IDEAL-D Framework for Device Innovation: A Consensus Statement on the Preclinical Stage

The need for state-of-the-art orthopedic surgical technology in low- to middle income countries : The case of distraction epiphyseolysis for limb lengthening in children with fibular hemimelia in Uzbekistan

INTRODUCTION

Amongst low- to middle income countries (LMIC), outdated and poorly documented orthopedic interventions may pose patients at risk for complications, serious adverse events (SAE) and unsatisfactory results, contradicting the World Health Organization's (WHO) Safe Surgery mandates. Use cases of conditions managed inadequately in LMIC environments are necessary to increase awareness of stakeholders and overcome deficiencies in collaboration with high-income countries (HIC).

MATERIALS AND METHODS

Methodological and clinical experts from the BG Kliniken and the Charité, Berlin, Germany, were invited to investigate established processes for musculoskeletal disorders and injuries in Tashkent, Uzbekistan. Congenital lower leg discrepancy due to fibular hemimelia was recognized as an illustrative example to prove the effectiveness of local treatment guidelines, still relying on distraction epiphyseolysis (chondrodiatasis) via an Ilizarov frame. Routine data from hospital records, images and outpatient follow-up examinations were compared to estimates from a review of studies of limb-lengthening by other techniques.

RESULTS

Data from 16 of 49 immature patients (10 males, 6 females, mean age at surgery, 4.2 ± 2.3 years) undergoing chondrodiatasis between 2017 and 2021 showed a mean limb elongation of 2.4 (95% confidence interval [CI], 1.9 to 2.9) cm after a median follow-up of 29 (range, 24 to 36) months. While no complications or SAE were noted, findings are compatible with a risk of 21% under an upper 97.5% confidence limit for null events. No reproducible classification of hemimelia, surgical or general complications, assessment of functional outcomes or health-related quality of life were available. The pooled average length gain from 21 studies on different other interventions with osteotomy enrolling 458 limbs was 5.1 (95% CI, 5.0 to 5.3) cm.

CONCLUSIONS OF THE USE CASE

Limb lengthening for hereditary fibular hemimelia in Uzbekistan revealed rather obsolete surgical algorithms, inadequate documentation, and unreliable outcome assessment. Resource limitations notwithstanding, knowledge transfer, implementation of current procedures and hardware, and international collaboration is vital to improve quality of care in this scenario and for the benefit of LMIC in general.

Innovative External Cranial Devices for Protecting a Craniectomy Site: A Scoping Review on Noninvasive Approaches for Patients Awaiting Cranioplasty

BACKGROUND AND OBJECTIVES

Decompressive craniectomy (DC) is a commonly performed procedure to alleviate high intracranial pressure. To enhance patient quality of life and minimize complications after DC in patients awaiting cranioplasty (CP), multidisciplinary teams have designed and implemented external protective prototypes, including 3-dimensional printing and plaster models, whenever feasible. The aim of this scoping review was to assess the evidence available on innovative external cranial devices that protect the craniectomy site for patients who have undergone DC while awaiting CP in high-income countries and low- and middle-income countries.

METHODS

This scoping review was conducted following the methodology outlined by the Joanna Briggs Institute. Searches were performed in databases such as MEDLINE, Embase, Web of Science, Scielo, Scopus, and World Health Organization Global Health Index Medicus. Patent documents were also searched in Espacenet, Google Patents, and World Intellectual Property Organization. This scoping review included external protective devices for adult patients who underwent DC and CP, while invasive devices were excluded.

RESULTS

A total of 9 documents described external cranial devices, with 7 of them led by researchers from high-income countries, including the United States (n = 4), Singapore (n = 1), the United Kingdom (n = 1), and Hong Kong SAR, China (n = 1). Among these devices, 77.7% (n = 7) were created using 3-dimensional printing, while 22.3% (n = 2) were developed through plaster hand modeling. The individual study results were summarized.

CONCLUSION

Sustainable Development Goal (SDG) 3, SDG 9, and SDG 10 play a crucial role in the advancement of innovative strategies to ensure access to essential neurosurgical care, reduce global disparities in treatment outcomes, mitigate postoperative complications, and provide life-saving interventions. This scoping review provides fundamental evidence for multidisciplinary teams involved in designing noninvasive innovations to minimize the risks associated with post-DC complications. It is anticipated that more cost-effective models, particularly in low- and middle-income countries, can be implemented based on the findings of this review.

Novel Design of Interlocking 3-Dimensional Miniplate in Mandibular Angle Fractures: An In Vitro Study

The evolution of osteosynthesis has led to the development of novel miniplate designs, including 3-dimensional (3D) miniplates, which offer improved biomechanical stability. However, mandible fractures resulting from the high impact have a complex fracture configuration. Hence, the authors developed interlocking 3D miniplate to overcome the difficulty in miniplate and screw placement to avoid critical anatomic structures, that is, dental roots and nerve, while still providing stability for the fracture fragments. The interlocking 3D miniplates can be formed according to the specific needs by adjusting the horizontal and vertical cross struts configuration. This study describes a design process of interlocking 3D miniplates and evaluates biomechanical performance compared to standard miniplates. Finite element analysis was performed to evaluate the design's stress state using human and goat mandible models under various loading conditions. After the authors, established that our design was feasible for fabrication, the authors developed the prototype for biomechanical testing. Biomechanical testing was conducted on 10 goat mandibles to compare stability and displacement under various load between the interlocking 3D miniplate and the standard miniplate configuration. Biomechanical testing revealed reduced displacement in all directions with the interlocking 3D miniplate compared to the standard miniplate. Furthermore, there was a significant difference in all loads in the buccal-lingual displacement ( P <0.05). The novel interlocking 3D miniplate design shows an adequate ability to provide stability for fixation for mandibular fractures, as evidenced by finite element analysis and biomechanical testing. Further research is necessary to validate these findings and explore the clinical application of interlocking 3D miniplates in mandibular fracture management.

Robotic assisted orbital surgery for resection of advanced periocular tumours - a case series report on the feasibility, safety and outcome

PURPOSE

Orbital surgery benefits from well-designed instrumentation that offers gentle tissue manipulation, high manoeuvrability and control. Nevertheless, in confined spaces, tissue manipulation must be accomplished with exceptionally high accuracy and precision. This is where robotic surgery offers an advantage. We aimed to evaluate a robotic-assisted surgical system's feasibility, safety and outcome in assisting tumour clearance.

PATIENTS AND METHODS

A case series of patients with advanced periocular tumours undergoing robotic-assisted globe-sparing resection was performed using the DaVinci XI system (Intuitive Surgical, Inc). Institutional ethics and multidisciplinary approval were sought in all cases.

RESULTS

Four patients with advanced periocular tumours underwent robotic-assisted orbital surgery at a mean age of 63 years (range 42-86). Two patients were diagnosed with squamous cell carcinoma, and two had basal cell carcinoma. One patient was found to have positive lymph nodes at the time of surgery and underwent simultaneous parotidectomy and lymph node clearance. Clear resection of the primary tumour was achieved in all patients; three patients underwent further resection due to narrow margins prior to reconstruction. Patients were follow-up for at least one year, and three remained disease-free. One patient with pre-existing extra-orbital disease developed metastatic disease four months post-op. All patients preserved vision peri-operatively, with no complaints of diplopia. Moderate ocular surface disease was noted in two patients.

CONCLUSION

Our series highlights the potential advantage of three-dimensional optics, multi-directional instrumentation and motion scaling technology to achieve globe-sparing tumour resection in advanced periocular tumours. However, further robotic instrumentation development is required for orbital surgery.

Robotic Assistance in Percutaneous Liver Ablation Therapies: A Systematic Review and Meta-Analysis

Objective

The aim of this systematic review and meta-analysis is to identify current robotic assistance systems for percutaneous liver ablations, compare approaches, and determine how to achieve standardization of procedural concepts for optimized ablation outcomes.

Background

Image-guided surgical approaches are increasingly common. Assistance by navigation and robotic systems allows to optimize procedural accuracy, with the aim to consistently obtain adequate ablation volumes.

Methods

Several databases (PubMed/MEDLINE, ProQuest, Science Direct, Research Rabbit, and IEEE Xplore) were systematically searched for robotic preclinical and clinical percutaneous liver ablation studies, and relevant original manuscripts were included according to the Preferred Reporting items for Systematic Reviews and Meta-Analyses guidelines. The endpoints were the type of device, insertion technique (freehand or robotic), planning, execution, and confirmation of the procedure. A meta-analysis was performed, including comparative studies of freehand and robotic techniques in terms of radiation dose, accuracy, and Euclidean error.

Results

The inclusion criteria were met by 33/755 studies. There were 24 robotic devices reported for percutaneous liver surgery. The most used were the MAXIO robot (8/33; 24.2%), Zerobot, and AcuBot (each 2/33, 6.1%). The most common tracking system was optical (25/33, 75.8%). In the meta-analysis, the robotic approach was superior to the freehand technique in terms of individual radiation (0.5582, 95% confidence interval [CI] = 0.0167-1.0996, dose-length product range 79-2216 mGy.cm), accuracy (0.6260, 95% CI = 0.1423-1.1097), and Euclidean error (0.8189, 95% CI = -0.1020 to 1.7399).

Conclusions

Robotic assistance in percutaneous ablation for liver tumors achieves superior results and reduces errors compared with manual applicator insertion. Standardization of concepts and reporting is necessary and suggested to facilitate the comparison of the different parameters used to measure liver ablation results. The increasing use of image-guided surgery has encouraged robotic assistance for percutaneous liver ablations. This systematic review analyzed 33 studies and identified 24 robotic devices, with optical tracking prevailing. The meta-analysis favored robotic assessment, showing increased accuracy and reduced errors compared with freehand technique, emphasizing the need for conceptual standardization.

Theory and evidence-base for a digital platform for the delivery of language tests during awake craniotomy and collaborative brain mapping

Objectives

Build the theoretical and evidence-base for a digital platform (map-OR) which delivers intraoperative language tests during awake craniotomy and facilitates collaborative sharing of brain mapping data.

Design

Mixed methodology study including two scoping reviews, international survey, synthesis of development guiding principles and a risk assessment using failure modes and effects analysis.

Setting

The two scoping reviews examined the literature published in the English language. International survey was completed by members of awake craniotomy teams from 14 countries.

Main outcome measures

Scoping review 1: number of technologies described for language mapping during awake craniotomy. Scoping review 2: barriers and facilitators to adopting novel technology in surgery. International survey: degree of language mapping technology penetration into clinical practice.

Results

A total of 12 research articles describing 6 technologies were included. The technologies required a range of hardware components including portable devices, virtual reality headsets and large integrated multiscreen stacks. The facilitators and barriers of technology adoption in surgery were extracted from 11 studies and mapped onto the 4 Unified Theory of Acceptance and Use of Technology constructs. A total of 37 awake craniotomy teams from 14 countries completed the survey. Of the responses, 20 (54.1%) delivered their language tests digitally, 10 (27.0%) delivered tests using cards and 7 (18.9%) used a combination of both. The most commonly used devices were tablet computers (67.7%; n=21) and the most common software used was Microsoft PowerPoint (60.6%; n=20). Four key risks for the proposed digital platform were identified, the highest risk being a software and internet connectivity failure during surgery.

Conclusions

This work represents a rigorous and structured approach to the development of a digital platform for standardized intraoperative language testing during awake craniotomy and for collaborative sharing of brain mapping data.

Trial registration number

Scoping review protocol registrations in OSF registries (scoping review 1: osf.io/su9xm; scoping review 2: osf.io/x4wsc).

Assessing the application of barbed sutures in comparison to conventional sutures for surgical applications: a global systematic review and meta-analysis of preclinical animal studies

BACKGROUND

Following an initiative published by Lancet in 2002 and an IDEAL-D framework, the value of preclinical animal studies has garnered increasing attention in recent research. Numerous preclinical animal experiments tried to generate evidence to guide the development of barbed sutures. However, discernible drawbacks and incongruities in outcomes have emerged between clinical and preclinical animal studies. Therefore, this meta-analysis aimed to review the preclinical animal experiments comparing barbed sutures with conventional sutures. The authors hope to facilitate clinical translation of barbed sutures by evaluating effectiveness, safety, and physical properties/reliability.

MATERIALS AND METHODS

A systematic search of PubMed, EMBASE, Cochrane Library, and ClinicalTrials.gov was conducted to identify controlled preclinical animal experiments comparing barbed sutures with conventional sutures. The risk of bias was assessed using SYRCLE. GRADE approach was used to evaluate evidence quality. Revman was applied to analyze all the data. Subgroup, sensitivity, and meta-regression analyses were also performed.

RESULTS

A total of 62 articles were eligible with low to moderate quality, including 2158 samples from 10 different animal species across 27 surgical procedures. Barbed suture exhibited a significant reduction in suture time, limited change in Cross-Sectional Area (CSA), and decreased instances of tissue disruption (all P <0.05). Subgroup analyses, considering both clinical and research significance, indicated that barbed sutures might cause more specific adverse events and demonstrate suboptimal performance of physical properties/reliability. Meta-regression suggested that heterogeneity resulted from variations in studies and animal models.

CONCLUSION

Although barbed suture demonstrated superiority in numerous surgeries for time efficiency, its safety and physical properties/reliability might be influenced by diverse preclinical models, sutures' brand, surgeries, and anatomical sites. Further evaluation, based on standardized and well-designed animal experiments, is essential for medical device development and applications in human beings.

Prospective development study of the Versius Surgical System for use in transoral robotic surgery: an IDEAL stage 1/2a first in human and initial case series experience

PURPOSE

Transoral robotic surgery is well established in the treatment paradigm of oropharyngeal pathology. The Versius Surgical System (CMR Surgical) is a robotic platform in clinical use in multiple specialities but is currently untested in the head and neck. This study utilises the IDEAL framework of surgical innovation to prospectively evaluate and report a first in human clinical experience and single centre case series of transoral robotic surgery (TORS) with Versius.

METHODS

Following IDEAL framework stages 1 and 2a, the study evaluated Versius to perform first in human TORS before transitioning from benign to malignant cases. Iterative adjustments were made to system setup, instrumentation, and technique, recorded in accordance with IDEAL recommendations. Evaluation criteria included successful procedure completion, setup time, operative time, complications, and subjective impressions. Further evaluation of the system to perform four-arm surgery was conducted.

RESULTS

30 TORS procedures were successfully completed (15 benign, 15 malignant) without intraoperative complication or conversion to open surgery. Setup time significantly decreased over the study period. Instrumentation challenges were identified, urging the need for TORS-specific instruments. The study introduced four-arm surgery, showcasing Versius' unique capabilities, although limitations in distal access were observed.

CONCLUSIONS

TORS is feasible with the Versius Surgical System. The development of TORS-specific instruments would benefit performance and wider adoption of the system. 4-arm surgery is possible however further evaluation is required. Multicentre evaluation (IDEAL stage 2b) is recommended.

Participatory methods used in the evaluation of medical devices: a comparison of focus groups, interviews, and a survey

BACKGROUND

Stakeholder engagement in evaluation of medical devices is crucial for aligning devices with stakeholders' views, needs, and values. Methods for these engagements have however not been compared to analyse their relative merits for medical device evaluation. Therefore, we systematically compared these three methods in terms of themes, interaction, and time-investment.

METHODS

We compared focus groups, interviews, and an online survey in a case-study on minimally invasive endoscopy-guided surgery for patients with intracerebral haemorrhage. The focus groups and interviews featured two rounds, one explorative focussing on individual perspectives, and one interactive focussing on the exchange of perspectives between participants. The comparison between methods was made in terms of number and content of themes, how participants interact, and hours invested by all researchers.

RESULTS

The focus groups generated 34 themes, the interviews 58, and the survey 42. Various improvements for the assessment of the surgical procedure were only discussed in the interviews. In focus groups, participants were inclined to emphasise agreement and support, whereas the interviews consisted of questions and answers. The total time investment for researchers of focus groups was 95 h, of interviews 315 h, and survey 81 h.

CONCLUSIONS

Within the context of medical device evaluation, interviews appeared to be the most appropriate method for understanding stakeholder views since they provide a scope and depth of information that is not generated by other methods. Focus groups were useful to rapidly bring views together. Surveys enabled a quick exploration. Researchers should account for these methodological differences and select the method that is suitable for their research aim.

New robotic platform for transoral robotic surgery: an IDEAL stage 0 study

Objectives

This study aims to assess the feasibility to perform transoral robotic surgery (TORS) with a new robotic platform, the Versius Surgical System (CMR Surgical, UK) in a preclinical cadaveric setting in accordance to stage 0 of the IDEAL-D framework.

Design

IDEAL stage 0 preclinical assessment of the Versius Robotic System in TORS in human cadavers.

Setting

All procedures were performed in a simulated operating theatre environment at a UK surgical training centre.

Participants

11 consultant head and neck surgeons from the UK, mainland Europe and the USA took part in TORS procedures on six human cadavers.

Interventions

3 key index procedures were assessed that represent the core surgical workload of TORS: lateral oropharyngectomy, tongue base resection and partial supraglottic laryngectomy.

Main outcome measures

The primary outcome was the successful completion of each surgical procedure. Secondary outcomes included the optimisation of system setup, instrumentation and surgeon-reported outcomes for feasibility of each component procedural step.

Results

33 cadaveric procedures were performed and 32 were successfully completed. One supraglottic laryngectomy was not fully completed due to issues dividing the epiglottic cartilage with available instrumentation. Surgeon-reported outcomes met the minimal level of feasibility in all procedures and a consensus that it is feasible to perform TORS with Versius was reached. Available instrumentation was not representative of other robotic platforms used in TORS and further instrument optimisation is recommended before wider dissemination.

Conclusions

It is feasible to perform TORS with the Versius Surgical System (CMR Surgical) within a pre-clinical cadaveric setting. Clinical evaluation is needed and appropriate with the system. Further instrument development and optimisation is desirable.

IDEAL-D Phase 0 Evaluation of the Avatera System in Robot-Assisted Prostate, Bladder and Renal Surgery

Purpose: To evaluate the utilization of novel Avatera system in urological operations according to the IDEAL-D framework recommendations for high-risk invasive surgical devices. Materials and Methods: Three surgeons attempted to perform 23 upper and lower urinary tract operations on human cadavers and in live porcine models using the Avatera system. Total operative time and the duration of the substeps were evaluated. Surgical performance was assessed with the Global Evaluative Assessment of Robotic Skills (GEARS) score. Suturing was rated using the technical checklist for the assessment of suturing in robotic surgery. Attending surgeons rated their satisfaction with the Avatera system on a scale of 1-5. Results and Limitation: Seventeen out of 18 operations performed on cadavers were completed, while one pyeloplasty was discontinued. All five operations performed in porcine models were completed. Although 1 pig was euthanized on the fifth postoperative day, its symptoms were unrelated to surgery. Mean GEARS and Suturing scores in the upper urinary tract were 29 ± 0.7 and 29.5 ± 0.95, respectively, and in the lower urinary 28.5 ± 1.2 and 29.5 ± 0.5, respectively. Surgeons' satisfaction was high or very high for all procedures. Conclusions: The Avatera system was associated with good surgical performance and high surgeons' satisfaction rates. All urological procedures performed were shown to be feasible, with comparable risks to other robot-assisted surgery systems.

The IDEAL framework for surgical robotics: development, comparative evaluation and long-term monitoring

The next generation of surgical robotics is poised to disrupt healthcare systems worldwide, requiring new frameworks for evaluation. However, evaluation during a surgical robot's development is challenging due to their complex evolving nature, potential for wider system disruption and integration with complementary technologies like artificial intelligence. Comparative clinical studies require attention to intervention context, learning curves and standardized outcomes. Long-term monitoring needs to transition toward collaborative, transparent and inclusive consortiums for real-world data collection. Here, the Idea, Development, Exploration, Assessment and Long-term monitoring (IDEAL) Robotics Colloquium proposes recommendations for evaluation during development, comparative study and clinical monitoring of surgical robots-providing practical recommendations for developers, clinicians, patients and healthcare systems. Multiple perspectives are considered, including economics, surgical training, human factors, ethics, patient perspectives and sustainability. Further work is needed on standardized metrics, health economic assessment models and global applicability of recommendations.

European Glaucoma Society - A guide on surgical innovation for glaucoma

PROLOGUE: Glaucoma surgery has been, for many decades now, dominated by the universal gold standard which is trabeculectomy augmented with antimetabolites. Tubes also came into the scene to complement what we use to call conventional or traditional glaucoma surgery. More recently we experienced a changing glaucoma surgery environment with the "advent" of what we have become used to calling Minimally Invasive Glaucoma Surgery (MIGS). What is the unmet need, what is the gap that these newcomers aim to fill? Hippocrates taught us "bring benefit, not harm" and new glaucoma techniques and devices aim to provide safer surgery compared to conventional surgery. For the patient, but also for the clinician, safety is important. Is more safety achieved with new glaucoma surgery and, if so, is it associated with better, equivalent, or worse efficacy? Is new glaucoma surgery intended to replace conventional surgery or to complement it as an 'add-on' to what clinicians already have in their hands to manage glaucoma? Which surgery should be chosen for which patient? What are the options? Are they equivalent? These are too many questions for the clinician! What are the answers to the questions? What is the evidence to support answers? Do we need more evidence and how can we produce high-quality evidence? This EGS Guide explores the changing and challenging glaucoma surgery environment aiming to provide answers to these questions. The EGS uses four words to highlight a continuum: Innovation, Education, Communication, and Implementation. Translating innovation to successful implementation is crucially important and requires high-quality evidence to ensure steps forward to a positive impact on health care when it comes to implementation. The vision of EGS is to provide the best possible well-being and minimal glaucomainduced visual disability in individuals with glaucoma within an affordable healthcare system. In this regard, assessing the changes in glaucoma surgery is a pivotal contribution to better care. As mentioned, this Guide aims to provide answers to the crucial questions above. However, every clinician is aware that answers may differ for every person: an individualised approach is needed. Therefore, there will be no uniform answer for all situations and all patients. Clinicians would need, through the clinical method and possibly some algorithm, to reach answers and decisions at the individual level. In this regard, evidence is needed to support clinicians to make decisions. Of key importance in this Guide is to provide an overview of existing evidence on glaucoma surgery and specifically on recent innovations and novel devices, but also to set standards in surgical design and reporting for future studies on glaucoma surgical innovation. Designing studies in surgery is particularly challenging because of many subtle variations inherent to surgery and hence multiple factors involved in the outcome, but even more because one needs to define carefully outcomes relevant to the research question but also to the future translation into clinical practice. In addition this Guide aims to provide clinical recommendations on novel procedures already in use when insufficient evidence exists. EGS has a long tradition to provide guidance to the ophthalmic community in Europe and worldwide through the EGS Guidelines (now in their 5th Edition). The EGS leadership recognized that the changing environment in glaucoma surgery currently represents a major challenge for the clinician, needing specific guidance. Therefore, the decision was made to issue this Guide on Glaucoma Surgery in order to help clinicians to make appropriate decisions for their patients and also to provide the framework and guidance for researchers to improve the quality of evidence in future studies. Ultimately this Guide will support better Glaucoma Care in accordance with EGS's Vision and Mission. Fotis Topouzis EGS President

Intraoperative Applications of Artificial Intelligence in Robotic Surgery: A Scoping Review of Current Development Stages and Levels of Autonomy

OBJECTIVE

A scoping review of the literature was conducted to identify intraoperative artificial intelligence (AI) applications for robotic surgery under development and categorize them by (1) purpose of the applications, (2) level of autonomy, (3) stage of development, and (4) type of measured outcome.

BACKGROUND

In robotic surgery, AI-based applications have the potential to disrupt a field so far based on a master-slave paradigm. However, there is no available overview about this technology's current stage of development and level of autonomy.

METHODS

MEDLINE and EMBASE were searched between January 1, 2010 and May 21, 2022. Abstract screening, full-text review, and data extraction were performed independently by 2 reviewers. The level of autonomy was defined according to the Yang and colleagues' classification and stage of development according to the Idea, Development, Evaluation, Assessment, and Long-term follow-up framework.

RESULTS

One hundred twenty-nine studies were included in the review. Ninety-seven studies (75%) described applications providing Robot Assistance (autonomy level 1), 30 studies (23%) application enabling Task Autonomy (autonomy level 2), and 2 studies (2%) application achieving Conditional autonomy (autonomy level 3). All studies were at Idea, Development, Evaluation, Assessment, and Long-term follow-up stage 0 and no clinical investigations on humans were found. One hundred sixteen (90%) conducted in silico or ex vivo experiments on inorganic material, 9 (7%) ex vivo experiments on organic material, and 4 (3%) performed in vivo experiments in porcine models.

CONCLUSIONS

Clinical evaluation of intraoperative AI applications for robotic surgery is still in its infancy and most applications have a low level of autonomy. With increasing levels of autonomy, the evaluation focus seems to shift from AI-specific metrics to process outcomes, although common standards are needed to allow comparison between systems.

A Fluorescent and Magnetic Hybrid Tracer for Improved Sentinel Lymphadenectomy in Prostate Cancer Patients

In prostate cancer, sentinel lymph node dissection (sLND) offers a personalized procedure with staging ability which is at least equivalent to extended LND while inducing lower morbidity. A bimodal fluorescent-radioactive approach was introduced to improve sentinel LN (SLN) detection. We present the first in-human case series on exploring the use of a fluorescent-magnetic hybrid tracer in a radiation-free sLND procedure. Superparamagnetic iron oxide nanoparticles and indocyanine green were administered simultaneously in five prostate cancer patients scheduled for extended LND, sLND and radical prostatectomy. In situ and ex vivo fluorescence and magnetic signals were documented for each LN sample detected via a laparoscopic fluorescence imaging and magnetometer system. Fluorescence and magnetic activity could be detected in all patients. Overall, 19 lymph node spots could be detected in situ, 14 of which were fluorescently active and 18 of which were magnetically active. In two patients, no fluorescent LNs could be detected in situ. The separation of the LN samples resulted in a total number of 30 SLNs resected. Ex vivo measurements confirmed fluorescence in all but two magnetically active SLNs. One LN detected in situ with both modalities was subsequently shown to contain a metastasis. This study provides the first promising results of a bimodal, radiation-free sLND, combining the advantages of both the magnetic and fluorescence approaches.

Lightfield hyperspectral imaging in neuro-oncology surgery: an IDEAL 0 and 1 study

Introduction

Hyperspectral imaging (HSI) has shown promise in the field of intra-operative imaging and tissue differentiation as it carries the capability to provide real-time information invisible to the naked eye whilst remaining label free. Previous iterations of intra-operative HSI systems have shown limitations, either due to carrying a large footprint limiting ease of use within the confines of a neurosurgical theater environment, having a slow image acquisition time, or by compromising spatial/spectral resolution in favor of improvements to the surgical workflow. Lightfield hyperspectral imaging is a novel technique that has the potential to facilitate video rate image acquisition whilst maintaining a high spectral resolution. Our pre-clinical and first-in-human studies (IDEAL 0 and 1, respectively) demonstrate the necessary steps leading to the first in-vivo use of a real-time lightfield hyperspectral system in neuro-oncology surgery.

Methods

A lightfield hyperspectral camera (Cubert Ultris ×50) was integrated in a bespoke imaging system setup so that it could be safely adopted into the open neurosurgical workflow whilst maintaining sterility. Our system allowed the surgeon to capture in-vivo hyperspectral data (155 bands, 350-1,000 nm) at 1.5 Hz. Following successful implementation in a pre-clinical setup (IDEAL 0), our system was evaluated during brain tumor surgery in a single patient to remove a posterior fossa meningioma (IDEAL 1). Feedback from the theater team was analyzed and incorporated in a follow-up design aimed at implementing an IDEAL 2a study.

Results

Focusing on our IDEAL 1 study results, hyperspectral information was acquired from the cerebellum and associated meningioma with minimal disruption to the neurosurgical workflow. To the best of our knowledge, this is the first demonstration of HSI acquisition with 100+ spectral bands at a frame rate over 1Hz in surgery.

Discussion

This work demonstrated that a lightfield hyperspectral imaging system not only meets the design criteria and specifications outlined in an IDEAL-0 (pre-clinical) study, but also that it can translate into clinical practice as illustrated by a successful first in human study (IDEAL 1). This opens doors for further development and optimisation, given the increasing evidence that hyperspectral imaging can provide live, wide-field, and label-free intra-operative imaging and tissue differentiation.

Current and Future Advances in Surgical Therapy for Pituitary Adenoma

The vital physiological role of the pituitary gland, alongside its proximity to critical neurovascular structures, means that pituitary adenomas can cause significant morbidity or mortality. While enormous advancements have been made in the surgical care of pituitary adenomas, numerous challenges remain, such as treatment failure and recurrence. To meet these clinical challenges, there has been an enormous expansion of novel medical technologies (eg, endoscopy, advanced imaging, artificial intelligence). These innovations have the potential to benefit each step of the patient's journey, and ultimately, drive improved outcomes. Earlier and more accurate diagnosis addresses this in part. Analysis of novel patient data sets, such as automated facial analysis or natural language processing of medical records holds potential in achieving an earlier diagnosis. After diagnosis, treatment decision-making and planning will benefit from radiomics and multimodal machine learning models. Surgical safety and effectiveness will be transformed by smart simulation methods for trainees. Next-generation imaging techniques and augmented reality will enhance surgical planning and intraoperative navigation. Similarly, surgical abilities will be augmented by the future operative armamentarium, including advanced optical devices, smart instruments, and surgical robotics. Intraoperative support to surgical team members will benefit from a data science approach, utilizing machine learning analysis of operative videos to improve patient safety and orientate team members to a common workflow. Postoperatively, neural networks leveraging multimodal datasets will allow early detection of individuals at risk of complications and assist in the prediction of treatment failure, thus supporting patient-specific discharge and monitoring protocols. While these advancements in pituitary surgery hold promise to enhance the quality of care, clinicians must be the gatekeepers of the translation of such technologies, ensuring systematic assessment of risk and benefit prior to clinical implementation. In doing so, the synergy between these innovations can be leveraged to drive improved outcomes for patients of the future.

Optimising trajectory planning for stereotactic brain tumour biopsy using artificial intelligence: a systematic review of the literature

PURPOSE

Despite advances in technology, stereotactic brain tumour biopsy remains challenging due to the risk of injury to critical structures. Indeed, choosing the correct trajectory remains essential to patient safety. Artificial intelligence can be used to perform automated trajectory planning. We present a systematic review of automated trajectory planning algorithms for stereotactic brain tumour biopsies.

METHODS

A PRISMA adherent systematic review was conducted. Databases were searched using keyword combinations of 'artificial intelligence', 'trajectory planning' and 'brain tumours'. Studies reporting applications of artificial intelligence (AI) to trajectory planning for brain tumour biopsy were included.

RESULTS

All eight studies were in the earliest stage of the IDEAL-D development framework. Trajectory plans were compared through a variety of surrogate markers of safety, of which the minimum distance to blood vessels was the most common. Five studies compared manual to automated planning strategies and favoured automation in all cases. However, this comes with a significant risk of bias.

CONCLUSIONS

This systematic review reveals the need for IDEAL-D Stage 1 research into automated trajectory planning for brain tumour biopsy. Future studies should establish the congruence between expected risk of algorithms and the ground truth through comparisons to real world outcomes.

Treating addiction with deep brain stimulation: Ethical and legal considerations

BACKGROUND

The use of neuromodulation in the treatment of psychiatric conditions is controversial despite its lengthy history. This particularly applies to the use of invasive neuromodulation, such as deep brain stimulation (DBS), to treat substance use disorder (SUD) due to the considerable risks of the procedures. However, given the advances in DBS research and the shortcomings of current treatment modalities for addiction, off-label use and clinical trials are being implemented for the management of treatment-refractory patients.

METHODS

Here we conduct an ethical and legal analysis of DBS for SUD, referencing the four foundational principles of medical ethics and key legal concepts.

RESULTS

There are major concerns related to the capacity of a SUD patient to provide informed consent, as well as the risks and benefits of DBS compared to traditional treatment methods. In addition to ethical concerns, we explore potential legal issues that may arise from DBS in the treatment of addiction. These include the potential mandate of these procedures in the context of the criminalization of substance use, and the issue of familial consent in the decision-making process. Given the paucity of relevant clinical guidelines or legal cases, general medico-legal principles serve as the reference in making decisions about the responsible use of DBS as a treatment for addiction.

CONCLUSIONS

Given the rapidly increasing evidence for DBS as a treatment for SUD, it is an urgent imperative to consider the relevant key ethical and legal issues. Incorporating IDEAL (Idea, Development, Exploration, Assessment, Long-term follow-up) framework into future research in DBS is recommended to evaluate patient safety and ethical perspectives. With the broad criminalization of SUD across the globe, legal coercion of DBS is not impossible, especially if proven to be effective to treat SUD. It is advised for stakeholders to urgently consider incorporating DBS-related drug policies so that the potential benefits of DBS within the rights of people with SUD are not hindered by the lack of clinical guidance and legislations.

Is occlusion of the main pancreatic duct by thermal ablation really safe? A surgical innovation assessed according to IDEAL recommendations

INTRODUCTION

Pre-clinical studies suggest that thermal ablation of the main pancreatic duct (TAMPD) is more recommendable than glue for reducing postoperative pancreatic fistula (POPF). Our aims were (1) to analyze the changes in the pancreas of patients after TAMPD and (2) to correlate the clinical findings with those obtained from a study on an animal model.

MATERIALS AND METHODS

A retrospective early feasibility study of a marketed device for a novel clinical application was carried out on a small number of subjects (n = 8) in whom TAMPD was conducted to manage the pancreatic stump after a pancreatectoduodenectomy (PD). Morphological changes in the remaining pancreas were assessed by computed tomography for 365 days after TAMPD.

RESULTS

All the patients showed either Grade A or B POPF, which generally resolved within the first 30 days. The duct's maximum diameter significantly increased after TAMPD from 1.5 ± 0.8 mm to 8.6 ± 2.9 mm after 7 days (p = .025) and was then reduced to 2.6 ± 0.8 mm after 365 days PO (p < .0001). The animal model suggests that TAMPD induces dilation of the duct lumen by enzymatic digestion of ablated tissue after a few days and complete exocrine atrophy after a few weeks.

CONCLUSIONS

TAMPD leads to long-term exocrine pancreatic atrophy by completely occluding the duct. However, the ductal dilatation that occurred soon after TAMPD could even favor POPF, which suggests that TAMPD should be conducted several weeks before PD, ideally by digestive endoscopy.

Innovation in Neurosurgery: Lessons Learned, Obstacles, and Potential Funding Sources

Innovation is central to neurosurgery and has dramatically increased over the last twenty years. Although the specialty innovates as a whole, only 3-4.7% of practicing neurosurgeons hold patents. Various roadblocks to innovation impede this process such as lack of understanding, increasing regulatory complexity, and lack of funding. Newly emerging technologies allow us to understand how to innovate and how to learn from other medical specialties. By further understanding the process of innovation, and the funding that supports it, Neurosurgery can continue to hold innovation as one of its's central tenets.

Intraoperative visualisation of pancreatic leakage (ViP): study protocol for an IDEAL Stage I Post Market Clinical Study

INTRODUCTION

Pancreatic resections are an important field of surgery worldwide to treat a variety of benign and malignant diseases. Postoperative pancreatic fistula (POPF) remains a frequent and critical complication after partial pancreatectomy and affects up to 50% of patients. POPF increases mortality, prolongs the postoperative hospital stay and is associated with a significant economic burden. Despite various scientific approaches and clinical strategies, it has not yet been possible to develop an effective preventive tool. The SmartPAN indicator is the first surgery-ready medical device for direct visualisation of pancreatic leakage already during the operation. Applied to the surface of pancreatic tissue, it detects sites of biochemical leak via colour reaction, thereby guiding effective closure and potentially mitigating POPF development.

METHODS AND ANALYSIS

The ViP trial is a prospective single-arm, single-centre first in human study to collect data on usability and confirm safety of SmartPAN. A total of 35 patients with planned partial pancreatectomy will be included in the trial with a follow-up of 30 days after the index surgery. Usability endpoints such as adherence to protocol and evaluation by the operating surgeon as well as safety parameters including major intraoperative and postoperative complications, especially POPF development, will be analysed.

ETHICS AND DISSEMINATION

Following the IDEAL-D (Idea, Development, Exploration, Assessment, and Long term study of Device development and surgical innovation) framework of medical device development preclinical in vitro, porcine in vivo, and human ex vivo studies have proven feasibility, efficacy and safety of SmartPAN. After market approval, the ViP trial is the IDEAL Stage I trial to investigate SmartPAN in a clinical setting. The study has been approved by the local ethics committee as the device is used exclusively within its intended purpose. Results will be published in a peer-reviewed journal. The study will provide a basis for a future randomised controlled interventional trial to confirm clinical efficacy of SmartPAN.

TRIAL REGISTRATION NUMBER

German Clinical Trial Register DRKS00027559, registered on 4 March 2022.

Translational research in health technologies: A scoping review

Introduction

The current debate on the process of technological innovation points out as a challenge for universities consolidation of competencies that allow the generation and transfer of knowledge to society. The Translational Research (TR) approach has as one of its main objectives the acceleration of the innovation process, based on the transposition from basic science to applied science and innovation, which comprises the different stages of research, development and innovation. The literature points out that the dynamics of translation, which results in new technologies, are complex, transdisciplinary, inter-institutional, systemic, and non-linear. The main objective of this review is to contribute to the adoption of institutional strategies and the formulation of public policies aimed at solving today’s social and economic challenges, ensuring access to technologies and sustainability for the health system. The specific objectives were: (i) to systematize studies that characterized translational research in medical devices; (ii) map the challenges for the implementation of translational health research; (iii) contribute to the design of institutional strategies; and (iv) support the formulation of public policies.

Methods

This study used the scoping review technique, according to PRISMA-ScR and the Joanna Briggs Institute guidelines. Concerning the extraction of relevant articles, the journals indexed in Bireme, Pubmed, Scopus, Web of Science, and Google Scholar were consulted for selecting relevant articles. The search was carried out on November 28, 2021, updated on April 29, 2022, and there were no restrictions as to the year of publication, language or type of analysis. Studies that did not answer the research question were excluded, as they dealt exclusively with the pharmaceutical segment, the translation of knowledge into clinical practice, or addressed the process of translational research applied to specific diseases or technologies.

Results

Thirty-three articles were included indicating that the approach of translation of research is multidisciplinary and transdisciplinary and encompasses knowledge and aspects that go beyond basic and applied research and incorporates final steps concerning regulatory aspects, clinical research, market analysis, technology transfer, production and incorporation of technologies into the health system.

Neurosurgical Team Acceptability of Brain-Computer Interfaces: A Two-Stage International Cross-Sectional Survey

OBJECTIVE

Invasive brain-computer interfaces (BCIs) require neurosurgical implantation, which confers a range of risks. Despite this situation, no studies have assessed the acceptability of invasive BCIs among the neurosurgical team. This study aims to establish baseline knowledge of BCIs within the neurosurgical team and identify attitudes toward different applications of invasive BCI.

METHODS

A 2-stage cross-sectional international survey of the neurosurgical team (neurosurgeons, anesthetists, and operating room nurses) was conducted. Results from the first, qualitative, survey were used to guide the second-stage quantitative survey, which assessed acceptability of invasive BCI applications. Five-part Likert scales were used to collect quantitative data. Surveys were distributed internationally via social media and collaborators.

RESULTS

A total of 108 qualitative responses were collected. Themes included the promise of BCIs positively affecting disease targets, concerns regarding stability, and an overall positive emotional reaction to BCI technology. The quantitative survey generated 538 responses from 32 countries. Baseline knowledge of BCI technology was poor, with 9% claiming to have a good or expert knowledge of BCIs. Acceptability of invasive BCI for rehabilitative purposes was >80%. Invasive BCI for augmentation in healthy populations divided opinion.

CONCLUSIONS

The neurosurgical team's view of the acceptability of invasive BCI was divided across a range of indications. Some applications (e.g., stroke rehabilitation) were viewed as more appropriate than other applications (e.g., augmentation for military use). This range in views highlights the need for stakeholder consultation on acceptable use cases along with regulation and guidance to govern initial BCI implantations if patients are to realize the potential benefits.

Specialised Surgical Instruments for Endoscopic and Endoscope-Assisted Neurosurgery: A Systematic Review of Safety, Efficacy and Usability

While there have been great strides in endoscopic and endoscope-assisted neurosurgical approaches, particularly in the treatment of deep-sited brain and skull base tumours, the greatest technical barrier to their adoption has been the availability of suitable surgical instruments. This systematic review seeks to identify specialised instruments for these approaches and evaluate their safety, efficacy and usability. Conducted in accordance with the PRISMA guidelines, Medline, Embase, CENTRAL, SCOPUS and Web of Science were searched. Original research studies that reported the use of specialised mechanical instruments that manipulate tissue in human patients, cadavers or surgical models were included. The results identified 50 specialised instruments over 62 studies. Objective measures of safety were reported in 32 out of 62 studies, and 20 reported objective measures of efficacy. Instruments were broadly safe and effective with one instrument malfunction noted. Measures of usability were reported in 15 studies, with seven reporting on ergonomics and eight on the instruments learning curve. Instruments with reports on usability were generally considered to be ergonomic, though learning curve was often considered a disadvantage. Comparisons to standard instruments were made in eight studies and were generally favourable. While there are many specialised instruments for endoscopic and endoscope-assisted neurosurgery available, the evidence for their safety, efficacy and usability is limited with non-standardised reporting and few comparative studies to standard instruments. Future innovation should be tailored to unmet clinical needs, and evaluation guided by structured development processes.

Comparative Learning Curves of Microscope Versus Exoscope: A Preclinical Randomized Crossover Noninferiority Study

Background

An exoscope heralds a new era of optics in surgery. However, there is limited quantitative evidence describing and comparing the learning curve.

Objectives

This study aimed to investigate the learning curve, plateau, and rate of novice surgeons using an Olympus ORBEYE exoscope compared to an operating microscope (Carl Zeiss OPMI PENTERO or KINEVO 900).

Methods

A preclinical, randomized, crossover, noninferiority trial assessed the performance of seventeen novice and seven expert surgeons completing the microsurgical grape dissection task “Star’s the limit.” A standardized star was drawn on a grape using a stencil with a 5 mm edge length. Participants cut the star and peeled the star-shaped skin off the grape with microscissors and forceps while minimizing damage to the grape flesh. Participants repeated the task 20 times consecutively for each optical device. Learning was assessed using model functions such as the Weibull function, and the cognitive workload was assessed with the NASA Task Load Index (NASA-TLX).

Results

Seventeen novice (male:female 12:5; median years of training 0.4 [0–2.8 years]) and six expert (male:female 4:2; median years of training 10 [8.9–24 years]) surgeons were recruited. “Star’s the limit” was validated using a performance score that gave a threshold of expert performance of 70 (0–100). The learning rate (ORBEYE −0.94 ± 0.37; microscope −1.30 ± 0.46) and learning plateau (ORBEYE 64.89 ± 8.81; microscope 65.93 ± 9.44) of the ORBEYE were significantly noninferior compared to those of the microscope group (p = 0.009; p = 0.027, respectively). The cognitive workload on NASA-TLX was higher for the ORBEYE. Novices preferred the freedom of movement and ergonomics of the ORBEYE but preferred the visualization of the microscope.

Conclusions

This is the first study to quantify the ORBEYE learning curve and the first randomized controlled trial to compare the ORBEYE learning curve to that of the microscope. The plateau performance and learning rate of the ORBEYE are significantly noninferior to those of the microscope in a preclinical grape dissection task. This study also supports the ergonomics of the ORBEYE as reported in preliminary observational studies and highlights visualization as a focus for further development.

IDEAL approach to the evaluation of machine learning technology in epilepsy surgery: protocol for the MAST trial

Epilepsy and epilepsy surgery lend themselves well to the application of machine learning (ML) and artificial intelligence (AI) technologies. This is evidenced by the plethora of tools developed for applications such as seizure detection and analysis of imaging and electrophysiological data. However, few of these tools have been directly used to guide patient management. In recent years, the Idea, Development, Exploration, Assessment, Long-Term Follow-Up (IDEAL) collaboration has formalised stages for the evaluation of surgical innovation and medical devices, and, in many ways, this pragmatic framework is also applicable to ML/AI technology, balancing innovation and safety. In this protocol paper, we outline the preclinical (IDEAL stage 0) evaluation and the protocol for a prospective (IDEAL stage 1/2a) study to evaluate the utility of an ML lesion detection algorithm designed to detect focal cortical dysplasia from structural MRI, as an adjunct in the planning of stereoelectroencephalography trajectories in children undergoing intracranial evaluation for drug-resistant epilepsy.