Achieving day-case laparoscopic nissen fundoplication: an analysis of patient and operative factors.

INTRODUCTION: Day-case laparoscopic Nissen fundoplication has been described; however, its achievability and limitations in the setting of a busy Foundation Trust hospital are unclear. SUBJECTS AND METHODS: A retrospective cohort study of all cases undergoing laparoscopic Nissen fundoplication between January 1, 2009 and December 31, 2010 at three hospitals in the largest and the least densely populated Trust in the United Kingdom was undertaken. Primary end points of planned and achieved day-case surgery were compared with logistic regression analysis. Secondary end points were unplanned re-admission and complications. RESULTS: During the study period 126 consecutive patients underwent laparoscopic Nissen fundoplication. There were 64 female patients and 62 male patients. Primary surgery was undertaken in 115 patients and revisional surgery in 11. The age range was 21-73 years. Patients had traveled up to 52.3 miles or 80.2 minutes for their surgery. The median length of stay was 0 days in the planned day-case cohort and 1 day in the inpatient cohort. Day-case surgery was planned in 85 (68.55%). Successful day-case discharge was achieved in 71 cases (83.5%). There was no difference in age, geographical remoteness, surgeon volume, or length of surgery between planned and achieved day-case surgery. Patients were more likely to need unplanned admission if their American Society of Anesthesiologists grade was 2, when undergoing revisional surgery, and if the operation was completed after 1300 hours (1 p.m.). After multivariate regression analysis only operation completion time remained significant (P≤.05). The rate of unplanned re-admission related to surgery was 3/126 (2.38%). CONCLUSIONS: Day-case laparoscopic Nissen fundoplication can be achieved in the majority of patients. Unplanned admission is to be expected in approximately 15% of planned cases and cannot be predicted.

Risk factors in laparoscopic cholecystectomy: a multivariate analysis.

BACKGROUND: Laparoscopic cholecystectomy (LC) is the operation of choice in the treatment of symptomatic gallstone disease. The aim of this study is to identify risk factors for LC, outcomes include operating time, length of stay, conversion rate, morbidity and mortality. METHODS: All patients undergoing LC between 1998 and 2007 in a single district general hospital. Risk factors were examined using uni- and multivariate analysis. RESULTS: 2117 patients underwent LC, with 1706 (80.6%) patients operated on electively. Male patients were older, had more co-morbidity and more emergency surgery than females. The median post-operative hospital stay was one day, and was positively correlated with the complexity of surgery. Conversion rates were higher in male patients (OR 1.47, p = 0.047) than in females, and increased with co-morbidity. Emergency surgery (OR 1.75, p = 0.005), male gender (OR 1.68, p = 0.005), increasing co-morbidity and complexity of surgery were all positively associated with the incidence of complications (153/2117 [7.2%]), whereas only male gender was significantly associated with mortality (OR 5.71, p = 0.025). CONCLUSION: Adverse outcome from LC is particularly associated with male gender, but also the patient's co-morbidity, complexity and urgency of surgery. Risk-adjusted outcome analysis is desirable to ensure an informed consent process.

Construct validity of the ProMIS laparoscopic simulator.

BACKGROUND: Laparoscopic surgery challenges both the surgical novice and experienced open surgeon with unique psychomotor adaptations. Surgical skills assessment has historically relied on subjective opinion and case experience. Objective performance metrics have stimulated much interest in surgical education over the last decade and proficiency-based simulation has been proposed as a paradigm shift in surgical skills training. New assessment tools must be subjected to scientific validation. This study examined the construct validity of a hybrid laparoscopic simulator with in-built motion tracking technology. METHODS: Volunteers were recruited from four experience groups (consultant surgeon, senior trainee, junior trainee, medical student). All subjects completed questionnaires and three tasks on the ProMIS laparoscopic simulator (laparoscope orientation, object positioning, sharp dissection). Motion analysis data was obtained via optical tracking of instrument movements. Objective metrics included time, path length (economy of movement), smoothness (controlled handling) and observer-recorded penalty scores. RESULTS: One hundred and sixty subjects completed at least one of the three tasks. Significant group differences were confirmed for number of years qualified, age and case experience. Significant differences were found between experts and novices in all three tasks. Sharp dissection was the strongest discriminator of four recognised laparoscopic skill groups: consultants outperformed students and juniors in all three performance metrics and objective penalty score (p < 0.05), and only accuracy of dissection did not distinguish them from senior trainees (p = 0.261). Seniors dissected faster, more efficiently and more accurately than juniors and students (p < 0.05). CONCLUSIONS: ProMIS provides a construct valid laparoscopic simulator and is a feasible tool to assess skills in a cross-section of surgical experience groups. ProMIS has the potential to objectively measure pre-theatre dexterity practice until an agreed proficiency level of dexterity is achieved. Future work should now examine whether training to expert criterion levels on ProMIS correlates with actual operative performance.

Spontaneous splenic rupture in a patient with pneumonia and sepsis.

We present the case of a patient who presented with evidence of pneumonia, sepsis and anaemia but no significant abdominal signs. A routine abdominal ultrasound scan revealed evidence of spontaneous splenic rupture. He underwent splenectomy but passed away subsequently from respiratory complications. The many associations of spontaneous splenic rupture are discussed. The diagnosis should be considered in any patient presenting with shock and non-specific abdominal signs and in those with pre-existing conditions known to cause splenomegaly.