Visualising improved peritoneal perfusion at lower intra-abdominal pressure by fluorescent imaging during laparoscopic surgery: A randomised controlled study.

BACKGROUND: Laparoscopy is the gold standard for many surgical procedures and is embraced as minimally invasive surgery in the enhanced recovery after surgery programme. Lowering intra-abdominal pressure during laparoscopy may decrease the degree of surgical injury and further enhance patient outcomes. This study aims to assess the effect of low pressure pneumoperitoneum on peritoneal perfusion during laparoscopic surgery. MATERIALS AND METHODS: We performed a prospective randomized intervention study in 30 adults undergoing colorectal robot assisted laparoscopic surgery at a secondary care medical center in the Netherlands between June and December 2018. A 3 min video recording of the parietal peritoneum was made with the Da Vinci® Firefly mode following intravenous injection of 0.2 mg/kg indocyanine green at a pneumoperitoneum pressure of 8, 12 or 16 mmHg. Observers were blinded for the level of intra-abdominal pressure that was used. Fluorescent intensity in [-] over time was extracted from each video in MATLAB. Time to reach maximal fluorescent intensity (TMFI) and maximum fluorescent intensity (MFI) were compared among groups. The study was registered at clinicaltrials.gov (NCT03928171). RESULTS: Mean TMFI was shorter at low pressure (8 mmHg) than standard pressure (12 and 16 mmHg): 44 ± 12 versus 58 ± 18 s (p = 0.032), respectively. Mean MFI was higher at 8 mmHg than 12 and 16 mmHg (222 ± 25 versus 188 ± 54, p = 0.033). Regression analysis identified intra-abdominal pressure, mean arterial pressure and female gender as significant predictors of peritoneal perfusion. CONCLUSION: Low pressure pneumoperitoneum was associated with improved perfusion of the parietal peritoneum. Current available evidence supported feasibility and enhanced postoperative recovery. Future investigations should focus on optimizing factors that facilitate lower intra-abdominal pressure and explore effects on other clinically relevant patient outcomes such as anastomotic leakage and immune homeostasis.

Appendectomy by residents is safe and not associated with a higher incidence of complications: a retrospective cohort study.

OBJECTIVE: The purpose of this retrospective cohort study was to investigate whether current practice where residents perform appendectomies affects quality of care. Therefore, we investigated whether there was a difference in incidence of complications and mortality in appendectomies performed by surgeons (S), supervised residents (SR), or unsupervised residents (UR). BACKGROUND: Appendicitis is among the most frequent conditions requiring urgent surgery. Admittance and surgery are often managed by residents. Recent studies have shown that laparoscopic appendectomy can be safely performed by residents. It is not known whether these results are applicable on appendectomies in general. METHODS: All patients undergoing appendectomy in our hospital between January 1, 2000, and December 31, 2009, were included in the analysis. Patients undergoing appendectomy by surgeons, supervised residents, and unsupervised residents were compared. Primary endpoints were complications and mortality. RESULTS: During the study period, 1538 patients were operated. The risk of complications (S: 20% vs SR: 17% vs UR: 16%; P = 0.209, S vs SR; P = 0.149, S vs UR; and P = 0.872, SR vs UR) and mortality (S: 0.3% vs SR: 0.2% vs UR: 0.4%, P = 1.000 for all comparisons) were similar in all groups. In the multivariate model, the odds ratio for complications in the group operated by supervised residents was 0.84 (95% CI: 0.58-1.22, P = 0.357) versus 0.81 (95% CI: 0.55-1.18, P = 0.265) in the unsupervised residents' group. CONCLUSIONS: Current practice where residents perform appendectomies either unsupervised or supervised by an experienced surgeon should not be discouraged. We found that it is safe and does not lead to more complications or negatively affect quality of care.

[A boy with a painful foot]. / Een jongen met een pijnlijke voet.

A 4-year-old boy visited the emergency department with a painful foot. We diagnosed osteochondrosis of the tarsal navicular, also known as Köhler's disease. The patient was successfully treated with a plaster bandage for 4 weeks.

[A woman with a swollen finger]. / Een vrouw met een gezwollen vinger.

A 70-year-old woman presented with osteomyelitis of the distal phalanx of her left middle finger, after a paronychia which was treated conservatively.