Urethral Catheterization Is Not Necessary During Nononcological Laparoscopic Pelvic Surgery.

OBJECTIVES: Expert opinion remains divided regarding whether routine urethral catheterization is required before nononcological laparoscopic pelvic surgery. Catheterization is thought to reduce the incidence of bladder injury when inserting a suprapubic laparoscopic port and prevent obstruction of the view of the pelvis because of bladder filling. However, catheterization comes with a risk of nosocomial infection and harbors financial cost. Moreover, indwelling catheters inhibit early mobilization and increase postoperative discomfort. METHODS: A systematic review was undertaken using the Meta-Analysis of Observational Studies guidelines to identify eligible publications. End points included bladder injury, positive postoperative urinary microbiology, and postoperative urinary symptoms. RESULTS: The reported incidence rates of laparoscopic bladder injury in included publications ranges from 0% to 1.3%. Importantly, bladder injury has occurred during both catheterized and noncatheterized operations. Our meta-analysis also shows that patients who are catheterized have a 2.33 times relative risk of developing postoperative positive microbiology in their urine (P = 0.01) and a 2.41 times relative risk of postoperative urinary symptoms (P = 0.005), when compared with noncatheterized patients. CONCLUSIONS: This meta-analysis indicates that omitting a catheter in emergency and elective nononcological laparoscopic pelvic surgery may be a safe option. Catheterization does not remove the risk of bladder injury but results in more urinary tract infections and symptoms. It may be reasonable to ask a patient to void immediately before anesthesia, after which an on-table bladder scan should be performed. If there is minimal residual volume, a urinary catheter may not be necessary, unless operative time is estimated to be greater than 90 minutes.

Should pre-hospital resuscitative thoracotomy be reserved only for penetrating chest trauma?

PURPOSE: The indications for pre-hospital resuscitative thoracotomy (PHRT) remain undefined. The aim of this paper is to explore the variation in practice for PHRT in the UK, and review the published literature. METHODS: MEDLINE and PUBMED search engines were used to identify all relevant articles and 22 UK Air Ambulance Services were sent an electronic questionnaire to assess their PHRT practice. RESULTS: Four European publications report PHRT survival rates of 9.7, 18.3, 10.3 and 3.0% in 31, 71, 39 and 33 patients, respectively. All patients sustained penetrating chest injury. Six case reports also detail survivors of PHRT, again all had sustained penetrating thoracic injury. One Japanese paper presents 34 cases of PHRT following blunt trauma, of which 26.4% survived to the intensive therapy unit but none survived to discharge. A UK population reports a single survivor of PHRT following blunt trauma but the case details remain unpublished. Ten (45%) air ambulance services responded, each service reported different indications for PHRT. All perform PHRT for penetrating chest trauma, however, length of allowed pre-procedure down time varied, ranging from 10 to 20 min. Seventy percent perform PHRT for blunt traumatic cardiac arrest, a procedure which is likely to require aggressive concurrent circulatory support, despite this only 5/10 services carry pre-hospital blood products. CONCLUSIONS: Current indications for PHRT vary amongst different geographical locations, across the UK, and worldwide. Survivors are likely to have sustained penetrating chest injury with short down time. There is only one published survivor of PHRT following blunt trauma, despite this, PHRT is still being performed in the UK for this indication.

Which pen? A comparative study of surgical site markers.

A preoperative requirement is the correct and clear marking of a specific surgical site. We aimed to compare the ability of marker pens to withstand surgical preparation. Five volunteers with different Fitzpatrick skin types were marked with ten pens. Marked skin sites were prepared with chlorhexidine followed by chlorhexidine, betadine followed by chlorhexidine, and betadine followed by betadine. Each site was photographed in theatre. Two volunteers ranked the top three most visible marker pens from each photograph. The results showed that Sharpie® W10 black, Dual Tip (Purple Surgical), and Easimark modern regular tip (Leonhard Lang) were the best performers across all skin types. Red pen should be avoided with betadine skin preparation. The study concludes that the above named three markers are the best at withstanding surgical skin preparation. Different skin types require different colour ink for maximal clarity in marking. Biro and drywipe markers should never be used for surgical marking.