First-in-Human Whole-Eye Transplantation: Ensuring an Ethical Approach to Surgical Innovation

As innovations in the field of vascular composite allotransplantation (VCA) progress, whole-eye transplantation (WET) is poised to transition from non-human mammalian models to living human recipients. Present treatment options for vision loss are generally considered suboptimal, and attendant concerns ranging from aesthetics and prosthesis maintenance to social stigma may be mitigated by WET. Potential benefits to WET recipients may also include partial vision restoration, psychosocial benefits related to identity and social integration, improvements in physical comfort and function, and reduced surgical risk associated with a biologic eye compared to a prosthesis. Perioperative and postoperative risks of WET are expected to be comparable to those of facial transplantation (FT), and may be similarly mitigated by immunosuppressive protocols, adequate psychosocial support, and a thorough selection process for both the recipient and donor. To minimize the risks associated with immunosuppressive medications, the first attempts in human recipients will likely be performed in conjunction with a FT. If first-in-human attempts at combined FT-WET prove successful and the biologic eye survives, this opens the door for further advancement in the field of vision restoration by means of a viable surgical option. This analysis integrates recent innovations in WET research with the existing discourse on the ethics of surgical innovation and offers preliminary guidance to VCA programs considering undertaking WET in human recipients.

Overcoming Challenges in Hemihyperplasia Through Surgical Innovation and Genetic Diagnosis: A Case Report

This case report sheds light on the complex management of hemihyperplasia (HHP), highlighting the difficulties associated with diagnosis and the critical importance of a multimodal approach to treatment. The story of Acharya Vinoba Bhave Rural Hospital's (AVBRH) successful resolution following a misdiagnosis at another clinic emphasizes the value of expert care. The successful outcome resulted from the fusion of surgical innovation, genetic insights, and psychosocial factors through genetic testing, liposuction, and postoperative rehabilitation. This example emphasizes the need to treat congenital illnesses holistically and the transforming power of individualized, multidisciplinary treatment to improve the functional and esthetic elements of life for patients with HHP.

Patient-specific automated cerebrospinal fluid pressure control to augment spinal wound closure: a case series using the LiquoGuard®

OBJECTIVE

Spinal cerebrospinal fluid (CSF) leaks are common, and their management is heterogeneous. For high-flow leaks, numerous studies advocate for primary dural repair and CSF diversion. The LiquoGuard7® allows automated and precise pressure and volume control, and calculation of patient-specific CSF production rate (prCSF), which is hypothesized to be increased in the context of durotomies and CSF leaks.

METHODS

This single-centre illustrative case series included patients undergoing complex spinal surgery where: 1) a high flow intra-operative and/or post-operative CSF leak was expected and 2) lumbar CSF drainage was performed using a LiquoGuard7®. CSF diversion was tailored to prCSF for each patient, combined with layered spinal wound closure.

RESULTS

Three patients were included, with a variety of pathologies: T7/T8 disc prolapse, T8-T9 meningioma, and T4-T5 metastatic spinal cord compression. The first two patients underwent CSF diversion to prevent post-op CSF leak, whilst the third required this in response to post-op CSF leak. CSF hyperproduction was evident in all cases (mean >/=140ml/hr). With patient-specific CSF diversion regimes, no cases required further intervention for CSF fistulae repair (including for pleural CSF effusion), wound breakdown or infection.

CONCLUSIONS

Patient-specific cerebrospinal fluid drainage may be a useful tool in the management of high-flow intra-operative and post-operative CSF leaks during complex spinal surgery. These systems may reduce post-operative CSF leakage from the wound or into adjacent body cavities. Further larger studies are needed to evaluate the comparative benefits and cost-effectiveness of this approach.

Teach Design to Surgical Trainees: One Small Step for Surgeons, One Giant Leap for Surgery

The field of surgery faces complex, systemic challenges that will require new academic frameworks. In this paper, we propose design thinking as a useful problem-solving technique to apply to such challenges. We define design thinking and provide a brief history of this practice. Finally, we offer suggestions to introduce design thinking to surgical trainees, drawing from the experience of innovation programs that have incorporated this technique.

Revolutionising Breast Surgery: A Comprehensive Review of Robotic Innovations in Breast Surgery and Reconstruction

Robotic innovations in breast surgery have ushered in a new era of precision, safety, and patient-centred care. This comprehensive review explores the multifaceted realm of robotic breast surgery, from preoperative planning to postoperative outcomes, learning curves for surgeons, and the implications for healthcare policies. We examine the ethical considerations, cost-effectiveness, and future directions, including integrating artificial intelligence and telesurgery. Key findings reveal that robotic systems provide improved surgical precision, reduced complications, and enhanced patient satisfaction. Ethical concerns encompass informed consent, resource allocation, and equitable access. The future of breast surgery lies in continued research and development, ensuring that robotics becomes a standard of care accessible to all patients. This technology is reshaping breast surgery and offering new possibilities for minimally invasive, patient-centred care, ultimately redefining the standards of care in this critical field of medicine.

A new approach for single-haptic retropupillary iris-claw lens subluxation - The "fencing" technique

INTRODUCTION

Single-haptic iris-claw intraocular lens (IOL) dislocation is not an uncommon complication. A few different surgical techniques are available for its refixation but usually involve a more invasive approach. We aim to demonstrate an original and simple approach for refixation of single haptic retropupillary iris-claw IOL subluxations.

METHODS

We present a case of an 80-year-old male with a single haptic retropupillary iris-claw IOL subluxation in a previously vitrectomized eye. We used a new surgical approach to refix this type of subluxation.

RESULTS

This new technique uses only two 30-gauge needles (one of them connected to a viscosurgical device) to re-enclavate the subluxated haptic of the retropupillary iris-claw IOL. By minimising surgical manipulation, the patient's postoperative period was uneventful.

CONCLUSIONS

We highlight a new, quick, safe, and unusual surgical approach to single-haptic retropupillary iris-claw IOL dislocation in vitrectomized eyes. Because of its characteristics, we named it the "fencing" IOL repositioning technique.

Eye-tracking in surgery: a systematic review

BACKGROUND

Surgery is constantly evolving with the assistance of rapidly developing novel technology. Eye-tracking devices provide opportunities to monitor the acquisition of surgical skills, gain insight into performance, and enhance surgical practice. The aim of this review was to consolidate the available evidence for the use of eye-tracking in the surgical disciplines.

METHODS

A systematic literature review was conducted in accordance with PRISMA guidelines. A search of OVID Medline, EMBASE, Cochrane library, Scopus, and Science Direct was conducted January 2000 until December 2022. Studies involving eye-tracking in surgical training, assessment and technical innovation were included in the review. Non-surgical procedures, animal studies, and studies not involving surgical participants were excluded from the review.

RESULTS

The search returned a total of 12 054 articles, 80 of which were included in the final analysis and review. Seventeen studies involved eye-tracking in surgical training, 48 surgical assessment, and 20 were focussing on technical aspects of this technology. Twenty-six different eye-tracking devices were used in the included studies. Metrics such as the number of fixations, duration of fixations, dwell time, and cognitive workload were able to differentiate between novice and expert performance. Eight studies demonstrated the effectiveness of gaze-training for improving surgical skill.

CONCLUSION

The current literature shows a broad range of utility for a variety of eye-tracking devices in surgery. There remains a lack of standardization for metric parameters and gaze analysis techniques. Further research is required to validate its use to establish reliability and create uniform practices.

Anatomy segmentation in laparoscopic surgery: comparison of machine learning and human expertise - an experimental study

BACKGROUND

Lack of anatomy recognition represents a clinically relevant risk in abdominal surgery. Machine learning (ML) methods can help identify visible patterns and risk structures; however, their practical value remains largely unclear.

MATERIALS AND METHODS

Based on a novel dataset of 13 195 laparoscopic images with pixel-wise segmentations of 11 anatomical structures, we developed specialized segmentation models for each structure and combined models for all anatomical structures using two state-of-the-art model architectures (DeepLabv3 and SegFormer) and compared segmentation performance of algorithms to a cohort of 28 physicians, medical students, and medical laypersons using the example of pancreas segmentation.

RESULTS

Mean Intersection-over-Union for semantic segmentation of intra-abdominal structures ranged from 0.28 to 0.83 and from 0.23 to 0.77 for the DeepLabv3-based structure-specific and combined models, and from 0.31 to 0.85 and from 0.26 to 0.67 for the SegFormer-based structure-specific and combined models, respectively. Both the structure-specific and the combined DeepLabv3-based models are capable of near-real-time operation, while the SegFormer-based models are not. All four models outperformed at least 26 out of 28 human participants in pancreas segmentation.

CONCLUSIONS

These results demonstrate that ML methods have the potential to provide relevant assistance in anatomy recognition in minimally invasive surgery in near-real-time. Future research should investigate the educational value and subsequent clinical impact of the respective assistance systems.

The Value of Scientific Publications in Surgical Device Innovation

BACKGROUND

Clinical trials represent a significant risk in the commercialization of surgical technologies. There is incentive for companies to mitigate their regulatory risk by targeting 510K over Premarket Approval (PMA) pathways in order to limit the scope, complexity and cost of clinical trials. As such, not all companies will publish clinical data in the scientific literature.

PURPOSE

We set out to investigate the relationship between scientific publication by surgical device companies and the impact it has on company valuation. We hypothesize that publishing in the scientific literature correlates with success of the surgical device companies as measured by funding.

RESEARCH DESIGN

We first obtained a list of surgical device startup companies and their financial deals using the Pitchbook database. Those companies were then cross referenced with the FDA database and the Dimensions database for product registrations and peer reviewed publications, respectively. Analysis was then performed using these query results.

STUDY SAMPLE AND DATA COLLECTION

We obtained a list of US surgical device startups financing deals closed between 2010 and 2020 from the Pitchbook database. We queried the Pitchbook for deal dates from January 1, 2010 to January 1, 2020 for deal types spanning early stage investment to IPO. Deals were limited to those conducted in the United States and to the surgical device industry. We queried the FDA database for product registration information associated with each of the companies involved in the deals. We tabulated the number of journal articles associated with surgical device companies using the Dimensions Search API as well as a manual confirmation.

RESULTS

Five hundred thirty five (535) deals from 222 companies were found in Pitchbook that met our criteria. Querying the FDA database resulted in 578 registrations associated with these companies. Publications per company ranged widely.

CONCLUSIONS

Companies that are able to generate a more numerous publications had correspondingly higher valuations during funding rounds. A subset of outstanding companies were analyzed and at least four factors affect: direct value of publications, indirect valve of publications, survivorship bias, and adoption share; each of which will be discussed in this manuscript.

The SUPER reporting guideline suggested for reporting of surgical technique

Background

Existing reporting guidelines pay insufficient attention to the detail and comprehensiveness reporting of surgical technique. The Surgical techniqUe rePorting chEcklist and standaRds (SUPER) aims to address this gap by defining reporting standards for surgical technique. The SUPER guideline intends to apply to articles that encompass surgical technique in any study design, surgical discipline, and stage of surgical innovation.

Methods

Following the EQUATOR (Enhancing the QUAlity and Transparency Of health Research) Network approach, 16 surgeons, journal editors, and methodologists reviewed existing reporting guidelines relating to surgical technique, reviewed papers from 15 top journals, and brainstormed to draft initial items for the SUPER. The initial items were revised through a three-round Delphi survey from 21 multidisciplinary Delphi panel experts from 13 countries and regions. The final SUPER items were formed after an online consensus meeting to resolve disagreements and a three-round wording refinement by all 16 SUPER working group members and five SUPER consultants.

Results

The SUPER reporting guideline includes 22 items that are considered essential for good and informative surgical technique reporting. The items are divided into six sections: background, rationale, and objectives (items 1 to 5); preoperative preparations and requirements (items 6 to 9); surgical technique details (items 10 to 15); postoperative considerations and tasks (items 16 to 19); summary and prospect (items 20 and 21); and other information (item 22).

Conclusions

The SUPER reporting guideline has the potential to guide detailed, comprehensive, and transparent surgical technique reporting for surgeons. It may also assist journal editors, peer reviewers, systematic reviewers, and guideline developers in the evaluation of surgical technique papers and help practitioners to better understand and reproduce surgical technique.

Trial Registration

https://www.equator-network.org/library/reporting-guidelines-under-development/reporting-guidelines-under-development-for-other-study-designs/#SUPER.

The Expanding Utility of Robotic-Assisted Flap Harvest in Autologous Breast Reconstruction: A Systematic Review

The expansion of robotic surgery has led to developments in robotic-assisted breast reconstruction techniques. Specifically, robotic flap harvest is being evaluated to help maximize operative reliability and reduce donor site morbidity without compromising flap success. Many publications are feasibility studies or technical descriptions; few cohort analyses exist. This systematic review aims to characterize trends in robotic autologous breast reconstruction and provide a summative analysis of their results. A systematic review was conducted using PubMed, Medline, Scopus, and Web of Science to evaluate robot use in breast reconstruction. Studies dated from 2006 to 2022 were identified and analyzed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Full-text, peer-reviewed, English-language, and human subject studies were included. Non-breast reconstruction articles, commentary, expert opinion, editor's letter, and duplicate studies were excluded. A total of 17 full-text articles were analyzed. The two robotic breast procedures identified were the deep inferior epigastric perforator (DIEP) and the latissimus dorsi (LD) flap. Results showed comparable complication rates and increased operative times compared to NSQIP data on their corresponding open techniques. Additional findings reported in studies included patient reported outcomes, incision lengths, and downward trends in operative time with consecutive procedures. The available data in the literature confirms that robotic surgery is a promising alternative to traditional open methods of breast reconstruction following mastectomy.

Follow Your Heart: Trials and Tribulations of Sir Terence English and the First Successful Heart Transplant in the United Kingdom

The journey of heart transplantation in the United Kingdom (UK) has been marked by challenges and triumphs. Following a series of unsuccessful transplant attempts in 1968, a moratorium was imposed on the procedure. However, in 1979, Sir Terence English broke the national ban, by performing the UK's first successful heart transplant at Papworth Hospital. This achievement opened doors for advancements in heart and lung transplantation and established the Papworth programme as a world leader in the field. Sir Terence's legacy stands as a testament to the transformative power of determination, perseverance and teamwork in overcoming the moratorium, lack of financial support, difficult colleagues and the failure of his first transplant attempt. Through a comprehensive review of the literature, qualitative interviews and Sir Terence's personal contributions, this article provides an account of his trials and tribulations, aiming to inspire and encourage physicians, surgeons and scientists in their pursuit of innovation in the field of medicine.

Comparison of Surgical Results of the Bridge Crane Technique Versus Laminectomy for the Treatment of Thoracic Myelopathy Caused by Ossification of the Ligamentum Flavum

STUDY DESIGN

A retrospective study.

OBJECTIVES

This study aimed to evaluate the safety and effectiveness of the bridge crane technique versus laminectomy for the treatment of thoracic myelopathy caused by ossification of the ligamentum flavum (OLF).

METHODS

Totally 41 patients who underwent surgical decompression due to thoracic OLF from May 2017 to June 2018 in our institution were enrolled in this study and were divided into group BG (bridge crane technique, n = 19) and group L (laminoectomy, n = 22). Demographic data was collected from medical records and the modified Japanese Orthopaedic Association (JOA) scoring system was used to evaluate the neurological outcomes during the follow-up. Surgery-related complications were analyzed.

RESULTS

The mean duration of follow-up was comparable between group BG (19.4 ± 1.5 months) and group L (19.6 ± 1.4 months). No statistical differences were observed between two groups in terms of gender, age, duration of symptoms, preoperative occupying rate, involved levels, operation time, intraoperative blood loss, and complications. The JOA score significantly increased at the final follow-up in both groups. However, patients in group BG had higher JOA score and recovery rate (P < 0.05). Four patients in group L experienced complications, including 3 cerebrospinal fluid (CSF) leakage and one postoperative hematoma. Only one patient in group BG had CSF leakage.

CONCLUSION

The results of this study suggested that bridge crane technique may be relatively safe and effective for patients with symptomatic thoracic OLF with more satisfactory clinical improvement. However, high-quality studies are still required to validate the results of this study.

Deep Learning Applications in Surgery: Current Uses and Future Directions

Deep learning (DL) is a subset of machine learning that is rapidly gaining traction in surgical fields. Its tremendous capacity for powerful data-driven problem-solving has generated computational breakthroughs in many realms, with the fields of medicine and surgery becoming increasingly prominent avenues. Through its multi-layer architecture of interconnected neural networks, DL enables feature extraction and pattern recognition of highly complex and large-volume data. Across various surgical specialties, DL is being applied to optimize both preoperative planning and intraoperative performance in new and innovative ways. Surgeons are now able to integrate deep learning tools into their practice to improve patient safety and outcomes. Through this review, we explore the applications of deep learning in surgery and related subspecialties with an aim to shed light on the practical utilization of this technology in the present and near future.

Effectiveness of intra-operative topical amiodarone for prevention of postcardiac surgery new-onset atrial fibrillation: A review of current evidence

BACKGROUND

Postoperative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery and is associated with increased morbidity. Intraoperative topical amiodarone application on epicardial tissue has been shown to reduce systemic concentrations while maintaining therapeutic myocardial concentrations, thereby, lowering the risk of extracardiac adverse effects associated with oral and intravenous amiodarone therapy. However, the efficacy and safety of topical amiodarone in preventing POAF is unclear.

OBJECTIVES

This study summarizes the clinical studies to-date that have investigated the efficacy and safety of topical amiodarone administration in preventing POAF following cardiac surgery.

METHODS

A database search was conducted using Medline, Embase, and Cochrane Library to identify relevant studies. Abstracts were screened and data were extracted from relevant full-text articles that met the inclusion and exclusion criteria.

RESULTS

The search returned four studies with variable findings on the effect of topical amiodarone therapy on the incidence of POAF, cardiac effects, extracardiac effects, and hospital length of stay.

CONCLUSION

Prophylactic topical application of amiodarone may be effective and safe for preventing post-operative new-onset atrial fibrillation. Further investigation is required to evaluate the efficacy and safety of topical amiodadrone therapy before it can be widely integrated into current practice.

Heads, Bodies, Brains, and Selves: Personal Identity and the Ethics of Whole-Body Transplantation

Plans to attempt what has been called a head transplant, a body transplant, and a head-to-body transplant in human beings raise numerous ethical, social, and legal questions, including the circumstances, if any, under which it would be ethically permissible to attempt whole-body transplantation (WBT) in human beings, the possible effect of WBT on family relationships, and how families should shape WBT decisions. Our assessment of many of these questions depends partially on how we respond to sometimes centuries-old philosophical thought experiments about personal identity. As with so much in bioethics, it is impossible to escape, or at least inadvisable to try to bypass, the relevant foundational philosophical concerns.

Creating a Single Inflow Orifice From Living Donor Kidney Allografts With Multiple Renal Arteries

Background: Multiple renal arteries (MRA) are often encountered during living-donor kidney transplantation (LDKT), requiring surgeons to pursue complex renovascular reconstructions prior to graft implantation. With improvements in reconstruction and anastomosis techniques, allografts with MRA can be successfully transplanted with similar outcomes to allografts with a single renal artery. Here, we describe in detail various surgical techniques for reconstruction of MRA grafts with the intent of creating a single arterial inflow.

Methods: We retrospectively reviewed the medical records of all LDKT recipients with laparoscopically procured MRA kidneys between March 2008 and July 2021. Recipient and donor characteristics, operative data, type of reconstruction, and recipient outcomes were analyzed. The primary outcomes were the incidence of developing delayed graft function (DGF) and/or a vascular or urological complication within 12 months post-transplant.

Results: Seventy-three LDKT recipients of MRA donor allografts were evaluated. Two renal arteries (RA) were encountered in 62 allografts (84.9%) and three RA in 11 allografts (15.1%). Renal artery reconstruction was performed in 95.8% (70/73) of patients. Eighteen different reconstruction techniques of MRA were utilized, the most common being side-to-side anastomosis in allografts with two RA (N = 44) and side-to-side-to-side anastomosis in allografts with three RA (N = 4). Interposition grafting was performed in seven cases (9.6%). A single ostium was created in 69 cases (94.5%), and the median warm ischemia time was 27 (range 20–42) minutes. None of the patients developed DGF or post-operative vascular or urological complications. Median creatinine at 3, 6, and 12 months post-transplant remained stable at 1.1 mg/dl. With a median follow-up of 30.4 months post-transplant, only one graft failure has been observed–death-censored graft survival was 98.6%.

Conclusion: Complex reconstruction techniques to create a single renal artery ostium for graft implantation anastomosis in allografts with MRA show acceptable warm ischemic times, with no increased risk of post-operative vascular or urological complications.

A Framework for Successful Adoption of Surgical Innovation

Background

Innovation Adoption Frameworks are applied in healthcare industry, but surgical innovation does not follow the same models as medical innovation and it is not always adopted fully by members of the team.

Purpose

The aim of this paper is to develop a framework for successful adoption of surgical innovation.

Research design

This paper is inspired by design thinking. Based on a pragmatic research philosophy, a mixed method approach was selected including semi-structured interview and focus groups, following a questionnaire.

Study sample

A sample of five specialists in the field (doctors and managers) were selected for interview. Six focus groups were conducted. On average, five people were involved in each focus groups, 30 participants in total, including consultants, senior and junior ward nurses, health care assistant (HCA), cancer nurse specialist, stoma nurses, theatre senior and junior staff.

Data collection/analysis

Qualitative data was collected and analyzed using Thematic Analysis.

Results

Following a design thinking approach; firstly, an initial Surgical Adoption Model was proposed, based on the existing literature. Then, the challenges, processes and teams involved in Robotic Surgery adoption, an existing surgical innovation in a local NHS hospital, were explored. Five main themes were extracted from interviews and focus groups data - ‘Innovation Perception’, ‘Guilty vs. Undervalued’, ‘Knowledge is Power’, ‘Ex-novation’ and ‘Facilitators and Super-users’. This resulted into the development of an adapted Surgical Innovation Framework.

Conclusions

The Surgical Innovation Framework incorporated the themes extracted from the data. The framework is unique within the field of surgical innovation and is designed with the aim of improving surgical innovation adoption success rate. Future research can trial the framework to evaluate its effectiveness.

Evaluation of an Integrated Smart Sensor System for Real-Time Characterization and Digitalization of Postoperative Abdominal Drain Output: A Pilot Study

Background: For centuries, surgeons have relied on surgical drains during postoperative care. Despite all advances in modern medicine and the area of digitalization, as of today, most if not all assessment of abdominal secretions excreted via surgical drains are carried out manually. We here introduce a novel integrated Smart Sensor System (Smart Drain) that allows for real-time characterization and digitalization of postoperative abdominal drain output at the patient’s bedside. Methods: A prototype of the Smart Drain was developed using a sophisticated spectrometer for assessment of drain output. The prototype measures 10 × 6 × 6 cm and therefore easily fits at the bedside. At the time of measurement with our Smart Drain, the drain output was additionally sent off to be analyzed in our routine laboratory for typical markers of interest in abdominal surgery such as bilirubin, lipase, amylase, triglycerides, urea, protein, and red blood cells. A total of 45 samples from 19 patients were included. Results: The measurements generated were found to correlate with conventional laboratory measurements for bilirubin (r = .658, P = .000), lipase (r = .490, P = .002), amylase (r = .571, P = .000), triglycerides (r = .803, P = .000), urea (r = .326, P = .033), protein (r = .387, P = .012), and red blood cells (r = .904, P = .000). Conclusions: To our best knowledge, for the first time we describe a device using a sophisticated spectrometer that allows for real-time characterization and digitalization of postoperative abdominal drain output at the patient’s bedside.

Reciprocal Learning Between Military and Civilian Surgeons: Past and Future Paths for Medical Innovation

Numerous surgical advances have resulted from exchanges between military and civilian surgeons. As part of the U.S. National Library of Medicine Michael E. DeBakey Fellowship in the History of Medicine, we conducted archival research to shed light on the lessons that civilian surgery has learned from the military system and vice-versa. Several historical case studies highlight the need for immersive programs where surgeons from the military and civilian sectors can gain exposure to the techniques, expertise, and institutional knowledge the other domain provides. Our findings demonstrate the benefits and promise of structured programs to promote reciprocal learning between military and civilian surgery.

Safety with Innovation in Colon and Rectal Robotic Surgery

Robotic colorectal surgery has been touted as a possible way to overcome the limitations of laparoscopic surgery and has shown promise in rectal resections, thus shifting traditional open surgeons to a minimally invasive approach. The safety, efficacy, and learning curve have been established for most colorectal applications. With this and a robust sales and marketing model, utilization of the robot for colorectal surgery continues to grow steadily. However, this disruptive technology still requires standards for training, privileging and credentialing, and safe implementation into clinical practice.

An economical and available solution for surgical smoke in video-assisted thoracic surgery

During video-assisted thoracic surgery, surgical smoke can interfere with surgeons' vision and attention. In addition, the harmful substances in the surgical smoke also threaten the health of surgical staff. In practice, we designed an economical and available solution for the smoke in video-assisted thoracic surgery and got satisfactory results. This paper introduces the principle and procedure of this solution.

The Use of Decision Analytic Modeling in the Evaluation of Surgical Innovations: A Scoping Review

OBJECTIVES

The main objective of this review was to map how decision analytic models are used in surgical innovation (in which research phase, with what aim) and to understand how challenges related to the assessment of surgical interventions are incorporated.

METHODS

We systematically searched PubMed, Embase, and the Cochrane Library for studies published in 2018. We included original articles using a decision analytic model to compare surgical strategies. We included modeling studies of surgical innovations. General, innovation, and modeling characteristics were extracted, as were outcomes, recommendations, and handling of challenges related to the assessment of surgical interventions (learning curve, incremental innovation, dynamic pricing, quality variation, organizational impact).

RESULTS

We included 46 studies. The number of studies increased with each research phase, from 4% (n = 2) in the preclinical phase to 40% (n = 20) in phase 3 studies. Eighty-one studies were excluded because they investigated established surgical procedures, indicating that modeling is predominantly applied after the innovation process. Regardless of the research stage, the aim to determine cost-effectiveness was most frequently identified (n = 40, 87%), whereas exploratory aims (eg, exploring when a strategy becomes cost-effective) were less common (n = 9, 20%). Most challenges related to the assessment of surgical interventions were rarely incorporated in models (eg, learning curve [n = 1, 2%], organizational impact [n = 2, 4%], and incremental innovation [n = 1, 2%]), except for dynamic pricing (n = 10, 22%) and quality variation (n = 6, 13%).

CONCLUSIONS

In surgical innovation, modeling is predominantly used in later research stages to assess cost-effectiveness. The exploratory use of modeling seems still largely overlooked in surgery; therefore, the opportunity to inform research and development may not be optimally used.

The Value of Surgical Data-Impact on the Future of the Surgical Field

The combination of computing power, connectivity, and big data has been touted as the future of innovation in many fields, including medicine. There has been a groundswell of companies developing tools for improving patient care utilizing healthcare data, but procedural specialties, like surgery, have lagged behind in benefitting from data-based innovations, given the lack of data that is well structured. While many companies are attempting to innovate in the surgical field, some have encountered difficulties around collecting surgical data, given its complex nature. As there is no standardized way in which to interact with healthcare systems to purchase these data, the authors attempt to characterize the various ways in which surgical data are collected and shared. By surveying and conducting interviews with various surgical technology companies, at least 3 different methods to collect surgical data were identified. From this information, the authors conclude that an attempt to outline best practices should be undertaken that benefits all stakeholders.

What We Owe the World Wars: Challenges That Fueled Surgical Innovation

War has the unique ability to intensify obstacles that surgeons face daily in civilian hospitals. After a brief overview of the historical context of the first and second world wars, this article will focus on how those daily challenges, namely limited skill, bleeding, and infection, led to an era of surgical innovation and standardization of surgical education.

Ethics in Surgical Innovations from the Patient Perspective

OBJECTIVE

Surgical innovation (SI) can place patients at risk. We sought to explore what clinical information is readily available to patients who have been offered innovative surgical procedures, using two examples drawn from our recent experience: one a surgical technique, and the other a prosthetic material. We wanted to determine from our review the extent to which information available on the Internet might augment the medical literature and help satisfy the ethical requirements for patients to be adequately informed before they proceed with innovative surgery.

METHODS

A scoping review of the medical literature was performed to look for studies addressing the review aims; targeted searches on Google, YouTube, and patient websites were carried out to find readily available patient information on two chosen innovative surgical procedures. We conducted a content analysis of the selected references to determine the availability, relevance, and the utility of the published information to a layperson.

RESULTS

Medical database searches identified 614 records, 91 were screened and only six were relevant. The Internet searches returned thousands of results; however, we limited our screening to the first five pages of results for those sources. From both types of searches, 348 references were excluded because they did not meet the inclusion criteria and 51 were included in the analysis. The findings are presented in four themes: safety and feasibility of the technique, availability and accessibility to a layperson, relevance and utility to a layperson, and commercial information.

CONCLUSION

The review has shown that lay people seeking to find out more about the two innovations would get very little useful information from Google, YouTube, or patient websites. Practitioners offering SI should provide sufficient information to allow their patients to make an autonomous decision about whether to proceed. For major SI, we encourage innovators to develop a plain language statement that would be made available on the Internet to the mutual advantage of both innovators and patients.

Royal Society of Medicine Surgical Innovation Day Adrian Tanner Prize Winner 2019: Multidisciplinary care and surgical innovation for the benefit of the patient with head and neck cancer of unknown primary

Head and neck carcinoma of unknown primary accounts for approximately 1–5% of all head and neck cancers and presents a genuine diagnostic and therapeutic dilemma. Despite advanced investigations, the primary tumour location remains unknown in up to 40% of these cases. Transoral robotic surgery presents a viable diagnostic and therapeutic option in these patients. This surgical innovation alongside advances in the understanding of head and neck cancer biology means that a multidisciplinary approach in the management of these complex patients is of utmost importance to ensure optimal therapeutic outcomes.

Fetal Repair of Open Neural Tube Defects: Ethical, Legal, and Social Issues

Open neural tube defects or myelomeningoceles are a common congenital condition caused by failure of closure of the neural tube early in gestation, leading to a number of neurologic sequelae including paralysis, hindbrain herniation, hydrocephalus and neurogenic bowel and bladder dysfunction. Traditionally, the condition was treated by closure of the defect postnatally but a recently completed randomized controlled trial of prenatal versus postnatal closure demonstrated improved neurologic outcomes in the prenatal closure group. Fetal surgery, or more precisely maternal-fetal surgery, raises a number of ethical issues that we address including who the patient is, informed consent, surgical innovation and equipoise as well maternal assumption of risk. As the procedure becomes more widely adopted into practice, we suggest close monitoring of new fetal surgery centers, in order to ensure that the positive results of the trial are maintained without increased risk to both the mother and fetus.

Ethical Use of Public Networks and Social Media in Surgical Innovation

The use of social media among surgeons is increasing in the professional domain as a result of the benefits of rapid communication for advertising, professional development, advocacy, and innovation. Social media allows for collaboration and consultation on cases that may be difficult or uncommon, drawing on collective wisdom but also bypassing traditional privacy protections and other regulatory firewalls. The expanded access that comes with social media produces challenges, including the management of information dissemination and ensuing perceptions, the risk of biased patient/research participant recruitment, the potential for overlap between personal and professional lives, and the precarious nature of self-interest in professional social media use. The ethics of surgical innovation in the context of social media has not been extensively discussed. The nature of social media favors attention grabbing, sensationalized content. Innovation is inherently sensational and demands attention. The alignment of these intrinsic characteristics forms a basis for its appeal and contagion on social media. Despite strict regulatory clinical research environment, many surgical innovations and subsequent evolution in practice arise from a longitudinal surgical culture of trial and error that happens every day. The difficulty in distinguishing innovation from research and the precarious nature of interactions found on social media create a unique ethical dilemma to be addressed for the innovative surgeon. Therefore, the use of social media in surgical innovation thus requires a more robust ethical analysis.

Surgical treatment of the cancer of the optic nerve and orbit. An historical overview

Introduction: Aim of the present study is to present an historical overview of the surgical techniques introduced for the treatment of the cancer of the optic nerve and orbit.Methods: From the late 19th and early twentieth century there were introduced many novel surgical techniques for the treatment of the cancer of the optic nerve and orbit. The majority of these techniques concerned for the cure of orbital malignance, while optic nerve cancer many times was treated by enucleation of the eyeball.Results: Except of the extraction of the malignant tumors the surgeons of the time tried to present the best aesthetic result, fact which points the progress of the surgery those years.Conclusions: Many of the techniques introduced those years are still in use.

Energy-based devices in thyroid surgery-an overview

In the mid-20^th century Theodor Kocher standardized the conventional clamp-and-tie thyroidectomy, and a procedure that was banned or prohibited for so long was labeled as "extremely safe and efficient". Ever since, innovations and refinements in the field of thyroid surgery have focused on improving patient clinical outcome profiles, and offering patients procedures that are tailored to their concerns and desires without compromising the concepts of safety and efficacy. This led to a paradigm shift in thyroid surgery and the introduction of minimal access thyroid procedures. Unsurprisingly, this paralleled the constant technological evolution in surgical devices. Advanced energy-based devices were introduced into thyroid surgery more than a decade ago. Initially, their introduction was surrounded by sckepticism, and was considered a double-edged sword equally giving accolade and criticism. Ultimately, they have proved to be very useful in thyroid surgery, and pivotal to its evolution. In experienced hands, thyroid surgery performed using an advanced energy-based device is considered 'at least' as safe and effective as its conventional clamp-and-tie counterpart. Furthermore, it offers additional advantages that meet the best interest of the patient, surgeon, health care facility, and the society. This article provides an overview on the introduction of innovative technology into thyroid surgery.

Evaluation of an early-stage innovation for full-thickness excision of benign colonic polyps using the IDEAL framework

AIMS

Colectomy is the current approach for patients with endoscopically unresectable benign polyps but risks considerable morbidity. Full-thickness laparoendoscopic excision (FLEX) is a novel procedure, specifically developed to treat endoscopically unresectable benign colonic polyps, which could reduce the treatment burden of the current approach and improve outcomes. However, traditional evaluations of surgical innovations lack methodological rigour. This study reports the development and feasibility of the FLEX procedure in selected patients.

METHOD

A prospective development study using the Idea, Development, Evaluation, Assessment, Long-term study (IDEAL) framework was undertaken, by one surgeon, of the FLEX procedure in selected patients with endoscopically unresectable benign colonic polyps. Three-dimensional (3D)-CT colonography reconstructions were used preoperatively to rehearse patient-specific, critical manoeuvres. Targetted, full-thickness excision was performed: after marking the margin of the caecal polyp using circumferential endoscopic argon plasma coagulation, transmural endoscopic sutures were used to evert the bowel and resection was undertaken by laparoscopic linear stapling. Feasibility outcomes (establishing 'local success') included evidence of complete polyp resection without adverse events (especially safe closure of the excision site).

RESULTS

Ten patients [median (interquartile range) age: 74 (59-78) years] with polyp median diameters of 35 (30-41) mm, were referred for and consented to receive the FLEX procedure. During the same time frame, no patient underwent colectomy for benign polyps. One further patient received FLEX for local excision of a presumed malignant polyp because severe comorbidity prohibited standard procedures. The FLEX procedure was successfully performed locally, with complete resection of the polyp and safe closure of the excision site, in eight patients. Three noncompleted procedures were converted to laparoscopic segmental colectomy under the same anaesthetic because of endoscopic inaccessibility (two patients) and transcolonic suture failure (one patient).

CONCLUSIONS

The FLEX procedure is still under development. Early data demonstrate that it is safe for excision of selected benign polyps. Modifications to transcolonic suture delivery are now required and there is a need for wider adoption before more definitive evaluation can be performed.

Addressing the ethical grey zone in surgery: a framework for identification and safe introduction of novel surgical techniques and procedures

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as 'the biggest unaudited free-for-all in the history of surgery' due to 'a lack of effective centralised control'. Whether a new surgical intervention is considered an acceptable 'minor' variation of an established procedure, or is sufficiently 'novel' to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first-in-human setting. In phase I (first-in-human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the 'first in human' stage.

Use of the IDEAL framework in the urological literature: where are we in 2018?

OBJECTIVES

To assess uptake and application of the IDEAL principles in original surgical procedure- or device-related clinical research studies, as well as its reported relevance as characterized by secondary publications, editorials and reviews.

MATERIALS AND METHODS

IDEAL (Idea, Development, Exploration, Assessment, Long-term study) is a framework that provides stage-specific guidance for surgical innovation and represented a major advance towards raising evidential standards. We performed a comprehensive literature search of all urology-related publications citing one or more of seven key publications on IDEAL in The Lancet and BMJ using multiple databases up to 31 December 2017.

RESULTS

We identified a total of 150 urology-related manuscripts citing IDEAL, of which 83 (55.3%) were original research and 67 (44.7%) were secondary publications. Among the original research articles, 40 (48.2%) did not explicitly apply IDEAL principles or were not surgical innovation studies. The IDEAL phases of the 43 (51.8%) remaining original research studies were IDEAL, in nine (20.9%), 27 (62.8%), four (9.3%), 0 (0%), and three publications (7.0%), respectively. Across IDEAL stages, 30 (75.0%) studies were prospective, 29 (85.3%) reported ethical oversight, and 39 (90.7%) captured treatment-related harms. None of the studies collected information on physician experience.

CONCLUSIONS

The IDEAL framework has found widespread adoption in the urology literature as witnessed by a large number of original manuscripts and secondary publications citing IDEAL; however, its application is largely limited to the early stages of surgical innovation, frequently with inappropriate and incomplete implementation. Further efforts are needed to guide investigators in the optimal use of the IDEAL framework as it relates to surgical innovation in urology.

Adoption of a novel surgical innovation into clinical practice: protocol for a qualitative systematic review examining surgeon views

INTRODUCTION

Efficient adoption of clinically effective novel surgical innovations has great potential benefits for patients. Factors affecting the adoption of surgical innovation are not well understood and proposed models of adoption do not accurately correlate with historical evidence. This protocol is for a systematic review that aims to identify the qualitative evidence relating to surgeon views regarding the adoption of novel surgical innovation into clinical practice.

METHODS AND ANALYSIS

A systematic review following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidance will be performed. Two independent reviewers will search the following databases: MEDLINE, Embase, Science Direct, Scopus, Web of Science and the Cochrane Library of Systematic Reviews. Inclusion criteria are studies which report on the views of surgeons who adopt a novel surgical innovation into clinical practice. Each article will be screened for inclusion and assessed according to a Critical Appraisal Skills Programme tool. Data will be synthesised and analysed according to thematic analysis. Given the anticipated yield of a small heterogeneous body of evidence meeting the eligibility criteria for the review, a narrative-based summary is planned.

ETHICS AND DISSEMINATION

This review does not require formal ethical approval as it does not involve direct patient contact or patient-identifiable data. The results of this review will be published in a peer-reviewed journal and presented at relevant conferences. The results will also inform an empirical qualitative study exploring surgeon and other stakeholder views regarding the introduction of novel surgical technology and procedures into clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42017076715.

Protocol for the systematic review of the reporting of transoral robotic surgery

INTRODUCTION

Transoral robotic surgery (TORS) has been adopted in some parts of the world as an innovative approach to the resection of oropharyngeal tumours. The development, details and outcomes of early-to-later phase evaluation of this technique and the quality of evidence to support its adoption into practice have hitherto not been summarised. The aim of this review is to identify and summarise the early and later phase studies of, and evidence for, TORS and to understand how early phase studies report intervention development, governance procedures and selection and reporting of outcomes to optimise methods for using the Idea, Development, Exploration, Assessment, Long-term follow-up (IDEAL) framework for surgical innovation that informs evidence-based practice. The protocol has been written in line with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols checklist.

METHODS AND ANALYSIS

Electronic searches in OVID SP versions of Medline and EMBASE, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews from the start of indexing to 30 April 2017 will identify studies reporting TORS. At least two independent researchers will identify studies for inclusion. Two researchers will extract data from each paper. Studies will be categorised into IDEAL stages of study design from 'pre-IDEAL' to randomised controlled trials (stage 3). Data will be collected about the (1) novel intervention and criteria for modification, (2) governance arrangements and patient information provision, (3) outcome domains selected and reported and (4) quality of study design, conduct and reporting. Descriptive statistics and a narrative synthesis will be presented.

ETHICS AND DISSEMINATION

The results of this systematic review will be presented at relevant conferences. The methods will be used to inform future reviews exploring other novel surgical innovations. The findings will be published in a peer-reviewed journal. This study does not require ethical approval.

A Novel Nonelectrosurgical Technique for Incising the Pylorus in Laparoscopic Pyloromyotomy

OBJECTIVE

Since the loss of the protected arthrotomy knife several years ago, pediatric surgeons have struggled to find a safe, reliable, and inexpensive way to incise the pyloric serosa before spreading the muscle. The most widely accepted method of cutting the serosa is with electrocautery, although some still question its safety. We introduce a novel technique of incising the serosa with a percutaneously inserted needle without the use of electrocautery.

DESCRIPTION

In this case series, we describe the experience of a single surgeon with a novel technique of incising the serosa. A retrospective chart review was conducted between January 2012 and September of 2015. In 6 patients, the serosal incision on the pylorus was made using a percutaneously inserted 18 gauge needle to cut the serosa and the superficial hypertrophied muscle fibers. As the body of the needle is not sharp, it protects the mucosa from being lacerated as the incision is carried out given a fixed depth of cut.

RESULTS

The last 6 patients with hypertrophic pyloric stenosis underwent this technique. There were no conversions to open. In addition, there were no perforations and no complications related to the alteration in technique.

CONCLUSIONS

Although many manufacturers pursue both disposable and nondisposable solutions to this problem, we believe this is a safe, reliable, and very inexpensive solution to this simple problem.

Ethics Oversight Mechanisms for Surgical Innovation: A Systematic and Comparative Review of Arguments

Surgical innovation typically falls under the purview of neither conventional clinical ethics nor research ethics. Due to a lack of oversight for surgical innovation-combined with a potential for significant risk-a wide range of arguments has been advanced in the literature to support or undermine various oversight mechanisms. To scrutinize the argumentation surrounding oversight options, we conducted a systematic review of published arguments. We found that the arguments are typically grounded in common sense and speculation instead of evidence. Presently, the justification or superiority for any single oversight mechanism for surgical innovation cannot be established convincingly. We suggest ways to improve the argument-based literature and discuss the value of systematic reviews of arguments and reasons.

Surgical Innovation and the Multiple Meanings of Randomized Controlled Trials: The First RCT on Minimally Invasive Cholecystectomy (1980-2000)

This article uses the case of the first randomized controlled trial (RCT) evaluating laparoscopic cholecystectomy to investigate the introduction of minimally invasive surgery in the 1990s and explore the meaning of RCTs within the context of the introduction of a new surgical technology. It thus brings together the history of the use of laparoscopic cholecystectomy to remove the gallbladder, and the history of the RCT, shedding light on particular aspects of both. We first situate the RCT in the context of the history of the various treatment options for gallstones, or cholelithiasis, then characterize the specific situation of the rapid, patient-driven spread of laparoscopic cholecystectomy, and in a next step describe how the local context of laparoscopic cholecystectomy as a new technology made it possible and desirable to conduct an RCT, despite numerous obstacles. This article then shows that in order to capture and understand the rationale of an RCT it is worth it to explore the various levels and dimensions of its context, demonstrating how even the RCT as an ostensibly universal tool draws its meaning from its contexts and that this meaning goes beyond the simple determination of efficiency and safety, including, maybe most importantly, the control and management of new technologies.

The Preliminary Study on Procurement Biliary Convergence from Donors with Complicated Bile Duct Variant in Emergency Right Lobe Living Donor Liver Transplantation

BACKGROUND

The incidence of biliary complications after living donor adult liver transplantation (LDALT) is still high due to the bile duct variation and necessity reconstruction of multiple small bile ducts. The current surgical management of the biliary variants is unsatisfactory. We evaluated the role of a new surgical approach in a complicated hilar bile duct variant (Nakamura type IV and Nakamura type II) under emergent right lobe LDALT for high model for end-stage liver disease score patients.

METHODS

The common hepatic duct (CHD) and the left hepatic duct (LHD) of the donor were transected in a right-graft including short common trunks with right posterior and anterior bile ducts, whereas the LHD of the donor was anastomosed to the CHD and the common trunks of a right-graft bile duct and the recipient CHD was end-to-end anastomosed.

RESULTS

Ten of 13 grafts (Nakamura types II, III, and IV) had two or more biliary orifices after right graft lobectomy; seven patients had biliary complications (53.8%). Later, the surgical innovation was carried out in five donors with variant bile duct (four Nakamura type IV and one type II), and, consequently, no biliary or other complications were observed in donors and recipients during 47-53 months of follow-up; significant differences (P < 0.05) were found when two stages were compared.

CONCLUSION

Our initial experience suggests that, in the urgent condition of LDALT when an alternative live donor was unavailable, a surgical innovation of cutting part of the CHD trunks including variant right hepatic ducts in a complicated donor bile duct variant may facilitate biliary reconstruction and reduce long-term biliary complications.

Macquarie Surgical Innovation Identification Tool (MSIIT): a study protocol for a usability and pilot test

INTRODUCTION

Medicine relies on innovation to continually improve. However, innovation is potentially risky, and not all innovations are successful. Therefore, it is important to identify innovations prospectively and provide support, to make innovation as safe and effective as possible. The Macquarie Surgical Innovation Identification Tool (MSIIT) is a simple checklist designed as a practical tool for hospitals to identify planned surgical innovations. This project aims to test the usability and pilot the use of the MSIIT in a surgical setting.

METHODS AND ANALYSIS

The project will run in two phases at two Australian hospitals, one public and one private. Phase I will involve interviews, focus groups and a survey of hospital administrators and surgical teams to assess the usability and system requirements for the use of the MSIIT. Current practice regarding surgical innovation within participating hospitals will be mapped, and the best implementation strategy for MSIIT completion will be established. Phase II will involve trialling the MSIIT for each surgery within the trial period by various surgical personnel. Follow-up interviews, focus groups and a survey will be conducted with trial participants to collect feedback on their experience of using the MSIIT during the trial period. Comparative data on rates of surgical innovation during the trial period will also be gathered from existing hospital systems and compared to the rates identified by the MSIIT.

ETHICS AND DISSEMINATION

Ethical approval has been obtained. The results of this study will be presented to interested health services and other stakeholders, presented at conferences and published in a peer-reviewed MEDLINE-indexed journal.

Justice and Surgical Innovation: The Case of Robotic Prostatectomy

Surgical innovation promises improvements in healthcare, but it also raises ethical issues including risks of harm to patients, conflicts of interest and increased injustice in access to health care. In this article, we focus on risks of injustice, and use a case study of robotic prostatectomy to identify features of surgical innovation that risk introducing or exacerbating injustices. Interpreting justice as encompassing matters of both efficiency and equity, we first examine questions relating to government decisions about whether to publicly fund access to innovative treatments. Here the case of robotic prostatectomy exemplifies the difficulty of accommodating healthcare priorities such as improving the health of marginalized groups. It also illustrates challenges with estimating the likely long-term costs and benefits of a new intervention, the difficulty of comparing outcomes of an innovative treatment to those of established treatments, and the further complexity associated with patient and surgeon preferences. Once the decision has been made to fund a new procedure, separate issues of justice arise at the level of providing care to individual patients. Here, the case of robotic prostatectomy exemplifies how features of surgical innovation, such as surgeon learning curves and the need for an adequate volume of cases at a treatment centre, can exacerbate injustices associated with treatment cost and the logistics of travelling for treatment. Drawing on our analysis, we conclude by making a number of recommendations for the just introduction of surgical innovations.

Surgical innovation: the ethical agenda: A systematic review

The aim of the present article was to systematically review the ethics of surgical innovation and introduce the components of the learning health care system to guide future research and debate on surgical innovation.Although the call for evidence-based practice in surgery is increasingly high on the agenda, most surgeons feel that the format of the randomized controlled trial is not suitable for surgery. Innovation in surgery has aspects of, but should be distinguished from both research and clinical care and raises its own ethical challenges.To answer the question "What are the main ethical aspects of surgical innovation?", we systematically searched PubMed and Embase. Papers expressing an opinion, point of view, or position were included, that is, normative ethical papers.We included 59 studies discussing ethical aspects of surgical innovation. These studies discussed 4 major themes: oversight, informed consent, learning curve, and vulnerable patient groups. Although all papers addressed the ethical challenges raised by surgical innovation, surgeons hold no uniform view of surgical innovation, and there is no agreement on the distinction between innovation and research. Even though most agree to some sort of oversight, they offer different alternatives ranging from the formation of new surgical innovation committees to establishing national registries. Most agree that informed consent is necessary for innovative procedures and that surgeons should be adequately trained to assure their competence to tackle the learning curve problem. All papers agree that in case of vulnerable patients, alternatives must be found for the informed consent procedure.We suggest that the concept of the learning health care system might provide guidance for thinking about surgical innovation. The underlying rationale of the learning health care system is to improve the quality of health care by embedding research within clinical care. Two aspects of a learning health care system might particularly enrich the necessary future discussion on surgical innovation: integration of research and practice and a moral emphasis on "learning activities." Future research should evaluate whether the learning health care system and its adjacent moral framework provides ethical guidance for evidence-based surgery.

Disclosure, consent, and the exercise of patient autonomy in surgical innovation: a systematic content analysis of the conceptual literature

The classification of surgical innovation as clinical care, research, or as third distinct type of activity creates ambiguity which impacts standards for disclosure and informed consent. We conducted a systematic review of the conceptual literature to identify positions expressed about consent and disclosure, as well as major tension points associated with this issue. Literature overwhelmingly favors special consent and disclosure. Four major tension points were identified: the use of biasing/biased terminology to characterize innovation; patient vulnerability; the relationship between surgeon-innovator and patient; and practices and associated gaps related to consent and disclosure. Recommendations often focused on the informed consent process.

Expanding neurosurgery

The history of medicine is replete with innovations in neurosurgery that have spurred further developments across the medical spectrum. Surgeons treating pathologies in the head and spine have broken ground with new approaches, techniques, and technologies since ancient times. Neurosurgeons occupy a vital nexus in patient care, interfacing with the clinical symptoms and signs afflicting patients, the pathology at surgery, and imaging studies. No other physicians occupy this role within the nervous system. This power of observation and the ability to intercede place neurosurgeons in a unique position for impacting disease. Yet despite these pioneering achievements, more recently, forces in the workplace may be challenging neurosurgery's opportunities to contribute to the future growth of the neurosciences and medicine. The authors posit that, in the current health care climate, revenue generation by neurosurgical clinical activity is valued by the system more than neurosurgical research and academic output. Without providing the talented stream of new neurosurgeons with the opportunities and, in fact, the directive to achieve beyond simple financial success, the specialty is missing the opportunity to optimize its progress. The authors contend that the key to remaining relevant with the incorporation of new technologies to the treatment of neurosurgical patients will be to be flexible, open-minded, and nimble with the adaptation of new procedures by training and encouraging neurosurgical residents to pursue new or neglected areas of the specialty. Only by doing so can neurosurgery continue to expand.

Single-incision laparoscopic ileorectal anastomosis

AIM

Minimally invasive approaches for stoma closure offer considerable benefits for patients. Single port access via an end ileostomy site after stoma take-down in patients with prior total colectomy and a rectal stump remnant could allow restoration of ileorectal continuity by anastomosis but has not been detailed previously.

METHODS

After mobilisation of the end ileostomy, the anvil of a circular stapler is secured into the open end of the distal ileum and the intestine returned into the abdominal cavity. A single port access device (in this description, a 'surgical glove port') is placed then into the stoma site and full laparoscopy performed. Once the rectal stump is identified and prepared, an intracorporeal anastomosis can be constructed in a tension-free manner using a Knight-Griffin technique. Leak-testing can also be performed and the operation concluded with closure of the solitary incision.

RESULTS

In selected cases, adhesiolysis and anastomosis can be safely performed in toto. If the peritoneal environment is challenging, access can be escalated to multiport laparoscopy or even laparotomy.

CONCLUSION

Initiation of ileorectal anastomosis construction by single port laparoscopy at least allows peritoneal assessment but can provide for the operation's completion. This can confer maximum patient benefit for the most minimally invasive option.