How to Article: Prehabilitation and postoperative treatment at Shouldice Hospital.

Shouldice Hospital has grown beyond its beginnings in the 1940s to become a leading centre of excellence for mesh-free hernia repair. Little is known to the international surgical community about the preoperative and postoperative care at Shouldice Hospital, and colleagues working at Shouldice Hospital have been repeatedly asked to provide more details at international and national congresses. Therefore, this article aims to summarize preoperative and postoperative care at Shouldice Hospital based on previously published literature. The authors believe that the long-standing tradition of prehabilitation and postoperative treatment may play a role in facilitating patient satisfaction and superior postoperative results after hernia surgery.

Matching males and females undergoing non mesh primary unilateral inguinal hernia repair: evaluating sex differences in preoperative and acute postoperative pain.

PURPOSE: The objective was to compare pain and related psychological factors during the preoperative and acute postoperative period between male and female patients, who underwent non mesh primary unilateral inguinal hernia repair. METHODS: After ethics approval, informed consent was obtained, and data were collected. Male and female participants were compared by manually matching one-to-one on 10 variables. Descriptive statistics (mean ± standard deviation and frequency) as well as numerical rating scales from 0 to 10 were used. Comparison tests were performed using Chi-square or Fisher's Exact test for categorical data and independent samples t-test or non-parametric equivalent tests for numerical scores. p < 0.05 is reported as statistically significant. To control type I error, Bonferroni correction was used. RESULTS: 72 participants with 36 matched pairs were included. Sex differences were found for operation length (p = .006), side of operation (p = .002), and hernia type (p = .013). Significant differences between the sexes were not found at the preoperative or postoperative time for resilience, pain interference or pain severity related measures, postoperative hernia pain incidence, pain catastrophizing, depression and anxiety symptoms, or return to normal activities. CONCLUSION: When controlling for known confounders and using a conservative Type I error rate, pain and related factors between the sexes did not differ significantly.

Temporal patterns for inguinal hernia recurrence operations after Shouldice Repair.

PURPOSE: Shouldice Repair for inguinal hernias results in a low recurrence rate; however, little is known about the risk factors for these relapses. In the present study, we reviewed all patient's undergoing a reoperation for recurrence after a primary Shouldice Repair. METHODS: Patients undergoing recurrent inguinal hernia repair from 2013 to 2017 were identified. The subgroup of patients with the first recurrence after a Shouldice Repair at this institution was selected and included. Data collection from the index and the reoperation surgery were performed, as well as statistical analysis. RESULTS: A total of 125 patients were included in the analysis. The mean age was 50.8 ± 13.9 (body mass index: 24.6 ± 2.6 kg/m2), 97% were male. The most common interval for a recurrence reoperation was in the first 5 years following the initial surgery (37.6% of patients; mode: 1 year; median: 7 years; mean: 13.7 ± 13.8 years). A temporal median pattern for recurrence reoperation according to age interval was noted (patients < 41 years old: 20 years; patients aged 41-60 years old: 10 years and patients > 61 years: 2 years)). CONCLUSION: Patients undergoing reoperations for recurrent inguinal hernias after a primary Shouldice Repair presented a pattern of temporal recurrence according to age. Older patients present with earlier recurrences than younger ones, an important consideration in the assessment of patients postoperatively.

Incidence of opioid use and early postoperative pain intensity after primary unilateral inguinal hernia repair at a single-center specialty hospital.

PURPOSE: This research examined opioid use, pain intensity, and pain management after primary unilateral inguinal hernia repair (PUIHR) at a single-center specialty hospital. METHODS: After research, ethics board approval, and informed consent, pain scores (0-10 numerical rating scale [NRS]) were obtained from survey-based questionnaires administered at the pre- and 3-day postoperative timepoints. Descriptive results are presented as frequency, mean, standard deviation, range, median, and interquartile ranges, as appropriate. Significance tests were conducted to compare participants who did and did not receive opioids after surgery. p-value <0.05 is considered statistically significant. As the standard of care, participants received nonopioid multimodal analgesia (acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs)) and opioids, when necessary. RESULTS: A total of 414 and 331 participants completed the pre- and 3-day postoperative questionnaires, respectively. Out of the 414 participants, 38 (9.2%) received opioids during the postoperative stay. There was no significant difference between pain frequency or mean preoperative NRS pain intensity scores of those who did and did not receive opioids. Mean NRS pain intensity scores on day 3 after surgery were significantly higher for participants who received opioids (3.15±2.08) than those who did not (2.19±1.95), p=0.005. CONCLUSION: Most participants did not receive opioids after PUIHR and had lower mean postoperative NRS pain intensity scores compared to those who did, most likely reflecting the need for opioids among the latter. Opioids were discontinued by day 3 for all participants who received them. Therefore, for most patients undergoing PUIHR, effective pain control can be achieved with nonopioid multimodal analgesia in the early postoperative period.

Muscular groin hernias: an anatomical variation as a cause of recurrence.

PURPOSE: The objective of this study was to understand our center's experience with the rare entity of muscular groin hernias. Specifically, to determine this hernia's incidence and characteristics and provide valuable information to surgeons that can be utilized at the time of a hernia repair regardless of modality used. METHODS: This was a retrospective chart review between 2005 and 2019. Patients who had a primary or recurrent groin hernia operation for an atypically located hernia (other than direct, indirect, or femoral) were included. Descriptive statistics were utilized to present the hernia and patient data as median (interquartile range, range). RESULTS: There were 152 patients with 155 muscular hernias identified in primary operations and 41 patients with 41 muscular hernias identified in recurrent operations. In both primary and recurrent groups there were more males, and the males were on average younger with a higher body mass index (BMI) than females. Most muscular hernias were located lateral (76) or lateral/superior (33) to the internal ring with a median distance between 2 and 3 cm (1, 0.3-5; 2.8,2-5) from the internal ring. A concurrent ipsilateral inguinal hernia was found and repaired in 42.3% of left and 46.8% of right sided primary muscular hernia operations. A concurrent ipsilateral inguinal hernia was noted in 5% of left and 14.3% of right sided recurrent muscular operations. In left sided recurrent operations for a muscular hernia, 68.9% had a previous ipsilateral inguinal hernia repair and in right sided recurrent operations, 67.7% had a previous ipsilateral inguinal hernia repair. CONCLUSION: This study describes a previously unidentified groin muscular hernia in both primary and recurrent hernia operations as a potential cause of hernia recurrence and identifies muscular hernia locations. This information can be utilized at the time of surgery to identify and subsequently repair these defects, leading to improved patient and hernia outcomes.

Spigelian hernias: A high volume institutional review.

Purpose: The objective of this study was to evaluate a high-volume hernia center's experience with primary Spigelian hernias. Introduction: Spigelian hernias are rare entities presenting a diagnostic dilemma for clinicians that often lead to a delay in treatment or need for emergency surgery. Given this low incidence true patient and hernia characteristics are unknown. Methods: This was a retrospective chart review evaluating patients who underwent a Spigelian hernia repair between 2005 and 2019. Descriptive statistics were utilized. Results: The incidence of Spigelian hernias at our institution was 0.14 %. There were 141 patients with 143 spigelian hernias (two patients had bilateral hernias) repaired at our institution during the study period, the majority of these were in male patients, left sided and repaired under conscious sedation with or without the use of mesh. Conclusion: This study adds a large dataset to the paucity of literature that exists in the context of Spigelian hernias and alerts the clinician that these hernias are not exclusive to the older female population. Furthermore, this study provides the need for a high index of suspicion in patients presenting with vague abdominal pain who may not fit the typical Spigelian hernia mold.

The Shouldice Method: an expert's consensus.

BACKGROUND: Hernia repairs are a commonly performed surgical procedure and the Shouldice Repair of inguinal hernias has been well described before in terms of its outcomes. However, the purpose of this paper was to understand what experts from Shouldice Hospital consider to be the essential steps to the Shouldice Method. METHODS: Utilizing a Delphi Methodology, surgeons at Shouldice Hospital who are considered content experts, provided their answers on what is essential to the Shouldice Method. The median, interquartile range, and percent agreement from the responses as well as the Delphi's overall Cronbach's Alpha were determined. All Delphi items were ranked on a five-point Likert scale and consensus was reached when Cronbach's Alpha was ≥ 0.8. The items from the survey that ranked as 5-completely agree or 4-partially agree by ≥ 80% of participants on the five-point Likert scale were included in the final framework. RESULTS: The final consensus for the Shouldice Method included 39 items with 7 overarching steps: preoperative preparation of the patient, anesthetic component, incision and nerve identification, treatment of the cremasteric muscles, hernia identification and treatment, reconstruction of the posterior wall, and post-operative management of patients. CONCLUSION: The results of this consensus provide a step-by-step approach to the Shouldice Method, as well as information that is timely and can be utilized by surgeons incorporating non-mesh hernia repairs into their practice.

Fournier's gangrene by perianal abscess / Gangrena de Fournier por abscesso perianal

ABSTRACT Objective: To describe and analyze the cases of Fournier's Gangrene caused by perianal abscess treated in a tertiary hospital in western Paraná, correlating possible factors that influence mortality, with emphasis on late diagnosis and therapy. Methods: A retrospective and descriptive case series was carried out based on the analysis of medical records of patients with Fournier's Gangrene due to perianal abscess from January 2012 to December 2017. Results: Thirty-one patients with Fournier's Gangrene due to perianal abscess were treated in the period: 26 men and 5 women. Mean age was 53.51 ± 14.5 years. The most prevalent comorbidity in this group was type 2 diabetes mellitus, showing a strong correlation with mortality. The mean time from disease progression, from the initial symptom to the admission at the service, was 9.6 ± 6.81 days. All patients were submitted to antibiotic therapy and surgical treatment, with a mean of 3.25 ± 2.89 procedures/patient. Seven (22.58%) patients died and all of them showed signs of sepsis on admission; only 2 patients with sepsis did not die. Conclusion: The presence of sepsis on admission and type 2 diabetes mellitus were strongly correlated with mortality.

RESUMO Objetivo: Descrever e analisar os casos de gangrena de Fournier por abscesso perianal atendidos em hospital terciário do oeste do Paraná, correlacionando possíveis fatores que influenciem a mortalidade, com ênfase ao diagnóstico e terapêuticas tardias. Métodos: Realizou-se um estudo de série de casos, retrospectivo e descritivo baseado na análise de prontuários de pacientes portadores de gangrena de Fournier devido a abscesso perianal no período de Janeiro de 2012 à Dezembro de 2017. Resultados: Foram tratados 31 pacientes com gangrena de Fournier por abscesso perianal no período, sendo 26 homens e 5 mulheres. A média de idade foi de 53,51 ± 14,5 anos. A comorbidade de maior prevalência neste grupo foi diabete melitus tipo 2, demonstrando forte correlação com mortalidade. A média do tempo de evolução da doença, do sintoma inicial até entrada no serviço, foi de 9,6 ± 6,81 dias. Todos os pacientes foram submetidos à antibioticoterapia e tratamento cirúrgico com média de 3,25 ± 2,89 procedimentos/paciente. Sete (22,58%) pacientes evoluíram para óbito e todos estes apresentavam sinais de sepse na admissão; apenas 2 pacientes com sepse não evoluíram a óbito. Conclusão: Presença de sepse a admissão e diabete melitus tipo 2 foram fortemente correlacionadas com mortalidade.

Development and application of a swine model for training ultrasonography-guided central venous access.

INTRODUCTION: simulation based teaching is a powerful tool in medical education, allowing hands on practice under a controlled environment and with repeated maneuvers. Central venous access venipuncture is one of the most frequent procedures carried out in the hospital setting, due to its various clinical indications and, when performed with the help of ultrasonography, the risk of adverse events is minimized. Aim: to develop, to describe and to test a porcine model that simulates the central venous access puncture aided by ultrasonography. METHOD: a low cost porcine model was developed to train medical students and residents on central venous access guided by ultrasonography. Both students and medical residents underwent a theoretical training regarding the model, followed by a hands-on training session. Afterwards, the participants assessed the model by answering a questionnaire. RESULTS: there were 51 participants. The average score regarding the similarity between the model and the human anatomy was 9.15. When the characteristics were separately assessed, the mean scores regarding the similarity of the vessels, anatomic disposition and ultrasonographic characteristics as well as the venipuncture were, respectively, 9.27; 9.31; 9.54 and 8.86. CONCLUSION: The model was approved and considered appropriate for the training of central venous venipuncture by all the participants. Furthermore, it is a low cost, simple and reproducible model, that presents high similarity with the human anatomy. Therefore, it may be used as an aid to train people on ultrasonography guided central venous access.

Development and application of a swine model for training ultrasonography-guided central venous access / Desenvolvimento e aplicação de um modelo porcino para treinamento de acesso venoso central guiado por ultrassonografia

ABSTRACT Introduction: simulation based teaching is a powerful tool in medical education, allowing hands on practice under a controlled environment and with repeated maneuvers. Central venous access venipuncture is one of the most frequent procedures carried out in the hospital setting, due to its various clinical indications and, when performed with the help of ultrasonography, the risk of adverse events is minimized. Aim: to develop, to describe and to test a porcine model that simulates the central venous access puncture aided by ultrasonography. Method: a low cost porcine model was developed to train medical students and residents on central venous access guided by ultrasonography. Both students and medical residents underwent a theoretical training regarding the model, followed by a hands-on training session. Afterwards, the participants assessed the model by answering a questionnaire. Results: there were 51 participants. The average score regarding the similarity between the model and the human anatomy was 9.15. When the characteristics were separately assessed, the mean scores regarding the similarity of the vessels, anatomic disposition and ultrasonographic characteristics as well as the venipuncture were, respectively, 9.27; 9.31; 9.54 and 8.86. Conclusion: The model was approved and considered appropriate for the training of central venous venipuncture by all the participants. Furthermore, it is a low cost, simple and reproducible model, that presents high similarity with the human anatomy. Therefore, it may be used as an aid to train people on ultrasonography guided central venous access.

RESUMO Introdução: o ensino baseado em simulação é poderosa ferramenta para o aprendizado na educação médica, permitindo a prática de procedimentos em ambientes controlados e por repetidas vezes. A realização de acesso venoso central é um dos procedimentos médicos mais realizados em ambiente hospitalar, tendo várias indicações e, quando realizada com o auxilio da ultrassonografia, os riscos das complicações do procedimento são minimizados. Objetivo: desenvolver, descrever e aplicar um modelo porcino para simulação de acesso venoso central guiado por ultrassonografia. Métodos: modelo porcino de baixo custo foi desenvolvido para treinamento de acesso venoso central guiado por ultrassonografia. Estudantes de medicina e médicos residentes receberam treinamento teórico em relação ao procedimento, seguido de treinamento prático no modelo. Posteriormente, os participantes avaliaram o modelo desenvolvido por meio de um questionário. Resultados: o estudo contou com 51 participantes. O escore médio de semelhança geral do modelo com a realidade foi 9,15. Quando separadas por características, as médias dos escores de semelhança da imagem dos vasos, da disposição anatômica das estruturas, das características ultrassonográficas e da punção foram, respectivamente, 9,27; 9,31; 9,54 e 8,86. Conclusão: o modelo foi aprovado e considerado útil para treinamento do procedimento por todos os participantes, além de ter baixo custo, ser simples, reprodutível e apresentar alta semelhança com a realidade, podendo ser utilizado como adjunto no treinamento de acesso venoso central guiado por ultrassonografia.

Epidemiology, prognostic factors, and outcome of trauma patients admitted in a Brazilian intensive care unit.

BACKGROUND: Trauma is a major cause of hospital admissions and is associated with manifold complications and high mortality rates. However, data on intensive care unit (ICU) admissions are scarce in developing and low-income countries, where its incidence has been increasing. OBJECTIVES: To analyze epidemiological and clinical factors and outcomes in adult trauma patients admitted to the ICU of a public teaching hospital in a developing country as well as to identify risk factors for complications in the ICU. PATIENTS AND METHODS: Retrospective cohort of adult trauma patients admitted to the general ICU of a public teaching hospital in southern Brazil in the year 2012. Demographic, clinical, and outcome data from the ICU were analyzed. RESULTS: During the study period, 144 trauma patients were admitted (83% male, Acute Physiology and Chronic Health Evaluation Score II =18.6±7.2, age =33.3 years, 93% required mechanical ventilation). Of these, 60.4% suffered a traffic accident (52% motorcycle), and 31.2% were victims of violence (aggressions, gunshot wounds, or stabbing); 71% had brain trauma, 37% had chest trauma, and 21% had abdominal trauma. Patients with trauma presented a high incidence of complications, such as infections, acute renal failure, acute respiratory distress syndrome, and thrombocytopenia. The ICU mortality rate was 22.9%. CONCLUSION: In a Brazilian public teaching ICU, there was a great variability of trauma etiologies (mainly traffic accidents with motorcycles and victims of violence); patients with trauma had a high incidence of complications and mortality in the ICU.

Basic ultrasound training assessment in the initial abdominal trauma screening.

OBJECTIVE: to verify the efficiency and usefulness of basic ultrasound training in trauma (FAST - Focused Assessment with Sonography in Trauma) for emergency physicians in the primary evaluation of abdominal trauma. METHODS: a longitudinal and observational study was carried out from 2015 to 2017, with 11 emergency physicians from Hospital Universitário do Oeste do Paraná, submitted to ultrasound training in emergency and trauma (USET® - SBAIT). FAST results started to be collected two months after the course. These were compared with a composite score of complementary exams and surgical findings. Information was stored in a Microsoft Excel program database and submitted to statistical analysis. RESULTS: FAST was performed in 120 patients. In the study, 38.4% of the assessed patients had a shock index ≥0.9. The composite score detected 40 patients with free peritoneal fluid, whereas FAST detected 27 cases. The method sensitivity was 67.5%, specificity was 98.7%, the positive predictive value was 96.4%, the negative predictive value was 85.39% and accuracy was 88%. All those with a positive FAST had a shock index ≥0.9. Fifteen patients with positive FAST and signs of instability were immediately submitted to surgery. CONCLUSIONS: the basic training of emergency physicians in FAST showed efficiency and usefulness in abdominal trauma assessment. Due to its low cost and easy implementation, this modality should be considered as a screening strategy for patients with abdominal trauma in health systems.

Basic ultrasound training assessment in the initial abdominal trauma screening / Avaliação de treinamento básico em ultrassom na triagem inicial do trauma abdominal

ABSTRACT Objective: to verify the efficiency and usefulness of basic ultrasound training in trauma (FAST - Focused Assessment with Sonography in Trauma) for emergency physicians in the primary evaluation of abdominal trauma. Methods: a longitudinal and observational study was carried out from 2015 to 2017, with 11 emergency physicians from Hospital Universitário do Oeste do Paraná, submitted to ultrasound training in emergency and trauma (USET® - SBAIT). FAST results started to be collected two months after the course. These were compared with a composite score of complementary exams and surgical findings. Information was stored in a Microsoft Excel program database and submitted to statistical analysis. Results: FAST was performed in 120 patients. In the study, 38.4% of the assessed patients had a shock index ≥0.9. The composite score detected 40 patients with free peritoneal fluid, whereas FAST detected 27 cases. The method sensitivity was 67.5%, specificity was 98.7%, the positive predictive value was 96.4%, the negative predictive value was 85.39% and accuracy was 88%. All those with a positive FAST had a shock index ≥0.9. Fifteen patients with positive FAST and signs of instability were immediately submitted to surgery. Conclusions: the basic training of emergency physicians in FAST showed efficiency and usefulness in abdominal trauma assessment. Due to its low cost and easy implementation, this modality should be considered as a screening strategy for patients with abdominal trauma in health systems.

RESUMO Objetivo: verificar a eficiência e a utilidade do treinamento básico em ultrassom no trauma (Focused Assessment with Sonography in Trauma - FAST) para emergencistas, na avaliação primária do trauma abdominal. Métodos: estudo longitudinal, observacional, realizado durante o período de 2015 a 2017, com 11 emergencistas do Hospital Universitário do Oeste do Paraná, submetidos ao treinamento em ultrassom na emergência e trauma (USET® - SBAIT). Resultados dos FAST começaram ser coletados dois meses após o curso. Estes foram comparados com escore composto de exames complementares e achados cirúrgicos. Informações foram armazenadas em banco de dados do programa Microsoft Excel® e submetidas à análise estatística. Resultados: foram realizados FAST em 120 pacientes. No estudo, 38,4% dos pacientes avaliados apresentavam índice de choque ≥0,9. O escore composto detectou 40 pacientes com líquido livre peritoneal. FAST detectou 27 casos de líquido livre peritoneal. A sensibilidade do método foi de 67,5%, a especificidade de 98,7%, o valor preditivo positivo de 96,4%, o valor preditivo negativo de 85,39% e a acurácia foi de 88%. Todos que tiveram FAST positivo apresentavam índice de choque ≥0,9. Quinze pacientes com FAST positivo e sinais de instabilidade foram conduzidos imediatamente para cirurgia. Conclusões: o treinamento básico de emergencistas em FAST demonstrou eficiência e utilidade na avaliação do trauma abdominal. Por seu baixo custo e facilidade de implantação, esta modalidade deve ser considerada como estratégia de triagem de pacientes com trauma abdominal nos sistemas de saúde.

Educational project: low cost porcine model for venous cutdown training / Projeto de ensino: modelo porcino de baixo custo para treinamento de dissecção venosa

ABSTRACT Objective: to describe and evaluate the acceptance of a porcine experimental model in venous cutdown on a medical education project in Southwest of Brazil. Method: a porcine experimental model was developed for training in venous cutdown as a teaching project. Medical students and resident physicians received theoretical training in this surgical technique and then practiced it on the model. After performing the procedure, participants completed a questionnaire on the proposed model. This study presents the model and analyzes the questionnaire responses. Results: the study included 69 participants who used and evaluated the model. The overall quality of the porcine model was estimated at 9.16 while the anatomical correlation between this and human anatomy received a mean score of 8.07. The model was approved and considered useful in the teaching of venous cutdown. Conclusions: venous dissection training in porcine model showed good acceptance among medical students and residents of this institution. This simple and easy to assemble model has potential as an educational tool for its resemblance to the human anatomy and low cost.

RESUMO Objetivo: descrever e avaliar a aceitação de um modelo experimental porcino no aprendizado de dissecção venosa em projeto de educação médica no sudoeste do Brasil. Método: um modelo experimental porcino foi desenvolvido para treinamento em dissecção venosa como projeto de ensino. Estudantes de medicina e médicos residentes receberam treinamento teórico sobre esta técnica cirúrgica e em seguida a praticaram no modelo. Após realizar o procedimento, os participantes preencheram um questionário sobre o modelo proposto. Este estudo apresenta o modelo e analisa as respostas ao questionário. Resultados: o estudo contou com 69 participantes que utilizaram e avaliaram o modelo. A qualidade geral do modelo porcino foi estimada em 9,16 enquanto a correlação anatômica entre este e a anatomia humana recebeu o escore médio de 8,07. O modelo foi aprovado e considerado útil no ensino da dissecção venosa. Conclusão: o treinamento de dissecção venosa em modelo porcino apresentou boa aceitação entre estudantes e residentes de medicina desta Instituição. Este modelo simples e de fácil confecção, tem potencial como instrumento de aprendizado por sua semelhança com a anatomia humana, e baixo custo.

Surgical model pig ex vivo for venous dissection teaching in medical schools.

PURPOSE: To investigate a method for development of surgical skills in medical students simulating venous dissection in surgical ex vivo pig model. METHODS: Prospective, analytical, experimental, controlled study with four stages: selection, theoretical teaching, training and assessment. Sample of 312 students was divided into two groups: Group A - 2nd semester students; Group B - students of 8th semester. The groups were divided into five groups of 12 students, trained two hours per week in the semester. They set up four models to three students in each skill station assisted by a monitor. Teaching protocol emergency procedures training were applied to venous dissection, test goal-discursive and OSATS scale. RESULTS: The pre-test confirmed that the methodology has not been previously applied to the students. The averages obtained in the theoretical evaluation reached satisfactory parameters in both groups. The results of applying OSATS scale showed the best performance in group A compared to group B, however, both groups had satisfactory medium. CONCLUSION: The method was enough to raise a satisfactory level of skill both groups in venous dissection running on surgical swine ex vivo models.

Surgical model pig ex vivo for venous dissection teaching in medical schools

Abstract Purpose: To investigate a method for development of surgical skills in medical students simulating venous dissection in surgical ex vivo pig model. Methods: Prospective, analytical, experimental, controlled study with four stages: selection, theoretical teaching, training and assessment. Sample of 312 students was divided into two groups: Group A - 2nd semester students; Group B - students of 8th semester. The groups were divided into five groups of 12 students, trained two hours per week in the semester. They set up four models to three students in each skill station assisted by a monitor. Teaching protocol emergency procedures training were applied to venous dissection, test goal-discursive and OSATS scale. Results: The pre-test confirmed that the methodology has not been previously applied to the students. The averages obtained in the theoretical evaluation reached satisfactory parameters in both groups. The results of applying OSATS scale showed the best performance in group A compared to group B, however, both groups had satisfactory medium. Conclusion: The method was enough to raise a satisfactory level of skill both groups in venous dissection running on surgical swine ex vivo models.

Hospital costs associated with laparoscopic and open inguinal herniorrhaphy.

PURPOSE: The purpose of this study was to compare the total hospital costs associated with elective laparoscopic and open inguinal herniorrhaphy. METHODS: A prospectively maintained database was used to identify patients who underwent elective inguinal herniorrhaphy from April 2009 to March 2011. A retrospective review of electronic patient records was performed along with a standardized case-costing analysis using data from the Ontario Case Costing Initiative. The main outcomes were operating room (OR) and total hospital costs. RESULTS: Two hundred eleven patients underwent elective unilateral inguinal herniorrhaphy (117 open and 94 laparoscopic), and 33 patients underwent elective bilateral inguinal herniorrhaphy (9 open and 24 laparoscopic). OR and total hospital costs for open unilateral inguinal hernia repair were significantly lower than for the laparoscopic approach (median total cost, $3207.15 vs $3723.66; P < .001). OR and total hospital costs for repair of elective bilateral inguinal hernias were similar between the open and laparoscopic approaches (median total cost, $4574.02 vs $4662.89; P = .827). CONCLUSIONS: In the setting of a Canadian academic hospital, when considering the repair of an elective unilateral inguinal hernia, the OR and total hospital costs of open surgery were significantly lower than for the laparoscopic techniques. There was no statistical difference between OR and total hospital costs when comparing open surgery and laparoscopic techniques for the repair of bilateral inguinal hernias. Given the perioperative benefits of laparoscopy, further studies incorporating hernia-specific outcomes are necessary to determine the cost-effectiveness of each approach and to define the optimal treatment strategy.

Pulmonary emboli after blunt trauma: timing, clinical characteristics and natural history.

BACKGROUND: Venous thromboembolism (VTE) frequently complicates the recovery of trauma patients, and contributes to morbidity and mortality. Recent studies showed an increase in diagnosis of pulmonary embolism (PE) mainly in the early or immediate period after trauma. The clinical significance of those incidental PEs is unclear. METHODS: The study cohort included all blunt trauma patients who had a contrast-enhanced CT of the chest performed as part of their initial trauma assessment from January 1, 2005 to January 31, 2007 in a large academic Canadian trauma centre. Patients diagnosed with PE at any point during admission were identified using our institutional trauma registry. All chest CT scans and electronic charts were reviewed. Patients were classified according to time of PE detection (immediate, early or late) and symptoms (asymptomatic or symptomatic). The clinical characteristics and hospital course of the patients who were diagnosed with immediate PE were described. RESULTS: 1259 blunt trauma patients were reviewed. Six patients presented with immediate PE (0.5%); nine patients were found to have early PE (0.7%) and 13 had late PE (1.0%). All six of the patients with immediate PE were classified as asymptomatic. Five of the nine patients with early PE were symptomatic and all 13 patients who developed late PE were symptomatic. Amongst the six patients with immediate PE, five survived 24h hospitalisation. Four of them were managed with prophylactic low molecular weight heparin and no other thromboembolic events were observed during admission or after discharge. CONCLUSIONS: The increased use of advanced CT technology in trauma patients has resulted in an increased diagnosis of incidental PEs that are asymptomatic. The clinical significance and management of these small, incidental PE are uncertain and further studies are needed to clarify the natural history of this controversial finding.

Temporal distribution of trauma deaths: quality of trauma care in a developing country.

BACKGROUND: Examination of the epidemiology and timing of trauma deaths has been deemed a useful method to evaluate the quality of trauma care. OBJECTIVE: The purpose of this study was to evaluate the quality of trauma care in a regional trauma system and in a university hospital in Brazil by comparing the timing of deaths in the studied prehospital and in-hospital settings to those published for trauma systems in other areas. METHODS: We analyzed the National Health Minister's System of Deaths Information for the prehospital mortality and we retrospectively collected the demographics, timelines, and trauma severity scores of all in-hospital patients who died after admission through the Emergency Unit of Hospital das Clinicas de Ribeirao Preto between 2000 and 2001. RESULTS: During the study period, there were 787 trauma fatalities in the city: 448 (56.9%) died in the prehospital setting and 339 (43.1%) died after being admitted to a medical facility. In 2 years, 238 trauma deaths occurred in the studied hospital, and we found a complete clinical set of data for 224 of these patients. The majority of deaths in the prehospital setting were caused by penetrating injuries (66.7%), whereas in-hospital mortality was mainly because of blunt traumas (59.1%). The largest number of in-hospital deaths occurred beyond 72 hours of stay (107 patients-47%). CONCLUSION: The region studied showed some deficiencies in prehospital and in-hospitals settings, in particular in the critical care and short-term follow-up of trauma patients when compared with the literature. Particularly, the late mortality may be related to training and human resources deficiency. Based on the timeline of trauma deaths, we can suggest that the studied region needs improvements in the prehospital trauma system and in hospital critical care.

Retrograde urethrocystography impairs computed tomography diagnosis of pelvic arterial hemorrhage in the presence of a lower urologic tract injury.

BACKGROUND: There is controversy about the appropriate sequence of urologic investigation in patients with pelvic fracture. Use of retrograde urethrography or cystography may interfere with regular pelvic CT scanning for arterial extravasation. STUDY DESIGN: We performed a retrospective study at a regional trauma center in Toronto, Canada. Included were adult blunt trauma patients with pelvic fractures and concomitant bladder or urethral disruption who underwent initial pelvic CT before operation or hospital admission. Exposure of interest was whether retrograde urethrography (RUG) and cystography were performed before pelvic CT scanning. Main outcomes measures were indeterminate or false negative initial CT examinations for pelvic arterial extravasation. RESULTS: Sixty blunt trauma patients had a pelvic fracture and either a urethral or bladder rupture. Forty-nine of these patients underwent initial CT scanning. Of these 49 patients, 23 had RUG or conventional cystography performed before pelvic CT scanning; 26 had cystography after regular CT examination. Performing cystography before CT was associated with considerably more indeterminate scans (9 patients) and false negatives (2 patients) for pelvic arterial extravasation (11 of 23 versus 0 of 26, p < 0.001) compared with performing urologic investigation after CT. In the presence of pelvic arterial hemorrhage, indeterminate or false negative CT scans for arterial extravasation were associated with a trend toward longer mean times to embolization compared with positive scans (p=0.1). CONCLUSIONS: Extravasating contrast from lower urologic injuries can interfere with the CT assessment for pelvic arterial extravasation, delaying angiographic embolization.