R. Waldron

A 10-Step Intraoperative Surgical Checklist (ISC) for Laparoscopic Cholecystectomy—Can It Really Reduce Conversion Rates to Open Cholecystectomy?

IntroductionThe recent introduction of a Surgical Safety Checklist has significantly reduced the morbidity and mortality of surgery. Such a simple measure that can impact so highly on surgical outcomes causes all surgeons to pause for thought. This paper documents the introduction of a 10-step intraoperative surgical checklist (ISC) to standardize performance, decision-making, and training during laparoscopic cholecystectomy (LC). The checklist’s impact on conversion rates to open cholecystectomy (OC) is presented.MethodsIn 2004, a 10-step ISC was introduced by a single consultant surgeon for the performance of LCs. Data were collected comparing LCs between 1999–2003 (period 1) and 2004–2008 (period 2). Data on sex, age, American Society of Anesthesiology grade, previous abdominal surgery, severity of gallbladder pathology, and conversion to OC were recorded. The chi-squared test with Yates correction was used to compare groups.ResultsIn total, 637 LCs were performed, 277 during period 1 and 360 during period 2. Risk factors for conversion (gender, age, previous abdominal surgery, and severity of gallbladder pathology) were not significantly different in the two periods studied. The overall conversion rate to OC fell significantly in period 2 (p = 0.001). Subgroup analysis also showed a significant reduction in conversion rates in female patients (p = 0.002) and patients with grades III and IV gallbladder disease (p = 0.001).ConclusionsThe introduction of a 10-step ISC was temporally related to reduced conversion rates to OC. The standardization of a frequently performed operation such as a LC that could potentially lead to an impact as great the one we observed warrants further attention in prospective, appropriately designed studies.

Mortality in perforated duodenal ulcer depends upon pre-operative risk: a retrospective 10-year study

IntroductionMost patients presenting with acutely perforated duodenal ulcer undergo operation, but conservative treatment may be indicated when an ulcer has spontaneously sealed with minimal/localised peritoneal irritation or when the patient’s premorbid performance status is poor. We retrospectively reviewed our experience with operative and conservative management of perforated duodenal ulcers over a 10-year period and analysed outcome according to American Society of Anesthesiologists (ASA) score.MethodsThe records of all patients presenting with perforated duodenal ulcer to the Department of Surgery, Mayo General Hospital, between January 1998 and December 2007 were reviewed. Age, gender, co-morbidity, ASA-score, clinical presentation, mode of management, operative procedures, morbidity and mortality were considered.ResultsOf 76 patients included, 48 (44 operative, 4 conservative) were ASA I–III, with no mortality irrespective of treatment. Amongst 28 patients with ASA-score IV/V, mortality was 54.5% (6/11) following operative management and 52.9% (9/17) with conservative management.ConclusionIn patients with a perforated duodenal ulcer and ASA-score I–III, postoperative outcome is uniformly favourable. We recommend these patients have repair with peritoneal lavage performed, routinely followed postoperatively by empirical triple therapy. Given that mortality is equivalent between ASA IV/V patients whether managed operatively or conservatively, we suggest that both management options are equally justifiable.

Higher surgical training opportunities in the general hospital setting; getting the balance right.

BackgroundThe general hospital can play an important role in training of higher surgical trainees (HSTs) in Ireland and abroad. Training opportunities in such a setting have not been closely analysed to date.AimsThe aim of this study was to quantify operative exposure for HSTs over a 5-year period in a single institution.MethodsAnalysis of electronic training logbooks (over a 5-year period, 2007–2012) was performed for general surgery trainees on the higher surgical training programme in Ireland. The most commonly performed adult and paediatric procedures per trainee, per year were analysed.ResultsStandard general surgery operations such as herniae (average 58, range 32–86) and cholecystectomy (average 60, range 49–72) ranked highly in each logbook. The most frequently performed emergency operations were appendicectomy (average 45, range 33–53) and laparotomy for acute abdomen (average 48, range 10–79). Paediatric surgical experience included appendicectomy, circumcision, orchidopexy and hernia/hydrocoele repair. Overall, the procedure most commonly performed in the adult setting was endoscopy, with each trainee recording an average of 116 (range 98–132) oesophagogastroduodenoscopies and 284 (range 227–354) colonoscopies.ConclusionsGeneral hospitals continue to play a major role in the training of higher surgical trainees. Analysis of the electronic logbooks over a 5-year period reveals the high volume of procedures available to trainees in a non-specialist centre. Such training opportunities are invaluable in the context of changing work practices and limited resources.

Beware the ischiorectal abscess.

INTRODUCTION Ischiorectal abscesses have been shown to form sinuses with various deep structures but continuity with the spinal canal is extremely rare. PRESENTATION OF CASE A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches. He had systemic sepsis and resultant coagulapathy (INR 3.4) which precluded investigation of neurological symptoms by lumbar puncture. MRI rectum demonstrated a well circumscribed fluid collection with direct connection to the spinal canal and containing meningeal tissue. It extended inferiorly to the right ischiorectal fossa and abutted the natal cleft. A radiological diagnosis of ischiorectal abscess which had become continuous with a previously existing anterior sacral myelomeningocoele (ASM) was made. He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought. He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically. DISCUSSION Few general surgeons would be faced with acute management of complicated ASM. Paucity of literature made application of evidence based medicine difficult. In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously. Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis). The patient in this case was adamant that he did not consent to definitive surgical intervention. CONCLUSION This case highlights challenges encountered in the management of complicated ASM in a general hospital.