This study was funded by the National Natural Science Foundation Cultivation Program of The Third Affiliated Hospital of Sun Yat-sen University (2023GZRPYMS08) and funding by Science and Technology Projects in Guangzhou (SL2023A03J01216).&#160;The authors would also like to acknowledge the joint funding project of&#160;the Third Affiliated Hospital of Sun Yat-sen University and Chaozhou Central Hospital.

The protocol follows the guidelines of the human research ethics committee of Sun Yat-Sen University. No specific ethics approval is required since this treatment was performed in routine clinical care.
1. 3D reconstruction
<ol>
	<li>Import DICOM data from neck-enhanced CT scans into 3DSlicer10, utilizing a window width of 350 Hounsfield units (HU) and a window level of 40 HU.</li>
	<li>Segment and reconstruct the neck 3D model using a semi-automatic approach.
	<ol>
		<li>Segment and reconstruct the skin using the Threshold and Hollow functions. First, create a segmentation for CT values greater than -250 HU with the Threshold function. Then, utilize the Hollow function to remove the interior of this segmentation.</li>
		<li>Segment and reconstruct the thyroid, lesion, trachea, and esophagus using the Grow from seeds function based on either arterial or venous phase images. Manually delineate seeds within the target structures across cross-sectional, sagittal, and coronal images. Following this, automatically generate the target segmentation using the Grow from seeds function.</li>
		<li>Segment and reconstruct the bone using the Threshold function based on plain scanning images. Create this segmentation for CT values exceeding 200 HU.</li>
		<li>Segment and reconstruct arteries using the Local threshold function based on arterial phase images. Manually delineate seeds within the arteries in the coronal images. Subsequently, create a segmentation with a CT value range consistent with the seeds using the Local threshold function, and repeat the procedure to gradually expand the segmentation.</li>
		<li>Segment and reconstruct veins using the Local threshold function based on venous phase images. Use the specific operations identical to those described in the previous step.</li>
	</ol>
	</li>
	<li>Automatically reconstruct the neck 3D model using volume rendering.
	<ol>
		<li>Select either arterial phase images or venous phase images within the volume rendering module.</li>
		<li>Opt for an optimal automatic reconstruction protocol, typically the coronary enhanced CT reconstruction protocol, emphasizing visualizing the superior and inferior thyroid vessels.</li>
		<li>Minimize unnecessary reconstruction by precisely adjusting the region of interest.</li>
	</ol>
	</li>
</ol>
2. Constructing the neck virtual hologram
<ol>
	<li>Export the semi-automatically reconstructed neck 3D model from 3DSlicer as an OBJ file.</li>
	<li>Create a new project in Unity3D utilizing the Mixed Reality Toolkit (MRTK) and configure the necessary components.
	<ol>
		<li>Add a control border by utilizing the Box collider component.</li>
		<li>Implement a movable cursor using the Cursor Context Object Manipulator component.</li>
		<li>Add movement, scaling, and rotation functions through the Object manipulator, Near interaction Grabbable, and Min Max Scale Constraint components.</li>
		<li>Enable transparency control by utilizing the Slider Transparency Controller component.</li>
	</ol>
	</li>
	<li>Import the OBJ file into the project and associate the aforementioned components with the neck 3D model.</li>
	<li>Debug the neck virtual hologram on the MR head-mounted device (HMD) using the Holographic Remoting program, followed by packaging and exporting the project from Unity3D11.</li>
	<li>Install the neck virtual hologram onto the MR HMD using the Visual Studio program.</li>
</ol>
3. MR device manipulation
<ol>
	<li>Wear the MR HMD before surgery or have circulating nurses assist in wearing the HMD during surgery.</li>
	<li>Use MR HMD to manipulate the neck virtual holograms.
	<ol>
		<li>Control the movement, scaling, and rotation of the neck virtual hologram using a Grab gesture.</li>
		<li>Adjust the transparency of the neck virtual hologram by dragging the corresponding virtual slider.</li>
		<li>Align the neck virtual hologram with the patient&#39;s position, ensuring proper alignment of anatomical markers such as the mandible and clavicle.</li>
	</ol>
	</li>
	<li>Import clinical data such as neck CT images, ultrasonography and laboratory examination results into the MR HMD to access this information at any time during surgery.</li>
	<li>Control the HMD to capture MR images and videos through voice commands.</li>
	<li>Share the first-person perspective through the MR HMD via a Wi-Fi connection.</li>
</ol>
4. Preoperative stage
<ol>
	<li>Inclusion criteria
	<ol>
		<li>Include patients with papillary thyroid carcinoma (PTC) with a maximum diameter &#8804; 3 cm.</li>
		<li>Include patients who express a requirement for beauty.</li>
	</ol>
	</li>
	<li>Exclusion criteria
	<ol>
		<li>Exclude patients who are unable to tolerate surgery or general anesthesia.</li>
		<li>Exclude patients exhibiting extrathyroidal invasion or distant metastasis of PTC.</li>
		<li>Exclude patients with a history of thyroid surgery, ablation, or radioactive iodine treatment.</li>
		<li>Exclude patients with chest or clavicle deformities.</li>
		<li>Exclude patients with hypoparathyroidism or vocal cord dysfunction.</li>
	</ol>
	</li>
	<li>Auxiliary examination
	<ol>
		<li>Conduct neck-enhanced CT and ultrasonography to assess the PTC and its surrounding anatomy.</li>
		<li>Conduct chest radiography, electrocardiogram, complete blood count, liver and kidney function tests, and coagulation tests to exclude any absolute surgical contraindications.</li>
		<li>Conduct thyroid and parathyroid function tests, along with thyroglobulin levels.</li>
		<li>Conduct fiberoptic laryngoscopy to evaluate vocal cord function.</li>
	</ol>
	</li>
	<li>Preoperative preparation
	<ol>
		<li>Fast patients for 10 h and administer intravenous glucose saline or Ringer&#39;s solution.</li>
		<li>Administer midazolam, propofol, sufentanil, and atracurium intravenously to induce general anesthesia, followed by transoral tracheal intubation. Avoid using muscle relaxants during the maintenance phase of anesthesia.</li>
		<li>Perform urethral catheterization.</li>
		<li>Connect the intraoperative neuromonitoring (IONM) device.</li>
		<li>Position the patient in a split-leg configuration and extend their neck by tilting their head back. Position the endoscope system at the front of the patient&#39;s head.</li>
	</ol>
	</li>
</ol>
5. Surgical procedure (breast approach)
<ol>
	<li>Disinfect the surgical field, lay down the aseptic operating towels, and connect the endoscope, electrocoagulation hook, suction unit, and ultrasound knife.</li>
	<li>Identify the observation hole located 2 cm to the right of the midpoint of the line connecting the bilateral nipples. Inject expansion fluid subcutaneously and dissect using a stripping rod.</li>
	<li>Place a 10 mm Trocar and introduce carbon dioxide to establish an operating space with internal pressure maintained at less than 6 mmHg.</li>
	<li>Use the upper edge of both areolas as the operating channel. Dissect the subcutaneous cavities on both sides with two 5 mm or 10 mm Trocar needles under 30&#176; laparoscopic visualization. Insert the ultrasonic knife and scatheless forceps, and extend the subcutaneous space towards the front of the neck.</li>
	<li>Separate the cervical white line to free the thyroid gland. Suspend the ribbon muscles with sutures to extend the field of view.</li>
	<li>Inject carbon nanoparticles into the thyroid gland to stain it and the cervical lymph nodes.</li>
	<li>Disconnect the isthmus of the thyroid to expose the trachea and detach the suspensory ligament of the thyroid.</li>
	<li>Utilize the ultrasonic knife to coagulate the superior thyroid artery and vein, inferior thyroid artery, and middle thyroid vein. Secure the larger blood vessels with absorbable clamps.</li>
	<li>Perform auto-transplantation of PGs into the homolateral sternocleidomastoid muscle if the PG is removed or its blood supply is destroyed.</li>
	<li>Identify the RLN and superior laryngeal nerve using the IONM probe. Protect the nerves with wet gauze to prevent thermal injury.</li>
	<li>Carefully separate and excise the lesional thyroid gland, ensuring it is completely retrieved using a specimen bag.</li>
	<li>Perform homolateral lymphadenectomy in the cervical central region. If indicated, proceed with contralateral thyroidectomy and lymphadenectomy.</li>
	<li>Ensure all bleeding is thoroughly controlled, and rinse the surgical field with sterile distilled water. Insert a drainage tube in the operating channel and suture the incision layer by layer.</li>
</ol>
6. Postoperative management
<ol>
	<li>Provide electrocardiogram monitoring and oxygen therapy as patients return to the ward. Subsequently, administer treatments that include fluid replacement, intravenous calcium, pain relief, inhalation drug therapy, and phlegm clearance. If required, administer hemostatic drugs and initiate physical therapy.</li>
	<li>On the first postoperative day, discontinue electrocardiogram monitoring and oxygen therapy and remove the urinary catheter. Patients may resume a full diet and take daily oral doses of levothyroxine and calcium.</li>
	<li>On the second or third postoperative day, remove the drainage tube and prepare for patient discharge.</li>
	<li>Instruct the patient to visit the outpatient department for follow-up during the first week after surgery, as well as at 1 month, 3 months, 6 months, and 12 months postoperatively. Routinely review thyroid function and thyroglobulin levels, and perform neck ultrasonography.</li>
</ol>

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The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

MR is a cutting-edge AI technology based on various algorithmic models and sensing devices. The purpose of this protocol is to utilize MR to assist in radical ET. Moreover, the key procedure is the construction of the neck 3D model and virtual hologram. Subjective scales indicate positive results, demonstrating that MR is benefitial for surgeons in performing radical ET with ease. Additionally, MR exhibits potential advantages in preventing complications associated with ET. However, the small sample size limits the signi...

Over the past decade, the global incidence of thyroid nodules has risen to 29.29%, reflecting an increase of 7.76% compared to the previous decade. This trend positions thyroid nodules as one of the most prevalent diseases1. Concurrently, the incidence of thyroid cancer has reached 20/100,000, ranking it seventh among all cancers and third among females. Radical surgery remains the preferred treatment approach2.
Thyroidectomy can be categorized into open, endoscopic, and robotic surgeries. Endoscopic thyroidectomy (ET) is a form of cosmetic surgery that employs the length of endoscopic instruments to create subcutaneous tunnels through incisions made in the areola, axilla, oral cavity, and other concealed areas, thereby facilitating a scarless appearance in the neck. This approach is particularly appealing to women, who constitute the majority of thyroid cancer patients3. However, ET still requires further optimization from a surgical perspective. Firstly, ET is challenged by limited surgical space and a lack of tactile feedback, which complicates the operation and contributes to a prolonged learning curve4. Secondly, the thyroid possesses special physiological functions and complex local anatomy, making ET susceptible to serious complications, such as hypoparathyroidism and recurrent laryngeal nerve (RLN) injury5. Additionally, thyroid cancer often presents with occult lymphatic metastasis, and incomplete cervical lymph node dissection may further elevate the risk of postoperative lymphatic recurrence6, leading to the necessity for secondary or even multiple surgeries in some patients.
Artificial intelligence (AI) is an emerging field that seeks to simulate and enhance human intelligence through computer algorithms. Extended reality (XR) is a category of AI techniques that can deliver highly realistic audiovisual information in real-time, particularly suited for surgical applications7. Mixed reality (MR), a subset of XR, integrates virtual holograms with real-world entities, enabling users to interact seamlessly between reality and virtual environments8. Three-dimensional (3D) reconstruction is a computer graphics technique that transforms two-dimensional (2D) images composed of pixels into 3D models made up of voxels. The presentation of 3D models is crucial, and the primary application of MR in surgery involves displaying 3D models constructed from tomographic images, such as computed tomography (CT) and magnetic resonance imaging (MRI).
In this study, MR was utilized to assist in radical ETwith the aim of enhancing its efficacy and safety while reducing surgical complexity. Patients diagnosed with thyroid cancer who met specified inclusion and exclusion criteria were randomly assigned to either the experimental group or the control group. Those in the experimental group underwent MR-assisted radical ET. A comparative analysis of the surgical outcomes between the two groups was conducted. Furthermore, the National Aeronautics and Space Administration Task Load Index Scale (NASA-TLX) and the Likert Subjective Rating Scale were employed to assess the impact of MR-assisted ET on the surgeons. NASA-TLX is recognized as the gold standard for subjective workload assessment and comprises six dimensions: mental demand (MD), physical demand (PD), temporal demand (TF), own performance (OP), effort (EF), and frustration (FR)9. Each dimension is rated independently on a scale of 0 to 100. The Likert Subjective Rating Scale includes a series of questions with five response levels ranging from very satisfied (5 points) to very dissatisfied (1 point), with the intermediate levels being satisfied (4 points), acceptable (3 points), and dissatisfied (2 points).

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>3DSlicer</td>
			<td>Slicer</td>
			<td></td>
			<td>https://www.slicer.org/</td>
		</tr>
		<tr>
			<td>HoloLens2</td>
			<td>Microsoft</td>
			<td></td>
			<td>a type of mixed reality helmet mounted display 
			https://www.microsoft.com/en-us/hololens/hardware#document-experiences</td>
		</tr>
	</tbody>
</table>

mixed reality assisted radical endoscopic thyroidectomy

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, the thyroid&#39;s unique physiological functions and intricate surrounding anatomy may result in various surgical complications. Mixed reality (MR), a real-time holographic visualization technology, enables the creation of highly realistic 3D models in the real world and facilitates multiple human-computer interactions. MR can be utilized for both preoperative evaluation and intraoperative navigation. First, semi-automatic 3D reconstruction of the neck from enhanced computed tomography images is performed using 3Dslicer. Next, the 3D model is imported into Unity3D to create a virtual hologram that can be displayed on an MR helmet-mounted display (HMD). During surgery, surgeons can wear the MR HMD to locate lesions and surrounding anatomy through the virtual hologram. In this study, patients requiring radical ET were randomly assigned to either the experimental group or the control group. Surgeons performed MR-assisted radical ET in the experimental group. A comparative analysis of surgical outcomes and the results of scales was conducted.&#160;This study successfully developed the neck 3D model and the virtual hologram. According to the NASA Task Load Index Scale, the experimental group exhibited significantly higher scores in &#39;Own Performance&#39; and lower scores in &#39;Effort&#39; compared to the control group (p = 0.002). Additionally, on the Likert Subjective Evaluation Scale, the mean scores for all questions exceeded 3. Although the incidence of surgical complications was lower in the experimental group than in the control group, the differences in surgical outcomes were not statistically significant.MR is beneficial for enhancing performance and alleviating the burden of surgeons during the perioperative period. Furthermore, MR has demonstrated the potential to enhance the safety of ET. Therefore, it is essential to further investigate the surgical applications of MR.

This study successfully constructed the neck 3D model of patients with PTC (Figure 1) and performed 14 cases of MR-assisted radical ET (Figure 2).
A total of 32 ETs were performed by a senior surgeon, who completed the NASA-TLX and the Likert Subjective Rating Scale (Table 1 and Table 2) following the surgeries. In the NASA-TLX, the experimental group exhibited a significantly higher OP score and lowe...

Radical endoscopic thyroidectomy is associated with various surgical complications. This study utilizes mixed reality techniques to assist surgeons in performing radical endoscopic thyroidectomy, aiming to enhance its safety and lower the surgical threshold.

Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Radical endoscopic thyroidectomy (ET) offers superior cosmetic outcomes and enhanced visibility of the surgical field compared to open surgery. However, ...

mixed-reality-assisted-radical-endoscopic-thyroidectomy

Research

JoVE Journal

Medicine

143 Views.  The Third Affiliated Hospital of Sun Yat-Sen University. Radical endoscopic thyroidectomy is associated with various surgical complications. This study utilizes mixed reality techniques to assist surgeons in performing radical endoscopic thyroidectomy, aiming to enhance its safety and lower the surgical threshold.

Video: Mixed Reality Assisted Radical Endoscopic Thyroidectomy

Accuracy in Dental Medicine, A New Way to Measure Trueness and Precision

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base for dental restorations. The current limitation of many reference scanners is the lack of accuracy scanning large objects like full dental arches, or the limited possibility to assess detailed tooth surfaces. A new reference scanner, based on focus variation scanning technique, was evaluated with regards to highest local and general accuracy. A specific scanning protocol was tested to scan original tooth surface from dental impressions. Also, different model materials were verified. The results showed a high scanning accuracy of the reference scanner with a mean deviation of 5.3 &#177; 1.1 &#181;m for trueness and 1.6 &#177; 0.6 &#181;m for precision in case of full arch scans. Current dental impression methods showed much higher deviations (trueness: 20.4 &#177; 2.2 &#181;m, precision: 12.5 &#177; 2.5 &#181;m) than the internal scanning accuracy of the reference scanner. Smaller objects like single tooth surface can be scanned with an even higher accuracy, enabling the system to assess erosive and abrasive tooth surface loss. The reference scanner can be used to measure differences for a lot of dental research fields. The different magnification levels combined with a high local and general accuracy can be used to assess changes of single teeth or restorations up to full arch changes.

Accuracy is a major demand in dental medicine. To verify accuracy, reference scanners are needed. This article presents a new reference scanner with an adjusted scanning method to acquire a broad variety of dental morphologies with high trueness and precision.

Reference scanners are used in dental medicine to verify a lot of procedures. The main interest is to verify impression methods as they serve as a base ...

Robot-Assisted Radical Antegrade Modular Pancreatosplenectomy Including Resection and Reconstruction of the Spleno-Mesenteric Junction

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the spleno-mesenteric junction, for cancer of the body-tail of the pancreas. The patient is placed supine with the legs parted and a pneumoperitoneum is established and maintained at 10 mmHg. To use the surgical system, four 8 mm ports and one 12 mm port are required. The optic port is placed at the umbilicus. The other ports are placed, on either side, along the pararectal line and the anterior axillary line at the level of the umbilical line. The assistant port (12 mm) is placed along the right pararectal line. Dissection begins by detaching the gastrocolic ligament, thus opening the lesser sac, and by a wide mobilization of the splenic flexure of the colon. The superior mesenteric vein is identified along the inferior border of the pancreas. Lymph node number 8a is removed to permit clear visualization of the common hepatic artery. A tunnel is then created behind the neck of the pancreas. To permit safe resection and reconstruction of the spleno-mesenteric junction, further preemptive dissection is required before dividing the pancreatic neck to bring in clear view all relevant vascular pedicles. Next, the splenic artery is ligated and divided, and the pancreatic neck is divided, with selective ligature of the pancreatic duct. After vein resection and reconstruction, dissection proceeds to complete the clearance of peripancreatic arteries that are peeled off from all lympho-neural tissues. Both celiac ganglia are removed en-bloc with the specimen. The Gerota fascia covering the upper pole of the left kidney is also removed en-bloc with the specimen. Division of short gastric vessels and splenectomy complete the procedure. A drain is left near the pancreatic stump. The round ligament of the liver is mobilized to protect the vessels.

The robotic technique shown herein aims at faithfully reproducing the open procedure for radical treatment of cancer of the body-tail of the pancreas. The protocol also demonstrates the ability to master involvement of major peripancreatic vessels without conversion to open surgery.

This article shows the technique of robot-assisted radical antegrade modular pancreatosplenectomy, including resection and reconstruction of the ...

OP-IVM: Combining In vitro Maturation after Oocyte Retrieval with Gynecological Surgery

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte retrieval with routine gynecological surgery. OP-IVM is suitable for patients undergoing benign gynecological surgery who have the need for fertility preservation (FP) or infertility treatments such as in vitro fertilization and embryo transfer (IVF-ET). In the operating room, patients undergoing benign gynecological surgery are first anesthetized and receive ultrasound-guided immature follicle aspiration (IMFA) treatment. As the subsequent gynecological surgery is performed, the cumulus-oocyte complexes (COCs) are examined, and the immature COCs are transferred into the IVM medium and cultured for 28-32 hours in the IVF laboratory. After assessment, mature oocytes in the MII stage will be selected and cryopreserved in liquid nitrogen for FP or fertilized by intracytoplasmic sperm injection (ICSI) for IVF-ET. By combining IVM with gynecological surgery, immature oocytes that would have been discarded can be saved and used for assisted reproductive technology (ART). The procedure, significance and critical aspects of OP-IVM are described in this article.

In vitro maturation (IVM) before gynecological operation (OP-IVM) combines IVM following oocyte retrieval with routine gynecological surgery and serves as an extension of conventional IVM applications for fertility preservation.

The use of in vitro maturation (IVM) before gynecological operation (OP-IVM) is an extension of conventional IVM that combines IVM following oocyte ...

Robot-Assisted Kidney Transplantation

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed in the supine Trendelenburg position. Kidney allografts are provided by a living donor. Before vascular anastomosis, the kidney allograft is prepared by inserting a double-J stent in the ureter, and the temperature for the anastomosis is lowered by wrapping it in an ice-packed gauze. A 12 mm or 8 mm port for the robotic camera and three 8 mm ports for robotic arms are placed. A peritoneal pouch is created for the kidney allograft by raising the peritoneal flaps on both sides over the psoas muscle before dissecting the iliac vessels and bladder. A 6 cm Pfannenstiel incision is made to insert the kidney into the peritoneal pouch, lateral to the right iliac vessels. 
After clamping the external iliac vein with Bulldogs clamps, a venotomy is performed, and the graft renal vein is anastomosed to the external iliac vein in an end-to-side continuous manner with a 6/0 polytetrafluoroethylene suture. After clamping the graft renal vein, the iliac vein is declamped. This is followed by clamping of the external iliac artery, arteriotomy, arterial anastomosis with a 6/0 polytetrafluoroethylene suture, clamping of the graft renal artery, and declamping of the external iliac artery. Reperfusion is then carried out, and ureteroneocystostomy is performed using the Lich-Gregoir technique. The peritoneum is closed at a few locations with polymer locking clips, and a closed-suction drain is placed through one of the working ports. After deflating the pneumoperitoneum, all incisions are closed.

This paper provides technical details for robot-assisted kidney transplantation from a living donor.

This paper describes robot-assisted kidney transplantation (RAKT) from a living donor. The robot is docked between the parted legs of the patient, placed ...

Endoscopic Ultrasound-Guided Biliary Drainage: Endoscopic Ultrasound-Guided Hepaticogastrostomy in Malignant Biliary Obstruction

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde Cholangiopancreatography (ERCP) is the primary biliary drainage method whenever possible. Percutaneous Transhepatic Biliary Drainage (PTBD) is used as a salvage method if ERCP fails. Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) provides a feasible alternative biliary drainage method where one of the methods is EUS guided Hepaticogastrostomy (EUS-HGS). Here we describe the EUS-HGS technique in a case of unresectable malignant hilar biliary obstruction to achieve biliary drainage.
Presented here is the case of a 71-year-old female with painless jaundice and weight loss for 2 weeks. Computed Tomography (CT) imaging showed a 4 x 5 cm hilar tumor with lymphadenopathy and liver metastasis. EUS fine needle biopsy (FNB) of the lesion was consistent with cholangiocarcinoma. Her bilirubin levels were 212 &#181;mol/L (&lt;15) during presentation.
A linear echoendoscope was used to locate the left dilated intrahepatic ducts (IHD) of the liver. The segment 3 dilated IHD was identified and punctured using a 19 G needle. Contrast was used to opacify the IHDs under fluoroscopic guidance. The IHD was cannulated using a 0.025-inch guidewire. This was followed by the dilation of the fistula tract using a 6 Fr electrocautery dilator along with a 4 mm biliary balloon dilator. A partially covered metallic stent of 10 cm in length was deployed under fluoroscopic guidance. The distal part opens in the IHD and the proximal part was deployed within the working channel of the echoendoscope that subsequently released into the stomach. The patient was discharged three days after the procedure. Follow up performed in the second and fourth weeks showed that the bilirubin levels were 30 &#181;mol/L and 14 &#181;mol/L, respectively. This indicates that EUS-HGS is a safe method for biliary drainage in unresectable malignant biliary obstruction.

Endoscopic Ultrasound-Guided Biliary Drainage (EUS-BD) is an alternative method of biliary decompression in malignant biliary obstruction. Here we describe the technique of EUS guided-Hepaticogastrostomy (EUS-HGS) in a case of unresectable malignant hilar biliary obstruction.

Patients with unresectable malignant biliary obstruction often require biliary drainage to decompress the biliary system. Endoscopic Retrograde ...

Endoscopic Cholesteatoma Surgery

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. Compared to the microscopic approach with an excellent but straight-line view and limited illumination, the introduction of endoscopes provides a wide-angled panoramic view. Moreover, angled lenses allow the surgeon to visualize the middle ear and its hidden recesses through a transcanal, minimally-invasive approach. The endoscope enables the surgeon to remove limited cholesteatoma of the middle ear and its recesses using an exclusive endoscopic technique by taking advantage of these benefits. This reduces the rate of residual disease and sparing external incisions and excessive temporal bone drilling as in a transmastoid approach. Since transcanal endoscopic access is mainly a one-handed technique, it implies the need for specific procedures and technical refinements. This article describes a step-by-step guide as a surgical manual for endoscopic removal of epitympanic cholesteatoma. Different techniques for cholesteatoma dissection and bone removal for epitympanectomy, including curettage and powered instruments such as drills and ultrasonic devices with their outcomes, are discussed. This may offer ear surgeons insight into technical refinements and the latest technological developments and open the horizon for different techniques.

The present protocol describes a step-by-step guide for the complete endoscopic removal of epitympanic cholesteatoma with different techniques for cholesteatoma dissection and bone removal for epitympanectomy.

Implementation of endoscopes in cholesteatoma surgery resulted in considerable changes in the management of cholesteatoma in the last two decades. ...

Retzius-Sparing Robot-Assisted Radical Prostatectomy

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The technique is described step-by-step and further illustrated by a video to enhance reproducibility. Early oncological and functional results were evaluated. In total, 77 patients were included with a median follow-up of 11 months (range: 3-21 months). Fifty-one percent of patients had local high-risk or locally advanced prostate cancer. There were no intra-operative complications, and all high-grade complications (2.6%) were related to pelvic lymph node dissection performed concomitant with RS-RARP. Median operation time was 160 min (range: 122-265 min) and median hospital stay was 3 (range: 3-8) days. A positive surgical margin was reported in 42.9%. One-year biochemical recurrence-free survival was 90.1%. After 6 months, all patients were socially continent and after 1 year, 94.3% were fully continent. Of sexually active patients who underwent at least unilateral nerve-sparing, 43.3% were able to have sexual intercourse. This series underlines the surgical safety of performing RS-RARP by a standardized technique and confirms the beneficial effect on the early return of continence. The patient needs to be informed about the risk of a positive surgical margin.

Robot-assisted Retzius-sparing radical prostatectomy is a technique that enables to preserve urinary continence or facilitates recovery of urinary continence in the majority of patients. Patients must be informed about the risk of a positive surgical margin.

The technique of Retzius-sparing robot-assisted radical prostatectomy (RS-RARP) and initial experience with it at a single center are provided. The ...

The Use of Mixed Reality in Custom-Made Revision Hip Arthroplasty: A First Case Report

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed reality were used to perform complex revision hip arthroplasty in January 2019. The use of mixed reality allowed for a very good visualization of the structures and resulted in precise implant fixation. According to the authors' knowledge, this is the first described case report of the combined use of these two innovations. The diagnosis preceding the qualification for the procedure was the loosening of the left hip's acetabular component. Mixed reality headset and holograms prepared by engineers were used during the surgery. The operation was successful, and it was followed by early verticalization and patient rehabilitation. The team sees opportunities for technology development in joint arthroplasty, trauma, and orthopedic oncology.

A complex revision hip arthroplasty was performed using a custom-made implant and mixed reality technology. According to the authors&#39; knowledge, this is the first report of such procedure described in the literature.

The technology of 3D printing and visualization of anatomical structures is rapidly growing in various fields of medicine. A custom-made implant and mixed ...

A Modified Vessel-Sparing Microsurgical Vasoepididymostomy

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, preserving the vasal vessels during MVE might better simulate the normal physiological structure and be meaningful for patients who have undergone varicocelectomy. Nevertheless, preserving the vasal vessels might elevate the risk of increasing the tension of anastomosis, affecting the patency rate and leading to delayed postoperative bleeding. Therefore, we developed a novel vessel-sparing MVE to make it safer. Here is a summary of the improvements to the procedure. 1) The retrograde dissociation of the vasal vessels on the proximal testicular side was adopted as the main method, and the anterograde dissociation of the vasal vessels on the distal testicular side was adopted as a supplement to dissociate the vasal vessels to be preserved. This improvement ensures the blood supply to the vas deferens that will be used for anastomosis and also provides longer vasal vessels, which reduces the tension of anastomosis. 2) By fixing the vas deferens to be anastomosed and the broken end of the vas deferens, the free vasal vessels get fixed, which resolves the problem of transmission of vas tension to the vasal vessels and reduces the risk of vasal vessel hemorrhage. 3) Dissociation of the vas deferens after opening the tunica vaginalis increases the mobilization of the vas deferens, which also makes the new procedure easier to complete. The evaluation of the outcomes of this new procedure showed that no significant postoperative complications occurred in the patients, and the patency rate was no different from that of the conventional procedure. Therefore, this new, improved procedure can be considered safe, with satisfactory postoperative results.

Here, we present a protocol to preserve the vasal vessels in microsurgical vasoepididymostomy. The surgical security is enhanced by preserving the vasal vessels using a retrograde-anterograde dissociation and fixing the vasal vessels.

Microsurgical vasoepididymostomy (MVE) is the main surgical treatment for epididymal obstruction. The vasal vessels are ligated during MVE. However, ...

Transoral Endoscopic Thyroidectomy Vestibular Approach for Thyroid Lobectomy

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine position with extension and fixation of the neck. One 20 mm transverse incision and two 5 mm incisions are made through the mucosa of the oral vestibule for camera and instrument placement after disinfection of the skin and oral cavity. The workspace is established and maintained by the skin suspension device, which is made of unabsorbable string (3-0) and rubber bands, and the CO2 insufflation pressure. Lobectomy using a medial-to-lateral technique and prophylactic ipsilateral central neck dissection is performed simultaneously on patients with papillary thyroid cancer (PTC). The specimen is extracted through the 20 mm incision. The parathyroid gland is immediately searched for in the specimen and auto-transplanted to the left brachioradialis. A drainage tube is inserted through the retractor hole into the bed of the thyroid gland, and absorbable sutures are used to close the mucosal incisions in the oral vestibule and the linea alba cervicalis. Prophylactics administered intravenously are recommended for the first 24 h after surgery, and oral antibiotics are used for 7 days postoperatively.

Here, we present a protocol to describe the methodology for the transoral endoscopic thyroidectomy vestibular approach in detail.

The manuscript describes the transoral endoscopic thyroidectomy vestibular approach (TOETVA) for thyroid lobectomy. The patient is placed in the supine ...