Building a sustainable clinical academic workforce to meet the future healthcare needs of Australia and New Zealand: report from the first summit meeting.

The delivery of healthcare that meets the requirements for quality, safety and cost-effectiveness relies on a well-trained medical workforce, including clinical academics whose career includes a specific commitment to research, education and/or leadership. In 2011, the Medical Deans of Australia and New Zealand published a review on the clinical academic workforce and recommended the development of an integrated training pathway for clinical academics. A bi-national Summit on Clinical Academic Training was recently convened to bring together all relevant stakeholders to determine how best to do this. An important part understood the lessons learnt from the UK experience after 10 years since the introduction of an integrated training pathway. The outcome of the summit was to endorse strongly the recommendations of the medical deans. A steering committee has been established to identify further stakeholders, solicit more information from stakeholder organisations, convene a follow-up summit meeting in late 2015, recruit pilot host institutions and engage the government and future funders.

Laparoscopic cholecystectomy: the missed diagnosis.

BACKGROUND: All 534 laparoscopic cholecystectomies performed by five surgeons at a single institution over a 3-year period were reviewed as part of a quality assurance process. The aim of the review, which has previously been published in this journal, was to identify and quantify complications of the procedure. Five cases in this series were recognized where major intra-abdominal pathology not identified at the time of laparoscopic cholecystectomy required laparotomy shortly thereafter. These five cases are reported here because there has been little discussion in the literature of this problem associated with laparoscopic cholecystectomy. METHODS: The records of all 534 patients having a laparoscopic cholecystectomy between October 1990 and September 1993 were reviewed and entered into a computer database (Microsoft Access). This data collection and recording have subsequently become an ongoing process of quality assurance. RESULTS: Five of 534 patients treated by laparoscopic cholecystectomy failed to have resolution of their symptoms postoperatively. A laparotomy was subsequently required within 3-12 months which demonstrated causative pathology present, but not detected at, the time of laparoscopic cholecystectomy. Where possible, treatment of these laparotomy findings resolved the initial presenting symptoms of colicky epigastric pain. CONCLUSIONS: The rate of 'missed diagnosis' is found to be < 1%. Laparoscopic cholecystectomy is a therapeutic, rather than diagnostic, procedure, and pre-operative discussion should include the possibility of further procedures being required subsequently, particularly when symptoms and signs are atypical.

Major vascular injury and laparoscopy.

Iatrogenic vascular trauma is a hazard that must be considered constantly during any laparoscopic procedure. We present a case of vessel penetration presenting as CO2 embolism during insufflation where delayed recognition of the vascular implications of this event led to death from exsanguination. The pattern of laparoscopic vascular injuries in Australia as reported to the Medical Defence Union (UK) and the New South Wales Medical Defence Union is reviewed and compared with previously reported cases of vascular trauma in laparoscopy. Recommendations are made for the diagnosis and most importantly for the prevention of CO2 embolism and major vascular injury at laparoscopy.

Use of the Hasson cannula producing major vascular injury at laparoscopy.

Despite the recent demonstration that vascular lesions occur significantly more frequently in patients having closed rather than "open" laparoscopy, there never has been a published case report of injury to the great vessels associated with the open technique of initial access to the peritoneal cavity at laparoscopy. We present the first two such cases reported, along with a brief review of the literature related to such major vascular injuries (MVI) sustained at laparoscopy. Lacking appreciation of aortic anatomy and intraoperative technical factors contribute to the occurrence of these injuries. Delayed diagnosis and management contribute to poor outcomes. Secondary injury frequently is associated with MVI at laparoscopy.