatr Surg 2024; 33:151384. [PMID: 38245991 DOI: 10.1016/j.sempedsurg.2024.151384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Abstract
The breadth of pediatric surgical practice and variety of anatomic anomalies that characterize surgical disease in children and neonates require a unique level of operative mastery and versatility. Intraoperative navigation of small, complex, and often abnormal anatomy presents a particular challenge for pediatric surgeons. Clinical experience with fluorescent tissue dye, specifically indocyanine green (ICG), is quickly gaining widespread incorporation into adult surgical practice as a safe, non-toxic means of accurately visualizing tissue perfusion, lymphatic flow, and biliary anatomy to enhance operative speed, safety, and patient outcomes. Experience in pediatric surgery, however, remains limited. ICG-fluorescence guided surgery is poised to address the challenges of pediatric and neonatal operations for a growing breadth of surgical pathology. Fluorescent angiography has permitted intraoperative visualization of colorectal flap perfusion for complex pelvic reconstruction and anastomotic perfusion after esophageal atresia repair, while its hepatic absorption and biliary excretion has made it an excellent agent for delineating the dissection plane in the Kasai portoenterostomy and identifying both primary and metastatic hepatoblastoma lesions. Subcutaneous and intra-lymphatic ICG injection can identify iatrogenic chylous leaks and improved yields in sentinel lymph node biopsies. ICG-guided surgery holds promise for more widespread use in pediatric surgical conditions, and continued evaluation of efficacy will be necessary to better inform clinical practice and identify where to focus and develop this technical resource.
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Affiliation(s)
- John Sincavage
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Brian C Gulack
- Division of Pediatric Surgery, Rush University Medical Center, Chicago, IL, United States
| | - Irving J Zamora
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232, United States.
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20
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Symeonidis S, Mantzoros I, Anestiadou E, Ioannidis O, Christidis P, Bitsianis S, Zapsalis K, Karastergiou T, Athanasiou D, Apostolidis S, Angelopoulos S. Biliary Anatomy Visualization and Surgeon Satisfaction Using Standard Cholangiography versus Indocyanine Green Fluorescent Cholangiography during Elective Laparoscopic Cholecystectomy: A Randomized Controlled Trial. J Clin Med 2024; 13:864. [PMID: 38337557 PMCID: PMC10856121 DOI: 10.3390/jcm13030864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Revised: 01/26/2024] [Accepted: 01/28/2024] [Indexed: 02/12/2024] Open
Abstract
Background: Intraoperative biliary anatomy recognition is crucial for safety during laparoscopic cholecystectomy, since iatrogenic bile duct injuries represent a fatal complication, occurring in up to 0.9% of patients. Indocyanine green fluorescence cholangiography (ICG-FC) is a safe and cost-effective procedure for achieving a critical view of safety and recognizing early biliary injuries. The aim of this study is to compare the perioperative outcomes, usefulness and safety of standard intraoperative cholangiography (IOC) with ICG-FC with intravenous ICG. Methods: Between 1 June 2021 and 31 December 2022, 160 patients undergoing elective LC were randomized into two equal groups: Group A (standard IOC) and group B (ICG-FC with intravenous ICG). Results: No significant difference was found between the two groups regarding demographics, surgery indication or surgery duration. No significant difference was found regarding the visualization of critical biliary structures. However, the surgeon satisfaction and cholangiography duration presented significant differences in favor of ICG-FC. Regarding the inflammatory response, a significant difference between the two groups was found only in postoperative WBC levels. Hepatic and renal function test results were not significantly different between the two groups on the first postoperative day, except for direct bilirubin. No statistically significant difference was noted regarding 30-day postoperative complications, while none of the complications noted included bile duct injury events. Conclusions: ICG-FC presents equivalent results to IOC regarding extrahepatic biliary visualization and postoperative complications. However, more studies need to be performed in order to standardize the optimal dose, timing and mode of administration.
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Affiliation(s)
- Savvas Symeonidis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Ioannis Mantzoros
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Elissavet Anestiadou
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Orestis Ioannidis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Panagiotis Christidis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Stefanos Bitsianis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Konstantinos Zapsalis
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Trigona Karastergiou
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Dimitra Athanasiou
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
| | - Stylianos Apostolidis
- 1st Propaedeutic Department of Surgery, AHEPA University Hospital, Aristotle University of Thessaloniki, 54636 Thessaloniki, Greece;
| | - Stamatios Angelopoulos
- 4th Department of General Surgery, Aristotle University of Thessaloniki, General Hospital of Thessaloniki “G. Papanikolaou”, 54124 Thessaloniki, Greece; (S.S.); (I.M.); (E.A.); (P.C.); (S.B.); (K.Z.); (T.K.); (D.A.); (S.A.)
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21
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Esposito C, Rathod KJ, Cerulo M, Del Conte F, Saxena R, Coppola V, Sinha A, Esposito G, Escolino M. Indocyanine green fluorescent cholangiography: The new standard practice to perform laparoscopic cholecystectomy in pediatric patients. A comparative study with conventional laparoscopic technique. Surgery 2024; 175:498-504. [PMID: 38007385 DOI: 10.1016/j.surg.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 10/01/2023] [Accepted: 10/25/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND This study aimed to compare outcomes of standard laparoscopic cholecystectomy and indocyanine green fluorescent cholangiography laparoscopic cholecystectomy over a 10-year period. METHODS From 2013 to 2023, 173 laparoscopic cholecystectomies were performed in 2 pediatric surgery units: 83 using standard technique (G1) and 90 using indocyanine green fluorescent cholangiography (G2). Patients included 96 girls and 77 boys, with a median age of 12.3 years (range 4-17) and a median weight of 51 kg (range 19-114). The 2 groups were compared regarding the following: (1) perioperative complications rate; (2) overall length of surgery (T1); (3) length of cystic duct isolation, clipping, and sectioning (T2); (4) time of gallbladder removal (T3); (5) degree of visualization of biliary tree; (6) safety and feasibility of indocyanine green fluorescent cholangiography; (7) incidence of anatomical anomalies detected intraoperatively. RESULTS All laparoscopic cholecystectomies were accomplished without conversion to open. The perioperative complications rate was significantly higher in G1 compared with G2 (12% vs 0%; P = .0007). Median T1, T2, and T3 were significantly longer in G1 (90, 37, 35 minutes) compared with G2 (55, 17, 19 minutes) (P = .0001), respectively. The visualization rate of the complete biliary tree was significantly higher in G2 (98.8%) than in G1 (80.7%) (P = .0001). No adverse reactions to indocyanine green were recorded. The incidence of biliary anomalies detected intraoperatively was significantly higher in G2 (7.8%) than in G1 (1.2%) (P = .03). CONCLUSION Indocyanine green fluorescent cholangiography can be considered the new standard practice to perform laparoscopic cholecystectomy in pediatrics. Indocyanine green fluorescence provided superior visualization of biliary anatomy, increased detection of anatomic variants, faster procedure, and fewer complications compared with conventional technique. Indocyanine green fluorescent cholangiography was safe, feasible, simple, inexpensive, and a timesaving tool.
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Affiliation(s)
- Ciro Esposito
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy.
| | - Kirtikumar J Rathod
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Mariapina Cerulo
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Fulvia Del Conte
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Rahul Saxena
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | - Vincenzo Coppola
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
| | - Arvind Sinha
- Department of Pediatric Surgery, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
| | | | - Maria Escolino
- Division of Pediatric Surgery, Federico II University Hospital, Naples, Italy
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22
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Ortenzi M, Corallino D, Botteri E, Balla A, Arezzo A, Sartori A, Reddavid R, Montori G, Guerrieri M, Williams S, Podda M. Safety of laparoscopic cholecystectomy performed by trainee surgeons with different cholangiographic techniques (SCOTCH): a prospective non-randomized trial on the impact of fluorescent cholangiography during laparoscopic cholecystectomy performed by trainees. Surg Endosc 2024; 38:1045-1058. [PMID: 38135732 DOI: 10.1007/s00464-023-10613-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/26/2023] [Indexed: 12/24/2023]
Abstract
AIMS The identification of the anatomical components of the Calot's Triangle during laparoscopic cholecystectomy (LC) might be challenging and its difficulty may increase when a surgical trainee (ST) is in charge, ultimately allegedly affecting also the incidence of common bile duct injuries (CBDIs). There are various methods to help reach the critical view of safety (CVS): intraoperative cholangiogram (IOC), critical view of safety in white light (CVS-WL) and near-infrared fluorescent cholangiography (NIRF-C). The primary objective was to compare the use of these techniques to obtain the CVS during elective LC performed by ST. METHODS This was a multicentre prospective observational study (Clinicalstrials.gov Registration number: NCT04863482). The impact of three different visualization techniques (IOC, CVS-WL, NIRF-C) on LC was analyzed. Operative time and time to achieve the CVS were considered. All the participating surgeons were also required to fill in three questionnaires at the end of the operation focusing on anatomical identification of the general task and their satisfaction. RESULTS Twenty-nine centers participated for a total of 338 patients: 260 CVS-WL, 10 IOC and 68 NIRF-C groups. The groups did not differ in the baseline characteristics. CVS was considered achieved in all the included case. Rates were statistically higher in the NIR-C group for common hepatic and common bile duct visualization (p = 0.046; p < 0.005, respectively). There were no statistically significant differences in operative time (p = 0.089) nor in the time to achieve the CVS (p = 0.626). Three biliary duct injuries were reported: 2 in the CVS-WL and 1 in the NIR-C. Surgical workload scores were statistically lower in every domain in the NIR-C group. Subjective satisfaction was higher in the NIR-C group. There were no other statistically significant differences. CONCLUSIONS These data showed that using NIRF-C did not prolong operative time but positively influenced the surgeon's satisfaction of the performance of LC.
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Affiliation(s)
- Monica Ortenzi
- Department of General and Emergency Surgery, Università Politecnica delle Marche, Ancona, Italy.
| | - Diletta Corallino
- Department of General Surgery and Surgical Specialties, Sapienza University of Rome, Rome, Italy
| | - Emanuele Botteri
- General Surgery, ASST Spedali Civili di Brescia PO Montichiari, Montichiari, Brescia, Italy
| | - Andrea Balla
- Coloproctology and Inflammatory Bowel Disease Surgery Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- UOC of General and Minimally Invasive Surgery, Hospital "San Paolo", Largo Donatori del Sangue 1, Civitavecchia, 00053, Rome, Italy
- Department of Surgical Sciences, University of Torino, Turin, Italy
| | - Alberto Arezzo
- Department of General Surgery, Ospedale Di Montebelluna, Montebelluna, Treviso, Italy
| | - Alberto Sartori
- Department of Colorectal Surgery, King's College Hospital, London, UK
| | | | | | - Mario Guerrieri
- Department of General and Emergency Surgery, Università Politecnica delle Marche, Ancona, Italy
| | | | - Mauro Podda
- Department of Surgical Science, University of Cagliari, Cagliari, Italy
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23
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Zidan MHED, Seif-Eldeen M, Ghazal AA, Refaie M. Post-cholecystectomy bile duct injuries: a retrospective cohort study. BMC Surg 2024; 24:8. [PMID: 38172774 PMCID: PMC10765830 DOI: 10.1186/s12893-023-02301-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 12/23/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND Bile duct injury (BDI) is still a major worrisome complication that is feared by all surgeons undergoing cholecystectomy. The overall incidence of biliary duct injuries falls between 0.2 and 1.3%. BDI classification remains an important method to define the type of injury conducted for investigation and management. Recently, a Consensus has been taken to define BDI using the ATOM classification. Early management brings better results than delayed management. The current perspective in biliary surgery is the laparoscopic role in diagnosing and managing BDI. Diagnostic laparoscopy has been conducted in various entities for diagnostic and therapeutic measures in minor and major BDIs. METHODS 35 cases with iatrogenic BDI following cholecystectomy (after both open and laparoscopic approaches) both happened in or were referred to Alexandria Main University Hospital surgical department from January 2019 till May 2022 and were analyzed retrospectively. Patients were classified according to the ATOM classification. Management options undertaken were mentioned and compared to the timing of diagnosis, and the morbidity and mortality rates (using the Clavien-Dindo classification). RESULTS 35 patients with BDI after both laparoscopic cholecystectomy (LC) (54.3%), and Open cholecystectomy (OC) (45.7%) (20% were converted and 25.7% were Open from the start) were classified according to ATOM classification. 45.7% were main bile duct injuries (MBDI), and 54.3% were non-main bile duct injuries (NMBDI), where only one case 2.9% was associated with vasculobiliary injury (VBI). 28% (n = 10) of the cases were diagnosed intraoperatively (Ei), 62.9% were diagnosed early postoperatively (Ep), and 8.6% were diagnosed in the late postoperative period (L). LC was associated with 84.2% of the NMBDI, and only 18.8% of the MBDI, compared to OC which was associated with 81.3% of the MBDI, and 15.8% of the NMBDI. By the Clavien-Dindo classification, 68.6% fell into Class IIIb, 20% into Class I, 5.7% into Class V (mortality rate), 2.9% into Class IIIa, and 2.9% into Class IV. The Clavien-Dindo classification and the patient's injury (type and time of detection) were compared to investigation and management options. CONCLUSION Management options should be defined individually according to the mode of presentation, the timing of detection of injury, and the type of injury. Early detection and management are associated with lower morbidity and mortality. Diagnostic Laparoscopy was associated with lower morbidity and better outcomes. A proper Reporting checklist should be designed to help improve the identification of injury types.
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Affiliation(s)
- Mohamed Hossam El-Din Zidan
- Faculty of Medicine, Alexandria University, Alexandria, Egypt.
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt.
| | - Mostafa Seif-Eldeen
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt
| | - Abdelhamid A Ghazal
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt
| | - Mustafa Refaie
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
- Alexandria Main University Hospital, Alexandria University, Alexandria, Egypt
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24
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Salo JC. Major Intraoperative Complications during Minimally Invasive Esophagectomy: Experience is a Hard Teacher. Ann Surg Oncol 2024; 31:23-24. [PMID: 37899409 DOI: 10.1245/s10434-023-14457-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 10/04/2023] [Indexed: 10/31/2023]
Affiliation(s)
- Jonathan C Salo
- Department of Surgery, Levine Cancer Institute, Carolinas Medical Center, Atrium Health, Charlotte, NC, USA.
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25
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Xie Q, Yang M, Jiang K, Zhang L, Mao T, Gao F. Laparoscopic cholecystectomy assisted by combined intravenous and intracholecystic fluorescent cholangiography: a case report. J Int Med Res 2023; 51:3000605231216396. [PMID: 38064274 PMCID: PMC10710120 DOI: 10.1177/03000605231216396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Accepted: 11/07/2023] [Indexed: 12/18/2023] Open
Abstract
This case report describes a laparoscopic approach using fluorescence imaging guidance to treat gangrenous cholecystitis with perforation (GCP). A male patient in his early 60s presented with 3 days of right upper abdominal pain. Computed tomography and ultrasonography findings were consistent with a stone incarcerated in the gallbladder neck, GCP, and localized peritonitis. Percutaneous gallbladder drainage was initially performed, followed by laparoscopic cholecystectomy 7 days later, using combined intravenous and intracholecystic fluorescent cholangiography. This technique allowed visualization of the cystic and common bile ducts during surgery and enabled safe removal of the diseased gallbladder. The patient recovered well without complications, and reported no pain or discomfort at a 2-month follow-up.
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Affiliation(s)
- Qingyun Xie
- Department of Hepato-Pancreato-Biliary Surgery, the People’s Hospital of Leshan, Leshan, China
| | - Manyu Yang
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Kangyi Jiang
- Department of Hepato-Pancreato-Biliary Surgery, the People’s Hospital of Leshan, Leshan, China
| | - Ling Zhang
- Department of Hepato-Pancreato-Biliary Surgery, the People’s Hospital of Leshan, Leshan, China
| | - Tianyang Mao
- Department of Clinical Medicine, North Sichuan Medical College, Nanchong, China
| | - Fengwei Gao
- Department of Hepato-Pancreato-Biliary Surgery, the People’s Hospital of Leshan, Leshan, China
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26
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Khalid MU, Laplante S, Masino C, Alseidi A, Jayaraman S, Zhang H, Mashouri P, Protserov S, Hunter J, Brudno M, Madani A. Use of artificial intelligence for decision-support to avoid high-risk behaviors during laparoscopic cholecystectomy. Surg Endosc 2023; 37:9467-9475. [PMID: 37697115 DOI: 10.1007/s00464-023-10403-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2023] [Accepted: 08/14/2023] [Indexed: 09/13/2023]
Abstract
INTRODUCTION Bile duct injuries (BDIs) are a significant source of morbidity among patients undergoing laparoscopic cholecystectomy (LC). GoNoGoNet is an artificial intelligence (AI) algorithm that has been developed and validated to identify safe ("Go") and dangerous ("No-Go") zones of dissection during LC, with the potential to prevent BDIs through real-time intraoperative decision-support. This study evaluates GoNoGoNet's ability to predict Go/No-Go zones during LCs with BDIs. METHODS AND PROCEDURES Eleven LC videos with BDI (BDI group) were annotated by GoNoGoNet. All tool-tissue interactions, including the one that caused the BDI, were characterized in relation to the algorithm's predicted location of Go/No-Go zones. These were compared to another 11 LC videos with cholecystitis (control group) deemed to represent "safe cholecystectomy" by experts. The probability threshold of GoNoGoNet annotations were then modulated to determine its relationship to Go/No-Go predictions. Data is shown as % difference [99% confidence interval]. RESULTS Compared to control, the BDI group showed significantly greater proportion of sharp dissection (+ 23.5% [20.0-27.0]), blunt dissection (+ 32.1% [27.2-37.0]), and total interactions (+ 33.6% [31.0-36.2]) outside of the Go zone. Among injury-causing interactions, 4 (36%) were in the No-Go zone, 2 (18%) were in the Go zone, and 5 (45%) were outside both zones, after maximizing the probability threshold of the Go algorithm. CONCLUSION AI has potential to detect unsafe dissection and prevent BDIs through real-time intraoperative decision-support. More work is needed to determine how to optimize integration of this technology into the operating room workflow and adoption by end-users.
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Affiliation(s)
- Muhammad Uzair Khalid
- Temerty Faculty of Medicine, University of Toronto, Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada.
| | - Simon Laplante
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Caterina Masino
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
| | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Shiva Jayaraman
- Department of Surgery, University of Toronto, Toronto, ON, Canada
- Department of Surgery, St Joseph's Health Centre, Toronto, ON, Canada
| | - Haochi Zhang
- DATA Team, University Health Network, Toronto, ON, Canada
| | | | - Sergey Protserov
- DATA Team, University Health Network, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Jaryd Hunter
- DATA Team, University Health Network, Toronto, ON, Canada
| | - Michael Brudno
- DATA Team, University Health Network, Toronto, ON, Canada
- Department of Computer Science, University of Toronto, Toronto, ON, Canada
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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27
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Awan B, Elsaigh M, Marzouk M, Sohail A, Elkomos BE, Asqalan A, Baqar SO, Elgndy N, Saleh O, Szul J, San Juan A, Alasmar M. A Systematic Review of Laparoscopic Ultrasonography During Laparoscopic Cholecystectomy. Cureus 2023; 15:e51192. [PMID: 38283459 PMCID: PMC10817818 DOI: 10.7759/cureus.51192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2023] [Indexed: 01/30/2024] Open
Abstract
We aim to investigate the potential of laparoscopic ultrasonography (LUS) as a replacement for intraoperative cholangiography (IOC) in the context of laparoscopic cholecystectomy focusing on various aspects related to both techniques. We made our search through PubMed, Web of Science, Cochrane Library, and Scopus, with the use of the following search strategy: ("laparoscopic ultrasonography" OR LUS OR "laparoscopic US" OR "laparoscopic ultrasound") AND ("laparoscopic cholecystectomy" OR LC). We incorporated diverse studies that addressed our topic, offering data on the identification of biliary anatomy and variations, the utilization of laparoscopic ultrasound in cholecystitis, the detection of common bile duct stones, and the criteria utilized to assess the accuracy of LUS. A total of 1526 articles were screened and only 20 were finally included. This systematic review assessed LUS and IOC techniques in cholecystectomy. IOC showed higher failure rates due to common duct catheterization challenges, while LUS had lower failure rates, often linked to factors like steatosis. Cost-effectiveness comparisons favored LUS over IOC, potentially saving patients money. LUS procedures were quicker due to real-time imaging, while IOC required more time and personnel. Bile duct injuries were discussed, highlighting LUS limitations in atypical anatomies. LUS aided in diagnosing crucial conditions, emphasizing its relevance post surgery. Surgeon experience significantly impacted outcomes, regardless of the technique. A previous study discussed that LUS's learning curve was steeper than IOC's, with proficient LUS users adjusting practices and using IOC selectively. Highlighting LUS's benefits and limitations in cholecystectomy, we stress its value in complex anatomical situations. LUS confirms no common bile duct stones, avoiding cannulation. LUS and IOC equally detect common bile duct stones and visualize the biliary tree. LUS offers safety, speed, cost-effectiveness, and unlimited use. Despite the associated expenses and learning curve, the enduring benefits of using advanced probes in LUS imaging suggest that it could surpass traditional IOC. The validation of this potential advancement relies heavily on incorporating modern probe studies. Our study could contribute to the medical literature by evaluating their clinical validity, safety, cost-effectiveness, learning curve, patient outcomes, technological advancements, and potential impact on guidelines and recommendations for clinical professionals.
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Affiliation(s)
- Bakhtawar Awan
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Mohamed Elsaigh
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Mohamed Marzouk
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Azka Sohail
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | | | - Ahmad Asqalan
- Thoracic Surgery, Norfolk and Norwich University Hospital, Norwich, GBR
| | - Safa O Baqar
- Colorectal Surgery, Derriford Hospital, University Hospitals Plymouth, Plymouth, GBR
| | - Noha Elgndy
- Acute and Emergency Medicine, Frimley Park Hospital, Surrey, GBR
| | - Omnia Saleh
- General and Gastrointestinal Surgery, Laboratory for Surgical and Metabolic Research, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Justyna Szul
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Anna San Juan
- General and Emergency Surgery, Northwick Park Hospital, London, GBR
| | - Mohamed Alasmar
- General Surgery, Salford Royal Hospital, University of Manchester, Manchester, GBR
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28
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Shapira SS, Ehrlich Z, Koren P, Sroka G. Comparing a novel wide field of view laparoscope with conventional laparoscope while performing laparoscopic cholecystectomy. Surg Endosc 2023; 37:8910-8918. [PMID: 37735219 DOI: 10.1007/s00464-023-10393-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/13/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND The limited 70° field of view (FoV) used in standard laparoscopy necessitates maneuvering the laparoscope to view the ports, follow the surgical tools, and search for a target region. Complications related to events that take place outside the FoV are underreported. Recently, a novel laparoscopic system (SurroundScope, 270Surgical) was reported to dramatically expand the FoV from 70 to 270°. This study focuses on differences in performing laparoscopic cholecystectomy using the SurroundScope compared to the standard laparoscope. METHODS Forty-four laparoscopic surgeries were performed and video recorded. A subanalysis of 21 Cholecystectomies was performed and compared to 21 Cholecystectomies, performed with the standard laparoscope during the study period by the same surgeon. RESULTS No accidental or intraoperative adverse events occurred when using the SurroundScope. Subanalysis of 21 Cholecystectomies revealed shorter fog/smoke cleaning times using the SurroundScope compared to the standard scope (1.45 ± 5.08 sec vs. 54.95 ± 137.77 sec, p = 0.0454). Furthermore, operations performed with the SurroundScope had a shorter trocar placement duration (85.0 ± 40.9 sec vs. 111.3 ± 70.5 sec; p = 0.077), shorter time to achieve critical view of safety (9.5 ± 4.14 min vs. 15.8 ± 11.87 min; p = 0.015), and shorter procedure duration (31.9 ± 10.4 min vs. 42.9 ± 22 min; p = 0.025). In post-operative evaluations, the surgeon noted that tools could be continuously followed and ports were visible without camera manipulation. Also, the surgeon agreed that the procedure could be better planned due to the wide FoV and that surgical workflow was improved. Furthermore, the surgeon agreed that the procedure was safer using the SurroundScope. CONCLUSIONS Initial results demonstrate the advantages of the SurroundScope over standard laparoscopy. By expanding the FoV, visualization is improved, the procedure is more efficient, significantly shorter and most important, patient safety, per surgeons' testimonials is improved. Further investigation to quantify these benefits in a larger group of patients and among various surgical procedures should be considered.
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Affiliation(s)
| | - Zvi Ehrlich
- Department of Obstetrics and Gynaecology, Shaare Zedek Medical Centre, Hebrew University, Jerusalem, Israel
| | - Pazit Koren
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel
| | - Gideon Sroka
- Department of Surgery, Bnai Zion Medical Center, Haifa, Israel.
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Kawamura M, Endo Y, Fujinaga A, Orimoto H, Amano S, Kawasaki T, Kawano Y, Masuda T, Hirashita T, Kimura M, Ejima A, Matsunobu Y, Shinozuka K, Tokuyasu T, Inomata M. Development of an artificial intelligence system for real-time intraoperative assessment of the Critical View of Safety in laparoscopic cholecystectomy. Surg Endosc 2023; 37:8755-8763. [PMID: 37567981 DOI: 10.1007/s00464-023-10328-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/19/2023] [Indexed: 08/13/2023]
Abstract
BACKGROUND The Critical View of Safety (CVS) was proposed in 1995 to prevent bile duct injury during laparoscopic cholecystectomy (LC). The achievement of CVS was evaluated subjectively. This study aimed to develop an artificial intelligence (AI) system to evaluate CVS scores in LC. MATERIALS AND METHODS AI software was developed to evaluate the achievement of CVS using an algorithm for image classification based on a deep convolutional neural network. Short clips of hepatocystic triangle dissection were converted from 72 LC videos, and 23,793 images were labeled for training data. The learning models were examined using metrics commonly used in machine learning. RESULTS The mean values of precision, recall, F-measure, specificity, and overall accuracy for all the criteria of the best model were 0.971, 0.737, 0.832, 0.966, and 0.834, respectively. It took approximately 6 fps to obtain scores for a single image. CONCLUSIONS Using the AI system, we successfully evaluated the achievement of the CVS criteria using still images and videos of hepatocystic triangle dissection in LC. This encourages surgeons to be aware of CVS and is expected to improve surgical safety.
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Affiliation(s)
- Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan.
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Hiroki Orimoto
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Shota Amano
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Yoko Kawano
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Misako Kimura
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Aika Ejima
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Yusuke Matsunobu
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Ken'ichi Shinozuka
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Tatsushi Tokuyasu
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
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Marchegiani F, Conticchio M, Zadoroznyj A, Inchingolo R, Memeo R, De'angelis N. Detection and management of bile duct injury during cholecystectomy. Minerva Surg 2023; 78:545-557. [PMID: 36883937 DOI: 10.23736/s2724-5691.23.09866-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
INTRODUCTION Cholecystectomy represents one of the most performed surgical procedures. Bile duct injuries (BDIs) are a dangerous complication of this intervention. With the advent of the laparoscopy, the rate of BDIs showed a growing trend that was partially justified by the learning curve of this technique. EVIDENCE ACQUISITION A literature search was conducted on Embase, Medline, and Cochrane databases to identify studies published up to October 2022 that analyzed the intraoperative detection and management of BDIs diagnosed during cholecystectomy. EVIDENCE SYNTHESIS According to the literature, approximately 25% of BDIs is diagnosed during the laparoscopic cholecystectomy. In the clinical suspicion of BDI, an intraoperative cholangiography is performed to confirm it. Complimentary technology, such as near-infrared cholangiography, can be also adopted. Intraoperative ultrasound represents a useful tool to furtherly define the biliary and the vascular anatomy. The proper classification of the type of BDI allows to identify the correct treatment. When a good expertise in hepato-pancreato-biliary surgery is available, a direct repair is performed with good outcomes both in case of simple and complex lesions. When the local resources are limited or there is a lack of dedicated surgical experience, patient referral to a reference center shows better outcomes. In particular, complex vasculo-biliary injuries require a highly specialized treatment. The key elements to transfer the patients are a good documentation of the injury, a proper drainage of the abdomen, and an antibiotic therapy. CONCLUSIONS BDI management requires a proper diagnostic process and prompt treatment to reduce the morbidity and mortality of this feared complication occurring during cholecystectomy.
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Affiliation(s)
- Francesco Marchegiani
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Maria Conticchio
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Alizée Zadoroznyj
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France
| | - Riccardo Inchingolo
- Unit of Interventional Radiology, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Riccardo Memeo
- Unit of Hepato-Pancreato-Biliary Surgery, F. Miulli General Regional Hospital, Acquaviva delle Fonti, Bari, Italy
| | - Nicola De'angelis
- Unit of Colorectal and Digestive Surgery, DIGEST Department, Beaujon University Hospital, AP-HP, University of Paris Cité, Clichy, France -
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Toale C, O'Byrne A, Morris M, Kavanagh DO. Characterizing individual trainee learning curves in surgical training: Challenges and opportunities. Surgeon 2023; 21:285-288. [PMID: 36446700 DOI: 10.1016/j.surge.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022]
Abstract
The surgical learning curve is an observable and measurable phenomenon. In the era of competency-based approaches to surgical training, monitoring the trajectory of individual trainee competence attainment could represent a meaningful method of formative and summative assessment. While technology can assist this approach, a number of significant barriers to the implementation of such assessment methods remain, including: accurate data collection, standard setting, and reliable assessment. Translating individual learning curve data into quantifiable case minimum targets in training poses further difficulties, and may not be possible for all procedures, particularly those that are less frequently performed and assessed. In spite of these challenges, significant benefits could be realized through an individualized approach to competency assessment using trainee learning curve data. Tracking competence acquisition against criterion-referenced standards could allow for targeted training and remediation, conforming with modern theories of adult education and empowering trainees to take control of their own learning. Learning curve data could also be used to assess the effects of educational interventions such as simulation-based training on subsequent competence acquisition rates. Ultimately, the individual learning curves of trainees could be used to inform personalised decisions regarding entrustment, credentialing, and certification, allowing training programmes to move beyond minimum operative experience targets as a crude proxy measure of competence.
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Affiliation(s)
- C Toale
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland.
| | - A O'Byrne
- School of Medicine, Trinity College Dublin, The University of Dublin, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland
| | - M Morris
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland
| | - D O Kavanagh
- Department of Surgical Affairs, Royal College of Surgeons in Ireland, Ireland; Department of Surgery, Tallaght University Hospital, Dublin, Ireland
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Alkhamaiseh KN, Grantner JL, Shebrain S, Abdel-Qader I. Towards reliable hepatocytic anatomy segmentation in laparoscopic cholecystectomy using U-Net with Auto-Encoder. Surg Endosc 2023; 37:7358-7369. [PMID: 37491657 DOI: 10.1007/s00464-023-10306-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/12/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Most bile duct (BDI) injuries during laparoscopic cholecystectomy (LC) occur due to visual misperception leading to the misinterpretation of anatomy. Deep learning (DL) models for surgical video analysis could, therefore, support visual tasks such as identifying critical view of safety (CVS). This study aims to develop a prediction model of CVS during LC. This aim is accomplished using a deep neural network integrated with a segmentation model that is capable of highlighting hepatocytic anatomy. METHODS Still images from LC videos were annotated with four hepatocystic landmarks of anatomy segmentation. A deep autoencoder neural network with U-Net to investigate accurate medical image segmentation was trained and tested using fivefold cross-validation. Accuracy, Loss, Intersection over Union (IoU), Precision, Recall, and Hausdorff Distance were computed to evaluate the model performance versus the annotated ground truth. RESULTS A total of 1550 images from 200 LC videos were annotated. Mean IoU for segmentation was 74.65%. The proposed approach performed well for automatic hepatocytic landmarks identification with 92% accuracy and 93.9% precision and can segment challenging cases. CONCLUSION DL, can potentially provide an intraoperative model for surgical video analysis and can be trained to guide surgeons toward reliable hepatocytic anatomy segmentation and produce selective video documentation of this safety step of LC.
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Affiliation(s)
- Koloud N Alkhamaiseh
- Department of Electrical and Computer Engineering, Western Michigan University, Kalamazoo, MI, USA.
| | - Janos L Grantner
- Department of Electrical and Computer Engineering, Western Michigan University, Kalamazoo, MI, USA
| | - Saad Shebrain
- Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, MI, USA
| | - Ikhlas Abdel-Qader
- Department of Electrical and Computer Engineering, Western Michigan University, Kalamazoo, MI, USA
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Alius C, Serban D, Bratu DG, Tribus LC, Vancea G, Stoica PL, Motofei I, Tudor C, Serboiu C, Costea DO, Serban B, Dascalu AM, Tanasescu C, Geavlete B, Cristea BM. When Critical View of Safety Fails: A Practical Perspective on Difficult Laparoscopic Cholecystectomy. MEDICINA (KAUNAS, LITHUANIA) 2023; 59:1491. [PMID: 37629781 PMCID: PMC10456257 DOI: 10.3390/medicina59081491] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 08/12/2023] [Accepted: 08/17/2023] [Indexed: 08/27/2023]
Abstract
The incidence of common bile duct injuries following laparoscopic cholecystectomy (LC) remains three times higher than that following open surgery despite numerous attempts to decrease intraoperative incidents by employing better training, superior surgical instruments, imaging techniques, or strategic concepts. This paper is a narrative review which discusses from a contextual point of view the need to standardise the surgical approach in difficult laparoscopic cholecystectomies, the main strategic operative concepts and techniques, complementary visualisation aids for the delineation of anatomical landmarks, and the importance of cognitive maps and algorithms in performing safer LC. Extensive research was carried out in the PubMed, Web of Science, and Elsevier databases using the terms "difficult cholecystectomy", "bile duct injuries", "safe cholecystectomy", and "laparoscopy in acute cholecystitis". The key content and findings of this research suggest there is high intersocietal variation in approaching and performing LC, in the use of visualisation aids, and in the application of safety concepts. Limited papers offer guidelines based on robust data and a timid recognition of the human factors and ergonomic concepts in improving the outcomes associated with difficult cholecystectomies. This paper highlights the most relevant recommendations for dealing with difficult laparoscopic cholecystectomies.
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Affiliation(s)
- Catalin Alius
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Dragos Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Dan Georgian Bratu
- Faculty of Medicine, University “Lucian Blaga”, 550169 Sibiu, Romania; (D.G.B.)
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Laura Carina Tribus
- Faculty of Dental Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021Bucharest, Romania;
- Department of Internal Medicine, Ilfov Emergency Clinic Hospital Bucharest, 022104 Bucharest, Romania
| | - Geta Vancea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Third Clinical Infectious Disease Department, Clinical Hospital of Infectious and Tropical Diseases “Dr. Victor Babes”, 030303 Bucharest, Romania
| | - Paul Lorin Stoica
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Ion Motofei
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Department of General Surgery, Emergency Clinic Hospital “Sf. Pantelimon” Bucharest, 021659 Bucharest, Romania
| | - Corneliu Tudor
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
- Fourth General Surgery Department, Emergency University Hospital Bucharest, 050098 Bucharest, Romania
| | - Crenguta Serboiu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Daniel Ovidiu Costea
- Faculty of Medicine, Ovidius University Constanta, 900470 Constanta, Romania;
- General Surgery Department, Emergency County Hospital Constanta, 900591 Constanta, Romania
| | - Bogdan Serban
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Ana Maria Dascalu
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Ciprian Tanasescu
- Faculty of Medicine, University “Lucian Blaga”, 550169 Sibiu, Romania; (D.G.B.)
- Department of Surgery, Emergency County Hospital Sibiu, 550245 Sibiu, Romania
| | - Bogdan Geavlete
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
| | - Bogdan Mihai Cristea
- Faculty of Medicine, Carol Davila University of Medicine and Pharmacy Bucharest, 020021 Bucharest, Romania; (C.A.); (G.V.); (I.M.); (C.T.); (C.S.); (B.S.); (A.M.D.); (B.G.); (B.M.C.)
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Piccolo G, Barabino M, Lecchi F, Formisano G, Salaj A, Piozzi GN, Bianchi PP. Utility of near infrared fluorescent cholangiography in detecting biliary structures during challenging minimally invasive cholecystectomy. Langenbecks Arch Surg 2023; 408:282. [PMID: 37462733 DOI: 10.1007/s00423-023-02995-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 06/17/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Surgeons can minimize the risk of bile duct injury (BDI) during challenging mini-invasive cholecystectomy through technical standardization by means of a precise anatomical landmark identification (Critical View of Safety) and advanced technology for biliary visualization. Among these systems, the adoption of magnified stereoscopic 3-dimensional view provided by robotic platforms and near infrared fluorescent cholangiography (NIRF-C) is the most promising. METHODS In this prospective cohort study, we evaluated all consecutive minimally invasive cholecystectomies (laparoscopic and robotic) performed with NIRF-C between May 2022 and January 2023 at General Surgery Unit, Department of Health Sciences, University of Milan, San Paolo Hospital (Milan, Italy). Inclusions criteria were as follows: (1) acute cholecystitis (emergency group), (2) history of chronic cholecystitis or complicated cholelithiasis (deferred urgent group), (3) difficult cases (patients affected by cirrhosis, with scleroatrophic gallbladder or BMI > 35 kg/m2). For each group, the detection rate and visualization order of the main biliary structures were reported (cystic duct, CD; common hepatic duct, CHD; common bile duct, CBD; and CD-CHD junction). RESULTS A total of 101 consecutive patients were enrolled, including 83 laparoscopic and 18 robotic cholecystectomies. All patients were stratified into three subgroups: (a) emergency group (n = 33, 32.7%), (b) deferred urgent group (n = 46, 45.5%), (c) difficult group (n = 22, 21.8%). Visualization of at least one biliary structure was possible in 94.1% of cases (95/101). Interestingly, all four main structures were detected in 43.6% of cases (44/101). The CD was the structure identified most frequently, being recognized in 91/101 patients (90.1%), followed by CBD (83.2%), CHD (62.4%), and CD-CHD junction (52.5%). In the subset of patients that underwent emergency surgery for AC, the CD-CHD confluence was identified in only 45.5% of cases. However, early and precise identification of CBD (75.8%) and CD (87.9%) allowed safe isolation, clipping, and transection of the cystic duct. In the deferred urgent group, the CBD and the CD were easily identified as first structure in a high percentage of cases (65.2% and 41.3% respectively), whereas the CD-CHD junction was the third structure to be identified in 67.4% of cases, the highest value among the three subgroups. In the difficult group, NIRF-C did not prove to be a useful tool for biliary visualization. The rates of failure of visualization were elevated: CBD (27.3%), CD (18.2%), CHD (54.5%), and CD-CHD (68.2%). CONCLUSIONS NIRF-C is a powerful real-time diagnostic tool to detect CBD and CD during minimally invasive cholecystectomy, especially when inflammation due to acute or chronic cholecystitis subverted the anatomy of the hepatoduodenal ligament.
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Affiliation(s)
- Gaetano Piccolo
- General Surgery Unit, Department of Health Sciences (DISS), University of Milan, San Paolo Hospital, Via Antonio Di Rudinì 8, Milan, 20142, Italy.
| | - Matteo Barabino
- General Surgery Unit, Department of Health Sciences (DISS), University of Milan, San Paolo Hospital, Via Antonio Di Rudinì 8, Milan, 20142, Italy
| | - Francesca Lecchi
- General Surgery Unit, Department of Health Sciences (DISS), University of Milan, San Paolo Hospital, Via Antonio Di Rudinì 8, Milan, 20142, Italy
| | - Giampaolo Formisano
- General Surgery Unit, Department of Health Sciences (DISS), University of Milan, San Paolo Hospital, Via Antonio Di Rudinì 8, Milan, 20142, Italy
| | - Adelona Salaj
- General Surgery Unit, Department of Health Sciences (DISS), University of Milan, San Paolo Hospital, Via Antonio Di Rudinì 8, Milan, 20142, Italy
| | | | - Paolo Pietro Bianchi
- General Surgery Unit, Department of Health Sciences (DISS), University of Milan, San Paolo Hospital, Via Antonio Di Rudinì 8, Milan, 20142, Italy
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Garcia-Martinez A, Manrique-Cordoba J, De La Casa-Lillo MA, Sabater-Navarro JM, Juan CG. Enhancing surgeons' gaze strategies in endoscopic surgery during simulated surgical emergency situations thanks to computer vision . ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2023; 2023:1-4. [PMID: 38083476 DOI: 10.1109/embc40787.2023.10340430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
Deficient visualization in minimally invasive surgery often causes misperceptions, which can lead to an increase of iatrogenic lesions and complications. This is especially critical for novice surgeons, who are prone to adopt inadequate switching gaze strategies, thereby increasing the chance of unforeseen complications. In this paper the use of an additional computer-aided vision system was tested for improvement of the reaction of the surgeons to unforeseen complications. Gaze patterns were analyzed using a gaze tracker, as well as other metrics such as task completion time or reaction time to sudden bleeding. While completion time did not show significant difference between tested modalities (p<0.1), the reaction time showed a downward trend as more auxiliary computer-aided vision systems were added (p<0.005). These results support the benefits of including additional vision systems for minimally invasive surgery processes.Clinical Relevance- This work assesses the advantages of including an additional computer vision system to prevent unforeseen complications during minimally invasive surgeries.
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Endo Y, Tokuyasu T, Mori Y, Asai K, Umezawa A, Kawamura M, Fujinaga A, Ejima A, Kimura M, Inomata M. Impact of AI system on recognition for anatomical landmarks related to reducing bile duct injury during laparoscopic cholecystectomy. Surg Endosc 2023:10.1007/s00464-023-10224-5. [PMID: 37365396 DOI: 10.1007/s00464-023-10224-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/16/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND According to the National Clinical Database of Japan, the incidence of bile duct injury (BDI) during laparoscopic cholecystectomy has hovered around 0.4% for the last 10 years and has not declined. On the other hand, it has been found that about 60% of BDI occurrences are due to misidentifying anatomical landmarks. However, the authors developed an artificial intelligence (AI) system that gave intraoperative data to recognize the extrahepatic bile duct (EHBD), cystic duct (CD), inferior border of liver S4 (S4), and Rouviere sulcus (RS). The purpose of this research was to evaluate how the AI system affects landmark identification. METHODS We prepared a 20-s intraoperative video before the serosal incision of Calot's triangle dissection and created a short video with landmarks overwritten by AI. The landmarks were defined as landmark (LM)-EHBD, LM-CD, LM-RS, and LM-S4. Four beginners and four experts were recruited as subjects. After viewing a 20-s intraoperative video, subjects annotated the LM-EHBD and LM-CD. Then, a short video is shown with the AI overwriting landmark instructions; if there is a change in each perspective, the annotation is changed. The subjects answered a three-point scale questionnaire to clarify whether the AI teaching data advanced their confidence in verifying the LM-RS and LM-S4. Four external evaluation committee members investigated the clinical importance. RESULTS In 43 of 160 (26.9%) images, the subjects transformed their annotations. Annotation changes were primarily observed in the gallbladder line of the LM-EHBD and LM-CD, and 70% of these shifts were considered safer changes. The AI-based teaching data encouraged both beginners and experts to affirm the LM-RS and LM-S4. CONCLUSION The AI system provided significant awareness to beginners and experts and prompted them to identify anatomical landmarks linked to reducing BDI.
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Affiliation(s)
- Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan.
| | - Tatsushi Tokuyasu
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Yasuhisa Mori
- Department of Surgery 1, School of Medicine, University of Occupational and Environmental Health, Kitakyushu, Fukuoka, Japan
| | - Koji Asai
- Department of Surgery, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Akiko Umezawa
- Minimally Invasive Surgery Center, Yotsuya Medical Cube, Tokyo, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
| | - Aika Ejima
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Misako Kimura
- Department of Information System and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, Oita, Japan
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Gunda YR, Gupta S, Singh LK. Assessing human performance and human reliability: a review. INTERNATIONAL JOURNAL OF SYSTEM ASSURANCE ENGINEERING AND MANAGEMENT 2023; 14:817-828. [DOI: 10.1007/s13198-023-01893-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 07/19/2023]
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Fujinaga A, Endo Y, Etoh T, Kawamura M, Nakanuma H, Kawasaki T, Masuda T, Hirashita T, Kimura M, Matsunobu Y, Shinozuka K, Tanaka Y, Kamiyama T, Sugita T, Morishima K, Ebe K, Tokuyasu T, Inomata M. Development of a cross-artificial intelligence system for identifying intraoperative anatomical landmarks and surgical phases during laparoscopic cholecystectomy. Surg Endosc 2023:10.1007/s00464-023-10097-8. [PMID: 37142714 DOI: 10.1007/s00464-023-10097-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 04/19/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Attention to anatomical landmarks in the appropriate surgical phase is important to prevent bile duct injury (BDI) during laparoscopic cholecystectomy (LC). Therefore, we created a cross-AI system that works with two different AI algorithms simultaneously, landmark detection and phase recognition. We assessed whether landmark detection was activated in the appropriate phase by phase recognition during LC and the potential contribution of the cross-AI system in preventing BDI through a clinical feasibility study (J-SUMMIT-C-02). METHODS A prototype was designed to display landmarks during the preparation phase and Calot's triangle dissection. A prospective clinical feasibility study using the cross-AI system was performed in 20 LC cases. The primary endpoint of this study was the appropriateness of the detection timing of landmarks, which was assessed by an external evaluation committee (EEC). The secondary endpoint was the correctness of landmark detection and the contribution of cross-AI in preventing BDI, which were assessed based on the annotation and 4-point rubric questionnaire. RESULTS Cross-AI-detected landmarks in 92% of the phases where the EEC considered landmarks necessary. In the questionnaire, each landmark detected by AI had high accuracy, especially the landmarks of the common bile duct and cystic duct, which were assessed at 3.78 and 3.67, respectively. In addition, the contribution to preventing BDI was relatively high at 3.65. CONCLUSIONS The cross-AI system provided landmark detection at appropriate situations. The surgeons who previewed the model suggested that the landmark information provided by the cross-AI system may be effective in preventing BDI. Therefore, it is suggested that our system could help prevent BDI in practice. Trial registration University Hospital Medical Information Network Research Center Clinical Trial Registration System (UMIN000045731).
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Affiliation(s)
- Atsuro Fujinaga
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan.
| | - Yuichi Endo
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Tsuyoshi Etoh
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Masahiro Kawamura
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Hiroaki Nakanuma
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Takahide Kawasaki
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Takashi Masuda
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Teijiro Hirashita
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
| | - Misako Kimura
- Department of Information Systems and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Yusuke Matsunobu
- Department of Information Systems and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Ken'ichi Shinozuka
- Department of Information Systems and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Yuki Tanaka
- Advanced AI Technology Research, Advanced Technology Research, Olympus Corporation, Tokyo, Japan
| | - Toshiya Kamiyama
- Advanced AI Technology Research, Advanced Technology Research, Olympus Corporation, Tokyo, Japan
| | - Takemasa Sugita
- Advanced AI Technology Research, Advanced Technology Research, Olympus Corporation, Tokyo, Japan
| | - Kenichi Morishima
- Advanced AI Technology Research, Advanced Technology Research, Olympus Corporation, Tokyo, Japan
| | - Kohei Ebe
- Information Aided Medical Solutions Development, Application Software Engineering, Olympus Medical Systems Corporation, Tokyo, Japan
| | - Tatsushi Tokuyasu
- Department of Information Systems and Engineering, Faculty of Information Engineering, Fukuoka Institute of Technology, Fukuoka, Japan
| | - Masafumi Inomata
- Department of Gastroenterological and Pediatric Surgery, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-Machi, Oita, 879-5593, Japan
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Parelkar SV, Makhija DP, Sanghvi BV, Gupta RK, Mudkhedkar KP, Shah RS, Kumar A, Rangnekar A, Shah N. Initial experience with 3D laparoscopic choledochal cyst (CDC) excision and hepatico-duodenostomy (HD) in 21 children. Pediatr Surg Int 2023; 39:189. [PMID: 37133562 DOI: 10.1007/s00383-023-05472-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/13/2023] [Indexed: 05/04/2023]
Abstract
INTRODUCTION Minimal access surgery has gradually become the standard of care in the management of choledochal cysts (CDC). Laparoscopic management of CDC is a technically challenging procedure that requires advanced intracorporeal suturing skills, and hence, has a steep learning curve. Robotic surgery has the advantages of 3D vision, articulating hand instruments making suturing easy and thus is ideal. However, the non-availability, high costs and necessity for large-size ports are the major limiting factors for robotic procedures in the paediatric population. Use of 3D laparoscopy incorporates the advantage of 3D vision and at the same time allows the use of small-sized conventional laparoscopic instruments. With this background, we discuss our initial experience with the use of 3D laparoscopy using conventional hand instruments in CDC management. AIM To study our initial experience in the management of CDC in paediatric patients with 3D laparoscopy in terms of feasibility and peri-operative details. MATERIALS AND METHOD All patients under 12 years of age treated for choledochal cyst in a period of initial 2 years were retrospectively analysed. Demographic parameters, clinical presentation, intra-operative time, blood loss, post-operative events and follow-up were studied. RESULTS The total number of patients were 21. The mean age was 5.3 years with female preponderance. Abdominal pain was the most common presenting symptom. All patients could be completed laparoscopically. No patient needed conversion to open procedure or re-exploration. The average blood loss was 26.67 ml. None of the patients required a blood transfusion. One patient developed a minor leak postoperatively and was managed conservatively. CONCLUSION 3D laparoscopic management of CDC in the paediatric age group is safe and feasible. It offers the advantages of depth perception aiding intracorporeal suturing, with the use of small-sized instruments. It is thus a 'bridging the gap' asset between conventional laparoscopy and robotic surgery. LEVEL OF EVIDENCE Treatment study level IV.
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Affiliation(s)
- Sandesh V Parelkar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Deepa P Makhija
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India.
| | - Beejal V Sanghvi
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Rahul K Gupta
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Kedar P Mudkhedkar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Rujuta S Shah
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Abhijit Kumar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Aditi Rangnekar
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
| | - Nehal Shah
- Department of Paediatric Surgery, Seth G.S. Medical College and K.E.M. Hospital, Mumbai, Maharashta, India
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Shah AP, Walker KA, Walker KG, Hawick L, Cleland J. "It's making me think outside the box at times": a qualitative study of dynamic capabilities in surgical training. ADVANCES IN HEALTH SCIENCES EDUCATION : THEORY AND PRACTICE 2023; 28:499-518. [PMID: 36287293 PMCID: PMC9607851 DOI: 10.1007/s10459-022-10170-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 09/27/2022] [Indexed: 05/11/2023]
Abstract
Craft specialties such as surgery endured widespread disruption to postgraduate education and training during the pandemic. Despite the expansive literature on rapid adaptations and innovations, generalisability of these descriptions is limited by scarce use of theory-driven methods. In this research, we explored UK surgical trainees' (n = 46) and consultant surgeons' (trainers, n = 25) perceptions of how learning in clinical environments changed during a time of extreme uncertainty (2020/2021). Our ultimate goal was to identify new ideas that could shape post-pandemic surgical training. We conducted semi-structured virtual interviews with participants from a range of working/training environments across thirteen Health Boards in Scotland. Initial analysis of interview transcripts was inductive. Dynamic capabilities theory (how effectively an organisation uses its resources to respond to environmental changes) and its micro-foundations (sensing, seizing, reconfiguring) were used for subsequent theory-driven analysis. Findings demonstrate that surgical training responded dynamically and adapted to external and internal environmental uncertainty. Sensing threats and opportunities in the clinical environment prompted trainers' institutions to seize new ways of working. Learners gained from reconfigured training opportunities (e.g., splitting operative cases between trainees), pan-surgical working (e.g., broader surgical exposure), redeployment (e.g., to medical specialties), collaborative working (working with new colleagues and in new ways) and supervision (shifting to online supervision). Our data foreground the human resource and structural reconfigurations, and technological innovations that effectively maintained surgical training during the pandemic, albeit in different ways. These adaptations and innovations could provide the foundations for enhancing surgical education and training in the post-pandemic era.
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Affiliation(s)
- Adarsh P Shah
- Centre for Healthcare Education Research and Innovation (CHERI), School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK.
| | - Kim A Walker
- Centre for Healthcare Education Research and Innovation (CHERI), School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Kenneth G Walker
- NHS Education for Scotland, Centre for Health Science, Inverness, UK
| | - Lorraine Hawick
- Centre for Healthcare Education Research and Innovation (CHERI), School of Medicine, Medical Sciences and Nutrition, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Jennifer Cleland
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore
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Klos D, Gregořík M, Pavlík T, Loveček M, Tesaříková J, Skalický P. Major iatrogenic bile duct injury during elective cholecystectomy: a Czech population register-based study. Langenbecks Arch Surg 2023; 408:154. [PMID: 37079112 PMCID: PMC10116090 DOI: 10.1007/s00423-023-02897-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 04/14/2023] [Indexed: 04/21/2023]
Abstract
PURPOSE Bile duct injury (BDI) remains the most serious complication following cholecystectomy. However, the actual incidence of BDI in the Czech Republic remains unknown. Hence, we aimed to identify the incidence of major BDI requiring operative reconstruction after elective cholecystectomy in our region despite the prevailing modern 4 K Ultra HD laparoscopy and Critical View of Safety (CVS) standards implemented in daily surgical practice among the Czech population. METHODS In the absence of a specific registry for BDI, we analysed data from The Czech National Patient Register of Reimbursed Healthcare Services, where all procedures are mandatorily recorded. We investigated 76,345 patients who were enrolled for at least a year and underwent elective cholecystectomy during the period from 2018-2021. In this cohort, we examined the incidence of major BDI following the reconstruction of the biliary tract and other complications. RESULTS A total of 76,345 elective cholecystectomies were performed during the study period, and 186 major BDIs were registered (0.24%). Most elective cholecystectomies were performed laparoscopically (84.7%), with the remaining open (15.3%). The incidence of BDI was higher in the open surgery group (150 BDI/11700 cases/1.28%) than in laparoscopic cholecystectomy (36 BDI/64645 cases/0.06%). Furthermore, the total hospital stays with BDI after reconstruction was 13.6 days. However, the majority of laparoscopic elective cholecystectomies (57,914, 89.6%) were safe and standard procedures with no complications. CONCLUSION Our study corroborates the findings of previous nationwide studies. Therefore, though laparoscopic cholecystectomy is reliable, the risks of BDI cannot be eliminated.
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Affiliation(s)
- Dušan Klos
- Department of Surgery I., Faculty of Medicine and Dentistry, University Hospital Olomouc and Palacký University Olomouc, Zdravotníků 248/7, CZ-77900, Olomouc, Czech Republic
| | - Michal Gregořík
- Department of Surgery I., Faculty of Medicine and Dentistry, University Hospital Olomouc and Palacký University Olomouc, Zdravotníků 248/7, CZ-77900, Olomouc, Czech Republic
| | - Tomáš Pavlík
- Institute of Health Information and Statistics of the Czech Republic, Palackého náměstí 4, CZ-12801, Prague, Czech Republic
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice 753/5, CZ-62500, Brno, Czech Republic
| | - Martin Loveček
- Department of Surgery I., Faculty of Medicine and Dentistry, University Hospital Olomouc and Palacký University Olomouc, Zdravotníků 248/7, CZ-77900, Olomouc, Czech Republic
| | - Jana Tesaříková
- Department of Surgery I., Faculty of Medicine and Dentistry, University Hospital Olomouc and Palacký University Olomouc, Zdravotníků 248/7, CZ-77900, Olomouc, Czech Republic
| | - Pavel Skalický
- Faculty of Medicine, Institute of Biostatistics and Analyses, Masaryk University, Kamenice 753/5, CZ-62500, Brno, Czech Republic.
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Ríos MS, Molina-Rodriguez MA, Londoño D, Guillén CA, Sierra S, Zapata F, Giraldo LF. Cholec80-CVS: An open dataset with an evaluation of Strasberg's critical view of safety for AI. Sci Data 2023; 10:194. [PMID: 37031247 PMCID: PMC10082817 DOI: 10.1038/s41597-023-02073-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/15/2023] [Indexed: 04/10/2023] Open
Abstract
Strasberg's criteria to detect a critical view of safety is a widely known strategy to reduce bile duct injuries during laparoscopic cholecystectomy. In spite of its popularity and efficiency, recent studies have shown that human miss-identification errors have led to important bile duct injuries occurrence rates. Developing tools based on artificial intelligence that facilitate the identification of a critical view of safety in cholecystectomy surgeries can potentially minimize the risk of such injuries. With this goal in mind, we present Cholec80-CVS, the first open dataset with video annotations of Strasberg's Critical View of Safety (CVS) criteria. Our dataset contains CVS criteria annotations provided by skilled surgeons for all videos in the well-known Cholec80 open video dataset. We consider that Cholec80-CVS is the first step towards the creation of intelligent systems that can assist humans during laparoscopic cholecystectomy.
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Affiliation(s)
- Manuel Sebastián Ríos
- Department of Electric and Electronic Engineering, Universidad de Los Andes, Bogotá D.C., Colombia
| | | | - Daniella Londoño
- Department of General Surgery, Universidad CES, Medellín, Colombia
| | - Camilo Andrés Guillén
- Department of Electric and Electronic Engineering, Universidad de Los Andes, Bogotá D.C., Colombia
| | - Sebastián Sierra
- Department of General Surgery, Universidad CES, Medellín, Colombia
| | - Felipe Zapata
- Department of General Surgery, Universidad CES, Medellín, Colombia
| | - Luis Felipe Giraldo
- Department of Biomedical Engineering, Universidad de Los Andes, Bogotá D.C., Colombia.
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Grover K, Korenblit N, Babu A, Podolsky D, Carbonell A, Orenstein S, Pauli EM, Novitsky Y, Madani A, Sullivan M, Nieman D. Understanding How Experts Do It: A Conceptual Framework for the Open Transversus Abdominis Release Procedure. Ann Surg 2023; 277:498-505. [PMID: 36538631 DOI: 10.1097/sla.0000000000005756] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The safe and effective performance of a posterior component separation via a transversus abdominis release (TAR) requires intraoperative judgement and decision-making skills that are difficult to define, standardize, and teach. We herein present the first qualitative study which builds a framework upon which training and objective evaluation of a TAR can be based. METHODS Hierarchical and cognitive task analyses for a TAR procedure were performed using semistructured interviews of hernia experts to describe the thoughts and behaviors that exemplify optimal performance. Verbal data was recorded, transcribed, coded, and thematically analyzed. RESULTS A conceptual framework was synthesized based on literary sources (4 book chapters, 4 peer-reviewed articles, 3 online videos), 2 field observations, and interviews of 4 hernia experts [median 66 minutes (44-78)]. Subject matter experts practiced a median of 6.5 years (1.5-16) and have completed a median of 300 (60-500) TARs. After 5 rounds of inductive analysis, 80 subtasks, 86 potential errors, 36 cognitive behaviors, and 17 decision points were identified and categorized into 10 procedural steps (midline laparotomy, adhesiolysis, retrorectus dissection, etc.) and 9 fundamental principles: patient physiology and disease burden; tactical modification; tissue reconstruction and wound healing; task completion; choice of technique and instruments; safe planes and danger zones; exposure, ergonomics, environmental limitations; anticipation and forward planning; and tissue trauma and handling. CONCLUSION This is the first study to define the key tasks, decisions, and cognitive behaviors that are essential to a successful TAR procedure.
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Affiliation(s)
- Karan Grover
- Division of General Surgery, Rutgers Biomedical and Health Sciences-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Nechama Korenblit
- Division of General Surgery, Rutgers Biomedical and Health Sciences-Robert Wood Johnson Medical School, New Brunswick, NJ
| | - Archana Babu
- Division of General Surgery, Jefferson Medical Center, Philadelphia, PA
| | - Dina Podolsky
- Division of General Surgery, Columbia University Medical Center, New York, NY
| | - Alfredo Carbonell
- Department of Surgery, University of South Carolina School of Medicine-Greenville/Prisma Health, Greenville, SC
| | - Sean Orenstein
- Division of Gastrointestinal and General Surgery, Oregon Health and Science University School of Medicine, Portland, OR
| | - Eric M Pauli
- Department of Surgery, Penn State Hershey Medical Center, Hershey, PA
| | - Yuri Novitsky
- Division of General Surgery, Columbia University Medical Center, New York, NY
| | - Amin Madani
- Division of General Surgery, University Health Network - Toronto General Hospital, Toronto, Canada
| | - Maura Sullivan
- Surgical Skills Simulation and Education Center, Keck School of Medicine, Los Angeles, CA
| | - Dylan Nieman
- Division of General Surgery, Rutgers Biomedical and Health Sciences-Robert Wood Johnson Medical School, New Brunswick, NJ
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Stolz MP, Foxhall EN, Gibson BH, Gill S, McNamee MM. Improving the Safety of Laparoscopic Cholecystectomy with Indocyanine Green Dye Using Critical View of Safety Plus. Am Surg 2023:31348231161659. [PMID: 36857190 DOI: 10.1177/00031348231161659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2023]
Abstract
BACKGROUND During a laparoscopic cholecystectomy, the critical view of safety is obtained through dissection of the gallbladder from the liver until there is anterior and posterior visualization of the cystic duct and cystic artery. This view is used to allow for proper identification of the cystic duct and artery that will be clipped and incised during the operation. Indocyanine green (ICG) can be used during the operation to directly visualize the biliary tract because of its excretion through the biliary system and elimination via the GI tract. Using a laparoscope capable of visualizing ICG allows for identification of bile duct anatomy to include: common hepatic bile duct, cystic duct, and aberrant, or accessory bile ducts. Additionally, visualization of the biliary structures using ICG prior to clipping and incision will allow for identification and prevention of missed biliary anatomy which could reduce incidence of bile leak, a known complication of cholecystectomies. We propose that visualization of the critical view of safety with ICG fluoroscopy be termed the critical view of safety plus. PURPOSE We hypothesized that using the critical view of safety plus method for laparoscopic cholecystectomy will yield better scores and increase the decision of the control surgeon to choose to cut and proceed with the operation when compared with the traditional critical view of safety. RESEARCH DESIGN Comparision of operative photos of critical view of safety and critical view of safety plus which were randomized, double blinded, and graded by a single control surgeon. STUDY SAMPLE Our study consisted of fifty patients of which 72% female (n = 36) and 28% male (n = 14). The ethnic background included 76% non-Hispanic (n = 38) and 24% Hispanic or of Latino/a origin (n = 12). The average age of our patient was 49 years old (range 20 to 93 years old). Inclusion criteria consisted of patients undergoing laparoscopic cholecystectomy greater than or equal to 18 years old. Exclusion criteria included allergy to indocyanine dye or iodine and pregnancy. ANALYSIS The scores were evaluated using Chi-squared and paired T-test analysis using MedCalc, MedCalc Sofware Ltd, Belgium. RESULTS The decision to cut and proceed with the operation was chosen 29 times (58%) when viewing the critical view of safety plus vs 22 times (44%) with the critical view of safety (χ2 = 65.822, p < 0.0001). The decision to proceed with further dissection to isolate the cystic duct viewing the critical view of safety plus was chosen 8 times (16%) vs 11 times (22%) with critical view of safety (χ2 = 65.822, p < 0.0001) as shown in Fig. 2. The comparison of total scores with critical view of safety plus vs critical view of safety showed an average of 4.36 vs 4.04, p = 0.0733. The critical view of safety plus and critical view of safety individual criteria scores are: "two structures connected to the gallbladder" (average 1.54 vs 1.50, p = 0.598), "cystic plate clearance" (average 1.42 vs 1.28, p = 0.018), and "hepatocystic triangle clearance" (average 1.4 vs 1.26, p =0.0334). CONCLUSION We recommend routine use of ICG fluoroscopy to obtain the critical view of safety plus to allow for improved visualization of the biliary tree, identification of aberrant biliary anatomy, and the potential to reduce risk of bile duct injury.
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Affiliation(s)
- Michael P Stolz
- Department of General Surgery, 21055Northeast Georgia Medical Center and Health System, Gainesville, GA, USA
| | - Edward N Foxhall
- Department of General Surgery, 21055Northeast Georgia Medical Center and Health System, Gainesville, GA, USA
| | - Brian H Gibson
- GME-General Surgery, 235950Northeast Georgia Medical Center Gainesville, Gainesville, GA, USA
| | - Sujata Gill
- 534865Northside Hospital Inc, Atlanta, GA, USA
| | - Molly M McNamee
- Department of General Surgery, 21055Northeast Georgia Medical Center and Health System, Gainesville, GA, USA
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Laplante S, Namazi B, Kiani P, Hashimoto DA, Alseidi A, Pasten M, Brunt LM, Gill S, Davis B, Bloom M, Pernar L, Okrainec A, Madani A. Validation of an artificial intelligence platform for the guidance of safe laparoscopic cholecystectomy. Surg Endosc 2023; 37:2260-2268. [PMID: 35918549 DOI: 10.1007/s00464-022-09439-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 07/04/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Many surgical adverse events, such as bile duct injuries during laparoscopic cholecystectomy (LC), occur due to errors in visual perception and judgment. Artificial intelligence (AI) can potentially improve the quality and safety of surgery, such as through real-time intraoperative decision support. GoNoGoNet is a novel AI model capable of identifying safe ("Go") and dangerous ("No-Go") zones of dissection on surgical videos of LC. Yet, it is unknown how GoNoGoNet performs in comparison to expert surgeons. This study aims to evaluate the GoNoGoNet's ability to identify Go and No-Go zones compared to an external panel of expert surgeons. METHODS A panel of high-volume surgeons from the SAGES Safe Cholecystectomy Task Force was recruited to draw free-hand annotations on frames of prospectively collected videos of LC to identify the Go and No-Go zones. Expert consensus on the location of Go and No-Go zones was established using Visual Concordance Test pixel agreement. Identification of Go and No-Go zones by GoNoGoNet was compared to expert-derived consensus using mean F1 Dice Score, and pixel accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). RESULTS A total of 47 frames from 25 LC videos, procured from 3 countries and 9 surgeons, were annotated simultaneously by an expert panel of 6 surgeons and GoNoGoNet. Mean (± standard deviation) F1 Dice score were 0.58 (0.22) and 0.80 (0.12) for Go and No-Go zones, respectively. Mean (± standard deviation) accuracy, sensitivity, specificity, PPV and NPV for the Go zones were 0.92 (0.05), 0.52 (0.24), 0.97 (0.03), 0.70 (0.21), and 0.94 (0.04) respectively. For No-Go zones, these metrics were 0.92 (0.05), 0.80 (0.17), 0.95 (0.04), 0.84 (0.13) and 0.95 (0.05), respectively. CONCLUSIONS AI can be used to identify safe and dangerous zones of dissection within the surgical field, with high specificity/PPV for Go zones and high sensitivity/NPV for No-Go zones. Overall, model prediction was better for No-Go zones compared to Go zones. This technology may eventually be used to provide real-time guidance and minimize the risk of adverse events.
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Affiliation(s)
- Simon Laplante
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada.
- Department of Surgery, University of Toronto, Toronto, ON, Canada.
- MIS Fellow, Toronto Western Hospital, Division of General Surgery, 8MP-325., 399 Bathurst St, Toronto,, ON, M5T 2S8, Canada.
| | - Babak Namazi
- Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Parmiss Kiani
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
| | | | - Adnan Alseidi
- Department of Surgery, University of California, San Francisco, CA, USA
| | - Mauricio Pasten
- Instituto de Gastroenterologia Boliviano Japones, Cochabamba, Bolivia
| | - L Michael Brunt
- Department of Surgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Sujata Gill
- Department of Surgery, Northeast Georgia Medical Center, Georgia, USA
| | - Brian Davis
- Department of Surgery, Texas Tech Paul L Foster School of Medicine, El Paso, TX, USA
| | - Matthew Bloom
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Luise Pernar
- Department of Surgery, Boston medical center, Boston, MA, USA
| | - Allan Okrainec
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Amin Madani
- Surgical Artificial Intelligence Research Academy, University Health Network, Toronto, ON, Canada
- Department of Surgery, University of Toronto, Toronto, ON, Canada
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Near-infrared fluorescence cholangiography assisted laparoscopic cholecystectomy (FALCON): an international multicentre randomized controlled trial. Surg Endosc 2023:10.1007/s00464-023-09935-6. [PMID: 36849564 DOI: 10.1007/s00464-023-09935-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/05/2023] [Indexed: 03/01/2023]
Abstract
AIM To assess the added value of Near InfraRed Fluorescence (NIRF) imaging during laparoscopic cholecystectomy. METHODS This international multicentre randomized controlled trial included participants with an indication for elective laparoscopic cholecystectomy. Participants were randomised into a NIRF imaging assisted laparoscopic cholecystectomy (NIRF-LC) group and a conventional laparoscopic cholecystectomy (CLC) group. Primary end point was time to 'Critical View of Safety' (CVS). The follow-up period of this study was 90 postoperative days. An expert panel analysed the video recordings after surgery to confirm designated surgical time points. RESULTS A total of 294 patients were included, of which 143 were randomized in the NIRF-LC and 151 in the CLC group. Baseline characteristics were equally distributed. Time to CVS was on average 19 min and 14 s for the NIRF-LC group and 23 min and 9 s for the CLC group (p 0.032). Time to identification of the CD was 6 min and 47 s and 13 min for NIRF-LC and CLC respectively (p < 0.001). Transition of the CD in the gallbladder was identified after an average of 9 min and 39 s with NIRF-LC, compared to 18 min and 7 s with CLC (p < 0.001). No difference in postoperative length of hospital stay nor occurrence of postoperative complications was found. ICG related complications were limited to one patient who developed a rash after injection of ICG. CONCLUSION Use of NIRF imaging in laparoscopic cholecystectomy provides earlier identification of relevant extrahepatic biliary anatomy: earlier achievement of CVS, cystic duct visualisation and visualisation of both cystic duct and cystic artery transition into the gallbladder.
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Use of Critical View of Safety and Proctored Preceptorship in Preventing Bile Duct Injury During Laparoscopic Cholecystectomy-Experience of 3726 Cases From a Tertiary Care Teaching Institute. SURGICAL LAPAROSCOPY, ENDOSCOPY & PERCUTANEOUS TECHNIQUES 2023; 33:12-17. [PMID: 36730233 DOI: 10.1097/sle.0000000000001127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 09/06/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION Bile duct injury (BDI) continues to occur despite technological advances and improvements in surgical training over the past 2 decades. This study was conducted to audit our data on laparoscopic cholecystectomies performed over the past 2 decades to determine the role of Critical View of Safety (CVS) and proctored preceptorship in preventing BDI and postoperative complications. MATERIALS AND METHODS All patients undergoing elective laparoscopic cholecystectomy were analyzed retrospectively. The data were obtained from a prospectively maintained database from January 2004 to December 2019. Proctored preceptorship was used in all cases. Intraoperative details included the number of patients where CVS was defined, number of BDI and conversions. Postoperative outcomes, including hospital stay, morbidity, and bile duct stricture, were noted. RESULTS Three thousand seven hundred twenty-six patients were included in the final analysis. Trainee surgeons performed 31.6% of surgeries and 9.5% of these surgeries were taken over by the senior surgeon. A CVS could be delineated in 96.6% of patients. The major BDI rate was only 0.05%. CONCLUSION This study reiterates the fact that following the basic tenets of safe laparoscopic cholecystectomy, defining and confirming CVS, and following proctored preceptorship are critical in preventing major BDI.
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SAGES safe cholecystectomy modules improve practicing surgeons' judgment: results of a randomized, controlled trial. Surg Endosc 2023; 37:862-870. [PMID: 36006521 DOI: 10.1007/s00464-022-09503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 07/23/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Despite the advantages of laparoscopic cholecystectomy, major bile duct injury (BDI) rates during this operation remain unacceptably high. In October 2018, SAGES released the Safe Cholecystectomy modules, which define specific strategies to minimize the risk of BDI. This study aims to investigate whether this curriculum can change the knowledge and behaviors of surgeons in practice. METHODS Practicing surgeons were recruited from the membership of SAGES and the American College of Surgeons Advisory Council for Rural Surgery. All participants completed a baseline assessment (pre-test) that involved interpreting cholangiograms, troubleshooting difficult cases, and managing BDI. Participants' dissection strategies during cholecystectomy were also compared to the strategies of a panel of 15 experts based on accuracy scores using the Think Like a Surgeon validated web-based platform. Participants were then randomized to complete the Safe Cholecystectomy modules (Safe Chole module group) or participate in usually scheduled CME activities (control group). Both groups completed repeat assessments (post-tests) one month after randomization. RESULTS Overall, 41 participants were eligible for analysis, including 18 Safe Chole module participants and 23 controls. The two groups had no significant differences in pre-test scores. However, at post-test, Safe Chole module participants made significantly fewer errors managing BDI and interpreting cholangiograms. Safe Chole module participants were less likely to convert to an open operation on the post-test than controls when facing challenging dissections. However, Safe Chole module participants displayed a similar incidence of errors when evaluating adequate critical views of safety. CONCLUSIONS In this randomized-controlled trial, the SAGES Safe Cholecystectomy modules improved surgeons' abilities to interpret cholangiograms and safely manage BDI. Additionally, surgeons who studied the modules were less likely to convert to open during difficult dissections. These data show the power of the Safe Cholecystectomy modules to affect practicing surgeons' behaviors in a measurable and meaningful way.
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Justaniah A, Abughararah MZ, Ahmad N, Ashour M, Alqarni H. Percutaneous Management of Hepatic Duct Injury Using Extra-Anatomic Biliary Catheters. Cureus 2023; 15:e35012. [PMID: 36938281 PMCID: PMC10021372 DOI: 10.7759/cureus.35012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/17/2023] Open
Abstract
Iatrogenic bile duct injury during laparoscopic cholecystectomy is a known complication of low incidence. The outcome can be devastating if not recognized and managed timely and properly. In cases of iatrogenic biliary injury due to cholecystectomy, the management depends on the level of injury, the timing of discovery (intraoperative or postoperative), and the patient's condition. If discovered intraoperatively, the injury should be managed immediately. In case expertise is lacking, a surgical drain with external biliary drainage can provide a temporary alternative solution to allow for referral to a tertiary care center. If the patient is septic or not fit for surgery, a percutaneous internal-external biliary drainage (PTBD) catheter can be placed until the patient's condition improves. We report a case of complete transection of the common hepatic duct during laparoscopic cholecystectomy managed by extra-anatomic PTBD.
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Affiliation(s)
- Almamoon Justaniah
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Mohamed Z Abughararah
- General Surgery, Hepatobiliary Unit, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Niaz Ahmad
- Surgery, St. James's University Hospital, Leeds, GBR
| | - Majed Ashour
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
| | - Hassan Alqarni
- Department of Radiology, King Faisal Specialist Hospital and Research Centre, Jeddah, SAU
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Potharazu AV, Gangemi A. Indocyanine green (ICG) fluorescence in robotic hepatobiliary surgery: A systematic review. Int J Med Robot 2023; 19:e2485. [PMID: 36417426 PMCID: PMC10078519 DOI: 10.1002/rcs.2485] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 11/08/2022] [Accepted: 11/21/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Indocyanine green fluorescence (ICG-F) stains hepatic tumours and delineates vascular and biliary structures in real-time. We detail the efficacy of ICG-F in robotic hepatobiliary surgery. METHODS PubMed, EMBASE, Web of Science, and Cochrane Central were searched for original articles and meta-analyses detailing the outcomes of ICG-F in robotic hepatobiliary surgery. RESULTS 214 abstracts were reviewed; 16 studies are presented. One single-institution study reported ICG-F in robotic right hepatectomy reduced postoperative bile leakage (0% vs. 12%, p = 0.023), R1 resection (0% vs. 16%, p = 0.019), and readmission (p = 0.023) without prolonging operative time (288 vs. 272 min, p = 0.778). Improved visualisation aided in attainment of R0 resection in partial hepatectomies and radical gallbladder adenocarcinoma resections. Fewer ICG-F-aided robotic cholecystectomies were converted to open procedure compared to laparoscopic cholecystectomies (2.1% vs. 8.9%, p = 0.03; 0.15% vs. 2.6%, p < 0.001). CONCLUSIONS ICG-F improves clinical outcomes in robotic hepatobiliary surgery without prolonging operative time. There is an opportunity to standardise ICG administration protocols, especially for hepatectomies.
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Affiliation(s)
- Archit V Potharazu
- College of Medicine, University of Illinois at Chicago, Chicago, IL, USA
| | - Antonio Gangemi
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, Policlinico Sant'Orsola IRCCS, Bologna, Italy
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