IPEG 2021 - SS2 Advance Technology: Anorectal I

Next, we're going to kick off our next scientific session, uh, Advanced Technologies and Anorectal One. We've got um uh 3 discussants on for this session, um, uh, Marcela Baez, Oliver Munster, and Atul Savawal. So, um, I think we're right on schedule here and we should plan on going right into the next session. So let's do that. Thank you very much. Uh, we'll do our best to keep things going on session, on time, uh, in the session which is Advanced technologies and anorectal one. First paper, Doctor Maura is going to tell us about a multi-quadrant robotic surgery through a single hidden incision. Doctor Maura. Technological advances have introduced a new robotic platform which allows surgeons the ability to operate in multiple quadrants. Utilizing the da Vinci XI platform, we were able to perform a left ovarian cystectomy and cholecystectomy through a single incision. The patient being presented as a 114 year old female who initially presented with abdominal pain. Following her workup, she was diagnosed with gallstone pancreatitis. The patient also exhibited respiratory symptoms and was found to be COVID-19 positive. Given her respiratory symptoms, she was treated conservatively and scheduled for an elective resection. A CT scan of the abdomen and pelvis performed during her workup also demonstrated an incidental left adnexal mass measuring 3.6 by 3.9 in its greatest dimensions and most consistent with a dermoid cyst. The decision was made to proceed with resection of the mass at the timing of her cholecystectomy. A single 2.5 centimeter trans umbilical incision was created to accommodate a da Vinci five lemon port. On evaluation of the adnexal structures, a left ovarian mass was noted, most consistent with a dermoid cyst. Using the hook cautery, the ovarian cortex was incised with careful attention paid to not enter the cyst. The ovarian cortex was then gently grasped, and the underlying cyst was dissected away from the cortex using traction and counter traction. After the cyst was fully removed, hemostasis was achieved. A 10 millimeter endocach bag was then placed through the assist port. Once the specimen was secure, the robot was undocked. And the specimen was extracted. The robot was then redocked with the right upper quadrant as a new target region. The single side approach provided the advantage of easier surgical planning and allowed for easy triangulation when transitioning from the pelvic to the right upper quadrant dissection. The right upper quadrant dissection was carried out with the hook cautery to obtain the critical view of safety. The cystic duct and the cystic artery were then clipped and divided without difficulty. The gallbladder was then dissected off the gallbladder fossa using the hook cautery. At the completion, the robot was undocked and the specimen extracted. The patient tolerated this procedure well without any complications, and she was discharged home from PACU. The use of single site surgery coupled with a new XI robot platform provided the advantage of easier surgical planning and allowed for this combined case to be performed with ease. This approach can be utilized for other combined procedures in the correct surgical setting and the appropriate patient. Thank you very much, Doctor Maura. Uh, beautiful video. I'd like to congratulate you and your team on that. Uh, just one quick question. Uh, we've, uh, a couple of folk have mentioned about robots and techniques and so forth. Uh, I won't call myself old or a dinosaur, I'll call myself a traditionalist. Let's say I'm doing this through a 5 millimeter incision, uh, near the umbilicus and 3, maybe 4 other ports. What would you say is the one biggest advantage of your technique? I enjoyed your video, I enjoyed the technique. Tell me one advantage I can, you can tell me to sell this technique. I think that the best approach to it is that ergonomically it actually gives you feasibility to both the right upper quadrant as well as the pelvis. I think if you're starting with multi-port for a laparoscopic cholecystectomy, then trying to adjust those ports to give you feasibility in ergonomics to the pelvis is a little bit more difficult. So I think surgical planning would be a lot more feasible with a single site and a lot easier for those also in training to. Um, perform the dissection. Thank you very much. We've got time for one more question or comment? And he was like, yeah, we have a hand up there. Dan, I think you're muted. I don't have a, I don't have a question. I have a, yeah, I have a question, but I have a question for the entire group, and maybe people could just use the reactions tab to raise your hand, um, and I'm asking this question because I don't have what I'm about to ask. What, how many people on this call actually have access to a da Vinci? On a routine basis. So it looks like maybe 1/3. Cause it's something we struggle with in pediatric surgery is when do we go, move forward with robotic surgery as an institution because we need a certain amount of volume to make it worthwhile. So, it's interesting, it's, it's inevitable it will happen, um, but it's clearly not entirely mainstream yet in pediatric surgery. So congratulations on, on bringing another opportunity for us to experience it. I, I have a comment also. Congrats. I, I think the same, but I think I don't want to be a dinosaur, the same as thought. I have that thought and I think this is going to evolve and everything will be like that, and I'm coming for not a rich country, so we need to push forward with innovation. So I congrats. My only question is, why not keeping both together to go in only one structure in one bag. Were you afraid of losing the, the ovary, for example, the, the dermoid? We were, um, that was one of the concerns was that it was a dermoid and in efforts to avoid losing the specimen and potentially causing injury to it and having spillage, we opted that the safest thing to do was to remove it. And if they performed the gallbladder first, I think that leaving it on top of the liver would have given us that possibility. And the other The other question is, uh, is there a possibility to use bipolar in the ovary with robotics because There is, um, we just opted that the hook actually gave us a little bit more feasibility to actually lift up the cortex to excise and actually get into it, um, but we did discuss multiple different options on how to actually incise that. Uh, this is good for pediatric surgeons who can still do liver and gynecology together. So this is something interesting. Thank you for the present. We've got time for one more, I'm afraid, and Mark Mikowski, you had your hand up first. I'm sorry. OK, thank you, thank you very much. Um, nice job, Carmen, and you know, just to follow up on Dan's comment, uh, with regards to accessibility, you know, right now in the US anyway. Um, there are a little over 30 free-standing children's hospitals that have, uh, a, a robot, uh, you know, within their system, but I think it's also important, and, and, and this was, uh, talked about a little bit in the, in, in the last session, um, you know, I think it's also important to realize that many of us, uh, uh, are, are, um, uh, conducting pediatric surgery within the confines of an adult institution. And many, many more adult institutions have robotic technology, um, and, you know, uh, a lot of times it's, um, it's, uh, you know, hidden in plain sight. So I, I do think, again, as was touched on in the last session, you know, if you're interested in robotic technology, um, it, it is worthwhile, uh, looking around to seeing what your institution, you know, what your greater institution, especially if you're closely linked with an adult facility, has to offer. Thank you very much. So, I don't, it's not a comment on the paper. I just want to say one quick thing before Carmen leaves. I wanna make a special note about Carmen. I think everyone here needs to know what happened this year. Um, one of the best assets IPEC offers this year are the surgical technique videos that are spectacular. Uh, George Ozzie and Dafi Davies started this project. Karen and Carmen, uh, grew a 600%, uh, increase in the number of videos. You're all gonna have access to these videos. Thank Carmen. She did incredible work for IPEG this year. We're all going to be benefiting from it. Thank you very much for that, Dodd. Thank you. OK, just a, a quick before we move on to the next paper, you do have the facility, of course, to ask questions as most of you know in the chat functions. If you want to direct them directly to the presenters, they can answer them for you, uh, during subsequent presentations just so we don't miss any good questions. OK, moving on to Doctor Ott who's going to tell us about transanal use of fluorescent urethral stent fibers for neonatal colorectal operations. Hello and thank you for the opportunity to present our work on transanal use of fluorescent ureteral stent fibers for neonatal colorectal operations. We have no disclosures. Near infrared technology is increasingly available in the modern pediatric OR. Recent advances allow instrumentation to be visualized, which has opened up a host of new potential applications. The SPY system by Stryker endoscopy includes 6 French iris ureteral stents that have become popular with adult colorectal surgeons. And neurologists, but no dedicated pediatric infrared hardware is currently available. These stents can be used in other orifices, clearly, but are too large for neonatal applications and are not sufficiently flexible to navigate turns of intestine or rectum. We report an innovative application of these stents by removing the 0.75 millimeter fibers from the flexible sheath and deploying them across intestinal orifices to illuminate the rectum in two neonatal operations. The picture on the left shows fiber removal from the stent. The picture on the right shows one of the fibers highlighted with the red arrow. The first patient was a 4 month old female undergoing re-resection of a sacrococcygeal teratoma due to incomplete resection at birth. In prone jackknife position, the reoperative tissue planes inferior to the coccyx were difficult to dissect. To better delineate the rectum, insertion of an infraredureteral stent was attempted. However, the stent was too stiff to easily traverse the distal rectum. Thus, the inner fibers were removed from the two stents, taped together, and easily advanced per anus well into the rectum. Using the open field camera as seen in the figure, additional tissue outside of the rectal cirrhosa was identified and resected, facilitating a more complete dissection. The second patient was a 6-week-old male with an anal rectal malformation comprising imperforate anus with a prostatic rectal urethral fistula. Cystoscopy confirmed a fistula from the prostatic urethra to the rectum. The working channel of the scope and the fistula itself were too small to accommodate the full ureteral stent. Therefore, the infrared fibers were removed and passed through the fistula easily under visualization. The fistula was clearly identified at laparoscopy, as can be seen in the figure on the left, informing appropriate dissection margins. The infant was turned prone for posterior sagittal anal rectoplasty, and the open field camera additionally located the fistula, expediting safe ligation without injury. To the prostate or urethra. Fluorescence guided surgery is an innovative new technique that can aid pediatric surgical care. The development of near infrared instruments such as lighted ureteral stents represents an exciting advance that does not rely on endocyanin green. These novel uses of the urethrost components may trigger additional commercial development and will need to be assessed on a larger scale to determine ideal applications as well as limitations. Thank you again and I welcome any questions or comments. Thank you very much, Doctor Odd. OK, before I ask anything, uh, I'll open this to the floor. Um, I see one hand up. Eduardo, is that for this paper, is that a legacy hand from the previous one you have? No, nothing there. Anybody from the floor? It looks, it looks like there's um a question in the chat, uh, from Ben Padilla asking about if anybody's tried to use a similar technique for an H-type fistula. Um, yeah, that's actually something we have discussed and are looking for a patient to try. It's a very interesting application for this, uh, use with the, uh, near infrared stents and removing the stent and just using the fibers, um, so we're excited to do that very soon. Great question. OK. Todd, I'm sorry, did I see your hand up, or was that going to be your question? It's OK. No, but it's OK. OK. It was a great, that was just very innovative, just very, very cool. I will say for anybody looking to do this, uh, uh, using it through the, using the near infrared fibers through the rectum, uh, you have to be a little bit careful, uh, getting them around the folds of the rectum, but you just accomplish that by twisting the fibers. They're pretty pliable and so they easily go around. That, that was the reason why we had to remove the stents in the first place. The stents are too stiff. OK, great. uh Oliver. You're muted, Oliver. Yeah, are you afraid that maybe if you don't put them or use them inside the stents that the fibers could break and, uh, you know, be dispersed in the body? So that's a concern in both these applications using them in the rectum, we were less concerned just because we were so distal that if it did break, it would just come out the rectum, um, but definitely as we look at future applications, you know, obviously in the esophagus and things, you'd worry about that a little bit more. So you'd want to do it under visualization. Have you manipulated? I mean, do they break? Do the fibers eventually break? It'd be pretty hard to break it. You'd have to use quite a bit of force. Um, yeah, we've manipulated them quite a bit in the OR, um, and, you know, talked with Stryker about their break, and so far it doesn't seem like they're very easily to break. OK. Uh, Matt, do you have your hand up as well? Yeah, I guess my question is, uh, maybe it's a simple or strange question, but do these heat up? Because if they're using infrared, I mean, do you worry about temperature injury to the structure that you're going through? No, they're not warm at all. Thank you. So, uh, designed to be in the ureter. So you know, when you think about that, in the ureter, if there was any kind of heat that would cause significant damage to the ureter. So, um, there is no heat that's associated with it. Great, thank you. OK, we'll, we'll move on to the next, uh, paper in that case. Uh, Doctor Murray Pina can tell us about image guided pediatric surgery using Hindocyanin green fluorescence in laparoscopic and robotic surgery. Good morning. I'm talking about image guided pediatric surgery using endosaline inflorescence in laparoscopic and robotic surgery. I have nothing to disclose. ICD guided near infrared fluorescence has been recently adopted in pediatric minimally invasive surgery. This study aims to report our experience with the ICG guided near infrared fluorescence in pediatric laparoscopy and robotics and to evaluate its usefulness and technique of application. In different pediatric pathology, just some pieces of chemistry, ICG is a water-soluble organic canyon. The radiation from the light source is fated by the filter. The blood and the ICG suspension under the tissue absorb the excitation wavelengths and neat inflorescent bands. Which are the advantages. Better identification of surgical anatomy. The SCG dye is very cheap, easily available, and the procedure is not time-consuming since it requires only a preoperative intravenous ICG injection, and fluorescent images of the interest organs are obtained in real time at any point during surgery. The procedure is safe and the only contraindication is. Patients who have a history of allergy. Um, we need, uh, a special camera system and the laparoscope and obviously the product, the RCD. In case of robotic surgery, the robotic da Vinci Xcise system has an integrated RCG fluorescence technology, and, uh, we need a special camera with a special filter uh for optimal detection of near infrafluorescence. As for our study, ICG technology was adopted in 76 laparoscopic and or robotic procedure accomplished in a single division of pediatric surgery over a 24 month period. The ICG solution was administered into peripheral vein in all indications except for varicocele and lymphoma in. Which was respectively injected into the testis body um or the target organ. Regarding the timing of the administration, the ICG solution was administered inoperatively in all indications except for a cholecystectomy in which the ICG injection was performed 1518, 8 hours. Hours before surgery. As for our results, no conventions to open or laparoscopy occurred, no allergic reaction to IG, no postoperative complications. As for vari cholesterectomy, we recorded no persistence and or recurrence of disease or testicular atrophy or. As for partial nephrectomy, ICD was injected after the division of the geota fascia and allowed to visualize the vascularization of the kidney within 5 minutes. As for the Renna's cyst, uh, ICD allowed to clearly distinguish the non-vascular. from the vascularized renal pharynx. As for the cholecystectomy, I is very useful to identify and to visualize the gallbladder and the biliary structures, including the cystic duct and the common bile duct. In conclusion, we can say that ICD guided near infrared fluorescence is a very useful tool in minimally invasive surgery to perform a true immediate guided surgery, allowing an easy identification of an atomic structure, especially in difficult cases. ICD and acid fluorescence was technically easy to apply and safe for the patient. Reported no adverse reaction to the product. So the only limitation is represented by specific equipment needed to apply ICT guided near infrared fluorescence in laparoscopic procedure, while robotic Daminci XI system as an integrated um fluorescent system into the robotic platform. Thank you for your attention. Thank you very much, Doctor Mario Pao. Uh, lovely presentation there. Enjoyed that. Um, one quick question from me, you mentioned that apart from the Firefly system where the other equipment is already incorporated, if you don't have that, can you just give us a quick overview of what else you need except uh as well as obviously the ICG itself? Good evening. Um, for, uh, the, the technology, we need a special camera with a special filter and, uh, um, only the ICG product. So it's a, a very cheap, uh, um. It's a very technology can be used and if you don't have the robotic system, you can use the laparoscopic system, but you only need a special camera with a special filter, then we have bicar stored, so it's very cheap and easy to perform, and the only contraindication is the history of allergy, and that's all. OK, great. Uh, we've got a couple of comments or questions on the chat function. I'll just read the first one out to you. Have you tried paratesticular injection of ICG instead of into the testes? And if yes, how was the percentage of visualization of lymph vessels? No, we only use the technique of intrasticular injection in our series, but we can, we can check it. OK. Um, and next one, what's the, what is the maximum thickness of tissue that ICG can be visualized through? Um, actually, I don't know the exact thickness, but, uh, even in case of, uh, very thin, uh, um, uh, lymphatic vessels, we can, uh, see everything in, uh, during the ICG, uh, injection in a very, uh, it's very quickly, just, mm, 30 seconds, 1 minute. OK. We had a couple of comments about the thickness there, ranging from 10 to 15 millimeters, about 1 centimeter. OK, that's great. Um, If we have no other pressing questions, we'll move on to the next paper. Thank you. Yeah, and uh I have the pleasure of introducing our speaker. Her name is Hiba Alghul, and she is going to uh stay on the topic and report a systematic review of the intraoperative use of near infrared uh fluoroscopy uh spectroscopy in pediatric surgery. Uh, this is all, uh, just of note, this, uh, she's from the Islamic University of Gaza in Palestine. And uh this is a collaboration between uh her and uh the colleagues in Boston, in uh Buffalo, and in Nashville, Tennessee. Heba, thank you very much for coming. Hello. I have nothing to disclose. Near infrared spectroscopy or NIRS has been widely used in surgery for many years and still evolving. In this systematic review, we aim to summarize its interoperative applications in pediatric surgery. We searched PubMed, MPs, COPA, and group of science databases. We then evaluated the level of evidence based on the Oxford Center for Evidence-based Medicine tool, in which 1 is the highest and 5 is the lowest. We included all study designs but excluded any non-English studies, basic science or cadaveric studies, and finally, irrelevant uses of an IRA such as in cerebral perfusion or uses outside the OR. In this prisma flow chart, we screened 11,390 articles and finally included 53 articles. So the majority of included studies were case reports or case theories, and therefore, they were mainly level 4 of evidence. This table summarizes the uses across different systems, most commonly oncology and hematobiliary. So for oncology, the main use was to detect primary tumors such as hematolastoma and its metastasis to lung and peritoneum, also detecting tumors in adrenal glands and facilitating free marginal resection. In hebatobiliary, the main use was to visualize the biliary system, for example, in labli, thus preventing duct injury. In this image, hepatolastoma was not seen on the pre-op CT in Figure A, but it was seen in an IRS camera on Figure B. Figure C shows the tumor in gross morphology. Here we can see on the right, the use of an IRS and ICG during lab coli compared to without on the left side. So in neurology, it's used to assess perfusion in kidney transplant, to visualize vessels in varicosectomy, and also to diagnose callous leakage during tracheoesophageal fistula repair. Also, it can assess bowel viability to establish anastomatic site after resection. So the main advantages of NIRS is that overall, it has higher sensitivity in cancer detection compared to conventional imaging. However, it can still miss small and deeply localized cancerous tissues. A few studies show that NIRS has the potential to reduce operative time. However, its use can be limited in obese patients and those with severe cholecystitis. In summary, NARS is an exciting technology that augments surgery, mainly in cancer resection and hepatobiliary operations. Despite being a promising modality, more studies are needed to assess cost effectiveness and outcomes of an IRS augmented surgery. Thank you for your listening. Yeah, well, thank you so much. Are there any questions? So I have a question. Hey, but, when you looked at all the literature, um, did you all come across any problems associated with ICG and near infrared spectroscopy? I mean, any adverse effects, complications, um, you know, any allergies that might have occurred or anything like that? Thank you for your question. Actually, it's only like one reported complication. It's like a minimally or zero risk technology. The only complication was you should avoid using the ICG in people who have allergy to iodine because it's like composed of sodium iodide, so only that complication, it's the only reported complication actually. There is nothing else. Is that a theoretical risk, or is there actually a description of an anaphylactic reaction or something occurring? Actually, through my, uh, the research that I have done, I didn't find like actual cases. It's only like I think in the literature because I didn't find specific cases on that. Great. Are there any other questions? OK. Great. Well, thank you so much for, you know, that great analysis. Oh, here going, there's Novotny. My goal in doing this review was obviously to see what others have done, but also to stimulate ideas for how we can apply this new technology. I love the ideas already. Absolutely. Now, I think this, this has a lot of applications and, and, you know, I was always concerned that there was some downside of it, but I'm more reassured now that you said, you know, you looked at all the literature for us and, and haven't encountered any complications. Thanks so much. Thank you. This is, this is a great, uh, example of a collaborative, uh, study as well. This is the, the purpose of IPEG. So, congratulations on that, and I do believe that we're learning more and more about how ICG is gonna be incorporated into our practice. We're trying new things all the time, and I would say half of the time, it doesn't help, and half of the time it does. So just keep trying different things and see what works. I, I have a question. Um, congratulations on your work. I guess one of the things that, uh, kind of Um, Worry me when we apply these things for tumor resection is the risk of resecting something that you've seen there but not tumor, so false positive, basically. How you, how do you, you know, determine that and how do you build that into your practice so that you don't over resect the lesion that show up at the IGG but not tumor that can cause harm to the patient. So actually from the literature that we have seen, it's like the false positive report, it was like I think 10%, let's say, but for a tumor resection, the ICG can detect like for 0.06 millimeter of cancerous tissue, which is like only through pathology. They confirmed that so. I think it's pretty precise in resecting tumors, although I don't have enough experience in this, and maybe we need more in the literature and more research to give us such an idea or to give us an answer on this because, you know, NIRS and ICG is still evolving in pediatric surgery and we're still in the imperial stage for this technique in pediatrics. Great, thanks so much. And then uh we'll be leaving the field of ICG and near infrared fluoroscopy to go on to something very exciting, artificial intelligence. Everybody's talking about it, and Alejandra Casar will tell us about artificial intelligence for using it to, to diagnose um pyloric stenosis, which I find a great idea. Alexandra. Your podium. Hi everyone. This is Alex Cassar, and I'm here to talk about AI-driven automatic detection of pyloric stenosis and ultrasound images. We have nothing to disclose other than this project being funded by an IPEC research grant in 2019. Our proof of concept studies were very basic algorithms for detection of femur fractures and intracranial bleeds using IBM Watson. Our current work rests on the premises that pediatrics have specialty expertise is a limited resource, that AI algorithms are broadly used in general daily life and other sciences now, and that these resources are translatable. Extending our expertise with artificial intelligence has the potential to help it reach rural and global communities, improve care provided after hours, improve performance by alerting for findings and preventing misdiagnosis, and improve workflow by triaging reads or providing preliminary findings, hopefully translating to reduce costs, delays, unnecessary transfers, and burden on the healthcare system. We trained our model on the tasks of classification and segmentation. We elected to use machine learning methodology to include a human expertise factor in a manual feature extraction stage, as opposed to proceeding with the pure black box functions of deep learning. We utilized 120 ultrasound images with longitudinal views of the pylorus from a 1 to 1 mix of patients with pyloric stenosis and normal controls. I personally annotated these images by creating mask layers with the features displayed. Our biomedical informatics team then proceeded to augment our sample using generational adversarial networks and benchmark benchmark state of the art convolutional neural networks for the purposes of binary classification and segmentation, BGG 16 and UNET respectively. These algorithms are celebrated winners of global image recognition competitions in general and medical images with accuracies of 93 and 92% respectively. Model performance was then evaluated using Tversky loss, a measure of precision and recall and classification, and dice coefficient, a measure of overlap between the ground truth and the predicted segmentation. Our segmentation model achieved 85% pixel to pixel accuracy, and our classification model achieved 90% accuracy. This performer provides a great starting point for more complex blended models currently underway. This study is currently limited by a small sample size and the use of a single non-expert annotator. It also relies on very few iterations of training without independent customization of the model nodes. This is currently being addressed by an addition of more than 600 new ultrasound images and the introduction of a second expert annotator before proceeding with further customization of our combined models predicted to achieve accuracies greater than 95%. Very nice, very, very innovative. Uh, I have a, a question. I mean, I was, when I read it, I, I thought it was, it was fantastic doing this. I was a little bit, uh, uh, um, uh. Surprised that you used an ultrasound image as your basis, because it's so dependent on the person who performs the ultrasound. Why not, you know, focus on something that is on a CT scan, like a, you know, different types of intracranial hemorrhages, or, or liver lacerations, splenic laceration. Um, because, you know, it's, it's a CTM image that is always the same, and, you know, it depends, it's user dependent, uh, your ultrasound image is much more complex for the AI algorithm, isn't it? Uh, it is if we use the entire, uh, sort of group of images acquired during the ultrasound. Uh, for this case in particular, because it was our first round, we actually just used that longitudinal view, uh, and we intentionally use uh some poor quality images and some good quality images to try to minimize the operator bias, but ultimately, it's still, you know, a pediatric stand-alone children's hospital that you're going to have a certain level of expertise with it. Uh, we did not use CT because of the computational power required, uh, to run these analysis. Uh, I did all the annotations myself and the, uh, biomedical inform informatics team that was doing this was doing this just out of their pure kindness. We did not pay them. Uh, so the time it, it takes to train with large volume of, of images is not something that can be easily accomplished in the laptop that we purchased for. For this, it's something that requires, uh, at least leasing of some computational power, um, which increases not only the complexity of the algorithm, uh, but again, the time and the money that we wanted to start with something simpler and it was something that was very, first of all, very pediatric surgery specific. Uh, of interest to pediatric surgeons, uh, and something that ultimately if we had trouble with annotating this way, we actually had, uh, a measure of length and thickness that is sort of more globally accepted as a measure that we could fall back on, uh, as features for extraction. Uh, H and Baron had, uh, questions. How, yours first. Oh, sorry, that was the old uh hand raise. I have to put it down. And Baron, did you have a question? Yeah, uh, thank you for this nice study. Uh, what I wonder is, uh, what are the numbers for the training and the test groups? I mean, you have, uh, only 60 patients, I think, for positive and 60 patients for negative. So to get this accuracy, uh, what's the number in your test group? Because it's really important to say that, that much accuracy. So, what we did is in that part where we use uh generational adversarial networks, we actually expanded our sample size to approximately 600. So the way that the general uh generational adversarial networks work, it's not like the deep fakes you see on videos on TikTok and stuff like that when people's faces are replaced by Artists and stuff like that, the generational adversarial networks that we use, uh, create certain deformation in images that already exist by either rotating them or creating, uh, an angle in something. So they're still real images, but they add as, add to our sample size by counting, uh, in different positions, different ratios. Uh, that could mean just different perspectives of the same image. Uh, so we ended up using approximately 500 in the training and 100 in the testing derived from, uh, this 120 that we turned into 600. So, so you have a sense, so I, I, uh, Byron, maybe, uh, you guys can get in touch offline. Um, it's fascinating, so many images, and equally fascinating is the number of patients our next speaker will, uh, present, uh, 725, uh, 4 patients with lab-assisted endorectal pull through over a history of 16 years experience, and, uh, this is gonna be presented by Igor, uh, Puruor. Poduni from Moscow, Igor. Dear colleagues, we are pleased to present our team experience in the laparoscopic treatment of children with Houston's disease. Nothing to disclose. The laparoscopic approach to pediatric Histon's disease continues to advance. We present our experience in treatment of Histon disease in children using a modified laparoscopy assisted and directly pull through technique. The data of 724 patients having undergone laparoscopic procedures, primary and redo, for the established Hirschpong's disease during the 16-year period was retrospectively analyzed. Primary laparoscopic procedure was performed in 524 patients and has reduced surgery in 200 patients after previous surgery done elsewhere. Extensive gangliosis, including subtotal and total, was present in 21.2% patients in group one and 35.5% in group two. The operative technique in our modification entailed laparoscopic bowel dissection with ultra low rectal mobilization in the mesorectal plane and transcendal and rectal dissection synchronically performed by two surgeons whilst leaving a very short muscular cough. All procedures were completed with 0% conversion rate. Simultaneous operation by 2 surgeons has reduced the operation time by 50%. Intraoperative complications were encountered in 1.5% in Group two and none in Group one. The overall rate of post-operative complications, which required further surgical interventions, was 2.3% in both groups and was lower in group one than in group two. Functional long-term outcomes followed up in 300 patients were assessed as satisfactory considering continence and constipation in 86.4% of patients in group one and 70% in group two. Laparoscopic procedure in our modification is safe and effective for pediatric patients with various types of Houston disease, including extensive angliosis and redo operations. To achieve better patient outcomes, we recommend our technique be used in pediatric surgery centers specializing in colorectal disorders. Thank you. Thank you so much, Igor. I'm gonna um kick things off here with a question. You have an extensive experience of redo procedures. Were these all A ganglionic pull-throughs from the outside, um, you know, like, were there, was there still a substantial amount of a ganglionic bowel left, or were these stenosis or status post uh infections or some or other reasons for do a re-pull uh redo pull through. Uh, no, no, there are new procedures, the group consisted of two parts. Uh, the main, uh, the majority of cases were, uh, as we called it, the staged procedures. Uh, these patients were stomised before the laparoscopic procedure in our, in other clinics, and, uh, the number of these patients was 120. And 8080 patients were re-operated laparoscopically in our clinic after previously performed 1 or 2 or 10 procedures after uh uh their radical repair of Hirschton's disease. Uh, with, uh, uh, very, various techniques, uh, open, uh, and, uh, uh, uh, transcendal or laparoscopic, uh, so, uh, uh, 2/3 of the group of radio group were the patients, uh, who had stomas. Uh, the only procedure was, uh, stomising and uh correcting of the, uh, after, uh, stomising complications. I get it. So they were not, uh, redo pull-throughs. Yes, uh, about 880 patients were redople through. OK, I get it. Uh, Mar Marcella, you had a question. Yeah, thank you. I, I, I, for your experience, it's huge experience. I, I would like to ask you, I didn't get if you split the calf at the back or at any place or just leave a short calf, and this will be a nice discussion with the next paper, so we may. Answer now or after the next paper I can answer now. We do not split the cuff because we leave two or maximum 3 centimeters cuff, so it does not need any splitting to our in our experience. OK, so do you think if there are any other questions, Oliver, we continue with the last three papers. Yeah, there's one more question. It's how do you position the patient to expose the peritoneum for the second surgeon while not compromising the intraabdominal uh pneumoperitoneum. So, uh, I guess it's, it's about how do you get, uh, the, uh, pneumoperitoneum to last when you're doing the pull-through itself. Oh, really it's not a problem, uh, uh, because we start, uh, the procedure, the primary procedure we start simultaneously from the perineum and, uh, from the abdominal cavity, 3 trochars placed in, uh, uh, common places on the abdominal cavity, uh, so, uh, the, uh, legs do not, uh, uh, uh. Make real problems for laparoscopic dissection, maybe only mobilization of the splenic flexure sometimes, but it's not the problem, really, it's not the problem, but it makes the operating time. Very short. And especially if I have one minute, it is very useful when performing redo procedure, procedure after multiple surgery in in the pelvis because this simultaneous and controlled dissection from perineum and from the abdominal cavity, to my mind, it makes it more safely, safe because we can control their pelvic organs such as. Uters and so on, uh, better and we can dissect and resect all the scar tissues, uh, from the, uh, anal channel, uh, from the perineum and from the abdominal cavity, uh, from, from the peritoneal cavity, uh, just to what is, what will be, uh, I agree. I, I agree with that completely agree. I'm gonna pass on our, uh, the baton to, uh, my co-moderator Maria Marcella, and she's gonna, uh, moderate the last three papers. Hi, and thank you everybody because IPEC is innovation and also experience and long-term results for safety patients. So I, I, you know, I couldn't sleep when I got this session. I was studying and trying to understand all the innovative procedures. I was dreaming of this meeting today. So thank you every innovator and now I want to welcome Masahiro Takera from, who is presenting a collaborative study of three centers in Japan. And post-operative Hirschprun associated enterocolitis and a review of 153 pull-through patients treated over 30 years, so go. Thank you for allowing me to present our work today. The impetus for designing this study was apparent lower incidence of postoperatives associated enterolitis in overseas and lack of evidence for correlations between the sa grading scale and duration of symptoms, elevated inflammation in blood tests and management protocols. Post-bra shear spoon asciated anthrocrite episodes were retrospectively classified using the APSA grading scale. The duration of diarrhea, fever, elevated inflammation, antibiotic treatment, rectal irrigation, and fasting for each grade were investigated. This is the modified pursuit procedure we developed. The concept of complete resection of the posterior wall of the muscle cuff has remained unchanged for more than 30 years. In this study, 13 episodes of post-operative sperm asciated enterocolitis developed in 10 patients. Classified as Grade 14 cases, Grade 28 cases, and Grade 31 case. The patient with grade 3 had transitional segment called plow. The incidence of obstructive symptoms after pursue was 3.3%. The difference between the incidence of postoperative hillspun acid and enteral colitis with or without obstructive symptoms was statistically significant. Grades of hair sperm asciated enterocritis were not quite rid of any duration of symptoms or elevated inflammation in blood tests. Grades of his sperm acidated enterocritis were also not quite rated of duration of antibiotic administration, duration of rectal irrigation, and duration of fasting. The low incidence of severe shell spoon associated enterocritis in this series is a direct consequence of our modified pur procedures favorable effect on postoperative obstructive symptoms. Grades of hair sperm associated enterocolitis were not correlated with durations of symptoms or management. Algorithm, it does not classify patients based only on the findings at the time of initial diagnosis, but rather takes into account changes in symptoms over time could be more practical. Thank you. Wow. So, any questions, any comments before our comments? I, can we see the chat? Anyone is raising hands? Wow. Uh, I want to congratulate the group. I think it's a, uh, a 30 years experience and a, and a follow-up from 3 different universities. So, uh, I would like to agree. But we don't have that data, but we will do it, that enterocolitis is related a lot of times to some technical issues, and I think it's good to discuss this in this society. So we need to get out of the way of, of the causes of enterocolitis that, that are related to our technique, yes, and, and this group is talking about splitting the calf. And there might be another, another causes which is the huge prunes left on site. I mean, insufficient pull through. So I would like to bring this to discussion for the last two presenters because the last, the, the, the previous presenter was not splitting cash with 6.4% of obstructive symptoms. This group is completely split in half and I am saying that that might be the cause of a low incidence of obstructive symptoms. So open to the audience and to the other moderators. Maria, can I have a comment? Of course. I, I think, uh, I think in enough procedure. Can you hear me good? Yes, welcome. Yes, just, uh, uh. You know, I won't say they're cutting the remaining muscle calf is Not enough, we have to excise. The entire posterior rectal calf that is crucial to prevent postoperative enterocolitis. I think only dividing the muscle cuff is not good enough. I think leading to the postoperative enterocolitis, and if you leave. And without cutting the rectal muscle calf, even 2 centimeters, 1 centimeter, it is for me. Constriction is still remains post-operatively, and for me, it is, looks like a short ravine procedure. So I, I think at least. Half or 1/3 of posterreal cuff should be entirely. Excised to prevent postoperative complications. That's clear and that's the technique that they are presenting. Yes, it that's, I mean, JAMA techniques is published and they remove the complete calf, not only split. Thank you for the clearance. My pleasure. I, I think if you're going to talk about enterocolitis, you have to talk about incontinence too. Because if you do an aggressive operation to prevent enterocolitis, you will probably see an increase in incontinence. And the two, I think, are inversely related to each other. No, I don't think so. I'm sorry to say, if we dissect the from Anna's line, we don't see any incontinence. As you mentioned, if the dissection is too aggressive, I mean, starting from very low, it will cause postoperative incontinence. That's why you have to be very careful about starting point for dissecting the transanally. I agree. So what is your starting point? And the line. At the anorectal line, yeah, in the top of the line of the intention zone over the internal sphincter, yes, oh, I, I think she's asking how distance where you start, the dissection over the internal sphincter. So the concepts are we need to keep the internal sphincter, not to get incontinence in here, and the two groups are showing. Good results. One, leaving a shortcut, and the other one, splitting the whole line. But this is interesting because it's what we are getting after long-term results to improve our results. So, but I don't know which is the answer. But if you cut into a sphincter. Incontinence incontinence, so. Of the incision also crucial. Good. Any other comments or questions so we can follow? Is there anything in the chat? OK, so can we follow with the next paper which is telling us how to treat these problems with histrions. robotic swabca incision in a patient with obstructive symptoms after transanal endorectal pull-through by embry devices from each university. We present a 16-year-old girl who underwent a transanal and rectal pull-through in infancy for Hirprung's disease. She was re-operated 6 months ago because of an obstructive muscular cuff. The cuff was incised laparoscopically from the anterior side. Her obstructive symptoms had recurred, and a contrast enema study showed a recurrent obstruction due to the cough again. The robotic approach was favored this time. The positioning of the patient and the trocher sites could be seen here. The adhesions in the pelvis, due to former operations, were all cut using scissors and cautery. The uterus and the colon were identified, and the dissection was carried out in between, towards deeper structures. The muscular cuff was reached and dissected separately from the surrounding levator muscle fibers. The cup was started to be separated from the rectum inside it. The dissection was continued outside, between the cuff and the vagina. The 3D visualization and close-up views of the robotic approach was most useful at this part of the operation. The muscle fibers of the cuff and the rectum were separately identified and dissected without any damage to the rectum or surrounding organs. After dissecting from inside and outside, the cup could be seen as a separate thick layer now. Deciding enough dissection has been made, the excision of the cuff was started from the right side. Followed by the anterior part. And lastly, the left side. Here the finger of an assistant could be seen moving inside the rectum determining the rectal wall thickness and the distance from the anus. Anterior 270 degrees of the surrounding cuff was excised, whereas the posterior quarter of it was left in place. The lateral cut edges of the cuff were shown, and the rectum was resting free in between. The exciseolavikov could be seen here. The patient on follow-up is now continent and passes stool daily. Well, we are running out of time and we have little time for comments, any comments of this robotic dissection in the pelvis? Mario, I have a question for me, for Iyama. Is that OK? Yes. Yeah, what, what, what is it is a very nice video. What is a landmark to Dissecting uh the until where? That's the first question, and the second question, if the patient is a boy, do you still use uh removing the anterior cuff rather than removing the posterior rectal cuff? That was my question. Good. Thanks for your question. Could you hear me? Uh, first of all, uh, it's very hard to dissect from the posterior side in this patient. This patient has an operation, uh, about 15 years ago and other operations also. We, about 6 months ago, uh, we, we Uh, started to do, uh, the laparoscopic incision, but it's very hard from the anterior side and so we cannot dissect from the posterior side. It's very, uh, problematic. Uh, my first choice is to start from, uh, from the posterior side, as indeed, but it's really very hard, so, uh, I think that we excite from the lateral sides and a bit anterior side. Anterior side, I Couldn't go, uh, deeper a lot because there's a vagina, but from the lateral sides, uh, we excise most of the, uh, cough, um, from the line, uh, from the level, it's, I think that it's very hard to say something about it, and what I say, it's, it's, I assume that it's like here, but it's really very, um, probably, uh, some, uh, obstructions and some adhesions, so it's really hard. Uh, but for this patient, uh, maybe in the literature, you can see that, uh, you can do it from a transcanal, uh, excision or another procedure. This patient is 16 years old and the obstructive cuff is very high and it would be very hard, uh, to achieve to approximate from the transanal, so, uh, we prefer to do it from laparoscopy or robotic surgery. Well, we will need to go to the next. Some of the lessons learned is this is preventable, 16 year old, we should have a short calf, yes, so it might not happen. And good view of the robotic dissection Congress. So next, we need to go to the last one, which is, will be laparoscopic assisted anorectoplasty for intermediate type rectal vestibular fistula, a comparison study with modified anterior anorectoplasty by Sanyu. Friends, it's my great honor to give this presentation. Here is our work, laparoscopic assistant neatoplasty for IRVF, a comparison study with anterior sagittal neoplasty. All the authors have nothing to disclosure. Vestibular fistula is the most common type of arms in girls. The IRVF is characterized by its high rectal punch and long fistula tract. Currently, the Ministry for the correction of IRVF is conducted by the perineal approach. This study aimed to evaluate the safety and efficacy of leper in comparison with asper for patients with IRVF. This slide shows the demographic and clinical features of the two groups. 22 AMS patients with IRVF underwent leper. The outcomes were compared with 39 patients with IRVF who underwent SPER. As shown in T1, there was no significant differences between these two groups in terms of age associated anomalies or the post-operating hospital state, but the operating time in the leper group was significantly shorter than that in the expert group. As shown in table 2, most patients in the leper group recovered without complications. However, certain patients suffered from complications post-operative in as per group, including wound infection, rectal prolapse, recurrent fistula, and rectal rejection. Then we evaluate cosmetic results in the two groups. Cosmetic satisfaction was higher in the leper group. Developed retro prolapse was the most common cause of dissatisfaction. In conclusion, the leper technique is safe and effective with the advantage of lower risk of wound infection, recurrent fistula, and vaginal injury for IRVF patients to compare with asper. That's the end of my presentation and thanks for your attention. I'm sure there will be comments. We have very little time. We are 2 minutes late. Uh, I, I just have two questions. Are the same surgeons compared? Is, are the lab surgeons experts and the, the other ones, uh, trainees? And I think there is, even they have very good time, 60 and 80. Uh, in the presentation, it's, uh, it's not well done. I mean, the, the longest time is the lab and they conclude that it's the last time, so, I need, we need to change that. And so, what, why do you think you have so many complications with the anterior sarp? Those are my questions. I don't know if there are other questions. From the audience. Yes, uh, do you hear me? Uh, hello, everyone. Uh, let's see, uh, the two operations, uh, in 2 groups were actually were performed by 1 surgical team. So, in the modified anterior surgical and electroplastic, uh, the infection rate in our area is higher. Uh, including the vaginal, uh, uh, recurrence of the fistula and the, the wound infection. And also, uh, recently, we made the, uh, long-term, uh, uh, follow-up for, uh, for continents. Uh, the, for the continents, Uh, and the soiling is similar in both group. However, in that group, the constipation rate is significantly lower than anterior skeletal group. So we prefer to perform such a laparoscopic, uh, approach. Well, I don't know if we have time for discussion or because we, Marcella, I think we're a little late, so I think we should wrap things up and go on to the next session. OK, thank you, everyone. That was a fantastic, innovative session, and I'm looking forward to more of it.