142 Chapter 7 gold standard 18. To mitigate potential bias from the white light images, the LSCI perfusion mode was activated when the surgeons entered the operating theatre and the (dissected) mesentery of the bowel loops was covered by a gauze for blinding. All five senior surgeons participating in the study entered the operating room individually and were asked to answer three specific questions based on the LSCI derived visual feedback. The questions posed to the surgeons were as follows: (1) Could you identify an ischemic intestinal loop? (2) Could you detect a perfusion difference in the other two loops? (3) Could you identify the best perfused loop? After responding to the questions, the surgeons were shown the corresponding white light images for further evaluation and comparison. Identification of anastomotic perfusion To evaluate the ability of senior surgeons to make decisions regarding anastomosis creation based on additional visual feedback, a hand-sewn anastomosis was created using a healthy and an ischemic small bowel loop. The ischemic loop was created 30 minutes prior to questioning by dissecting eight peripheral arteries and veins. The state of perfusion was confirmed by three specialists based on white light images. All five senior surgeons participating in the study entered the operating room individually and were asked three specific questions based on the perfusion images. The questions posed to the surgeons were as follows: (1) Would you advise creating an anastomosis based on this additional visual feedback? (2) Can you identify a perfusion difference? and (3) What is the worst perfused tissue? Usability of PerfusiX-Imaging for intestinal perfusion assessment A questionnaire was designed to assess the usability of the device. The questionnaire consisted of six items, each addressing a specific aspect of usability. The items were answered using the Likert scale from one to five, with the one representing the least favorable response and five indicating the most favorable response. The questionnaire can be found in Supplemental material S1. RESULTS The surgical procedure was performed without any complications nor adverse events. Identification of three differently perfused intestinal loops The results indicated that surgeons demonstrated a good ability to identify ischemic intestinal loops using LSCI derived visual feedback (Figure 2). Specifically, all five senior surgeons correctly identified the ischemic loop, achieving a 100% accuracy rate when relying solely on this feedback. After the identification of the ischemic bowel loop using only LSCI, the white light images were shown. All surgeons still agreed with the identified ischemic region and no one doubted his/hers decision based on this additional information. Regarding the ability to detect perfusion differences in the other two loops, again LSCI derived visual feedback
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