Comparison of three-dimensional and 4K imaging systems in novice surgeons: a cross-over study.

BACKGROUND: Laparoscopy has revolutionized the surgical field with the advent of minimally invasive techniques leading to smaller surgical wounds, enhanced recovery, early discharge from the hospital and early return to work. Since the initiation of three-dimensional (3D) systems, studies have failed to prove significant advantages over traditional two-dimensional systems which could be attributed to suboptimal image quality, poor illumination and high cost of earlier systems. Recent advances in stereoscopy have led to the introduction of high-definition (HD) systems with improvement in image quality in both two-dimensional and 3D systems. With HD and new 4K imaging system, the previous data are now obsolete. METHODS: We devised a cross-over study using the Olympus 4K camera imaging system compared with the HD 3D systems using 40 novice surgeons with no prior surgical skills to perform standardized surgical tasks and the groups were crossed over to assess any difference in the learning curve with the imaging systems. RESULTS: The data showed a statistically significant difference in errors performed with the 3D imaging system with reduction in errors for passing needle through a ring, knot tying, cutting circle and touching circles with a needle. The time taken to perform those tasks was comparable except in knot tying where there was significant reduction in the time taken to tie knots with a P-value of <0.001 in both groups. CONCLUSION: The study showed no significant difference in the time to perform tasks. The precision of the tasks was significantly improved with the 3D systems.

Small Bowel Evisceration through the Vaginal Vault: A Rare Surgical Emergency.

Small bowel evisceration through the vagina is a rare surgical emergency that requires urgent surgical intervention because of the risk of developing acute small bowel ischemia. We present a case of a 91 year old female presenting with acute small bowel evisceration with majority of her small bowel visible outside the vagina. The bowel wall was edematous requiring emergent laparotomy and reduction of bowel with repair of the vaginal vault. The patient did not require bowel resection. Transvaginal small bowel evisceration is uncommonly described in the literature. Rare cases are reported in elderly, post-menopausal women who have undergone hysterectomy. Multiple approaches to surgical management including laparoscopic, open abdominal, transvaginal as well as combined approaches have been described. Perineal herniation must be kept in the differential in elderly post-hysterectomy patients with sudden onset of abdominal pain with urgent surgical intervention advised.

Development and implementation of an enhanced recovery after surgery protocol for renal transplantation.

BACKGROUND: Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome. METHODS: A standardized ERAS protocol was designed for the renal transplant recipient and implemented in July 2017. Data collected prospectively of recipients transplanted from July 2017 to December 2018 were compared to prospectively collected data of recipients who were transplanted prior to ERAS implementation from January 2016 to July 2017 from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate. RESULTS: There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4. CONCLUSION: An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

Perforated Giant Meckel's Diverticulum Mimicking Colonic Ischemia.

Meckel's Diverticulum is one of the most common congenital anomalies of the gastrointestinal tract. However, its presentation as a complicated Giant Meckel's Diverticulum in an adult is rare. We present a case of a perforated Giant Meckel's mimicking ischemia of the right colon. This case report highlights the importance of having a high index of suspicion for this rare diagnosis.

Laparoscopic-assisted Ex Vivo Reconstruction of Renal Artery Aneurysm with Internal Iliac Artery and Auto-transplantation.

Renal artery aneurysms (RAA) represent a complex and an often incidentally found disease commonly treated with endovascular approaches. In cases where in situ approaches are unsuitable, laparoscopic-assisted ex vivo repairs offer significant advantages during and post-surgery. We present a case of a female patient who presented with a long-standing right-sided flank pain. She was diagnosed with bilateral asymptomatic RAAs positioned well into the hilum, therefore making in situ repair infeasible. A laparoscopic-assisted ex vivo repair of the renal artery was performed using a graft from the internal iliac artery, which is a novel approach.