Over the past 50 years the capability of technology to improve surgical care has been realised and while surgical trainees and trainers strive to deliver care and train; the technological ‘solutions’ market continues to expand. However, there remains no coordinated process to assess these technologies. The FOS:TEST Report aimed to (1) define the current, unmet needs in surgical training, (2) assess the current evidence-base of technologies that may be beneficial to training and map these onto both the patient and trainee pathway and (3) make recommendations on the development, assessment, and adoption of novel surgical technologies. The FOS:TEST Commission was formed by the Association of Surgeons in Training (ASiT), The Royal College of Surgeons of England (RCS England) Robotics and Digital Surgery Group and representatives from all trainee specialty associations. Two national datasets provided by Health Education England were used to identify unmet surgical training needs through qualitative analysis against pre-defined coding frameworks. These unmet needs were prioritised at two virtual consensus hackathons and mapped to the patient and trainee pathway and the capabilities in practice (CiPs) framework. The commission received more than 120 evidence submissions from surgeons in training, consultant surgeons and training leaders. Following peer review, 32 were selected that covered a range of innovations. Contributors also highlighted several important key considerations, including the changing pedagogy of surgical training, the ethics and challenges of big data and machine learning, sustainability, and health economics. This summates to 7 Key Recommendations and 51 concluding statements. The FOS:TEST Commission was borne out of what is a pivotal point in the digital transformation of surgical training. Academic expertise and collaboration will be required to evaluate efficacy of any novel training solution. However, this must be coupled with pragmatic assessments of feasibility and cost to ensure that any intervention is scalable for national implementation. Currently, there is no replacement for hands-on operating. However, for future UK and ROI surgeons to stay relevant in a global market, our training methods must adapt. The Future of Surgery: Technology Enhanced Surgical Training Report provides a blueprint for how this can be achieved.

Non-invasive therapeutic-focused ultrasound (US) can be used for the mechanical dissociation of tissue and is described as histotripsy. We have performed US histotripsy in viable perfused ex vivo porcine livers as a step in the development of a novel approach to hepatocyte cell transplantation. The histotripsy nidus was created with a 2 MHz single-element focused US transducer, producing 50 pulses of 10 ms duration, with peak positive and negative pressure values of P+ = 77.7 MPa and P− = –13.7 MPaat focus, respectively, and a duty cycle of 1%. Here, we present the histological analysis, including 3D reconstruction of histotripsy sites. Five whole porcine livers were retrieved fresh from the abattoir using human transplant retrieval and cold static preservation techniques and were then perfused using an organ preservation circuit. Whilst under perfusion, histotripsy was performed to randomly selected sites on the live. Fifteen lesional sites were formalin-fixed and paraffin-embedded. Sections were stained with Haematoxylin and Eosin and picro-Sirius red, and they were also stained for reticulin. Additionally, two lesion sites were used for 3D reconstruction. The core of the typical lesion consisted of eosinophilic material associated with reticulin loss, collagen damage including loss of birefringence to fibrous septa, and perilesional portal tracts, including large portal vein branches, but intact peri-lesional hepatic plates. The 3D reconstruction of two histotripsy sites was successful and confirmed the feasibility of this approach to investigate the effects of histotripsy on tissue in detail.

Background: Informed consent is an essential process in clinical decision‐making, through which healthcare providers educate patients about benefits, risks, and alternatives of a procedure. Statistical risk information is difficult to communicate and the effectiveness of aids aimed at supporting this type of communication is uncertain. This systematic review aims to study the impact of risk communication adjuncts on patients' understanding of statistical risk in surgery and interventional procedures.Methods: A systematic search was performed across Medline, Embase, PsycINFO, Scopus, and Web of Science until July 2021 with a repeated search in September 2022. RCTs and observational studies examining risk communication tools (e.g., information leaflets and audio‐video) in adult (age >16) patients undergoing a surgical or interventional procedure were included. Primary outcomes included the objective assessment of statistical risk recall. Secondary outcomes included patient attitudes with respect to statistical information. Due to the study heterogeneity, a narrative synthesis was performed.Results: A total of 4348 articles were identified, and following abstract and full‐text screening 14 articles, including 9 RCTs, were included. The total number of adult patients was 1513. The most common risk communication tool used was written information (n = 7). Most RCTs (7/9, 77.8%) showed statistically significant improvements in patient understanding of statistical risk in the intervention group. Quality assessment found some concerns with all RCTs.Conclusion: Risk communication tools appear to improve recall of statistical risk. Additional prospective trials comparing various aids simultaneously are warranted to determine the most effective method of improving understanding.

Adamantinomatous craniopharyngiomas (ACPs) are rare, sellar-suprasellar benign tumors that cause considerable morbidity and mortality due to local invasion and treatment-related damage to surrounding structures, including central diabetes insipidus (CDI). Trametinib is a highly selective inhibitor of MEK1 and MEK2, which has been evaluated in both adult and pediatric cancers/ tumors with activation of the oncogenic mitogen-activated protein kinase (MAPK) pathway. Despite being thought to have fewer side effects than conventional cytotoxic chemotherapy, off-target toxicities such as hyponatremia have been described. The use of MEK inhibitors in ACPs are limited to case reports and a phase II trial is currently underway. We report a pediatric patient with multiply progressive ACP and known brittle CDI who developed severe hyponatremia associated with a significant decrease in desmopressin dosing after starting trametinib and a rapid rebound of desmopressin requirement with its cessation. We recommend close monitoring of serum sodium levels and a review of desmopressin doses in patients with CDI when started on treatment with MEK inhibitors.

Background: Artificial intelligence (AI) is expected to play a greater role in neurosurgery. There is a need for neurosurgeons capable of critically appraising AI literature to evaluate its implementation or communicate information to patients. However, there are a lack of courses delivered at a level appropriate for individuals to develop such skills. We assessed the impact of an online digital literacy course on the ability of individuals to critically appraise AI literature in neurosurgery. Methods: We performed a prospective, non-randomised, controlled study with a mixed-methods analysis. The intervention arm comprised of individuals enrolled in our two-day digital health literacy course, with a waiting-list control arm used for comparison. We assessed participants’ pre- and post-course knowledge, confidence and course acceptability using Qualtrics surveys. Results: A total of 62 participants (33 participants, 29 waitlist controls), including neurosurgical trainees and both undergraduate and post-graduate students, attended the course and completed the pre-course survey. The two groups did not vary significantly in terms of age or demographics. Following the course, participants significantly improved in their knowledge of AI (mean difference=3.86, 95% CI=2.97-4.75, p-value<0.0001) and confidence in critically appraising literature using AI (p-value=0.002). Similar differences in knowledge (mean difference=3.15, 95% CI=1.82-4.47, p-value<0.0001) and confidence (p-value<0.0001) were found when compared to the control group. Conclusion: Bespoke courses delivered at an appropriate level can improve clinicians’ understanding of the application of AI in neurosurgery, without the need for in-depth technical knowledge or programming skills.