Adrian Harris

Systematic review and meta-analysis of single-incision versus conventional multiport appendicectomy.

The aim of this systematic review and meta‐analysis was to compare clinical outcomes following single‐incision laparoscopic appendicectomy (SILA) and conventional multiport laparoscopic appendicectomy (CLA) for the treatment of acute appendicitis.

Appendiceal faecaliths are associated with right iliac fossa pain

INTRODUCTION There is debate over whether a normal-looking appendix should be removed at diagnostic laparoscopy performed for right iliac fossa (RIF) pain. Faecaliths are associated with appendicitis. This study assessed whether there was an association between the removal of normal appendices containing faecaliths and improvement of symptoms. PATIENTS AND METHODS Analysis of the histology database for all appendicectomies during 2003-2007 with normal histology, noting presence of a faecalith. Retrospective study using a telephone questionnaire for frequency/duration of pre-operative symptoms, postoperative symptom recurrence, re-admission rates and complications. The faecalith-positive (f(+)) group was compared to a similar control group of patients who had a normal appendix removed which did not contain a faecalith (f(-)). RESULTS Out of 203 appendicectomies performed with normal histology, 26 (13%) were f(+). Of these, 21 responded to the questionnaire. Thirty-one consecutive patients with normal histology and no faecalith were identified. A similar proportion in each group presented with three or more episodes of pain prior to appendicectomy (38% f(+); 39% control). Only one (5%) of the f(+) patients had recurring symptoms after the operation, compared with 14 (48%) of the control group (P = 0.0016). Only one (5%) of the f(+) patients underwent further investigations, compared with 11 (36%) of the control group (P < 0.02). None of the f(+) patients were re-admitted, compared to 19% of the control population. There were no significant postoperative complications in either group. CONCLUSIONS Appendiceal faecaliths may be a cause of right iliac fossa pain in the absence of obvious appendiceal inflammation. In this study, the policy of routine removal of a normal-looking appendix at laparoscopy in the absence of any other obvious pathology appeared to be an effective treatment for recurrent symptoms in those cases with a faecalith. Further studies are needed to assess this putative association.

Biliary peritonitis caused by a leaking T-tube fistula disconnected at the point of contact with the anterior abdominal wall: a case report

IntroductionOperations on the common bile duct may lead to potentially serious complications such as biliary peritonitis. T-tube insertion is performed to reduce the risk of this occurring postoperatively. Biliary leakage at the point of insertion into the common bile duct, or along the fistula, can sometimes occur after T-tube removal and this has been reported extensively in the literature. We report a case where the site at which the T-tube fistula leaked proved to be the point of contact between the fistula and the anterior abdominal wall, a previously unreported complication.Case presentationA 36-year-old sub-Saharan African woman presented with gallstone-induced pancreatitis and, once her symptoms settled, laparoscopic cholecystectomy was performed, common bile duct stones were removed and a T-tube was inserted. Three weeks later, T-tube removal led to biliary peritonitis due to the disconnection of the T-tube fistula which was recannulated laparoscopically using a Latex drain.ConclusionThis case highlights a previously unreported mechanism for bile leak following T-tube removal caused by detachment of a fistula tract at its contact point with the anterior abdominal wall. Hepatobiliary surgeons should be aware of this mechanism of biliary leakage and the use of laparoscopy to recannulate the fistula.

Conversion to open cholecystectomy is decreasing

We were surprised to read the assertion by Gurusamy and Davidson in their excellent review of gallstones that there was no difference in rates of conversion to open cholecystectomy after a laparoscopic cholecystectomy between early versus delayed cholecystectomy for acute cholecystitis, being 20% …

Elective “True Day Case” Laparoscopic Inguinal Hernia Repair in a District General Hospital: Lessons Learned from 1000 Consecutive Cases

Introduction Laparoscopic inguinal hernia repair (LIHR) is ideal for day case surgery. It is recommended that at least 70% should be day cases as a measure of cost-effectiveness. The aims of this study were to (i) assess the rate of true day case (TDC) surgery and (ii) identify predictors associated with unexpected overnight stay (UOS). Methods Data was collected prospectively on 1000 consecutive elective LIHR performed in a District General Hospital (DGH) over a 7-year period. Data was collected on baseline patient demographics, ASA grade, and intraoperative details. A multivariate analysis was performed in order to identify predictors of UOS. Results 1000 patients (927 males) underwent elective LIHR. Mean age was 57.3±15.2 years. 915 patients were planned as day case procedures. 822/915 day cases (89.8%) were discharged on the same day and 93 (10.2%) stayed overnight unexpectedly. Patient age, duration of procedure, and patient slot in the operating list were found to be independent predictors (p<0.05) of UOS. Conclusion Our results demonstrate that LIHR is a “true” day case procedure in a DGH. Although some factors associated with UOS cannot be altered, careful patient selection and operating list planning are of paramount importance in order to minimise the burden on healthcare resources.