A combined open and laparoscopic technique for the management of De Garengeot's hernia with acute appendicitis: A case report.

INTRODUCTION: De Garengeot's hernia is a rare type of femoral hernia which describes the vermiform appendix incarcerated within the hernia sac. In this case report we present our case and review the surgical approaches described in the literature. PRESENTATION OF CASE: We present the case of an 84-year-old female with a background of Parkinson's Disease who presented to the emergency department with a five day history of a right-sided groin lump with worsening pain, nausea and reduced appetite. Computed tomography of the abdomen and pelvis revealed an inflamed appendix herniating through the right femoral canal. She had a two staged surgical approach involving an open repair of her femoral hernia followed by laparoscopic appendicectomy. DISCUSSION: Due to its rarity, there is no standard surgical approach to the appendicectomy and femoral hernia repair. Multiple approaches have been described in the literature, however most reports describe a simultaneous femoral hernia repair and appendicectomy. If an additional abdominal incision is required to complete the appendicectomy safely, we advocate the consideration of a hybrid open-laparoscopic approach, particularly in patients such as this with a history of Parkinson's disease. CONCLUSION: Here we highlight the usefulness of combining an open low inguinal approach followed by a laparoscopic appendicectomy.

Systemic adjuvant chemotherapy for cholangiocarcinoma surgery: A systematic review and meta-analysis.

BACKGROUND: The role of adjuvant therapy for biliary tract cancer is not clearly defined with conflicting results demonstrated across nonrandomized and randomized studies. We report a systematic review and meta-analysis to delineate the effect of AT on overall survival. METHODS: Eligible studies were identified from MEDLINE, EMBASE, Cochrane and PubMed. Studies comparing adjuvant chemotherapy or chemoradiotherapy after curative-intent surgery with curative surgery only for biliary tract cancer were included. Data pertaining to tumours of the gallbladder and bile ducts were included. The primary outcome assessed was overall survival. Random-effects meta-analysis was performed, as well as pooling of unadjusted Kaplan-Meier curve data. RESULTS: 35 studies involving 42,917 patients were analysed. There was a significant improvement in overall survival with any adjuvant therapy after surgery compared with surgery only (HR 0.74; 95% CI, 0.67 to 0.83; P < 0.001). There was a significant benefit for adjuvant therapy in those with margin positive surgery (RR, 0.83; 95% CI, 0.77 to 0.91; P < 0.001) and node-positive disease (RR 0.82; 95% CI 0.76 to 0.89; P < 0.001) CONCLUSION: Our review advocates the use of adjuvant therapy in bile duct cancer after curative intent resection. Further prospective studies are needed to determine the optimal regime and timing of an adjuvant approach.

Systematic Review of Virtual Haptics in Surgical Simulation: A Valid Educational Tool?

BACKGROUND: Virtual reality (VR)-based surgical simulation is an expanding and rapidly advancing modality which aims to serve the increasing demand to acquire surgical skills outside the live operating room. Haptic, or "force-feedback" technology in VR simulation is a rapidly developing field, however the role of haptics in surgical education and its efficacy is unclear. METHODS: A systematic literature search was carried out until September 2018 in MEDLINE, Embase, and Cochrane Library using the following keywords: (VR OR VR OR simulation OR simulator) AND (Haptic feedback OR Haptics OR Force feedback) AND (Surgery). All randomized controlled studies comparing VR training with and without haptics were included. PRISMA guidelines were adhered to RESULTS: Eight randomized controlled trials that compare VR training with and without haptics were included and 1 survey study with a total of 215 participants, 116 of which received haptic feedback and 99 were assigned to nonhaptic feedback group. Training tasks included basic proficiency based laparoscopic tasks such as object translocation, cutting, camera navigation, and more complex tasks including diathermy, suturing, dissection, knot tying, and operative maneuvers. Six randomized controlled trials demonstrated that haptic enhanced VR simulation is significantly more effective than without haptics for skill training with a reduced learning curve and faster time to proficiency and task completion, particularly in novice learners. Two studies showed no significant differences in task-assessed parameters between the haptics and nonhaptics cohorts, whereas 1 survey study suggested haptics negatively affected training with decreased realism. CONCLUSION: Haptic feedback has been shown to improve the fidelity, realism and thus the training effect of VR simulators. However, at present haptic simulators are expensive and in a nascent stage and further research as well as cost-benefit analyses of such tools must be considered to determine whether haptics is truly a surgical necessity.

Trends in quality of life reporting for radical cystectomy and urinary diversion over the last four decades: A systematic review of the literature.

Objective: To report the trends in quality of life (QoL) reporting for radical cystectomy (RC) and urinary diversion (UD) over the last four decades, as RC for bladder cancer is associated with significant morbidity and QoL issues. Material and methods: We searched PubMed, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica dataBASE (EMBASE), Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane library for published studies from January 1980 to January 2017 in the English language. We divided the published articles into three time periods: period-1 (1980-1997), period-2 (1998-2007) and period-3 (2008-2017). Results: A total of 85 QoL studies (8417 patients) were identified, of which 3347 (39.8%) patients had an ileal conduit (IC), 1078 (12.8%) had a continent UD (CD), 3264 (38.8%) had a neobladder (NB), and in the remaining 728 (8.6%) the type of UD was not specified. Whilst there were 15, 24 and 41 studies in period-1, period-2 and period-3 respectively, two (13%), 20 (83%) and 37 (90%) used a validated QoL tool; and none, six (25%) and 23 (56%) used a urology specific QoL tool during these three time periods. Similarly, the number of prospective studies increased from one (7%) to four (17%) and 14 (34%) in these three time periods. The proportion of reported IC patients reduced from 65% (784 patients) to 36% (899) and 35% (1664) from period-1 to period-3, whereas the proportion of NB patients increased from 4.5% (54) to 44% (1105) and 44% (2105). Over the last few years there have been QoL studies on laparoscopic and robotic IC and NB UDs. Conclusion: Our review suggests an increasing use of validated, bladder cancer-specific questionnaires with UD-specific constructs. Abbreviations: BCI: Bladder Cancer Index; BDI: Beck Depression Inventory; BIS: Body Image Scale; CD: continent urinary diversion; EORTC QLQ-30C: European Organisation for the Research and Treatment of Cancer Quality of Life 30-item core questionnaire; ERAS: enhanced recovery after surgery; FACT(-BL)(-G)(-VCI): Functional Assessment of Cancer Therapy(-Bladder Cancer)(-General)(-Vanderbilt Cystectomy Index); IC: ileal conduit; NB: neobladder; (HR)QoL: (health-related) quality of life; (RA)RC: (robot-assisted) radical cystectomy; SF-36: 36-item short-form health survey; SIP: Sickness Impact Profile; UD: urinary diversion.

The pre-operative neutrophil-lymphocyte ratio predicts overall and disease-free survival following cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) in patients with pseudomxyoma peritonei of appendiceal origin.

AIM: The neutrophil-lymphocyte ratio (NLR) and other inflammation-based scores have been used as a prognostic tool to predict survival in solid tumours including pseudomyxoma peritonei (PMP). The aim was to evaluate the prognostic value of this marker and risk stratify PMP patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). METHODS: Retrospective analysis was conducted of a prospectively collected database of patients with PMP who underwent CRS and HIPEC between 1994 and 2015. The NLR was calculated by dividing the pre-operative neutrophil count by lymphocyte count. Predicted overall survival (OS) and disease-free interval (DFI) were calculated using a Kaplan-Meier survival model. RESULTS: The study included 699 patients, stratified into four groups as defined by their NLR. Group A: 200 (28.6%) patients (NLR = 0.10-2.00), Group B: 160 (22.8%) patients (NLR = 2.10-2.78), Group C: 184 (26.3%) patients (NLR = 2.79-4.31) and Group D: 155 (22.2%) patients (NLR ≥ 4.32). The median follow-up for this cohort was 36 months. The predicted DFI was 132.2, 113.1, 84.4 and 47.9 months and the OS was 141.1, 117.6, 88.7 and 51.2 months for Groups A, B, C and D, respectively. As the NLR increases, there is a reduction in long-term survival. CONCLUSION: The pre-operative NLR is cost effective and has equivalent prognostic value to pre-operative tumour markers for patients with PMP treated with CRS and HIPEC. The NLR is a reliable tool that may have a role in predicting outcomes following CRS and HIPEC for patients with PMP of appendiceal origin.

Trends of intervention for paediatric stone disease over the last two decades (2000-2015): A systematic review of literature.

OBJECTIVE: To ascertain the publication trends of interventions for paediatric kidney stone disease (KSD) we conducted a systematic review of literature over the last 16 years. PATIENTS AND METHODS: With a rise of paediatric KSD and related interventions, a systematic review using PubMed was done over the last 16 years for all published papers on 'Paediatric stone disease intervention - ureteroscopy (URS), shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), open stone surgery, and laparoscopic stone surgery'. The search was limited to English language articles with a published abstract, whilst case reports, animal and laboratory studies, were excluded. We also analysed the data in two time periods, period-1 (2000-2007) and period-2 (2008-2015). RESULTS: During the last 16-years, 339 papers were published on paediatric stone disease intervention on PubMed. This included papers on URS (95), PCNL (97), SWL (102), open stone surgery (34) and laparoscopic stone surgery (11). During period-1 and period-2 there were 30 and 65 papers on URS, 16 and 81 papers on PCNL, 33 and 60 papers on SWL, nine and 25 papers on open surgery, respectively. When comparing the two periods, there were 92 published papers for all interventions in period-1 and this had risen almost threefold to 247 papers in period-2. CONCLUSIONS: Our systematic review shows that intervention for KSD in the paediatric age group has risen over the last 8 years. Whilst URS, SWL, open surgery and laparoscopic surgery have all doubled, PCNL has risen fivefold reflecting an increase in the new minimally invasive PCNL techniques.

The role of single-shot metronidazole in the prevention of Clostridium difficile infection following ileostomy reversal surgery.

PURPOSE: Symptomatic infection with Clostridium difficile is strongly linked to antibiotic use and rates are higher for colorectal surgery. In February 2015, trust policy for antibiotic prophylaxis of ileostomy reversal surgery was changed from three doses of metronidazole plus cefuroxime to single-dose metronidazole, in a bid to reduce rates of Clostridium difficile infection. METHODS: A retrospective cohort study was conducted at a single, large hospital trust between February 2014 and February 2016, before and after change in antimicrobial policy. Theatre data, clinical notes and pathology results were all reviewed. Outcome data, patient age, gender, length of operation and hospital stay were extracted. RESULTS: One hundred three patients underwent ileostomy reversal surgery between February 2014 and February 2015. All received cefuroxime together with metronidazole at induction of anaesthesia followed by two further post-operative doses as operative prophylaxis. Ninety-six patients underwent ileostomy reversal surgery between February 2015 and February 2016. All received single-dose metronidazole at induction as prophylaxis. Post-operative diarrhoea was significantly reduced in patients given single-dose metronidazole compared with patients managed with multiple dose, dual antibiotic therapy (32 vs 12.5%, P 0.001). Rates of CDI were also significantly reduced in patients given single-dose metronidazole (6.8 vs 1%, P 0.038). CONCLUSIONS: Single-dose, pre-operative metronidazole is effective at reducing post-operative diarrhoea and CDI in ileostomy reversal surgery compared with multiple-dose cefuroxime plus metronidazole. Metronidazole may be effective as a prophylactic antibiotic against CDI in colonic surgery.