Microtools: A systematic review of validated assessment tools in microsurgery.

BACKGROUND: Microsurgery is a technically demanding aspect of surgery that is integral to a variety of sub-specialties. Microsurgery is required in high-risk cases where time is limited and pressure is high, so there is increasing demand for skills acquisition beforehand. The aim of this review was to analyse the available literature on validated microsurgical assessment tools. METHODS: Covidence was used to screen papers for inclusion. Keywords included 'microsurgery', 'simulation', 'end-product assessment' and 'competence'. Inclusion criteria specified simulation models which demonstrate training and assessment of skill acquisition simultaneously. Tools which were used for training independently of technical assessment were excluded and so were tools which did not include a microvascular anastomosis. Each assessment tool was evaluated for validity, bias, complexity and fidelity and reliability using PRISMA and SWiM guidelines. RESULTS: Thirteen distinct tools were validated for use in microsurgical assessment. These can be divided into overall assessment and end-product assessment. Ten tools assessed the 'journey' of the operation, and three tools were specifically end-product assessments. All tools achieved construct validity. Criterion validity was only assessed for the UWOMSA1 and GRS.2 Interrater reliability was demonstrated for each tool except the ISSLA3 and SAMS.4 Four of the tools addressed demonstrate predictive validity.4-7 CONCLUSION: Thirteen assessment tools achieve variable validity for use in microsurgery. Interrater reliability is demonstrated for 11 of the 13 tools. The GRS and UWOMSA achieve intrarater reliability. The End Product Intimal Assessment tool and the Imperial College of Surgical Assessment device were valid tools for objective assessment of microsurgical skill.

The influence of SARS-CoV-2 vaccination on post-operative outcomes in microsurgery patients.

BACKGROUND: The healthcare industry's efforts to immunize the global community against severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) have been unprecedented. Given the fast-tracking of the novel vaccine, its short- and long-term medical implications remain largely to-be-determined in most patient populations. This study aims to analyze 90-day post-operative outcomes in microsurgical patients, who have received or not received SARS-CoV-2-vaccination, using a continuously updated federated electronic medical record network (TriNetX Inc, Cambridge, MA). METHODS: After screening 70 million de-identified records, 16,799 microsurgery patients aged 18-99 meeting medical coding criteria were allocated into two cohorts. Cohort One received SARS-CoV-2-vaccination prior to undergoing microsurgery whereas Cohort Two did not. Two equally sized cohorts, totaling 818 patients were created after propensity score matching for characteristics including: age, race, ethnicity, smoking, hypertension, heart disease, diabetes, obesity, chronic obstructive pulmonary disease, and history of SARS-CoV-2 exposure. Postoperative outcomes within 30-, 60-, and 90-days of microsurgery were analyzed. RESULTS: Patients who were SARS-CoV-2-immunized experienced significantly lower (p < .01) surgical site infections (Absolute Risk Reduction (ARR)[95%CI]) = (3.79%-5.36% [0.84-8.54]) ICU admission (9.47%-9.82%[5.45-13.88]), generalized infections (7.68%-9.92%[3.15-14.64]), and hospitalizations (28.48%-32.57%[20.99-40.13]) within 30-, 60-, and 90-days of microsurgery. Additionally, SARS-CoV-2-vaccinated patients also experienced significantly less flap failure (2.49%[0.97-4.02]) and death (2.46%[0.96-3.97]) within 30- and 60-days post-operatively. CONCLUSION: Our analysis examines the potential protective effect of SARS-CoV-2-vaccination in microsurgical patients. Limitations include the retrospective nature of this analysis and the inherent reliance on medical coding. Future prospective studies are warranted to better understand if in fact pre-operative SARS-CoV-2-vaccination has the potential to protect against post-operative microsurgery outcomes.

The role of autologous micrografts injection from the scalp tissue in the treatment of COVID-19 associated telogen effluvium: Clinical and trichoscopic evaluation.

The clinical presentation of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2 COVID-19) varies from asymptomatic infection to a life-threatening, multiorgan disease. One of these manifestations is telogen effluvium (TE) which is characterized by diffuse hair loss occurring in patients previously infected with SARS-CoV-2 and lasts ~3 months, after which excessive hair loss follows. Hair follicles are known to contain a well-characterized niche for adult stem cells which is the bulge containing epithelial and melanocytic stem cells. Stem cells in the hair bulge, a demarcated structure within the lower permanent portion of hair follicles, can generate the interfollicular epidermis, hair follicle structures, and sebaceous glands. This study aims to evaluate autologous micrografts from scalp tissues as a therapeutic modality in the management of TE caused by COVID-19. Twenty patients of previous COVID-19 infection suffered from TE were included in this study for human follicle stem cells micrograft scalp treatment and they were evaluated after 3 months of treatment and after 6 months. There was significant improvement of the hair thickness and density compared with the start of the treatment and 6 months of follow-up. Autologous micrograft of the scalp showed marked improvement in the treatment of COVID-19 TE.

A Novel Intraoperative Ultrasound Probe for Transsphenoidal Surgery: First-in-human study.

Background. Ultrasound has been explored as an alternative, less bulky, less time-consuming and less expensive means of intraoperative imaging in pituitary surgery. However, its use has been limited by the size of its probes relative to the transsphenoidal corridor. We developed a novel prototype that is more slender than previously reported forward-viewing probes and, in this report, we assess its feasibility and safety in an initial patient cohort. Method. The probe was integrated into the transsphenoidal approach in patients with pituitary adenoma, following a single-centre prospective proof of concept study design, as defined by the Innovation, Development, Exploration, Assessment and Long-Term Study (IDEAL) guidelines for assessing innovation in surgery (IDEAL stage 1 - Idea phase). Results. The probe was employed in 5 cases, and its ability to be used alongside the standard surgical equipment was demonstrated in each case. No adverse events were encountered. The average surgical time was 20 minutes longer than that of 30 contemporaneous cases operated without intraoperative ultrasound. Conclusion. We demonstrate the safety and feasibility of our novel ultrasound probe during transsphenoidal procedures to the pituitary fossa, and, as a next step, plan to integrate the device into a surgical navigation system (IDEAL Stage 2a - Development phase).

A Novel Three-Dimensional Robot Arm Steered Camera for Ear Surgery.

ABSTRACT: Ear surgery requires magnified imaging of anatomical structures from its beginning to achieve safe and successful surgical outcomes. The historical evolution of magnification in otology has developed from monocular to binocular, and to three-dimensional and even to digital in modern times. Current technological advancements pursue high-quality visualization for the best surgical outcomes but also ergonomic for surgeons. Here, we evaluated the usability of such new technology in common otological surgeries like cochlear implantation and stapedectomy for the first time in patients. A three-dimensional camera mounted to a robot arm has hands-free control by goggles worn by the surgeon on a head mount. The camera at a distance of the patients but can also be draped in a sterile way that it forms a barrier tent between patient and surgical personnel in the theatre. The main reason to evaluate the feasibility of this new exoscope was driven by COVID-19 obligate measures for elective surgery such as hearing restoration. This new technology can be considered an important advantage for the surgeons working in microsurgery to perform their elective operations without aerosolization of the drill rinsing water possibly containing contaminated tissue. From a subjective point of view, the image quality is equivalent to conventional microscopes to provide safe otologic surgery.

Microsurgical autologous breast reconstruction in the midst of a pandemic: A single-unit COVID-19 experience.

INTRODUCTION: COVID-19 has disrupted the provision of breast reconstructive services throughout the UK. Autologous free flap breast reconstruction was restarted in our unit on 3 June 2020. We aimed to compare the unit's performance of microsurgical autologous breast reconstruction in the "post-COVID" period compared with the exact time period in the preceding year. METHODS: We retrospectively reviewed prospectively collected data in the "pre-COVID" (from 3 June 2019 to 31 December 2019) and "post-COVID" period (from 3 June 2020 to 31 December 2020). Patient demographics included age, body mass index, co-morbidities, Anaesthesiologists (ASA) grade and smoking status. Surgical factors included neoadjuvant chemotherapy, previous chest wall radiotherapy, unilateral or bilateral reconstruction, reconstruction timing, number of pedicles, contralateral symmetrisation and other procedures. dependant variables were ischaemic time, operative time, mastectomy weight, flap weight, length of stay, return to theatre and complication rates. The number of trainers and trainees present in theatre was recorded and analysed. RESULTS: Fewer DIEP flaps were performed in the "post-COVID" period (45 vs. 29). No significant difference was observed in mastectomy resection weight, but flap weight was significantly increased. No significant difference was found in ischaemic time as well. The postoperative length of stay was significantly reduced. No significant difference was found in rates of return to theatre, unplanned admission, infection, haematoma, seroma or wound dehiscence. No cases of venous thromboembolism or flap failures were recorded. The mean number of trainers and trainees, and the trainee-to-trainer ratio was not found to be significantly different between cohorts. CONCLUSION: Although fewer cases were performed, autologous breast reconstruction was safely delivered throughout the COVID-19 pandemic in the first wave without affecting training.

Low-tech intraocular ophthalmic microsurgery simulation: A low-cost model for home use.

In order to maintain manual dexterity and surgical skills, trainees are encouraged to partake in regular simulation. Current options for intraocular surgical simulation require specialist microscopic equipment which is expensive and requires access to simulation facilities. A set of core simulation exercises and basic surgical skills of performing the corneal incisions, capsulorhexis, improving the manual dexterity, and suturing were identified, discussed, and agreed among authors before designing this simulation exercise. In this paper, we propose a smartphone-based, low-cost, low-tech model with corresponding exercises for intraocular simulation that can be used at home for the above-mentioned surgical skill set. This model provides an easy, portable, and reproducible method of simulation and can serve as an adjunct to patient-facing surgical training, especially in the current pandemic, where the excess to the simulation facilities or setup of these facilities may be difficult.

The era of artificial intelligence and virtual reality: transforming surgical education in ophthalmology.

Training the modern ophthalmic surgeon is a challenging process. Microsurgical education can benefit from innovative methods to practice surgery in low-risk simulations, assess and refine skills in the operating room through video content analytics, and learn at a distance from experienced surgeons. Developments in emerging technologies may allow us to pursue novel forms of instruction and build on current educational models. Artificial intelligence, which has already seen numerous applications in ophthalmology, may be used to facilitate surgical tracking and evaluation. Within immersive technology, growth in the space of virtual reality head-mounted displays has created intriguing possibilities for operating room simulation and observation. Here, we explore the applications of these technologies and comment on their future in ophthalmic surgical education.

International Microsurgery Club Webinar Series-Bridging the Knowledge Gap during the COVID-19 Pandemic.

BACKGROUND: The impact of the coronavirus disease 2019 (COVID-19) outbreak shut down most conferences. To minimalize the influence, virtual meetings sprang up subsequently. International Microsurgery Club (IMC), as one of the largest professionals-only online microsurgery education groups worldwide, began to host regular weekend webinars during the pandemic to fill the knowledge gap. This study aims to discuss how webinars have fundamentally changed the way knowledge is delivered and exchanged. METHODS: From February 29, 2020 to March 14, 2021, 103 IMC webinars were reviewed and analyzed in detail to determine the use, benefit, and effect. A comparison between webinars hosted by the different societies was made as well. A questionnaire survey focusing on attendees' behavior, attitude, and using habit about webinars was also made. RESULTS: As for the 103 IMC webinar events, the peak participants were 112.3 people in average. The members requesting to join IMC abruptly increased during the pandemic, and the group activity increased dramatically. From the questionnaire (n = 68), the satisfaction level was high (8.88 ± 1.18/10). The respondents were most satisfied with the good quality of the speakers (73.5%). Not only hosts our webinar series but IMC also serves as the platform that welcomes webinars from other societies to share their information. In September 2020, International Microsurgery Webinar League was established via the significant webinar hosts, with more than 300 recorded webinar talks connected successfully. CONCLUSION: As the knowledge revolution driven by COVID-19 will continue, IMC will keep playing an essential role in exploring new and emerging opportunities to improve knowledge dissemination worldwide beyond the space-time boundary.

Breast reconstruction during the COVID-19 pandemic: A systematic review.

BACKGROUND: The novel coronavirus disease 2019 (COVID-19) has changed people's way of life and posed great challenges to plastic surgery. Most of plastic surgeries are considered elective surgeries and are recommended to be delayed. But breast reconstruction in plastic surgery is special. Doctors' associations from different countries have different rules on whether breast reconstruction surgery should be delayed. For the controversial topic of immediate breast reconstruction in the COVID-19 pandemic, we conducted this study. METHODS: We searched English databases such as PubMed, Cochrane Library, and Embase. The publication time of papers was set to be from the establishment of the databases to February 2021. All studies on immediate breast reconstruction in the COVID-19 pandemic were included in our study. RESULTS: A total of 6 studies were included in this study. Four studies recommended the use of breast implants or tissue expansion for breast reconstruction surgery and had good results in their clinical practice. In addition, 1 study planned to use autologous free tissue transfer for breast reconstruction, and 1 study planned to use microsurgical techniques for breast reconstruction. But these 2 technologies are still in the planning stage and have not yet been implemented. CONCLUSIONS: In our opinion, breast cancer surgery belongs to confine operation, and breast reconstruction surgery should be performed immediately after the completion of breast cancer surgery. We recommend the use of breast implants for breast reconstruction surgery during the COVID-19 epidemic. Due to the limitations of the study, our proposed protocol for breast reconstruction surgery during the COVID-19 epidemic needs to be further validated in clinical studies.

Aerosol generation through pars plana vitrectomy.

PURPOSE: To assess whether pars plana vitrectomy (PPV) is an aerosol-generating procedure (AGP) in an ex vivo experimental model. METHODS: In this ex vivo study on 10 porcine eyes, optical particle counter was used to measure particles ≤10 µm using cumulative mode in the six in-built channels: 0.3 µm, 0.5 µm, 1 µm, 2.5 µm, 5 µm and 10 µm aerosols during PPV. Two parts of the study were as follows: (1) to assess the pre-experimental baseline aerosol count in the theatre environment where there are dynamic changes in temperature and humidity and (2) to measure aerosol generation with 23-gauge and 25-gauge set-up. For each porcine eye, five measurements were taken for each consecutive step in the experiment including pre-PPV, during PPV, fluid-air exchange (FAX) and venting using a flute with 23-gauge set-up and a chimney with 25-gauge set-up. Therefore, a total of 200 measurements were recorded. RESULTS: With 23-gauge and 25-gauge PPV, there was no significant difference in aerosol generation in all six channels comparing pre-PPV versus PPV or pre-PPV versus FAX. Venting using flute with 23-gauge PPV showed significant reduction of aerosol ≤1 µm. Air venting using chimney with 25-gauge set-up showed no significant difference in aerosol of ≤1 µm. For cumulative aerosol counts of all particles measuring ≤5 µm, compared with pre-PPV, PPV or FAX, flute venting in 23-gauge set-up showed significant reduction unlike the same comparison for chimney venting in 25-gauge set-up. CONCLUSION: PPV and its associate steps do not generate aerosols ≤10 µm with 23-gauge and 25-gauge set-ups.

Heads-up Surgery: Endoscopes and Exoscopes for Otology and Neurotology in the Era of the COVID-19 Pandemic.

A new era of surgical visualization and magnification is poised to disrupt the field of otology and neurotology. The once revolutionary benefits of the binocular microscope now are shared with rigid endoscopes and exoscopes. These 2 modalities are complementary. The endoscope improves visualization of the hidden recesses through the external auditory canal or canal-up mastoidectomy. The exoscope provides an immersive visual experience and superior ergonomics compared with binocular microscopy. Endoscopes and exoscopes are poised to disrupt the standard of care for surgical visualization and magnification in otology and neurotology.

A Protocol for Performing Reconstructive Microsurgery on Patients With COVID-19.

On March 11, 2020, the World Health Organization declared COVID-19 to be a pandemic, challenging health care systems all over the world. National health care systems have reorganized to cope with the disease. Surgical services departments around the world have been affected and elective surgical procedures have been postponed to conserve medical resources. When a patient with COVID-19 requires an urgent microsurgical free flap due to trauma or a tumor, personnel from the health care facility must have a protocol in place to follow for the patient's care and follow-up. In this article, we present our protocol for patients with COVID-19 requiring reconstructive microsurgery.

Master Series Microsurgery for Residents: Results from a Comprehensive Survey of a Multitudinous Online Course during COVID-19 Pandemic.

BACKGROUND: Since COVID-19 emerged, it has significantly affected medical education. Surgical training has been blocked and the learning curve flattened. However, COVID-19 led to the outbreak of multitudinous online courses. Master series: microsurgery for residents (MSMR) has been the most extensive and accessible online nonfee course transmitted so far regarding reconstructive microsurgery. The primary aim of this study was to assess the impact of the MSMR in the surgical community as an international educational tool during pandemic confinement. METHODS: A retrospective, observational, analytic, and transversal study was designed. An 11-item survey was sent to all the 1,513 attendees who completed at least 60% of course attendance during 2 days. Descriptive and analytic statistics were performed. The impact was measured by considering answers to questions 6 to 9 and 11 (course usefulness, microsurgery interest increase, desire to pursue a microsurgical career, attendance to in-person conferences, and overall score, respectively). RESULTS: A total of 1,111 (73.4%) of eligible subjects were included. In total, 55.8% were plastic surgery residents. After the course, 98.9% would pursue a career in reconstructive microsurgery, and 45% would stop attending in-person conferences. The overall score of the event was 9.06 ± 0.9 (from 0 to 10) regardless of the current training status. CONCLUSION: The MSMR was a high impact course and has established a paradigm shift that will lead to an evolution in plastic surgery learning.

Retrospective study in clinical governance and financing system impacts of the COVID-19 pandemic in the hand surgery and microsurgery HUB center.

INTRODUCTION: The authors presented a retrospective study in the surgical activity of the HUB center for Hand Surgery and Microsurgery in Emilia-Romagna comparing the data between March and April 2020, in the peak of Covid pandemic, with the same period in 2019. MATERIALS AND METHODS: During the two months period of March-April 2020 versus 2019 the authors analyzed the surgical procedures performed in elective and emergency surgery with hospitalization and Day or Outpatient surgery regime. Surgical treatments with no hospitalization were planned in the Day-Surgery Service. The financing system impacts were analyzed according to the Diagnosis Related Groups (DRG), the costs accounting method mostly used in European countries. RESULTS: An overall reduction of 68.5% was recorded in surgical procedures, with a more relevant reduction of 92.3% in elective surgery and a significantly less relevant reduction of 37.2% in urgent one. Replantation did not present a reduction in number of cases, while cutting lesions of tendons at the hand and fingers increased such as the bone and ligament injuries during domestic accidents. The negative impact in the financial system recorded a reduction of 32.5%. DISCUSSION: The epidemiology of hand trauma looks not only at the artisanal and industrial injuries, but also mostly at the accidents in daily life activities. The data of the study evidenced the significantly increase in the injuries occurring in the domestic environment. Elective surgery was canceled. The 86% of surgical procedures performed were urgent ones and the 72.8% of these were possible in Day and Outpatient surgery with significantly reduction in hospitalization. All procedures followed a rigid process for patient and healthcare workers with regard for personal protection and safety. Telemedicine was arranged in emergencies, and economic damage was analyzed also in the following rebound effect during summer period. CONCLUSIONS: The significantly less reduction recorded in urgent surgery vs the more relevant reduction in elective one showed how the hand injuries remained a major issue also during the lockdown. The data highlighted the relevant role of the organizational aspects of the surgical procedures and planning in hand trauma. Despite the financial impact of the elective surgery, the presence of a functional and skill Emergency Service and Day-Surgery Service resulted fundamental in the efficacy and efficiency of the patient management and in containment of economic damage. The telemedicine was significantly limited by liability and risk management issues.