Catastrophic complications of a robot-assisted laparoscopic sacrocolpopexy with a barbed suture: ischaemic bowel.

Robot-assisted laparoscopic sacrocolpopexy with barbed sutures has become increasingly utilized due to known benefits of minimally invasive surgery. It is equally as important to recognize the unusual life-threatening complications which may arise in patients presenting with an acute abdomen up to several weeks post-robotic surgery. A 54-year-old woman presented with acute, sudden onset abdominal pain and underwent a diagnostic laparoscopy for suspected small bowel ischemia. The procedure progressed to an open laparotomy where it was found that a V-Loc suture placed during robot-assisted laparoscopic sacrocolpopexy several weeks prior was causing strangulation of the small bowel. Following resection and side-to-side anastomosis the patient spent several days in the intensive care unit and developed a post-operative ileus, however, was eventually discharged home. When evaluating the acute abdomen in the context of recent robotic surgery, ischaemic bowel must be considered as a complication.

Impact of COVID-19 on surgical exposure and training for general surgery trainees in Australia: a national audit.

PURPOSE: The COVID-19 pandemic has caused a major disruption in operative volumes over the last few years, which has directly impacted on surgical training. This study aims to quantify the impact of COVID-19 and the relevant restrictions on General Surgery trainees in Australia. METHODS: Logbook data of General Surgery trainees from 2019 to 2021 was analysed and compared to assess the impact of COVID-19 on operative numbers and supervision levels during major operations. RESULTS: There was a statistically significant reduction in overall operative numbers in Australia, with a decrease of 2.0% in 2020 (IRR 0.980, 95% CI 0.973-0.986, P < 0.001) and 6.8% in 2021 (IRR 0.932, 95% CI 0.926-0.938, P < 0.001). Elective operations reduced by 6.6% in 2020 (IRR 0.934, 95% CI 0.927-0.942, P < 0.001) and 10.3% in 2021 (IRR 0.934, 95% CI 0.927-0.942, P < 0.001). Victoria and NT were the most affected jurisdictions; while hepatobiliary, trauma and surgical oncology were the most affected subspecialties. The proportion of overall primary operating has significantly decreased (41.8% vs. 40.2%, P < 0.001) between 2019 and 2020, and decreased further to 39.7% in 2021. CONCLUSION: The COVID-19 pandemic has had an overall negative impact on surgical training in General Surgery. Efforts should be directed at minimizing detraining of trainees and further disruptions to their training.

Innovations and Implementation of Telemedicine in Surgical Clinics Beyond COVID-19: A Narrative Review.

Introduction: Telemedicine has emerged as a powerful tool in the delivery of health care to surgical patients and innovations are developing to address challenges in the technology, enhancing consumer-provider encounters while located remotely. Our study aims at collating and commenting on the published evidence for how current challenges in telemedicine for surgical clinics are met by innovations currently in development. We also comment on the implementation and monitoring strategies for telemedicine. Methods: Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science, and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient"; and "surgical clinic." For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting, and if they had a focus during the COVID-19 pandemic. Results: Three hundred forty-five articles were identified and screened, so that 73 articles were included in the review. Almost all articles were from Western countries (n = 69), mostly in surgical journals (n = 39) and from a range of sub-specialties, but pre-dominantly orthopedics (n = 12) and general surgery (n = 9). The majority were original comparative studies, with 31 studies directly comparing telemedicine with in-person appointments and 22 articles focused on implementation during COVID-19. Discussion/Conclusion: Advanced telecommunication technology has enabled telemedicine to become an effective and safe form of health care delivery, with high consumer and provider satisfaction. Innovative protocol and technology developments have addressed the limitations of telemedicine. Sophisticated and familiar medical software integrates with electronic medical records to automate and streamline documentation, consent, and billing processes. Surgical clinics are investing in telehealth workflow co-ordination and information technology support to troubleshoot any technical difficulties as well as education for providers and consumers to address technology illiteracy. As health care services continue to transition their systems to an online network, further research is required to understand the ability and assess the feasibility of telemedicine to fully integrate.

Bariatric surgery in a public hospital: a 10-year experience.

INTRODUCTION: Obesity is common and adversely impacts quality-of-life and healthcare cost. In Australia, less than 10% of bariatric surgeries are performed in the public sector. This study reports our 10-year experience from a high volume public bariatric service which delivers multi-disciplinary care for primary and revisional procedures with mid- to long-term follow-up. METHODS: A prospectively maintained database of all patients who underwent bariatric surgery from January 2010 to January 2020 at a tertiary metropolitan hospital was analysed. We analysed patient demographics, comorbidities, perioperative outcomes, 2- and 5-year weight loss as well as comorbidities reduction. RESULTS: A total of 995 patients underwent 1086 (674 primary and 412 revisional) bariatric procedures with mean age of 46.9 years, mean BMI of 49.6 ± 9.1 kg/m2 and 92% patients with ≥1 obesity-related co-morbidity. Length-of-stay was longer for revisional than primary surgery (5.6 vs. 3.5 days). Major complication rate was 4.2%. Overall, % Total body weight loss (%TBWL) for primary surgeries at 2 years was 26.2%, and for revision surgery was 17.4%. At 2 years follow-up, treatment was ceased or reduced in 65% of diabetics, 29% of hypertensive patients and 69% of sleep apnoea patients. CONCLUSION: This study confirms that bariatric surgery in Australia can be delivered effectively in resource constrained public health system with outcomes similar to private sector.

Early Versus Postoperative Chemical Thromboprophylaxis Is Associated with Increased Bleeding Risk Following Abdominal Visceral Resections: a Multicenter Cohort Study.

BACKGROUND: Abdominal visceral resections incur relatively higher rates of postoperative bleeding and venous thromboembolism (VTE). While guidelines recommend the use of perioperative chemical thromboprophylaxis, the most appropriate time for its initiation is unknown. Here, we investigated whether early (before skin closure) versus postoperative commencement of chemoprophylaxis affected VTE and bleeding rates following abdominal visceral resection. METHODS: Retrospective review of all elective abdominal visceral resections undertaken between January 1, 2018, and June 30, 2019, across four tertiary-referral hospitals. Major bleeding was defined as the need for blood transfusion, reintervention, or > 20 g/L fall in hemoglobin from baseline. Clinical VTE was defined as imaging-proven symptomatic disease < 30 days post-surgery. RESULTS: A total of 945 cases were analyzed. Chemoprophylaxis was given early in 265 (28.0%) patients and postoperatively in 680 (72.0%) patients. Mean chemoprophylaxis exposure doses were similar between the two groups. Clinical VTE developed in 14 (1.5%) patients and was unrelated to chemoprophylaxis timing. Postoperative bleeding occurred in 71 (7.5%) patients, with 57 (80.3%) major bleeds, requiring blood transfusion in 48 (67.6%) cases and reintervention in 31 (43.7%) cases. Bleeding extended length-of-stay (median (IQR), 12 (7-27) versus 7 (5-11) days, p < 0.001). Importantly, compared to postoperative chemoprophylaxis, early administration significantly increased the risk of bleeding (10.6% versus 6.3%, RR 1.45, 95% CI 1.05-1.93, p = 0.038) and independently predicted its occurrence. CONCLUSIONS: The risk of bleeding following elective abdominal visceral resections is substantial and is higher than the risk of clinical VTE. Compared with early chemoprophylaxis, postoperative initiation reduces bleeding risk without an increased risk of clinical VTE.

Preventing calcium and vitamin D deficiencies following weight loss and metabolic surgery.

INTRODUCTION: Uncertain nutritional outcomes following common metabolic surgical techniques are concerning given the long-term potential for postoperative metabolic bone disease. This study aims to investigate the variations in serum calcium, vitamin D, and parathyroid hormone (PTH) levels following Roux-en-Y Gastric bypass (RYBP) and Sleeve Gastrectomy (SG). METHODS: A retrospective analysis of 370 patients who underwent metabolic surgery at a single-centre group practice in Melbourne, Australia, over 2 years. RESULTS: Patients underwent SG (n = 281) or RYGP (n = 89), with 75% and 87% of the cohort being female, respectively. Postoperative mean serum calcium levels and median serum vitamin D levels improved significantly by 24 months within both cohorts. Serum PTH levels within the RYBP group were significantly higher than the SG group across all time points. PTH levels significantly fell from 5.7 (IQR 4.2-7.4) to 5.00 (4.1-6.5) pmol/L by 24 months following SG. However, PTH levels following RYBP remained stable at 24 months, from 6.1 (IQR 4.7-8.7) to 6.4 (4.9-8.1) pmol/L. Furthermore, we failed to notice a significant improvement in PTH levels following RYBP among those with higher PTH levels preoperatively. CONCLUSION: Higher PTH levels following RYBP, compared to SG, may imply we are undertreating patients who are inherently subjected to a greater degree of malabsorption and underlying nutritional deficiencies. This finding calls for a tailored supplementation protocol, particularly for those with high preoperative PTH levels undergoing RYBP, to prevent deficiencies.

Cyanoacrylate Glue Versus Absorbable Tacks in Mesh Fixation for Laparoscopic Extraperitoneal Inguinal Hernia Repair: A Randomized Controlled Trial.

BACKGROUND: Cyanoacrylate glue (Glubran 2) is a synthetic adhesive mesh fixation material. Its utility is being evaluated in laparoscopic total extraperitoneal (TEP) inguinal hernia repair (IHR). A multicentre randomized controlled trial was performed comparing Glubran 2 to standard of care absorbable tacks, particularly assessing chronic postoperative inguinal pain and its effects. MATERIALS AND METHODS: Patients undergoing elective TEP IHR at 2 centers from 2017 to 2019 were randomly assigned to Glubran 2 or absorbable tack mesh fixation, and followed for 6 months. All other aspects of surgery and aftercare remained the same. Surgeons documented operative and fixation time, and the placement of fixation on standardized diagrams. Via a questionnaire, aspects of inguinal pain were evaluated before surgery, and at various time-points postoperatively over 6 months. Postoperative clinical factors were also collected. RESULTS: A total of 106 operative sides were randomized to either glue (51) or tack (55) mesh fixation over a 14-month period. Similar median operative times between tack (83.0 min) and glue fixation (75.0 min) were observed. There were no significant surgical complications or observed hernia recurrences in either group. There was no significant difference in pain scores between the 2 groups at all time-points after analysis through mixed effects modeling. Temporal pain profiles over time were also similar. Totally, 55% of patients in the glue group had returned to work within 2 weeks of surgery. There was no increase in complications or pain scores despite regular lateral fixation of glue in these patients. CONCLUSION: Adding to known data, we observed no significant difference in postoperative pain, demonstrating that cyanoacrylate glue is a viable and safe alternative fixation method to absorbable tacks in laparoscopic TEP IHR. As secondary outcomes, cyanoacrylate glue permits some patients to return to work early, and we observed regular lateral mesh glue fixation without increased pain or complications.

Current and future use of telemedicine in surgical clinics during and beyond COVID-19: A narrative review.

INTRODUCTION: Telemedicine has emerged as a powerful tool in the delivery of healthcare to surgical patients and enhances clinician-patient encounters during all phases of patient care. Our study aims were: to review the current use and applicability of telemedicine; evaluate its suitability, safety and effectiveness in a surgical outpatient setting, particularly in the era of social distancing restrictions and provide insight into future applications. METHODS: Databases searched included: PubMed, OVID Medline, Embase, Scopus, Web of Science and review of reference lists. Key words used were "telemedicine"; "telehealth"; "videoconference"; "outpatient" and "surgical clinic". For inclusion, articles required to be in English, published between 2000 and 2021, were in an outpatient surgical setting and if they had a focus during the COVID-19 pandemic. RESULTS: 335 articles were identified and screened, so that 63 articles were included in the review. Almost all articles were from Western countries (n = 60), mostly in surgical journals (n = 35) and from a range of sub-specialities, but pre-dominantly orthopaedics (n = 12) and general surgery (n = 7). The majority were original comparative studies where 31 studies directly compared telemedicine to in-person appointments and 14 papers focused on implementation during COVID-19. DISCUSSION/CONCLUSIONS: Telemedicine has been safely used across various phases of surgical outpatient care, with its effectiveness evaluated by clinical outcomes, economics and user/provider satisfaction. Telemedicine has multiple accepted benefits including time efficiency, patient/healthcare cost savings and community access, but with reported limitations of clinical uncertainty, technology infrastructure requirements, cybersecurity vulnerabilities and healthcare regulatory restraints. These limitations are being overcome by accelerated implementation during COVID-19 via fast-tracked practice development. Further work is required via development of research protocols to refine the application of emerging telemedicine technologies and their applicability to different surgical sub-specialties.

Atraumatic splenic rupture in patient with acute pancreatitis.

Atraumatic splenic rupture (ASR) is a rare complication of acute pancreatitis with high mortality and morbidity rates. We present a case of a 63-year-old woman with a history of hypertension, presenting with acute pancreatitis who subsequently developed a splenic rupture requiring a laparotomy and splenectomy. ASR is a rare but life-threatening complication requiring prompt recognition and management and should be considered in patient with pancreatitis who develops sudden haemodynamic compromise and worsening anaemia.

Variations in practice of thromboprophylaxis across general surgical subspecialties: a multicentre (PROTECTinG) study of elective major surgeries.

BACKGROUND: Despite guidelines recommending perioperative thromboprophylaxis for patients undergoing general surgery, we have observed significant variations in its practice. This may compromise patient safety. Here, we quantify the heterogeneity of perioperative thromboprophylaxis across all major general surgical operations, and place them in relation to their risk of bleeding and venous thromboembolism. METHODS: Retrospective review of all elective major general surgeries performed between 1 January 2018 and 30 June 2019 across seven Victorian hospitals was conducted. RESULTS: A total of 5912 patients who underwent 6628 procedures were reviewed. Significant heterogeneity was found in the use of chemoprophylaxis, timing of its initiation, type of anticoagulant administered and application of extended chemoprophylaxis. These variations were observed within the same procedure, and between different surgeries and subspecialties. Contrastingly, there was minimal heterogeneity with the use of mechanical thromboprophylaxis. Oesophago-gastric, liver and colorectal cancer resections had the highest thromboembolic risk. Breast, oesophago-gastric, liver, pancreas and colon cancer resections had the highest bleeding risk. CONCLUSION: Perioperative chemoprophylaxis across general surgery is highly variable. This study has highlighted key areas of variance. Our findings also enable surgeons to compare their practices, and provide baseline data to inform future efforts towards optimizing thromboprophylaxis for general surgical patients.

Pre-operative and intra-operative chemical thromboprophylaxis increases bleeding risk following elective cholecystectomy: a multicentre (PROTECTinG) study.

BACKGROUND: Cholecystectomy is commonly performed in general surgery. Despite guidelines recommending chemical thromboprophylaxis in the perioperative period, the most appropriate time for its initiation is unknown. Here, we investigated whether timing of chemoprophylaxis affected venous thromboembolism (VTE) and bleeding rates post-cholecystectomy. METHODS: Retrospective review of all elective cholecystectomies performed between 1 January 2018 and 30 June 2019, across seven Victorian hospitals. Clinical VTE was defined as imaging-proven symptomatic disease within 30 days of surgery. Major bleeding was defined as the need for blood transfusion, surgical intervention or >20 g/L fall in haemoglobin from baseline. RESULTS: A total of 1744 cases were reviewed. Chemoprophylaxis was given early (pre- or intra-operatively), post-operatively or not given in 847 (48.6%), 573 (32.9%) and 324 (18.6%) patients, respectively. This varied significantly between surgeons, fellows, trainees and institutions. Clinical VTE occurred in 5 (0.3%) patients and was not associated with chemoprophylaxis timing. Bleeding occurred in 42 (2.4%) patients. Of this, half were major events, requiring surgical control in 5 (11.9%) patients and blood transfusion in 9 (21.4%) patients. Bleeding also extended length of stay (mean (SD), 3.1 (4.0) versus 1.4 (2.2) days, P < 0.001). One bleeding-related mortality was recorded. Importantly, when compared with post-operative (risk ratio 1.46, 95% confidence interval 1.21-1.62) and no (RR 1.23, 95% CI 1.03-1.35) chemoprophylaxis, early usage significantly increased bleeding risk and independently predicted its occurrence. CONCLUSIONS: Perioperative chemoprophylaxis is variable among patients undergoing elective cholecystectomy. The rate of clinical VTE post-cholecystectomy is low. Early chemoprophylaxis increases bleeding risk without an appreciable additional protection from VTE.

Midgut Volvulus: A Rare but Fatal Cause of Abdominal Pain in Pregnancy-How Can We Diagnose and Prevent Mortality?

Midgut volvulus in pregnancy is rare but life-threatening, resulting in high maternal and fetal mortality. This surgical emergency commonly masquerades as symptoms of pregnancy, which together with its low incidence often leads to delay in diagnosis and definitive treatment. Here, we review the last three decades of the literature, discuss the challenges in managing this rare condition, and raise awareness among clinicians to minimise loss of life.

Laparoscopic Roux en Y gastric bypass in the super obese.

Bariatric surgery in super obese patients presents technical, metabolic and risk related challenges. Moreover, there is concern that weight loss and health outcomes of surgery, including gastric bypass, may be lesser than in non super obese (morbidly obese) patients. This may drive clinicians toward more aggressive forms of surgery at the risk of greater morbidity. This review examines outcomes pertaining to laparoscopic Roux en Y gastric bypass (LRYGB) in the super obese and determines the role of such surgery in the current day. Whilst a minor increase in morbidity and mortality risk exists, weight loss outcomes when measured as percentage total body weight loss are equivalent to non super obese patients. Final BMI is not an appropriate indicator of benefit in such patients and may lead to escalation surgery inappropriately. Surgeons employing the use of LRYGB in the super obese should have adequate training and expertise in the technique and operating upon super obese patients should be avoided during the learning curve phase to minimise morbidity risk.

Over-ordering of ultrasound and pre-operative investigations for inguinal hernia repair at Northern Health: a Choosing Wisely audit.

BACKGROUND: Choosing Wisely Australia is an initiative aimed at reducing the incidence of unnecessary investigations. This study is an audit of Northern Health's adherence to two Choosing Wisely recommendations in the context of inguinal hernia repair. Recommendation 1: Avoid routinely performing pre-operative investigations in patients, but instead order in response to patient factors, signs and symptoms, disease or planned surgery. Recommendation 2: Do not order ultrasound for clinically apparent inguinal hernias. METHODS: Records of 264 patients who underwent elective inguinal hernia repair at Northern Health in 2016 were reviewed. RESULTS: Recommendation 1: Results demonstrated over-ordering of coagulation studies. Thirty-four percent of patients received coagulation studies, 86% of which were unindicated. There was better adherence to Choosing Wisely guidelines for other investigations: 38% of patients received a full blood examination (42% unindicated), 38% received a urea, electrolytes and creatinine (14% unindicated), 7% received a glycated haemaglobin (0% unindicated) and 38% received an electrocardiogram (11% unindicated). Recommendation 2: Seventy percent (n = 186) of patients received an ultrasound of which 25% (n = 46) had a documented indication. Correlation with surgical findings showed a positive predictive value of 95.6% and sensitivity of 97.8% for ultrasound. CONCLUSION: Recommendation 1: Most pre-operative coagulation studies were unindicated, while adherence to Choosing Wisely guidelines was better for pre-operative full blood examination, urea, electrolytes and creatinine, glycated haemaglobin and electrocardiogram. Recommendation 2: The majority of patients received an inguinal hernia ultrasound, most of which had no documented indication.