Augmented Reality and Image-Guided Robotic Liver Surgery

Artificial intelligence makes surgical resection easier and safer, and, at the same time, can improve oncological results. The robotic system fits perfectly with these more or less diffused technologies, and it seems that this benefit is mutual. In liver surgery, robotic systems help surgeons to localize tumors and improve surgical results with well-defined preoperative planning or increased intraoperative detection. Furthermore, they can balance the absence of tactile feedback and help recognize intrahepatic biliary or vascular structures during parenchymal transection. Some of these systems are well known and are already widely diffused in open and laparoscopic hepatectomies, such as indocyanine green fluorescence or ultrasound-guided resections, whereas other tools, such as Augmented Reality, are far from being standardized because of the high complexity and elevated costs. In this paper, we review all the experiences in the literature on the use of artificial intelligence systems in robotic liver resections, describing all their practical applications and their weaknesses.

The Solid Tumor Microenvironment - Breaking The Barrier For T Cells

The tumor microenvironment plays a pivotal role in the behavior and development of solid tumors as well as shaping the immune response against them. As the tumor cells proliferate, the space they occupy and their physical interactions with the surrounding tissue increases. The growing tumor tissue becomes a complex dynamic structure, containing connective tissue, vascular structures, and extracellular matrix that facilitates stimulation, oxygenation, and nutrition, necessary for its fast growth. Mechanical cues such as stiffness, solid stress, interstitial fluid pressure, matrix density, and microarchitecture influence cellular functions and ultimately tumor progression and metastasis. In this fight, our body is equipped with T cells as its spearhead against tumors. However, the altered biochemical and mechanical environment of the tumor niche affects T cell efficacy and leads to their exhaustion. Understanding the mechanobiological properties of the tumor microenvironment and their effects on T cells is key for developing novel adoptive tumor immunotherapies.

Ultrasonic diagnostics of vascular complications after laser procedures

A clinical case of treatment of rosacea with a high-intensity laser at different stages, performed under control of high-resolution ultrasound (HRU), is presented. According to clinical guidelines, patients in the erythematous stage of rosacea (stage I) undergo selective coagulation of superficial vessels with a neodymium laser. Diagnosis and determination of the severity of the disease are carried out based on the presence of primary and secondary elements of the rash. There are no criteria for ultrasound assessment of the skin and its vascularization in patients with rosacea. During ultrasound examination after 4 laser procedures in B-mode, the dermis is heterogeneous due to hypoechoic papillary and hyperechoic reticular layers, without signs of infiltrative changes, in the color Doppler mapping mode there is a pronounced vascularization of the papillary dermis in the area of interest, represented by multiple vessels in contrast to single vascular structures seen on ultrasound after two laser treatments. According to the results of ultrasound examination, a more severe degree of the disease was diagnosed, which served as the basis for prescribing therapy with systemic retinoids. Clinical observation demonstrates the capabilities of ultrasound in planning laser procedures in order to reduce the risk of complications, their early diagnosis and monitoring of treatment if they occur.

Dermoscopy of Small Diameter Melanomas with the Diagnostic Feasibility of Selected Algorithms—A Clinical Retrospective Multicenter Study

Objective: The aim of the study was to verify two hypotheses. The first concerned the possibility of diagnostic dermoscopic differentiation between cutaneous melanomas of the histopathological category in situ (pTis) and thin melanomas (pT1a) in terms of their diameter. The second assessed the diagnostic feasibility of two dermoscopic algorithms aiming to detect ≤ 5.0 mm-sized melanomas histopathologically confirmed as pTis and pT1a. Methods: Dermoscopic images of consecutive cases of histopathologically confirmed melanomas were evaluated by three independent investigators for the presence of the predefined criteria. The melanomas were subdivided according to their diameter into small melanomas, so-called micromelanomas (microM)—sized ≤ 5.0 mm and >5.0 mm, according to published definitions of small melanocytic lesions. The Triage Amalgamated Dermoscopic Algorithm (TADA) and the revisited 7-point checklist of dermoscopy (7-point) algorithm were chosen for the diagnostic feasibility. Odds ratios and corresponding 95% confidence limits (CL) were calculated using the logistic regression adjusted for age for the melanoma-specific dermoscopic structures, the dermoscopic patterns and the diagnostic feasibility of the 7-point checklist and TADA algorithms. The p-values of the results were corrected using the Bonferroni method. Results: In total, 106 patients with 109 melanomas, 50 sized ≤ 5.0 mm and 59 exceeding the diameter of 5.0 mm, were retrospectively analyzed. The prevalent general pattern of microM was the spitzoid one (48% vs. 11.86%, p = 0.0013). Furthermore, 40% of microM vs. 6.78% melanomas sized > 5.0 mm (p = 0.0023) did not present melanoma-specific patterns. The asymmetric multicomponent pattern was present in 64.41% melanomas sized > 5.0 mm and in 26.00% microM (p = 0.0034). The asymmetry of structures or colors was detected in 56% microM vs. 89.83% (p = 0.0020) and 56% microM and 94.92% (p = 0.000034) melanoma sized > 5.0 mm, respectively. The differences in frequency of the detected dermoscopic structures specific to melanomas revealed that microM are almost deprived of negative networks (p = 0.04), shiny white structures (p = 0.0027) and regression features (p = 0.00003). Neither prominent skin markings nor angulated lines were found in the entire study group. Out of the vascular structures, microM presented only dotted (32%) or polymorphous (28%) vessels, although more rarely than melanomas sized > 5.0 mm (66.1% p = 0.017 and 49% p > 0.05, respectively). The diagnostic feasibility revealed a score ≥ 3 of the 7-point algorithm (indicative for malignancy) in 60% microM and 98.31% melanomas sized > 5.0 mm (p = 0.000006). The TADA algorithm revealed melanoma-specific patterns in 64% microM and 96.61% > 5.0 mm-sized melanomas (p = 0.00006) and melanoma-specific structures in 72% and 91.53% (p > 0.05), respectively. Conclusion: In the dermoscopy, 40% of micromelanomas histopathologically staged as pTis and pT1a did not reveal melanoma-specific patterns. Among the general melanocytic patterns, the spitzoid one was the most frequently found in melanomas sized ≤ 5.0 mm. The 7-point checklist and TADA dermoscopic algorithms were helpful in the identification of the majority of melanomas sized ≤ 5.0 mm.

Discovery of Lijianmin-Chengkun Complexes and Their Oncological Application in Osseous and Intraarticular Lesions Around the Knee

Objective: This research aims to refresh the limited understanding about the canal and vascular structures within the epiphysis and metaphysis of the tibia and femur and their oncological significance.Methods: This study was started with characterization of a novel structure using radiographs and anatomic dissections, followed by a descriptive clinical study with 55 participants to investigate the effects of tumors on this novel discovery and a retrospective cohort study with 82 participants to investigate whether the structure would be a risk factor for tumor recurrence after the curettage of giant cell tumor of bone.Results: A new anatomical knee structure, the Lijianmin-Chengkun (LC) complex, was discovered in healthy adults, and its clinical implications were examined in this study. This new-found anatomical structure is composed of an epiphyseal and metaphyseal canal which surrounds a blood vessel, foramen, and foramen-covered synovium. All LC complexes showed similar radiographical, anatomical, and histological characteristics and were located within specific tibial and femoral intercondylar regions. These LC complexes seem to facilitate tumor residue and extension and may be a risk factor for tumor recurrence after curettage of femoral and tibial giant cell tumors (P = 0.031).Conclusion: The LC complexes are related to local tumor recurrence and bidirectional tumor dissemination between intraosseous and intraarticular regions. These findings have opened up a new perspective and may provide new targets for intervention in malignant and aggressive tumors around the knee joint.

Quantitative Prediction of the Location of Carotid Bifurcation and Neurovascular Structures in the Carotid Region: A Cross-Sectional Cadaveric Study

Introduction. The carotid region is encountered in vascular and neurological surgery and carries a potential for vascular and cranial nerve trauma. The carotid bifurcation is an especially important landmark and difficult to predict based on currently established landmarks. This study is a detailed analysis of the carotid region and proposes a novel methodology to predict the height of the bifurcation. Materials and Methods. Superficial and deep dissections were performed on the anterior triangle of the neck to expose the carotid region in twenty-one formalin-fixed donor cadavers. Musculoskeletal and neurovascular structures were assessed in relation to the carotid bifurcation and the medial border of the clavicle (MBC). Results. The carotid bifurcation occurred, on average, 11.4 mm higher on the left ( p < 0.001 ; 95% CI: 9.28, 13.54). The superior thyroid artery ( p < 0.001 ), facial vein ( p < 0.001 ), and cranial nerve XII ( p < 0.001 ) were all more distal on the left side when measured from the MBC while the angle of the mandible and stylohyoid muscle remained symmetric. Left- and right-sided vascular structures were symmetric when measured from the carotid bifurcation. Conclusions. Neurovascular structures within the carotid region are likely to be anatomically superior on the left side while vessels are likely to remain symmetric in relation to the carotid bifurcation. When measured from the MBC, the bifurcation height can be predicted by multiplying the distance between the MBC and mastoid process by 0.65 (right side) or 0.74 (left side). This novel methodological estimation may be easily learned and directly implemented in clinical practice.

Automated landmarking of bends in vascular structures: a comparative study with application to the internal carotid artery

Automated tools for landmarking the internal carotid artery (ICA) bends have the potential for efficient and objective medical image-based morphometric analysis. The two existing algorithms rely on numerical approximations of curvature and torsion of the centerline. However, input parameters, original source code, comparability, and robustness of the algorithms remain unknown. To address the former two, we have re-implemented the algorithms, followed by sensitivity analyses. Of the input parameters, the centerline smoothing had the least impact resulting in 6–7 bends, which is anatomically realistic. In contrast, centerline resolution showed to completely over- and underestimated the number of bends varying from 3 to 33. Applying the algorithms to the same cohort revealed a variability that makes comparison of results between previous studies questionable. Assessment of robustness revealed how one algorithm is vulnerable to model smoothness and noise, but conceptually independent of application. In contrast, the other algorithm is robust and consistent, but with limited general applicability. In conclusion, both algorithms are equally valid albeit they produce vastly different results. We have provided a well-documented open-source implementation of the algorithms. Finally, we have successfully performed this study on the ICA, but application to other vascular regions should be performed with caution.

Early pancreaticogastrostomy: a better and novel approach for high grade traumatic pancreatic injuries - case report from tertiary care centre in India

Traumatic pancreatic injury is a rare entity which is associated with severe morbidity and mortality. The management varies according to the American association for the surgery of trauma-organ injury scale (AAST-OIS) grading of injury, hemodynamic status and time of definitive diagnosis. Non-operative versus operative management has potential risks and benefits and long term debate on the ideal management is still ongoing. A 19-year boy, with severe, generalised pain abdomen was admitted after road traffic accident. Upon admission, the investigations: ultrasonography (USG) and computed tomography (CT) scan abdomen, showed traumatic pancreatic injury (AAST-OIS, grade V), was taken for exploratory laparotomy which revealed lacerated head of pancreas along with normal distal segment of pancreas with no associated injury to nearby hollow viscera, vascular structures. He underwent primary closure of head of pancreas with distal segment pancreaticogastrostomy. Postoperatively he recovered well with no complications. In the present case, as he had traumatic pancreatic injury (AAST-OIS, grade V) and there was no involvement of hollow viscera and vascular structures, the operative intervention can decrease morbidity as by pancreaticogastrostomy we have diverted the pancreatic fluid into stomach, subsequently decreasing the chances of pseudocyst, fistula, necrosis of pancreas. Thus we conclude, high grade blunt traumatic abdomen injuries should be managed with adequate resection and subsequent reconstruction and/or drainage procedure. Pancreaticoduodenectomy, distal pancreatectomy, pancreaticogastrostomy, pancreaticojejunostomy are the available options to be used according to the grading of injury and associated injuries.