Comparison of the effects of remifentanil and dexmedetomidine on surgeon satisfaction with surgical field visualization and intraoperative bleeding during rhinoplasty

Objective We aimed to compare the effect of dexmedetomidine with remifentanil on hemodynamic stability, surgical field quality, and surgeon satisfaction during rhinoplasty. Methods and materials In this double-blind randomized controlled-trial, 60 participants scheduled for rhinoplasty at the Mother and Child Hospital, Shiraz, Iran, was randomely divided into the dexmedetomidine group (IV infusion of 1 μg/kg dexmedetomidine over 20 min before induction of anesthesia then 0.6 μg/kg/hr. dexmedetomidine from the time of induction until the end of the operation) or in the the remifentanil group (an infusion rate of 0.25 μg/kg/min from the time of anesthesia induction until the end of the operation). Bleeding volume, surgeon satisfaction, postoperative pain (visual analog scale (VAS)), Level of sedation (Richmond Agitation Sedation Scale (RASS)), Patient satisfaction, Vital signs & recovery, and the Aldrete Score (used to discharge the patients from recovery) were measured for all participants. Results The patients in the dexmedetomidine group had less bleeding (p = 0.047) and shorter time to return of respiration, extubation, and the postoperative recovery time (p < 0.001). The surgeon satisfaction was higher in the dexmedetomidine group (p < 0.001). Patient satisfaction was significantly different between the two groups (p < 0.001). VAS scores, intaking paracetamol, and RASS score were significantly lower in the remifentanil group (p < 0.001). SBP, DBP, MAP, and heart rate were lower in dexmedetomidine group. Conclusion Dexmedetomidine was associated with relatively stable hemodynamics, leading to decreased intraoperative bleeding, recovery time, and greater surgeon satisfaction and the level of consciousness in the recovery ward. However, painlessness and patient satisfaction were greater with the use of remifentanil. Trial registration IRCT20141009019470N112.

A nationwide survey on the perceptions of general surgeons on artificial intelligence

Aim: Artificial intelligence (AI) has the potential to improve perioperative diagnosis and decision making. Despite promising study results, the majority of AI platforms in surgery currently remain in the research setting. Understanding the current knowledge and general attitude of surgeons toward AI applications in their surgical practice is essential and can contribute to the future development and uptake of AI in surgery. Methods: In March 2021, a web-based survey was conducted among members of the Dutch Association of Surgery. The survey measured opinions on the existing knowledge, expectations, and concerns on AI among surgical residents and surgeons. Results: A total of 313 respondents completed the survey. Overall, 85% of the respondents agreed that AI could be of value in the surgical field and 61% expected AI to improve their diagnostic ability. The outpatient clinic (35.8%) and operating room (39.6%) were stated as area of interest for the use of AI. Statistically, surgeons working in an academic hospital were more likely to be aware of the possibilities of AI (P = 0.01). The surgeons in this survey were not worried about job replacement, however they raised the greatest concerns on accountability issues (50.5%), loss of autonomy (46.6%), and risk of bias (43.5%). Conclusion: This survey demonstrates that the majority of the surgeons show a positive and open attitude towards AI. Although various ethical issues and concerns arise, the expectations regarding the implementation of future surgical AI applications are high.

The Exoscope in Neurosurgery: An Overview of the Current Literature of Intraoperative Use in Brain and Spine Surgery

Background: Exoscopes are a safe and effective alternative or adjunct to the existing binocular surgical microscope for brain tumor, skull base surgery, aneurysm clipping and both cervical and lumbar complex spine surgery that probably will open a new era in the field of new tools and techniques in neurosurgery. Methods: A Pubmed and Ovid EMBASE search was performed to identify papers that include surgical experiences with the exoscope in neurosurgery. PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analyses) were followed. Results: A total of 86 articles and 1711 cases were included and analyzed in this review. Among 86 papers included in this review 74 (86%) were published in the last 5 years. Out of 1711 surgical procedures, 1534 (89.6%) were performed in the operative room, whereas 177 (10.9%) were performed in the laboratory on cadavers. In more detail, 1251 (72.7%) were reported as brain surgeries, whereas 274 (16%) and 9 (0.5%) were reported as spine and peripheral nerve surgeries, respectively. Considering only the clinical series (40 studies and 1328 patients), the overall surgical complication rate was 2.6% during the use of the exoscope. These patients experienced complication profiles similar to those that underwent the same treatments with the OM. The overall switch incidence rate from exoscope to OM during surgery was 5.8%. Conclusions: The exoscope seems to be a safe alternative compared to an operative microscope for the most common brain and spinal procedures, with several advantages that have been reached, such as an easier simplicity of use and a better 3D vision and magnification of the surgical field. Moreover, it offers the opportunity of better interaction with other members of the surgical staff. All these points set the first step for subsequent and short-term changes in the field of neurosurgery and offer new educational possibilities for young neurosurgery and medical students.

Surgical Applications of Lymphatic Vessel Visualization Using Photoacoustic Imaging and Augmented Reality

Lymphaticovenular anastomosis (LVA) is a widely performed surgical procedure for the treatment of lymphedema. For good LVA outcomes, identifying lymphatic vessels and venules is crucial. Photoacoustic lymphangiography (PAL) is a new technology for visualizing lymphatic vessels. It can depict lymphatic vessels at high resolution; therefore, this study focused on how to apply PAL for lymphatic surgery. To visualize lymphatic vessels, indocyanine green was injected as a color agent. PAI-05 was used as the photoacoustic imaging device. Lymphatic vessels and veins were visualized at 797- and 835-nm wavelengths. First, it was confirmed whether the branching of the vasculature as depicted by the PAL was consistent with the actual branching of the vasculature as confirmed intraoperatively. Second, to use PAL images for surgical planning, preoperative photoacoustic images were superimposed onto the patient limb through augmented reality (AR) glasses (MOVERIO Smart Glass BT-30E). Lymphatics and venule markings drawn using AR glasses were consistent with the actual intraoperative images obtained during LVA. To anastomose multiple lymphatic vessels, a site with abundant venous branching was selected as the incision site; and selecting the incision site became easier. The anatomical morphology obtained by PAL matched the surgical field. AR-based marking could be very useful in future LVA.

Above and Beyond Robotic Surgery and 3D Modelling in Paediatric Cancer Surgery

Although the survival rates for children's cancers have more than doubled in the last few decades, the surgical practise has not significantly changed. Among the most recent innovations introduced in the clinic, robotic surgery and augmented reality are two of the most promising, even if they are not widespread. The increased flexibility of the motion, the magnification of the surgical field and the tremor reduction provided by robotic surgery have been beneficial to perform complex oncological procedures in children. Besides, augmented reality has been proven helpful in planning for tumour removal, facilitating early discrimination between cancer and healthy organs. Nowadays, research in the field of surgical oncology is moving fast, and new technologies and innovations wich will help to shape a new way to perform cancer surgery. Paediatric surgeons need to be ready to adopt these novel devices and intraoperative techniques to allow more radical tumour resections with fewer complications. This review aims to present the mechanism of action and indications of several novel technologies such as optical imaging surgery, high definition cameras, and intraoperative loco-regional treatments. We hope this will enhance early adoption and more research on how to employ technology for the benefit of children.

Unusual Complicated Gastric Ulcers

We here draw attention to a practical issue: the approach to certain unusual gastric ulcers with haemorrhage- or perforation-induced complications. This category of ulcers, i.e., giant (over 2–3 cm) and multiple ulcers, is rarely encountered. We discuss the circumstances determining the occurrence of such lesions, their diverse aetiology and pathogenesis, their common manifestations, and the severity of their evolution. Some of the lesions are benign (chronic or acute ulcers), whereas others are neoplastic: carcinoma, stromal tumours, and lymphomas. In gastric ulcers, the characteristics of this particular and rare category of lesions strictly places them in the surgical field, requiring primary surgical intention. Conservative treatments are not effective in such cases, and preoperative biopsies are not appropriate for emergency interventions. Whether these unusual ulcers are benign or malign, they need to be surgically removed.

ROLE OF ACCESS OSTEOTOMY IN HEAD AND NECK LESIONS – A REVIEW

The surgical resection of the head and neck lesions summarizes the principles, classifications, applications, complications, and post-operative care of osteotomy with the standard protocols performed safely. It often poses a great surgical challenge due to the anatomical complexity, difficulty in accessibility, and proximity of vital structures. A multidisciplinary approach is often required in these situations for their better exposure to provide surgical access. Access osteotomy is the choice and type for these head and neck lesions, which are most often based on the anatomic extent of the lesion, vascularity of the lesion, and involvement of neurovascular structures in and around it. The literature search using Medline from the year 1986 to 2019 were performed and textbooks were also collected by hand search from the same period. The role of aggressive surgical resection has not been established for malignant head and neck lesions with the technical feasibility and its efficacy for specific tumor types must be defined by the future studies. Thus, we would like to conclude that access osteotomy allows the surgeon a better view and an access of the surgical field to resect the tumor completely with safer margins, preserving the vital structures, pre-operative functions, and reducing post-operative complications.

Laparoscopic surgery produced less surgical smoke and contamination comparing with open surgery: the pilot study in fresh cadaveric experiment in COVID-19 pandemic

Background The SARS-CoV2 virus has been identified in abdominal cavity of the COVID-19 patients. Therefore, the potential viral transmission from any surgical created smoke in these patients is of concern especially in laparoscopic surgery. This study aimed to compare the amount of surgical smoke and surgical field contamination between laparoscopic and open surgery in fresh cadavers. Methods Cholecystectomy in 12 cadavers was performed and they were divided into 4 groups: laparoscopic approach with or without smoke evacuator, and open approach with or without smoke evacuator. The increased particle counts in surgical smoke of each group were analyzed. In the model of appendectomy, surgical field contamination under ultraviolet light and visual contamination scale between laparoscopic and open approach were compared. Results Open cholecystectomy significantly produced a greater amount of overall particle sizes, particle sizes < 5 μm and particle sizes ≥ 5 μm than laparoscopic cholecystectomy (10,307 × 103 vs 3738 × 103, 10,226 × 103 vs 3685 × 103 and 81 × 103 vs 53 × 103 count/m3, respectively at p < 0.05). The use of smoke evacuator led to decrease in the amount of overall particle sizes of 58% and 32.4% in the open and laparoscopic chelecystectomy respectively. Median (interquatile range) visual contamination scale of surgical field in open appendectomy [3.50 (2.33, 4.67)] was significantly greater than laparoscopic appendectomy [1.50 (0.67, 2.33)] at p < 0.001. Conclusions Laparoscopic cholecystectomy yielded less smoke-related particles than open cholecystectomy. The use of smoke evacuator, abeit non-significantly, reduced the particles in both open and laparoscopic cholecystectomy. Laparoscopic appendectomy had a lower degree of surgical field contamination than the open approach.