Evolution of the digital operating room: the place of video technology in surgery

PURPOSE

The aim of this review was to collate current evidence wherein digitalisation, through the incorporation of video technology and artificial intelligence (AI), is being applied to the practice of surgery. Applications are vast, and the literature investigating the utility of surgical video and its synergy with AI has steadily increased over the last 2 decades. This type of technology is widespread in other industries, such as autonomy in transportation and manufacturing.

METHODS

Articles were identified primarily using the PubMed and MEDLINE databases. The MeSH terms used were "surgical education", "surgical video", "video labelling", "surgery", "surgical workflow", "telementoring", "telemedicine", "machine learning", "deep learning" and "operating room". Given the breadth of the subject and the scarcity of high-level data in certain areas, a narrative synthesis was selected over a meta-analysis or systematic review to allow for a focussed discussion of the topic.

RESULTS

Three main themes were identified and analysed throughout this review, (1) the multifaceted utility of surgical video recording, (2) teleconferencing/telemedicine and (3) artificial intelligence in the operating room.

CONCLUSIONS

Evidence suggests the routine collection of intraoperative data will be beneficial in the advancement of surgery, by driving standardised, evidence-based surgical care and personalised training of future surgeons. However, many barriers stand in the way of widespread implementation, necessitating close collaboration between surgeons, data scientists, medicolegal personnel and hospital policy makers.

Video labelling robot-assisted radical prostatectomy and the role of artificial intelligence (AI): training a novice

Video labelling is the assigning of meaningful information to raw videos. With the evolution of artificial intelligence and its intended incorporation into the operating room, video datasets can be invaluable tools for education and the training of intelligent surgical workflow systems through computer vision. However, the process of manual labelling of video datasets can prove costly and time-consuming for already busy practising surgeons. Twenty-five robot-assisted radical prostatectomy (RARP) procedures were recorded on Proximie, an augmented reality platform, anonymised and access given to a novice, who was trained to develop the knowledge and skills needed to accurately segment a full-length RARP procedure on a video labelling platform. A labelled video was subsequently randomly selected for assessment of accuracy by four practising urologists. Of the 25 videos allocated, 17 were deemed suitable for labelling, and 8 were excluded on the basis of procedure length and video quality. The labelled video selected for assessment was graded for accuracy of temporal labelling, with an average score of 93.1%, and a range of 85.6–100%. The self-training of a novice in the accurate segmentation of a surgical video to the standard of a practising urologist is feasible and practical for the RARP procedure. The assigning of temporal labels on a video labelling platform was also studied and proved feasible throughout the study period.

Immediate vaginal and perineal reconstruction after abdominoperineal excision using the Inferior Gluteal Artery Perforator Flap (V-IGAP)

BACKGROUND

The fasciocutaneous inferior gluteal artery perforator (IGAP) has been previously demonstrated to be a robust reconstructive choice after abdominoperineal excision (APE), with comparably low morbidity relative to other flaps. In patients who undergo concurrent vaginectomy, we demonstrate in this retrospective cohort study how IGAP modification allows simultaneous vaginal reconstruction with a favourable complication profile and long-term return to sexual activity.

METHODS

Oncological resection was completed with the patient prone. Unilateral or bilateral IGAP flaps may be used based on vaginal defect size and surgeon preference. In this study, important features of flap design, mobilisation and inset are presented, together with a retrospective cohort study of all cases who underwent vaginal reconstruction. Clinical outcomes were determined by the length of stay, early to late complications, and quality of life assessment including a return to sexual function.

RESULTS

Over a 10-year period, 207 patients underwent abdominoperineal resection (APE) in our cross-centre study (86% subject to neoadjuvant chemoradiotherapy), with 22/84 female patients electing for vaginal reconstruction (19 partial, 3 total vaginectomies). Minor complications were observed in 6/22 cases, with two patients progressing to healing after-theatre debridement (major). The median follow-up time was 410 days. Quality of life questionnaires reported high patient satisfaction, with 70% of patients returning to sexual activity.

CONCLUSIONS

For patients undergoing APE with concurrent vaginectomy, the IGAP flap can be used alone for both perineal dead space management and neovaginal reconstruction, negating the need for an alternative second flap and avoiding significant donor morbidity. This study shows excellent long-term clinical outcomes, including a return to sexual activity.

Augmented Reality: Moving Robotics Forward

Compared with other fields, adoption of robotics in colorectal surgery remains relatively slow. One of the reasons for this is that the expected benefits of robotics, such as greater accuracy, speed, and better patient outcomes, are not born out in evidence comparing use of robotics for colorectal procedures to conventional laparoscopy. But evidence also suggests that outcomes with colorectal robotic procedures depend on the experience of the surgeon, suggesting that a steep learning curve is acting as a barrier to the benefits of robotics being realized. In this paper, we analyze exactly why surgeon skill and proficiency is such a critical factor in colorectal surgery, especially around the most complex procedures associated with cancer. Shortening of the learning curve is crucial for both the adoption of the technique and the efficient use of expert trainers. Looking beyond the basics of training and embracing a new generation of digital learning technologies that facilitate peer-to-peer collaboration and development beyond the confines of individual institutions may be an important contributor to achieve these goals in the future.

Epidermal graft encourages wound healing by down-regulation of gap junctional protein and activation of wound bed without graft integration as opposed to split-thickness skin graft

Wound coverage by split-thickness skin graft (SSG) and epidermal graft (EG) shortens healing time, with comparable outcomes. However, the healing mechanism of EG is not as well understood as SSG. The difference in the healing mechanisms of EG and SSG was investigated using gap junctional proteins, proliferative marker, and cytokeratin markers. Paired punch biopsies were taken from the wound edge and wound bed from patients undergoing EG and SSG at weeks 0 and 1 to investigate wound edge keratinocyte migratory activities (connexins 43, 30, and 26), wound bed activation (Ki67), and the presence of graft integration to the wound bed (cytokeratins 14 and 6). Twenty-four paired biopsies were taken at weeks 0 and 1 (EG, n = 12; SSG, n = 12). Wound edge biopsies demonstrated down-regulation of connexins 43 (P = .023) and 30 (P = .027) after EG, indicating accelerated healing from the wound edge. At week 1, increased expression of Ki67 (P < .05) was seen after EG, indicating activation of cells within the wound bed. Keratinocytes expressing cytokeratins 6 and 14 were observed on all wounds treated with SSG but were absent at week 1 after EG, indicating the absence of graft integration following EG. Despite EG and SSG both being autologous skin grafts, they demonstrate different mechanisms of wound healing. EG accelerates wound healing from the wound edges and activates the wound bed despite not integrating into the wound bed at week 1 post-grafting as opposed to SSG, hence demonstrating properties comparable with a bioactive dressing instead of a skin substitute.

Fat grafting and platelet-rich plasma for the treatment of diabetic foot ulcers: A feasibility-randomised controlled trial

Chronic, nonhealing diabetic foot ulcers (DFU) are increasing in prevalence and are often unresponsive to conventional therapy. Adipose tissue, containing adipose-derived stem cells, and platelet rich plasma (PRP) are regenerative therapies rich in growth factors which may provide a solution to chronic wound healing. This study aimed to assess the feasibility of conducting a definitive randomised controlled trial (RCT) to investigate the efficacy of these therapies for the treatment of DFU. This was a single centre, feasibility, three-arm, parallel group RCT. Eligible DFU patients were randomised on a 1:1:1 basis to three intervention arms: control (podiatry); fat grafting; fat grafting with PRP. The intervention was delivered once and patients were followed-up for 12 weeks. The primary objective was to assess measures of trial feasibility. Clinical outcomes and health-related quality of life (HRQoL) were also evaluated. Three hundred and thirty four patients were screened and 32 patients (9.6%) were deemed eligible with 18 enrolled in the trial (6 per arm) over 17 months. All participants completed the trial with no withdrawals or crossover. Participant engagement was high with most HRQoL questionnaires returned and only 4.8% follow-up appointments missed. There were five adverse events (AEs) related to the trial with no serious AEs. Five (28%) of the wounds healed. There was no difference between any of the groups in terms of clinical outcomes. This feasibility study demonstrated that a multi-centre RCT is safe and feasible with excellent patient engagement. We have highlighted crucial information regarding methodology and recruitment, which will guide future trial design. Registration number: NCT03085550 clinicaltrials.gov. Registered 01/03/2017.

Lower donor site morbidity and higher patient satisfaction with epidermal grafting in comparison to split thickness skin grafting: A randomized controlled trial (EPIGRAAFT Trial)

BACKGROUND

Split thickness skin grafting (SSG) is an important modality for wound coverage; however, it leads to donor site morbidity. Epidermal grafting (EG) is a promising option for autologous skin grafting which offers minimal donor site morbidity, though it is not known if EG is an effective clinical alternative for SSG. This study compared the efficacy of EG as an alternative to SSG in terms of wound healing outcomes, donor site morbidity, patient satisfaction and adverse events.

METHODS

EPIGRAAFT is a Phase 2, randomized, open-label trial with two parallel groups: EG and SSG. Patients referred for skin grafting with a healthy granulating wound bed were included. The co-primary endpoints were the proportion of wounds healed and donor site healing time. The secondary endpoints include donor site morbidity measured using Vancouver Scar Scale, mean time for complete wound healing, patient satisfaction assessed using a validated skin grafting questionnaire and incidence of adverse events.

RESULTS

Of the 61 patients screened, 44 patients were randomized. There was no difference in the proportion of wounds healed at 6 weeks (p=0.366) and 3 months(p=0.24) as well as the mean time for wound healing (p=0.12). EG resulted in lower donor site morbidity (p=0.001), faster donor site healing time (EG: 4.86 days vs. SSG: 21.32 days) (p<0.0001), and higher overall satisfaction (p<0.001). There were no adverse events reported.

CONCLUSION

This study demonstrated that EG has superior donor site outcomes with faster donor site healing and lower morbidity compared to SSG, while having comparable wound healing outcomes. Patients receiving EG also experienced higher donor site satisfaction compared to SSG. ClinicalTrials.gov identifier: NCT02535481.

Systematic review of the efficacy of fat grafting and platelet-rich plasma for wound healing

Adipose-derived stem cells found in fat grafts may have significant healing properties. When fat is combined with autologous platelet-rich plasma (PRP), there may be enhanced healing effects due to the pro-angiogenic and anti-inflammatory effects of PRP. This study aimed to evaluate the current evidence on fat grafting in combination with PRP for wound healing to establish the efficacy of this technique. A comprehensive search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (to March 2017) was conducted to identify studies on fat grafting and PRP for wound healing. Case series of less than 3 cases and studies only describing harvest technique were excluded. The database identified 571 articles, of which 3 articles that used a combination of fat and PRP for wound healing (1 RCT and 2 case series) were included in this review. A total of 69 wounds in 64 patients were treated with an average wound size of 36.32cm² . Of these, 67% of wounds achieved complete healing. When reported, the mean time to healing was 7.5 weeks for those who underwent a single treatment. There were no significant complications in any patients. The combination of fat grafting and PRP may achieve adequate wound healing with relatively quick wound healing time compared with standard wound management options. However, evidence is extremely limited, and further studies are required to evaluate its efficacy for wound healing.

Body Contouring Surgery and the Maintenance of Weight-Loss Following Roux-En-Y Gastric Bypass: A Retrospective Study

BACKGROUND

Bariatric surgery leads to significant weight loss with reduced morbidity and mortality. However, excess skin as a consequence of weight loss represents a major problem, impacting upon patient's functionality with potential negative effects on weight loss.

OBJECTIVES

We evaluated the effect of body-contouring surgery on weight-loss maintenance following bariatric surgery.

METHODS

We undertook a retrospective analysis of patients undergoing Roux-en-Y gastric bypass (RYGB) +/- body-contouring surgery (BC). The control group (n = 61) received RYGB, the test group (n = 30) received RYGB+BC 12 to 18 months after bariatric surgery. Each RYGB+BC patient was matched to two control patients for age, sex, glycaemic status, and weight on day of surgery. Per cent weight loss (%WL) was calculated at 3, 6, 12, 24, 36, 48, and 60 months post-RYGB for both groups.

RESULTS

The %WL was similar at 3, 6, and 12 months post-RYGB. At 24 months, %WL was 35.6% in the RYGB+BC group and 30.0% in the RYGB group (P < 0.05). At 36 months, the RYGB+BC group maintained their weight loss (%WL 33.0%), in contrast, the RYGB gained weight (%WL = 27.3%, P < 0.05). This trend continued (RYGB+BC vs RYGB) at 48 months (%WL 30.8% vs 27.0%) and at 60 months (%WL 32.2% vs 22.7%, P < 0.05).

CONCLUSIONS

Our results suggest patients who undergo body contouring after bariatric surgery are able to lose significantly more weight and maintain weight loss at five years of follow up compared to those undergoing bariatric surgery alone.

The management of pretibial lacerations

Introduction Pretibial lacerations are common injuries, often presenting in the elderly and infirm. Unclear management pathways often result in inappropriate care. We identify patient demographics, morbidity risk factors, injury severity and management options. Materials and methods This retrospective study involved analysing databases and hardcopy notes for patients admitted with pretibial lacerations to Addenbrooke's Hospital, January to December 2012. Microsoft Excel and Fishers exact test were used to analyse the data with a P-value of less than 0.05 representative of statistical significance. Information on patient demographics, site of lesion, preoperative symptoms, management, operative details and clinical outcomes were collected. Results A total of 36 patients were identified; the mean age was 79 years (± 16 years, 1 standard deviation) with a three to two female to male preponderance; 57% of injuries were caused by mechanical fall, 33% traumatic blunt impact and 7% road traffic accidents. American Society of Anesthesiologists physical status classification was 43% level III, 40% II, 9% I and 9% IV. Dunkin classification of severity was 33% grade III, 30% grade I, 24% grade IV and 12% grade II. Median inpatient duration was 11 days for surgically managed compared with 15 days for conservatively managed patients. Discussion Pretibial lacerations tend to affect the elderly. Management is compounded by polypharmacy and comorbidities. If inadequately managed, such injuries can adopt characteristics of chronic wounds, with lengthy inpatient stays. Surgical intervention may be appropriate where injuries are severe and the patient stable enough for theatre. Conclusions We believe that surgical management with autologous tissue repair, with minimal delay between presentation and theatre, is warranted for extensive injuries wherever possible, with conservative management used for predominantly less extensive pretibial lacerations.

Assessing the effects of changes in care commissioning guidelines at a tertiary centre in London on the provision of NHS-funded procedures of limited clinical effectiveness: an 11-year retrospective database analysis

OBJECTIVES

The main objective of this study was to assess the impact of changes in care commissioning policies on National Health Service (NHS)-funded cosmetic procedures over an 11-year period at our centre.

SETTING

The setting was a tertiary care hospital in London regulated by the North Central London Hospitals NHS Trust care commissioning group.

PARTICIPANTS

We included all patients logged on to our database at the time of the study which was 2087 but later excluded 61 from analysis due to insufficient information.

PRIMARY AND SECONDARY OUTCOME MEASURES

The main outcome measures were the results of tribunal assessment for different cosmetic surgeries which were either accepted, rejected or inconclusive based on the panel meeting.

RESULTS

There were a total of 2087 patient requests considered between 2004 and 2015, of which 715 (34%) were accepted, 1311 (63%) were declined and 61 (3%) had inconclusive results. The implementation of local care commissioning guidelines has reduced access to cosmetic surgeries. Within this period, the proportion of procedures accepted has fallen from 36% in 2004 to 21% in 2015 (χ²; p<0.05, 95% CI).

CONCLUSION

Local guidance on procedures of limited clinical effectiveness is a useful, although not evidence-based selection process to reduce access to cosmetic surgery in line with increasing financial constraints. However, patients with a physical impairment may not receive treatment in comparison to previous years, and this can have a negative impact on their quality of life.

Protocol for a systematic review of the efficacy of fat grafting and platelet-rich plasma for wound healing

BACKGROUND

The use of fat grafting as a reconstructive surgical option is becoming much more common. Adipose-derived stem cells found in fat grafts are believed to facilitate wound healing via differentiation into fibroblasts and keratinocytes and the release of pro-healing growth factors. Several small studies have shown a positive effect of fat grafting in healing of wounds of a variety of aetiologies. When fat is combined with autologous platelet-rich plasma (PRP), there may be enhanced healing effects. This may be due to the pro-angiogenic and anti-inflammatory effects of PRP. We aim to synthesise the current evidence on combination fat grafting and PRP for wound healing to establish the efficacy of this technique.

METHODS/DESIGN

We will conduct a comprehensive literature search in the MEDLINE, EMBASE, CENTRAL, Science Citation Index, and Google Scholar databases (up to July 2017) to identify studies on fat grafting and PRP for wound healing. All primary studies and systematic reviews of these studies will be included, except case reports and case series with fewer than three patients, to evaluate the outcome of fat grafting and PRP on wound healing either on its own or when compared to other studies. Primary outcome measures are expected to be the proportion of total wounds healed at 12 weeks and the average wound healing time (time for 100% re-epithelialisation). Expected secondary outcome measures are the proportion of wounds achieving 50% wound healing, the type of wound benefitting most from fat grafting, economic evaluation, health-related quality of life, and adverse events. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology.

DISCUSSION

This review will provide robust evidence of the efficacy of fat grafting and PRP for wound healing. This is an emerging technique, and this review is expected to guide clinical practice and ongoing research aimed at improving wound care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016049881.

Migraine: A look down the nose

BACKGROUND

Studies have suggested that contact between opposing mucosal surfaces in the nasal wall and cavity can be a target of the surgical treatment of migraines. Unfortunately, not enough is known about the role of nasal pathology in the pathogenesis of this condition. The co-existence of further rhinological disorders can be an impediment to defining the cause and effect of anatomical variants. The authors compared the MRI scans of migraine- and non-migraine patients (MPs and NMPs, respectively) to determine the prevalence of such mucosal contact points in order to extrapolate whether there is a significant association with migraines.

METHODS

Coronal and axial MRI brain scans of 522 patients (412 migraineurs and 110 non-migraineurs) were analysed for the prevalence of anatomical variations of the nasal cavity, e.g. concha bullosa, septal deviations, mucosal swelling and contact points.

RESULTS

The results showed no significant difference between MPs and NMPs patients for any of the parameters examined. Moreover, 87% MPs and 79% NMPs had at least one contact point. The most frequent contact point was between the middle turbinate and the septum, observed in 54% of MPs and 45% of NMPs.

CONCLUSIONS

Contact points with the nasal mucosa are highly prevalent in both MPs and NMPs. Although a contact point does not cause a migraine in the absence of the disease, the concomitant presence of migraine and contact points can trigger an attack, and therefore, it is necessary to differentiate or exclude a rhinological disorder in these patients.

Systematic review and meta-analysis of the efficacy of epidermal grafting for wound healing

Autologous skin grafting is an important method for wound coverage; however, it is an invasive procedure and can cause donor site morbidity. Epidermal grafting (EG) enables epidermal transfer to wounds with minimal donor site morbidity. However, data to date have been heterogeneous. This study aims to synthesise the current evidence on EG for wound healing to establish the efficacy of this surgical technique. A comprehensive search in the MEDLINE, EMBASE and CENTRAL databases was conducted. The endpoints assessed were proportion of wounds healed and mean wound-healing time. This systematic review was conducted and reported according to the Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines. We identified 1568 articles, of which seven articles were included in this review - a total of 209 wounds in 190 patients. The mean wound duration was 17·06 weeks (95% CI 8·57-25·55). Of these, 71·5% (95% CI 56·7-84·2) of the wounds achieved complete healing. Mean time for complete wound healing was 5·53 weeks (95% CI 3·18-7·88). The mean donor site healing time was 7·48 days (95% CI 4·83-10·13), with no reported donor site morbidity. The current data are small and lack level 1 evidence.

Epidermal grafting for wound healing: a review on the harvesting systems, the ultrastructure of the graft and the mechanism of wound healing

Epidermal grafting for wound healing involves the transfer of the epidermis from a healthy location to cover a wound. The structural difference of the epidermal graft in comparison to the split-thickness skin graft and full-thickness skin graft contributes to the mechanism of effect. While skin grafting is an epidermal transfer, little is known about the precise mechanism of wound healing by epidermal graft. This paper aims to explore the evolution of the epidermal graft harvesting system over the last five decades, the structural advantages of epidermal graft for wound healing and the current hypotheses on the mechanism of wound healing by epidermal graft. Three mechanisms are proposed: keratinocyte activation, growth factor secretion and reepithelialisation from the wound edge. We evaluate and explain how these processes work and integrate to promote wound healing based on the current in vivo and in vitro evidence. We also review the ongoing clinical trials evaluating the efficacy of epidermal graft for wound healing. The epidermal graft is a promising alternative to the more invasive conventional surgical techniques as it is simple, less expensive and reduces the surgical burden for patients in need of wound coverage.

The CelluTome epidermal graft-harvesting system: a patient-reported outcome measure and cost evaluation study

Conventional split skin grafts (SSG) require anaesthesia, specialist equipment and can have high donor site (DS) morbidity. The CelluTome epidermal graft-harvesting device is a novel alternative, providing pain-free epidermal skin grafts (ESG) in the outpatient setting, with projected minimal DS trauma and improved patient satisfaction. This study aimed to compare ESG with SSG by evaluating patient-related outcome measures (PROMs) and the cost implications of both. Twenty patients answered a graft satisfaction questionnaire that evaluated: donor/graft site noticeability, aesthetic concerns, adverse problems and patient satisfaction. Cost/patient was calculated based on total operative expenses and five clinic follow-ups. In 100% of the ESG cases, there were no DS noticeability or adverse problems compared to 25% in the SSG group. Complete satisfaction with DS appearance was observed in 100% of the ESG cases (50% SSG). Noticeability, adverse problems and overall satisfaction were significantly better in ESG cases (P < 0.05). Graft site parameters were comparable with similar healing outcomes. The cost per patient for ESG was £431 and £1489 for SSG, with an annual saving of £126 960 based on 10 grafts/month. For the right patient, CelluTome provides comparable wound healing, with reduced DS morbidity and higher patient satisfaction.

Protocol for a systematic review of the efficacy of epidermal grafting for wound healing

BACKGROUND

Autologous skin grafting is an important modality for wound coverage; however, it can result in donor site morbidity. Epidermal grafting is an emerging option to overcome this challenge. Furthermore, it can be done in an outpatient setting with minimal or no pain. To date, the evidence on the efficacy of this technique for wound healing has yet to be outlined. We aim to synthesise the current evidence on epidermal grafting for wound healing to establish the efficacy of this technique.

METHODS/DESIGN

We will conduct a comprehensive search in the MEDLINE, EMBASE, and CENTRAL databases (up to May 2016) to identify studies on epidermal grafting for wound healing. We will include any primary studies (excluding case reports or case series lesser than three patients) or systematic reviews of such studies to assess the outcome of epidermal grafting for wound healing either on its own or compared to other methods. The expected primary outcome measures are the efficacy of epidermal grafting for wound healing (measured by the proportion of wounds healed at 6 weeks) and the mean wound-healing time (time for complete re-epithelialisation). Secondary outcome measures are the mean donor site-healing time, need for anaesthesia, costs associated with resource use, health-related quality of life, and proportion of patients with adverse event. Subgroup analysis will be performed for the proportions of wounds healed based on wound aetiology.

DISCUSSION

This is a timely systematic review, and the finding of this systematic review is expected to guide research and clinical practice aimed at improving wound care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016033051.

Epidermal grafting versus split-thickness skin grafting for wound healing (EPIGRAAFT): study protocol for a randomised controlled trial

Background

Split-thickness skin grafting (SSG) is an important modality for wound closure. However, the donor site becomes a second, often painful wound, which may take more time to heal than the graft site itself and holds the risk of infection and scarring. Epidermal grafting (EG) is an alternative method of autologous skin grafting that harvests only the epidermal layer of the skin by applying continuous negative pressure on the normal skin to raise blisters. This procedure has minimal donor site morbidity and is relatively pain-free, allowing autologous skin grafting in an outpatient setting. We plan to compare EG to SSG and to further investigate the cellular mechanism by which each technique achieves wound healing.

Methods/design

EPIGRAAFT is a multicentre, randomised, controlled trial that compares the efficacy and wound-healing mechanism of EG with SSG for wound healing. The primary outcome measures are the proportion of wounds healed in 6 weeks and the donor site healing time. The secondary outcome measures include the mean time for complete wound healing, pain score, patient satisfaction, health care utilisation, cost analysis, and incidence of adverse events.

Discussion

This study is expected to define the efficacy of EG and promote further understanding of the mechanism of wound healing by EG compared to SSG. The results of this study can be used to inform the current best practise for wound care.

Trial registration

Clinicaltrials.gov identifier, NCT02535481. Registered on 11 August 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-016-1352-y) contains supplementary material, which is available to authorized users.

A prospective, multicentre study on the use of epidermal grafts to optimise outpatient wound management

Current wound management through the use of a split-thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft-harvesting device (CelluTome) that allows pain-free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.

A Randomized Control Trial Exploring the Effect of Mental Rehearsal and Cognitive Visualization on Microsurgery Skills

Background Many factors are known to influence the performance of surgeons within the operating theater, including tiredness, previous experience, and stress levels. The effects of mental rehearsal and cognitive visualization on microsurgical skills have not been assessed. Methods Thirty-six subjects recruited from the Northwick Park Microsurgery Skills Course were randomized into three groups; (1) a control group (C) with no mental rehearsal script, (2) a visual anastomosis group (VA), with a detailed rat anastomosis script, and (3) a visual relaxation (VR) group with a relaxation script, unrelated to the anastomosis. Participants ran through relevant scripts from day 2 to 5 and were assessed through recorded arterial rat anastomosis, scored using the structured assessment of microsurgery skills. Results Results were analyzed by double-blinded assessors. No statistical significance was found on Monday and Tuesday (first day post intervention), p = 0.326 (VA vs. C) and p = 0.283 (VR vs. C). A statistically significant difference was noted at the end of day 4; p < 0.001 (VA vs. VR) and p = 0.001 (VA vs. C). Further analysis demonstrated that domains within the global rating scoring system showed statistical significance for (1) dexterity: VA versus VR, p = 0.001, (2) visuospatial skills: VA versus VR, p = 0.001, and VA versus C, p = 0.002, and (3) operative flow: VA versus VR, p = 0.044, and VA versus C, p = 0.026. Conclusion The benefits of cognitive visualization and mental rehearsal in microsurgery may result in fewer complications from errors and thus lead to enhanced patient safety and better operative outcomes.

Assessment of Emergency Department Eye Examinations in Patients Presenting with Mid-Face Injury

BACKGROUND

One-fifth of patients with severe facial trauma suffer ophthalmic injury. Currently, patients presenting with mid-face injury to the emergency department (ED) undergo visual examination and then further assessment by ophthalmologists and with computed tomography (CT) scanning. The utility of the initial visual examination in the ED, performed by nonophthalmologists, remains unclear.

OBJECTIVE

We aimed to objectively identify whether a more thorough initial visual assessment, performed by nonophthalmologists in the ED, was associated with improved ophthalmic outcomes.

METHODS

Patients (n = 100) were retrospectively recruited from a tertiary craniomaxillofacial center. Visual examinations performed in the ED were scored objectively and measured against defined management and prognostic outcomes.

RESULTS

There was no significant difference between more thorough initial visual examination and reduced time to ophthalmology assessment or reduced visual complications. There was no correlation between more comprehensive examination and incidence of CT scanning.

CONCLUSIONS

We identified no significant difference between a comprehensive visual examination performed by nonophthalmologists in the ED, and improved ophthalmic outcomes. Physicians assessing patients with mid-face trauma in the ED should rule out eye emergencies, including retrobulbar hemorrhage and penetrating globe injury, and initiate expeditious CT scan and assessment by specialist ophthalmologists.

Complications of facial fillers: resource implications for NHS hospitals

Facial rejuvenation seeks to reverse the negative sequelae of multiple factors but most importantly of genetic predisposition, sun damage and smoking. With the advent of the so-called 'non-surgical' techniques, and perhaps fuelled by these austere times, volumetric facial augmentation using dermal fillers has soared in popularity among both patients and practitioners. However, legislation has yet to keep pace with the change in clinical practices leaving patients poorly informed and with no protection against unscrupulous suppliers and unregulated practitioners. When things go wrong, patients often turn to the National Health Service (NHS) to rectify both the acute and chronic sequelae resulting in potentially difficult ethical and resource implications. Here, we report one of an increasing number of cases presenting to our NHS craniofacial service with acute filler-related complications.

Facing the World: audit of activity 2002-2010

BACKGROUND

Craniofacial anomalies, although uncommon, can have considerable effects on the individual, their family and society.(1-4) They carry with them a large morbidity and require a highly specialized, multidisciplinary approach to treatment.(5) Facing the World (FTW), was founded in 2002, to offer facial reconstructive surgery to children with complex, craniofacial anomalies with no prospect of local treatment, from developing countries anywhere in the world.

METHODS

We present an 8-year audit of the cases treated by FTW, where children are brought from their own countries to the UK for treatment. Patient selection takes place prior to their arrival in the UK by a multidisciplinary team. Specifically the condition has to be correctable to a degree that justifies the risks involved with the surgery, and the disruption to the child and their family.

RESULTS

Since inception, FTW has evaluated more than 300 cases and provided treatment in the UK for over 24 cases from 18 different countries. We present our range of cases and complications. We discuss our complication rate of 28% and mortality rate of 4% (1 case).

CONCLUSIONS

Key to the sustainability of FTW is the development of local healthcare infrastructure within the developing countries to facilitate eventual local management of the more straightforward cases and follow up of these patients by well-trained medical staff. By establishing these programs, FTW aims to not only change these children's lives but to raise awareness, and help to expand the global craniofacial network whereby in the future, satellite partners will be present to help manage these conditions locally.

LEVEL OF EVIDENCE

III.

Surgical management of two complex cases of large juvenile orbital ossifying fibroma

Ossifying fibroma is a rare benign tumour of the craniofacial skeleton, which can have an aggressive biological behaviour in the paediatric population. Complete surgical excision, where possible, is the ideal. This case report discusses the multidisciplinary, surgical management of two complex cases of large juvenile ossifying fibroma (JOF), involving the orbit. Both patients underwent resection of the orbital ossifying fibroma with no macroscopic evidence of recurrence at 4 years follow-up. Full functional outcome was achieved with preservation of vision and facial nerve function as well as good facial symmetry and aesthetics. The successful surgical outcome of these cases was due to a combination of a multidisciplinary team approach, rigorous pre-operative planning, maximal tumour resection, and the use of a novel surgical technique involving a medial zygomatic-orbito-maxillary rotational osteotomy.