Aiming to provide an instructional and educational platform of learning for all surgeons around the world, JOVS puts great emphasis on instructional and educational video clips, photos, schematics of visualized surgical procedures. As part of this initiative, JOVS has launched a “Video Gallery” section dedicated to collecting all published articles containing video(s).
To enhance the presentation of the video articles and to further advance surgical education and techniques, we are honored to have brief interviews with the corresponding authors of video articles to share their valuable insights and surgical practices.
Corresponding Authors of Video Gallery
Tatsuya Nakao, New Tokyo Hospital, Japan
Thirugnanam Agasthian, National University Cancer Institute (NCIS), Singapore
Luigi Bonavina, University of Milan, Italy
Boon-Hean Ong, National Heart Centre Singapore, Singapore
Miroslav P. Peev, University of Chicago, USA
George Rakovich, Maisonneuve-Rosemont Hospital, Canada
Johannes Bonatti, University of Pittsburgh School of Medicine, USA
Interviews
Tatsuya Nakao
Key message of the video: This case (28-year-old male, Marfan syndrome) developed rapid dilatation of the descending aorta after total arch replacement using frozen elephant technique (FET) (Frozenix), but it was technically easy to perform additional emergency thoracic endovascular aortic repair (TEVAR). There have been similar reports in the past using long elephant trunks, but unlike FET, additional TEVAR treatment is likely to be difficult.
Professor Tatsuya Nakao became president of New Tokyo Hospital, Japan in June 2023. He has been working as a foreign proctor of arch repair with the Frozenix open stent-graft (Japan Lifeline, Japan), especially in Taiwan region. He also has been serving as an editorial board member of AME Case Reports.
JOVS: What role do you think the presentation and dissemination of surgical videos play in the medical community?
Prof. Nakao: The widespread use of surgical video screenings has created many opportunities for real-time education in the medical community. Because the education is in a different environment than live surgery, repeated videos of the surgery are provided. It has the advantage of being visible.
JOVS: Would you be interested in viewing more videos from peer professionals on “total arch replacement with frozen elephant technique” or “thoracic endovascular aortic repair”, showcasing various techniques and procedures? If so, which surgical teams or regions' experiences would intrigue you the most?
Prof. Nakao: The Frozenix OSG has been commercially available as FET since July 2014 in Japan by Japan Life-line Co., Ltd. Prof. Roberto Di Bartolomeo’s group (University of Bologna, Italy) describes their FET surgery with an E-vita open plus system. On the other hand, off-label usage of TEVAR in place of the Frozenix has been performed in Taiwan region. The Frozenix has spread immediately all around Japan. The Frozenix FET technique is easy to learn, even from young less-experienced Drs. It includes a few pitfalls and should be a feasible bailout strategy. Therefore, the Frozenix could be used in many hospitals without hybrid theater and specialists of TEVAR procedure.
JOVS: Do you have preferred platforms or tools that you find most effective or user-friendly for recording and editing surgical videos? Additionally, are there specific approaches or techniques you employ when creating surgical videos to enhance their educational effectiveness?
Prof. Nakao: Surgical videos are recorded using a zoom camera on the ceiling during surgery (Panasonic System Solutions Japan Co., Ltd., operating room video distribution system). To edit surgical recordings, a staff member specializing in video processing is hired, and the surgeon picks up the image surgery time required for editing and requests the editing (using general editing software).
Thirugnanam Agasthian
Key message of the video: The key message of the video is the importance of awareness of various anatomical surgical variations when performing major lung resections especially segmentectomy. Though most variations can be predicted by preoperative CT scan mapping and planning it is still important to do meticulous intraoperative dissection and identification of the various structures before division.
Dr. Thirugnanam Agasthian is a thoracic surgeon practising in private practise at Mount Elizabeth Hospital in Singapore. His main areas of interest are thoracic oncology and minimally invasive surgery. Dr. Agasthian is a board member and founding president of the South East Asian Thoracic Society (SEATS) as well as founding board member of Asia Thoracoscopic Surgery Education Program (ATEP), Ethicon Thoracic Advisory Board and ASEAN VATS Study Group. Dr. Agasthian was previously the Deputy Director and Head of Surgical Oncology at National University Cancer Institute, Singapore (NCIS) at the National University Hospital (NUS), and a senior consultant at National Cancer Center Singapore (NCCS).
Dr. Agasthian believes surgical videos have completely transformed surgical education and training. Dr. Agasthian recalled that when he was a young surgeon apart from watching his senior mentors at surgery the only other form of mastering a surgical technique was from colored pictures from textbooks which were not realistic and instructive. Surgical videos however give a more accurate instructive real time version of the surgical technique. It can be watched repeatedly by the surgeon to master the fine points at his own time and pace. It is also a boon for surgeons who work in small remote hospitals to learn new surgical techniques. As many surgeons cannot travel to centers of excellence for various reasons to watch and learn from master surgeons, surgical videos offer an excellent alternative to learn remotely.
Mastery and perfection of surgical technique is never complete and can always be improved and is a lifelong process. Learning from other surgeons is an important integral part of the journey. Most major surgical meetings can accommodate only a few speakers to showcase their techniques. Due to this lack of adequate platforms, outstanding unrecognized surgeons are unable to showcase and share their techniques and innovations to the rest of the community. Dr. Agasthian is glad that JOVS has filled this important need and given a crucial platform and recognition for surgeons from which ever part of the world to showcase their work and techniques.
Dr. Agasthian also suggests that journals and societies should actively promote courses and instructive articles on surgical video editing as many surgeons still struggle with video editing. He thinks video editing should be made mandatory as part of surgical training curriculum especially early at resident level. Though there are many platforms for video editing, he personally use the AVS Video editor as he find it to be a simple and quick. However, there is no one perfect platform, and each surgeon must find one which suits their own needs.
Key message of the video: The video highlights the surgical challenges faced during delayed laparoscopic approach to a colovesical fistula (CVF) complicating acute sigmoid diverticulitis. A bladder-sparing, one-stage laparoscopic sigmoidectomy without use of uretheral stents was performed one month after the onset of symptoms and computed-tomography confirmation of CVF. Immediate preoperative cystoscopy and left uretheral catheterization was performed to allow retrograde injection of indocyanine-green and fluorescence-guided surgical dissection. Sigmoidectomy with transanal Knight-Griffen colorectal anastomosis was uneventful and no diverting ileostomy was required.
Luigi Bonavina, MD, PhD, FACS (Hon), FEBS, is a Full professor of surgery at the University of Milan Medical School and Director of the Department of Surgery at IRCCS Policlinico San Donato. After his general and thoracic surgical training at the University of Padua Medical School, Dr. Bonavina completed a Post-doctoral Research Fellowship at the University of Chicago and Creighton University. His current clinical practice focuses on surgical management of esophageal disease via minimally invasive transoral, thoracoscopic, and laparoscopic approaches. Dr. Bonavina has served as a Visiting Professor in several academic and non-academic institutions around the world. He has also been invited to deliver key-note lectures at major international meetings. He has authored more than 450 articles on peer-reviewed journals and more than 50 book chapters. He currently serves as an Associate Editor for Updates in Surgery, the official journal of the Italian Society of Surgery, and is a Member of the Editorial Board of World Journal of Emergency Surgery.
Dr. Bonavina has been nominated Honorary Member of the American college of Surgeons and of the Association of Laparoscopic Surgeons of Great Britain & Ireland. He is an active member of the Italian Society of Surgery, European Surgical Association, Académie National de Chirurgie, American Foregut Society, International Society for Diseases of the Esophagus, Society for Surgery of the Alimentary Tract, and World Society of Emergency Surgery. He has also served as past-president of the European Foregut Society.
Dr. Bonavina thinks surgical education is a lifelong process and visual cues through audio-visual material have a great potential to enhance this pathway. Video-based surgical education has been shown to be effective for teaching/learning surgical skills and operative techniques, and represents a very useful addition to the curriculum of medical students, surgical trainees, and expert surgeons as well. A structured platform providing well edited videos is a potent resource to augment practical knowledge and to integrate the information provided by articles in surgical journals.
Dr. Bonavina also would like to view more videos from peer professionals on laparoscopic treatment of colovesical fistula. He believes that high-quality videos demonstrating both laparoscopic and robotic techniques for CVF repair performed by expert surgeons and urologists cooperating in different clinical scenarios and hospital settings can further contribute to standardization of minimally invasive surgical care and better surgical outcomes with low conversion rates in these patients.
When it comes to recording and editing surgical videos, Dr. Bonavina believes it is a perfectible art and requires specific technical, scientific, and didactic skills. It should be done by expert professionals keeping in mind that the educational value depends on clarity of images and animations, audio/text narration, conciseness, and the ability to control replay speed and navigate through the video. A person typically retains less than 15% of the reading material and less than 30% of the listening material; however, retention of knowledge increases up to 50% when effective audio-visual materials are used for teaching purposes.
Boon-Hean Ong
Key message of the video: The novel cloud-based 3D reconstruction software solution that we have been using at our institution was extremely useful in performing complex thoracosopic segmentectomies, and that such cloud-based solutions may confer additional benefits over traditional non-cloud-based platforms.
Clinical Assistant Professor Boon-Hean Ong is a Senior Consultant and the Director of Thoracic Surgery at the National Heart Centre Singapore. He graduated from the Faculty of Medicine, National University of Singapore, then completed cardiothoracic surgery training at the National Heart Centre Singapore. He was then awarded the Singapore Ministry of Health-SingHealth HMDP Award to pursue an advanced clinical fellowship in general thoracic surgery at Brigham and Women’s Hospital, Harvard Medical School in the United States of America. Subsequently, he returned from fellowship training to practice cardiothoracic surgery with subspecialty interests in minimally invasive thoracic surgery, thoracic oncology and lung transplantation at the National Heart Centre Singapore. He currently the service chief at the Singapore General Hospital campus for the SingHealth Duke-NUS Lung Centre and is the Vice Chairman of the Chapter of Cardiothoracic Surgeons, Academy of Medicine Singapore.
Speaking of the role of surgical videos play in the medical community, Prof. Ong shares, “Presently, surgical videos represent a very important medium for spreading surgical innovation and education. With widespread availability of high-quality surgical videos on various platforms (including JOVS!), they have become an invaluable resource for surgeons of all levels to learn from each other and refine their surgical technique. This is especially so for rare and unusual operations or situations which many surgeons may not necessarily have encountered before during their formal surgical training. Moreover, the videos also allow for the rapid propagation of new, important techniques which then benefit countless patients worldwide that must undergo these operations.”
Prof. Ong is interested in viewing more videos from peer professionals on VATS segmentectomy guided by cloud-based 3D reconstruction platform. He mentioned, “I would be particularly interested to see what my colleagues in North America and Europe use, as I have previously only seen what the surgeons in East Asia (Japan/China/South Korea) normally use.”
Talking about the preferred platforms or tools for recording and editing surgical videos, Prof. Ong shares that he has only used the default Windows Movie Maker for the editing of my surgical videos, and he has found it sufficient for my needs. When editing his surgical videos for a presentation or publication, he find that the most important thing to try to achieve is to make sure that there is no wasted time in the video. Every frame should be illustrating an important point and should be either narrated or subtitled to bring the point across to the audience. Labelling the anatomical structures of interest at the appropriate juncture are also helpful for many viewers. Alternatively, he also finds that non-edited surgical videos have quite a lot of educational value when they are available, because we are able to see every step of a particular operation, but they do take longer to watch and are not commonly available.
Miroslav P. Peev
Video article: Multi-vessel off-pump total endoscopic coronary artery bypass—pearls and pitfalls
Key message of the video: Robotic coronary artery bypass grafting emerged as a safe and reproducible technique with excellent short- and long-term outcomes. This sternum sparing method allows the use of bilateral internal thoracic arteries (ITAs) as well as it provides the unique opportunity to access the various parts of the heart in a minimally invasive way while achieving substantially fewer complications, less pain, early discharge and return to work. In our video, we demonstrate an abbreviate version of our technique based on over 600 operations with guided reference to key pearls and pitfalls.
Dr. Miroslav Peev is a board-certified thoracic surgeon practicing all aspects of cardiovascular surgery at SSM St. Mary’s Hospital in Madison, WI. Dr. Peev completed my general surgery training at the New York University in Manhattan and subsequently CT surgery fellowship at the University of Chicago under the mentorship of Dr. Val Jeevanandam, Dr. Chris Salerno and Dr. Sam Balkhy. Dr. Peev have completed postdoctoral research fellowships at the Massachusetts General Hospital/Harvard Medical School in Boston as well as at the New York - Presbyterian/Weill Cornell Medical Centre in New York City. His research focuses on innovation and development of advanced technologies for heart and aortic surgery.
Dr. Peev thinks surgical videos are without a doubt an effective and easy to digest tool that allow rapid spread of research, techniques, and innovation within the surgical community. Guided surgical videos allow the audience to become quickly submerged in the pathology and the corresponding therapy. It is quite engaging and makes transfer of knowledge much easier.
Minimally invasive surgical revascularization is certainly an evolving field. As a strong proponent of innovation and robotic surgery, Dr. Peev is interested to learn more from the peers and the way bypass surgery is conducted using alternative less invasive techniques. For example, there are well known heart surgery groups in New York city as well as in Philadelphia known for their extensive expertise in MIDCAB and/or robotic assisted coronary bypass. Those surgeons have years of experience and plethora of knowledge that would help penetration of the minimally invasive heart surgery in the modern surgical practice.
There are wide variety of software that could help edit videos. Dr. Peev says, “I am pretty sure that the same result could be achieved using just about any of those. My personal preference is iMovie – user friendly software with all functions needed to create a high-quality video. In terms of recording, we use our standard operating room equipment. When building a video, I try to integrate chronologically the key steps of the operation with focus on the technique. As mentioned before, adding short text descriptions and guided audio tremendously help with understanding and communicating the main message of the video.”
George Rakovich
Video article: Thoracoscopic S2 segmentectomy by a posterior approach for a central metastasis: a case report
Key message of the video: There has to be a rationale that guides surgical approaches and technique. In this case, what guides the surgical approach (and justifies a posterior approach) is the goal of obtaining direct access to the structures at the root of the target segment. As a matter of principle, this minimizes required dissection, spares tissue planes, and streamlines the surgical procedure. It is also extremely helpful to break down the procedure into a series of key steps, which I tried to keep to a minimum. Each step has a well-defined surgical objective which involves well-defined anatomic structures, and steps follow one another in a logical sequence. This helps both with how one conceptualizes the procedure, as well as with future technical execution and, eventually, mentoring. Each step is highlighted using a key intraoperative view, and each of the proposed key views illustrates the optimal intraoperative exposure that one seeks; proper exposure is probably the most challenging aspect of S2 segmentectomy specifically (as well as segmentectomies in general), and it certainly warrants the surgeon’s due consideration, time, and effort. Inadequate exposure can make even a simple procedure tedious, while optimal exposure can make even difficult cases manageable.
Dr. George Rakovich is Chief of Thoracic Surgery at Maisonneuve-Rosemont Hospital, and he teaches at the University of Montreal School of Medicine in Montreal, Canada. Dr. Rakovich hold a Master’s degree in medical education, which involved research in visual perception, and he recently completed a preparatory program in philosophy, with a special interest in the philosophy of medicine. Dr. Rakovich’s clinical practice spans the field of thoracic surgery, but his interests are focused on advanced minimally invasive techniques and anatomic sublobar resection in particular. In collaboration with sister engineering schools, Dr. Rakovich supervises several graduate students and co-lead research programs in pulmonary and parenchymal staple line biomechanics and advanced imaging in lung resection surgery, with a view towards constant improvement of minimally invasive technique and patient outcomes. Dr. Rakovich has served on the editorial boards of several journals, most recently the World Journal of Surgery and Shanghai Chest.
Surgery, especially in the era of minimally invasive techniques, relies heavily on visual information. Minimally invasive surgery platforms make it both easier and more necessary to represent surgical procedures visually. Surgical videos are an ideal way to render the actual intraoperative appearance of tissues and anatomic structures, as opposed to static images and illustrations. On the other hand, schematic representations are a useful tool for conceptualization of 3D structures and anatomic relationships. In many ways, both intraoperative videos and illustrations are required for a proper grasp of surgical technique, much like a map is required for accurate navigation. An ideal video incorporates and makes use of this interplay between both conceptual and “real world” representations. The increasing sophistication of 3D imaging technologies, augmented reality, as well as virtual reality, will no doubt further expand the realm of surgical videos and maximize their didactic value.
Surgical technique is influenced by an evolving understanding of disease, by evolving technologies, and by evolving technical expertise. These, in turn, may be influenced by local or regional treatment philosophies and preferences. Access to surgical technologies may vary in relation to available resources (economic and otherwise) and is also a function of the structure of healthcare systems. One of the most interesting aspects of surgery is how surgeons adapt to their specific circumstances and maximize the use of the resources available to them. This often requires creative thinking and innovation, and so Dr. Rakovich thinks that appreciating techniques from multiple provenances and diverse contexts is an excellent way to foster surgical advancement.
JOVS: What are your preferred platforms or tools for recording and editing surgical videos?
Dr. Rakovich: Minimally invasive surgery makes recording surgical videos straightforward. We recover videos directly onto a memory stick from our thoracoscopic camera platform. Video editing software is now readily available, and even simple versions should be more than adequate for surgeons’ needs. High end “special-effects” are unnecessary and probably tend to distract from the more important points.
We are fortunate to have an outstanding audio-visual department as well as a medical illustrator in our hospital, and we routinely collaborate with them for our videos. They provide invaluable technical help, iron out “glitches”, suggest optimal selection of video sequences, help frame the focus and adjust the flow of the video images, and produce outstanding schematic representations. I also find that the use of a professional narrator really helps one to better follow the procedures. I encourage anyone with access to such specialists to involve them in their projects. I have found that they are very excited to have the opportunity to work on surgical technique, and I have had the opportunity to learn a lot from them as well.
Johannes Bonatti
Key message of the video: The key takeaway message in this video is that totally endoscopic coronary artery bypass grafting is well feasible using robotic technology. Colleagues watching the video can get very detailed guidance on how to place ports, harvest the left internal mammary artery, how to create comfortable conditions to perform a graft to coronary artery anastomosis with the surgical robot, and how to carry out the same.
Johannes Bonatti is an attending cardiac surgeon at the University of Pittsburgh Medical Center (UPMC) Heart and Vascular Institute and Professor of Cardiothoracic Surgery at the University of Pittsburgh. He has performed cardiac surgery using robotic devices since 2001 and has carried out 1000+ cases. He introduced and ran robotic heart surgery programs at Innsbruck Medical University, the University of Maryland, the Cleveland Clinic in Ohio, the Cleveland Clinic Abu Dhabi, and most recently re-introduced robotic cardiac surgery at UPMC. He held academic and leadership positions at these institutions and performed several “world firsts” including the first successful quadruple totally endoscopic coronary artery bypass grafting procedure in robotic fashion. Dr. Bonatti has published more than 380 papers according to ResearchGate and has given scientific talks at respected meetings around the world. He was President of the Minimally Invasive Robotics Association (MIRA) from 2011-2012 and President of the International Society for Minimally Invasive Cardiothoracic Surgery (ISMICS) during the 2017/2018 term. He is currently serving on the task forces for robotic cardiac surgery at EACTS and STS, and leads the corresponding working group at ISMICS.
Surgical videos have made learning surgical techniques much easier than in times when technical aspects of surgery were taught through descriptions or schemes in a text book or in a surgical atlas. Dr. Bonatti thinks video presentations are a main part the future of surgical teaching and learning.
Dr. Bonatti is very interested in viewing more videos from peer professionals on robotic totally endoscopic coronary artery bypass grafting, showcasing various techniques and procedures. He strongly suggests to include Dr. Husam Balkhy from the University of Chicago, USA, Dr. Sloane Guy from the Georgia Heart Institute, Gainesville, GA, USA , Dr. Gianluca Torregrossa from Lankenau Hospital, Pennsylvania, USA, Dr. Gulam Murtaza, SSM health, Madison WI, USA, Dr. Jean Luc Jansens from the CHU UCL Namur, Belgium, Dr. Dr. Nitin Rajput Medanta Gurugram, India, and Dr. Sathyaki Nambala from Apollo Hospitals, Bengaluru, India.
For video editing, Dr. Bonatti uses Adobe Premier Pro. He thinks surgical videos need a voice over, and he likes to include several team members to be part of the explanations to make the video more lively. For taking videos in the operating room it is extremely important that people who really know and understand the procedure take the video shots. Institutional video teams often lack this knowledge and film scenes that are important to the public but not for surgeons. If they are included, they need detailed real time instructions by people with surgical know how. When taking shots it is important to get zoom outs very often to see how the whole team is working. Often times only surgical details inside the operative field are shown and the big picture of the operation is lost.