Summary:Augmented reality (AR) is defined as “a technology that superimposes a computer-generated image on a user’s view of the real world, thus providing a composite view.”1 This case report describes how emerging AR telesurgery technologies may be used to facilitate international surgeon–surgeon collaboration and training. Here, we illustrate how a remote surgeon in Beirut, Lebanon, was able to offer assistance to a surgeon in Gaza, Palestine, during a complex hand reconstruction case following a bomb-blast injury in an 18-year-old male. We discuss the implications of AR technology on the future of global surgery and how it may be used to reduce structural inequities in access to safe surgical care.

Over the past decade, driven by advances in educational theory and pressures for efficiency in the clinical environment, there has been a shift in surgical education and training towards enhanced simulation training. Microsurgery is a technical skill with a steep competency learning curve on which the clinical outcome greatly depends. This paper investigates the evidence for educational and training interventions of traditional microsurgical skills courses in order to establish the best evidence practice in education and training and curriculum design. A systematic review of MEDLINE, EMBASE, and PubMed databases was performed to identify randomized control trials looking at educational and training interventions that objectively improved microsurgical skill acquisition, and these were critically appraised using the BestBETs group methodology. The databases search yielded 1,148, 1,460, and 2,277 citations respectively. These were then further limited to randomized controlled trials from which abstract reviews reduced the number to 5 relevant randomised controlled clinical trials. The best evidence supported a laboratory based low fidelity model microsurgical skills curriculum. There was strong evidence that technical skills acquired on low fidelity models transfers to improved performance on higher fidelity human cadaver models and that self directed practice leads to improved technical performance. Although there is significant paucity in the literature to support current microsurgical education and training practices, simulated training on low fidelity models in microsurgery is an effective intervention that leads to acquisition of transferable skills and improved technical performance. Further research to identify educational interventions associated with accelerated skill acquisition is required.

Chronic, nonhealing diabetic foot ulcers (DFU) are increasing in prevalence and are often unresponsive to conventional therapy. Adipose tissue, containing adipose‐derived stem cells, and platelet rich plasma (PRP) are regenerative therapies rich in growth factors which may provide a solution to chronic wound healing. This study aimed to assess the feasibility of conducting a definitive randomised controlled trial (RCT) to investigate the efficacy of these therapies for the treatment of DFU. This was a single centre, feasibility, three‐arm, parallel group RCT. Eligible DFU patients were randomised on a 1:1:1 basis to three intervention arms: control (podiatry); fat grafting; fat grafting with PRP. The intervention was delivered once and patients were followed‐up for 12 weeks. The primary objective was to assess measures of trial feasibility. Clinical outcomes and health‐related quality of life (HRQoL) were also evaluated. Three hundred and thirty four patients were screened and 32 patients (9.6%) were deemed eligible with 18 enrolled in the trial (6 per arm) over 17 months. All participants completed the trial with no withdrawals or crossover. Participant engagement was high with most HRQoL questionnaires returned and only 4.8% follow‐up appointments missed. There were five adverse events (AEs) related to the trial with no serious AEs. Five (28%) of the wounds healed. There was no difference between any of the groups in terms of clinical outcomes. This feasibility study demonstrated that a multi‐centre RCT is safe and feasible with excellent patient engagement. We have highlighted crucial information regarding methodology and recruitment, which will guide future trial design. Registration number: NCT03085550 http://clinicaltrials.gov. Registered 01/03/2017.

Current wound management through the use of a split-thickness skin graft often requires hospital admission, a period of immobility, attentive donor site wound care and pain management. This study evaluates the feasibility of using a novel epidermal graft-harvesting device (CelluTome) that allows pain-free epidermal skin grafting in the outpatient clinic setting. A prospective series of 35 patients was performed in 2 centres, involving 10 acute and 25 chronic wounds. All patients were subjected to epidermal grafting in the outpatient specialist clinic, without the use of anaesthesia, and allowed to return home after the procedure. Completely healed wounds were noted in 22 patients (62·9%). The overall mean time for 50% and 100% reduction in wound size was 3·31 ± 2·33 and 5·91 ± 3·48 weeks, respectively. There was no significant difference in healing times between the acute and chronic wounds (50% reduction in wound size; acute 2·20 ± 0·91 weeks versus chronic 3·73 ± 2·63 weeks, P = 0·171. Hundred percent reduction in wound size; acute 4·80 ± 1·61 weeks versus chronic 6·83 ± 4·47 weeks, P = 0·183). The mean time for donor site healing was 5·49 ± 1·48 days. The mean pain score during graft harvest was 1·42 ± 0·95, and the donor site Vancouver Scar Scale was 0 for all cases at 6 weeks. This automated device offers autologous skin harvesting in the outpatient setting with minimal or no pain and a scar free donor site, equally benefiting both the acute and chronic wounds. It has the potential to save NHS resources by eliminating the need for theatre space and a hospital bed while at the same time benefiting patient care.

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Breast cancer-related lymphedema (BCRL) is a common complication of breast cancer. 1 Indocyanine green (ICG) lymphography 2 can assess lymphatic functionality. However, some patients undergoing taxane-based chemotherapy experience a period of interstitial edema during which no flow is observed on ICG lymphography, because when the dye is injected near the first web space over the dorsum of the hand, it does not flow beyond the wrist. 3 Over time, this resolves and either returns to normal or results in dermal backflow (DBF). The present study aimed to investigate the association between lymphatic functionality and the risk factors for BCRL using ICG lymphography, while particularly focusing on the no-flow pattern.This study retrospectively reviewed 422 breast cancer cases involving axillary lymph node dissection (ALND). BCRL was diagnosed based on ICG lymphography patterns or, for patients with edema unable to undergo ICG lymphography, by comparing volume differences. The patients were divided into two groups based on the presence/absence of BCRL: BCRL( + ) and BCRL( −). The following characteristics were compared between the groups: age, body mass index, laterality, type of surgery (breast-conserving or mastectomy), disease staging, regional lymph node irradiation, hormone therapy, and type of chemotherapy (taxane, nontaxane, or no chemotherapy).Patients exhibiting the no-flow pattern underwent ICG lymphography every 3 months. DBF patterns typically do not change within such a short period, but because the noflow pattern was the result of temporary interstitial edema, changes were observed from one lymphography to the next ( Figure 1 ). Patients with prolonged edema who could not be diagnosed by ICG lymphography alone were assessed by lymphoscintigraphy. 4 Of the 422 patients who underwent ALND, 100 (23.7%) were diagnosed with BCRL. Compared with the BCRL( −) group, the BCRL( + ) group had significantly higher rates of lymph node irradiation (45% vs. 32%; P = 0.020) and taxanebased chemotherapy (94% vs. 63%; P < 0.001). Postsurgical disease staging was significantly more severe in the BCRL( + )

Epidermal grafting for wound healing involves the transfer of the epidermis from a healthy location to cover a wound. The structural difference of the epidermal graft in comparison to the split-thickness skin graft and full-thickness skin graft contributes to the mechanism of effect. While skin grafting is an epidermal transfer, little is known about the precise mechanism of wound healing by epidermal graft. This paper aims to explore the evolution of the epidermal graft harvesting system over the last five decades, the structural advantages of epidermal graft for wound healing and the current hypotheses on the mechanism of wound healing by epidermal graft. Three mechanisms are proposed: keratinocyte activation, growth factor secretion and reepithelialisation from the wound edge. We evaluate and explain how these processes work and integrate to promote wound healing based on the current in vivo and in vitro evidence. We also review the ongoing clinical trials evaluating the efficacy of epidermal graft for wound healing. The epidermal graft is a promising alternative to the more invasive conventional surgical techniques as it is simple, less expensive and reduces the surgical burden for patients in need of wound coverage.

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