THIS WEEK'S ARTICLES
Best Practices in Microsurgical Instrument Care - Sponsored Content
First Robot-Supported Microsurgical Operations Performed on Humans
Physicians used an innovative operating method that can reduce the potential for human error.
Drs. Maximilian Kückelhaus and Tobias Hirsch from the Centre for Musculoskeletal Medicine at the University of Münster in Germany recently performed the first completely robot-supported microsurgical operations on humans using a new method in which a robot designed for microsurgery is networked with a robotic microscope.
The robot mimics human hand movements with an electromagnetic field and joysticks. Via tiny surgical instruments, the surgeon’s movements are reduced in size by up to 20 times, which eliminates the shaking that may be present in human hands. Five operations have been successfully performed, with more set to follow. The approach is described as ideal for use on breast cancer patients who need complex reconstructions or after accidents in which patients need tissue transplants.
"Our hope is that with this new method we can not only perform operations with a greater degree of precision and safety but also, in the case of the tiniest structures, go beyond limits imposed by the human body," says Dr. Kückelhaus. "This new method for operations enables us to work with a much higher degree of delicacy and precision than is possible with conventional operating techniques. As a result, less tissue is destroyed, and patients recover faster."
The technology makes it possible for the surgeon to remove themselves completely from the sterile field, theoretically allowing them to operate more comfortably. "As we can now operate on patients in a remote fashion, we have much better ergonomics," says Dr. Hirsch. "This protects us from fatigue, and that means that our concentration can be maintained over a period of many hours. In initial studies involving the systems, we were already able to confirm the positive effects on the quality of operations and on ergonomics."
While such technology is not likely to be widely available to surgeons for some time, it exemplifies the inexorable direction in which microsurgery is headed.
CMS Microsurgery Reimbursements Fall Behind Inflation
Study examined CPT codes for a wide variety of procedures from 2007 to 2020.
Are microsurgeons doing more work for less pay? They very well could be, according to a recent analysis of microsurgery procedures from 2007 to 2020 that shows Medicare reimbursements aren’t keeping up with inflation.
The study, published in Plastic and Reconstructive Surgery, reviewed Centers for Medicare & Medicaid Services (CMS) reimbursements for 34 CPT codes for procedures that included free flaps with microvascular anastomosis; breast reconstruction; arm, digit, forearm and thumb replantation; bone grafts; toe-to-hand transfers; blood vessel repairs; pharyngeal wall resections; partial esophagectomies and multiple microsurgical techniques performed with an operating microscope.
The average increase for each code from 2007 to 2020 was 2.28%, although the range of new reimbursements for each procedure was wide, from 22% decreases to 24% increases. The consumer price index rose by 27% during this 13-year timeframe, according to U.S. Department of Labor statistics. After adjusting for changes in the inflation rate over the 13 years, the average reimbursement rate increase for the 34 CPT codes was 1.74%.
The study shows that reimbursements for other components of procedures in which these CPT codes were used — such as physician fees, practice expenses and malpractice insurance — also decreased after adjustment for inflation.
"Our results demonstrate that Medicare reimbursement rates for microsurgery are lagging behind consumer price index inflation," notes the study. "A recent study showed that microsurgical procedures are profitable for hospitals while reimbursement rates remain low for physicians by looking at projected Medicare payments to the surgeon and hospital for head and neck reconstructive microsurgery procedures; similar trends for low reimbursement for breast reconstruction have also been demonstrated."
The authors note that inflation can have a particularly high impact on Medicare reimbursements for microsurgical procedures because they have added layers of complexity due to coding rules and reimbursement bundles.
"It is crucial for these data to be readily available to physicians given that Medicare may now include certain patients under age 65," notes the study. "Microsurgical procedures are performed on patients of all ages, so understanding these trends is particularly important in this context."
Best Practices in Microsurgical Instrument Care
Communication, collaboration and instrument care across the team are key to best outcomes and patient safety.
It takes a concerted effort by a dedicated team to follow best practices for taking care of the microsurgical instruments used every day in facilities. In fact, everyone on that team needs to be aware of the regulatory standards that must be followed to ensure the proper sterilization for these delicate instruments. In some instances, this is not the case so it is important to take steps to achieve the highest level of patient care and safety.
Building trust in the reprocessing process takes time and attention – and it also takes constant vigilance to make sure everyone on the team is on the same page. Here are some important steps to follow for proper instrument care that OR teams need to keep in mind:
Use checklists and build in the proper time. It is essential that the staff involved in the process follow the steps to complete instrument reprocessing and they have the time to do it properly. A busy OR schedule creates pressures, but a checklist will help keep the focus on what’s important and ensure successful results.
Meticulous cleaning. Members of the surgical team must make sure used instruments are prepared correctly before sending them to the sterile processing department for thorough manual decontamination. This can include an adenosine triphosphate (ATP) monitoring system that detects the presence of organic material and identifies instruments that need to be recleaned before sterilization.
Cooperation and communication. Everyone on the team – from surgeons to surgical techs and the sterile processing department — must communicate effectively so there is a clear understanding of what is going on at any given time. If someone needs help with something related to instrument care, it’s more likely to be addressed quickly if the team has an existing rapport and communicates well. It’s important that the team members fully understand each other’s roles, responsibilities and time crunches and works together.
The managers and supervisors of the sterile processing department and the surgery team can work best if they team up, find out what their unique challenges are and work together to solve them in a positive, supportive climate.
Note: For more information please go to www.synovismicro.com.
Surgeon Skill Called Into Question
Study identifies link between ability and outcomes during certain microsurgeries.
A retrospective analysis of all digit replantations and revascularizations found that the skill of surgeons varied widely. "A link between surgeon ability and patient outcomes is logical, yet few studies have strived to measure the operative proficiency of attending surgeons and determine its association with outcomes," according to the study.
The researchers, who published their study in JAMA Network Open, analyzed all digit replantations and revascularizations performed at a single U.S. university medical center between January 2000 and August 2020. The study involved 145 patients and 226 digits (116 replantations and 110 revascularizations) treated by 11 surgeons with training in hand or microsurgery. The researchers assigned each surgeon a proficiency score based on the expected procedure difficulty and outcomes from a sample of their cases. Those scores were then used to determine associations with outcomes from subsequent cases.
"In this case series, greater surgeon proficiency… was associated with a greater likelihood of digit survival and fewer complications even after controlling for case mix and injury characteristics known to affect outcomes," the researchers write. "Surgeon proficiency scores accounted for 17% of the variation in digit survival. These results suggest that improving surgeon proficiency may not only improve quality of surgical care delivered but also optimize healthcare resource use."
The researchers say their study is significant because previous analyses focused on the relationship between surgeon volume and outcomes rather than surgeon proficiency and outcomes. "In our study, operative proficiency score explained the variation in outcomes to a greater degree than procedure volume," they write. "Furthermore, operative proficiency score, but not procedure volume, was associated with surgeons’ overall complication rates. This implies that surgeon volume and operative performance may have synergistic associations with some outcomes but distinct associations with others. It is plausible that some surgeons, despite having high procedural volume, are prone to repeating certain mistakes or improper techniques unless these are identified and corrected."
Efforts to improve surgeon proficiency in these highly complex procedures can improve patient outcomes and yield healthcare savings, conclude the researchers.
Why Aren’t Robots Assisting With Plastic Surgeries?
New platforms introduced over the next decade could increase the use of robotic assistance in cosmetic procedures.
Plastic surgery has failed to capitalize on the clinical benefits of robotic assistance, but a recent literature review suggests more surgeons will employ the technology in the near future.
"Within the last 20 years, robotic-assisted surgeries have been implemented as routine procedures in many surgical fields, except in plastic surgery," write the researchers, who published their findings in Journal of Clinical Medicine. "The generally very innovative field of plastic surgery has not integrated robotics into its routine clinical work yet. Although several case series report promising results, technical and economic aspects have prevented its translation into clinical routine."
The review — based on case reports, case series, clinical and preclinical trials — describes eight systems used for robotic-assisted microsurgery and their potential to be translated into a clinical routine for plastic surgery. The authors say that combining robot-assisted surgery with artificial intelligence could change surgeons from active operators to supervisor in the coming years.
The authors add that potential applications for robotics in reconstructive surgery, where overcoming human physiological boundaries may facilitate better treatment options, are on the rise and that the industry is shifting its focus toward customization for supermicrosurgery. Currently, dedicated robotic systems for microsurgical applications have received CE certification for use in Europe. "These systems hold great potential to support procedures performed mainly by plastic surgeons," they write. "After the initial clinical experience, they will aim for FDA approval as well."
Robotic systems intended specifically for open microsurgery are designed around different philosophies, note the authors. Some focus on cost-effectiveness, others on highly sophisticated, miniaturized, single-use tools. "It will be interesting to observe whether all systems prevail or whether there will be mergers," they write. "In view of the extremely complex and cost-intensive training of competent microsurgeons, these systems potentially offer the possibility of benefiting from the experience of older surgeons for a longer period of time, even in the case of declining physical fitness." They add that the ability of robots to simplify supermicrosurgical procedures may allow more surgeons to perform the challenging operations, in the process expanding patient access to the procedures.
The authors say good indications for the use of novel robotic systems for plastic microsurgeries could include lymphovenous anastomoses, anastomoses in the context of free flap surgery, replantation and nerve coaptation. "For initial clinical application, the comparatively simple anastomoses of elective free flaps may be the entry point," they say.