Comparison of surgeon gaze behaviour against objective skill assessment in laparoscopic cholecystectomy-a prospective cohort study.

BACKGROUND: Eye tracking technology may provide the basis of a novel, objective technical skill assessment in surgery. Past research has showed differences in the gaze patterns between expert and novice surgeons. The aim of this study was to investigate the relationship between gaze behaviors and technical skill during laparoscopic cholecystectomy as determined by objective assessment scores. METHODS: Gaze behaviors of surgeons performing laparoscopic cholecystectomies were mapped using wearable eye tracking apparatus. Two impartial surgeons retrospectively analyzed video footage of the procedure to perform Objective Structured Assessment of Technical Skill (OSATS) assessments. Primary endpoints were correlation between gaze behaviours (dwell time (%) and fixation frequency (count/s)) and OSATS scores. Dwell time was defined as the percentage of time spent fixating on particular visual areas of interest (AOI). Pearson's correlation coefficient was used to estimate the relationship between primary endpoints and AOIs. Statistical significance was set at p < 0.05. RESULTS: 13 procedures were analyzed. Throughout all operative segments, a negative correlation was present between operating theatre dwell time and OSATS scores (p < 0.05). During dissection of Calot's triangle, there was a strong positive correlation between laparoscopic screen dwell time and OSATS scoring [r = 0.655, p < 0.05]. Scrub nurse dwell time during dissection of Calot's triangle showed a strong negative correlation with OSATS scoring [r = -0.619, p < 0.05]. During dissection of gallbladder fossa, operating theatre fixation frequency negatively correlated against OSATS scores [r = -0.566, p < 0.05]. CONCLUSION: The results suggest a greater focus on significant visual stimuli alongside a lack of attention to non-essential stimuli during critical stages of the operative period is associated with greater technical skill. This aids the validation of eye tracking as an adjunct high-stakes technical skill assessment.

Laparoscopic resection of a gastrointestinal stromal tumour in a Meckel's diverticulum.

A Meckel's diverticulum (MD) is a congenital abnormality of the gastrointestinal tract which is estimated to be present in 2% of the population. Gastrointestinal stromal tumours (GISTs) are rare, soft-tissue tumours which represent 0.1%-3% of all gastrointestinal tumours. The association of an MD and a GIST is extremely unusual since fewer than 3% of MD harbour primary neoplasms and most of these neoplasms are carcinoid tumours. While MDs may remain asymptomatic throughout life, a small proportion may be complicated by occult gastrointestinal bleeding, inflammation, perforation and small bowel obstruction. A tumour in an MD may be asymptomatic or can cause vague abdominal pain and small bowel obstruction if it is larger in dimension. The authors present a rare case of a 5.5 cm GIST in an MD that was completely resected through a laparoscopic approach.

Early and Late Closure of Loop Ileostomies: A Retrospective Comparative Outcomes Analysis.

The optimal timing of loop ileostomy reversal remains largely unknown, but evidence that delayed ileostomy closure may increase postoperative complication rates is increasing. PURPOSE: Retrospective research was conducted to compare outcomes between patients who had early (<6 months) or late (>6 months) loop ileostomy closure. METHODS: Records of patients >18 years of age who underwent circumstomal reversal of a loop ileostomy over a period of 5 years in 1 hospital's colorectal unit were abstracted and analyzed. Data from patients who had a planned or conversion to laparotomy, a concurrent bowel resection, reversal of double-barrel small bowel and colonic stomas, or closure of an end ileostomy or patients whose records were incomplete were excluded. Demographic information, American Society of Anesthesiologists (ASA) grade, primary operation indication, surgery and inpatient dates, readmission within 30 days of discharge, reasons for readmission, complication type, and Clavien-Dindo classification were extracted and compared between early and late closure groups using independent-sample t test and Fisher's exact test. RESULTS: Among the 75 study participants, 25 had an early closure (mean age 68.6 [range 26 - 93] years, mean time since primary surgery 3.8 months) and 50 had a late closure procedure (mean age 71.6 [range 46 - 93] years, mean time since primary surgery 12.8 months). Gender distribution, ASA grades, primary surgery indication, and total number of readmissions were similar between the 2 groups. Hospital length of stay was significantly shorter (5.5 days vs 9.4 days; P = .01) and average number of complications was significantly lower (0.33 vs 0.61; P = .04) in the early closure group. Rates of postoperative ileus, anastomotic bleed, and wound-related complications were not significantly different. CONCLUSION: Hospital length of stay and average number of postoperative complications following circumstomal loop ileostomy closure were significantly lower in the early than in the late closure group. Additional studies are warranted to help guide practice.

Can the General Surgeon Use Quilting Sutures to Prevent Seromas Following Abdominal Wall Surgery?

A common post-operative complication of many operations is seroma formation, which, while generally considered to be relatively minor, can be problematic for patients and a drain on healthcare resources due to the need for frequent outpatient reviews and repeated aspirations. Several mechanisms have been implicated in the development of seromas, and drains have traditionally been used as a preventative strategy. However, drains are falling out of favour, not least because the evidence to support their use is limited and conflicting. In recent years, the use of quilting sutures, also known as progressive tension sutures, is starting to emerge as a favourable alternative for preventing post-operative seroma formation. Several studies and trials support their use in abdominal wall operations such as abdominoplasties and at abdominal wall donor sites in reconstructive breast operations. General surgeons perform many operations on the abdominal wall, such as ventral hernia repair, that predispose the patient to seroma formation. Can quilting sutures be used in operations on the abdominal wall to prevent seroma formation? This aim of this review was to evaluate the use of quilting sutures as described in several studies to reduce the incidence of post-operative seroma.

Anatomical and Radiological Considerations When Colonic Perforation Leads to Subcutaneous Emphysema, Pneumothoraces, Pneumomediastinum, and Mediastinal Shift.

While colonoscopy is generally regarded as a safe procedure, colonic perforation can occur and the risk of this is higher when interventional procedures are undertaken. The presentation may be acute or delayed depending on the extent of the perforation. Extracolonic gas following colonic perforation can migrate to several body compartments that are embryologically related and it has previously been reported in the thorax, mediastinum, neck, scrotum, and lower limbs. This review discusses in detail the anatomical pathways that led to a rare case of widespread subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, and mediastinal shift from colonic perforation during a diagnostic colonoscopy. This is further supported by a description of the radiological images.

The Many Guises of Endometriosis: Giant Abdominal Wall Endometriosis Masquerading as An Incisional Hernia.

Endometriosis is defined by the presence of ectopic endometrial tissue outside the uterine cavity. Although it is a leading cause of chronic pelvic pain and infertility, its clinical presentation can vary, resulting in diagnostic and therapeutic challenges. Extrapelvic endometriosis is particularly difficult to diagnose owing to its ability to mimic other conditions. Endometrial tissue in a surgical scar is uncommon and often misdiagnosed as a granuloma, abscess, or malignancy. Cyclical hemorrhagic ascites due to peritoneal endometriosis is exceptionally rare. We report the case of a pre-menopausal, nulliparous 44-year-old woman who presented with ascites and a large abdominal mass that arose from the site of a lower midline laparotomy scar. Five years previously, she had undergone open myomectomy for uterine fibroids. Soon after her initial operation she developed abdominal ascites, which necessitated percutaneous drainage on multiple occasions. We performed a laparotomy with excision of the abdominal wall mass through an inverted T incision. The extra-abdominal mass consisted of mixed cystic and solid components, and weighed 1.52 kg. It communicated with the abdominopelvic cavity through a 2 cm defect in the linea alba. The abdomen contained a large amount of odourless, brown fluid which drained into the mass. There was a large capsule that covered the small and large bowel, liver, gallbladder, and stomach. Final histology reported a 28×19×5 cm mass of endometrial tissue with no evidence of malignant transformation. The patient recovered well post-operatively and has remained asymptomatic. Our case illustrates that, despite being a common disease, endometriosis can masquerade as several other conditions and be missed or diagnosed late. Delay in diagnosis will not only prolong symptoms but can also compromise reproductive lifespan. It is therefore paramount that endometriosis is to be considered early in the management of premenopausal women who present with an irregular pelvic mass or hemorrhagic ascites.

Application of the Prevena™ Incision Management System Following Complex Ventral Hernia Repairs with Abdominal Wall Reconstruction.

Surgical site infections (SSIs) are a drain on the healthcare economy. A recent development for the primary prevention of wound infections is the use of negative pressure wound therapy (NPWT) on closed wounds. The Prevena™ Incision Management System (KCI USA, Inc., San Antonio, TX) is a new NPWT designed for application on closed surgical incisions in order to prevent potential wound-related complications. We evaluated the use of this new technology on large abdominal incisions following complex ventral hernia repairs with abdominal wall reconstruction in patients with risk factors for developing wound complications and conducted a review of the current literature pertaining to the use of NPWT on closed incisions.

Pancreatic Pseudocyst Pleural Fistula in Gallstone Pancreatitis.

Extra-abdominal complications of pancreatitis such as pancreaticopleural fistulae are rare. A pancreaticopleural fistula occurs when inflammation of the pancreas and pancreatic ductal disruption lead to leakage of secretions through a fistulous tract into the thorax. The underlying aetiology in the majority of cases is alcohol-induced chronic pancreatitis. The diagnosis is often delayed given that the majority of patients present with pulmonary symptoms and frequently have large, persistent pleural effusions. The diagnosis is confirmed through imaging and the detection of significantly elevated amylase levels in the pleural exudate. Treatment options include somatostatin analogues, thoracocentesis, endoscopic retrograde cholangiopancreatography (ERCP) with pancreatic duct stenting, and surgery. The authors present a case of pancreatic pseudocyst pleural fistula in a woman with gallstone pancreatitis presenting with recurrent pneumonias and bilateral pleural effusions.

An atypical presentation of small bowel obstruction and perforation secondary to sporadic synchronous intra-abdominal desmoid tumours.

INTRODUCTION: Desmoid tumours (DTs) are rare, soft tissue tumours which account for 0.03% of all neoplasms. They are characteristically locally invasive but do not metastasize. There is frequent association with females of reproductive age, a history of abdominal surgery or trauma and a family history of fibromatoses. Intra-abdominal DTs are infrequently sporadic and more commonly associated with inherited disorders such as familial adenomatous polyposis (FAP), attenuated FAP and Gardener's syndrome. PRESENTATION OF CASE: The authors report a rare case of small bowel obstruction and perforation secondary to sporadic, synchronous intra-abdominal DTs in a 54-year old man with atypical symptoms and no risk factors or family history. DISCUSSION: Intra-abdominal DTs have a worse prognosis as they can cause intestinal bleeding, obstruction and perforation. Due to the rarity of these tumours there are no clear guidelines on their management and this is instead based on small case series from specialist centres. In the non-acute setting patients with sporadic intra-abdominal DTs should be managed in a specialist sarcoma unit by a multidisciplinary team. In the presence of FAP or other polyposis syndromes patients with DTs should be managed at a specialist colorectal unit. Emergent presentations require emergency surgery in suitable candidates. CONCLUSION: In non-emergency presentations of DTs, it is essential to exclude FAP, AFAP and other hereditary polyposis syndromes since this affects treatment and subsequent follow-up.

Metastases of lobular breast carcinoma in the terminal ileum and ileocaecal valve.

Gastrointestinal (GI) metastases from primary breast carcinoma are rare but more common in invasive lobular carcinoma than invasive ductal carcinoma. The symptoms may be non-specific and the presentation can occur many years after the initial primary breast carcinoma. Radiological and endoscopic findings can be difficult to distinguish from inflammatory bowel disease and primary carcinoma of the GI tract. Histological and immunohistopathology assessment will usually confirm the diagnosis of metastatic breast carcinoma. We report the first case of lobular breast carcinoma metastasizing to the terminal ileum and ileocaecal valve 19 years following treatment for breast cancer in an 82-year-old woman. Staging investigations revealed synchronous metastases in bones and the pleura. A high index of suspicion and awareness of the potential long interval in the presentation of metastatic breast cancer help in making an accurate diagnosis and rapid clinical management.

Calot's triangle.

Calot's triangle is an anatomical landmark of special value in cholecystectomy. First described by Jean-François Calot as an "isosceles" triangle in his doctoral thesis in 1891, this anatomical space requires careful dissection before the ligation and division of the cystic artery and cystic duct during cholecystectomy. The modern definition of the boundaries of Calot's triangle varies from Calot's original description, although the exact timing of this change is not entirely clear. The structures within Calot's triangle and their anatomical relationships can present the surgeon with difficulties, particularly when anatomical variations are encountered. Sound knowledge of the normal anatomy of the extrahepatic biliary tract and vasculature, as well as understanding of congenital variation, is thus essential in the prevention of iatrogenic injury. The authors describe the normal anatomy of Calot's triangle and common anatomical anomalies. The incidence of structural injury is discussed, and new techniques in surgery for enhancing the visualisation of Calot's triangle are reviewed. © .

William Sampson Handley (1872-1962): champion of the permeation theory of dissemination of breast cancer.

The Halsted radical mastectomy that prevailed in the first half of the 20th century derived its scientific basis from the 'lymphatic permeation theory' of William Sampson Handley, an Honorary Senior Consulting Surgeon and former Vice President of the Royal College of Surgeons. Through his pioneering work in the cancer research laboratories at the Middlesex Hospital in London, Handley propounded the theory of centrifugal lymphatic permeation as the leading mechanism for the spread of cancer. This work won him worldwide renown and celebrated recognition in 1911 from the Royal College of Surgeons of England for the best work in the pathology and therapeutics in cancer. During his active life he was one of the great names and influences in the world of surgery. He held many roles at the Royal College of Surgeons and was involved with the international surgical fraternity. His philosophy of the uniqueness of the individual and his kind and courteous disposition won him praise from juniors, colleagues and patients alike. Although much of his work was rejected later, much still remains noteworthy in the history of surgery and cancer research.