Single Incision Laparoscopic Surgery: Feasibility of the Direct Fascial Puncture Technique Without Working Trocars.

Introduction As single-incision laparoscopic surgery (SILS) became popular, many access platforms and techniques emerged. When we initially described the direct fascial puncture (DFP) technique, many suggested it was not practical for three reasons: (1) increased hernia formation, (2) inability to complete operations without instrument changes and (3) insurmountable instrument drag. This study sought to determine whether the technique was a feasible approach by evaluating the outcomes with DFP-SILS in a single surgeon unit. Methods This was a retrospective audit of all consecutive patients who had unselected SILS operations by a single surgeon. For the DFP-SILS operation, a single optical trocar was used at the umbilicus, a second was rail-roaded beside the optical trocar and a third was directly passed across the fascia at the left-lateral extent of the skin wound. We recorded the number of conversions or failed operations and examined the patients routinely after operation to evaluate for incisional herniae. Results There were 50 DFP-SILS operations performed: 37 cholecystectomies, 12 appendectomies and one jejunal resection. The operations were successful in all cases with no conversions or mortality recorded. One patient (2%) developed a superficial surgical site infection after SILS-DFP appendectomy. The therapeutic outcomes were comparable to existing series of multi-port laparoscopy. There were no incisional herniae detected. Conclusion Even in the resource-poor setting, SILS operations are feasible and safe using the DFP technique. The theoretic concerns have not been realized in clinical practice.

Laparoscopic Completion Cholecystectomy: An Audit from the Americas Hepato-Pancreato-Biliary Association (AHPBA) Caribbean Chapter.

Objective Removal of a gallbladder remnant occasionally becomes necessary when retained stones become symptomatic. Although the laparoscopic approach has been described, it is not yet considered the standard of care. We sought to determine the outcomes after completion cholecystectomies in the resource-poor setting within the Caribbean.  Methods We carried out an audit of the databases from all hepatobiliary surgeons in the Anglophone Caribbean. We identified all patients who had completion cholecystectomy over the five-year period from July 1, 2012 to June 30, 2018. Retrospective chart review was performed to extract the following data: patient demographics, diagnoses, presenting complaints, operative details, morbidity, mortality, and clinical outcomes. Descriptive statistics were generated using Statistical Packaging for Social Sciences (SPSS), version 12.0 (SPSS Inc., Chicago IL) Results There were 12 patients who were subjected to laparoscopic completion cholecystectomy for acute cholecystitis (7), severe biliary pancreatitis (3), and chronic cholecystitis (2) secondary to stones in a gallbladder remnant. There were 10 women and two men at a mean age of 47.4 years (range 32-60; standard deviation (SD) +/-7.81; median 48; mode 52) and a mean body mass index (BMI) of 30.8 Kg/M2 (SD +/-3.81; range 26-38; median 29.5). The mean interval between the index operation and the completion operation was 14.8 months (SD +/- 12.3; range 1-48; median 13; mode 18). Five (42%) patients had their original cholecystectomy using the open approach. Five (42%) index operations were done on an emergent basis and the gallbladder remnant was deliberately left behind in three (25%) index operations. The completion cholecystectomies were all completed laparoscopically in 130.5 minutes (SD +/- 30.5; range 90-180, median 125; mode 125) without any conversions or mortality. There were two minor bile leaks that resolved without intervention through an indwelling drain.  Discussion Completions cholecystectomy can be completed via the laparoscopic approach with good outcomes and acceptable morbidity and mortality rates. The patients derive the same advantages as elective cholecystectomies. Therefore, the laparoscopic approach, when performed by hepatobiliary surgeons with advanced laparoscopic expertise in specialized centers, should be the new standard of care.

Reprint of: The Birth of the Caribbean Society of Endoscopic Surgeons - A historical article.

The Caribbean Society of Endoscopic Surgeons (CaSES) is a regional surgical organization that acts as a quality-enhancing body for the Caribbean region. It does so through many activities including an annual regional meeting. In this historical article, the history, purpose and future developments of the organization is outlined.

The birth of the Caribbean Society of Endoscopic Surgeons-A historical article.

The Caribbean Society of Endoscopic Surgeons (CaSES) is a regional surgical organization that acts as a quality-enhancing body for the Caribbean region. It does so through many activities including an annual regional meeting. In this historical article, the history, purpose and future developments of the organization is outlined.

A historical perspective on the introduction of laparoscopic basic surgical training in the Caribbean and factors that contribute to sustainability of such training.

OBJECTIVE: To report the development of minimally invasive training courses and workshops in the Caribbean and specifically the establishment of the Basic Surgical Skills Course of the Royal College of Surgeons of England (RCSEng) in Trinidad with respect to their value toward Surgical laparoscopic or minimally invasive training in the Caribbean. DESIGN: & Methods: The literature written on laparoscopy in the region was reviewed and in particular that related to the minimally invasive training courses provided over the period 2004 to 2019 and the development of laparoscopic surgical training described from a historic perspective. The factors that contribute to sustainability of courses were identified. RESULTS: Laparoscopic surgical training courses were sporadically introduced into the Caribbean over the period 2004 to 2019 in countries including Barbados, Curacao, Guyana, St. Lucia, Jamaica and Trinidad & Tobago. These were timed and closely related to the establishment of the Caribbean College of Surgeons (CCOS) with the help of the Royal College of Surgeons of England. However, the only certified course introduced was the Basic Surgical Skills (BSS) course of the RCSEng into Trinidad in 2012. This has now been established as a recognised overseas centre by the RCSEng and provides the Intercollegiate BSS course annually forming a solid basis for trainees to learn safe surgical and laparoscopic skills prior to commencing formal surgical training. This has resulted in the sustainable development of minimally invasive training in Trinidad in particular. CONCLUSION: Laparoscopic skills courses and workshops have been established in the Caribbean for 15 years beginning circa. 2004 to 2019 and have grown in number and locations throughout the Caribbean. The RCSEng and the CCOS have been instrumental in the development process. Of note, the only recognised overseas training centre for Basic Surgical Skills Course was established in Trinidad & Tobago with the support of the RCSEng and seems to be the main contributor to the successful, regular maintenance of these and other minimally invasive courses in General Surgery, ENT, Gynaecology and other fields on an annual, sustainable basis.

Complications after colorectal surgery without mechanical bowel preparation.

BACKGROUND: The current practice of mechanical bowel preparation (MBP) before colorectal surgery is questionable. Mechanical bowel preparation is unpleasant for the patient, often distressful, and potentially harmful. The results are often less than desired, increasing the risk of contamination. Cleansing the colon and rectum before surgery has never been shown in clinical trials to benefit patients. In animal experiments MBP has a detrimental effect on colonic healing. STUDY DESIGN: To investigate the outcomes of colorectal surgery without MBP, we prospectively evaluated a consecutive series of patients who underwent resection and primary anastomosis of the colon and upper rectum, including emergency operations. One surgeon performed all operations. Endpoints were wound infection, anastomotic failure, and death. Late signs and symptoms that might be secondary to leakage of the anastomosis were considered as an anastomotic failure as well, during a followup of 1 year. RESULTS: Two hundred fifty operations were performed, of which 199 (79.6%) were elective. Colectomies were left-sided in 65.6%. Anastomoses were ileocolic in 32%, colocolic in 20.8%, colorectal intraperitoneal in 34.4%, and extraperitoneal in 12.8%. No patient suffered from fecal impaction. Followup was complete in 97.2%. Eight patients (3.3%; 95% confidence interval [CI]: 1.4-6.4) developed superficial wound infections. In three patients there was leakage from an extraperitoneal colorectal anastomosis, in two of them after hospital discharge. The overall anastomotic failure rate was 1.2% (95% CI: 0.3-3.6). The in-hospital mortality rate was 0.8% (95% CI: 0.1-2.9) and was not related to abdominal or septic complications. CONCLUSION: Mechanical bowel preparation is not a sine qua non for safe colorectal surgery.

Mechanical bowel preparation or not? Outcome of a multicenter, randomized trial in elective open colon surgery.

PURPOSE: Mechanical bowel preparation is common practice in elective colon surgery. In recent literature the value of this procedure is under discussion. To verify the value of mechanical bowel preparation in elective open colon surgery, a randomized clinical trial was conducted. METHODS: During a prospective, multicenter, randomized study, 250 patients undergoing elective open colon surgery were randomized between receiving mechanical bowel preparation with polyethylene glycol (PEG group, 125 patients) and having a normal meal preoperatively (normal meal preoperatively group, 125 patients). Outcome parameters were wound infection with bacterial results of intraoperative swabs and anastomotic leak. RESULTS: In the polyethylene glycol group there were a total of nine wound infections (7.2 percent) and seven anastomotic leaks (5.6 percent) compared with seven wound infections (5.6 percent) (P = 0.61) and six anastomotic leaks (4.8 percent) (P = 0.78) in the normal meal preoperatively group. Bacterial results showed 52 percent sterile subcutis swabs in the PEG group and 63 percent sterile subcutis swabs in the normal meal preoperatively group (P = 0.11). CONCLUSION: In the present study we could not detect a difference in outcome parameters between patients receiving mechanical bowel preparation in elective open colon surgery and patients without preoperative treatment of the bowel. The present study, although underpowered, did not show a difference in the primary outcome of bacterial wound cultures between patients receiving preoperative mechanical bowel preparation and patients receiving no preoperative bowel treatment. We conclude that there may be no need to continue the use of mechanical bowel preparation in elective open colon surgery.