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Concept: Abu al-Qasim al-Zahrawi

139

Hydrogel nanomaterials, especially those that are of non-human and non-animal origins, have great potential in biomedical and pharmaceutical sciences due to their versatility and inherent soft-tissue like properties. With the ability to simulate native tissue function, hydrogels are potentially well suited for cellular therapy applications. In this study, we have fabricated nanofibrillar cellulose-alginate (NFCA) suture coatings as biomedical devices to help overcome some of the limitations related to cellular therapy, such as low cell survivability and distribution out of target tissue. The addition of sodium alginate 8% (w/v) increased the NFCA hydrogel viscosity, storage and loss moduli by slightly under one order of magnitude, thus contributing significantly to coating strength. Confocal microscopy showed nearly 100% cell viability throughout the 2-week incubation period within and on the surface of the coating. Additionally, typical morphologies in the dual cell culture of spheroid forming HepG2 and monolayer type SK-HEP-1 were observed. Twelve out of 14 NFCA coated surgical sutures remained intact during the suturing operation with various mice and rat tissue; however, partial peeling off was observed in 2 of the coated sutures. We conclude that NFCA suture coatings could perform as cell-carrier systems for cellular based therapy and post-surgical treatment.

Concepts: Abu al-Qasim al-Zahrawi, Catgut suture, Surgical staple, Coatings, Coating, Surgical suture

88

The current paradigm of robot-assisted surgeries (RASs) depends entirely on an individual surgeon’s manual capability. Autonomous robotic surgery-removing the surgeon’s hands-promises enhanced efficacy, safety, and improved access to optimized surgical techniques. Surgeries involving soft tissue have not been performed autonomously because of technological limitations, including lack of vision systems that can distinguish and track the target tissues in dynamic surgical environments and lack of intelligent algorithms that can execute complex surgical tasks. We demonstrate in vivo supervised autonomous soft tissue surgery in an open surgical setting, enabled by a plenoptic three-dimensional and near-infrared fluorescent (NIRF) imaging system and an autonomous suturing algorithm. Inspired by the best human surgical practices, a computer program generates a plan to complete complex surgical tasks on deformable soft tissue, such as suturing and intestinal anastomosis. We compared metrics of anastomosis-including the consistency of suturing informed by the average suture spacing, the pressure at which the anastomosis leaked, the number of mistakes that required removing the needle from the tissue, completion time, and lumen reduction in intestinal anastomoses-between our supervised autonomous system, manual laparoscopic surgery, and clinically used RAS approaches. Despite dynamic scene changes and tissue movement during surgery, we demonstrate that the outcome of supervised autonomous procedures is superior to surgery performed by expert surgeons and RAS techniques in ex vivo porcine tissues and in living pigs. These results demonstrate the potential for autonomous robots to improve the efficacy, consistency, functional outcome, and accessibility of surgical techniques.

Concepts: Tissues, Physician, Abu al-Qasim al-Zahrawi, Laparoscopy, Anastomosis, Surgeon, Laparoscopic surgery, Surgery

28

BACKGROUND: Our goal was to analyze reported instances of the da Vinci robotic surgical system instrument failures using the FDA’s MAUDE (Manufacturer and User Facility Device Experience) database. From these data we identified some root causes of failures as well as trends that may assist surgeons and users of the robotic technology. METHODS: We conducted a survey of the MAUDE database and tallied robotic instrument failures that occurred between January 2009 and December 2010. We categorized failures into five main groups (cautery, shaft, wrist or tool tip, cable, and control housing) based on technical differences in instrument design and function. RESULTS: A total of 565 instrument failures were documented through 528 reports. The majority of failures (285) were of the instrument’s wrist or tool tip. Cautery problems comprised 174 failures, 76 were shaft failures, 29 were cable failures, and 7 were control housing failures. Of the reports, 10 had no discernible failure mode and 49 exhibited multiple failures. CONCLUSIONS: The data show that a number of robotic instrument failures occurred in a short period of time. In reality, many instrument failures may go unreported, thus a true failure rate cannot be determined from these data. However, education of hospital administrators, operating room staff, surgeons, and patients should be incorporated into discussions regarding the introduction and utilization of robotic technology. We recommend institutions incorporate standard failure reporting policies so that the community of robotic surgery companies and surgeons can improve on existing technologies for optimal patient safety and outcomes.

Concepts: Abu al-Qasim al-Zahrawi, Hospital, Report, The Da Vinci Code, Failure, Da Vinci Surgical System, Robotic surgery, Surgery

28

OBJECTIVE: To compare the ergonomics and workload of the surgeon during single-site suturing while using the magnetic anchoring and guidance system (MAGS) camera vs a conventional laparoscope. METHODS: Seven urologic surgeons were enrolled and divided into an expert group (n = 2) and a novice group (n = 5) according to their laparoendoscopic single-site (LESS) experience. Each surgeon performed 2 conventional LESS and 2 MAGS camera-assisted LESS vesicostomy closures in a porcine model. A Likert scale (scoring 1-5) questionnaire assessing workload, ergonomics, technical difficulty, visualization, and needle handling, as well as a validated National Aeronautics and Space Administration Task Load Index (NASA-TLX) questionnaire were used to evaluate the tasks and workloads. RESULTS: MAGS LESS suturing was universally favored by expert and novice surgeons compared with conventional LESS in workload (3.4 vs 4.2), ergonomics (3.4 vs 4.4), technical challenge (3.3 vs 4.3), visualization (2.4 vs 3.3), and needle handling (3.1 vs 3.9 respectively; P <.05 for all categories). Surgeon NASA-TLX assessments found MAGS LESS suturing significantly decreased the workload in physical demand (P = .004), temporal demand (P = .017), and effort (P = .006). External instrument clashing was significantly reduced in MAGS LESS suturing (P <.001). The total operative time of MAGS LESS suturing was comparable to that of conventional LESS (P = .89). CONCLUSION: MAGS camera technology significantly decreased surgeon workload and improved ergonomics. Nevertheless, LESS suturing and knot tying remains a challenging task that requires training, regardless of which camera is used.

Concepts: Rocket, Task, Likert scale, Knot, Surgeon, Abu al-Qasim al-Zahrawi, Surgery

27

BACKGROUND: Laparoscopic myomectomy (LM) has increased recently as treatment options for symptomatic uterine myomas for a patient who wants to preserve her uterus. However, adequate suture of the uterine defect is difficult in LM, even for an experienced surgeon. The most time-consuming step of LM is the suturing procedure. The suture material can tangle easily and disentanglement is time-consuming. We introduce a simple but highly effective instrument named “Puller” for continuous intracorporeal suturing in LM. METHODS: After completion of myoma enucleation, the operator sutures the uterine defect with suture material in continuous manner. The tip of “Puller” looks like a hook. During the suture, the first assistant inserts the “Puller” on the suprapubic site and sets the suture material on the hook and pulls it extracorporeally. After one stitch, the operator pulls the suture material intracorporeally, and then the first assistant pulls the sutured portion of the thread extracorporeally with “Puller” and holds the stitch to maintain the adequate tension during the repair. RESULTS: From January 2011 to October 2011, 88 patients who were diagnosed with uterine myoma underwent LM using “Puller” by a single surgeon. The mean diameter of the myoma was 6.8 ± 2.1 cm, and multiple myomas were observed in 46 cases (52.3 %). As a result, the mean operation time was 65.0 ± 22.1 min, the estimated blood loss was 173.9 ± 179.8 ml. Mean weight of removed myoma was 141.5 ± 105.7 g. Postoperative febrile morbidity (body temperature higher than 37.7 °C) was observed in 15 patients (17 %). However, no patients had conversion to laparotomy and needed blood transfusion. There were no major complications that required reoperation or readmission. CONCLUSIONS: Laparoscopic myomectomy can be performed easily and effectively by using the “Puller” technique with standard instruments. Additionally, this “Puller” technique could be adopted in all minimally invasive surgery needed running suture for hemostasis and closure.

Concepts: Abu al-Qasim al-Zahrawi, Catgut suture, Invasive, Blood, Minimally invasive, Uterus, Surgical suture, Surgery

25

Abstract Introduction: Though minimally invasive pediatric surgery has become more widespread, pediatric-specific surgical skills have not been quantitatively assessed. Material and methods: As a first step toward the quantification of pediatric-specific surgical skills, a pediatric chest model comprising a three-dimensional rapid-prototyped pediatric ribcage with accurate anatomical dimensions, a suturing skin model with force-sensing capability, and forceps with motion-tracking sensors were developed. A skill assessment experiment was conducted by recruiting 16 inexperienced pediatric surgeons and 14 experienced pediatric surgeons to perform an endoscopic intracorporeal suturing and knot-tying task in both the pediatric chest model setup and the conventional box trainer setup. Results: The instrument motion measurement was successful in only 20 surgeons due to sensor failure. The task completion time, total path length of instruments, and applied force were compared between the inexperienced and experienced surgeons as well as between the box trainer and chest model setups. The experienced surgeons demonstrated better performance in all parameters for both setups, and the pediatric chest model was more challenging due to the pediatric features replicated by the model. Conclusion: The pediatric chest model was valid for pediatric skill assessment, and further analysis of the collected data will be conducted to further investigate pediatric-specific skills.

Concepts: Empiricism, Abu al-Qasim al-Zahrawi, Medicine, Research, Philosophy of science, Pediatric surgery, Physician, Surgery

25

Purpose: The finger grip and the palm grip are the most common needle holder grips for hand suturing in surgery. The major advantages of the palm grip are an increased versatility and the possibility to apply controlled force. However, there is a risk for a potential loss of precision and uncontrolled movement of the needle when disengaging the ratchet mechanism of the palmed instrument. The purpose of this study was to develop a new needle holder, referred to as the Frimand needle holder (FNH), and evaluate surgeons' perception of it. It was designed to overcome the above-mentioned disadvantages, hence facilitating palm and finger grip suturing. Moreover, we evaluated suture precision and attitudes related to the use of the finger grip and the palm grip. Methods: Thirty-two surgeons performed sutures utilizing both the palm grip and the finger grip on postmortem porcine skin and small bowels, comparing the FNH to a standard Crile-Wood needle holder (CWNH). The participants assessed the FNH on an evaluation form. Precision was determined by letting the surgeons perform 20 sutures utilizing the finger grip and the palm grip on a polyurethane pad with premarked insert and exit sites. The distance between the designated exit site and the real exit site defined precision and was measured with a digital sliding dimension scale. Results: We found that 28 (88%) of the 32 surgeons use the palm grip to some extent, and 31 surgeons (97%) experienced an advantage when suturing with the FNH using the palm grip. Twenty-four (75%) of the 32 surgeons would prefer to suture with the FNH instead of the CWNH. There was no significant difference in precision between the finger grip and the palm grip. Conclusion: This study presents a new needle holder facilitating palm grip suturing. A majority of the participants preferred the new FNH over the standard CWNH for hand suturing. © 2014 S. Karger AG, Basel.

Concepts: Statistical significance, Hand, Middle finger, Preference, The Palm, Abu al-Qasim al-Zahrawi, Surgical suture

15

Surgical site infection (SSI) remains a persistent and morbid problem in colorectal surgery. Key to its pathogenesis is the degree of intraoperative bacterial contamination at the surgical site. The purpose of this study was to evaluate a novel wound retractor at reducing bacterial contamination.

Concepts: Injury, Degree of a polynomial, Surgery, Islamic Golden Age, Abu al-Qasim al-Zahrawi, Infection, Immune system, Antiseptic

2

Postoperative surgical site infections are one of the most frequent complications after open abdominal surgery, and triclosan-coated sutures were developed to reduce their occurrence. The aim of the PROUD trial was to obtain reliable data for the effectiveness of triclosan-coated PDS Plus sutures for abdominal wall closure, compared with non-coated PDS II sutures, in the prevention of surgical site infections.

Concepts: Abu al-Qasim al-Zahrawi, Transmission and infection of H5N1, Surgery, Infection, Surgical staple, Antiseptic

1

Computer vision was used to predict expert performance ratings from surgeon hand motions for tying and suturing tasks.

Concepts: Abu al-Qasim al-Zahrawi, Artificial intelligence