Single hospital visit day case laparoscopic hernia repair without prior outpatient consultation is safe and acceptable to patients.

BACKGROUND: For some common conditions, pre-operative clinic visits are often of little value to the patient or surgeon with transfer to the waiting list being predictable. In response to local patient feedback, we introduced a single hospital visit laparoscopic hernia surgery pathway with focus on informed consent, patient-reported outcomes and post-operative interaction with primary care services. METHODS: A single hospital visit service for elective hernia repairs was created. Patients were not excluded on age, BMI or co-morbidity. Following referral, patients were telephoned by a surgeon. If considered appropriate, a symptom assessment tool, procedure information and consent form were sent. All patients were operated without attending clinic or pre-operative assessment. Surgeon-led telephone follow-up was made at either 2 or 7 days post-operatively and patient satisfaction assessed at 3 months. RESULTS: A total of 517 patients were referred for single-stop surgery between 2012 and 2015. Median age was 58 (range 20-92), 91 % were male, and mean BMI was 25.6 (17.4-52.0). No patient refused the single-visit pathway. Single-stop patients had higher knowledge questionnaire scores (mean 16 vs. 10, p = 0.01) than patients who had attended clinic. Nine (1.7 %) were requested to attend clinic to confirm diagnosis, and three (0.8 %) were cancelled by their surgeon on the operative day. A total of 393 hernia repairs (331 TEP, 63 open) were performed under general anaesthetic. 92 % were discharged on day zero. Telephone follow-up day two rather than seven decreased attendance to primary care services (25 % vs. 57 %, p = 0.001). At 3 months, 95 % were satisfied and symptom scores were reduced (median 5-0, p < 0.0001). CONCLUSION: Single-visit surgery appears to extend the patient benefits of laparoscopy by reducing hospital visits without compromising safety. Single hospital visit hernia surgery for unselected primary care referrals is possible and acceptable to patients.

Feasibility of a consultant-led, trainee-delivered urgent laparoscopic cholecystectomy service.

BACKGROUND: Urgent laparoscopic cholecystectomy has become the gold standard for the treatment of acute gallstone disease. Since 2005 we have implemented a consultant-delivered urgent surgical service for this condition. In an attempt to increase the capacity of this service, we have recently introduced a new policy of also allowing selected trainee surgeons to perform urgent laparoscopic cholecystectomy with consultant assistance available on request. The purpose of this study was to audit our initial experience of this new service. METHODS: Patients with acute gallstone disease had their surgery performed by a consultant or a trainee operating independently with consultant assistance available only on request. Allocation was based purely on surgeon availability. The clinical outcomes of 50 consecutive trainee and 50 consecutive consultant cases were compared and an attempt made to identify pre-operative predictors of technically-demanding trainee cases requiring consultant intervention. RESULTS: The mean operating time of trainees was significantly longer than consultants (80 +/- 5 mins vs 55 +/- 4 mins, p <0.001) although the conversion rates for trainees (4%) and consultants (2%) were similar. There were no significant differences between the groups with respect to postoperative morbidity. Of the 50 trainee cases, consultant intervention was required in 12 (24%) cases. There were no statistically significant pre-operative predictors of requirement for consultant assistance. CONCLUSIONS: Urgent laparoscopic cholecystectomy may be performed independently by appropriately skilled trainees within a consultant-led service. Although consultant intervention is often not required, the requirement for consultant assistance cannot be easily predicted based on pre-operative data.

Reduced access aortic exposure (RAAE) technique for infrarenal abdominal aortic aneurysm (AAA) repair.

OBJECTIVE: A reduced access aortic exposure (RAAE) technique for repair of infrarenal AAA repair has been evaluated and the short-term surgical outcomes are compared with conventional open repair (OPEN). METHODS: All consecutive patients having repair of infrarenal AAA over a period of 3 years were included in this study. A group of these patients had AAA repair using the RAAE technique with a small midline incision (<8 cm). Patient characteristics and peri-operative outcomes were compared with the other group treated with the traditional full-length midline incision (OPEN). RESULTS: Sixty patients underwent AAA repair in this study (38 in the RAAE group and 22 in the OPEN group). The age, sex distribution and co-morbidities were similar across the two groups (median age 76 and 75 years respectively). The RAAE group had a significantly shorter Intensive care stay (2 vs. 4 days, p=0.041) and a shorter total hospital stay (9 vs. 14 days, p=0.004). Significant postoperative chest infection was recorded in 13% (5/38) in the RAAE group as compared to 41% (9/21) in the OPEN group (p=0.025). CONCLUSIONS: The RAAE technique for infra renal AAA repair is feasible and safe, and allows quicker postoperative recovery with comparable morbidity and mortality to the conventional technique.

Blood and body fluid splashes during surgery--the need for eye protection and masks.

INTRODUCTION: While most surgeons make an effort to avoid needlestick injury, some can pay little attention to reduce the potential route of infection occurring when body fluids splash into the eye. It has been shown that transmission of HIV, hepatitis B or C can occur across any mucous membrane. This study aims to quantify how frequently body fluids splash the mask and lens of wrap around protective glasses thus potentially exposing the surgeon to infection. PATIENTS AND METHODS: A prospective study was carried out by a single surgeon on all cases performed over a 1-year period. Protective mask and glasses were examined before and after operations. RESULTS: A total of 384 operations were performed with 174 (45%) showing blood or body fluid splash on the lens. A high incidence of splashes was found in vascular surgical procedures (79%). All amputations showed splash on the protective lens. Interestingly, 50% of laparoscopic cases resulted in blood or body fluid splash on the protective lens. CONCLUSIONS: This study has shown a high incidence (45%) of blood and body fluid splashes found on protective glasses and masks. There was a very high incidence (79%) during vascular surgical procedures. With the prevalence of HIV and hepatitis increasing, it seems prudent to protect oneself against possible routes of transmission.

Diaphragm disease: the limitation of laparoscopy and assessment of the small bowel for strictures using a ball bearing.

Diaphragm disease is a rare cause of intestinal obstruction that will be seen with increasing frequency with the widespread use of nonsteroidal anti-inflammatory drugs (NSAIDs). We present a case study of a patient with diaphragm disease where the diagnosis was not apparent at laparoscopy, and passage of a steel ball through the small intestine was required to identify all strictures present. A high index of suspicion, recognition of the limitations of conventional diagnostic aids, and the need to assess the full length of the small bowel are all important in the surgical management of this condition.

Tourniquet use during varicose vein surgery: a survey of current practice among Wessex surgeons.

The use of a tourniquet during varicose vein surgery, has been shown, through previous randomised trials, to result in a significant reduction in blood loss, superior post-operative cosmesis with no increase in operating time. Nonetheless, it would seem that few surgeons use this technique. Using postal questionnaires (n = 107), we have assessed the views and current practice among general surgeons (consultants and higher surgical trainees) in Wessex where the method was first proposed, to see how widely it has been adopted. We find that the majority (69.5%) of general surgeons in Wessex never use a tourniquet during varicose vein surgery. Possible reasons for this include the belief that it is time consuming, inconvenient, compromises the sterility of the operative field and confers no advantage. We conclude, however, that by not using a tourniquet during varicose vein surgery, surgeons are overlooking an important, evidence-based technique. Given that in the UK over 50,000 patients per year undergo operative varicose vein procedures, this can only adversely affect the delivery of quality healthcare to a large group of patients.

Varicose veins made easy!

A novel device that is more convenient than other tourniquet systems is described.

Prospective randomized placebo-controlled trial of aprotinin for elective aortic reconstruction.

BACKGROUND: The serine protease antagonist, aprotinin, reduces perioperative blood loss in cardiac surgery and orthotopic liver transplantation. A pilot study suggested that the drug may also reduce bleeding during infrarenal aortic replacement; the aim was to confirm or refute this observation with a prospective, randomized, double-blind, placebo-controlled trial. METHODS: Some 136 patients were randomized to receive either aprotinin, given as a loading dose of 2 x 10(6) kallikrein inactivator (KI) units followed by 0.5 x 10(6) KI units/h or equal volumes of 0.9 per cent saline. After 80 patients had been randomized the infusion dose was doubled to ensure that plasma levels were similar to those seen in successful cardiac studies. Blood loss, coagulation and haematological parameters were recorded throughout surgery and for 7 days afterwards. Blood was transfused to maintain the haemoglobin level at 100 g/l. RESULTS: Four patients were withdrawn after randomization when found at laparotomy to be unsuitable for the planned reconstruction. The 30-day mortality rate was 4.5 per cent, with no excess complications in either group. Blood loss collected on swabs was reduced from 480 ml in placebo-treated patients to 379 ml with aprotinin (P = 0.014). Blood loss into suction drains in the first 24 h after operation was reduced from 295 to 205 ml in aprotinin-treated patients (P = 0.002). However, no significant reduction was found in intraoperative or total blood loss, or transfusion requirement. CONCLUSION: The small reduction in blood loss in patients treated with aprotinin demonstrated in this study does not support its use in routine elective aortic surgery.

Randomized controlled trial of patch angioplasty for carotid endarterectomy. The Joint Vascular Research Group.

A randomized controlled trial was performed to evaluate patch angioplasty for patients undergoing carotid endarterectomy. There were 213 patient episodes affecting 148 men and 65 women, with 109 allocated to patch angioplasty. Following surgery six patients suffered transient ischaemic attacks but these did not delay discharge from hospital. Six individuals (four patched operations, two not patched) required re-exploration for postoperative haemorrhage and eight (two patched procedures, six not) had potentially serious neurological problems after operation. Of these eight patients, four (none receiving patch angioplasty) underwent re-exploration and in each case a clot was removed and a patch inserted; three of the four made a good long-term recovery. The other four patients suffered completed strokes from which one died. Two further patients (one patched procedure, one not) died after operation from myocardial events, giving an overall 30-day stroke or mortality rate of 2.8 per cent. Objective follow-up assessment with duplex scanning at 1 year was completed by 94.8 per cent of patients; significantly more vessel restenoses and occlusions were observed in those not receiving patches (P < 0.01). Patch angioplasty reduces the number of immediate postoperative complications, and significantly lowers vessel restenosis and occlusion rates at 1 year after operation.

Review of the perceptions of general surgical staff within the Wessex region of the status of quality assurance and surgical audit.

The opinion of surgical staff about the present state and effectiveness of surgical audit within a single regional health authority has been obtained by questionnaire. Seventy-five per cent of registrars/senior registrars and 72 per cent of consultants completed and returned the proforma. The majority of registrars (86 per cent) believe that it is vital or very important to collect clinical outcome information that is relevant, accurate and complete. However, more than half (56 per cent) felt that these objectives were not being met. All consultants also agreed with the statement that meaningful surgical audit and quality assurance must be based on confidential critical peer review of relevant, accurate, ongoing and complete information. None, however, believed that this objective was being met completely, while only 41 per cent felt that they were doing even 'fairly well', with the principle reason for failure being lack of time. These results support the view that most surgeons are keen to achieve meaningful audit, but at present this objective is not being satisfactorily met.

Axillary nodal status in women with screen-detected breast cancer.

A prospective study of the axillary nodal status of women found to have an invasive breast cancer within the prevalence screening round is reported. Thirty-one per cent of patients were lymph node positive. Twenty-two per cent of patients with an impalpable tumour and 41% of those with a palpable tumour had involved axillary lymph nodes. Only 6% of patients with a tumour of less than 10 mm had diseased axillary nodes. Of the factors examined only the size of the invasive component of the primary tumour was related to the axillary lymph node status. This proportion of patients with positive lymph nodes is higher than might be expected and is likely to represent those patients with potentially symptomatic breast tumours detected by breast screening in the first round.

Antimicrobial prophylaxis in 'clean' surgery: hernia repair.

Antimicrobial prophylaxis is not traditionally employed for patients undergoing 'clean' surgery. The true rates of septic complications are grossly under reported for this group of patients, with up to 72% of all complications occurring, undetected by the surgical team, after discharge from hospital. The implied costs of these infections, coupled with the costs to both the patient and the community services, suggest that antimicrobial prophylaxis should be seriously considered for many types of 'clean' surgery. This can now be made both more straightforward and cost-effective by employing the oral route of administration.

Closure of laparotomy wounds: skin staples versus sutures.

To investigate the routine use of a skin stapling device for the closure of midline abdominal wounds, 48 patients were randomized to receive skin staples or subcuticular polydioxanone sutures. The mean (range) time for closure with staples was 8.0 (3.4-14.8) s cm-1 while subcuticular closure took 12.7 (9.6-28.0) s cm-1. The mean time saved per patient with skin staples was 77 s. Wound pain and requirements for analgesia were significantly lower in the sutured group. The mean cost per patient was 1.41 pounds for subcuticular closure and 7.72 pounds for stapling; the latter also incurred an additional cost of 6.27 pounds for staple removal. No clear benefit derives from the use of staples in the closure of abdominal wounds.

Non-invasive monitoring of cardiac output changes during aortic cross-clamping for infrarenal reconstruction--a new technique using suprasternal Doppler-derived cardiac output.

There is a significant morbidity and mortality associated with elective infrarenal aortic reconstruction. To examine the value of continuous cardiac output monitoring for predicting those at risk, 40 consecutive patients were monitored using Doppler-derived cardiac output. The anaesthetist was blind to all information from the monitor and managed the patients using standard techniques. In 28 patients there were no observed changes, while in seven, cardiac output rose after aortic cross-clamping. In five patients a fall in cardiac output occurred after cross-clamping. No cardiac events or cardiac deaths occurred in the 35 patients who showed a rise or no change in cardiac output. However, there were three cardiac events, including one cardiac death in the group of five patients in whom a fall in cardiac output was observed. It would appear that intraoperative non-invasive Doppler-derived cardiac output monitoring successfully predicts high-risk patients who would perhaps benefit from more intensive pre-, peri- and postoperative care.