Safety of robotic cholecystectomy as index training procedure: the UK experience.

AIMS: To evaluate the safety profile of robotic cholecystectomy performed within the United Kingdom (UK) Robotic Hepatopancreatobiliary (HPB) training programme. METHODS: A retrospective evaluation of prospectively collected data from eleven centres participating in the UK Robotic HPB training programme was conducted. All adult patients undergoing robotic cholecystectomy for symptomatic gallstone disease or gallbladder polyp were considered. Bile duct injury, conversion to open procedure, conversion to subtotal cholecystectomy, length of hospital stay, 30-day re-admission, and post-operative complications were the evaluated outcome parameters. RESULTS: A total of 600 patients were included. The median age was 53 (IQR 65-41) years and the majority (72.7%; 436/600) were female. The main indications for robotic cholecystectomy were biliary colic (55.5%, 333/600), cholecystitis (18.8%, 113/600), gallbladder polyps (7.7%, 46/600), and pancreatitis (6.2%, 37/600). The median length of stay was 0 (IQR 0-1) days. Of the included patients, 88.5% (531/600) were discharged on the day of procedure with 30-day re-admission rate of 5.5% (33/600). There were no bile duct injuries and the rate of conversion to open was 0.8% (5/600) with subtotal cholecystectomy rate of 0.8% (5/600). CONCLUSION: The current study confirms that robotic cholecystectomy can be safely implemented to routine practice with a low risk of bile duct injury, low bile leak rate, low conversion to open surgery, and low need for subtotal cholecystectomy.

Outcomes of laparoscopic subtotal cholecystectomy: a comparative analysis of fenestrating and reconstituting approaches in 170 cases.

BACKGROUND: Laparoscopic subtotal cholecystectomy (LSC) is a recognised alternative to laparoscopic cholecystectomy (LC) when it is unsafe to achieve the "critical view of safety". Although LSC reduces the risk of bile duct injury, it is associated with increased morbidity, primarily due to bile leak. LSC can be classified as fenestrating (F-LSC) or reconstituting (R-LSC), with the latter being more complex. The objective of this study was to evaluate the two LSC techniques, their complications, and overall outcomes. METHODS: We conducted a retrospective analysis of all adult patients who underwent LSC between January 2015 and December 2021 using our electronic database. Data collected included patient demographics, prior acute biliary presentations, operative details/techniques, length of stay (LOS), 30-day complications, 30-day mortality, readmissions, and follow-up investigations/procedures. Descriptive statistics, Chi-squared tests, and relative risk were employed for data analysis. RESULTS: In the study period, LSC was performed on 170 patients, showing an increasing trend over time. Most procedures (76%) were performed in the acute setting, and 37.1% of patients had a history of previous acute biliary presentations. Fenestrating LSC was the most performed technique (115 [67.6%] vs. 55 [32.4%]). Complications occurred in 80 (47.1%) patients; 60 patients (35.3%) had a bile leak. 16 patients (9.4%) required reoperation, and readmission was observed in 14 patients (8.2%). F-LSC was associated with more complications [p = 0.03 RR 2.46 (95% CI 1.5-4)], more bile leaks [p < 0.01, RR 2.1 (95% CI 1.2-3.7)], greater need for rescue postoperative endoscopic retrograde cholangiopancreatography (ERCP) [p < 0.01, RR 3.8 (95% CI 1.4-10.2)], and longer LOS (6 vs. 4 days p < 0.01). CONCLUSION: Although LSC is seen as a safe alternative to open conversion, our findings demonstrate a high morbidity, including reoperation/reintervention, readmissions, and complications, associated with LSC especially with F-LSC. We suggest that if LSC is performed, the reconstituted technique should be chosen, if feasible.

Impact of the COVID-19 Pandemic on the Management of Gallbladder, Biliary Tract, and Pancreatic Diseases.

Introduction Biliary diseases are a major acute general surgical burden. Laparoscopic cholecystectomy is the gold standard surgical procedure, although it was discontinued during an outbreak. Effective management permits decisive therapy, symptom alleviation, and fewer hospitalizations and complications. Throughout the initial COVID-19 situation, surgical procedures for patients were delayed. Invasive services were required to employ conservative or non-operative therapy, which could lead to increased recurring presentations and biliary-pancreatic problems. Aim Examining the impact of COVID-19 on the outcomes and hospitalizations of patients suffering from gallstone, biliary tract, and pancreatic diseases.  Methods The retrospective analysis included patients with the following ICD-10 codes who presented to our unit: cholelithiasis (K80), cholecystitis (K81), and acute pancreatitis (K85). We compared the interval of the first COVID-19 pandemic wave, from March to August 2020, with the period before the pandemic, referred to as Pre-COVID-19. After applying exclusion criteria, a total of 868 patients were enrolled in the trial, having initially recruited around 1,400 individuals using these codes. Patients with inaccurate coding, cancer, or non-stone disease were excluded (e.g., alcoholic pancreatitis). The demographic information, admission details, investigations, surgical therapy, operating specifics, and postoperative complications of the patients were noted. Changes in surgical management, patient representation, and postoperative complications were the key outcomes. Results A statistically significant (p<0.05) rise was seen in repeat presentations in the COVID group, most likely due to the failure of definitive treatment. The other outcome is the distribution of presentations was comparable, patients with acute cholecystitis and gallstone pancreatitis showed statistically significant (p<0.05) lower rates of definitive therapy. Conclusion During the COVID period, all surgeries except those for cancer were halted. Unknown causes led to several consequences related to the gallbladder, biliary tract, and pancreas. Patients with cholecystitis, gallstone pancreatitis, and pancreatic inflammation experienced a lower probability of treatment. The increase in hospitalizations and self-presentations indicated that definitive therapy, designed to restrict COVID-19 exposure, actually increased patient risk. Despite this risk, we had no COVID-19 instances in our cohort. The evaluation of the long-term consequences of the pandemic on acute pancreatitis and its care will require a large-scale, multicenter investigation.

Protocol to develop a core outcome set in incisional hernia surgery: the HarMoNY Project.

INTRODUCTION: Incisional hernia has an incidence of up to 20% following laparotomy and is associated with significant morbidity and impairment of quality of life. A variety of surgical strategies including techniques and mesh types are available to manage patients with incisional hernia. Previous works have reported significant heterogeneity in outcome reporting for abdominal wall herniae, including ventral and inguinal hernia. This is coupled with under-reporting of important clinical and patient-reported outcomes. The lack of standardisation in outcome reporting contributes to reporting bias, hinders evidence synthesis and adequate data comparison between studies. This project aims to develop a core outcome set (COS) of clinically important, patient-oriented outcomes to be used to guide reporting of future research in incisional hernia. METHODS: This project has been designed as an international, multicentre, mixed-methods project. Phase I will be a systematic review of current literature to examine the current clinical and patient-reported outcomes for incisional hernia and abdominal wall reconstruction. Phase II will identify the outcomes of importance to all key stakeholders through in depth qualitative interviews. Phase III will achieve consensus on outcomes of most importance and for inclusion into a COS through a Delphi process. Phase IV will achieve consensus on the outcomes that should be included in a final COS. ETHICS AND DISSEMINATION: The adoption of this COS into clinical and academic practice will be endorsed by the American, British and European Hernia Societies. Its utilisation in future clinical research will enable appropriate data synthesis and comparison and will enable better clinical interpretation and application of the current evidence base. This study has been registered with the Core Outcome Measures in Effectiveness Trials initiative. PROSPERO REGISTRATION NUMBER: CRD42018090084.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania.

INTRODUCTION: The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff. METHODS: This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC. RESULTS: 147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway. CONCLUSION: High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

Emergency repair of Morgagni hernia with partial gastric volvulus: our approach.

Morgagni hernias are a rare form of congenital diaphragmatic hernias, thus there is paucity in literature about the diagnosis and management of the condition. We report an 83-year-old woman who presented with vomiting and a metabolic acidosis with a previous computed tomography diagnosis of Bochdalek's hernia. Diagnostic laparoscopy revealed a Morgagni hernia containing transverse colon, greater curvature of the stomach and a partial gastric volvulus. The hernia was reduced with the sac untouched, and the defect was closed with a composite mesh using tac fixation. The operation was done successfully in 45 minutes with no complications.

Computed tomography in the investigation and management of obturator hernia.

INTRODUCTION: Obturator hernias are a rare groin hernia. They are most commonly found incidentally during laparoscopic inguinal hernia repair. We investigated our experience with obturator hernias in the elective and emergency setting. METHODS: Cases of obturator hernia were identified from a hospital database and reviewed retrospectively over the last 10 years. There were no exclusions. There were a number of surgeons involved with an interest in groin hernia surgery. RESULTS: Twenty-one patients were included. The mean age was 66 years old. Eleven were male. There were four emergency presentations. One emergency case presented with small bowel obstruction, while the other three cases presented with groin pain. Two patients had a preoperative computed tomography, which showed an obturator hernia confirmed at surgery. The patient with small bowel obstruction had an open bowel resection alone with no hernia repair. They were discharged with no complications or recurrence on follow-up. The other three cases had a mesh repair (one laparoscopic, one laparotomy, one pre-peritoneal). One patient who underwent a laparotomy died of a post-operative pneumonia. The others were discharged uneventfully. In the elective group of 17 patients, 8 patients were taken for an elective laparoscopic inguinal hernia repair but found to actually have an obturator hernia alone. An obturator hernia was found incidentally with an inguinal hernia in three patients. Five patients were expected to have an obturator hernia on clinical examination alone. At surgery, an obturator hernia was found in three cases. In the other two cases, no hernia was found. One patient had a pre-operative computed tomography, which showed an obturator hernia confirmed at surgery. CONCLUSIONS: Computed tomography would be recommended in cases of diagnostic uncertainty. It may avoid unnecessary surgery in the elective setting and allow a focused procedure in the emergency setting. Laparoscopic repair is feasible in the emergency and elective setting with excellent results.

Use of the Ambu® aScope 2TM in laparoscopic common bile duct exploration.

BACKGROUND: We have recently begun to use a sterile disposable endoscope to perform laparoscopic common bile duct exploration. We evaluated our practice in a large district general hospital and reported the early feasibility of this equipment in performing bile duct exploration. METHODS: We began to use the Ambu® aScope 2TM from June 2015 in our institution. Any case eligible for a laparoscopic common bile duct exploration was included. Our study period is from June 2015 to November 2015. Data were collected and analysed retrospectively. RESULTS: Thirteen patients were included. Nine were female and five were male. The mean age was 59 years old (range 28 to 82 years). Seven were performed as an emergency and six were performed for elective cases. All patients had common bile duct stones with no history of previous cholecystectomy. The Ambu® aScope 2TM was used in 11 cases, and a standard choledocoscope was used in two cases due to lack of availability of the Ambu® aScope 2TM. There was one conversion due to an impacted bile duct stone and technical difficulty intra-operatively. Five cases were performed as a transcystic exploration with 1 case being converted to a choledocotomy due to inability to pass the cystic duct using the Ambu® aScope 2TM. The mean operating time was 158 min (range 85-255 min). The mean operative time using the reusable endoscope was 130 min. The mean postoperative stay was 3 days (range 0-8 days). CONCLUSIONS: The use of the Ambu® aScope 2TM is safe and feasible in laparoscopic common bile duct exploration. It confers significant financial benefits and offers an economical alternative to expensive reusable endoscopes.

Laparoscopic common bile duct exploration: 15-year experience in a district general hospital.

INTRODUCTION: The treatment of common bile duct (CBD) stones remains controversial with debate between endoscopic cholangiopancreatography (ERCP) and CBD exploration. A recent meta-analysis has shown no significant difference between these approaches; however, there is a trend in the literature to favour a single-stage procedure in the form of laparoscopic CBD exploration. We report our experience over a 15-year period. METHODS: All cases of CBD exploration were identified from 2000 to 2015 and analysed retrospectively from a large NHS Foundation Trust in Northumbria. There were no exclusions. The mean clinical follow-up was 6 months (range 3-36 months). RESULTS: A total of 296 patients were included who underwent laparoscopic CBD exploration: 203 were female and 93 were male. The mean age was 60 years (range 16-84 years). A total of 231 procedures were performed electively and 65 as an emergency. Ten procedures were successfully performed as day cases. Eleven procedures were converted to an open procedure due to adhesions or a difficult dissection (4 %). Sixty-three procedures were performed with a transcystic approach with a mean post-op stay of 2 days (range 0-7). A total of 233 procedures were performed with a choledocotomy with a mean post-op stay of 6 days (range 3-14 days). Stone clearance was successful in 255 patients (86 %). Three patients died over the study period. Two were for medical complications and one for abdominal sepsis. Three patients returned to theatre for early post-operative bleeding (1 %). Sixteen patients had persistent bile leaks following a choledocotomy (6.8 %). No patients had a bile leak following transcystic exploration. Fourteen patients were followed up following failed stone removal. Nine had a successful ERCP, three had no stone seen on MRCP, and one patient required re-operation following a failed ERCP. CONCLUSIONS: Laparoscopic bile duct exploration can be performed successfully in both the emergency and elective settings. Day-case surgery is feasible in selected patients. A transcystic approach should be favoured where possible.

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.

Laparoscopic surgical skills assessment: can simulators replace experts?

INTRODUCTION: Global Rating Scales (GRS) quantify and structure subjective expert assessment of skill. Hybrid simulators measure performance during physical laparoscopic tasks through instrument motion analysis. We assessed whether motion analysis metrics were as accurate as structured expert opinion by using GRS. METHODS: A random sample of 10 consultant laparoscopic surgeons, 10 senior trainees, and 10 novice students were assessed on a Sharp Dissection task. Coded video footage was reviewed by two blinded assessors and scored using a Likert Scale. Correlation with metrics was tested using Spearman's rho. Inter-rater reliability was measured using intraclass correlation coefficient (ICC). RESULTS: Strongest GRS-Metric correlations were found for Time/Motion/Progress with Time (Spearman's rho 0.88; p < 0.05) and Instrument Handling with Path Length (Spearman's rho 0.8; p < 0.05). Smoothness correlated with Respect for Tissue in Rater 1 (rho 0.68) but not Rater 2 (rho 0.18). Mean GRS showed stronger inter-rater agreement than individual scale components (ICC 0.68). Correlation coefficients with actual experience group were 0.58-0.74 for mean GRS score and 0.67-0.78 for metrics (Spearman's rho, p < 0.05). CONCLUSIONS: Metrics correlate well with GRS assessment, supporting concurrent validity. Metrics predict experience level as accurately as global rating and are construct valid. Hybrid simulators could provide resource-efficient feedback, freeing trainers to concentrate on teaching.

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.