Fluorescent Cholangiography in Laparoscopic Cholecystectomy: An Updated Canadian Experience.

Background. Laparoscopic cholecystectomy (LC) is one of the most common general surgery procedures in Canada with approximately 100 000 cases performed per year. Bile duct injury remains a morbid complication with an incidence rate of 0.3% to 0.5%. Indocyanine green (ICG) fluorescent cholangiography is a noninvasive technology aiding in real-time identification of biliary structures for safe dissection within Calot's triangle. The objectives were to provide an update to our initial experience with ICG aiding in the identification of biliary structures and ensuring that no adverse patient reactions occurred with ICG administration. Methods. Prospective case series from 2016 to 2018 for elective LC with ICG technology performed at a single academic teaching institution. Patient demographics, indications for operation, biliary structures visualized, amount of ICG used, operative times, and complications were recorded. Results. One hundred eight cases were included for review. The cystic duct, common hepatic duct, and common bile duct were identified with ICG in 90%, 48%, and 84% of cases, respectively. ICG simultaneously visualized at least 2 of 3 biliary structures 83.4% of the time. Only 1 biliary structure was identified in 10% of cases. No biliary structures were identified in 6% of cases. Mean initial ICG dose given was 1.65 mL. No adverse patient reactions to ICG were noted. Conclusions. This updated series illustrates that administration of ICG enhances visualization of the biliary system during outpatient LC. ICG is safe and its application should be further studied in early LC for acute cholecystitis.

Use of safety scalpels and other safety practices to reduce sharps injury in the operating room: what is the evidence?

BACKGROUND: The occupational hazard associated with percutaneous injury in the operating room (OR) has encouraged harm reduction through behaviour change and the use of safety-engineered surgical sharps. Some Canadian regulatory agencies have mandated the use of "safety scalpels." Our primary objective was to determine whether safety scalpels reduce the risk of percutaneous injury in the OR, while a secondary objective was to evaluate risk reduction associated with other safety practices. METHODS: We used evidence review methods described by the International Liaison Committee on Resuscitation and conducted a systematic, English-language search of Ovid, MEDLINE and EMBASE using the following search terms: "safety-engineered scalpel," "mistake proofing device," "retractable/removable blade/scalpel," "pass tray," "hands free passing," "neutral zone," "sharpless surgery," "double/cutproof gloving" and "blunt suture needles." Included articles were scored according to level of evidence; quality; and whether they were supportive, opposed or neutral to the study question(s). RESULTS: Of 72 included citations, none was supportive of the use of safety scalpels. There was high-level/quality evidence (Cochrane reviews) in support of risk reduction through double-gloving and use of blunt suture needles, with additional evidence supporting a pass tray/neutral zone for sharps handling (4 of 5 articles supportive) and use of suturing adjuncts (1 article supportive). CONCLUSION: There is insufficient evidence to support regulated use of safety scalpels. Injury-reduction strategies should emphasize proven methods, including double-gloving, blunt suture needles and use of hands-free sharps transfer.

CONTEXTE: Les risques professionnels associés aux lésions percutanées subies à la salle d'opération ont favorisé la réduction des préjudices grâce à des changements de comportement et à l'utilisation d'aiguilles et de lames chirurgicales conçues en fonction de la sécurité. Certaines agences de réglementation du Canada ont imposé l'utilisation de « scalpels de sécurité ¼. Nous voulions déterminer principalement si les scalpels de sécurité réduisent le risque de lésions percutanées à la salle d'opération et, dans un deuxième temps, évaluer la réduction du risque associée à d'autres mesures de sécurité. MÉTHODES: Nous avons utilisé des méthodes d'examen des données probantes décrites par le Comité international de liaison sur la réanimation et procédé à une recherche systématique en anglais dans les bases de données Ovid, MEDLINE et EMBASE en utilisant les termes de recherche suivants : « safety-engineered scalpel ¼, « mistake proofing device ¼, « retractable/removable blade/scalpel ¼, « pass tray ¼, « hands free passing ¼, « neutral zone ¼, « sharpless surgery ¼, « double/cutproof gloving ¼ et « blunt suture needles ¼. Nous avons évalué les articles inclus en fonction du niveau de preuve, de la qualité et de la prise de position en faveur des questions à l'étude, contre celles ci ou neutre. RÉSULTANTS: Sur 72 citations incluses, aucune n'appuyait l'utilisation des scalpels de sécurité. Des éléments probants de haut niveau ou de grande qualité (examens Cochrane) appuyaient la réduction des risques par le port de doubles gants et l'utilisation d'aiguilles émoussées, et d'autres éléments de preuve appuyaient l'utilisation d'un plateau de transition ou d'une zone neutre pour la manipulation des aiguilles ou des lames (4 articles sur 5 en faveur) et l'utilisation de moyens auxiliaires de suture (1 article en faveur). CONCLUSIONS: Il n'y a pas suffisamment de preuves pour appuyer l'utilisation réglementée de scalpels de sécurité. Les stratégies de réduction des traumatismes devraient mettre l'accent sur les méthodes éprouvées, y compris le port de doubles gants, l'usage d'aiguilles émoussées et l'utilisation de moyens mains libres de transfert des aiguilles et des lames.

Intersectionality of Gender and Visible Minority Status Among General Surgery Residents in Canada.

Importance: Within medical specialties, surgical disciplines disproportionately and routinely demonstrate the greatest underrepresentation of women and individuals from racial/ethnic minority groups. Understanding the role that diversity plays in surgical resident training may identify strategies that foster resident resiliency, optimize surgical training, and improve patient outcomes. Objective: To examine the implication of gender and visible minority (VM [ie, nonaboriginal people who are not White individuals]) status for resiliency and training experiences of general surgery residents in Canada. Design, Setting, and Participants: In this survey study, a 129-item questionnaire was emailed from May 2018 to July 2018 to all residents enrolled in all Canadian general surgery training programs during the 2017-2018 training year. Survey responses were extracted and categorized into 5 major themes. The survey was designed by the Resident Committee and reviewed by the Governing Board of the Canadian Association of General Surgeons. French and English versions of the survey were created, distributed, and administered using Google Forms. Main Outcomes and Measures: Survey questions were formulated to characterize resident diversity and training experience. Self-perceptions of diversity, mentorship, and training experience were evaluated using a 5-point Likert scale (1 for strongly disagree, 2 for disagree, 3 for neither agree or disagree, 4 for agree, and 5 for strongly agree) and open-ended responses. The frequency of perceived unprofessional workplace encounters was evaluated using a 5-point scale (1 for daily, 2 for weekly, 3 for monthly, 4 for annually, and 5 for never). Results: Of the 510 general surgery residents invited, a total of 210 residents (40.5%) completed the survey. Most respondents were younger than 30 years (119 [56.7%]), were women (112 [53.3%]), reported English as their first language (133 [63.3%]), did not identify as a VM (147 [70.0%]), had no dependents (184 [87.6%]), and were Canadian medical graduates (178 [84.8%]). Women residents who identified as VM compared with male residents who did not identify as a VM were less likely to agree or strongly agree that they had a collegial relationship with staff, (21 [63.6%] vs 61 [89.7%]; P = .01), to feel like they fit in with their training programs (21 [63.6%] vs 56 [82.3%]; P = .003), and to feel valued at work (15 [45.4%] vs 47 [69.1%]; P = .03). Both female residents and female residents who identified as VM described significant concerns about receiving fewer training opportunities because of their gender vs their male peers (54 [48.2%] vs 3 [3.0%]; P < .001). Ninety-one of 112 female residents (81.2%) reported feeling that their medical expertise was dismissed because of their gender at least once annually, with 37 women (33.0%) experiencing dismissal of their expertise at least once every week (P < .001). In contrast, 98% of male residents reported never experiencing dismissal of their medical expertise because of their gender. Similarly, residents with VM status vs those without VM status reported at least monthly dismissal of their expertise because of their race/ethnicity (9 of 63 [14.3%] vs 1 of 147 [0.7%]; P < .001). Conclusions and Relevance: In this study, female sex and VM status appeared to be associated with adverse implications for the training experience of general surgery residents. These findings suggest that new strategies focused on the intersectionality of gender and race/ethnicity are needed to improve the training experience of at-risk residents.