A survey of current practices and barriers to expanding laparoscopic HPB surgery in Canada.

BACKGROUND: The purpose of this survey was to determine the extent to which laparoscopy is used in hepatopancreatobiliary (HPB) resections in Canada, and to assess HPB surgeons' attitudes and their perceived barriers to its further adoption. METHODS: Using an electronic questionnaire, 68 Canadian Hepatopancreatobiliary Association (CHPBA) surgical members were surveyed. The questionnaire consisted of 12 questions regarding: surgeon demographics, the use and limitations of laparoscopy in their practice, and interest in increasing the use of laparoscopic techniques. RESULTS: The survey response rate was 75%. Of the 51 respondents, 86% reported performing minor laparoscopic resections such as hepatic wedge resections. Only 23% of surgeons reported performing laparoscopic liver lobectomies. Eighty-two percent of respondents indicated a wish to increase the use of laparoscopy in their practice. Barriers identified included operating time constraints (61%), a lack of equipment (41%) and lack of adequate training (43%). DISCUSSION: This survey demonstrates that currently, most Canadian HPB surgeons use laparoscopy for minor HPB resections; however, there is a strong desire to expand the use of minimally invasive techniques amongst Canadian HPB surgeons. Training centered on addressing the limitations and barriers to the uptake of minimally invasive techniques in HPB surgery are needed.

Intraoperative ultrasonography and surgical strategy in hepatic resection: What difference does it make?

BACKGROUND: With modern advancements in preoperative imaging for liver surgery, intraoperative ultrasonography (IOUS) may be perceived as superfluous. Our aim was to determine if IOUS provides new information that changes surgical strategy in hepatic resection. METHODS: We retrospectively analyzed 121 consecutive liver resections performed at a single institution. Preoperative computed tomography and/or magnetic resonance imaging determined the initial surgical strategy. The size, location and number of lesions were compared between IOUS and preoperative imaging. Reviewing the operative report helped determine if new IOUS findings led to changes in surgical strategy. Pathology reports were analyzed for margins. RESULTS: Of 121 procedures analyzed, IOUS was used in 88. It changed the surgical plan in 15 (17%) cases. Additional tumours were detected in 10 (11%) patients. A change in tumour size and location were detected in 2 (2%) and 3 (4%) patients, respectively. Surgical plans were altered in 7 (8%) cases for reasons not related to IOUS. There was no significant difference (p = 0.74) in average margin length between the IOUS and non-IOUS groups (1.09 ± 1.18 cm v. 1.18 ± 1.05 cm). CONCLUSION: Surgical strategy was altered owing to IOUS results in a substantial number of cases, and IOUS-guided resection planes resulted in R0 resections in nearly all procedures. The best operative plan in hepatic resection includes IOUS.

CONTEXTE: Compte tenu des récentes avancées de l'imagerie préopératoire pour les chirurgies du foie, l'utilisation de l'échographie peropératoire pourrait paraître inutile. Notre objectif était de déterminer si cette pratique permet d'obtenir des images nouvelles motivant un changement de stratégie chirurgicale pendant une résection hépatique. MÉTHODES: Nous avons analysé rétrospectivement 121 résections hépatiques consécutives réalisées dans un même établissement. La tomographie par ordinateur ou l'imagerie par résonance magnétique préopératoires ont été utilisées pour choisir la stratégie chirurgicale initiale. La taille et la position des tumeurs détectées ainsi que leur nombre ont été comparés selon la méthode utilisée : échographie peropératoire ou imagerie préopératoire. Nous avons étudié les rapports opératoires pour déterminer si l'échographie peropératoire avait entraîné un changement de stratégie chirurgicale et avons examiné les rapports de pathologie pour connaître les résultats de l'analyse des contours. RÉSULTATS: L'échographie peropératoire a été utilisée dans 88 des 121 interventions étudiées. Elle a influé sur la stratégie chirurgicale dans 15 cas (17 %). De nouvelles tumeurs ont été détectées chez 10 patients (11 %), et un changement dans la taille ou la position de la tumeur a été détecté chez 2 (2 %) et 3 patients (4 %), respectivement. Dans 7 cas (8 %), la stratégie chirurgicale a été modifiée, mais pour des raisons indépendantes des résultats de l'échographie. Nous n'avons pas observé de différence significative (p = 0,74) entre la taille moyenne des contours pour les 2 groupes de patients, soit ceux qui ont été soumis à l'échographie peropératoire et ceux qui ne l'ont pas été (1,09 ± 1,18 cm par rapport à 1,18 ± 1,05 cm). CONCLUSION: La stratégie chirurgicale a été modifiée en fonction des résultats de l'échographie peropératoire dans un nombre important de cas, et dans presque tous les cas, l'échographie peropératoire a donné lieu à une résection complète. La meilleure approche lors d'une résection hépatique inclut donc l'échographie peropératoire.

Bilateral ureteral reimplantation at primary bladder exstrophy closure.

PURPOSE: We present the outcomes of children who underwent concurrent complete primary repair of bladder exstrophy and bilateral ureteral reimplantation vs those undergoing bladder exstrophy repair alone, focusing on the rate of postoperative febrile urinary tract infections. MATERIALS AND METHODS: We performed complete primary repair of bladder exstrophy with bilateral ureteral reimplantation using a cephalotrigonal technique in 15 patients (group 1) and without bilateral ureteral reimplantation in 23 patients (group 2). Postoperative assessment included ultrasound and voiding cystourethrogram in all patients. Outcome measurements included postoperative febrile urinary tract infections, hydronephrosis and presence of vesicoureteral reflux. RESULTS: Mean followup was 34 months (range 6 to 54) for group 1 and 70 months (23 to 117) for group 2. Median age at surgery was 3 days for both groups (range 1 to 140). There were 10 boys and 5 girls in group 1, and 11 boys and 12 girls in group 2. Two of 15 patients (13%) in group 1 had hydronephrosis postoperatively compared to 10 of 23 (43%) in group 2 (p = 0.05). One patient in group 1 (7%) had a febrile urinary tract infection vs 11 (48%) in group 2 (p = 0.01). No patients in group 1 had postoperative vesicoureteral reflux compared to 17 (74%) in group 2 (p = 0.04). There were no complications related to ureteral reimplantation. CONCLUSIONS: Bilateral ureteral reimplantation can be safely and effectively performed during primary closure of bladder exstrophy in newborns, potentially reducing postoperative febrile urinary tract infections and hydronephrosis by early correction of vesicoureteral reflux.