Richard Crawford

Patient Blood Management (PBM) has evolved from a transfusion-centered practice to a structured, patient-focused perioperative strategy aimed at improving surgical outcomes while preserving blood resources. In the operating room, where bleeding risk is anticipated and modifiable, PBM requires proactive intervention rather than reactive transfusion. This review synthesizes current evidence on perioperative blood conservation strategies specifically relevant to surgeons and anesthesiologists. Preoperative optimization begins with systematic identification and correction of anemia, most commonly iron deficiency, using appropriately timed oral or intravenous iron therapy and, in selected cases, erythropoiesis-stimulating agents. Careful management of anticoagulant and antiplatelet therapies, early recognition of acquired or inherited coagulopathies, and protocol-driven reversal strategies further reduce perioperative hemorrhagic risk. Intraoperatively, blood conservation depends on meticulous surgical technique, respect for anatomical planes, minimally invasive approaches, and the judicious use of advanced energy devices and topical hemostatic agents. Pharmacologic interventions-particularly tranexamic acid administered with appropriate timing and dosing-have demonstrated consistent reductions in blood loss and transfusion requirements across multiple surgical disciplines. Goal-directed coagulation management guided by viscoelastic testing allows targeted correction of specific hemostatic deficits while minimizing unnecessary blood product exposure. Acute normovolemic hemodilution and intraoperative cell salvage provide additional benefit in selected high-blood-loss procedures. Collectively, these multimodal strategies shift perioperative care from product-driven transfusion toward physiology-based blood conservation. When embedded within institutional protocols and supported by multidisciplinary collaboration, perioperative PBM reduces transfusion exposure, decreases morbidity, shortens hospital stay, and promotes sustainable stewardship of blood resources without compromising patient safety.

BACKGROUND: Minimally invasive surgery is rapidly expanding globally, yet there is insufficient knowledge of how to scale this technology safely and equitably across diverse health systems. We aimed to identify health-system factors associated with safe implementation of minimally invasive surgery globally, using minimally invasive cholecystectomy as a tracer procedure. METHODS: We conducted a multicentre, prospective cohort study of consecutive adults undergoing cholecystectomy between July 31 and Nov 19, 2023, in 1218 hospitals across 109 countries. Data were collected by more than 10 000 health-care workers using a core measurement set mapped to the WHO Health System Building Blocks and the Global Patient Safety Action Plan. The primary outcome was 30-day procedure-specific complications, with multilevel logistic regression used to examine associations between health-system features and patient outcomes. This study is registered on ClinicalTrials.gov (NCT06223061). FINDINGS: Among 52 187 included patients, the adjusted procedure-specific complication rate varied 40-fold between hospitals, from 0·3% in the lowest risk quintile to 12·1% in the highest risk quintile. Despite large structural differences across income groups in access to minimally invasive surgery, diagnostics, and emergency services, country income level was not independently associated with complication rates (adjusted odds ratio [OR] 0·81 [95% CI 0·59-1·10] for upper-middle income vs high income and 0·99 [0·70-1·39] for lower-middle income or low income vs high income). Three modifiable hospital-level factors were strongly associated with safer outcomes: establishment of local simulation-based training facilities (adjusted OR 0·78 [0·71-0·86]; p<0·0001), adoption of intraoperative safety and communication strategies (0·87 [0·79-0·96]; p=0·0046), and on-site CT diagnostics (0·79 [0·65-0·97]; p=0·0220). Training facilities showed the greatest benefit in hospitals with limited infrastructure and an inexperienced workforce: the number needed to treat to prevent a procedure-specific complication was 21 (95% CI 14-35; p<0·0001). INTERPRETATION: Safe implementation of minimally invasive surgery varies widely worldwide but is not defined by national income level; differences in outcomes reflect the ability of health systems to adopt and safely deploy new surgical techniques. We identified for the first time that the presence of local simulation-based training facilities is independently associated with improved patient outcomes. Simulation appears to be fundamental to the safe delivery of minimally invasive surgery, particularly in resource-constrained settings. Together with safety systems and diagnostic capacity, these findings offer actionable targets for health systems seeking to equitably scale up essential surgical technologies. FUNDING: NIHR Global Health Research Unit and Wellcome Leap SAVE Programme.

BACKGROUND: The Lancet Commission on Global Surgery (LCoGS) defined six indicators with 2030 targets to track national surgical system performance. The aim of this systematic review was to evaluate national reporting and attainment of benchmarks for each indicator and to assess the quality of modelling studies used to fill data gaps. METHODS: Seven bibliographic databases (1 April 2015-24 July 2024) and government domains of 48 countries committed to National Surgical, Obstetric, and Anaesthesia Plans were searched. Records providing national estimates of any LCoGS indicator were eligible. The primary outcome was the proportion of World Bank-classified countries meeting indicator benchmarks and the secondary outcome was the quality of modelled national estimates. This systematic review was prospectively registered in PROSPERO, the international prospective register of systematic reviews (CRD420250650890). RESULTS: Of 4245 records retrieved, 44 studies were included (35 research articles and 9 policy documents). Among 217 World Bank-classified countries, access to timely essential surgery (indicator 1) was reported for 94 countries (39% meeting benchmark), specialist surgical workforce density (indicator 2) was reported for 167 countries (50.3% meeting benchmark), surgical volume (indicator 3) was reported for 124 countries (31.5% meeting benchmark), perioperative mortality (indicator 4) was reported for 74 countries (no benchmark was set at country level), and financial risk protection indicators (indicators 5 and 6) were reported for five countries, with none meeting either benchmark. Across indicators, high-income countries were more likely to meet benchmarks. Most modelled studies lacked transparency in data sources, statistical methods, or model validation. CONCLUSION: Reporting of LCoGS indicators remains sparse and uneven, particularly in low- and middle-income countries. Without standardized, routine measurement and minimum quality standards for modelled estimates, progress towards 2030 cannot be credibly tracked. Integrating surgical metrics into national health information systems should be a policy priority.

Background: Robot-assisted surgery (RAS) is expanding rapidly across surgical specialities, yet adoption across the globe remains variable. There is growing recognition to expand RAS across all healthcare settings, to ensure equity of access and improve clinical outcomes for all patients. Facilitating the expansion of RAS requires the development of high-quality, durable and sustainable RAS programmes. The aim of the RoboDev study was to develop a universal, globally applicable guideline to aid development and expansion of RAS programmes. Methods: The RoboDev study was conducted as an international, multistakeholder Delphi process consisting of four phases: (1) scoping review and item generation, (2) questionnaire design and pre-testing, (3) accelerated two-round Delphi survey, and (4) consensus meetings. Participants were stratified by World Bank income classification. Recommendations achieving ≥80% agreement were retained. A subset of participants subsequently evaluated the final recommendations using the APEASE criteria (Acceptability, Practicability, Effectiveness, Affordability, Spill-over effects, and Equity). Results: A total of 1,000 participants completed Round 1 and 812 completed Round 2 of the Delphi, representing HIC (59.5%), UMIC (16.6%), LMIC (18.7%), and LIC (1.6%) stakeholders. From 245 initial statements across eight domains, 194 recommendations achieved global consensus. Tailored adaptations were added for each income group, resulting in 197 recommendations for HICs, 207 for UMICs, 206 for LMICs, and 216 for LICs. Training, infrastructure readiness, and multidisciplinary engagement showed the greatest variation across settings. APEASE evaluation confirmed overall acceptability, practicality, and equity, with LIC participants reporting the highest spill-over and equity benefits. Conclusion: The RoboDev study has developed the first global, evidence-based, and context-sensitive guidelines for building and expanding robot-assisted surgical programmes. By combining universal principles with context-specific adaptations, these recommendations provide a roadmap for equitable and sustainable expansion of robotic surgery worldwide. Adoption of these guidelines has the potential to improve patient outcomes, strengthen surgical systems and ensure that the benefits of robotic innovation are shared equitably across all global contexts.

Published in Impact Surgery, Issue 13: Robotic Surgery Special, Volume 2, pp. 254-265. Original DOI: https://doi.org/10.62463/surgery.282. Archived from https://impact-journals.org/index.php/pub/article/view/282 prior to domain expiry.

Published in Impact Surgery, Issue 13: Robotic Surgery Special, Volume 2, pp. 254-265. Original DOI: https://doi.org/10.62463/surgery.282. Archived from https://impact-journals.org/index.php/pub/article/view/282 prior to domain expiry.

Energy security, defined as the availability of reliable, clean, and sustainable energy necessary to ensure the continuous operation of health-care facilities, is essential for delivering safe and effective health care. Yet, it is rarely measured, financed, or governed as a component of core health infrastructure. Evidence from nearly a thousand hospitals shows that power outages were common, especially in lower-income settings, disrupting surgery, diagnostics, cold chains, and digital records, with reports of direct patient harm and environmental costs. This Viewpoint highlights four potential solutions. First, measure energy security with a simple, service-oriented indicator set that tracks outage frequency and duration, clinical disruption, and harm. Second, ensure a minimum energy service for essential care, including operating theatres, maternity services, intensive care units, oxygen, and vaccine cold chains, by protecting critical circuits and embedding these standards in national health plans and SDG7 strategies. Third, build clean resilience by shifting from diesel-only back-up to context-appropriate onsite renewables with storage, integrated with stable grids and smart switching. Fourth, ensure financing by ring-fencing both capital and maintenance budgets, using asset registers, uptime targets, performance-based service contracts, and local technical capacity for operation and repair. These strategic actions would enable clinical teams globally, especially in the Global South, to consistently deliver safe and effective care while simultaneously decarbonising health systems and communities.

Background: Acute appendicitis is one of the most common surgical emergencies worldwide. The presentation of appendicitis and its management can serve as a benchmark for evaluating the efficiency and effectiveness of emergency health systems. This prospective cohort study aims to identify areas for whole systems strengthening in emergency care using pre-defined key performance measures. Methods: This international prospective, multicentre cohort study will include all consecutive patients undergoing appendicectomy for suspected appendicitis. A measurement set comprising eight key outcome measures has been pre-defined to comprehensively evaluate emergency system performance across the world: time from symptom onset to surgical assessment, imaging rate, time from surgical assessment to theatre, laparoscopy rate, perforation rate, negative appendicectomy rate, post-operative length of stay and complication rate. Patients will be followed up at 30 days to collect outcome data. No changes will be made to routine patient care pathways/management or follow-up in this observational study. A mandatory hospital-level survey will explore available resources, infrastructure, surgical expertise, and relevant care protocols of sites participating in the study. It will allow us to account for variations in hospital capabilities and adjust analyses, improving the accuracy of cross-country comparisons and identifying system-level factors that may affect surgical success. Consultant Leads in each participating hospital will ensure appropriate study registration approval as per local regulations and this is mandatory for participation. There will be two optional sub-studies on waste management and sustainability and financing at select sites. Discussion: This study will generate granular data on the global variability in appendicectomy management and outcomes, offering insights into access to emergency care, imaging, and minimally invasive surgery for whole system strengthening. The findings will guide recommendations for both high-income and low- and middle-income countries, informing government policy and improving patient outcomes.

Published in Impact Surgery, Issue 12, Volume 2, pp. 185-192. Original DOI: https://doi.org/10.62463/surgery.204. Archived from https://impact-journals.org/index.php/pub/article/view/204 prior to domain expiry.

Published in Impact Surgery, Issue 12, Volume 2, pp. 185-192. Original DOI: https://doi.org/10.62463/surgery.204. Archived from https://impact-journals.org/index.php/pub/article/view/204 prior to domain expiry.

Spinal nerve sheath tumors are slow-growing neoplasms that arise from Schwann cell lineage and encompass schwannomas, neurofibromas, hybrid nerve sheath tumors, and malignant peripheral nerve sheath tumors. These lesions most commonly present as intradural extramedullary (IDEM) tumors, although extradural and dumbbell-shaped variants are also observed. Due to their typically benign behavior, gross total resection (GTR) remains the standard of care. However, there is a paucity of literature comparing the impact of open versus minimally invasive surgery (MIS) on postoperative extended length of stay (LOS). Prolonged hospitalization can increase healthcare costs, patient morbidity, and resource utilization. This study aims to compare the impact of MIS and open surgical approaches on extended LOS in patients undergoing resection of spinal nerve sheath tumors. Patients diagnosed with spinal nerve sheath tumors between 2004 and 2017 were identified from the National Cancer Database (NCDB) using ICD-O code 8680, 9560, 9490, 9540, and 9561. The cohort was stratified into four racial groups: White, Black, Hispanic, and Asian. Univariate analyses were performed to compare demographic, disease characteristics, and clinical outcomes. Additionally, a multivariate linear regression model was constructed to identify factors associated with extended length of stay, adjusting for sex, race, surgical modality (MIS, open, robotics), use of robotic surgery, facility type, insurance status, distance from facility to patient, comorbidities, age category, tumor behavior, and tumor size. Extended length of stay was defined as hospitalization exceeding the 75th percentile of the entire study population's length of stay. A total of 5,968 patients with spinal nerve sheath tumors were identified: 202 (3.4%) underwent MIS and 5,766 (96.6%) underwent open surgery. After 1:1 propensity score matching, 404 patients were equally distributed between the two groups. Prior to matching, MIS was more frequently used in the South Atlantic and East North Central regions compared to open surgery (29.3% vs. 21.4%; 20.1% vs. 16.1%; p = 0.008). Postoperative LOS was significantly shorter in the MIS group both before (4.4 ± 3.1 vs. 5.3 ± 3.5 days; p < 0.001) and after matching (4.4 ± 3.0 vs. 5.4 ± 3.5 days; p < 0.001). Patients treated with MIS were also less likely to experience an extended LOS both before (21.5% vs. 32.1%; p = 0.002) and after matching (21.5% vs. 35.4%; p = 0.002). On multivariable analysis, geriatric age (OR: 1.28; 95% CI: 1.12-1.46; p < 0.001), comorbidity burden (1 comorbidity: OR: 1.47; 95% CI: 1.25-1.72; ≥2: OR: 2.15; 95% CI: 1.72-2.68; p < 0.001), larger tumor size (OR: 1.02; 95% CI: 1.01-1.02; p < 0.001), and invasive behavior (OR: 1.41; 95% CI: 1.10-1.80; p = 0.007) were associated with increased odds of extended LOS. Male sex (OR: 0.83; 95% CI: 0.74-0.93; p = 0.001) and MIS approach (OR: 0.55; 95% CI: 0.36-0.80; p = 0.003) were associated with reduced odds. Robotic assistance did not significantly impact extended LOS (OR: 1.38; 95% CI: 0.61-3.01; p = 0.429). Gradient Boosting had the highest predictive performance among machine learning models (AUC: 0.594), followed by AdaBoost and logistic regression. SHAP analysis identified surgical approach, comorbidity score, tumor size, and behavior as the most influential features on extended LOS. MIS was associated with significantly lower odds of extended length of stay compared to open surgery for spinal nerve sheath tumor resection. Robotic assistance did not confer a significant additional benefit. These findings suggest that MIS may improve postoperative recovery and resource utilization in appropriately selected patients. Further prospective studies are needed to validate these results and clarify the role of MIS and robotic approaches in spinal tumor surgery.

Progress towards The Lancet Commission on Global Surgery's 2030 targets has been too slow and too patchy, particularly in low-income and middle-income countries. The unmet need for surgery has continued to grow, reaching at least 160 million operations per year. Ensuring high-quality surgical care remains a crucial global challenge, with 3·5 million adults dying after surgery each year. The COVID-19 pandemic exposed the fragility of surgical services long undermined by chronic underfunding, workforce shortages, and under-resourced infrastructure. However, The Lancet Commission on Global Surgery inspired a new generation of surgeons to engage with policy, and several countries have developed national surgical plans, although most remain unfunded. Advancements in surgical data science have allowed health systems to identify priorities for improvement. Preserving this infrastructure is important, especially during periods of uncertain global health funding. The next decade requires urgent change to prevent economic instability and armed conflict from forcing surgery down the global health agenda. Reframing surgery as an essential service that saves lives, strengthens health systems, and fosters economic productivity could unlock much needed investment. Sustained progress requires integration of funding both within hospital infrastructure and across care pathways. Such holistic approaches would reinforce entire hospital systems, which are essential to national security and wellbeing.

Background Infections are a common complication of abdominal surgery in low- and middle-income countries (LMICs). The role of a high fraction of inspired oxygen (FiO 2 ) and chlorhexidine mouthwash in preventing post-operative infections is unconfirmed. Methods Internal pilot phase of an international outcome assessor-blinded, 2x2 factorial randomised trial of patients aged ≥10-years undergoing midline laparotomy in LMIC hospitals. The main trial objectives are to compare the clinical effectiveness of preoperative 0.2% chlorhexidine mouthwash in preventing pneumonia versus no mouthwash, and 80–100% perioperative FiO 2 to prevent surgical site infection (SSI) versus 21–35% FiO 2 . This 12-month internal pilot assessed feasibility of hospital site opening, patient recruitment, intervention adherence, patient follow-up and safety. Patients were randomised in a 1:1:1:1 ratio to the four intervention group combinations and followed up for 30 days. Results We recruited 927 patients from seven hospitals in India and South Africa over 12 months from November 2020. There were 907 adults (97.8%) and 20 children aged ten or over (2.2%): 89/927 (9.6%) patients died. Site opening reached 70% of our target (7/10) hospitals, and patient recruitment 107% (927/870). 917/927 (99%) patients in the mouthwash arm, and 840/927 (91%) patients in the oxygen arm received the allocated intervention. Lower adherence to the oxygen intervention related mainly to clinically necessary FiO 2 increases in the 21–35% FiO 2 arm. 30-day follow-up was completed appropriately for 924/927 (99%) patients. and was performed by a masked assessor for all patients. There were no reported safety events. Conclusion This pilot showed the feasibility and safety of a major phase III trial in post-operative infection prevention in LMICs. Trial registration ClinicalTrials.gov NCT04256798.

Science and engineering practices are intended to engage students authentically in the work that scientists and engineers do in order to provide opportunities for meaningful engagement in disciplinary work, including design-based learning. Meaningful engagement, particularly for sensemaking purposes, requires a shift in who is leading the classroom community’s intellectual work, from the teacher to the students. When students are positioned with the intellectual responsibility of producing and evaluating ideas, there is potential for them to act with epistemic agency. Enacting epistemic agency involves socially negotiated framing and power dynamics. The purpose of this study is to determine the ways in which gendered power dynamics influence the negotiation of epistemic agency in a design-based learning context. Using a qualitative case study methodology, student negotiations of epistemic and positional framing from a mixed-gender group were observed. Transcripts from their discourse during two design challenges were mapped, and focal group interviews were holistically analyzed to understand students’ perceptions and navigation of epistemic and positional framings in a design-based learning context and to understand how power dynamics influence these negotiations. Students understood the epistemic goals of the design challenges to involve designing solutions to real-world problems. During the first challenge, the group distributed positions of epistemic authority among the members. However, the group experienced a change in composition, resulting in changed power dynamics and epistemic oppression. These findings have implications regarding the critical impact that classroom culture and interactional practices might have on students’ epistemic agency, especially considering their multiple identity markers.

Abstract In this work, a large-scale, high-viscosity vat photopolymerization additive manufacturing system is designed and fabricated to print 3D structures as large as 370 × 300 × 370 mm3 out of high-viscosity, low-reactivity elastomeric resins. A detailed overview is presented of the printer's design and capabilities, including a resin processing sub-system that stores and spreads high-viscosity resin; a roll-to-roll variable tensioning system to mitigate the separation forces after printing each layer; and a light patterning system that generates high-intensity light patterns across an area of 370 × 300 mm2 with a resolution of 3840 × 4320 pixels. The ability to print with both high-viscosity and low-reactivity resins and resins that require high-intensity light enables additive manufacturing of new classes of materials that could not be printed previously using vat photopolymerization techniques. These materials include highly reinforced silica nanoparticle composites, high-molecular-weight polymers such as silicones and acrylate or methacrylate resins, and low-reactivity resins such as photocurable platinum-catalyzed liquid silicone rubber.

Abstract The Singapore-U.S. Tactical All-Inclusive Navigation (SUSTAIN) initiative is an international research and development collaboration between military and academic scientists from both Singapore and the United States. SUSTAIN's goal is to bring to bear the strengths of both nations to solve navigation problems faced in degraded or denied Global Navigation Satellite System (GNSS) environments by dismounted warfighters. The SUSTAIN team is composed of 9 members and several subject matter experts and mentors with diverse technical backgrounds working as a single team rather than a group of distributed teams. The team members work in both the U.S. and Singapore, and are separated by over 15000 kilometers and a 13-hour time difference. The team faces cultural and political differences, and collaboration and communication are key challenges impacting the innovation process. Specific collaboration challenges are discussed including interpersonal relationships between team members, particularly communication and trust; sharing data, documents, and knowledge effectively without being co-located; and how to effectively identify problems of mutual interest, understand ideas conceived internationally, and solve relevant problems. Methods and tools being utilized to facilitate the collaborative process are described and discussed, in terms of needs and their perceived efficacy. Guidance, suggestions, and possible ideas for future international collaborative R&D teams of a similar nature are provided.

Abstract This research describes the design for additive manufacturing (AM) of a pneumatic soft robotic actuator that is uniquely enabled by a novel vat photopolymerization (VPP) AM process. Specifically, the device is a PneuNet style bending mechanism that is designed specifically for a high-viscosity, large-scale VPP AM system. This novel system is capable of fabricating high performance elastomeric materials, such as polydimethylsiloxane (PDMS) loaded with fumed silica nanoparticles or other fillers that result in viscosities too high to be printed with most existing VPP processes. Herein, a tough double network PDMS (DN-PDMS) is designed for printing pneumatic actuators. The mechanical properties of the DN-PDMS, along with the geometric resolution of resulting features, are characterized through experiments, and the results are used to guide the design process of the pneumatic actuator. The results show that the broad design space accessible through the high-viscosity VPP process corresponds with the target geometry identified in this research (determined by maximum bending angle). This design would be challenging or impossible to manufacture using other means; however, this VPP process enables printing of high viscosity materials, large overhangs, internal features, and a fully enclosed hollow structure. Results show that altering the chamber shape and incorporating internal structures leads to a 29.8% improvement in bending angle when compared with the original PneuNet actuator geometry simulated with the same material and pressurization.

BACKGROUND Burn injuries are a significant contributor to the burden of diseases. The management of burns at specialised burn centres has been shown to improve survival. However, in low- and middle-income countries (LMICs) major burns are managed at non-specialised burn centres due to resource constraints. There is insufficient data on survival from treatment at non-specialised burn centres in LMICs. This study aimed to compare the outcomes of burns treatment between a specialised burn centre and five non-specialised centres. METHODS A prospective cohort study was conducted on patients aged 18 years or above from January 1, 2021 to September 30, 2021. Participants were selected from the admission register at the emergency department. All burns irrespective of the mechanism of injury or %TBSA were included. Data were entered into REDCap. Statistical analysis of outcomes such as positive blood culture, length of hospital stay (LOHS) and 90-day mortality between specialised burn versus non-specialised centres was performed. Furthermore, an analysis of risk factors for mortality was performed and survival data computed. RESULTS Of the 488 study participants, 36% were admitted to a specialised burn centre compared to 64% admitted to non-specialised centres. The demographic characteristics were similar between centres. Patients at the specialised burn centre compared to non-specialised centres had a significantly higher inhalation injury of 30.9% vs 7.7% (p < 0.001), > 10%TBSA at 83.4% vs 45.7% (p < 0.001), > 20%TBSA at 46.9% vs 16.6% (p < 0.001), and a median (IQR) ABSI score of 6 (5-7) vs 5 (4-6) (p < 0.0001). Furthermore, patients from specialised burn vs non-specialised centres had a longer median (IQR) time from injury to first burn excision at 7 (4-11) vs 5 (2-10) days, higher rate of burn sepsis 69% vs 35%, increased LOHS 17 (11-27) vs 12 (6-22) days, and 90-day mortality rates at 19.4% vs 6.4%. After adjusting for cofounding variables, survival data showed no difference between specialised burn and non-specialised centres (HR 1.8 95% CI 1.0-3.2, p = 0.05). CONCLUSION Although it appears that the survival of burn patients managed at non-specialised centres in a middle-income country is comparable to those managed at specialised burn centres, there is uncounted bias in our survival data. Hence, a change in practice is not advocated. However, due to resource constraint specialised burn centres in addition to managing major burns should provide training and support to the non-specialised centres.