人工智能对胃肠疾病诊疗的推动作用

高速发展的计算机技术给日常生活及工作带来巨大变化。人工智能是计算机科学的一个分支,是让计算机去行使通常情况下具备智能生命才可能行使的活动,广义的人工智能涵盖机器学习和机器人等等,本文主要聚焦于机器学习与相关的医学领域,深度学习是机器学习中的人工神经网络,卷积神经网络(CNN)是深度神经网络的一种,是在深度神经网络基础上,进一步模仿大脑的视觉皮层构造和视觉活动原理而开发;目前在医疗大数据分析中应用的机器学习方式主要为CNN。在未来数年内,人工智能作为常规工具进入医学图像解读相关的科室是发展趋势。本文主要分享人工智能与生物医学的融合进展,并结合实际案例,重点介绍CNN在胃肠道疾病的病理诊断、影像学诊断及内镜诊断等方面的应用研究现状。     

Contemporary training methods in regional anaesthesia: fundamentals and innovations

Over the past two decades, regional anaesthesia and medical education as a whole have undergone a renaissance. Significant changes in our teaching methods and clinical practice have been influenced by improvements in our theoretical understanding as well as by technological innovations. More recently, there has been a focus on using foundational education principles to teach regional anaesthesia, and the evidence on how to best teach and assess trainees is growing. This narrative review will discuss fundamentals and innovations in regional anaesthesia training. We present the fundamentals in regional anaesthesia training, specifically the current state of simulation-based education, deliberate practice and curriculum design based on competency-based progression. Moving into the future, we present the latest innovations in web-based learning, emerging technologies for teaching and assessment and new developments in alternate reality learning systems.     

From the operating room of the present to the operating room of the future. Human-factors lessons learned from the minimally invasive surgery revolution

The minimally invasive surgical revolution has changed the way surgery is practiced. It has also helped surgical innovators to break the tethers that anchored the practice of surgery in an early 20th century operating room environment. To some in surgery, the Operating Room of the Future will be seen as a revolution but to others, an inevitable evolution of the changes ushered in by the adoption of minimally invasive surgery. Although minimally invasive surgery has conferred considerable advantages on the patient, it has imposed significant difficulties on the surgeon, which in turn, have impacted outcomes. These difficulties were primarily human factor in nature and were poorly understood by critical groups such as device manufacturers, surgeons, and surgery educators and trainers. This article details what these human factors were, how they related to the practice of minimally invasive surgery, and how they will impact on the practice of surgery in the Operating Room of the Future. Much of the technology for the Operating Room of the Future currently exists (eg, surgical robotics, virtual reality, and telemedicine). However, for it to function optimally it must be integrated in a fashion that takes on board the human factor strengths and limitations of the surgeon. These advanced technologies should then be harnessed to optimize surgical practice. In some cases, this will involve rethinking existing technologies (ie, three-dimensional camera systems), applying technologies that currently exist in a manner that is more systematic and better managed (ie, surgical robots and virtual reality), and a reconsideration of who should be applying these technologies for the practice of surgery in the 21st century. In all cases, there will be education and training implications for the practitioner. Lastly, there must be unequivocal demonstration that these changes bring about positive benefits for patients in terms of better outcomes and for surgeons in terms of ability and ease of doing their job. After the experiences of the last decade with minimally invasive surgery, the Operating Room of the Future should be seen as a well-grounded evolution, not a revolution.     

Use of computer navigation and robotics in adult spinal deformity

Recent years have seen significant advancements in the implementation of computer-assisted surgery in spine. Enabling technologies like robots and navigation have been refined to compliment the field's shift towards minimally invasive techniques and to fit more seamlessly into the existing workflow. Robotic-surgery and navigation in deformity can be particularly helpful in cases where the severe curves of the spinal column or the abnormal pedicle anatomy make pedicle screw placement challenging with the use of traditional anatomic landmarks. Furthermore, the ability to pre-plan patient specific rods has opened the door for greater precision in rod contouring. Drawbacks of robotic-assisted surgery include the steep upfront cost, the need for additional staff and training and the lack of tactile feedback. This review will discuss the current state of navigation and robotics, with a specific focus on their applications to deformity surgery.     

Adapting for the future: flexibility of UK postgraduate training

Postgraduate surgical training has undergone repeated reforms alongside changes in terms of employment. The broad structure of progression from Foundation years through core and specialist training to the award of a Certificate of Completion of Training is likely to continue for the foreseeable future. Technological developments including robotics, genomics and artificial intelligence together with an extension of the surgical team are likely to alter dramatically the nature of surgery in the future. Surgical training will need to incorporate training in new technologies, including simulation, which will be provided in the workplace, academic institutions and commercial facilities. There will be greater emphasis on non-technical skills and human factors, especially in relation to the use of new technologies and working in wider teams, including non-medical staff. Genomics will play an increasing role in determining individualized patient care, with a need for surgeons to have an understanding of this field and communicate this to their patients. Surgical training will need to be suitably flexible in order to accommodate these developments, to allow more part-time working and portfolio careers, and to encourage recruitment and retention.     

Robotic surgery: a current perspective

OBJECTIVE: To review the history, development, and current applications of robotics in surgery. BACKGROUND: Surgical robotics is a new technology that holds significant promise. Robotic surgery is often heralded as the new revolution, and it is one of the most talked about subjects in surgery today. Up to this point in time, however, the drive to develop and obtain robotic devices has been largely driven by the market. There is no doubt that they will become an important tool in the surgical armamentarium, but the extent of their use is still evolving. METHODS: A review of the literature was undertaken using Medline. Articles describing the history and development of surgical robots were identified as were articles reporting data on applications. RESULTS: Several centers are currently using surgical robots and publishing data. Most of these early studies report that robotic surgery is feasible. There is, however, a paucity of data regarding costs and benefits of robotics versus conventional techniques. CONCLUSIONS: Robotic surgery is still in its infancy and its niche has not yet been well defined. Its current practical uses are mostly confined to smaller surgical procedures.     

The future surgical training paradigm: Virtual reality and machine learning in surgical education

Surgical training has undergone substantial change in the last few decades. As technology and patient complexity continues to increase, demands for novel approaches to ensure competency have arisen. Virtual reality systems augmented with machine learning represents one such approach. The ability to offer on-demand training, integrate checklists, and provide personalized, surgeon-specific feedback is paving the way to a new era of surgical training. Machine learning algorithms that improve over time as they acquire more data will continue to refine the education they provide. Further, fully immersive simulated environments coupled with machine learning analytics provide real-world training opportunities in a safe atmosphere away from the potential to harm patients. Careful implementation of these technologies has the potential to increase access and improve quality of surgical training and patient care and are poised to change the landscape of current surgical training. Herein, we describe the current state of virtual reality coupled with machine learning for surgical training, future directions, and existing limitations of this technology.     

Adapting for the future: flexibility of UK postgraduate training

Postgraduate surgical training has undergone repeated reforms alongside changes in terms of employment. The broad structure of progression from Foundation years through core and specialist training to the award of a Certificate of Completion of Training is likely to continue for the foreseeable future. Technological developments including robotics, genomics, and artificial intelligence together with an extension of the surgical team are likely to alter dramatically the nature of surgery in the future. Surgical training will need to incorporate training in new technologies, including simulation, which will be provided in the work-place, academic institutions, and commercial facilities. There will be greater emphasis on non-technical skills and human factors, especially in relation to the use of new technologies and working in wider teams, including non-medical staff. Genomics will play an increasing role in determining individualized patient care, with a need for surgeons to have an understanding of this field and communicate this to their patients. Surgical training will need to be suitably flexible in order to accommodate these developments, to allow more part-time working and portfolio careers, and to encourage recruitment and retention.     

Review and current update of robotic-assisted laparoscopic vascular surgery

The field of vascular surgery is constantly evolving and is unsurpassed in its innovation and adoption of new technologies. Endovascular therapy has fundamentally changed the treatment paradigms for aneurysm and occlusive disease. As we continue to make advances in not only endovascular therapy, but also robotic surgery, artificial intelligence, and minimally invasive surgery, it is important that the vascular community stay at the forefront. Topics include the advantages of laparoscopic and robotic surgery over open surgery for aortic procedures, robotic versus laparoscopic aortic surgery, patient candidacy for robotic-assisted aortic surgery, and how to increase training and adoption of robotic-assisted laparoscopic aortic surgery. Future growth includes the development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics in vascular surgery.     

The value of haptic feedback in conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review

Background  Virtual reality (VR) as surgical training tool has become a state-of-the-art technique in training and teaching skills for minimally invasive surgery (MIS). Although intuitively appealing, the true benefits of haptic (VR training) platforms are unknown. Many questions about haptic feedback in the different areas of surgical skills (training) need to be answered before adding costly haptic feedback in VR simulation for MIS training. This study was designed to review the current status and value of haptic feedback in conventional and robot-assisted MIS and training by using virtual reality simulation. Methods  A systematic review of the literature was undertaken using PubMed and MEDLINE. The following search terms were used: Haptic feedback OR Haptics OR Force feedback AND/OR Minimal Invasive Surgery AND/OR Minimal Access Surgery AND/OR Robotics AND/OR Robotic Surgery AND/OR Endoscopic Surgery AND/OR Virtual Reality AND/OR Simulation OR Surgical Training/Education. Results  The results were assessed according to level of evidence as reflected by the Oxford Centre of Evidence-based Medicine Levels of Evidence. Conclusions  In the current literature, no firm consensus exists on the importance of haptic feedback in performing minimally invasive surgery. Although the majority of the results show positive assessment of the benefits of force feedback, results are ambivalent and not unanimous on the subject. Benefits are least disputed when related to surgery using robotics, because there is no haptic feedback in currently used robotics. The addition of haptics is believed to reduce surgical errors resulting from a lack of it, especially in knot tying. Little research has been performed in the area of robot-assisted endoscopic surgical training, but results seem promising. Concerning VR training, results indicate that haptic feedback is important during the early phase of psychomotor skill acquisition.     

In vivo miniature robots for natural orifice surgery: State of the art and future perspectives

Natural orifice translumenal endoscopic surgery (NOTES) is the integration of laparoscopic minimally invasive surgery techniques with endoscopic technology. Despite the advances in NOTES technology, the approach presents several unique instrumentation and technique-specific challenges. Current flexible endoscopy platforms for NOTES have several drawbacks including limited stability, triangulation and dexterity, and lack of adequate visualization, suggesting the need for new and improved instrumentation for this approach. Much of the current focus is on the development of flexible endoscopy platforms that incorporate robotic technology. An alternative approach to access the abdominal viscera for either a laparoscopic or NOTES procedure is the use of small robotic devices that can be implanted in an intracorporeal manner. Multiple, independent, miniature robots can be simultaneously inserted into the abdominal cavity to provide a robotic platform for NOTES surgery. The capabilities of the robots include imaging, retraction, tissue and organ manipulation, and precise maneuverability in the abdominal cavity. Such a platform affords several advantages including enhanced visualization, better surgical dexterity and improved triangulation for NOTES. This review discusses the current status and future perspectives of this novel miniature robotics platform for the NOTES approach. Although these technologies are still in pre-clinical development, a miniature robotics platform provides a unique method for addressing the limitations of minimally invasive surgery, and NOTES in particular.     

Esophageal atresia,Europe, and the future: BAPS Journal of Pediatric Surgery Lecture

Europe has changed remarkably over the past decades and so have concepts and outcomes of esophageal atresia repair. In this article, both the efforts to create a united Europe and the achievements in dealing with esophageal atresia from the 1950s on are outlined. Furthermore, this paper deals with the future of pediatric surgery and is focused on two aspects: the “Fourth Industrial Revolution” which builds on the digital revolution, artificial intelligence and robotics, and its potential impact on pediatric surgery and the life of patients. I suggest that pediatric surgeons should participate and lead in the development of machine learning, data control, assuring appropriate use of machines, control misuse, and in particular ensure appropriate maintenance of ethical standards. Changes in health care structures within Europe, in particular the effect of centralization, will affect the concept of treatment for patients with rare diseases.     

Emerging technologies for surgery in the 21st century.

Laparoscopic surgery is a transition technology that marked the beginning of the information age revolution for surgery. Telepresence surgery, robotics, tele-education, and telementoring are the next step in the revolution. Using computer-aided systems such as robotics and image-guided surgery, the next generation of surgical systems will be more sophisticated and will permit surgeons to perform surgical procedures beyond the current limitations of human performance, especially at the microscale or on moving organs. More fundamentally, there will be an increased reliance on 3-dimensional images of the patient, gathered by computed tomography, magnetic resonance imaging, ultrasound, or other scanning techniques, to integrate the entire spectrum of surgical care from diagnosis to preoperative planning to intraoperative navigation to education through simulation. By working through the computer-generated image, first with preoperative planning and then during telepresence or image-guided procedures, new approaches to surgery will be discovered. These technologies are complemented by new educational opportunities, such as tele-education, surgical simulation, and a Web-based curriculum. Telementoring will permit further extension of the educational process directly into the operating room.     

血管介入手术机器人及其力反馈技术研究进展

血管介入手术是一种利用导管和导丝等器械，在视觉影像引导下，通过皮肤微创穿刺进入血管，对病变部位进行诊疗的手术方式。它具有创伤小、恢复快、并发症少等优点，已成为心脑血管疾病等多种疾病的首选治疗方法。然而，由于血管的狭窄性和复杂性，在血管内部操作导管难以做到，加重了医生的认知负荷，延长了手术时间，继而增加操作者和患者的疲劳程度以及手术风险。另一方面，血管介入手术对医生操作熟练程度要求高，而可以开展大量手术的医生数量有限。这些都大大限制了血管介入手术的广泛应用。为了解决这些问题，机器人辅助血管介入手术因其精确性、灵活性、便捷性已经受到患者和医生的共同期待，是实现血管介入手术远程化、智能化、数字化的重要手段。然而，相对于血管介入手术机器人图像导航、机械臂结构等其他关键技术，力反馈技术仍然有较大空白，力反馈的缺失使其在复杂困难病变、钙化病变、慢性闭塞病变中的应用受到了限制。故笔者在此分析血管介入手术机器人力反馈技术的基本问题、实现方式和技术需求，并结合国内外研究进展，探讨了力反馈技术的发展方向，为血管介入手术机器人力反馈技术的研究提供了理论参考和实践指导。从工程设计的角度出发，从人手感知力问题和...     

Looking forward

With the rapid acceleration of technology, fundamental changes in the science of surgery are emerging within the lifetime of a surgeon's practice. This review includes the technologies of information systems, robotics, virtual reality, simulation and training, directed-energy surgical instruments, photonics, and brain chips, as well as their impact on the practice of surgery. Also considered are those technologies that may replace surgery, such as genetic engineering, tissue engineering, suspended animation, and nanotechnology. The evidence for each of these technologies is presented as preliminary reports of their success in research laboratories.     

Robotic surgery

The industrial revolution demonstrated the capability of robotic systems to facilitate and improve manufacturing. As a result, robotics extended to various other domains, including the delivery of health care. Hence, robots have been developed to assist hospital staff, to facilitate laboratory analyses, to augment patient rehabilitation, and even to advance surgical performance. As robotics lead usefulness and gain wider acceptance among the surgical community, the urologist should become familiar with this new interdisciplinary field and its “URobotics” subset: robotics applied to urology. This article reviews the current applications and experience, issues and debates in surgical robotics, and highlights future directions in the field.     

Augmented and virtual reality in spine surgery,current applications and future potentials

BACKGROUND CONTEXTThe field of artificial intelligence (AI) is rapidly advancing, especially with recent improvements in deep learning (DL) techniques. Augmented (AR) and virtual reality (VR) are finding their place in healthcare, and spine surgery is no exception. The unique capabilities and advantages of AR and VR devices include their low cost, flexible integration with other technologies, user-friendly features and their application in navigation systems, which makes them beneficial across different aspects of spine surgery. Despite the use of AR for pedicle screw placement, targeted cervical foraminotomy, bone biopsy, osteotomy planning, and percutaneous intervention, the current applications of AR and VR in spine surgery remain limited.PURPOSEThe primary goal of this study was to provide the spine surgeons and clinical researchers with the general information about the current applications, future potentials, and accessibility of AR and VR systems in spine surgery.STUDY DESIGN/SETTINGWe reviewed titles of more than 250 journal papers from google scholar and PubMed with search words: augmented reality, virtual reality, spine surgery, and orthopaedic, out of which 89 related papers were selected for abstract review. Finally, full text of 67 papers were analyzed and reviewed.METHODSThe papers were divided into four groups: technological papers, applications in surgery, applications in spine education and training, and general application in orthopaedic. A team of two reviewers performed paper reviews and a thorough web search to ensure the most updated state of the art in each of four group is captured in the review.RESULTSIn this review we discuss the current state of the art in AR and VR hardware, their preoperative applications and surgical applications in spine surgery. Finally, we discuss the future potentials of AR and VR and their integration with AI, robotic surgery, gaming, and wearables.CONCLUSIONSAR and VR are promising technologies that will soon become part of standard of care in spine surgery.     

Image-guided robotic surgery

Medical image processing leads to an improvement in patient care by guiding the surgical gesture. Three-dimensional models of patients that are generated from computed tomographic scans or magnetic resonance imaging allow improved surgical planning and surgical simulation that offers the opportunity for a surgeon to train the surgical gesture before performing it for real. These two preoperative steps can be used intra-operatively because of the development of augmented reality, which consists of superimposing the preoperative three-dimensional model of the patient onto the real intraoperative view. Augmented reality provides the surgeon with a view of the patient in transparency and can also guide the surgeon, thanks to the real-time tracking of surgical tools during the procedure. When adapted to robotic surgery, this tool tracking enables visual serving with the ability to automatically position and control surgical robotic arms in three dimensions. It is also now possible to filter physiologic movements such as breathing or the heart beat. In the future, by combining augmented reality and robotics, these image-guided robotic systems will enable automation of the surgical procedure, which will be the next revolution in surgery.     

In vivo laparoscopic robotics

Robotic laparoscopic surgery is evolving to include in vivo robotic assistants. The impetus for the development of this technology is to provide surgeons with additional viewpoints and unconstrained manipulators that improve safety and reduce patient trauma. A family of these robots have been developed to provide vision and task assistance. Fixed-base and mobile robots have been designed and tested in animal models with much success. A cholecystectomy, prostatectomy, and nephrectomy have all been performed with the assistance of these robots. These early successful tests show how in vivo laparoscopic robotics may be part of the next advancement in surgical technology.