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Hundreds of millions of operations are performed worldwide each year, and the rising uptake in minimally invasive surgery has enabled fiber optic cameras and robots to become both important tools to conduct surgery and sensors from which to capture information about surgery. Computer vision (CV), the application of algorithms to analyze and interpret visual data, has become a critical technology through which to study the intraoperative phase of care with the goals of augmenting surgeons’ decision-making processes, supporting safer surgery, and expanding access to surgical care. While much work has been performed on potential use cases, there are currently no CV tools widely used for diagnostic or therapeutic applications in surgery. Using laparoscopic cholecystectomy as an example, we reviewed current CV techniques that have been applied to minimally invasive surgery and their clinical applications. Finally, we discuss the challenges and obstacles that remain to be overcome for broader implementation and adoption of CV in surgery.

IntroductionAs the rate of obesity increases, so does the incidence of obesity-related comorbidities. Metabolic and bariatric surgery (MBS) is the most effective treatment for obesity, yet this treatment is severely underused. MBS can improve, resolve, and prevent the development of obesity-related comorbidities; this improvement in health also results in lower healthcare costs. The studies that have examined these outcomes are often limited by small sample sizes, reliance on outdated data, inconsistent definitions of outcomes, and the use of simulated data. Using recent real-world data, we will identify characteristics of individuals who qualify for MBS but have not had MBS and address the gaps in knowledge around the impact of MBS on health outcomes and healthcare costs.Methods and analysisUsing a large US employer-based retrospective claims database (Merative), we will identify all obese adults (21+) who have had a primary MBS from 2016 to 2021 and compare their characteristics and outcomes with obese adults who did not have an MBS from 2016 to 2021. Baseline demographics, health outcomes, and costs will be examined in the year before the index date, remission and new-onset comorbidities, and healthcare costs will be examined at 1 and 3 years after the index date.Ethics and disseminationAs this was an observational study of deidentified patients in the Merative database, Institutional Review Board approval and consent were exempt (in accordance with the Health Insurance Portability and Accountability Act Privacy Rule). An IRB exemption was approved by the wcg IRB (#13931684). Knowledge dissemination will include presenting results at national and international conferences, sharing findings with specialty societies, and publishing results in peer-reviewed journals. All data management and analytic code will be made available publicly to enable others to leverage our methods to verify and extend our findings.

Background Errors in judgment during thyroidectomy can lead to recurrent laryngeal nerve injury and other complications. Despite the strong link between patient outcomes and intraoperative decision-making, methods to evaluate these complex skills are lacking. The purpose of this study was to develop objective metrics to evaluate advanced cognitive skills during thyroidectomy and to obtain validity evidence for them. Methods An interactive online learning platform was developed ( www.thinklikeasurgeon.com ). Trainees and surgeons from four institutions completed a 33-item assessment, developed based on a cognitive task analysis and expert Delphi consensus. Sixteen items required subjects to make annotations on still frames of thyroidectomy videos, and accuracy scores were calculated based on an algorithm derived from experts’ responses (“visual concordance test,” VCT). Seven items were short answer (SA), requiring users to type their answers, and scores were automatically calculated based on their similarity to a pre-populated repertoire of correct responses. Test–retest reliability, internal consistency, and correlation of scores with self-reported experience and training level (novice, intermediate, expert) were calculated. Results Twenty-eight subjects (10 endocrine surgeons and otolaryngologists, 18 trainees) participated. There was high test–retest reliability (intraclass correlation coefficient = 0.96; n  = 10) and internal consistency (Cronbach’s α  = 0.93). The assessment demonstrated significant differences between novices, intermediates, and experts in total score ( p  < 0.01), VCT score ( p  < 0.01) and SA score ( p  < 0.01). There was high correlation between total case number and total score ( ρ  = 0.95, p  < 0.01), between total case number and VCT score ( ρ  = 0.93, p  < 0.01), and between total case number and SA score ( ρ  = 0.83, p  < 0.01). Conclusion This study describes the development of novel metrics and provides validity evidence for an interactive Web-based platform to objectively assess decision-making during thyroidectomy.

The increasing prevalence of obesity translates into a greater number of obese patients undergoing general surgery procedures. We questioned if increased awareness and recent prophylaxis guidelines impacted the incidence of venous thromboembolism (VTE) in the obese patients. A total of 33,325 patients who underwent 4 common general surgery procedures from 2005 to 2009 were identified from the American College of Surgeons’ National Surgical Quality Improvement Program database. Rates of VTE between 5 body mass index cohorts were compared with univariable analysis. No significant difference existed between rates of deep vein thrombosis or pulmonary embolism (PE) across the body mass index categories (P = .32 and P = .06, respectively). With the exception of the positive linear trend in the rate of PE for patients undergoing abdominal wall hernia repair (P < .01), there was no difference in deep vein thrombosis or PE rate exhibited by procedure. VTE rates in the obese patients are similar to that of the general population with the exception of PE in those undergoing abdominal wall hernia repair. •No difference existed between rates of VTE in normal weight versus obese patients.•Obesity did not impact DVT rate in any abdominal procedure alone.•PE events increased with BMI for patients undergoing abdominal hernia repair.•Recent prophylaxis efforts have minimized VTE events in the obese surgical patients.

PurposeThe aim of this study is to evaluate the change in rate of increase of bariatric surgery performed compared to the growth of obesity and severe obesity in the United States (US).Materials and MethodsThe number of primary adult bariatric procedures performed in the US between 2015 and 2018 was obtained from the Metabolic and Bariatric Surgery Accreditation Quality and Improvement Project (MBSAQIP) database. The US Census database was used to derive age-adjusted obesity and severe obesity prevalence among adults. Prevalence of bariatric surgery, by year, was estimated as the ratio of the number of patients undergoing surgery and the projected number of eligible individuals for that year.ResultsThere were 627,386 bariatric procedures performed for body mass index (BMI) ≥ 30 kg/m2, of which 73.3% (n = 459,800) were performed for BMI ≥ 40 kg/m2. Although the rate of obesity increased by 3.32% per year during this period (RR = 1.0332 per year increase; 95% CI = 1.0313, 1.0352), the rate of surgery per eligible population increased by only 2.47% (RR = 1.0247 per year increase; 95% CI = 1.0065, 1.0432). The prevalence of severe obesity increased from 7.70% (n = 17,494,910) in 2015 to 9.95% (n = 23,135,039) in 2018 while the prevalence of surgery decreased from 0.588 per 100 eligible population in 2015 to 0.566 per 100 eligible population in 2018.ConclusionThe rate of utilization has not kept up with the rate of increase in this disease, our costliest illness. There is a strong need to educate the public, healthcare professionals, insurance carriers, and legislators.

Introduction Despite remarkable progress, gender inequality in medicine remains a significant issue. This disparity extends beyond clinical practices and educational programs; it is also evident in the recognition and awards received by surgeons. Underrepresentation of women in Surgical Society awards is a multi-layered issue that needs a holistic approach since these awards are used to hire, promote, and advance surgeons. Methods and Procedures A retrospective observational study was performed between 1936 and 2023 on all recipients of awards from 22 surgical societies. The study examines the relationship between recipient gender and award year. Medians, and interquartile ranges (IQRs) were used for continuous data, and frequencies and percentages were used for categorical data. Chi-square and Wilcoxon rank sum tests were used to compare female and male recipients. Multiple logistic regression was used to estimate the probability that a female will receive an award. Results A total of 2588 awards were given out between 1936 and 2023. Among the 2588 awards, 2024 went to male surgeons, and 564 to female surgeons. Since 1936, there have been 0–25 women awarded annually, with a proportion of female awardees between 0 and 0.5. Since 1936, the proportion of women awardees has increased significantly ( p  < 0.01). Since 2006, female award winners have increased by 0.7% (95% CI 0.007–0.008, p  = 0.001) when controlling for surgical societies. A woman’s odds of receiving an award from a surgical society have increased by only 3% per year since 2006 (OR 1.03, 95% CI 1.01–1.07, p  = 0.004). Accordingly, female surgeon awards grew from 0.22 in 2006 to 0.35 in 2023. Conclusion Female surgeons’ continuous underrepresentation in Surgical Society awards is a crucial issue. The selection process of surgical societies needs to be more intentional as female recipients have steadily increased in recent years. Closing this gender gap is not only a matter of fairness but also imperative for the field’s progress.

Background Early reports of higher complication rates, specifically bile duct injuries, raised concerns over the safety of laparoscopy over open cholecystectomy. This study aims to ascertain the rate, management, and perioperative outcomes of bile duct injury in an era beyond the laparoscopic learning curve. Methods The New York State (NYS) Planning and Research Cooperative System longitudinal administrative database was used to identify patients. From 2005 to 2010, 156,315 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Patients were then tracked with unique identifiers for common bile duct injury. Common bile duct injury was identified by ICD-9 and CPT diagnosis and procedure codes for patients who subsequently underwent hepatectomy, hepaticojejunostomy, or other bile duct surgery. Results From 2005 to 2010, 156,958 patients were identified who had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis or acute or chronic cholecystitis. Of the total patients, 149 patients underwent a biliary duct procedure within a year. Twenty-four of them were diagnosed with gallbladder cancer and excluded, leaving 125 for further analysis. The biliary injuries were identified at a rate of 0.080 %. Thirty-one of those patients (24.8 %) underwent hepatectomy, 40 patients (32.0 %) underwent hepaticoenterostomy, and 54 patients (43.2 %) underwent primary repair of the bile duct. Thirty-two (26 %) patients were repaired on the same day of their initial procedure. Of the remaining 93 patients, 38 (30 %) were repaired within 10 days, seven (6 %) repaired between 11 and 20 days, and 48 (38 %) patients over 21 days from injury. Conclusion In NYS, the rate of bile duct injury has now decreased to 0.08 % and mirrors the historical figures quoted for open cholecystectomy. This improvement likely reflects increased experience, improved instrumentation, and movement beyond the “learning curve.”

IntroductionDuring laparoscopic cholecystectomy (LC), common bile duct (CBD) visualization either directly or with cholangiography (IOC) is less routine. Cholangiography can be used to identify and possibly prevent bile duct injury (BDI), which is a dreaded complication of cholecystectomy. The purpose of our study was to evaluate the trend of IOC/CBD exploration and BDI during LC for benign disease.MethodsA state-wide database (SPARCS) was used to identify all LC for benign biliary non-obstructive and obstructive disease between 2000 and 2014 in the state of New York. ICD-9 and CPT codes were used to identify IOC/CBD exploration and BDI. Multivariable logistic regression models were used in examining the linear trend in the risk of complication, 30-day readmission, 30-day ED visits, and BDI among all cholangiogram patients after controlling for possible confounding factors.ResultsDuring 2000–2014, 391,945 patients underwent laparoscopic cholecystectomy. The trend of IOC/CBD exploration performed significantly decreased for LC overall (12.37–10.44%, relative risk = 0.98, p <.0001) and particularly, in the outpatient setting (10.77–7.52%, relative risk = 0.96, p value <.0001). Among patients with IOC, overall complication rate, 30-day readmission rate, and 30-day ED visit rates increased. When looking at overall complication rate, there was an increase by about 4% per year (relative risk = 1.04, p value <.0001). After controlling for confounding factors, the complication risk and 30-day ED visit risk increased through years, while the 30-day readmission risk did not have significant change. Risk of BDI also increased significantly (p = 0.03).ConclusionIn an era of laparoscopy, the rate of IOC/CBD exploration during LC has significantly decreased, while BDI significantly increased.

BackgroundThe growing interest in analysis of surgical video through machine learning has led to increased research efforts; however, common methods of annotating video data are lacking. There is a need to establish recommendations on the annotation of surgical video data to enable assessment of algorithms and multi-institutional collaboration.MethodsFour working groups were formed from a pool of participants that included clinicians, engineers, and data scientists. The working groups were focused on four themes: (1) temporal models, (2) actions and tasks, (3) tissue characteristics and general anatomy, and (4) software and data structure. A modified Delphi process was utilized to create a consensus survey based on suggested recommendations from each of the working groups.ResultsAfter three Delphi rounds, consensus was reached on recommendations for annotation within each of these domains. A hierarchy for annotation of temporal events in surgery was established.ConclusionsWhile additional work remains to achieve accepted standards for video annotation in surgery, the consensus recommendations on a general framework for annotation presented here lay the foundation for standardization. This type of framework is critical to enabling diverse datasets, performance benchmarks, and collaboration.