Background Clinical practice guideline (CPG) development is a time- and resource-intensive process, yet their uptake may be limited by concerns among clinicians that guidelines could be used against them in malpractice cases. The role of CPGs in surgical litigation remains unclear. Aim To empirically evaluate how CPGs are used in surgical civil law and determine whether cited guidelines are surgery specific. Methods A systematic review of California Civil Trial Court Orders (Westlaw) was searched for surgery-related cases from 2021-2024. Case dockets were reviewed for guideline-based recommendations in expert testimony and in the Summary of Motion documents. Results A total of 192 cases were reviewed with eighty-three meeting inclusion criteria. CPGs were cited in three of eighty-three surgical malpractice cases (3.6 per cent), none of which were surgery specific. Conclusion CPGs appear to be rarely cited in surgical civil court cases and when referenced, they relate to non-surgical aspects of care. However, their violation may provide courts with decisive grounds for legal deliberation. Further studies evaluating a larger number of settlement cases using insurance company data would be invaluable to fully understand the role of surgical and non-surgical guidelines in shaping surgical medicolegal proceedings.
This in vitro pilot study aimed to determine the impact of two different CBCT fields of view, intraoral scan areas and surgical template sizes on the accuracy of static computer-aided implant surgery. A total of 20 implant sites in the anterior maxilla of 20 polyurethane models of partially edentulous arches were divided into four groups based on CBCT field of view and intraoral scan area. The groups used either a small (40 × 40 mm) or medium field of view (50 × 100 mm), a full-maxilla or partial intraoral scan area and a full or partial surgical guide. CBCT and intraoral scan data were registered for implant planning, and surgical templates (either supported by all the remaining teeth or only by teeth 11 and 23) were designed accordingly. The implants were randomly placed through the template in a fully guided manner. Postoperative surface scans were superimposed on the preoperative planning data to evaluate the angular and spatial deviation between the planned and inserted implants. Descriptive statistics were followed by a non-parametric Kruskal-Wallis test to compare the differences between the groups. No significant differences were found when comparing the effect of the size of field of view, intraoral scan area and surgical template on the accuracy of static computer-aided implant surgery (P > 0.05). Preliminary findings indicate that field of view size, intraoral scan area and surgical template dimensions do not significantly affect the accuracy of static computer-aided implant surgery in the partially edentulous anterior maxilla, supporting the application of As Low As Diagnostically Acceptable being Indication-oriented and Patient-specific principles. The authors declare there are no conflicts of interest relating to this study.
We evaluate stereo-differentiable rendering-based pose estimation for marker-free real-time surgical robots tracking, mitigating occlusion-prone marker-based tracking in cluttered surgical environments, potentially improving safety, reducing setup times, and enabling intelligent multi-robot interaction. This work extends the differentiable rendering-based markerless robot pose estimation framework roboreg for online real-time dynamic tracking in two ways. (i) Sequential optimisation propagates pose estimates across consecutive frames, with motion-adaptive hyperparameter tuning balancing convergence and precision during estimation. (ii) Integrate CUDA stream parallelisation for segmentation and the optimisation steps and combines it with CUDA-graph accelerated segmentation. We collect 38 displacement video sequence datasets with unobstructed robot and 5 occluded-robot dataset with static start/end ground-truth pose calibrations and dynamic marker-based reference tracking in between for accuracy evaluation under different scenarios. Real-time localisation at 30 fps for 1080p video sequence is achieved, accelerating from 14 fps in the vanilla roboreg, thereby matching the camera frame rate. Near-1 cm accuracy is demonstrated, with 1.7 cm translational and 0. 6 ∘ rotational error against static ground-truth pose calibration; and with 1.2 cm average 3D error across 27,460 frames against a marker-based reference standard (1.53 cm in over 1242 frames in occlusion evaluation). Our method outperforms FoundationPose by 11% (63% in occlusion dataset) in dynamic estimation and 250% in static estimation, while achieving 6 × faster inference. We demonstrate real-time high-resolution marker-free tracking of surgical robots through stereo-differentiable rendering. Localisation accuracy performed on par with marker-based approaches and improved upon foundational baselines.
Despite effective surgical evacuation, chronic subdural hematoma (cSDH) recurrence rates remain high. Middle meningeal artery (MMA) embolization has emerged as a promising adjunct significantly reducing recurrence rates but adding procedural risk, logistical complexity, and cost. Thus, single-stage cSDH evacuation with direct surgical MMA occlusion through a single pterional/frontotemporal burr hole could offer a practical alternative. This study assesses the applicability of this approach on routine preoperative imaging and evaluates both neuronavigation-guided and landmark-based localization of the MMA bifurcation. In this single-center study, preoperative noncontrast cranial computed tomography scans of patients undergoing burr hole trepanation for cSDH were analyzed. We assessed osseous MMA anatomy, visibility, and dominance of the MMA bifurcation; its spatial relationship to the cSDH; and distances from 3 external craniometric landmarks [Stephanion, Bregma, and external auditory canal (EAC)-zygomatic root plane]. Twenty patients with 26 cSDHs were included. A distinct osseous groove indicating the MMA bifurcation was identifiable in all cases (100%). The bifurcation overlapped with the hematoma in 18/26 (75%) and projected onto the region of maximal thickness in 5/26 (21%). Mean craniocaudal and anteroposterior distances from the Stephanion to the bifurcation were 27.3 ± 12.3 mm and 8.8 ± 5.5 mm; from the Bregma 113.9 ± 18.2 mm and 16.1 ± 8.6 mm, respectively. In the sagittal plane, the mean perpendicular distance from the EAC-zygomatic line to the bifurcation was 52.4 ± 10.8 mm, and the mean distance from EAC to the MMA bifurcation along this line was 29.9 ± 10.8 mm. Anatomic localization of the MMA bifurcation using standard noncontrast cranial computed tomography and external craniometric landmarks is feasible. Furthermore, the bifurcation overlaps the hematoma in most patients. These findings support the technical plausibility of surgical MMA occlusion via a strategically placed pterional burr hole (or an additional burr hole for occlusion if no overlap) as a straightforward alternative to endovascular embolization in selected patients with cSDH.
According to the Bethesda System for Reporting Thyroid Cytopathology, surgery is recommended for Bethesda classes I-III thyroid nodules only in selected situations, such as large or growing tumors with compressive symptoms or clinical suspicion of malignancy. Clinical findings and cytopathologic evaluation are often considered together to reduce discrepancies between preoperative cytology and final pathology. This study aimed to evaluate surgical outcomes in Bethesda classes I-III nodules and to identify risk factors predictive of malignancy. In this retrospective review, we included patients who underwent thyroidectomy for thyroid nodules classified as Bethesda classes I-III based on preoperative US-guided fine-needle aspiration (FNA) between 2010 and 2020. We collected data including preoperative cytopathology and ultrasound findings to analyze the risk factors related to malignancy and to evaluate treatment outcomes. Among 192 patients, carcinoma was confirmed in 62 (32.3%). The malignancy rates for Bethesda classes I, II, and III were 23.5%, 20.4%, and 49.4%, respectively. The malignant histologic types included papillary thyroid carcinoma (PTC; n = 34, 54.8%) and follicular thyroid carcinoma (FTC; n = 23, 37.1%), while five cases (8.1%) showed coexisting histologic types, including multiple PTC variants or a combination of minimally invasive FTC and PTC. Bethesda class III showed a significantly higher incidence of malignancy than the other classes (p < 0.001). In a subgroup analysis of class III nodules, larger nodule size on ultrasonography and atypia with both nuclear and architectural features (AUS-N/A) were associated with malignancy (p = 0.045 and p = 0.028, respectively). In a multivariate analysis, AUS-N/A was an independent predictor of malignancy (odds ratio 13.275, 95% confidence interval 1.354-130.3, p = 0.026). Bethesda class III nodules showed a higher risk of malignancy. Surgical intervention should be considered, particularly when AUS-N/A is identified in Bethesda class III nodules. Even in cases where carcinoma was confirmed after surgery for Bethesda classes I, II, and III, the probability of recurrence was very low and the prognosis is favorable.
Cervical anastomotic leakage (AL) remains a major complication after esophagectomy. We investigated the clinical course of cervical AL after minimally invasive McKeown esophagectomy within the SAFER surgical system and identified predictors of delayed healing. This retrospective study included 517 consecutive patients who underwent minimally invasive McKeown esophagectomy with retrosternal reconstruction under SAFER between January 2023 and December 2025. Among them, 50 developed cervical AL. A posterior mediastinal comparator cohort of 37 patients with cervical AL was included for comparison of leak severity and healing outcomes. AL severity was assessed using ECCG and Clavien-Dindo classifications. Cox regression was used to identify predictors of time to closure. In SAFER group, cervical AL occurred in 50 of 517 patients (9.7%). Compared with the historical same-surgeon PM leakage cohort, SAFER related leaks showed a lower severity profile, with fewer advanced ECCG events and a less severe Clavien-Dindo distribution. All SAFER group patients with cervical AL achieved eventual healing, and the median time to closure was shorter in the SAFER group. Low postoperative day 1 serum albumin (< 35 g/L) independently predicted delayed healing. Patients with low albumin had longer healing time and longer postoperative hospitalization. Within the SAFER surgical system, cervical AL after minimally invasive McKeown esophagectomy was predominantly low grade, manageable, and ultimately healed in all affected patients. Postoperative day 1 serum albumin may help identify patients at risk of prolonged recovery.
Postoperative delirium in older surgical patients drives morbidity, mortality, and resource utilization, yet real-world implementation and impact of standardized screening within older adult-focused surgical programs remain undefined. Retrospective cohort study of ACS NSQIP (January-December 2024) including inpatients aged ≥75 years. Primary endpoints were postoperative delirium screening and screen positivity. Outcomes were compared between American College of Surgeons Geriatric Surgery Verification (GSV) and non-GSV hospitals, with stratification by hospital-level screening frequency. Secondary endpoints included length of stay (LOS), prolonged LOS (top quartile), and 30-day readmissions. Among 97,886 patients (mean age 81.7±5.3 years), 53.0% underwent delirium screening. Screening was higher at GSV hospitals (94.3% vs. 52.5%). Overall delirium screen positivity was 12.5% and did not differ between GSV and non-GSV hospitals (11.3% vs. 12.5%, p=0.25), with similar delirium risk per 100 patient-days. Among screened patients, GSV hospitals demonstrated shorter LOS and fewer prolonged LOS. Among patients with positive delirium screens, LOS, prolonged LOS, and 30-day readmissions were similar across hospital types. GSV hospitals achieve substantially higher delirium screening without increased detection rates, suggesting observed variation reflects screening practices rather than true incidence. Shorter LOS among screened patients at GSV hospitals indicates that structured geriatric perioperative care processes may improve efficiency and outcomes independent of delirium occurrence, whereas outcomes converge once delirium develops.
With the widespread use of low-dose computed tomography (LDCT), the detection rate of bilateral multiple pulmonary nodules (BMPNs) has increased significantly. Surgical treatment remains the main treatment for multiple pulmonary nodules (MPNs), and its therapeutic value for simultaneous BMPNs is becoming increasingly prominent. However, the safety and feasibility of synchronous bilateral surgery (SBS) remain underexplored. This study aimed to evaluate the perioperative outcomes and prognosis of patients who underwent SBS for multiple pulmonary nodules. We retrospectively analyzed the data from 108 patients who underwent synchronous bilateral resection for MPNs at Peking University Third Hospital between January 2015 and December 2025. Clinical, pathological, and perioperative data were collected. Postoperative complications were classified using the Clavien-Dindo system. Risk factors for postoperative complications were identified using a logistic regression analysis. Overall survival was estimated using the Kaplan-Meier method. Among the 108 patients, 62.0% were female, and 79.6% were nonsmokers. The most common surgical combination was wedge resection combined with wedge resection (44.4%). The mean postoperative hospital stay was 6.55 ± 3.03 days. The most common complications were constipation (53.7%) and sleep disorders (51.9%), while severe complications occurred in fewer than 5% of the patients. No 30-day mortality or unplanned secondary surgery was observed. Prolonged chest tube drainage (> 3 days) was identified as an independent risk factor for grade ≥ 2 complications (p < 0.05). The 5-year overall survival rate was 92.3%. SBS for MPNs is safe and feasible in selected patients, with acceptable perioperative outcomes and favorable survival.
Coronary angiography remains the principal imaging modality guiding coronary revascularization, but it provides only an anatomic representation of disease and does not reliably identify lesion-specific ischemia. This review summarizes contemporary evidence on coronary physiology and intravascular imaging in percutaneous and surgical revascularization. Physiology-guided percutaneous coronary intervention (PCI) improves clinical outcomes by refining lesion selection and supporting safe deferral of nonflow-limiting stenoses. Fractional flow reserve and instantaneous wave-free ratio are supported by long-term randomized data, while angiography-derived quantitative flow ratio has shown favorable outcomes compared with angiography-guided PCI, although equivalence to pressure-wire-based strategies remains unsettled. In parallel, intravascular ultrasound and optical coherence tomography enhance procedural optimization by improving stent sizing, expansion, and detection of mechanical complications, with the strongest benefit observed in anatomically complex lesions. Postprocedural physiologic testing frequently reveals residual ischemia despite acceptable angiographic results. In coronary bypass surgery, physiologic assessment may refine target selection and clarify mechanisms of competitive flow, and postoperative quantitative flow ratio has been explored in assessing functional completeness; however, consistent improvement in clinical outcomes has not been demonstrated. Current evidence strongly supports integration of coronary physiology and intravascular imaging in PCI, whereas their role in coronary artery bypass grafting remains investigational.
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Chronic subdural hematoma (cSDH) is a common and growing neurosurgical condition, particularly in the elderly, with high recurrence rates following conventional surgical evacuation. Traditional management strategies primarily address mass effect through drainage but fail to target the underlying pathophysiological mechanisms responsible for hematoma persistence and recurrence. Increasing insights into the role of inflammation, angiogenesis, and fragile neovascular membranes supplied by the middle meningeal artery (MMA) have led to the development of MMA embolization as a targeted therapeutic approach. Over the past decade, MMA embolization has evolved from an experimental salvage technique to an evidence-based intervention. Early observational studies and meta-analyses demonstrated marked reductions in cSDH recurrence and reoperation rates compared with standard surgical management. More recently, large randomized controlled trials have provided consistent, high-level evidence confirming that MMA embolization, particularly as a surgical adjunct, lowers rates of hematoma recurrence, treatment failure, and serious adverse events. Consequently, contemporary consensus guidelines released in 2025 endorse MMA embolization as a class I recommended adjunct therapy for selected patients with nonemergent cSDH. Beyond its adjunctive role, MMA embolization is increasingly being explored as a standalone treatment option. This minimally invasive strategy holds particular promise for frail, elderly patients or those with significant comorbidities who are at high risk for surgical complications. Ongoing trials are aimed at refining patient selection, optimal intervention timing, and embolic techniques. In summary, current evidence supports a paradigm shift in cSDH management toward a pathophysiology-driven, preventive, and increasingly endovascular treatment model. KEY POINTS: Question Does middle meningeal artery (MMA) embolization represent a paradigm shift in chronic subdural hematoma (cSDH) management? Findings Randomized trials show MMA embolization, as a surgical adjunct, reduces recurrence and treatment failure in cSDH, earning a Class I guideline recommendation. Clinical relevance MMA embolization shifts cSDH management from reactive surgical drainage to a proactive strategy targeting the pathologic neomembranes. This pathophysiology-based approach prevents hematoma recurrence, improving long-term outcomes and establishing a new treatment paradigm.
Immune checkpoint inhibitor-based combination therapies have increased the likelihood that a subset of patients with initially unresectable hepatocellular carcinoma (HCC) may achieve sufficient tumor regression to become technically resectable However, when resectability emerges systemic therapy, the optimal next step remains uncertain. Surgical resection may eradicate residual macroscopic disease, whereas continued systemic therapy may help maintain control of occult micrometastatic disease. In this review, we summarize the available evidence on surgical consolidation after conversion and propose a conceptual response-guided consolidation framework to support post-conversion decision-making. The current evidence base remains dominated by retrospective comparative studies, although early randomized data have recently emerged in selected populations. Overall, surgical consolidation appears feasible and may improve progression-related outcomes in carefully selected responders, but definitive survival benefit across all response categories remains unproven. Within the proposed framework, partial response appears to represent the most consistent clinical scenario supporting surgery, stable disease should be interpreted as a heterogeneous category requiring further biological and radiographic discrimination, and complete response remains the most uncertain setting in which surgery may not always be necessary. Beyond radiographic response alone, pathological response and biomarker-based predictive enrichment may help refine future selection strategies. We therefore suggest that post-conversion resectability should be viewed not simply as a technical surgical endpoint, but as a therapeutic decision point requiring multidisciplinary assessment of anatomical feasibility, response depth and durability, hepatic reserve, and biological risk. This proposed framework is intended as a practical interim model rather than an established clinical standard and requires prospective validation.
To evaluate safety and clinical course in pregnant idiopathic subglottic stenosis (iSGS) patients and to identify variables associated with operative dilation requirement during pregnancy. Pregnancy in patients with iSGS presents management challenges that may impact maternal and fetal health. Clinical studies and shared experiences are limited. A retrospective chart review was conducted evaluating pregnant iSGS patients and an age-matched never pregnant iSGS control group. Pregnant patients were subcategorized based on whether they required surgery during pregnancy. The analyzed variables included demographics, inter-dilation intervals, time to first recurrence, intraoperative stenosis percent, and fetal and maternal safety. Thirty-three patients were included, 23 in the pregnancy group, and 10 in the control group. Thirteen patients required operative intervention during pregnancy. The mean age at iSGS diagnosis was 31.1 years. All pregnancies resulted in live births. No surgical or anesthesia-related complications were reported. Antinuclear antibody (ANA) positivity was more frequent in the surgical-intervention group compared to the nonintervention group (5/10 vs. 0, p < 0.05). The overall inter-dilation interval was longer in the pregnancy group compared to the control group (median: 70.9 vs. 39.6 weeks, p < 0.05) Average stenosis percentages in surgical dilations during and prior to pregnancy were comparable (60.4 ± 21.6 vs. 55.2 ± 27.8). Surgical management of iSGS patients is safe during pregnancy. Greater than 50% patients experienced exacerbation during pregnancy that required operative intervention. The only notable patient-specific factor associated with dilation during pregnancy was ANA positivity. There were no pregnancy-specific factors associated with the need for intervention.
Diagnosis-related group (DRG)-based prospective payment is intended to improve efficiency and control healthcare costs, but its impact on high-complexity surgical services remains uncertain. Thoracic surgery, characterized by a high proportion of complex procedures, provides a useful setting to examine how clinical structure and operational performance evolve under DRG constraints. A retrospective longitudinal study was conducted using DRG data from 2023 to 2025 in a tertiary hospital. Indicators included surgical volume, case-mix index (CMI), length of stay (LOS), and resource consumption indices. Interdepartmental comparisons were performed within the homogeneous DRG group EB19, and structural differences across DRG groups were evaluated. All analyses were conducted for descriptive and exploratory purposes. EB19 accounted for 26.1% of thoracic admissions and showed a high DRG-specific CMI (4.02). Surgical volume increased in two units over the study period, while overall case complexity remained stable, indicating no apparent evidence of case-mix dilution at the aggregated level. Mean LOS declined across units, accompanied by reductions in resource consumption indices; for example, the cost consumption index in one unit decreased from 1.52 in 2023 to 0.97 in 2025. Within the EB19 group, substantial interdepartmental variation was observed despite identical DRG classification, with differences in LOS, cost, and financial performance across units. In addition, different DRG groups contributed differently to financial outcomes. The transition from RE16 (2023-2024) to RN16 and RN18 (2025) coincided with more homogeneous grouping and more interpretable performance patterns. The findings describe patterns of operational variation and convergence across units, suggesting the potential role of governance-related factors in shaping performance under DRG-based payment, with implications for understanding efficiency and care delivery in high-acuity surgical settings. Given the descriptive nature of the study and the absence of patient-level clinical outcomes, the findings should be interpreted with appropriate caution.
Dorsal augmentation rhinoplasty is a technically demanding procedure that requires careful selection of grafting materials and techniques to achieve durable and aesthetically pleasing results. This review summarizes contemporary approaches to dorsal augmentation rhinoplasty, emphasizing material selection, surgical indications, and evolving techniques. Autologous grafts (septal, auricular, and costal cartilage) are widely used due to their lack of immunogenicity and relatively low rates of infection and extrusion. Diced cartilage techniques have gained recent popularity due to their flexibility and smooth dorsal contouring. Alloplastic and allogeneic materials can be carefully considered in specific patient populations who accept their associated risks. Injection filler rhinoplasty may be considered for patients seeking a lower-cost, temporary option for nasal augmentation with minimal downtime. A comprehensive understanding of the spectrum of surgical techniques for dorsal augmentation rhinoplasty is essential for individualized surgical planning. Familiarity with the indications, strengths, and limitations of each approach will enable surgeons to optimize outcomes in dorsal augmentation rhinoplasty.
Obstructive sleep apnea syndrome (OSAS) is a potentially life-threatening condition that is increasingly prevalent in developed countries. OSAS treatment involves multiple components, including general lifestyle modifications and specific interventions such as intraoral fixation devices and continuous positive airway pressure (CPAP). Surgical treatments, including correction of nasopharyngeal and oropharyngeal structures, orthognathic operations, and bariatric surgery, are used under strict indications. Until recently, pharmacological management was limited to nasal decongestants for rhinitis exacerbation and modafinil for daytime sleepiness. However, low compliance with non-surgical therapies and limited efficacy of some surgical procedures highlight the need for effective drug treatments for OSAS. Despite decades of research, a highly effective pharmacological therapy was not available until the past 6-7 years, when new agents and their combinations were evaluated. Randomization by OSAS endotype is now recognized as crucial in clinical studies. This review summarizes recent advances in OSAS drug therapy, primarily based on randomized clinical trials, with a focus on agents such as semaglutide, tirzepatide, atomoxetine-oxybutynin, solriamfetol, sultiame, and acetazolamide, as well as established drugs. Further research with long-term follow-up and consideration of OSAS endotypes and drug side effects is needed. The importance of combining different therapeutic approaches for OSAS is emphasized. Синдром обструктивного апноэ сна (СОАС) является потенциально жизнеугрожающим явлением, стремительно распространяющимся в популяциях развитых стран. Лечение СОАС включает несколько компонентов, начиная от общих мер улучшения образа жизни и заканчивая специфическими методами лечения синдрома. К таким методам относятся применение внутриротовых фиксирующих устройств, терапия повышенным давлением в верхних дыхательных путях (СИПАП). По строгим показаниям прибегают и к хирургическим методам лечения: коррекции структур носо- и ротоглотки, ортогнатическим операциям, бариатрической хирургии. Применение лекарственных средств, облегчающих клиническую картину СОАС, до недавнего времени было ограничено назальными деконгестантами с целью улучшения носового дыхания при обострении ринита и модафинилом для борьбы с дневной сонливостью. Однако недостаточно высокая комплаентность к консервативным методам лечения и недостаточная эффективность ряда хирургических пособий ставят вопрос о разработке действенного медикаментозного лечения обструктивного нарушения дыхания во сне. Несмотря на полувековой поиск фармакотерапии СОАС, высокоэффективный препарат для облегчения его симптомов долгое время так и не был найден. Прорыв произошел в последние 6—7 лет, когда для лечения синдрома были опробованы недавно синтезированные препараты и их комбинации. Большое значение в современных исследованиях играет рандомизация пациентов с учетом эндотипа СОАС. В настоящем обзоре отражены последние достижения медикаментозной терапии СОАС преимущественно на основе рандомизированных клинических исследований. Основное внимание уделено наиболее эффективным средствам, таким как: семаглутид, тирзепатид, атомоксетин-оксибутинин, солриамфетол, сультиам, ацетазоламид; а также приводятся данные по результатам применения более старых и известных лекарственных средств, используемых при лечении СОАС. Отмечено, что дальнейшие исследования следует проводить с учетом эндотипов СОАС, с длительным катамнестическим наблюдением и учетом побочных эффектов препаратов. Подчеркивается важная роль сочетания различных методов лечения СОАС.
Hand surgery is a multidisciplinary field involving surgical and rehabilitation disciplines. Although clinical care often requires collaboration between specialties, the academic structure of hand surgery research and the relative contributions of different disciplines remain incompletely characterized. We studied specialty representation and patterns of interdisciplinary collaboration in hand surgery literature over four decades. A cross-sectional bibliometric analysis was done on publications indexed in PubMed from six dedicated hand surgery journals between 1980 and 2025. Bibliographic metadata were retrieved through automated database queries and author affiliations were analysed using computational text pattern matching to classify specialties represented in each publication. Specialty representation and interdisciplinary collaboration were assessed across the decades. A total of 22,021 publications were identified, of which 18,229 contained analysable affiliation data. Orthopaedic surgery represented the most frequent specialty involvement, followed by hand surgery units and plastic surgery. Plastic surgery maintained a relatively stable proportion across the decades despite reports of declining participation in hand surgery training. Interdisciplinary collaboration increased substantially over time, with a fivefold increase in multi-specialty publications across the decades. Hand therapy was the most frequent non-surgical collaborator and surgeon-hand therapist publications increased progressively over the study period. Hand surgery research has evolved toward greater interdisciplinary collaboration. Orthopaedic surgery remains the most represented specialty, while plastic surgery maintains a stable academic contribution. These findings support the concept of hand surgery as a shared academic domain in which collaboration between surgical and rehabilitation disciplines may drive future innovation and improvements in patient outcomes.
Laparoscopic ultrasound (LUS), performed with an endoscopic ultrasound probe, has shown potential in addressing challenges related to haptic perception and lesion detection in minimally invasive surgery. The aim of the present study was to evaluate the learning curve of gynecologic surgery fellows in achieving competency in LUS image acquisition during minimally invasive procedures. This prospective single-center study included six gynecologic fellows with limited ultrasound experience who completed a one-day structured training program. Fellows performed laparoscopic ultrasound during elective surgeries for benign conditions and early-stage gynecologic cancers, assessing five anatomical sites. Competency was evaluated using learning curve cumulative summation (LC-CUSUM) analysis based on image quality and examination time. Learning curve time and quality score for each surgeon and anatomical site were measured. A total of 56 patients and examinations were analyzed. All fellows achieved competency within 2-5 procedures, with LC-CUSUM showing rapid and sustained skill acquisition. Ovarian imaging required fewer attempts than myometrial wall and iliac vessel imaging, with the right external iliac vessels being the most challenging. Patient characteristics did not differ among fellows. After targeted training, gynecologic surgery fellows can achieve proficiency in LUS within a short learning curve. These findings support the feasibility of integrating LUS training into gynecologic surgical education and highlight its potential to enhance surgical precision and to reduce surgical overall time.
To evaluate management strategies and outcomes of decompressive craniectomy (DC) in pregnant women with severe traumatic brain injury (TBI), specifically addressing the clinical dilemma of surgical timing and the 'simultaneous procedure' paradigm in the viable fetus. A systematic review was conducted following PRISMA guidelines and registered with PROSPERO (CRD420251041759). Five major electronic databases were searched through 2025 for studies reporting DC outcomes in pregnancy. Data were stratified into pre-viable (<24 weeks) and viable (>24 weeks) cohorts to analyze trimester-specific management. Maternal functional recovery was assessed using the Glasgow Outcome Scale (GOS). Thirteen cases (mean age 25.2 years; all from motor vehicle accidents) were identified. Maternal survival was achieved in 9 of 13 patients. Among survivors, 6 of 9 achieved complete functional independence (GOS 5), while 3 of 9 remained severely disabled. For the viable cohort (n = 8), a simultaneous paradigm-performing cesarean delivery and DC in a single surgical sitting-was utilized in 6 of 8 cases. This simultaneous approach resulted in live births for all 8 neonates within the viable group. Total fetal/neonatal mortality was 2 of 13 cases, occurring exclusively in the pre-viable trimesters. Notably, intracranial pressure (ICP) monitoring was implemented in only 2 of 13 cases, identifying a significant gap in pregnancy-specific neuromonitoring. DC appears to be a beneficial intervention for gravid TBI, based on limited evidence showing favorable maternal survival and functional recovery. In the presence of a viable fetus, the high neonatal survival rate suggests that a 'simultaneous' surgical approach may be considered as the preferred management strategy in selected cases. This review advocates for the transition from reactive, case-by-case management to a prescriptive, multidisciplinary 'Neuro-Obstetric Trauma' protocol.