Real‐time electromagnetic navigation for breast‐conserving surgery using NaviKnife technology: A matched case‐control study

Breast‐conserving surgery (BCS) is a mainstay in breast cancer treatment. For nonpalpable breast cancers, current strategies have limited accuracy, contributing to high positive margin rates. We developed NaviKnife, a surgical navigation system based on real‐time electromagnetic (EM) tracking. The goal of this study was to confirm the feasibility of intraoperative EM navigation in patients with nonpalpable breast cancer and to assess the potential value of surgical navigation. We recruited 40 patients with ultrasound visible, single, nonpalpable lesions, undergoing BCS. Feasibility was assessed by equipment functionality and sterility, acceptable duration of the operation, and surgeon feedback. Secondary outcomes included specimen volume, positive margin rate, and reoperation outcomes. Study patients were compared to a control group by a matched case‐control analysis. There was no equipment failure or breach of sterility. The median operative time was 66 (44‐119) minutes with NaviKnife vs 65 (34‐158) minutes for the control (P = .64). NaviKnife contouring time was 3.2 (1.6‐9) minutes. Surgeons rated navigation as easy to setup, easy to use, and useful in guiding nonpalpable tumor excision. The mean specimen volume was 95.4 ± 73.5 cm³ with NaviKnife and 140.7 ± 100.3 cm³ for the control (P = .01). The positive margin rate was 22.5% with NaviKnife and 28.7% for the control (P = .52). The re‐excision specimen contained residual disease in 14.3% for NaviKnife and 50% for the control (P = .28). Our results demonstrate that real‐time EM navigation is feasible in the operating room for BCS. Excisions performed with navigation result in the removal of less breast tissue without compromising postive margin rates.     

Computer‐assisted Orthopaedic Surgery

Nowadays, operating rooms can be inefficient and overcrowded. Patient data and images are at times not well integrated and displayed in a timely fashion. This lack of coordination may cause further reductions in efficiency, jeopardize patient safety, and increase costs. Fortunately, technology has much to offer the surgical disciplines and the ongoing and recent operating room innovations have advanced preoperative planning and surgical procedures by providing visual, navigational, and mechanical computerized assistance. The field of computer‐assisted surgery (CAS) broadly refers to surgical interface between surgeons and machines. It is also part of the ongoing initiatives to move away from invasive to less invasive or even noninvasive procedures. CAS can be applied preoperatively, intraoperatively, and/or postoperatively to improve the outcome of orthopaedic surgical procedures as it has the potential for greater precision, control, and flexibility in carrying out surgical tasks, and enables much better visualization of the operating field than conventional methods have afforded. CAS is an active research discipline, which brings together orthopaedic practitioners with traditional technical disciplines such as engineering, computer science, and robotics. However, to achieve the best outcomes, teamwork, open communication, and willingness to adapt and adopt new skills and processes are critical. Because of the relatively short time period over which CAS has developed, long‐term follow‐up studies have not yet been possible. Consequently, this review aims to outline current CAS applications, limitations, and promising future developments that will continue to impact the operating room (OR) environment and the OR in the future, particularly within orthopedic and spine surgery.     

Peri‐operative management of anti‐platelet agents

Background: Increasing numbers of patients treated with anti‐platelet agents are presenting for non‐cardiac surgery. We examined the peri‐operative management of anti‐platelet therapy in patients undergoing elective non‐cardiac surgery and the process by which patients received instructions. Methods: We interviewed and collected outcome data on 213 consecutive patients aged ≥45 years presenting for elective non‐cardiac surgery at our institution over a 6‐week period regarding the peri‐operative management of anti‐platelet and warfarin therapy. Results: Anti‐platelet therapy was prescribed in 22.5% and warfarin in 5.2% of the study subjects. Aspirin was stopped peri‐operatively in 55.3%, while clopidogrel was stopped in the sole patient treated with this. The frequency of anti‐platelet agent discontinuation was similar for major and minor surgery. Warfarin was discontinued prior to surgery in all cases. Only 54.2% of those treated with anti‐platelet therapy recalled being given instruction regarding pre‐operative management of their anti‐platelet therapy compared with 90.9% of patients treated with warfarin (P= 0.04). In the absence of instructions, a number of patients made their own decision to stop their aspirin pre‐operatively. Post‐operatively, only 37% recalled receiving instructions regarding restarting anti‐platelet therapy. As a result, three patients failed to do so. In contrast, all those treated with warfarin received clear post‐operative instructions. Conclusion: Peri‐operative anti‐platelet management and communication with patients appears to be sub‐optimal. There is a need for standardized processes whereby informed decisions regarding peri‐operative anti‐platelet therapy are made and communicated clearly to the patients.     

Robotic da Vinci Xi‐assisted nipple‐sparing mastectomy: First clinical report

Nipple‐sparing mastectomy (NSM) is increasingly popular for the treatment of selected breast cancers and prophylactic mastectomy. Surgical scarring and esthetic outcomes are important patient‐related cosmetic considerations. Today, the concept of minimally invasive surgery has become popular, especially using robotic surgery. The authors report the first case of NSM using the latest version of the da Vinci Xi surgical system (Xi). The final incision used to remove the entire mammary gland was located behind the axillary line. In this position, hidden by the arm of the patient, the incision was not visible and was compatible with immediate breast reconstruction.