Management of pelvic ring injuries

Jan Lindahl: MANAGEMENT OF PELVIC RING INJURIES Unstable pelvic ring injuries are relatively rare injuries, but they constitute a major cause of death and disability in high-energy polytrauma patients Massive hemorrhage is the leading cause of potentially preventable death following a blunt pelvic trauma. The overall aim of surgical treatment for unstable pelvic ring injuries is to restore the pelvic anatomy and perform neural decompression, thus allowing normal function with a low rate of complications. This doctoral thesis was initiated to investigate the outcomes of acute and definitive management strategies for unstable pelvic ring injuries. The first study investigated the radiological and functional results of treating type B and C pelvic injuries with an anterior external fixation frame. The second study focused on identifying factors for early predictions of mortality-related outcome and prognosis in patients with pelvic fracture-related arterial bleeding that were treated with transcatheter angiographic embolization (TAE). The third study investigated the outcomes of type C pelvic fractures treated with standardized reduction and internal fixation methods. The fourth study evaluated outcomes and identified prognostic factors for operatively-treated, H-shaped sacral fractures with spinopelvic dissociation. Study I showed that an anterior external fixator failed to achieve and properly maintain reduction in 75% of type B open book injuries and in nearly all (95%) type C pelvic ring injuries. Therefore, an external frame is not a suitable method of treatment for the most unstable pelvic ring injuries as a definitive treatment. The current clinical applications of anterior pelvic external fixators comprise the resuscitation phase, initial fracture stabilization phase, and sometimes, in complex injuries (type C), the definitive phase for fixation of the anterior part of the pelvic ring, in conjunction with posterior internal fixation. Study II of pelvic fracture related arterial bleedings showed that the worst prognosis was related to exsanguinating bleeding from the main trunk of the internal or external iliac artery (large pelvic arteries) or from multiple branches of the internal or external iliac vasculature (high vessel size score). Definitive control of arterial bleeding was achieved with TAE in all patients. In massive hemorrhage with several bleeding arteries uni- or bilaterally, it is reasonable to use non-selective embolization by promptly occluding the main trunk of the internal iliac artery, either uni- or bilaterally. Study III of operatively treated type C pelvic fractures revealed that, internal fixation of injuries in the posterior and anterior pelvic ring provided excellent or good radiological results in 90% of cases. Additionally, because a reduction with displacement less than or equal to 5 mm was more often associated with a good functional outcome, that should be the goal of operative management. However, the prognosis is also often dependent on associated injuries, particularly a permanent lumbosacral plexus injury. The results favoured internal fixation of all the injured elements of the pelvis for improved stability and a more accurate anatomical result in the entire pelvic ring. The H-shaped sacral fracture with spinopelvic dissociation is a rare injury pattern. Study IV revealed that lumbopelvic fixation was a reliable treatment method. The study also showed that neurological recovery and clinical outcome were associated with the degree of initial translational displacement of the transverse sacral fracture component. Permanent neurological deficits were more frequent and the clinical outcome was worst in completely displaced transverse sacral fractures. An accurate operative reduction of all sacral fracture components was associated with better neurological recovery and clinical outcome. We conclude, that with appropriate treatment of unstable pelvic ring injuries, and associated injuries in other organs, it is possible to achieve better survival rates and functional results, and to reduce long-term disability.Jan Lindahl: LANTIORENKAAN MURTUMIEN HOITO (MANAGEMENT OF PELVIC RING INJURIES) Lantiorenkaan murtumat ovat suhteellisen harvinaisia vammoja käsittäen 1% kaikista sairaalahoitoa vaativista murtumista Suomessa. Epätukevat lantiorenkaan murtumat syntyvät yleensä suuren vammaenergian seurauksena ja niihin liittyy usein muiden kehonosien vammoja. Massiivinen verenvuoto on merkittävin ja usein estettävissä oleva kuolinsyy tylpällä vammamekanismilla syntyneissä lantiorenkaan vammoissa. Mikäli akuuttivaiheen hoito ei ole tehokasta, massiivinen verenvuoto johtaa sydämen ja verenkierron pettämiseen ja potilaan kuolemaan. Tämän väitöskirjatutkimuksen tarkoituksena oli selvittää: 1) ulkoisen tukilaitteen soveltuvuus B- ja C-tyypin lantiorenkaan murtumien lopulliseksi hoitomuodoksi, 2) hengenvaarallisten, runsaasti vuotavien lantionmurtumien alkuvaiheen vuodon tukkimista embolisaation (TAE) avulla ja samalla kartoittaa riskitekijöitä, jotka ennustavat huonoa lopputulosta ja potilaan kuolemaa vaikeimmin vammautuneiden lantionmurtumapotilaiden kohdalla, 3) C-tyypin murtumien kohdalla standardoidun leikkaushoidon ja sisäisen kiinnitysmenetelmän luotettavuutta ja hoidon pitkäaikaistulokset ja 4) ristiluun vaikeimpien ns. H-tyypin murtumien leikkaushoidon luotettavuutta sekä saavutetun asennonkorjauksen, murtumakiinnityksen ja hermorakenteiden vapautuksen pitkäaikaistulokset sekä toipumisennusteeseen vaikuttavat tekijät. Ensimmäisen osajulkaisun tulokset osoittivat, että lantiorenkaan etuosaan kiinnitettävä ulkoinen kiinnityslaite (externi fiksaatiolaite) ei ollut luotettava, eikä sillä voitu taata asianmukaista murtuman paikalleen asettamista ja hyvää lopputulosta vaikeimmissa B- ja C-tyypin murtumissa. Toinen osajulkaisu osoitti, että vuotavien lantionmurtumien kohdalla huonoin ennuste liittyi lantiovammoihin, joissa valtimoiden varjoainekuvauksessa (angiografiassa) todettiin lantion päävaltimon (arteria iliaca interna tai externa) repeämä tai useampia samanaikaisia pienempien valtimosuonten repeämiä. Embolisaatio osoittautui luotettavaksi hoitomenetelmäksi ja kaikki valtimoperäiset vuodot pystyttiin tukkimaan. Kriittisessä vuototilanteessa, jossa angiografiassa todetaan useita vuotokohtia lantion valtimoissa, tulee embolisaatio suorittaa ei-selektiivisesti siten, että lantion aluetta suonittava päävaltimo (arteria iliaca interna) tukitaan välittömästi. Näin vuoto saadaan nopeammin hallintaan ja potilaan selviytymisennuste paranee. C-tyypin lantionmurtumien sisäinen kiinnitysmenetelmä, lantiorenkaan kiinnitys edestä levyin sekä takaa ruuvein tai levyin, osoittautui luotettavaksi (kolmas osajulkaisu). Saavutettu asento säilyi seurannassa erinomaisena tai hyvänä 90%:ssa tapauksista. Leikkauksessa saavutettu murtuman hyvä asento korreloi hyvään neurologiseen toipumiseen ja toiminnalliseen tulokseen. Epäanatominen tulos siten, että murtuman lopullinen siirtymä oli yli 5 mm, ennusti huonompaa toiminnallista lopputulosta. Merkittävin toimintakykyä rajoittava tekijä aiheutui lantion alueen hermopunosvauriosta. Tulokset tukevat käsitystä, jonka mukaan C-tyypin vammoissa tulee korjata ja kiinnittää kaikki murtumat lantiorenkaan etu- ja takaosassa, jolloin saavutetaan parempi anatominen tulos ja samalla parempi lantiorenkaan kokonaistukevuus. Ristiluun H-tyypin murtuma, johon liittyy selkärangan ja lantiorenkaan irtoama toisistaan, on harvinainen lantion takaosan alueen vammakokonaisuus. Neljännessä osajulkaisussa käytetty lannerangan ja lantion välinen kiinnitysmenetelmä (lumbopelvinen kiinnitys) osoittautui luotettavaksi. Lantiohermopunoksen (alaraajojen osittainen halvaus) ja ristiluuhermojen vammat (ns. kauda equina syndrooma) ovat tähän vammatyyppiin liittyen yleisiä. Hermovaurion korjaantuminen ja kokonaistoipumisen ennuste oli riippuvainen ristiluun poikittaisen murtuman siirtymän asteesta. Hermovaurio oli vaikeampiasteinen ja toipumistulos huonompi, mikäli siirtymä ensimmäisessä kuvauksessa oli yli ristiluun paksuuden, kun tuloksia verrattiin siihen potilasryhmään, jolla siirtymä oli osittainen. Hyvä leikkauksessa saavutettu asento kaikissa ristiluun murtumalinjoissa oli yhteydessä parempaan toipumisennusteeseen. Systemaattisella tutkimisella sekä määrätietoisella ja vaikuttavalla hoidolla voidaan vähentää lantiorenkaan murtumiin liittyvää kuolleisuutta, sairastavuutta ja pysyvää vammautumista

Clinical and radiological aspects of traumatic pelvic ring injury

Epidemiological data regarding High-Energy Traumatic Pelvic Ring Injury in Sweden was missing. Further, there was no data regarding current knowledge and level of experience of Swedish first line trauma officers about the management of traumatic pelvic ring injury. While conventional X-ray has been widely criticized as an optimal tool in assessment of pelvic ring injuries, a practical substitute has not been proposed. We planned to study epidemiological aspects of High Energy Traumatic Pelvic Ring Injury using data from the Karolinska Trauma Center. To assess first line trauma medical officer’s knowledge and level of experience regarding acute management of pelvic trauma. To investigate alternative practical options instead of conventional X-ray during the treatment of pelvic fractures. We used data from the Swedish National Trauma Registry (SweTrau). We used the Karolinska University Hospital´s Patient Notes and PACS. We used a questionnaire in order to assess Swedish trauma unit’s medical officers about acute management of pelvic trauma. We further used three dimensional models for image fusion and motion analysis in order to investigate symmetry of human pelvis and to investigate a pelvic fracture model. We found that the incidence of High Energy Traumatic Pelvic Ring Injury was about 3.5/100 000 inhabitants per year in Stockholm. The 30-day mortality was 7.8% and the 1 year mortality was 9%. The main cause of mortality was traumatic brain injury. Intentional injuries had a mortality rate of 15%. The reoperation frequency was 22%. Main cause of reoperation was due to metalwork problems, and a majority of them were potentially avoidable. We found that a majority of the Swedish first line trauma officers were aware of presence of a pelvic binder in their department and knew how to apply it, while there was more experience in the university hospitals. There was a general misconception regarding limitation of pelvic binders as 55% believed that a pelvic binder can stop an arterial bleeding. We were further able to show that human hemi pelvises are symmetrical and the 3D images of the contralateral hemi pelvis can be used for pre-operative templating. We were able to show that using fusion of serial 3D images of a pelvic model, translations of ±0.2 mm and rotations of ±0.2° could be detected. We can hereby conclude that monitoring 30-day mortality seems enough while studying high energy pelvic injuries. Intentional injuries need further future studies as per high mortality rate. Reoperation frequency following fixation of disrupted high energy pelvic fractures is high and needs addressing and early detection. Limitations of pelvic binders should be addressed during the trauma courses. Low dose CT-scan together with serial image fusion can be a future substitute for conventional X-ray. Human hemi pelvises are symmetrical and the contralateral side can be used for templating

Pelvic ring injuries:recovery of patient-perceived physical functioning and quality of life

Sustaining a pelvic ring injury is a life event that is likely to have a major and long-lasting effect on the patient’s daily life. Even after two years, 25% of patients have not yet returned to their pre-injury level of physical functioning and quality of life. The physical and mental consequences require a holistic approach to both treatment and outcome evaluation. Valid and reliable patient-reported outcome measures (PROMs) on physical and mental functioning and quality of life should be the most important aspects in evaluation of treatment and rehabilitation protocols. These PROMs may be an important step toward further improving rehabilitation programs. Ideally, rehabilitation should be approached multidisciplinary and involves trauma surgeons, rehabilitations physicians, geriatricians, physiotherapists, psychologists and dieticians. By encouraging the patient to stay in charge of his own health, the focus can shift towards the patient’s strength rather than his weakness, and subsequently improve resilience. Special attention should be paid to the fragile elderly patient who is at risk for serious injuries, even after minor trauma, complications and high-mortality up to 27% within a year. This can be related to the pre-existing limited physical condition as a result of comorbidities or decreased muscle quality and quantity, of which the latter was found to be present in almost half of elderly patients with pelvic ring injuries. Surgical treatment of pelvic ring injuries can be improved by using three-dimensional assisted techniques which tend to have a positive influence on operating time, blood loss, radiation and screw accuracy

Minimally Invasive Derotational Osteotomy of Long Bones: Smartphone Application Used to Improve the Accuracy of Correction

Correction of rotational malalignments caused by fractures is essential as it may cause pain and gait disturbances. This study evaluated the intraoperative use of a smartphone application (SP app) to measure the extent of corrective rotation in patients treated using minimally invasive derotational osteotomy. Intraoperatively, two parallel 5 mm Schanz pins were placed above and below the fractured/injured site, and derotation was performed manually after percutaneous osteotomy. A protractor SP app was used intraoperatively to measure the angle between the two Schanz pins (angle-SP). Intramedullary nailing or minimally invasive plate osteosynthesis was performed after derotation, and computerized tomography (CT) scans were used to assess the angle of correction postoperatively (angle-CT). The accuracy of rotational correction was assessed by comparing angle-SP and angle-CT. The mean preoperative rotational difference observed was 22.1°, while the mean angle-SP and angle-CT were 21.6° and 21.3°, respectively. A significant positive correlation between angle-SP and angle-CT was observed, and 18 out of 19 patients exhibited complete healing within 17.7 weeks (1 patient exhibited nonunion). These findings suggest that using an SP app during minimally invasive derotational osteotomy can result in accurate correction of malrotation of long bones in a reproducible manner. Therefore, SP technology with integrated gyroscope function represents a suitable alternative for determination of the magnitude of rotational correction when performing corrective osteotomy.ope

APPLICATIONS OF MODERN IMAGING TECHNOLOGY IN ORTHOPAEDIC TRAUMA SURGERY

Orthopaedic trauma surgery is a complex surgical speciality in which anatomy, physiology and physics are mixed. Proper diagnosing and based on that planning and performing surgery is of crucial matter. This article briefly summarizes available radiological modalities used for diagnostics and for surgical planning. It focuses on utility of rapid prototyping process in trauma surgery. Moreover, a case study in which this technique was used is described. Rapid prototyping proved its usefulness and in future it may become a modality of choice for planning complex trauma procedures.&nbsp

Stellenwert der Navigation in der Becken- und Acetabulumchirurgie : Systematische Literaturanalyse und Umfrage unter den unfallchirurgischen Kliniken Deutschlands

Die navigierten Operationsverfahren spielen in der Medizin eine zunehmende Rolle. In der Becken- und Acetabulumchirurgie besitzen sie das Potential bei der perkutanen Schraubenplatzierung im Vergleich zum Verfahren unter Standardfluoroskopie eine präzisere Schraubenplatzierung bei gleichzeitiger Einsparung der Strahlendosis zu ermöglichen. Zusätzlich liefern sie eine bessere Darstellung des Operationsgebiets und eine einfachere intraoperative Verfügbarkeit, wodurch die Orientierung für den Operateur und letztlich die Implantatplatzierung erleichtert werden, allerdings nur unter Berücksichtigung diverser Limitationen und entsprechender Expertise des Operateurs. Ziel der Arbeit war es anhand einer deutschlandweit durchgeführten Umfrage aller unfallchirurgischen und orthopädischen Abteilungen kombiniert mit einer strukturierten Literaturrecherche den aktuellen Stellenwert der Navigation (2D-, 3D-, CT-Navigation) in der Becken- und Acetabulumchirurgie zu erarbeiten. Neben einer strukturierten Literaturanalyse wurden 574 deutsche Kliniken kontaktiert, worunter sich 150 Kliniken mit gültigen Fragebögen zurückmeldeten. Der Fragebogen wurde dahingehend konzipiert, dass sich die Kliniken den drei Institutionsarten Universitätsklinik, Lehrkrankenhaus oder BG-Klinik bzw. den drei Arten des Traumazentrums gemäß des Traumanetzwerks der DGU (überregional, regional und lokal) zuordnen ließen um anschließend Aussagen über die Versorgungsstruktur treffen zu können. Die Umfrage ergab, dass 86 % der Universitätskliniken, 80 % der BG-Klinken und 52 % der Lehrkrankenhäuser bzw. 76 % der überregionalen Traumazentren und 50 % der regionalen und lokalen Traumazentren an ihrer Klinik ein Navigationssystem zur Verfügung stehen haben. Bei der operativen Versorgung von Beckenfrakturen (bzw. Acetabulumfrakturen) gaben davon 64 % (bzw. 50 %) der Universitätskliniken, 40 % (bzw. 40 %) der BG-Kliniken und 52 % (bzw. 7 %) der Lehrkrankenhäuser sowie 42 % (bzw. 33 %) der überregionalen Traumazentren und 58 % (bzw. 5 %) der regionalen Traumazentren an das Navigationssystem anzuwenden. Bei den Lehrkrankenhäusern bzw. lokalen Traumazentren waren dies deutlich weniger. Darunter gaben Universitätskliniken bzw. überregionale Traumazentren am häufigsten an jährlich 11 – 15 Patienten mit Beckenringfrakturen navigiert zu versorgen, während Lehrkrankenhäuser bzw. regionale Traumazentren am häufigsten 6 – 10 Patienten pro Jahr angaben. Die Zahl der jährlich navigiert versorgten Acetabulumfrakturen lag etwas tiefer. Eine eindeutig präferierte Navigationsart an deutschen Kliniken stellte sich nicht heraus, jedoch kommt die 3D-Navigation etwas häufiger als die 2D-Navigation zum Einsatz, während die CT-Navigation nur in Einzelfällen Anwendung findet. Dies deckt sich mit der in der Studienlage erkennbaren Verdrängung der CT-basierten Navigation zugunsten der 3D-Navigation. Unter den verschiedenen Navigationsarten besitzt die 3D-Navigation einen besonderen Stellenwert, da sie die Vorteile der verschiedenen Navigationsarten kombiniert. Sie vereint die Praktikabilität und intraoperativ einfache Verfügbarkeit der 2D-Navigation mit der hohen Bildqualität und konsekutiv erhöhten Präzision bei der Schraubenplatzierung der CT-Navigation. Die häufigsten Vorteile der Navigation wurden von den Kliniken in der erhöhten Präzision bei der Implantateinbringung und der Strahlenreduktion gesehen. Limitationen bildeten technische Schwierigkeiten und eine unzureichende Bildqualität, die bereits bei knapp der Hälfte der Kliniken zum vorzeitigen Abbruch der Navigation geführt haben. Ob sich die Navigation in der Becken- und Acetabulumchirurgie in Zukunft als Standardverfahren etablieren wird, konnten sich 64 % der Universitätskliniken, 60 % der BG-Kliniken und hingegen nur 24 % der Lehrkrankenhäuser (p = 0,006) bzw. 51 % der überregionalen Traumazentren und lediglich 23 % der regionalen und 20 % der lokalen Traumazentren vorstellen (p = 0,067). Zusammenfassend ergab die Analyse der aktuellen Studienlage zusammen mit den Ergebnissen der Umfrage, dass Navigationssysteme in der Beckenring- und Acetabulumchirurgie zunehmend an Bedeutung gewinnen, jedoch noch nicht flächendeckend als Standardverfahren an deutschen Kliniken eingesetzt werden. Trotz der genannten Vorteile limitieren ein struktureller und personeller Mehraufwand, technische Schwierigkeiten sowie erhöhte Anschaffungs- und Wartungskosten den Einsatz der Navigationsverfahren, sodass die Navigation bisher vor allem großen Zentren (überregionale Traumazentren bzw. BG- und Universitätskliniken) vorbehalten ist. Zur weiteren Beurteilung und Etablierung der Navigationssysteme als Standardverfahren an deutschen Kliniken sind weitere kontrollierte randomisierte Studien in prospektivem Design erforderlich

A review of fracture fixation as it affects the small animal pelvis. an anatomic, ultrasonographic, cross-sectional and retrospective radiographic study

The pelvis is a stable structure comprising of paired hemipelves. A thick layer of muscles covers the pelvis almost completely, leaving only a few bony prominences in a subcutaneous position. In order for this stable and well protected structure to be fractured, severe external violence must be applied. This trauma is due to road traffic accidents in the majority of cases. Fractures of the pelvis are common and constitute 20 to 30% of all fractures seen in veterinary practice. Despite this, the canine and feline pelvis has not been well studied. Little information is available regarding fracture locations, frequency of particular anatomical sites and overall severity of the pelvic disruption. The majority of pelvic fractures are surgically managed but there is a lack of accessible data regarding optimal fixation methodologies, the potential hazards and the rate of complication. There is also a difficulty in the assessment of concomitant pelvic soft tissue damage. A review of the topographical canine musculature and cross sectional anatomy was carried out and an attempt was made to provide a correlation with image based registration extended field of view ultrasound. For the cross sectional study, greyhound type canine cadavers were sectioned transversely and radially. Lines, correlating to the lines of section on the cadavers were drawn on a live greyhound. These lines were used as markers for the ultrasound transducer to be scanned along. For the topographic study, extensive dissection was carried out in order to identify the pelvic musculature and to see if it was present in agreement with standard anatomical textbooks. The corresponding individual muscles were scanned on a live greyhound. It was found that although the ultrasonography demonstrated the cross sectional anatomy, it was difficult to identify individual muscles. Whereas, when the individual muscles and muscle groups were scanned a clearer picture was produced. It was hoped that as the normal pelvic anatomy was accurately displayed using this technology then it might have potential as a diagnostic tool for rapid exploration of clinical cases subjected to trauma. The second part of the cross sectional study was carried out using both canine and feline cadavers, to try and localise safe, hazardous, and unsafe corridors for external skeletal fixation pin insertion. In a selection of dog and cat cadavers, sections were prepared. Although this gave a clear indication of the complexity of the pelvic anatomy, it was difficult to deduce the exact external skeletal pin insertion site from these sections. Greater success was attained through extensive dissection and the use of anatomy textbooks and an atlas. Three safe and three hazardous corridors were found in each hemipelvis. Although this part of the study is at present theoretical, it seems at this stage that external fixation of the pelvis is a plausible method of fracture fixation. The blood supply to the pelvis was also investigated. This part of the study was divided in to two broad categories: observations of the nutrient foramina and arterial casting. There was a tremendous amount of variation of the positions and sizes of the pelvic nutrient foramina. Foramina were divided subjectively into principal (the largest) and secondary, and this was further subdivided into large and small. All results were recorded diagrammatically. Only a few principal foramina were notably present in the majority of specimens. Many authors maintain that pelvic fractures heal rapidly due to the abundant blood supply but to date no demonstration of this has been found. Methylmethacrylate casting of the pelvic arteries clearly demonstrated the extensive pelvic vascular tree. In conjunction with the major and well-documented arteries, there were also dense arborisations of small vessels that would have lain between or within the musculature of the pelvis and proximal hindlimb. A retrospective radiographic study was carried out. The main goal of this study was to elucidate which pelvic fractures were the most common in small animals. There is a lack of information in the literature pertaining to this. It was hoped that the information gained would aid in the future in the design and production of treatment protocols, especially for those locations damaged most often

Augmented Reality and Artificial Intelligence in Image-Guided and Robot-Assisted Interventions

In minimally invasive orthopedic procedures, the surgeon places wires, screws, and surgical implants through the muscles and bony structures under image guidance. These interventions require alignment of the pre- and intra-operative patient data, the intra-operative scanner, surgical instruments, and the patient. Suboptimal interaction with patient data and challenges in mastering 3D anatomy based on ill-posed 2D interventional images are essential concerns in image-guided therapies. State of the art approaches often support the surgeon by using external navigation systems or ill-conditioned image-based registration methods that both have certain drawbacks. Augmented reality (AR) has been introduced in the operating rooms in the last decade; however, in image-guided interventions, it has often only been considered as a visualization device improving traditional workflows. Consequently, the technology is gaining minimum maturity that it requires to redefine new procedures, user interfaces, and interactions. This dissertation investigates the applications of AR, artificial intelligence, and robotics in interventional medicine. Our solutions were applied in a broad spectrum of problems for various tasks, namely improving imaging and acquisition, image computing and analytics for registration and image understanding, and enhancing the interventional visualization. The benefits of these approaches were also discovered in robot-assisted interventions. We revealed how exemplary workflows are redefined via AR by taking full advantage of head-mounted displays when entirely co-registered with the imaging systems and the environment at all times. The proposed AR landscape is enabled by co-localizing the users and the imaging devices via the operating room environment and exploiting all involved frustums to move spatial information between different bodies. The system's awareness of the geometric and physical characteristics of X-ray imaging allows the exploration of different human-machine interfaces. We also leveraged the principles governing image formation and combined it with deep learning and RGBD sensing to fuse images and reconstruct interventional data. We hope that our holistic approaches towards improving the interface of surgery and enhancing the usability of interventional imaging, not only augments the surgeon's capabilities but also augments the surgical team's experience in carrying out an effective intervention with reduced complications