IPEG 2021 - Innovations Session

Anyways, so our next session is the innovation session. Uh, it's gonna be moderated by uh Saleem Islam, uh, Leslie Nodd, and Bethany Slater. We have a lot of abstracts and uh looking forward to the discussion. All right, thanks very much, Samir. Welcome everyone to the innovation session and awesome job, Yuri Oshin Horasha. Um, all right, we'll jump right in here. The first presentation in the innovation session is entitled As an Artificial Intelligence Subtype Deep Learning Study for Differentiation and Image Recognition of Filled or Empty organ lumens, a study on a medical imaging in Children, presented by Doctor Baran Tokar from Turkey. Hey, colleagues, this is Baran Tokar. My presentation topic is deep learning study for differentiation and image recognition of field or empty organ limits. Nothing to disclose. Deep neural network is a multilayer computational system having a set of interconnected processing elements with auto-detective quality, and image recognition is one of the cognitive function of deep learning. How we may implement deep learning into the pediatric surgeon, we may use images of surgical cases, especially medical scans. In this study, theoretic rhinography was a deep learning model for image recognition of field or empty organ. Our aim was constructing a deep learning model to detect a luminal organ as an image, locate its anatomic position, and also understand whether the lumin is empty or filled with contrast agent. Pre-specified 1260 renal images of 36 patients have been annotated. In the first part of our study, uh, we try to detect the kidney and also differentiate the right and left kidney in the different rhinography phases. In the second part of our study, the image recognition and differentiation performance of the machine for field and empty RPC renal pelvis, and colleagues were tested in two groups. Convolutional neural network with supervised training was used. What we found in the first part of our study, the kidney was detected with a site ofuniation as left or right, with 96% precision. Here you see the pipeline of the kidney detection. In the second part of the study, we found that following the training, the test group with 160 images had 88% increase for group one for the field uh women and 66% for group two, for empty lumen. Uh, the study may suggest that deep learning algorithms may detect and define the site and location of luminal organ. According to what we learned from the first part of the study, annotation by experienced physicians and training with a good number of input images increases the accuracy. Our study also showed the epiponic model was successful in determining the lumen field with the radio labeled agent. But, uh, the weakness of our model was to determined an empty lumen. The accuracy was 66%. Uretic granography has a lower image quality compared to other medical scans, so we have difficulties in annotation of empty lumens with unclear boundaries and the poor detailed visibilities. For future studies for a better labeling, the patch-based annotation or automatic image annotation platforms may be used. As a last conclusion, we may state that deep learning models may improve the assessment of medical scans with a better image recognition, and artificial intelligence is still far from demonstrating very high accuracy in medicine, and diploic models for the real-world clinical environment should be developed by the collaboration of medical doctors and engineers. Thank you. Thanks so much for Baron. Um, I of course love seeing all the AI presentations, and this was one of, um, a great one. Um, if there are any questions, feel free to write them in the chat, but I will start with, I was wondering how you chose this as your model. Uh, actually, uh, we, uh, want to demonstrate, uh, Whether we can uh work uh on an organ having lumens. So, this one was an easy one, actually, uh because uh we had a really uh big size of data sets. So we started with this study, but I think uh in the future, uh, we are going to make uh other studies for the gastrointestinal system and also other parts of the urinary system. Great. Um, well, that was going to be my next question, and sort of what your next steps were going to be. OK, answered. That's a good question. Actually, uh, we now demonstrated, uh, that the machine can detect the luminal organ, and also, uh, determine the location, uh, whether it's on the right side or left side, uh, with the FA score of 95%. The, uh, the also, uh, the. That the machine can easily detect the field organs, uh, field lumens, uh, with 88% accuracy, but the problem in our study is, it is really difficult to detect the uh empty lumen. Why? Because, you know, uh, the organ is an object, so, uh, uh, since in the empty lumen, you have a less matrix, less and less matrix, it is really difficult for a machine to understand. Uh, that there's an organ there. So we are planning now to make a time series study. Why? Because we will start from zero to end, and we will, uh, just, uh, put in, uh, put, uh, as an input, the, uh, field, uh, lumen and also the empty lumens and emission we work back and forth and then understand, uh, with this time series that, uh, this process, and also we are planning to make uh a patch based annotation. And we will just give the slices of the image uh for these difficult cases for uh with low resolution, so uh the uh image with this uh slices uh with details, the machine can understand uh the object in a better way. Great. Thank you very much for that explanation and that great presentation. Um, the next presentation is entitled Experience of Thoracoscopic esophageal Reconstruction for 53 Patients with pure esophageal atresia, presented by Wan Wang from Shanghai. Hello everyone. I'm happy to be here to share with you about our experience of thoracoscopic esophageal reconstruction for 53 patients with pure oesophageal attrition. Our aim is to summarize the experience of perioperative surgical treatment of these pure EA patients in order to explore the optimal treatment strategy. During the last 6 years, we accepted 53 patients and we classified them into two groups. Group A includes 23 patients who were born in our hospital or transferred to our hospital immediately after birth. Group B has 30 patients. They were transferred to our hospital after they have accepted gastrostomy in their local hospitals. The average gap of these 53 patients were around 4.5 vertebral bodies during their first evaluation in our hospital. Therefore, for 50 cases, we performed the technique boginate stretching before their um esophageal reconstruction. As you can see here, an example. The gap was obviously shortened after Pugin stretching. There are other 3 cases that their esophagus condition allow us to do the reconstruction directly with that Pugin stretching. Lastly, all 53 patients achieved esophageal reconstruction successfully. Among 53 patients, there 44 cases, they accepted thoracoscopic surgery and the other 9 cases, they accepted conventional open surgery. And we would like to point out that there are 3 cases they accepted a colon replacement due to the failure of attempt on esophageal elongation. All the patients were cured with 100% survival rate and their average follow-up is 21 months. Now, let's have a simple comparison between two groups. We found that the patients in Group A, they can start stretching and accept esophageal reconstruction earlier than Group B. And they need shorter postoperative hospital stay and they need less requirement of esophageal dilation after surgery compared to Group B. And for the common postoperative complications including anastomotic leakage, stenosis, reflux, hiatal hernia, and most importantly, TEF, there's no significant difference between two groups. During the following up, we found that there's no difference for their growth between two groups. So, our suggestion is the esophagus condition should be evaluated thoroughly and putinate stretching is an efficient way. Also, the thoracoscopic anastomosis is the preferred method from our experience. Thank you very much. Thank you very much for that very interesting presentation and a very impressive number of 53 patients with pure esophageal atresia. Um, are there any questions about this presentation? And while we're waiting, I will get started with, um, I was wondering, you described the average gap length initially for these patients, but what was the average gap length before you attempted anastomosis? Yeah, actually, when we receive this kind of patients, we plan to do the gastrectomy. During the gastrectomy, we can make the small hole from the stomach to evaluate the gap of the two ends of the esophagus and then make the decision. We do the gastrostomy or we can do the anastomosis directly. Actually, we have 3 cases. We, when we do the gastrostomy, we use the probe into the, the two sides of the esophagus and the X-ray check, we can find very clearly the gap of the both sides of the esophagus and then make the decision. To do the anastomosis directly or do the gastrostomy. Thank you. Great. And could you tell us a little bit more about the 3 patients that were not able to achieve anastomosis? Yeah, actually, if the gap is really long. Uh, this kind of certifications we get from the local hospital. Actually, in the local hospital, they did the first day, uh, they tried to do the, uh, anastomosis in their, in their, in their primary surgery, but they failed. So it's really complicated to perform the, uh, the use the native esophagus to reconstruct the esophagus. So we, we do the, the bouji, the stretch and uh it's felt, it's still really long gap. So we, we, we have to do the, uh Replacement of this uh gas. Great. Thank you very much and um Again, very impressive numbers. Thanks very much for uh showing us your outcomes. Yeah, thank you. OK. Our next presentation is overcoming the technical limitations of intraoperative recurrent laryngeal nerve monitoring in newborns and infants, presented by Jay Messner from Boston Children's Hospital. Hello. My name is Jay Meisner, and I'm going to talk about overcoming the technical limitations of intraoperative recurrent laryngeal nerve monitoring in newborns and infants. The recurrent laryngeal nerve provides motor input to the intrinsic muscles of the larynx. This nerve is at risk of injury in a variety of pediatric operations such as thyroid and cardiac operations. This leads to postoperative vocal cord dysfunction, which is either decreased or immobility of one or both vocal cords. This is morbid because it impairs the development of safe swallowing, breathing, and speaking in children. This is an under-recognized problem in surgery because most patients do not undergo routine pre and postoperative flexible laryngoscopic examinations. However, we can monitor the integrity of the recurrent nerve laryngeal muscle circuit by using intraoperative neurophysiology monitoring technology, specifically evoked electromyography, evoked EMG. Each channel of an EMG device requires 2 recording electrodes on the muscle of interest and 1 ground electrode. Each channel can monitor a separate muscle. Therefore, dual-channel EMGs can monitor two separate muscles, for example, the left and right vocal cord. The principle is that we deliver a supraphysiological stimulus to the recurrent nerve and measure the electrical activity in the corresponding laryngeal muscles, i.e. we evoke an EMG. The type and configuration of these recording electrodes can be modified and tailored to the patient. There are two broad categories, surface electrodes and needle electrodes. The surface electrodes can be adhesive or integrated into the endotracheal tube. Needle electrodes are placed into the larynx either percutaneously or transorally. They are difficult to place, easy to dislodge, but they are available options. Integrated electrodes are available in tubes as small as 50 outer diameters, which can work for patients 4 to 5 years or older. If dual-channel monitoring is desired in smaller patients, you have to use a needle or adhesive electrodes. There are a variety of adhesive electrodes available. But it is possible to modify a dual-channel adhesive electrode for use in tubes as small as 30 out of diameter or in patients as small as 2 to 3 kg. Our modification involves trimming one or both of the lateral electrodes on the adhesive electrode montage. Using a voltmeter to ensure functioning of the remaining electrodes, applying the adhesive montage onto the endotracheal tube, and then replacing the electrodes to be trimmed with percutaneous electrode inserted into the larynx as close to the vocal cords as possible. This maintains that two recording electrode per channel and individual muscle monitoring. It's also imperative to do routine pre and post-operative flexible laryngoscopic exams on these kids to realize the benefit of nerve monitoring. Thank you very much. This is really cool. I love that presentation. Um, My, um, my first question for you was, how long does this setup take to, um, insert and then to, um, get all the information from? Thank you so much. It takes less than 5 minutes to actually cut the electrodes, put it on the tube, and do the intubation, um, and then you have to wait at a separate point a little bit later in the operation, then you gotta test it, but it only takes a couple of minutes. Great. And then my next question is, um, did you notice any differences with the intraoperative monitoring that changed management, like staying away from nerves or noticing any um potential injuries? We do, um, every time we, we are near the larynx, especially where we think the recurrent nerve is inserting into The larynx will um drag the stimulator probe over the tissue. And if a structure containing the nerve or something connected to the nerve is there, it will activate that nerve and, and activate the EMG assuming everything is intact and so. At that point, we tend to dissect more carefully or move to a separate area, try to release different tissues to move that are, you know, more against the, the esophagus. That's great. I mean, I think that this is definitely under-recognized problem, as you mentioned, so that could be a really great device. Um, Doctor Goldstein had asked, how do you get the percutaneous needles close to the cords? When we use the percutaneous needles, we, we get them to the um thyroid cartilage on the outer lamina or we go through the cricothyroid membrane, um, and both, both locations have, have been successful. How far do you have to be from the tissue, um, to kind of stimulate the, the nerve? So, I mean, do you have, are you within 5 millimeters, 10 millimeters? How close are you with it when you're doing the surgery? It within 55 millimeters or less in terms of where the stimulator probe is towards the nerve. It's less than a millimeter current spread, but that depends on how intensely you're going to use the stimulator probe cause you can ramp up the current real high and, and have activation of everything in the field. Great. Thanks so much, Doctor Meisner, very interesting presentation. Um, the next presentation is augmented reality powered simulation training for minimally invasive surgery, presented by Doctor Maximiliano Marechik from, um, Argentina. My name is Maximiliano Marisi from Carahan Children's Hospital and Pedro Elizalde Children's Hospital, Buenos Aires, Argentina under the title or Working Team. I am presenting augmented Reality Power simulation training for minimal invasive surgery. We have nothing to disclose. Tutor a guide training with an augmented reality application using accessible technologies is a useful tool for acquisition of initial motor skills. This tool complements the training guided by a tutor and allows the user independence with precise objectives and goals. The objective is to present AI powered solution for MIS self-training. We have developed multiparametric tools, self-assessment forms, and tutor, tutorial videos to allow the participants to acquire certain initial and intermediate skill at any time, anywhere without tutor assistance. This solution consists of an application developed for mobile devices or tablet that allows to obtain performance data in relation to the working instruments, movements, and time. It used exercise adapted for mastering learning essential models that we previously developed for iPad. The app also provides feedback in real time. Additionally, we developed self-assessment forms. For the users that compare the results of their own practice with the pre-established parameters for each step of exercises. Faculty assistance will be available if needed, and with all these, we propose an autonomous training experience. Training box can be any as long as it allows to place a cellphone or a tablet. We also developed a very low cost do it-yourself option made of cardboard if none is available, as you can see in the video. Tutorials included in the application are how to use the app and self-assessment form, how to do your own box trainer, models and box trainer setting up, exercise, and basics for ergonomy. This is how the application works. The working area and instruments are calibrated. The exercise is carried out, and the alert feedback is obtained if instruments left the working area. Then users can see the records and videos. Self-assessment tool is a digital leaker type form that allows the users to compare their own performance with pre-established parameters and get graphics. In conclusion, tutorial guide training using augmented reality is an additional, accessible and useful tool for acquisition. Of initial and intermediate motor skills. Multi-parametric data collection and self-assessment forms are needed to obtain objective information from practice. Further experience is needed and we plan to analyze it combined with tutored MIS training in all stages, but mainly at the beginning of the learning curve. Thank you. Great, thanks so much. It's also really cool, and all I could think while watching is that I want to try to use it and play with it. Um, my, my question to you was, could you just tell us a little bit more about the self-assessment portion of it, cause I think that this is where a lot of the labor comes from, from evaluators, and it's really the, probably the most important part about doing these trainers. OK, I'm gonna turn into Spanish if you allow me. Sure, everyone can put on the interpretation. Bueno respecto a la planica de vaacioneso is esse commienzo and no tra applicacion esse commienzo no tresaros burqueno sorosvennamo travajando er enunmolo entrenamiento que sevasa and er activia serecisas vilida precisas andosela planicia devolione de la cuel partimo para desaro notromoder to er las act. Via queselana sha quenosotros er evalumocisament sauna planiciatipolicarquevalua tolos estados dumna viliad informa precisaique permite comparar alumno while participante consuppe performance base alvio al de sarocho questaciendo and el mijo momento. responded to. Yes, absolutely. Any other questions about this presentation? Great, we'll move on to the next one. And entitled Diagnosis of Appendicitis by Ultrasound with Artificial Intelligence, our presenter is Doctor Hayoshi. I'm Kentaro Hayashi. I'm going to talk about diagnosing appendicitis by ultrasound with artificial intelligence. Nothing to disclose. Appendicitis is usually diagnosed via ultrasound, but this is very difficult because it requires training and skills. So we started to construct artificial intelligence to detect appendicitis automatically. We use 70 videos, 50 videos to train artificial intelligence, and 20 videos to test. Within the 50 videos, total of 6900 images were included and 3500 images contained appendicitis. This is a successful case. When AI detect appendicitis, AI showed yellow color. In this video, AI successfully detected appendicitis. This is a failure case. AI could not detect appendicitis at all and indicate wrongly. Then, we conducted two tests. The first one is to assess the AI performance. We use the remaining 20 test videos and assessed by 3 other pediatric surgeons. Please look at the image. A was identified by a surgeon and B was true positive, indicated by AI and C was false positive indicated by the AI. We define detection percentage as what percentage of the true appendix was detected by AI calculated as B divided by A. We also defined percent accuracy as what percentage of the AI suggestion was correct, calculated as B divided by B + C. Each was categorized into most, partial, and none. This is a result. The lump was shown according to the depth of the scanner area. The proportion of none was dramatically decreased between the 8 centimeter and 7 centimeter. This means ultrasound with deep scan area may be related to poor performance. In the test 2, we evaluated the effect of AI on the pediatricians. The same 20 videos and examined on 10 pediatricians. As a scenario, each test video was shown as if each participant performed ultrasound by himself to evaluate patients suspected of having appendicitis. Three questions were asked. Question one is, which is the appendix? Question 2 is, how is your confidence for question one? And question 3 is, do you need to take a CT? The participants answered this question 123 before and after AI support, and we assessed how these answers changed and categorized into positive, negative, or no effect. This is the result. Please look at the negative effect. Only group 4 shows high negative effect, but the other did not. This means if only part of the appendix was detected, AI may still be helpful to examiners. However, if almost none of the appendix was detected, AI may have negative effect on the examiners. In conclusion, ultrasound with a shallow scan area may be easily assessed by artificial intelligence for appendicitis. Even if only a partial shadow of the appendix was detected, AI may still be helpful to the examiners. However, if almost none of the shadow of the appendix were detected, AI may have a negative effect on the examiners. Thank you for your attention. Thank you. That was very interesting and, and demonstrates how artificial intelligence could incorporate easily into our, our clinical practice with radiology, um, and pediatric surgery. A question for you, have you identified some features that would make, um, an ideal patient for identifying appendicitis with artificial intelligence, whether it be BMI, abdominal wall thickness, or even how big, uh, the diameter of the appendix is? Thank you for your question. Uh, actually, uh, we, we don't have the, uh, uh, uh, specific fea features, but we just, uh, found the shallow scanner and is related to a good outcome. It's maybe, uh, related to the young patient, maybe it's, it's small area. So the shallow area and, and maybe the small scan area and the less structure is maybe good for AI. Great. Thank you. Um, I had a couple of other questions, but for the sake of time, I want to get us back on track, so I'll move to the next presentation. Thank you. Uh, the next presentation is esophageal magnomosis for the treatment of type B esophageal atresia in a child with prohibitive operative risks. Presenting is, uh, Doctor Irving Zamora. Good afternoon and thank you for the opportunity to present. We have no disclosures. Our case today will demonstrate the first use in the United States of a novel magnemosis device system for delayed oesophageal anastomosis. The patient is a medically complex 13 month old male with a type B long gap oesophageal atresia. Before transferred to our institution, the infant, presumed to have isolated EA underwent a right thoracotomy to attempt esophageal anastomosis, but was ultimately aborted. Upon arrival to our institution at 5 months of age, we discovered a proximal pouch fistula on bronchoscopy. So we first performed a right neck exploration and repair of the proximal pouch fistula. Due to severe tracheal bronchomalacia, 8 weeks later, we proceeded with a left thoracoscopic aortopexy. At 11 months of age, we performed a right thoracoscopic posterior trachyopexy for ongoing airway collapse, and approximation of the esophageal ends without anastomosis, given a high degree of tension and risk of leak. He subsequently required tracheostomy for ventilator dependence. 8 weeks post-op, fluoroscopy confirmed the esophageal ends remained in close apposition. Given his multiple thoracic operations, poor cardiopulmonary condition, and high risk for perioperative complications, we decided to proceed with attempt at magnet anastomosis. The ConnectEA is a novel medical device system developed for the treatment of esophageal atresia. The magnets are disk shaped and 8 millimeters in diameter, with a unique bi-curved mating surface that generates an optimal magnetic force profile designed to create a robust, healthy primary esophageal anastomosis via an endoluminal approach. Given the advantages of avoiding a high risk re-operation, we received FDA approval for compassionate use of the ConnectEA in this patient. The procedure was performed using a combination of endoscopy and fluoroscopy to confirm position of the esophageal pouches on both AP and lateral views. A ferromagnetic endoscopic grasper was used to deliver each magnet. Get a gastrostomy, the first magnet was endoscopically positioned in the distalesophageal pouch as seen in figure A. With the distal endoscope left in place, the second magnet was similarly placed in the proximal esophageal pouch as seen in Figure B. The endoscopes were adjusted under fluoroscopy to bring the connect EA into proximity until they were magnetically mated. Orientation of the mated magnets was confirmed on X-ray, and the patient tolerated the 38 minute procedure well. The position of the magnets remained intact on daily chest X-rays. These two feeds were restarted post-op day 2, and he remained stable throughout the perioperative period. On post-op day 17, the maggots were retrieved, and he was noted to have an esophageal diverticulum proximal to the anaccidosis, which was treated with a covered biliary stent. He was ultimately discharged home and and is undergoing outpatient serial endoscopic interventions for closure of the diverticulum. In conclusion, the ect EA procedure is easily carried out endoscopically, does not require complex post-op management, and provides a novel endoluminal alternative to a hand sewn esophageal anastomosis. The approach effectively minimizes anesthesia, avoids need for major operative intervention, and should be considered for future use in severely complex patients. Thank you for your attention. OK, wonderful presentation and images. Thank you, Doctor Zamora. We have a question from the chat. What caused the diverticulum? Uh, thank you, Doctor Norica. Yeah, um, so I think what happened is, uh, in that operation when we were thoracoscopically, uh, opposing two ends, uh, it was under a lot of tension and so we first started with, uh, vicro sutures to oppose the two ends from the very tip, uh, so to bring them sort of in kissing apposition, but to try to decrease some of the tension, uh, I think when we were throwing some of the sutures we might have caused a demuscularization at the posterlateral aspect. Uh, with the sutures because we were trying to bring them together and that's the whole reason we decided to, to use the magnets because it was under so much tension, uh, so I think it was during that initial operation that we must have, uh, demuscularized, um, the, um, that, that, that segment of, of esophagus. Another comment in the chats, uh, you would have seen at the time of the magnet placement though. Did you notice anything intraoperatively that, that suggested that is the etiology? Yes, we did actually. So when we were doing it, uh, uh, with the proximal pouch when we did it, uh, endoscopically, we're able to see, uh, the diverticulum off to the side and we actually at first were having a little trouble deciding, you know, is this which was the, you know, the actual lumen versus the, uh, diverticulum and so, you know, we ultimately decided, um, uh, when they were in that position, uh, the orientation both on AP and lateral, which is really important when you're, uh, aligning the magnets for them to get them to mate appropriately. You have to be in the right orientation, both AP and lateral. And so after we, you know, use the, the fluoroscopic images we had Doctor Harrison and team on as a conference call and a multi-institutional, uh, transcontinental collaboration, we decided that that was the, the true lumen, but you could see the diverticulum proximal to where we were. Right, and Doctor Barus asks, um, could you have closed the defect at the time of tracheopexy? Uh, which defect? The diverticular defect, the the demuscularization of the area that you noticed. Oh, no, that we didn't notice that, uh, at the time of the tracheopexy. That was the time that we brought them in opposition. We noticed the diverticulum at the time of the endoscopic placement of the magnets. We didn't notice that there was a diverticulum at the time, I think that's when we caused it, just from trying to bring the two ends together. We demuscularized that. My, my question was actually why you couldn't get the two ends together at the time of the tracheopexy, not. The diverticulum. So the gap was just too significant for you to do so? Yeah, this was actually a long gap from the very beginning. This patient was transferred to us, um, and, uh, had a very long gap initially. Uh, it was initially recorded as 10 centimeters, which is why we did the first approach. It was a proximal type B, had a proximal pouch fistula, we approached cervical first, and then over time, we were able to mobilize it thoracoscopically, um, uh, but they were still just too, too far apart. But the distal end had actually been perforated. At the outside hospital during uh calibration studies and so what they initially thought was a was a 10 centimeter gap when they did the um calibration studies I think, uh, they demuscularized that distal end as well and so what pulled through was mucosa so there was a concern about, uh, the integrity of the tissue of that distal end as well, which is another reason why I wanted to be able to endoscopically look both inside to look at the integrity of that distal pouch and then ultimately that's when we decided as a group. That the, that tissue, the integrity of the tissue is going to be compromised for a, for, you know, uh, uh, primary anastomosis, and we just decided to put them together and that's when we, uh, uh, considered other options. Uh, we looked at the flourish device and then ultimately decided on, uh, using the, uh, Connect DA with Doctor Harriton's team. Mainly because it's a bigger anastomosis, it's an 8 millimeter versus a 3.8 millimeter, and this child was 1111 months old at the time. And so, uh, we figured an 8 millimeter anastomosis in a concave to convex manner is a much better anastomosis than a smaller 3.8 millimeter concave to concave uh with the with the flourish. Wonderful discussion and, and last question, you mentioned the 8 millimeter diameter of the um esophageal anastomosis and being uh greater than, you know, 3.8. Um, was there any planned routine, um, postoperative esophagram, uh, to evaluate for a stricture or to evaluate the anastomosis, uh, more long term? Yeah, we've been doing that now actually. The first esophagram was with the magnets still in to see, uh, because once they start changing in orientation, you know that they're starting to create the anastomosis and so we wanted to check that, uh, the, the patency, um, because initially they, you know, they're supposed to decouple they're supposed to remain coupled and pass initially, but he had a small thin membrane that didn't allow him to pass, and so we actually had to go in and retrieve them endoscopically, um, but we were able to confirm that with the esophagram and then following that we had done serial esophagrams. There was no leak. Um, but there was that diverticulum we were dealing with, which, uh, at this point that's become sort of the, the biggest issue from, uh, from the esophageal side is that we've had to do endoscopic serial cautery, which now we, we've got it pretty much closed, so it sounds like no stricture too. Great. Uh, stricture, but, uh, but easily, uh, um, uh, distended up with, uh, uh, endoscopic, uh, balloon dilation. So we, we've now done three interventions on them, 3 dilations. Thank you, Doctor Zamora. Thank you. Our, uh, next presentation is by Doctor Jeffrey, uh, Lucas, a novel, low-cost, minimally invasive system that allows for a translocation, uh, translation of modern pediatric surgery technology to low and middle-income countries. Good day, IPEG, members, guests, and my colleagues. There's a critical need for pediatric, surgical, humanitarian aid worldwide. Nearly 1/3 of the world's population are under the age of 18 years. Nearly 2.5 billion of these children live in low and middle-income nations that do not have access to safe and effective surgery. The role of minimally invasive surgery in these environments, with its reduction in hospitalization, pain, and wound care is logical. I am of the opinion that providing equivalent care to a poor child in a poor country should be our moral and ethical responsibility. In 2018, we reported at IPEG our experience with MIS over the last five years during World Pediatric Project missions. We found that the strategy could be employed in these austere environments safely and effectively. The children and folks clearly benefited. However, the costs, logistics, and sustainability of the strategy presented several potential challenges. In considering the standard MIS tower, we recognized that many of the components and interfacing technologies were decades old. They did not take advantage of modern and less expensive technology. Our goal was to develop a new low-cost, rapidly deployable, minimally invasive surgical system, the RDMIS for short, for use during remote pediatric surgical missions. The system components consisted of a universal serial bus interface laparoscopic camera, a portable computer, and a battery-powered wireless portable halogen laparoscopic light source. This entire system that you are looking at can be transported in a single standard carry-on luggage. The system effectively eliminates all components of the traditional tower that we are all used to, except for the CO2 insufflation component. We were concerned about the USB connector on the camera regarding sterilization procedures. So we opted for the conventional camera bag that we have all used in the past. To house the portable light source, we used a sterile 250 cc IV fluid bag. Our portable computer was placed at zero parallax for the surgeon next to our traditional MIS tower. We interchanged the conventional MIS system and the RDMIS system throughout the cases. Other than the smaller screen on the portable computer, all other laparoscopic components such as the lighting, clarity, and detail were equivalent and allowed for a safe surgical dissection. In conclusion, the rapidly deployable, minimally invasive surgical system appears to be a safe, inexpensive option that will allow for translation of modern MIS technology during GPS missions in remote locations. Further studies validating the RDMIS are indicated. However, the lower costs, ease of transport, and potential benefit to children in poor nations may be significant. Thank you for your attention. And I appreciate the Opportunity to present our study. Um, so this is very exciting, especially, um, it seems like you mentioned the quality is very similar in terms of the, uh, the computer monitor that you bring and the computer monitors that they have, and you're able to interchange even between those. Um, would love to hear a little bit of your, um, comments in terms of how you maintain that picture quality. Yeah, I mean, it's, it's a remarkable. Can you guys hear me? Yes. Yeah, it's a remarkable system. It's a Canadian-made USB interface camera, and then the portable light source is actually an Ethicon or Stryker uh uh piece that GI doctors use, and we just kind of put it all together, uh, to try and, you know, facilitate really, the concern was doing a lapCli or some advanced laparoscopic procedure in a, in a remote area and, and your tower goes down cause you only have one. Tower there. And so we needed a backup system. And so, uh, in the 2020 mission, we used it. I'm disappointed that we can't see the videos of the, of the interrupt because the clarity is about the it is the same, and we carried out the operations, a lap Collin and a lap AI and a lap Malone uh with the system and they're equivalent. And um I can't remember if I put it in the, in the. Uh, abstract or not, but the cost comparison, it's, it's much more reasonable for third world nation. Hospitals to afford. It's about 500%, like 507% less expensive than the typical hospital costs that we pay in high-income patients for the system. So, uh, I, I think, uh, our hope is to, uh, mass produce the system and get it out in the market. So really, a lot of us who do mission work can utilize it in that setting cause I think it's perfect for that setting. Doctor Wilkin had a follow-up question. What do you use for insufflation? I'm sorry, I can't hear you. Sorry, Doctor Wilkin had a question in the chat. And his question is written in the chat, what do you use for insufflation? So, you, you, you know, one of the insulation commercials that was on was that little micro recirculating insulation system. We use that. That's the one piece that we have not been able to, uh, change much from our original system. But CO2 is ubiquitous, tanked everywhere. It's pretty reasonable, and it's low cost everywhere. You can do it, you know, you can utilize, and they do that. This in third world nations, just use it inline, fill the abdomen, tap, close the valve off, and when they need more insufflation, they turn the pressure back on till it's a suitable laparoscopic or arthroposcopic vision piece. And so, uh, we did use the standard insufflator machine, but even if you took that device, you could still carry it all in a carry-on suitcase. Great. Thank you. For the um sake of time, please uh see a couple of questions in the chat. Um, if you can help us answer those, um, I'm gonna put one of my own in there as well cause I'm uh eager to hear a little bit more about this, but we do need to keep moving, so my apologies for that. Sure, thanks. Thank you. What's the absolute time we want to stop? Our next presentation is artificial intelligence and computer aided imaging diagnosis and pediatric surgery, automated detection of pyloric stenosis using ultrasound, and Doctor Cassar is presenting. Hi everyone, this is Alex Cassar, and I'm here to talk about the use of artificial intelligence and computer-aided image diagnosis in pediatric surgery. We have nothing to disclose other than an iPad research grant. To begin, our work rests on the following premises. Children are not just little adults. Pediatrics of specialty expertise leads to better patient outcomes. This expertise is limited, and the current distribution of resources leaves great segments of the population without access to this expertise. Our long-term purpose is to democratize this knowledge so that every child can have access to the same resources, providing the best care possible. Advances in image recognition are making this technology widespread, with many of us interacting with it daily through features like face ID and photo classifications. This technology is also permeating the medical sciences, with approved and validated algorithms ranging from risk fracture detection to pathology slide analysis, fundoscopic diagnosis of diabetic retinopathy, and commercially available software for detection of intracranial bleeds. Image recognition and pediatric surgery has the potential to extend our reach to rural and global communities, including providing care after hours. It can aid in performance improvement by preventing misdiagnosis and alerting for errors. It can also help with workflow improvement by triaging read by severity or providing actionable preliminary wet reads. All of this hopefully translating to reduce delays, misdiagnosis, costs, unnecessary patient transfers, and burden on our healthcare system. Our prior work included very basic proof of concept algorithms for detection of femur fractures and intracranial bleeds, using IBM Watson that were then coded into iPhone apps for stimulation. Our current work train models with 120 ultrasound images with longitudinal use of the pylorus from a 1 to 1 mix of patients with pyloric stenosis and normal controls using manual feature annotations by myself. This training data was then utilized to benchmark state of the art convolutional neural networks for the tasks of binary classification and segmentation. More information about this methodology is available in our scientific session presentation. Our segmentation model achieved 85% pixel to pixel accuracy, and our classification model achieved 90%. This performance provides a great starting point for more complex blended models currently underway. For comparison, the models we use as a starting point have won global competitions with accuracies around 92%. Although this study is currently limited by small sample size and the use of a single non-expertat. We have now added more than 600 new annotated images and introduced a second expert annotator and are currently in the process of customizing our own combined models predicted to achieve accuracies greater than 95%. We hope to then translate these models to other surgical diagnosis and imaging modalities. Thank you, Doctor Cassar. I see, um, I've tried to put some questions in the chat so that we can proactively try to save some time, so thank you. Um, did you wanna share your, uh, answer verbally? Yeah, so the question was if we are able to do length estimates or size estimates for the, for the pylorus, uh, we actually can, and that's why it's, uh, part of the annotations we were doing in the beginning. So we can have a triage read that says yes or no pyloric stenosis, uh, shows the localization in the image and And gives an estimate of the length and the thickness. Right now, the issue we are having with that is just that the pictures are all obtained at, uh, different sort of depths. So the 1 centimeter mark is not the same for all of them. So we are working on pretty much just training to recognize the scale so that they all translate to the same length. That's great. Thank you. I look forward to seeing uh the next uh diagnosis that you apply this to. Next, we have Nolapse, a stomal prolapse prevention device uh by Doctor Chen. Correct. Hi everyone. This is Alex. Hello. Thank you for correction this la laparostic gastropy using tea fasteners without the external bolsters, uh, with Doctor Slatnick. Good opportunity to share our work today. We have nothing to disclose. Laparoscopic placement of stem sutures or gastropexxy during laparoscopic gastrostomy tube placement can be challenging in patients with thick abdominal walls. Te fasteners are an effective method of gastropexy and are primarily used in endoscopic and percutaneous G-tube placements. However, when using te fasteners, the need for external anchors increases the risk of skin irritation and erosion. Today I'll describe our experience using the paired T fastener technique for laparoscopic G tube placement with the elimination of external of the external bolsters. Pediatric patients requiring enteral access who underwent laparoscopic G-tube placement using our per T-fastener method from 2019 to 2020 were reviewed. Here we demonstrate our technique. Two skin necks are made opposite of each other. And then two sets of tea fasteners are inserted through each skin neck, through the fascia, and into the stomach, and angled in such a way that the Ts are deployed into a square configuration to achieve the gastropxy. The G tube is in place in the center of the square pexi, and each pair of absorbable suture is then tied down subcutaneously, removing the T fastener bumpers. Here we show some intraoperative footage of the technique. And you can see again the T fastener is now under laparoscopic guidance inserted through the abdomen and into the stomach in a square configuration to create the gastroplexy. And the G tube is then inserted in the center of the Pixi. And the knots are again tied down subcutaneously. Operative time and 30-day postoperative complications are reported. 19 patients underwent single port laparoscopic G tube insertion using this technique. The mean age was 7.2 years with the mean weight of 21.6 kg. Tube size ranged from 12 to 16 French with a length of 1.5 centimeters to 3 centimeters. 12 procedures consisted of a gastrostomy tube insertion alone, and those procedures had a mean operative time of 55 minutes. 3 patients developed a local wound infection requiring antibiotics, 2 of whom were immunosuppressed. 3 developed granulomas. 4 patients underwent uncomplicated tube replacement within 30 days for dislodgement or for stem upsize, and of note in all of those cases, the gastroplexy was noted to be intact. There were no cases of postoperative bleeding or of peritonitis. The paired tea fastener technique is an efficient method for primary button gastrostomy placement with a secure gastropxy, and while wound infection and granuloma rates are comparable to those reported for alternate techniques, this method eliminates the need for additional trocars or for the external bolsters, and it may be helpful in patients with thick abdominal walls. Thank you for your time, and we're happy to take any questions. Thank you. That was a great demonstration of being able to directly visualize the G tube safely going into the stomach, but with a patient with a thick abdominal wall. Um, there's a few comments in the, the chat box. Um, we see there's a 3 centimeter button being used. Does that mean this can be used in teenagers? Uh, also, is there kind of an upper limit to the thickness of the abdominal wall that this could be applied in? Yes, um, thank you for the question. So far, we haven't encountered an upper limit. Um, in fact, we think the technique would be very useful, as we said, in patients with thick abdominal walls extending into the teenage years and even into the adult population as well. And then also how long do the tea fasteners stay in place? And is there any concern with them, uh, being embedded into the, the stomach and they'll be there longer than if you were normally to just clip them. Sure. Um, so it's a, the suture is an absorbable Biosin suture. Um, so it does, um, absorb over time and that metal anchor drops into place. It's, it's a blunt, uh, And that's actually sitting at the stomach wall. So we haven't encountered any issues with erosion, um, and I haven't seen that in other literature that uses this technique as well, but I suppose there is a, a theoretical risk to that. Great. Thank you. I look forward to trying it in my next teenage YouTube. All right, well, we're, we're rounding third base and getting towards home, I guess. So the last 5 talks we've been given marching orders to, uh, march this along because, uh, we're in towards the end. So the next, uh, talk is no lapse, the Stonewall Prolapse Prevention Device to be presented by Carrissa Chen from UCSF and San Jose State University. Hi, my name is Teresa Chen. I'm a general surgery resident and biodevice innovation fellow at the University of California, San Francisco. Today, I'll be presenting the NLlabs, an anti-somal prolapse device. I have no disclosures. Our advice addresses the need of stomal prolapse, which, as you know, is very common. Millions of people worldwide have an ostomy and up to 8% of them will experience prolapse at least once. Not only is this painful, but it's costly. Requiring frequent emergency room visits, hospitalizations, and even emergent surgeries. Therefore, we came up with a device that can be inserted into a stoma to safely and non-operatively prevent prolapse. Our patent design includes two rings connected by a rod made of biocompatible silicone. The inner ring is inserted into the bowel lumen to prevent prolapse, and the outer ring rests on the abdominal surface to maintain the device in place. The device is semi-flexible yet collapsible, meaning it's easy to insert or remove at the bedside without the need for anesthesia. In addition, it is a traumatic to bowel. In our preliminary pre-clinical studies, we've demonstrated that the no lapse can effectively prevent stomal prolapse without obstructing the passage of stool. In addition, using force testing, we proved that a significant force is required to accidentally dislodge the device. And lastly, the Nolapse is compatible with use of ostomy appliances. Our device has been successfully used in 3 emergency in human cases. One such patient was a 2 month old with a history of neck and bronchopulmonary dysplasia, which precluded her from tolerating a surgical procedure. She had recurring stomal prolapse despite multiple bedside manual reductions. An early prototype of our device was used and inserted into the patient for 24 hours. She tolerated the device well and even after the device was removed, did not have recurrence of stomal prolapse. We are currently working on additional pre-clinical studies using 4C model. Concurrently, we are finalizing our design which will include 6 different sizes and optimizing our manufacturing process. Ultimately, we plan to proceed with human clinical trials and the de novo pathway for FDA approval. Our team is composed of pediatric surgeons, trainees, and biomedical device specialists. We're also collaborating with a team of consultants well versed in product development. And that's all. Thank you for your time. I'm happy to take any questions. Thank you. This was a wonderful presentation for a, a difficult problem that we sometimes all face. How long can this last, or should it last when you place it? And do you put it in from the start or only when you get, for secondary prevention when you get a prolapse? Yeah, that's a really good question, and it's something that we are currently trying to work out with our pre-clinical models. So to date, we've only done a 24 hour time point, but we do have plans to do up to 2 weeks in pigs. Um, I think ideally it could be used in both in acute and chronic settings. So for the patients that have sepsis fluid overload, just need something temporarily um to get them through this episodic illness, um, it could be really beneficial, but then also I can see. The benefit in long-term patients who are high risk for stomal prolapse, whether they have had prior prolapse, um, they are obese, they have a transverse loop colostomy factors like that, um, but it's definitely something that we're trying to figure out. And Leslie's asking about whether um you have any plans to kind of um maybe patients putting it in themselves at home if they get a prolapse. Yes, uh, ultimately, because it's such a simple and easy to use design, um, it would be ideal if we could cut out the entire emergency room visit and the patient would be comfortable doing it by themselves. Well, congratulations. Great. There's some more questions in the chat that you can answer too. Unfortunately, I think Samir will come to my house and beat me if I don't proceed. Thank you. So that would be entertaining for everybody, but not so much for me. So the next talk is, um, initial clinical experience with a new vessel sealing technology presented by our one of our very own moderators, Bethany Slater from University of Chicago, Van Vanderbilt and Rocky Mountain. I'm Bethany Slater from the University of Chicago. Thank you for allowing us to present our work today. In, uh, disclosure, all of the authors of this presentation are consultants for Boulder Surgical, but it was not relevant to the study data collection. In late 2020, Boulder Surgical introduced a 5 millimeter laparoscopic sealer, divider, and dissector called the Cool Seal Trinity. It has an advanced bipolar radio frequency vessel sealing technology. The Cool Seal system is also compatible with the Cool Seal Mini, the only 3 millimeter vessel sealer on the market. A 5 millimeter sealer is a true all in one surgical device. It has fast seal times with seals around 1.4 seconds. It delivers less than 1 millimeter of thermal spread. It allows for a very rapid cooling of the jaws. And it has strong secure seals. In addition, the device has slim, curved dual action jaws for both grasping and dissection. For the study setup, once the Trinity was commercially available in the United States, data collection was performed for the 1st 100 cases. Both procedural data as well as surgeon perception was collected. There were 100 procedures performed during this time by 68 surgeons at 31 different hospitals. As can be seen with this chart on the right side, most of the procedures were performed either in the abdominal cavity or on bowel-related procedures, and 13% were thoracic procedures. There were no adverse events in this series. The Trinity was used in a range of patient ages and sizes, with an average age of 10 years and an average weight of 46 kg. The Trinity performed primary operational functions, including dissection capability, ability to cut tissue, and seal quality above expectations across all of the procedures. In addition, the surgeons were satisfied with the overall experience and the various device performance features. With measures above expectations for all qualities measured, including usability in tight spaces, visualization, seal time, and thermal spread. Thus, the Trinity exceeded the surgeon's expectations in this trial. In regards to safety, there was minimal thermal spread, which decreases the risk of injury to surrounding structures. And in regards to efficiency, there were rapid seal times and had the ability to grasp tissue. This can potentially decrease OR time, however, further studies are needed to quantify impact. Thus, in conclusion, the design and optimal thermal profile of the device enables safe and effective minimally invasive surgery in a wide range of patients and procedures. Thank you very much. Thank you. And it's a great presentation for a device that we all love using, for sure. Um, how do you set expectations? That seems kind of subjective. And how can you differentiate this device from what's currently available right now, um, as, as other ones that we use? Yeah, thanks very much for those questions. Um, the expectations, I agree, is fairly subjective, and they were on a 1 to 5 point scale that the surgeons received after using devices in the operating room. So it's, it is subjective, but just based on the scale. Um, in regards to the differentiation with other um sealing devices, the devices are similar. Um, the things that seem to really differentiate the cool seal is really the lack of thermal spread, so they can be used close to nerves, other vessels, and other organs without concern for injury. And then, um, the dual action jaws as a more of a Maryland type of dissector really allows the ability to not have to change the instrument to put in a Maryland to grasp things. So hopefully that'll sort of over time create less OR time and the better ability to dissect through a tissue. Cool. And there's a question from the audience about like, did, did you try the 3 millimeter device at all as well, or is it just the 5 millimeter one? Yeah, this was specifically just for the 5 millimeter device since it was a newer device and allows for the cutting mechanism, but it is the same technology of the 3 millimeter sealing device just allows um for the cutting and in larger patients with a longer shaft. So it is very similar to the 3 millimeter former just right cert sealer. Excellent. Well, we're all looking forward to start using. This too, uh, in our places, um, the next, uh, talk is a novel multi-functional device system for endoluminal creation of primary oesophageal anastomosis for the treatment of oesophageal atresia, some of the thunder of which Irving Zamora steals from you. So, uh, you can blame him for that. Lauren Evans and et al from UCSF. Good afternoon. I'm Lauren and I'm excited to talk to you about a novel device system for endoluminal esophageal atresia repair. I have no disclosures. The morbidity of esophageal atresia remains considerable and is primarily related to musculo musculoskeletal sequela of thoracotomy and anastomotic complications. While innovation to reduce morbidity has been promising, the technical difficulty of the anastomosis during thoracoscopic repair has limited its adoption, and the incidence of anastomotic complications has not improved in over 40 years, despite ongoing efforts to optimize operative technique. The mini magnemosis is a magnetic compression device component developed to be a minimally invasive alternative to a hand sewn repair that's less prone to complications related to tissue quality or variable surgeon technique. By offering a technically simple approach to repair, we can improve morbidity by increasing thoracoscopic adoption and increasing or decreasing anastomotic complications. Based on over 20 years of experience optimizing magnetic compression anastomosis, the novel anchor design differentiates the device from previous magnetic compression devices for oesophageal atresia. The convex concave mating geometry has a proprietary curvature engineered for robust anastomosis while also mitigating factors contributing to risk for stricture. There are no external attachments as they spontaneously release from a mature anastomosis. Four pre-clinical studies and piglets have demonstrated early epithelialization of mechanically robust anastomoses that were widely patented 8 weeks without stricture. 5 successful compassionate use cases have been completed in patients that were high risk for conventional repair. Patient benefit has been significant and ranges from eliminating the need for re-operation, minimizing anesthesia, even avoiding cervical esophagostomy. Placement took only 23 to 38 minutes and anastomotic outcomes have been highly favorable despite all patients being high risk for complications. There were no device related complications and strictures have been soft and responded well to only a limited number of deletions. Endoscopic anchor placement was performed under fluoroscopic guidance using a standard endoscopic grasper to attract the anchors. The anchors were brought into approximation until they were close enough to auto align and mate. Once mated, an X-ray was obtained to confirm the anchors needed appropriately. While we knew that this was successful, we also knew we could optimize this further. Based on those initial clinical experiences and feedback from our collaborating surgeons, we developed a multi-functional delivery tool to facilitate more controlled anchor placement and optimize safety, usability, and surgeon experience. The ConnectedA device system is a pair of two delivery tools, one for each esophageal pouch that are preloaded with the magnetic anchors. The delivery tool for the lower esophageal pouch is embedded with a malleable stylette to facilitate navigating the gastroesophageal junction. The device has 3 functions anchor insertion, release, and retrieval, which the surgeon controls with the handle. Magnetic attraction to an internal magnetic system secures the anchor to the end of the delivery tool. The position of the internal magnetic system and amount of magnetic force applied to the anchor determines the function of the delivery tool. Less force releases the anchor to mate with its pair, while more force enables the surgeon to retrieve the anchor by safely decoupling the mated pair. The magnetic force profile required to optimize each function corresponds to a predetermined distance between the internal magnetic system and the anchor. The handle controls the function of the delivery tool by moving the internal magnetic system to 3 predetermined positions corresponding to each function. The 3 settings on the handle allow the surgeon to easily toggle between functions during the case. Given how encouraging our experience with the anchors have been thus far, we believe the ConnectEA device system has the potential to revolutionize oesophageal atresia repair. I'd like to give a special thank you to our clinical collaborators and sources of funding, and in particular our mentor, Doctor Harrison. It's a privilege to present our work. Thank you. Thank you for that, uh, phenomenal presentation and showing how, you know, taking the magnet thing to the next level. I mean, this is amazing and it's great and we're, we're really looking forward to seeing that. You don't, I don't think you mentioned the gap information in those patients and, and why did you classify them as high risk? Sure, so to address the gap question, really the device itself was designed to address pouches that were already in approximation. We feel pretty strongly as a team that closing an esophageal gap using magnetic force produces a lot of tissue. because as the magnets get closer together, they exert more and more tension and trauma on the tissue. And so really this has been designed to do something or to intervene in kids where that gap has already been closed with a suture approximation similar to what Doctor Zamora described for the case of Vanderbilt. Um, and then could you repeat your second question? I'm so sorry. Uh, the second one was, uh, what did, what did you define as high risk? Oh sure, so the kids were really high risk because of prematurity issues with prolonged exposure to general anesthesia. Average, you know, repair for a thoracoscopic anastomosis can take 6 to 8 hours. So we did feel we really benefited the kids by cutting down that general anesthesia exposure by, you know, 5.5 hours or so on average. And then most of these kids had also already had previous operations. So having to being able to avoid going back and doing a re-operation in a space that had already been violated and avoiding risk related to adhesive disease and things like that is kind of how we determined that they were considered high risk. Well, no, this is great, and you know, I think that Dr. Harrison is on. We'd like to recognize him. He's been a gigantic figure for us in pediatric surgery and someone whose shoulders we stand on every time. Um, hopefully, those shoulders are not too tired at this point. And here he is, you can see him. You're muted, Doctor Harrison. Oh, you just want to wave to us. OK, sounds good. So, well, thank you again, and we hope you get FDA approval sometime soon, and we look forward to seeing this on the market. Um, thank you. All right. So we're coming down towards the end. We've already exceeded our time, so, uh, nervously, we move on to the last two. So, the number 14 is Story Cas, A Novel Approach to the Interactive Surgical Education, and by the charismatic and, you know, magnificent team at Cincinnati, uh, by the boss, man himself, Todd Ponsky, et all. Hi, I'm Rod Gerardo, research resident at the Cincinnati Children's Hospital Medical Center, and today we're gonna talk about story casts, a new innovative way that we think is gonna shake up surgical education. To do that, first, let's talk about how surgical trainees traditionally learn surgery. Textbooks, online resources, now even podcasts and review books, and perhaps the most important element of surgical training, in-person clinical experience. So when the COVID-19 pandemic hit in the spring of 2020, educators were left wondering, how do we teach our trainees proper clinical decision making remotely? That's where story casts come into play. You see, we've combined medical storytelling with the accessibility of a podcast, and the decision making of a choose your own adventure. Take a look. Hey, there you are. I just got the call. 5 year old male pulled from a house fire. Vitals are listed here. What should we do first? All right, airways intact. Breath sounds are equal and present bilaterally. Do you have distal pulses down there? Awesome. Only thing I'm worried about is I see some singed nose hairs. What do you wanna do? All right, tub's placed. She's moving air on both sides. 02 sat's coming up. It's at 98%. All right, go ahead and get large bore IVs in both arms. Yeah, let's get respiratory therapy in here. What do you want to do? Through story casts, we've brought surgical education and clinical decision making right to the student's phone, but it doesn't end there. You see, the program directors and surgical educators could use data collected on the back end of the app to find out any educational gaps or areas that need to be addressed in the student's education. Thus further tailoring the education content that their students need. For now, these story casts are available on the Stay Curtain pediatric surgery app or our live events to try some of our cases out today, we have neuroblastoma, burn, trauma, and thanks to Doctor Bethany Slater and Doctor Aaron Garrison, through work with IPEG, we also have tracheoesophageal fistula. Thank you. Well, that's fascinating, and I think that Rodrigo, you have a potential future in Hollywood if you choose to to have that. Thank you. I don't know about that. I'm trying, just trying to finish residency now. Yup. And so I, I think this is great, um, you know, um, the ability to use the data as a tool for educators is, is really good as well. Um, are you going to have this as a free model or is it gonna be a purchase subscription? How do you guys plan to use this? This is an ongoing discussion that Todd and I actually have, so it's funny that you asked that. I think that there's a role for free content like this for educators, but I think that where the purchase model comes into play is, think about, for all the program directors, you know, residency directors here in the audience, think about how much you spend on score, or how much you're spending on educational content like textbooks, or True Learn or things like that. Well, what if there was something like this, and it could spit back out at you. Almost like a multiple choice test, data that says, hey, your residents are, are really good at tracheoesophageal fistula. They know everything. But when it comes to pyloric stenosis, like you get really into the weeds with it, they're, they need to learn, they need to read X, Y, Z things because they're getting these clinical questions wrong every time. So, that's potential. Yeah, this is great because you have the ability to kind of have almost real-time feedback to the educators and to the people who are getting educated. Um, Todd just put in the chat in capital letters free, so he may have answered that question for you. Um, and, um, I mean, it, this sounds like it's actually directed towards medical students more than residents. I think it's a phenomenal teaching tool for them to be very honest. That's another point that Todd and I actually, uh, uh, if we argue about anything, we often argue about this is sometimes I make stuff for medical students and residents, and he wants stuff. For fellows and attendings, and we try to meet somewhere in the middle, but in the end, I think our, our idea is that we'll have content for all the above. So you can have it switched to a learner mode versus switch to I'm a new attending or a fellow and I need a little bit more details. Phenomenal. Do you ever win an argument with Todd? Because if you do, let me know what you, how you, how you do that so we can do that too. That's hard. I'll take notes next time. Yeah. All right, awesome. I'll, I'll, I'll get back with you on that. All right. So the last presentation for today and for the entire meeting, it looks like, is the role of motion tracking in assessing technical skill acquisition using a neonatal 3D printed thoracoscopic esophageal resia, tracheoesophageal fistula simulator, that's a mouthful. It's from our folks, friends in New Zealand. Um, and please take it away, Doctor Choi. This study looked at motion tracking as a potential tool to assess technical skill using a neonatal esophageal atresia tracheoesophageal fistula simulator. Several authors are directors of Simulus Limited, which designed the simulator. Esophageal atresia is challenging to repair at the best of times, and even more so thoracoscopically. The skills required are difficult to obtain as esophageal atresia is such a rare condition. Simulation is useful as it provides an alternative way to gain these technical skills without learning them on real life infants. Our high fidelity validated 3D printing simulator may help to achieve this. The aim of the study was to determine whether motion tracking could be used as a tool to assess the degree of technical skill obtained. This is our current simulator on the left with the motion tracking ports attached as used in the study. On the right is a thoracoscopic view that the user gets during the procedure. The motion tracking device detects the relative path length of both right and left surgical instruments from where they entered the simulator ports. Participants of varying skill levels were recruited and asked to complete a single intracorporeal suture of the esophagus, one of the more difficult components of the esophagery will repair. This graph shows the total path length of the right and left hands during the task. The group with the least previous operative experience, the novice group, is in blue. Moderate surgical skill group is in red and the most skilled surgeons in green. We assume that the right hand is dominant for surgical procedures, irrespective of normal hand dominance, and in general, a longer path length means lower technical skill and economy of movement. The novice group had the least control of the right hand compared to the other groups. The greatest disparity between left and right hands is in the moderate school group. The unexpectedly high left-hand movement may reflect a greater focus on the right hand. The most experienced group had the lowest path links in both hands compared to the other groups. These results show that there is a potential for motion tracking to assess technical skill acquisition. Increasing expertise is typically associated with less movement and greater ergonomic efficiency. A longer left-hand path length compared to the right may be a marker that the surgeon is still focused on developing right-hand skill. This is the aspect we were not expecting and warrants further investigation, as does the influence of inherent-handedness. Thank you very much for that phenomenal talk from the home of the Hagley Park Cricket Ground in Christchurch. That's what I remember it for. I'd love to be there to watch a, a game sometime. So. You use a single suture to assess them. Is that what you did? Not the anastomosis, correct? Uh, no, so we just, um, created a demo video to do one single suture across the upper patch and the lower patch, and that was all they needed to do. So just a single stitch. And um now what is your hypothesis on why the registrars, or as we would call them here, residents were even less accurate with their left hand than the medical students? Um, I'm not too sure, and as you can see, we only had 3 registrars, um, and the bulk of the, um, participant group were medical students, so it'll be good to see, um, the results with a bigger group of registrars and see how that compares, but Yeah, maybe they were focusing a bit more on their right hand, um, more so than the medical students, but because they're at a lower skill level than the consultants, um, that became more apparent in the increased path length in the left hand. Bethany thinks that because they played a lot of video games. But, um, so there's a question from uh Doctor Zundel, which says, uh, have you assessed how the motion tracking relates to the time you're needed for the task? No, we haven't, and that's actually really an important point, um, to bring up because, um, we think that this task was possibly a bit too hard for the, the medical students, um, because we set a 15-minute time limit and all the medical students went over that time limit. So it's very possible that the increased path length is just due to the time. And so that sort of reiterates the point that it's probably more important to repeat this with um registrars rather than medical students. And I guess that's the um target demographic with the simulator because it's for the training pediatric surgeons. Which would gain the most benefit from this. Well, thank you so much. Speaking of, uh, exceeding your time limit, uh, we seem to have done that. And so, um, I'm gonna stop now and hand it over back to, um, Samir and Matt, and hopefully they won't beat us up too much. Yeah, no, not at all. I mean, um, thanks for taking us through all of those presentations. I think you guys did a great job of pushing the schedule. It's, it's really hard with an agenda that's packed like this. And, um, you know, this, this session in particular is a reminder to me of what I love about iPEG so much, the innovations. Every single, um, year that I attend this meeting, I come away with new things, new ideas, new tricks, things that I'm going to do, like, tomorrow in the operating room. And um that along with the personalities of the of the people involved here just are what makes this meeting so special. Um, so, uh, so thank you to everybody.