Robotic donor hepatectomy: a niche advancement or the way forward? A perspective from the world’s largest center

The application of minimally invasive liver surgery (MILS) in the field of living donor hepatectomy has been exceedingly slow, and its impact is limited to a handful of centers worldwide. Widespread adoption has been primarily hampered by the technical limitations of laparoscopy, namely rigid instrumentation, suboptimal optics, and a seemingly steep learning curve. These deficiencies are magnified in the donor hepatectomy operation wherein the parenchyma and vasculature must be handled atraumatically to produce a pristine allograft fit for implantation. Donor safety concerns and medicolegal ramifications are also cited as impediments to MILS in donor surgery. In 2013, our institution embraced a purely laparoscopic approach to living donor left lateral sectionectomy, and it quickly became our default technique. However, with donor hemi-hepatectomy, we gravitated to the robotic surgical system as our preferred modality. Herein, we describe our experience with minimally invasive donor hepatectomy, which we now universally offer to all living donors. Our extensive familiarity with robotic donor hepatectomy will provide the reader with an instructive perspective on the attributes and merits of the robotic approach. With appropriate collaboration and proctorship, we believe that the robotic platform will actualize a more rapid and widespread adoption than that experienced with the purely laparoscopic technique.

TOTAL ENDOSCOPIC STAPES SURGERY. OUR TECHNIQUE AND EXPERIENCE OF 45 CASES

Objective: To assess the hearing results of transcanal endoscopic stapedotomy Study Design: Descriptive study. Place and Duration of Study: Pakistan Naval Ship Hafeez Islamabad Pakistan, from Jun 2016 to Jun 2020. Methodology: All patients with surgically confirmed otosclerosis were included in the study. All patients were operated with 0-degree 3mm, 14cm rigid endoscope under general anesthesia. Preoperative and post operative air bone gap was noted along with demographic data, middle ear anomalies (persistent stapedial artery, dehiscent facial nerve, anteriorly placed facial nerve, floating foot plate) and injury to chorda tympani. Postoperative air bone gap (A-B Gap) was documented 12 weeks after surgery. All patients were followed up for 6-12 months Results: Mean age of patients was, 37 years and standard deviation was 12.34 (range 27-52 years). Out of total 45 cases 13 were males (29%) and 32 females (71.%). Four (8.8%) patients had dehiscent facial canal and 1 (2.2%) patient had persistent stapedial artery. Average preoperative A-B gap was 35 db and Average Postoperative A-B Gap was 7 db. Chorda tympani was preserved in all cases. One patient (2.2%) complained of altered taste which resolved after 3 months. Four patients had Postoperative vertigo that lasted 2 days on average. Conclusion: Endoscopic trans canal Stapes surgery is scarless safe effective procedure demonstrable hearing benefits in all patients with minimum complications. The Technique is single handed and has steep learning curve.

THE TRANSNASAL APPROACH TO SELLAR LESIONS. A NEUROSURGICAL EXPERIENCE AND PERSPECTIVE

The transnasal approach for pituitary lesions has been adopted increasingly by neurosurgeons for removing sellar lesions. It has made surgery in this region safer with fewer complications in experienced hands. However, the approach requires good knowledge of nasal anatomy and formal training to achieve good results since the territory is unfamiliar to most neurosurgeons. The approach has a somewhat steep learning curve. In our experience of 41 cases, we have presented here. We have discussed the history of this approach, technique and relevant complications and their avoidance.

Does Holmium laser enucleation of the prostate (HoLEP) still have a steep learning curve? Our experience of 100 consecutive cases from Turkey

Aim: The aim of our study is to examine the learning curve of HoLEP and to discuss our results in the light of the literature. Methods: 100 patients who had LUTS resistant to medical treatment and complicated BPH to whom HoLEP procedure had been administered regardless of the size of the prostate in the last 1 year were analysed retrospectively. To evaluate the learning curve, the patients were classified into 4 main groups of 25 consecutively operated patients beginning from the first case. The 4 main groups were divided into 2 subgroups including patients who had prostate volume below or above 80 grams. Results: The mean age of the 100 patients who had HoLEP was 64.5 years. The mean prostate volume was 99.1 cc (45-281 cc). When those with prostate smaller than 80 g are examined, Enucleation efficiency was 0.76 g/min (0.46-0.97 g/min) and Morcellation efficiency was 3.07 g/min (3.34-4 g/min). When those with prostates larger than 80 g are examined, Enucleation efficiency was 0.89 g/min (0.66-1.04 g/min) and Morcellation efficiency was 4.01 g/min (3.93-4.25 g/min). These two parameters were statistically and significantly different in all the 4 groups (p < 0.05). Conclusions: HoLEP still has a steep learning curve. It is necessary to reach the number of cases of 25-50 to reach fundamental experience.

Iterative Design for Approachable, Mobile-Based Collaborative Electronic Music Instruments

<p>The steep learning curve for technology for electronic music creation enforces a barrier to entry for new electronic musicians that prevents them from enjoying the playful process of creating music, without significant investment of time, energy, or money. This thesis argues that this barrier to entry should be abolished by using creative technology as a platform in order to begin the democratisation of electronic music creation processes. By drawing upon specific values inherent to the playful process of creating music, this thesis suggests a framework for iterative design of social, electronic musical instruments. The combination of implementing this framework and informing design directions upon user feedback has resulted in the creation of Pyxis Minor, a new, smartphone and tablet based, electronic musical interface/instrument that allows users of any prior musical background to have a playful creative and social experience of making music. This is important for distinguishing that the apparent barrier to entry for electronic music creation may be unnecessary, and it is possible to develop instruments and interfaces for the playful creation of electronic music that fulfil the needs and requirements of a diverse range of users.</p>

Iterative Design for Approachable, Mobile-Based Collaborative Electronic Music Instruments

<p>The steep learning curve for technology for electronic music creation enforces a barrier to entry for new electronic musicians that prevents them from enjoying the playful process of creating music, without significant investment of time, energy, or money. This thesis argues that this barrier to entry should be abolished by using creative technology as a platform in order to begin the democratisation of electronic music creation processes. By drawing upon specific values inherent to the playful process of creating music, this thesis suggests a framework for iterative design of social, electronic musical instruments. The combination of implementing this framework and informing design directions upon user feedback has resulted in the creation of Pyxis Minor, a new, smartphone and tablet based, electronic musical interface/instrument that allows users of any prior musical background to have a playful creative and social experience of making music. This is important for distinguishing that the apparent barrier to entry for electronic music creation may be unnecessary, and it is possible to develop instruments and interfaces for the playful creation of electronic music that fulfil the needs and requirements of a diverse range of users.</p>

Moving beyond the Slit-Lamp Gonioscopy: Challenges and Future Opportunities

After almost a century from its introduction in clinical practice, slit-lamp gonioscopy is still considered the reference standard for evaluating the anterior chamber angle (ACA). Gonioscopy is essential for diagnosing angle closure disease, and ACA features are included in glaucoma’s diagnostics and treatments algorithms. However, shortcomings of slit-lamp gonioscopy include a steep learning curve, lack of agreement between examiners and poor documentation. Thanks to advances in miniaturization and computing, new instruments for digital gonioscopy have been developed and marketed. This narrative review focuses on the Gonioscope GS-1, which permits semi-automated circumferential documentation of the ACA in real-colour photographs. Advantages and disadvantages of GS-1 compared with slit-lamp gonioscopy and other ACA imaging technologies such as optical coherence tomography are discussed. Finally, potential opportunities offered by this device for telemedicine, virtual clinics, and automatic classification with deep learning are presented.

Interactive 3D visualization and post-processing analysis of vertex-based unstructured polyhedral meshes with ParaView

The development of physics-based 3D models that investigate the behavior of biological tissues requires effective and efficient visualization tools. The open-source software ParaView has such capabilities, but often impose a steep learning curve due to the use of the Visualization Toolkit (VTK) data structures. To overcome this, I show how to setup the components of 3D vertex-like models, i.e., vertices, faces, and polyhedra, into the VTK data format and then output as ParaView unstructured grid files. I present a few relevant tools to visualize and analyze the files in ParaView. All sample codes are available in the Github repository vis3Dvertex.

Augmented Reality Assisted Endoscopic Transforaminal Lumbar Interbody Fusion: 2-Dimensional Operative Video

Augmented reality (AR) is a novel technology for spine navigation. This tracking camera-integrated head-mounted display (HMD) represents a novel stereotactic computer navigation modality that has demonstrated excellent precision and accuracy with spinal instrumentation.1 Standard computer-assisted spine navigation systems have two major shortcomings: attention shift and line-of-sight limitations. The HMD allows visualization of the surgical field and navigation data concurrently in the same field of view.2,3 However, the use of AR in spine surgery has been limited to use for instrumentation, not for endoscopy. Fully endoscopic transforaminal interbody fusion under conscious sedation is an effective treatment option for degenerative spondylolisthesis and spinal stenosis. Although this technique has a steep learning curve, the advantages are vast, including preservation of normal tissue, smaller incisional requirement, and reduced postoperative pain, all enabling rapid recovery after surgery. As with other endoscopic spine surgeries, this procedure has a steep learning curve and requires a robust understanding of foraminal anatomy in order to safely access the disc space.4,5 However, with the introduction of AR, the safety and precision of this procedure could be greatly improved upon. In this video, we present a case of a 60-yr-old female who presented with a grade 1 spondylolisthesis and severe spinal stenosis and was treated with an L4-L5 interbody fusion. All instrumentation steps and localization for the endoscopic portion of the case were performed with assistance from the AR-HMD system. Informed written consent was obtained from the patient. The participant and any identifiable individuals consented to the publication of his/her image.