Roshan Lall Gupta’s Recent Advances in Surgery (Volume 18) Prof Puneet
Page numbers followed by b refer to box, f refer to figure, fc refer to flowchart, and t refer to table.
Abdomen 81f
acute 186
lower 106
ultrasonography of 61, 63t
upper 106
Abdominal drains 178
usage of 178
Abdominal surgery, elective 180
Abdominal wall, layers of 100
Ablative therapies 168
Abortion 59
Abscess 61, 68, 69
intra-abdominal 67
Absorption 18f
Acetaminophen 177
Achalasia 43, 44f
cardia 43, 44f
diagnosis of 43
Achlorhydria 77
Acute abdominal decision making model 11
Acute appendicitis 53, 54, 58, 63, 63t, 68t, 71
diagnosis of 53, 61
intraoperative grading of 67
Adenocarcinoma 137
staging system of 77
adrenal 152
non-functional 153
Adenoneuroendocrine carcinoma, mixed 77
Adjuvant chemotherapy 185, 254
use of 266
Adrenal adenoma, contrast-enhanced computed tomography of 158f
Adrenal gland, hypersecreting 161
Adrenal hyperplasia, bilateral 164
Adrenal incidentaloma 151153, 155t, 159b
differential diagnosis of 152, 153f
majority of 152
management of 151, 160
Adrenal masses, malignant 158t
Adrenal tumors, nonfunctional benign 166
Adrenalectomy 162f
laparoscopic 161, 165
Adrenaline 151, 174
Adrenocortical carcinoma 153155
contrast-enhanced computed tomography of 158f
management of 166
Adrenocorticotropic hormone 155, 174
confirmation of 156
Adult appendicitis score 54, 5658, 62
Advanced vessel sealing devices 67
Adverse allergic reactions 19
Albumin 19
ischemia-modified 60
Aldosterone 153
hypersecretion 154
secreting lesions 164
serum 156
simultaneous hypersecretion of 156
Aldosteronism 156
subclinical primary 164
surgical outcome, primary 165
Aldosteronomas 164
Alkaline phosphate 115
Allergy 198
Alpha-blockers 156
Alpha-fetoprotein 261, 262, 266
Alvarado scoring method 54
Alvimopan 179
American Association for Surgery of Trauma 68
American College of Gastroenterology 136, 142
American College of Surgeons National Surgical Quality Improvement Program 7, 66
American Joint Committee on Cancer 264
Tumor 75
American Society of Anesthesiologists 176, 181, 198
classification 7
Amniotic membrane 239
allograft 239
multimodal 181, 187
patient-controlled 179
Analgesics 176
drugs, usage of 178
Anaplastic lymphoma kinase 216
Anastomotic biliary stricture 127
excess 155
hypersecretion, majority of 156
Androstenedione 156
Anesthesia 7, 181
local 198
monitoring depth of 7
regional 198
thoracic epidural 198
Anesthetic gases, humidification of 178
Angiodysplasia 137, 138, 140, 142
Angioectasia 138
Angioembolization 142f
Angiography 35, 146
Angiomatous malformations 138f, 143
diagnosis of 141
Angiotensin-converting enzyme inhibitors 156
Angiotensin-receptor blockers 156
Ankle-brachial pressure index 229
Anomalous biliary anatomy, suspicion of 26
Antibiotics 235
prophylaxis 187
Antiemetics, different class of 177
Antigen, carcinoembryonic 250
Anti-hypertensive medication 156, 165
Antimicrobial prophylaxis 181
Antiseptics 235
Anxiety 154, 175
Anxiousness 90
Aortoenteric fistula 138
Apfel score 177
Aphasia 218
Appendectomy 64, 69
laparoscopic 67, 70
timing of 66
Appendiceal neuroendocrine tumors 95
Appendicectomy, incidental 53
Appendicitis 61, 63, 70
acuta multicenter 64
acute 53, 54, 58, 63, 63t, 68t, 71
complicated 67, 70
inflammatory response 54, 56, 57, 62
score 57
perforated 69
uncomplicated 6467, 71
urinary biomarker 60
Appendix 68
region of 61
Areola, removal of 253
Argentaffinomas 74
Armamentarium 82
Arrhythmias 154
Arterial blood gas 187
Arterial disease, peripheral 229
Arterial reconstruction, benefit of 119
Arteriovenous malformations 141
surgery 33
Artery, pulmonary 203, 204f
Artificial intelligence 19, 10f, 1113, 201
applications of 3
limitations of 11
role of 5, 7, 11,
tools, Gartner hype cycle for 4f
use of 5f
Artificial neural networks 2
Aspirin 240
Asthma 176
Atezolizumab 215
Atherosclerosis 33
Atrophie blanche 226
Atrophy-hypertrophy complex 26
Autoimmune disorders 131
Autoimmune inflammatory disease 131
Autologous peripheral blood mononuclear cells 218
Autologous stem cell transplantation 273
Autonomic nervous system 174
Autonomous cortisol secretion 155
mild 162
Avelumab 215
Axicabtagene ciloleucel 218
Axillary nodes, assessment of 252
dilatation 130
serial inflation of 144
acute lymphocytic leukemia 218
malignancy 218
maturation antigen 218
Benign biliary stricture 113, 113t, 118t, 126, 126f, 128, 129
management of 113
repair 26
Beta-human chorionic gonadotropin 261, 262, 266
Beta-lipoprotein 19
Bile duct
anastomosis, end-to-end 124
injury 26, 114, 120, 121t
mucosa 118
sharp transection of 124
stricture 122
Biliary anatomy, delineation of 25
Biliary anomalies 127
Biliary cirrhosis, secondary 126
Biliary enteric anastomosis 126
Biliary injury, management of 116
Biliary stricture
benign 113, 113t, 118t, 126, 126f, 128, 129
classification of 120
Biliary tract, surgery of 25
Biliary tree 26, 116
anomalies 23
Bilioenteric anastomosis 113, 129
Biliopathy, portal 113
Biopsy 81f, 160
forms of 253
metastatic lesion 261
pleural 195
Bipolar energy devices 67
Bisacodyl 179
Bismuth classification 121t
Bispectral index 7
disorders 140
duration of 139
gastrointestinal 136, 143
intestinal 136
lesions 144
types of 144, 144t
occult 144
overt 144
pattern of 140
rates 146
source of 136
Bleomycin 269, 270
circulation 35
pressure 181
Blurred vision 90
mass index 198
temperature 55
Botulinum injection 46
disease, inflammatory 137
preparation 177, 181
mechanical 173, 181
severe hypoperfusion of 30
Branched-chain aminotransferase 232
Breast 153
cancer 35, 216, 251
carcinomas 214
conservation surgery 253, 254
Paget's disease of 249, 251f
reconstruction 255f
skin-saving mastectomy 255f
surgery 30
tumor 255
Buffalo hump 161
Burn wounds, grading of 35
Calcifications 128
Calcitonin gene-related peptide 238
channel blockers 156
dobesilate 240
Calf muscle pump 224
screening for 228
Calf perforator vein 227
Calot's triangle 26
Calprotectin, exclusion of 60
Cameron's erosions 141
Cancer 211
cell 211
invasive 255
cervical 216
colorectal 131, 214
endometrial 216
esophageal 195, 196, 216
gallbladder 131
head and neck 216
immunotherapy 214
increasing stage of 255
prostate 219
vaccines 218
Capecitabine 81f, 85
directed deep enteroscopy 145
endoscopy 142144, 144t, 148
complex 176
rich liquids 175
Carbon dioxide insufflator 42
Carboplatin 85, 273
single cycle of 275
Carcinoid syndrome 77, 78, 95
incidence of 77
management of 83
symptoms of 95
Carcinoid tumor 74, 137
Carcinoma 137
adrenocortical 153155
colorectal 214
embryonal 259, 268
endometrial 217
hepatocellular 6, 214
invasive 249
neuroendocrine 76, 76f, 86
rectum 32f
urothelial 216
Cardiac index 177
Cardiomyopathy, hypertrophic 140
Cardiopulmonary bypass oxygenator 34
Cardiothoracic surgery 33
side hustle of 194
Cardiovascular disease, severe 138
Carinal resections 197
Catecholamines 153
excessive 90
hypersecretion 154
production of 174
Central nervous system 218
toxicity 272
Central venous catheter 21
Cerebral atrophy 272
Cerebrovascular surgery 32
Champagne glass sign 44f
Charge-coupled device 19
Chemoembolization, transarterial 96, 113
Chemokines 215
Chemotherapy 85, 273
adjuvant 185, 254
conventional dosage 273
cycles of 275
first cycle of 272
high-dose 273
hyperthermic intraperitoneal 8
Chest wall 194, 196
Chimeric antigen receptor T-cell therapy 217
Chlorhexidine-based solution 176
Cholangiocarcinoma 130, 131
Cholangiography 26
intraoperative 24
Cholangiopancreatography 116
eosinophilic 113
inflammatory 113
single-operator 122
Cholecystectomy 26, 113
laparoscopic 25
Cholecystitis, acute 26
Cholecystokinin 78
Choledochojejunostomy 129
Cholelithiasis, development of 83
Choriocarcinoma 259, 268
Chromogranin 75
Chronic venous disease 225
Ciltacabtagene autoleucel 218
Cirrhosis 138, 140
Cisplatin 85, 269, 270, 273
Clinical prediction rules 54, 55t, 57t
Clinical scoring system 54, 62f
Clot evacuation 196
Coagulation disorders 198
Coagulopathy 140
Coley's therapies 215
Colon adenocarcinomas 217
Colorectal anastomosis, vascularity of 27
Colorectal surgery, emergency 185
Common bile duct 26, 114, 121
junction 27f
Complex oncological operations 195
Complex surgical procedure 11
Component separation techniques 108
materials 237
methods 237
stockings 238
therapy 236
Computed tomography 62, 80, 81f, 84f, 92f, 118, 136, 145, 147, 148, 151, 152, 158
abdomen 61
angiography 145
contrast-enhanced 78, 87f, 261f, 262f, 271f
role of 230, 263
three-dimensional 194, 202
Computer vision 2, 4f, 8
Concomitant vascular injury 120
Confocal laser endomicroscopy 118
Confusion 90, 218
Conn's adenoma 153, 161f, 165
Conn's syndrome 154
Continuous positive airway pressure 187
Cooper's ligaments 103
Corona phlebectatica 226
Coronary artery bypass surgery 33
Cortisol 78, 174
hypersecretion 153
diagnosis of 156
levels 156
secreting lesions 161
simultaneous hypersecretion of 156
COVID-19 pandemic 186
Cowden disease 140
C-reactive protein 57
Crohn's disease 137, 143
Cronkhite-Canada syndrome 140
Cross-leg flaps 239
Crural vein 227
Cryptorchidism 260
Crystalloid administration, intraoperative 177
Cushing's adenoma 153, 161f
Cushing's syndrome 77, 162
clinical features of 161
Cyanoacrylate embolization 244
Cystic duct 26
clipping of 123
Cysts 153
concentrations 234
inflammatory 223
release syndrome 218
Cytometry, advantage of 213
Cytotoxic T-lymphocyte antigen 215
da Vinci robotic surgical system 20, 21f
Deep enteroscopy 144, 147
road map for 143
Deep learning 4f
Deep vein thrombosis 93, 224
Deficient mismatch repair 216, 217
Dehydration 239
Dehydroepiandrosterone sulfate 155
testing serum levels of 156
Dense fibrous Glisson's sheath 23
Dense perihepatic fibrosis 25
Deoxyribonucleic acid 212
damage, cisplatin-induced 274
Depression 93
Dermal backflow pattern 34
Dermatitis 93
Device-assisted deep enteroscopy 144, 145
Diabetes mellitus 46, 93, 176, 181
Diabetic autonomic neuropathy 47
Diaphragm 196
Diaphragmatic hernia repair 196
Diaphragmatic plication 196
Diarrhea 83, 85, 87f, 93, 94
Dieulafoy's lesion 137, 139
Diffuse neuroendocrine cell system 74
Digestive system tumors, WHO classification of 75
Digital subtraction angiography, intraoperative 32
Disseminated bilobar metastasis 96
Diverticula, multiple 139f
Dor's fundoplication 45
enteroscopy 144
technique 144
Doxazosin 156
Drainage, percutaneous 69, 70
Ductal carcinoma in situ 251f
Ductal ectasia 252
Ductotomy 125
Duodenal nets 87
Duodenal neuroendocrine tumors 88fc
Duodenum 136
Dyspepsia 87f
Dysrhythmia, cardiac 163
Echocardiography, transthoracic 178
Eckardt score 45
Eczema 226
Edema 68, 226
Elastic bandages 237
Electroencephalogram 177
Electromagnetic therapy 238
Electronic health records 3
Electrosurgical unit 42
Embolization, transarterial 146
Emilos 105
Empyema thoracis 195
En bloc resection 49
Endoclips 49
response 175
symptoms 95
system 174
Endoloops 42, 70
Endoscopes, high-definition 42
Endoscopic devices 42
Endoscopic fundoplication, role of 46
Endoscopic resection techniques 86
Endoscopic retrograde
cholangiopancreaticography 116
cholangiopancreatography 116, 118t
Endoscopic treatment 129, 130
Endoscopic ultrasound 79, 87f, 88, 118
major advantage of 79
Endoscopy 146
conventional 41
gastrointestinal 5
Endothelial cell injury 223
Endotracheal tube 203
Endowrist instruments 199f
Energy metabolism 211
Enhanced recovery after surgery 148, 173, 181, 182f
elements 182f, 189f
Enteral nutrition, early 181
Enterochromaffin cells 74, 85
Enterography 146
Enteroscope, distal tip of 144
Enteroscopy 136, 143, 144t
antegrade 144
comparison of 144
intraoperative 147
retrograde 144
Epidermal growth factor receptor 216
Epidermal wound bed, gene expression of 232
Epidermotropic theory 250
Epirubicin 273
Epithelial membrane antigen 250
Epithelization, essential for 232
Esophageal lumen, dilatation of 43
Esophageal obstruction, complex 43
Esophageal spasm, diffuse 43
Esophageal sphincter pressure, lower 45
Esophagectomy 29, 183, 196
Esophagogastric junction 43
Esophagus 136, 194, 196
abnormal contraction waves of 43
restoration of 48
Estradiol 156
Estrogen receptor 251f, 255
Etoposide 85, 269, 270
European Association of Endoscopic Surgery 69
European Association of Urology guidelines 263
European Network for Study of Adrenal Tumors 166
European Neuroendocrine Tumor Society 76
European Organisation for Research and Treatment of Cancer 254
European Society for Medical Oncology 263
European Society of Endocrine Surgeons 166
European-African Hepato-Pancreato-Biliary Association 124
Everolimus 85
Ex vivo lung perfusion 202, 203, 204f
systems 204f
Extracellular matrix 205
Extracorporeal sutures 102
Extrahepatic disease 97
Fat, subcutaneous 107
Femoral vein 227, 231
common 227, 231
deep 227
Fibrinous exudate 68
growth factor 234
proliferation 234
Fibrogenesis 234
Fibrosis, pancreatic 128
Fibrous stroma 76f
Fine-needle aspiration 118
Flap reconstruction 239
Flatulence 83
Flu-like symptoms 218
Fluorescence 32f
angiography 26, 28
based flow cytometry 212
cholangiography 26
detector 20f
emission wavelength spectrum of 18f
guided brain tumor surgery 33
guided surgery 17
scores 17
imaging system, basic configuration of 20f
intravenous injection of 118
microscopy 213
properties 18
visualization of 24
Fluorescent in situ hybridization 130
Fluorodeoxyglucose 81, 81f, 158, 166, 263, 269
positron emission tomography 152
Fluorouracil 85
Four-D syndrome 93
Frank ischemia 30
Free tissue transfer 239
Frey's procedure 129
Functional adrenal lesion, removal of 164
Fungal infections 153
Gabapentin 177
Gallbladder 26, 131
cancer 131
Gallium 80, 92f
Ganglioneuroma 153
Gangrenous appendix 68
Gardner syndrome 140
Gastrectomy, total 86
acid secretion 86
adenocarcinoma 86
antral vascular ectasia 137
conduit formation 29
decompression 173
dysmotility 46
emptying, delayed 176
mucosa 85
nets 85, 88fc
classification of 86t
peroral endoscopic myotomy 46, 47
resection 114
Gastrin 78
Gastrinoma 91, 92
symptoms of 93
triangle 93
Gastrocnemius vein 227
Gastroduodenal neuroendocrine tumors 85
Gastroenteropancreatic nets, WHO classification for 76t
Gastroenteropancreatic neuroendocrine tumor 74, 75, 78
principles of management of 82
site-specific 85
Gastroenteropancreatic system, neuroendocrine tumors of 74
Gastroepiploic vessels 29
Gastroesophageal junction 43
Gastroesophageal reflux disease, post-treatment 43
Gastrointestinal stromal tumor 43, 137, 138f
Gastrointestinal surgery 173
elective upper 180
emergency 184
upper 46
Gastrointestinal system 74
Gastrointestinal tract 42f
lower 136
lumen of 41
Gastroparesis 43, 47
Gemcitabine 273
expression 232
profile 212
minimal expression of 212
Genetic markers, nephrotoxicity-related 276
Germ cell
neoplasia in situ 258, 267, 259
tumors 259, 262
management of 267
nonseminomatous 259, 262, 266, 270fc
Glands, adrenal 151
Glucagon 78, 174
Glucagonoma 91, 93
Glucocorticoids 174
Glucose transporter, expression of 81
Glutathione S-transferase transporter protein 19
Goal-directed fluid therapy 177, 181, 187
Gome's grading 68
Gonadoblastoma 259
Gon-germ cell tumors 258
dysfunction, primary 203
failure, long-term 33
macrophage colony-stimulating factor, protein of 218
monocyte colony-stimulating factor 238
Granulomatous diseases 153
Granulosa cell tumor 259
Great saphenous vein 227, 240
high ligation of 240
stripping 241
enterochromaffin cells of 74
gangrene 185
neuroendocrine cells of 74
Handgrip dynamometry 176
Hannover classification 120
Harboring metastases 263
Health Insurance Portability and Accountability Act 13
failure, congestive 154
rate 181
Heartburn 93
Helicobacter pylori infection 93
Heller myotomy 45
Hemangioma 259
Hematemesis 140
Hematochezia 140
Hemicolectomy 95
Hemobilia 137
Hemorrhage 161f, 173
Hemostatic forceps 42
Hemosuccus pancreaticus 137
Heparin-binding epidermal growth factor 232
Hepatectomy 114, 125
partial 113
Hepatic acute phase response mediators 174
Hepatic artery
injuries 125
thrombosis 113, 127
Hepatic duct 117f
common 117f, 121
Hepatic extraction capacity 22
Hepatic metastatic lesions 24
Hepatic parenchyma, normal 25
Hepatic resection 10
segmental 125
Hepatic surgery, major 22
Hepatic tumors, fluorescence imaging for 24
Hepaticojejunostomy 124126
Hepaticotomy 125
Hepatobiliary iminodiacetic acid scan 116
Hepatoduodenal ligament 114
Hepatology intensive care unit 22
Hepp-Couinaud technique 26
defect 102f
epigastric 107f
infraumbilical incisional 109f
minimally invasive repair of 108
repair 104, 110
sac 101
ventral 101, 102f
Heyde syndrome 140
Hilum 23
Hirschsprung's disease 43, 48
Hodgkin's lymphoma 216
Holmium laser, use of 123
Hormonal hypersecretion, control of 168
Hormonal therapy 254
Hormone hypersecretion 151, 153
Horse chestnut extract 240
Hounsfield units 152, 157, 158, 159
Human amniotic membrane allografts 239
intraperitoneal onlay mesh 102
technique 107
theory 250
Hybridization signal 212
Hydralazine 156
Hydroxyethylrutoside 240
Hyperaldosteronism, primary 164
Hyperbilirubinemia 115
Hypercatecholaminism, diagnosis of 157
Hyperchromatic nuclei 76f
Hypercortisolism 156
causes of 156
Hyperemia 68
Hypergastrinemia, secondary 93
Hyperglycemia 85
Hyperplasia, intimal 33
Hypersecretion 153
resolution of 165
Hypersecretory syndromes 168
Hypertension 161, 181
gestational 163
severe 154
uncontrolled 176
venous 223
Hypoglycemia 90
intraoperative 176
Hypokalemia 77
correction of 165
Hypoparathyroidism, long-term 31
Hypotension 113, 115, 203, 218
Hypothalamic-pituitary-adrenal axis 174
Hypoxemia 203
Hypoxia 218
Ifosfamide 269, 270
Ileocecal valve 142
earlier resolution of 185
postoperative 179
Iliac fossa 56
Iliac vein
common 227
external 227
internal 227
cell profiling 211, 212b
clinical applications of 214
techniques 211
checkpoint inhibitors 211, 216t
effector cell-associated neurotoxicity syndrome 218
Immunoglobulin G4
cholangiopathy 131
sclerosing cholangitis 131
Immunohistochemistry 212
conventional 213
multiplexed 213
In situ carcinoma 249
In vivo lung perfusion 202, 205
Incidentally detected adrenal masses, management of 152fc
Incidentaloma 151, 160
adrenal 151153, 155t, 159b
Indocyanine green 17, 21, 27f, 29, 32f, 194
drug kit 20f, 21f
dye 18f
elimination 23
angiography 27, 28f
cholangiography 25
imaging 233
kinetics variables 23t
molecule 17
retention rate 24
role of 22, 25
use of 31
Indwelling urinary catheter 173
Inelastic bandages 237
Infections 85, 137
genitourinary 59
viral 219
Injection site subcutaneous nodules 83
immunologically induced 127
site of 114
Inotropes therapy 178
like growth factor-1 78
regulated peripheral transport proteins, responsiveness of 174
serum measurements of 78
Insulinoma 90, 92f
diagnosis of 92f
Intelligent machines, concept of 1
Intensive care unit 184, 187, 195, 218
Intercostal nerve blocks 198
Intermittent pneumatic compression 179, 237
Internal-external biliary catheter placement 127
International Cancer Control, union for 75
International Germ Cell Cancer Collaborative Group 263, 266, 266t
Interstitial fluid 19
Interval appendectomy, role of 70
Intestinal obstruction
acute 185
lower incidence of adhesive 125
Intestine, small 137
Intracorporeal rectus aponeuroplasty, laparoscopic 103
Intraductal ultrasound 118
Intraepidermal clear cells 250
Intraepidermal theory 250
Intrahepatic biliary radicles 115
Intralesional injection 238
Intraperitoneal onlay mesh 100102, 102f
Intratesticular mass 261
Intrinsic hepatic clearance 22
Invasive excision, laparoscopic 163
Invasive technique 146
Iodometomidate 167
Ionizing radiation 78
Ipilimumab 215, 216
Iron, deposition of 223
gradual 122
mesenteric 137
warm 203
Jackhammer esophagus 43
Japan Esophageal Society 43
Jaundice 115
Jejunal diverticula 137, 138, 139f
Jejunum 139f, 142
Keratinocytes 239
Kidney failure 93
Krenning scale scoring system, modified 81
Kulchitsky cell tumors 74
Lactate dehydrogenase 262, 266
Lactiferous duct 253
Lanthanide metals 213
Laparoscopy 27f
Laparotomy, emergency 177, 186, 187b
ablation, endovenous 240, 243
speckle imaging 232
surgery 224
healing, venous 231
nonhealing venous 232
venous 223, 239
Leiomyoma 43
esophageal 196
adrenal 153
adrenocortical 167
functional 161
nonfunctional 168
duodenal 87f
multifocal 24
submucosal 143
ulcerative 143
Leucine-rich alpha-2-glycoprotein 60
lymphoblastic 218
myeloid 218
Leukocyte adhesion 240
Leukoencephalopathy, progressive multifocal 272
Levofloxacin 66
Leydig cell tumor 259
Ligation 123
Lipid-rich adrenal adenoma, diagnostic of 159
Lipodermatosclerosis 226
blood flow 22
chronic 23
metastatic 96
extraction capacity 22
failure 126
function, dynamic assessment of 22
functional reserve 23
lesion 6, 9
metastasis 79f, 80f, 95
resection 22
segment 9
surgery 22
transplantation 22, 23, 82, 113, 126
Achilles heel of 127
Low-dose dexamethasone suppression test 155, 156
Low-molecular-weight heparin 179, 240
Lumbar hernias 103
Lung 153, 195
bioengineering 205
biopsy 195
cancer 195
staging thoracoscopy for 195
emphysematous 195
end-stage 205, 206
injury, ventilator-associated 198
nodule biopsy 195
perfusion, isolated 202
resections, sublobar 201
transplantation 202, 203
tumors 202
Lymph node
biopsy 195
conglomerated mass of 261f
enlarged 255
interaortocaval 262f, 271f
mesenteric 95
para-aortic 95, 261
retroperitoneal 270
Lymphadenectomy 86, 114
locoregional 167
Lymphedema, treatment of 34
Lymphoma 137
Lymphovascular invasion 267
Lytic replication 219
Machine learning 2, 4f, 12
Macroscopic fat, large areas of 157
Magic bullet 11
Magnetic compression anastomosis 122
Magnetic resonance
cholangiopancreatography 23, 118
enterography 145
imaging 5, 78, 79, 80f, 152, 253f, 261
role of 262
scans 151
venography, role of 230
Makuuchi decisional algorithm 24fc
Malignancy 140, 157
clinical signs of 253
colorectal 30
extra-adrenal 153
features of 159b
primary operable 160
Maltodextrin 176
Mammogram 251f
Mammography 252
Mannheim peritonitis index 176
Mass, adrenal 157, 160
Mastectomy 253
metallopeptidase 2 234
metalloproteinases 223
Maximum intensity projection 81f, 84f
May-Thurner syndrome 224
Mean arterial pressure 177
Mechanical obstruction, absence of 46
Meckel's diverticulum 137139, 146
Mediastinum 195
Medico-legal litigation 9
Melanoma 153, 216
cutaneous 30
Melena 140
Mesenteric lymph node 95
metastasis 95
Mesh materials, types of 100
Mesh placement 101f, 106, 109f
rectrorectus space 107f
Mesoappendix dissection 67
Metal stents, self-expanding 122
Metastasectomy, pulmonary 205
Metastasis 153, 154, 160
colorectal 6
Metastatic disease 261
evaluation of 78
management of 89
staging of 78
Methylxanthine 240
Metoclopramide 46
Metronidazole 66
Microarrays technology 212
Microcalcifications 252
Micronized purified flavonoid fraction 240
Microwave 96
ablation, endovenous 240
Minimally invasive
adrenalectomy procedure 163
approach 90, 178
endoscopic procedure 42
excision 163
surgery 4f, 9, 25, 181, 195
techniques 175, 178, 194
thoracic surgery 194, 199
Mini-phlebectomy 241
Mirizzi syndrome 113
Mitotic rate 75
Mitral regurgitation, severe 140
Mobilization 235
Molecular mass 18
Molecular targeted therapy 85
Monoclonal antibody 218
Monopolar energy devices 67
Moon facies 161
Mucosa 47
duodenal 47
Mucosal defect 42
Multicentric microcalcification 251f
Multilayer inelastic bandages 237
Multiorgan damage 218
Multiple endocrine neoplasia 75, 77, 86, 88, 154
Multiple intrahepatic strictures 130
Muscle wasting 175
Muscular vein 227
Myelolipoma 153, 161f
adrenal 158f
benign 157
Myotomy 42
anterior 46
endoscopic 44
site of 46
Nasogastric tube 173
National Comprehensive Cancer Network 263
Natural killer 174
Natural orifice transluminal endoscopic surgery 4f, 41
Nausea 83, 177, 182f
Near-infrared spectroscopy 230
Necrolytic migratory erythema 93
Necrosis, transmural 30
Needle aspiration cytology 118
Negative predictive value 263
Negative pressure wound therapy 238
Nerve-sparing retro-peritoneal lymph node dissection 270
Neuroblastoma 153
Neuroendocrine liver metastases 96
evaluation of 79
Neuroendocrine non-neuroendocrine neoplasm 76, 77
Neuroendocrine tumors 7476, 81f, 84f, 86, 87f, 91, 92f, 152
colorectal 95
Neurofibromatosis 75, 77, 154
Neuroglycopenia 90
Neurohormonal response 174
Neuromuscular blocking agents 198
Neuron-specific enolase 75
Neuropathy, autonomic 46
Neurosurgery 32
Neutropenia 85
Neutrophils, proportion of 59, 60
areola complex 249, 250, 252, 254
reconstruction 254
region 253
complete destruction of 251
Paget's disease of 249f
reconstruction 255f
removal of 253
Nociception level 11
Non-anastomotic biliary stricture 127
Noncardiac chest organs, surgical treatment of 194
Noninvasive ventilation 187
Nonlinear fluorescence quantum 36
Nonmetastatic disease 96
Nonoperative therapy 65
Nonsaphenous vein 227
Nonseminoma 268
Nonsmall cell lung cancer 215, 216
Nonsteroidal anti-inflammatory drugs 137, 139, 179
Nonthermal options involve sclerotherapy 240
Nontumescent options involve sclerotherapy 240
Normothermia 181
intraoperative 178
North American Neuroendocrine Tumor Society guidelines 89
N-terminal pro-brain natriuretic peptide 78
Nuclear medicine-based functional imaging 79
Nutritional supplements 245
Obesity, central 161
Obstruction, venous 224
Off-pump coronary artery bypass grafting 34
Oncolytic viruses 219
Open appendectomy 67
Open surgery 100
fluorescence imaging in 19
Opioid-free analgesics 184
Orchiectomy 266
care system lung 203
failure 30
triangular-shaped 151
Outflow obstruction 43
Ovarian cyst 59
Ovarian epithelial-type tumors 259
Overnight dexamethasone suppression test 156
Oxaliplatin 273
partial pressure, transcutaneous measurement of 233
to-see method 233
Paclitaxel 269, 273
Paget's cells 249, 250
Pain 81f
abdominal 1, 83, 115
acute 261
control 235
flank 154
Palpitation 90
Pancreas, small neuroendocrine tumor of 9
Pancreatectomy 9
fistula, postoperative 11
head lesion 92f
islet tumors 74
nets, functional 91t
neuroendocrine tumor 74, 79f, 89
functional 90
nonfunctional 89
resection 114
Pancreaticoduodenectomy 92f, 183
acute 113
autoimmune 131
chronic 113, 128, 129, 129f
Paracrine mechanisms 239
Paraganglioma syndrome, familial 154
Parasitic infestation 113
glands 31
surgery 31
Paravertebral blocks 198
Parkinson's disease 224
Partial hepatectomy 113
indications for 125
Pediatric appendicitis score 54, 56, 57
inflammatory disease 53, 59
procedures 53
vein 227
Pembrolizumab 216
single agent 215
Pentoxifylline 240
Peptic ulcer disease 91
Peptide receptor radionuclide therapy 81f, 83, 84f
Percutaneous transhepatic
approach 122
balloon stricture dilatation 125
biliary drainage 116
cholangiography 116
cholangioscopy 118
Periappendiceal adhesions increase 69
Periappendiceal phlegmon 68
Periareolar region 30
Peripheral opioid receptor blockers 181
Peripheral wide-bore cannula 21
Peritoneal tears, risk of 106
flaps 106
incision 106
Peritonitis 30
diffuse 68
Peroneal vein 227
Peroral cholangioscopy 118
Peroral endoscopic myotomy 4143, 44f, 45
steps of 44b
Per-rectal endoscopic myotomy 43, 48
Peutz-Jeghers syndrome 138, 140
Pharmacokinetics 19
Pheochromocytoma 153155, 161f, 162, 163, 164fc
contrast-enhanced computed tomography of 158f
diagnosis of 157
incidence of 163
malignant 153
recurrent 163
small noninvasive 163
subclinical 163
Phlegmon 61, 69
Photoplethysmography probes 229
Physical therapy 235
Placental site trophoblastic tumor 259
Plasma 165
aldosterone concentration 164
disappearance rate 23
free metanephrines 157
normetanephrine levels 157
renin activity 156, 164
Plastic surgery 34
Platelet derived growth factor 238
based perioperative chemotherapy 90
resistant disease 274
Plethora 161
Plethysmography 231
Pleural diseases 195
Pneumonia 7, 198
Pneumoperitoneum, creation of 101
Pneumothorax, recurrent 195
Polydioxanone 122
Polyglactic acid 122
Polymeric clips 70
Polymorphonuclear leukocytes, proportion of 57
familial adenomatous 138
syndromes 137, 140
hereditary 138
Popliteal vein 227, 231
Portal venous system 97
Ports, placement of 101
Portsmouth physiological and operative severity score 176
Positive end-expiratory pressure 187
Positron emission tomography 80, 81f, 84f, 92f, 158, 166, 263, 269
machine 79
role of 263
residual mass 276
surgery 273
bile duct injury 113
bismuth 117f
Post-coronary artery bypass grafting 33
Posterior rectus sheath 100, 107f
Posterior sheath closure 109f
Post-liver transplantation benign biliary stricture 127
Postoperative peak expiratory flow rate 183
Post-thrombotic syndrome 223
Prazosin 156
Prednisone 131
Pregabalin 177
Pregnancy 163
Preterm labor 59
Primary tumor
complete resection of 97
locoregional spread of 78
origin, regardless of 85
Progesterone 156
receptor 251f, 255
Programmed cell death protein 1 215
Progression free survival 82, 219, 266
Progressive chronic venous disease 223
Prostate cancer, metastatic castrate-resistant 219
Prostatic acid phosphatase 218
Proteolysis 234
Proteomic-based technologies 213
Proton-pump inhibitor 46, 91, 152
Proximal strictures 121
Pseudoaneurysm 142f
dye densitometry 22
pressure variation 177
Pyloric muscle ring 47
laparoscopic 46
peroral 46, 47
Pylorospasm 46
endoscopic dilatation for 46
enteritis 137
therapy 113
Radical mastectomy, modified 35
Radioembolization, transarterial 96
Radiofrequency 96
ablation 240, 242
Radiology 5
scan 146
therapy 83
Radiotherapy 269
Raja Isteri Pengiran Anak Saleha Appendicitis 54, 5658
Randomized controlled trial 188
Rapamycin, mammalian target of 85
Rapid-sequence induction 187
Reactive oxygen 223
Recklinghausen disease 75
Rectal neuroendocrine tumor 80f
Red blood cell scan 142
Relook endoscopy 141
Renal cell
cancers, metastatic 215
carcinoma 216
Renal disease, chronic 138
Rendezvous techniques, use of 121
Residual mass after chemotherapy 269fc
Respiratory complications 177
Reticular veins 226, 227
Retrograde biliary interventions 119
Retroperitoneal lymph node 270
dissection 274f
Retroperitoneum 32
nonadrenal pathology of 153
Retrorectus space creation 109f
Retrorectus telescopic dissection 104f
Retzius space 103
Reverse totally extraperitoneal procedure 105
Rheumatologic disorders 138
Rib tumors, excision of 196
Ribonucleic acid 212
Rives-Stoppa technique 108
Robotic adrenalectomy 163
Robotic biliary-enteric reconstruction 125
Robotic surgery 4, 9, 10f, 106, 199f
autonomous 13
Robotic-assisted thoracic surgery 194, 199
Rocuronium 181
Rouviere's sulcus 9
Roux-en-Y hepaticojejunostomy 118, 124
Salt supplementation 163
therapy 206
treatment 273, 274
Samuel's pediatric appendicitis score 59
Saphenous vein
anterior accessory 227
small 227
Sarcoidosis 153
Sarcomas 153
Scintigraphy 147
Sclerosing cholangitis 130f
primary 113, 129
secondary 113
Sclerosis, tuberous 75, 77
Sclerotherapy 243
Scrotal swelling, differential diagnosis of 260
Scrotum 261
Segmentectomy 201
Seizures 90
prophylaxis 218
Selective cyclooxygenase-2 inhibitors 139
Selective relaxant binding agent 181
Seminiferous tubules, germinal epithelium of 259
Seminoma 258, 259, 266, 268fc, 269, 269fc, 272
Seminomatous components 259
Sentinel lymph node
biopsy 254
mapping, use for 30
Sepsis 7, 30, 115
intra-abdominal 186
screen for 187
Septum, sides of 47
Seroma, high incidence of 107
Sertoli cell tumor 259
Serum tumor marker
characteristics of 262t
levels 261
Sex cord-stromal tumors 258, 259
Shock lung 203
Short bowel syndrome 30, 95
Single photon emission computed tomography 80
Single-balloon enteroscopy 144
assay 212
droplets 213
level 213
RNA sequencing, advantage of 213
Single-incision laparoscopic appendectomy 67
Single-nucleotide polymorphisms 212
decontamination of 176
perfusion pressure 233
saving mastectomy 254
Sleep apnea 198
Small benign adrenal masses 161
Small bowel
gastrointestinal stromal tumors 143
injury, drug-induced 137
neoplasms 139
varices 138
Small intestine
erosions 139
evaluation of 142
neuroendocrine tumors 95
tumor of 137
Small saphenous vein 227
procedures, operative technique for 241
Society of American Gastrointestinal and Endoscopic Surgeons Guidelines 69
Soft-tissue tumors 153
Soleal vein 227
analog 82, 88, 91
receptor 80, 83
overexpression of 79
Somatostatinoma syndrome 94
Somnolence 218
Spermatocytic tumor 259
Spermatogenesis 259
Sphincterotomy 113
Spinal anatomy 198
Spironolactone 164
Static stiffness index 237
Steam ablation, endovenous 240, 243
Steep learning curve 104
Stenosis 127
papillary 113
migration 46
number of 121
types of 121
Stereotactic radiosurgery 272
Steroid precursors 153
Stewart-Way classification 120
Stomach 136
adenocarcinomas 217
Strasberg classification 121t
Strasberg injuries 121
Streptococcus pyogenes 214
Streptozocin 85
Stroke volume
measurements of 177
variation 177
Subcutaneous onlay laparoscopic approach 106
Subfascial endoscopic perforator surgery 242
Submucosal tumors 43
resection of 49
Submucosal tunneling endoscopic
dissection 43
resection 49
septum division 47
Sugammadex 181
Sulodexide 240
Sunitinib 85
Superficial venous reflux 245
Suprafascial repairs 106
Suprainguinal venous obstruction evaluation 231
Surgery 1, 4, 123
colorectal 177
emergency 184
endocrine 31
gastrointestinal 173
hepatopancreaticobiliary 183
laparoscopic 20, 160, 167
reconstructive 34
reoperative 25
role of 240
Surgical site infection 66, 100, 187
rates of 183
risk of 7
Surgical stress response 174, 174fc
Suture ligation 70
Sweating 90
excessive 154
Swelling 260
painless 261
scrotal 260
Synaptophysin 75
Tachycardia 154
T-cell immune checkpoints 215
Telangiectasia 138, 226, 227
Temozolomide 81f, 85
Tenderness 115, 260
Teratoma 259, 268
syndrome 272
Testes, primary lymphatic drainage pathway of 261
Testicle 261
Testicular cancer
diagnosis of 261
management of 261
Testicular germ cell tumors 265t
Testicular tumors 258, 262t
classification of 259b
clinical features 260
diagnostic imaging 262
epidemiology 258
management of 258
prognosis 264
risk factors 260
signs of 261t
staging 264
symptoms of 261t
Testosterone 156
Therapeutic blockade 215
Thermal ablation 96
Thick wall atherosclerotic vessels 33
Thigh perforator vein 227
Third-space endoscopy 41, 42, 49
principle of 42f
procedures 43t
oncology 205
surgery 194, 201
surgical armamentarium 195
Thrombocytopenia 140
Thromboembolic events, risk of 175
Thromboembolism, venous 187
Thromboprophylaxis 179, 181
mechanical 187
Thulium laser vaporization 123
gland, dissection of 31
surgery 31
Tidal volume 187
Tisagenlecleucel 218
Tissue 249
perfusion, real-time assessment of 27
scaffold, form of 205
Tocilizumab 218
Toe pressure 229
Toker cells 250
Total endoscopic-assisted linea alba reconstruction 107
Totally extraperitoneal technique 103
Tracheobronchial tree 194
Tracheo-broncho-esophageal fistula 196
Transabdominal preperitoneal repair 105
Transabdominal retromuscular repair 106, 107f
Transabdominal retrorectus space dissection 107f
Transforming growth factor-beta 1 232
Transillumination guided rendezvous technique 48
Trans-scrotal ultrasonography 260
Transverse colon, enhancement of 28f
Transversus abdominis
plane 181
blocks 179
release 108, 109f
Trauma 113
surgery 11
Treitz ligament 136
Tremelimumab 215
Tremor 90
Tricarbocyanine molecule 18
Tuberculosis 137, 143, 153
adrenal 151
benign functional 152
cells 76f
excision 42
functional 160
grade 75
hematolymphoid 259
hypervascular 78
infiltrating lymphocytes 275
malignant 152
mediastinal 195
microenvironment 211
mutational burden 217
necrosis factor 174
neuroendocrine 7476, 81f, 84f, 86, 87f, 91, 92f, 152
nonseminomatous 269, 272
proportion score 216
stromal 137
subepithelial 49
submucosal 43
tissue 24
transcriptome of 212
types 259
Tyrosine kinase inhibitor 85
Ulcer 139
chronic venous 237f
clinical examination of 228
duodenal 184
healed 226
healing 239
lower leg 228
prevent recurrence of 245
recurrent venous 226
venous 223, 232, 234, 240
Ulnar nerve stimulation 177
endoscopic 79, 87f, 88, 118
examinations 151
high-frequency 79
high-intensity focused 240, 245
intravascular 231
Unilateral aldosterone-producing adenomas 164
Unilateral cortisol-secreting adenomas 161
Uniportal surgery, advantages of 197
Ureter identification, use for 31
Ureteral stents, placement of 32
Urinary catheter, early removal of 181
Urinary fractionated metanephrines 157
Urinary tract infection, rates of 178
Urine aldosterone levels 165
Vagotomy 46
Valve incompetence 223
Valvular reflux 224
Varicose veins 223, 226
endovenous technique for 242
Varicosities, local 241
Vascular ectasia 137
Vascular endothelial growth factor 234
Vascular injury 126
Vasculitis 137
Vasoactive intestinal
peptide 78
polypeptide 91, 238
Vater ampulla 89
Vein, anterior 227
Vena cava, inferior 34, 167, 227
VenaSeal sapheno closure system 244
Venoactive drug 240
Venography 231
Venous disease 223
Venous shear stress 223
Venous ulcer 223, 232, 234, 240
treatment of 234
typical location of 228f
Venous valve deterioration 240
Ventral hernia 102f
left-sided 101
repair 35, 100, 109t
right-sided 101
Verapamil 156
Verner–Morrison syndrome 94
Vessels, mesenteric 95
Video capsule endoscopy 142, 147
Video-assisted thoracic surgery 194, 195, 196f
indications of 195
nonintubated 197
types of 196
Video-capsule endoscopy, widespread use of 136
Video-laparoscopic cart 10
Vinblastine 269, 273
Vipoma 91, 94
Virtual-assisted lung mapping 201
Vomiting 177, 182f
von Hippel–Lindau
disease 154
syndrome 75
von Willebrand syndrome 140
Water jet 42
loss 84f, 93, 94
management 245
Werner syndrome 75
Whipple's operation 142f
Whipple's procedure 92f
Whipple's triad 92f
White blood cell 56, 57
count 60
World Society of Emergency Surgery 68
grading 68
care 236
healing 176, 232, 234
venous 232
infection 67, 238
therapies 242
Xenobiotics 260
Xiphoid 105
Yolk sac tumor 259, 268
Zenker's diverticulum 43, 47
Zenker's peroral endoscopic myotomy 47
Zollinger–Ellison syndrome 77
Chapter Notes

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Artificial Intelligence in SurgeryCHAPTER 1

Shaleen Agarwal,
Probal Neogi
Intelligence is the ability to acquire, understand, and apply the knowledge to achieve the goals. However, artificial intelligence (AI) means designing intelligence in an artificial device. In simple words, in the era of computer science, intelligent machines are created which work and react like human brain. It may perform tasks that require human intelligence such as visual perception, recognizing speech, and decision-making.1 Thus, AI may be described as an attempt to build a machine that can think like human, able to learn, and also utilize its own knowledge to solve the problem/issue.2,3 The term AI was coined by John McCarthy in 1956.
The concept of intelligent machines is not new, and such machines have been a part of human imagination for millennia. In fact, the earliest description of such a machine can be found in Greek literature in the form of a mechanical servant named “Talos.” Leonardo da Vinci described the design for a mechanical computer; however, it was in 1623 that Wilhelm Schickard built the first calculating machine called the “calculating clock” that could add or subtract six-digit numbers. Kurt Gödel, one of the leading logicians of the twentieth century, published his “incompleteness theorems” in 1931 that laid the foundation for the development of first programming language. The first operational computer was designed by Alan Turing in 1945. Alan Turing is widely considered to be the father of theoretical computer science and AI.
Artificial intelligence is a relatively new discipline of science that is an amalgamation of various other fields such as mathematics, computer science, philosophy, and biological sciences. The interaction and cross integration of these subjects promoted growth, provided vision, and simulated creation, leading to the development of AI.2,4 In the present era, theoretical understanding of neuron is increasing in biology, and computer scientists have also started preparing the prototype of the functional neurons on chip. Frank Rosenblatt (1958) first made a computational model of neurons called “Perceptron.” AI was first used by Gunn in 1976 for the evaluation of abdominal pain.12
The various AI technologies used in healthcare services include: Machine learning (ML), natural language processing (NLP), artificial neural networks (ANNs), computer vision (CV), reinforcement learning (RL), robotics, and cybernetics.2,3
Machine learning: It is a subset of AI. It enables machines to learn and provide predictions based on recognized patterns. ML may be supervised or unsupervised; in supervised, computer utilizes partial labeled data, while in unsupervised, structure is detected in the data without explicit programming to make predictions. Thus, supervised learning uses algorithms to predict a known outcome, and unsupervised learning searches for patterns within data. ML enables to utilize multiple algorithms to calculate predictions with high level of accuracy that may be unattainable with present conventional statistics.3,5 Next is RL, in which a program learns from its own success and mistake to complete the task.6
Natural language processing: It is a subfield in AI. It enables the computer to understand human language; it not only recognizes simple words but also semantics and syntax in analyzing the data. NLP is utilized in the analysis of large database of electronic medical record and detect whether any adverse events or any complications have developed in the postoperative period. NLP can comb the electronic record to identify specific word and phrases that suggest complications such as anastomotic leak following colorectal surgery.3,7
Artificial neural networks: They are a subset of ML, an important component in many AI applications, and are inspired by the biological nervous system. Each of these neural networks works as a computational unit, and they are connected to each other. Deep learning networks comprised many layers of neural networks and can perform complex task.3,8
Computer vision: Machine is trained to recognize images and videos. It is now used in the image acquisition and interpretation with its applications in diagnosis, image-guided surgery, and virtual colonoscopy. With ML and CV, image and video-based analysis of longitudinal studies and decision-making in surgery are made. The laparoscopic video of sleeve gastrectomy can accurately (92.8%) note the missing or unexpected steps.3,9
Applications of AI in health care have increased rapidly, and AI is now being utilized in almost all aspects of health care right from laboratory research to various facets of patient management. AI is being utilized for drug discovery, 3clinical trials, medical risk prediction, medical data security, and detection of fraud. Its application extends from diagnosing the disease using medical image analysis and improving genetic interpretation to treating the disease and monitoring. Algorithms have been laid down for interpreting radiographs, mammograms, and cancers on computed tomography (CT) scans. AI also finds application in pathology for objective evaluation of microscopic findings in various pathological conditions, especially oncopathology.
With the shift to digital medical record keeping and most healthcare facilities now becoming paperless, humongous volumes of medically relevant data have accumulated. Analysis of electronic health records (EHRs) offers promise in extracting clinically relevant information and making diagnostic evaluations as well as in providing real-time risk scores for transfer to intensive care, predicting outcomes such as in-hospital mortality, readmission risk, prolonged length of stay, and improving decision-making strategies. Proof-of-concept studies have aimed to improve the clinical workflow, including automatic extraction of semantic information from transcripts, recognizing speech in doctor–patient conversations, and even summarizing doctor–patient consultations.2
Artificial intelligence has the potential to bring about uniformity in clinical practice, improve efficiency, and prevent avoidable medical errors that will affect almost every patient during their lifetime. By providing novel tools to support patients and augment healthcare staff, AI could enable better care delivered closer to the patient in the community. AI tools could assist patients in playing a greater role in managing their own health; primary care physicians by allowing them to confidently manage a greater range of complex diseases, and specialists by offering superhuman diagnostic performance and disease management. Finally, through the detection of novel signals of disease that clinicians are unable to perceive, AI can extract novel insights from existing data.2,3
In recent years, the progressive use of AI in clinical practice has helped surgeons in clinical decision-making, diagnosis, predicting preoperative risk, intraoperative monitoring, and postoperative care. It also limits human errors, particularly in difficult and critical situations.10 AI is being used in the diagnosis of cancer and real-time monitoring of the intensive care patients.11,12 The use of AI in surgery is at much slow pace than in medicine and radiology; it is because of the high stakes in surgery and also complex decision-making involved. The use of AI in surgery involves algorithms and developing semiautonomous device that can perform various interventions/surgical procedures in interaction with the surgeons. The enthusiasm toward the use of AI in surgical practice is growing, and with all technological innovations in recent years, it will increase over time.4
zoom view
Fig. 1: Gartner hype cycle for artificial intelligence tools in surgery. (CV: computer vision; DL: deep learning; MIS: minimal invasive surgery; ML: machine learning; NLP: natural language processing; NOTES: natural orifice transluminal endoscopic surgery; RS: robotic surgery)
Artificial intelligence in surgery follows the Gartner hype cycle, according to Roger's diffusion of innovation theory, which is a classic S-shaped curve and has several phases before true innovation. The phases include: (1) Peak of inflated expectations, (2) ML, deep learning, NLP, CV, (3) trough of disillusionment, and (4) slope of enlightenment, followed by a long plateau phase. In this phase, real work occurs and is known as plateau of productivity (Fig. 1).10,13
The application of AI in surgery ranges from evaluating a patient, making a diagnosis, counseling and preparing for surgery, performing the surgery, anticipating complications, to managing them, and providing postoperative care. Thus, the role of AI in surgery can be described as (Fig. 2):
  • Preoperative: It includes imaging, endoscopy, tissue diagnosis, surgical decision-making, and risk assessment.
  • Intraoperative: It includes anesthesia, CV and context-aware assistance, surgical phase recognition and avoiding near misses, augmented reality (AR) and navigation surgery, and AI-assisted robotic surgery.
  • Postoperative: It includes postoperative monitoring, possible procedures to reduce complications, early diagnosis of complications, and postoperative pain management.5
zoom view
Fig. 2: Use of artificial intelligence in surgery.
Artificial Intelligence and Gastrointestinal Endoscopy
Artificial intelligence is currently being used to increase the diagnostic yield of endoscopy for detection of polyps as well as to differentiate hyperplastic from adenomatous polyps based on endoscopic images. It can also be used to differentiate malignant versus nonmalignant tissue and identify the depth of invasion and margins of endoscopic resection. An important feat achieved through AI is the evaluation of huge numbers of endoscopic images obtained by wireless capsule endoscopy as well as an integrated ultrasound system in the capsule for evaluation.14
Artificial Intelligence and Radiology
3D Visualization and Virtual Simulation
The preoperative assessment of the lesion is traditionally evaluated on two-dimensional (2D) images of CT and/or magnetic resonance imaging (MRI). The three-dimensional (3D) visualization of the liver lesion accurately interprets the lesion and also provides its relation to the surrounding structure.15 6The first use of 3D visualization of liver lesion was performed by Marescaux in 1998.16 3D reconstruction of 2D images of CT scan and MRI for liver lesion improves the preoperative planning and visualization of spatial relationship of the tumor and surrounding intrahepatic structures, identifying the normal vascular and biliary anatomy and its variations. It can assess the resectability of the liver lesions (hepatocellular carcinoma and colorectal metastasis) by performing virtual hepatectomy and also provide the information on future liver remnant.17 Studies have demonstrated that patients operated following 3D planning have less hepatic inflow occlusion time, less operative time, and reduced postoperative complications.18 Similarly, reduced intraoperative bleeding is reported with preoperative 3D reconstruction planning.19 3D reconstruction in hilar cholangiocarcinoma can predict tumor invasion into hilar vessels, variant hilar anatomy, and future liver volumes. These informations are vital in planning major radical resection, which has high morbidity as well as mortality. Similarly, 3D planning exclude peripancreatic vessel involvement in pancreatic cancer, resulting in significantly reduced blood loss, operative time, and hospital stay.20
3D Printed Models
Artificial intelligence converts the 3D reconstructed images with 3D printing technology into real physical models. The 3D printing was first used by Zein et al. in 2013.21 The 3D images and reconstruction as described above are useful, but the display remains on a 2D screen. Thus, this limitation is overcome by 3D printing, which is useful in liver lesions and transplantation. 3D printed model in operating room can precisely locate the site of lesion and its relations to its surrounding structures, useful in planning exact line of transaction. 3D printing is extremely helpful in planning liver resection in large and complex lesions of liver to avoid posthepatectomy decompensation. 3D printed liver models also be used in assessing size discrepancies between recipient and graft in living donor liver transplantation, particularly in small infants and neonates.22 Low-cost 3D printed models of liver can also be used for medical education, for better understanding of liver anatomy, and practice hepatectomy. Recently, 3D bioprinted models of liver are used in tissue engineering and in artificial liver.23
Artificial Intelligence and Surgical Decision-making
The surgical decision is a shared decision of patient in respect to treatment, compliance, and satisfaction. However, sometimes decisions are complex and involve high stakes that may affect the patient outcome. Surgical decision-making is sometimes dominated by hypothetical/deductive reasoning and individual judgment. These factors can lead to bias, error, and can potentially harm the patient. Traditional predictive analytics and 7clinical decision-support systems are intended to augment surgical decision-making, but their clinical utility is compromised by time-consuming manual data management and suboptimal accuracy. AI can help the surgeons to improve the accuracy and efficiency in diagnosis. ML identifies the complex relationships between various variables, analyzes large data from patient history, laboratory findings, and images to predict the most probable diagnosis. Similarly, AI may assist and support the diagnosis, also recommend further investigation required, and suggest the best treatment modality based on current evidence. In future, integration of AI with surgical decision-making will augment the decision for intervention, informed consent, identification of risk factors, and postoperative complications.2,10 AI tool extract data from large EHRs in the form of knowledge, which improves the decision-making of surgeons.
Artificial Intelligence and Risk Assessment
IBM Watson Oncology has been developed for the oncologists to provide current evidence and also to guide them in decision-making; however, it was not able to do so.24 The various cardiac risk assessment models (such as revised cardiac risk index and Gupta perioperative risk for myocardial infarction)25,26 and American Society of Anesthesiologists (ASA) classification fail to predict the risk accurately. AI-based platform containing vast data can identify and predict the risk accurately. My Surgery Risk platform, which uses EHR data, has shown to predict perioperative risk accurately. ML-based platform develops as Predictive OpTimization Trees in Emergency Surgery Risk (POTTER) calculator, based on the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. It accurately calculates the perioperative risk involved and associated mortality.27 POTTER integrated with EHR data can also identify the risk of surgical site infection (SSI), pneumonia, sepsis, cardiac complications, and postoperative intensive care unit stay.28
Artificial Intelligence in Anesthesia and Monitoring
Artificial intelligence has found application during the induction and maintenance phase of anesthesia. Monitoring the depth of anesthesia (DOA) requires the assessment of a multitude of parameters and is a complex task. AI utilizes the bispectral index (BIS), which is derived from electroencephalogram data, to maintain tight feedback and control of DOA. McSleepy automated intravenous infusion machines use the BIS along with vital signs to maintain DOA by administering propofol, narcotics, and muscle relaxants. However, the maintenance of DOA is a critical balance between 8infusion and assessment of parameters, and underdosing or excessive DOA may be caused by equipment imbalance; therefore, automated anesthesia is still in its infancy and not ready to be adopted in general practice.29,30
Apart from induction and maintenance, automated regional anesthetic blockade has been performed by the da Vinci® system, and the Magellan robot has been used to place peripheral nerve blocks. Intraoperative intelligence can help to predict return of consciousness after general anesthesia, and neural networks can predict postinduction hypotension as well as the rate of recovery from neuromuscular blockade. In an unblinded randomized clinical trial (HYPE trial), the use of a ML-derived early warning system compared resulted in less intraoperative hypotension with standard care. In supra major abdominal surgeries such as cytoreductive surgeries or hyperthermic intraperitoneal chemotherapy, it is recommended to use cardiac output monitoring.29,30
Computer Vision and Context-aware Assistance in Surgery
Artificial intelligence based CV may be used to standardize, automate, and scale the surgical performance. It gives an opportunity for the computer-based performance assessment of the surgical skills such as suturing and knotting. It also includes assessment of tissue handling and fluidity of motion. Now, the operation theater utilizes anesthesia and surgical machines that regularly provide status report. Such heterogeneous sensors stalled in operation rooms are known as context-aware assistance.31 AI-based system is used, which identifies the various phases of surgery. Thus, any deviation or delay in any surgical step is identified and informed to the surgeon. OR black box system (similar to aircraft) captures various data (such as audio, video, and physiological parameters from the monitor) during surgical procedure. Recently, studies are evaluating this analytical data of black box with the patient outcome.32
Navigated Surgery
Three-dimensional reconstruction and printing as well as 3D reconstructed images do not synchronize with actual surgery.15,33 This limitation can be overcome with the help of computer software that combines the preoperatively acquired 3D reconstructed images and intraoperative real-time information. It is possible with augmented virtuality (AV) (virtual environment that is controlled by real information) or AR (virtual information based on real images of patient). Thus, AV, AR, or mixed reality (MR) is a reliable surgical navigation that avoids the chance of misinterpretation and improves oncological safety with maximal functional preservation.34 During AR-based navigation, reconstructed images are superimposed on 9the real organs on monitor display during surgery which may be utilized for pancreatectomy, small neuroendocrine tumor of pancreas, and liver lesion.35
Artificial Intelligence and Minimally Invasive Surgery
Artificial intelligence has significant potential to improve the effectiveness and safety in minimally invasive surgery. AI can develop advanced navigation and guidance systems to improve the precision surgery. AI-based image analysis tools provide real-time guidance to operating surgeon, which can assist to diagnose unexpected complications and event.4,15 With the help of ML algorithms, various patterns are identified from data of past surgeries, helping surgeons in executing best surgical approach. Bile duct injury during laparoscopic cholecystectomy is well known and associated with high morbidity and also invites medico-legal litigation. AI-based models developed for laparoscopic cholecystectomy using four anatomical landmarks (the common bile duct, cystic duct, lower edge of the left medial liver segment, Rouviere's sulcus) can be easily identified intraoperatively,36 resulting in much reduced risk of bile duct injury. AR technology can be used where 3D reconstructed images of CT/MRI of the liver, superimposed with virtual image of the liver in 1:1 ratio, can help surgeon in hepatectomy.37 AR has vital role in education of the trainees in laparoscopy. AR-based models will improve skills of the trainee for laparoscopic surgical procedure and also decrease learning curve significantly.15
Artificial Intelligence and Robotic Surgery
“Robot” is defined as “a mechanical device that is capable of performing a variety of complex human tasks on command or after being programmed in advance.”
Medical robot can be divided into two types:
  1. Remote controlled
  2. Automated or semiautomated
In the remote controlled or synergistic type, the surgeon has direct real-time control of the robotic instruments from a console placed away from the patient and robotic arms. Da Vinci® Surgical System by Intuitive and Versius® system by CMR are examples of remote-controlled robotic systems. In the automated type of robots, the physician does not have to continuously control the motion of the robot; instead, the physician defines its task and monitors its execution, for example, the AcuBot robot used for CT-guided interventions.
Currently available surgical robotic platforms such as the da Vinci® (Intuitive Surgical, Inc., Sunnyvale, CA) or the Versius system by CMR are real-time tele-manipulators in a “master-slave” configuration.10
zoom view
Fig. 3: How artificial intelligence (AI) can enhance utility of robotic surgery? (3D: three dimensional)
These systems consist of a patient-site platform with four robotic operating arms and a video-laparoscopic cart (slave). There is also a surgeon-site console (master) equipped with a stereoscopic 3D camera offering an immersive environment to the surgeon with a sound depth perception and ergonomic handles, which command the robotic effectors replicating human hand movements into a precise and downscaled fashion. The limitation of depth perception of laparoscopic procedure can be overcome by 3D intraoperative views in robotic surgery, which is also 10-fold magnified (Fig. 3). This helps surgeons in dissection of delicate tissue, increased dexterity, and intracorporeal suturing even in narrow space.38 The sense of touch is missing in both in laparoscopy and robotic surgery; this limitation is also been overcome with use of AR.39 The see-through visualization technology in AR helps surgeon with port placement as per patient anatomical variation and lesions. AR allows identification of intrahepatic vascular structures with high accuracy, and its benefit has been reported in hepatic resection. The augmented endoscopic view provides the information of resection margin around tumor with high accuracy. With recent advancement, robots are enabled to automatically do simple surgical activities in vitro as suturing and knot tying.40 However, complete autonomy to robots in surgery is still far ahead to attain, and surgeons continue to control them because of complex decision-making and safety of the patients. The major intraoperative limitations while using 3D overlays arise when an unexpected object appears suddenly in field view of surgeon, causing inattentional blindness.4111
Machine learning algorithms use EHR data to predict the outcomes in terms of SSI, sepsis, and bleeding following various surgical procedures. They provide more accurate prediction than ASA and ACS-surgical risk calculator. The most dreadful complication following bowel suturing or anastomosis is the leak. AI-based analysis can accurately predict anastomotic leak following bariatric and colorectal surgery.28 Similarly, AI can also predict risk of postoperative pancreatic fistula (POPF) following pancreaticoduodenectomy.42 AI-based nociception level (NOL) index has been developed to minimize postoperative pain.
Artificial Intelligence in Surgical Learning
Artificial intelligence has potential to change the present-day training of the surgeon. In recent years, training of surgeons is changing with the introduction of simulators and specific task allocations in the same. The creation of AI-based simulation surgical training allows the trainees to acquire skill in managing complex surgical task in a controlled environment. This method has been seen to improve the confidence of the trainee as well as his/her performance. Simulation-based training has an advantage that it provides real-time feedback to improve surgical skill, can also assess the performance, and cause no harm to the actual patient. The personalized training program may be developed as per the need of the trainee based on feedback.4,43 AI has ability to improve all components of surgical training, including knowledge, surgical skill, and decreasing learning curve of complex surgical procedure.44 AI enhances attitude training through virtual patient cases and also helps trainees in developing attitudes and behavior required for successful surgeons.
Artificial intelligence in Emergency and Trauma Surgery
The video-consulting emergency (VCE) protocol is developed, which improves the decision-making between the emergency physician present onsite and remote surgeon. The devices used are usually smartphone, FaceTime, and Acute Abdominal Decision Making (AADM®) model.10,45 The Artificial Intelligence in Emergency and Trauma Surgery (ARIES) project was formulated following an international web survey that was endorsed by the World Society of Emergency Surgery for the use of AI in emergency and trauma surgery.46 The use of AI in emergency and trauma surgery may be utilized in monitoring and decision-making and prevent errors.
The media hype about AI has created unrealistic expectations that lead to disappointment and disillusionment. AI is not a “magic bullet” that can yield 12answers to all questions. There are instances where traditional analytical methods can outperform ML or where the addition of ML does not improve its results. AI is as good as the data that is used to generate the various management algorithms. The results will depend on the questions asked and the datasets that are available. Any glitches in these components will result in an incorrect algorithm. The following are important limitations of AI that are needed to be addressed in future:3
  • Challenges related to machine-learning science: Artificial intelligence algorithms have the potential to suffer from multiple shortcomings, including inapplicability outside the training domain, bias, and brittleness (tendency to be easily fooled). Important factors for consideration include dataset shift, accidentally fitting confounders rather than true signal, propagating unintentional biases in clinical practice, and the challenge of generalization to different populations.
  • Logistical difficulties in implementing AI systems: Many of the current challenges in translating AI algorithms to clinical practice are related to the fact that most healthcare data are not readily available for ML. Data are often soiled in a multitude of medical imaging archival systems, pathology systems, EHRs, electronic prescribing tools, and insurance databases, which are very difficult to bring together. Even if we understand the underlying mathematical principles of such models, it is difficult to interrogate the inner workings of models to understand how and why it made a certain decision. This is potentially problematic for medical applications, where it is essential to have approaches that are not only well-performing but also trustworthy, transparent, interpretable, and explainable.
  • Achieving robust regulation and rigorous quality control: A fundamental component of achieving safe and effective deployment of AI algorithms is the development of the necessary regulatory frameworks. This poses a unique challenge given the current pace of innovation, significant risks involved, and the potentially fluid nature of ML models. The comparison of algorithms across studies in an objective manner is challenging due to each study's performance being reported using variable methodologies on different populations with different sample distributions and characteristics. To make fair comparisons, algorithms need to be subjected to comparison on the same independent test set that is representative of the target population, using the same performance metrics. Without this, clinicians will have difficulty in determining which algorithm is likely to perform best for their patients.
  • Ethical and medicolegal aspects of AI: The ethical and legal implications of AI are heavily debated. It has already been explained that if the algorithm is flawed, AI will generate inaccurate results. Those errors are different 13from ones that occur because of network loss or computer malfunction. AI was initially used only to augment clinical decision-making, but with its current development and autonomy, flaws in the device that harm patients, resulting in medical negligence, require that responsibility needs to be predetermined. The allocation of responsibility was traditionally to the surgeon, but with the self-learning capability of AI, it may not be possible for the surgeon to override certain procedures.
Till date, no consensus has been reached with regards to legal implications of integration of advanced AI systems in surgery and healthcare practices in general. The responsibility of AI and autonomous robotic surgery is classified as (1) accountability; (2) liability; and (3) culpability. Accountability means the capacity of a system to explain its actions, liability is subject to action by the legal system, and culpability relates to punishment. Accountability can be determined by recording the actions, but the issues of liability and culpability require a consensus to adapt to the scenario of AI and robotics.
The medical records also carry sensitive personal information which may cause legal issues and concerns about the breach in personal privacy. There are many countries in the world that have formed legal systems for protecting personal information. Like in US, Health Insurance Portability and Accountability Act (HIPAA) established in 1996, similarly, in Europe, General Data Protection Regulation established in 2016.47 The International Medical Device Regulators Forum classified the software used in AI for medical use as “Software as a Medical Device (SaMD).”48 The policies need to be established which can regulate the devices used for medical purpose although such policies have been implemented in the US, Japan, Korea, and few other countries.
Artificial intelligence is expected to be widely used in healthcare system. Various research centers and governments are keen on building robust AI technologies. AI will augment patient care and can be used in preoperative evaluation, planning, and assessment of postoperative complications. Intraoperatively, automated anesthesia, AR, VR, and robotic surgery with AI technology would improve the safety, comfort, and outcome of the patient. AI in OR will not replace the surgeon; however, it will expand the capacity and capability of the surgeon with enhanced vision and dexterity. AI-based simulation surgical training allows the trainees to acquire skills in managing complex surgical tasks in a controlled environment. The use of AI in surgical learning will enhance the training quality and surgical competence, which will further improve patient care. AI is a powerful tool that is emerging fast; however, legal and ethical issues associated with AI still need to be addressed.14
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