The impact of cholecystectomy on the symptom relief and quality of life of patients with gallbladder dysmotility.

BACKGROUND: The aim of this study was to demonstrate the impact of laparoscopic cholecystectomy on the physical and mental health of patients with gallbladder dysmotility. METHODS: Retrospective data was collected from 314 patients who had undergone a hepatobiliary iminodiacetic acid (HIDA) scan between June 2012 and June 2022 in a District General Hospital in South East England. Sixty-three patients who were diagnosed with gallbladder dysmotility were then contacted and asked to participate in a telephone interview regarding their symptoms. We measured their health-related quality of life using the HRQoL SF-12 v2 (Health Related Quality of Life Short Form-12 version 2) questionnaire. Differences in the resolution of symptoms between those that had undergone a cholecystectomy and those who did not, were assessed using a chi square test. The two groups were then compared using the student t-test to assess statistically significant differences. RESULTS: 94% (n = 31/33) of the participants in the non-cholecystectomy group demonstrated persistent biliary pain symptoms as opposed to the 6% (n = 2/30) in the cholecystectomy group. A statistically significant improvement in five out of the eight domains of the HRQoL SF-12 questionnaire was demonstrated. These domains include PCS (physical component summary), MCS (mental component summary), mental health, general health and bodily pain. CONCLUSION: The results of our retrospective analysis demonstrate an improvement in both the physical and mental health-related quality of life symptoms in patients who underwent laparoscopic cholecystectomy. These findings support the use of laparoscopic cholecystectomy as an effective method for managing gallbladder dysmotility.

Surgical experience and identification of errors in laparoscopic cholecystectomy.

BACKGROUND: Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. METHODS: Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. RESULTS: Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). CONCLUSION: This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.

'Hot gall bladder service' by emergency general surgeons: Is this safe and feasible?

BACKGROUND: Despite NICE/AUGIS recommendations, the practice of early laparoscopic cholecystectomy (ELC) has been particularly poor in the UK offered only by 11%-20% surgeons as compared to 33%-67% internationally, possibly due to financial constraints, logistical difficulties and shortage of expertise, thus, reflecting the varied provision of emergency general surgical care. To assess whether emergency general surgeons (EGS) could provide a 'Hot Gall Bladder Service' (HGS) with an acceptable outcome. PATIENTS AND METHODS: This was a prospective HGS observational study that was protocol driven with strict inclusion/exclusion criteria and secure online data collection in a district general hospital between July 2018 and June 2019. A weekly dedicated theatre slot was allocated for this list. RESULTS: Of the 143 referred for HGS, 86 (60%) underwent ELC which included 60 (70%) women. Age, ASA and body mass index was 54* (18-85) years, II* (I-III) and 27* (20-54), respectively. 86 included 46 (53%), 19 (22%), 19 (22%) and 2 (3%) patients presenting with acute calculus cholecystitis, gallstone pancreatitis, biliary colic, and acalculus cholecystitis, respectively. 85 (99%) underwent LC with a single conversion. Grade of surgical difficulty, duration of surgery and post-operative stay was 2* (1-4) 68* (30-240) min and 0* (0-13) day, respectively. Eight (9%) required senior surgical input with no intra-operative complications and 2 (2%) 30-day readmissions. One was post-operative subhepatic collection that recovered uneventfully and the second was pancreatitis, imaging was clear requiring no further intervention. CONCLUSION: In the current climate of NHS financial crunch, COVID pandemic and significant pressure on inpatient beds: Safe and cost-effective HGS can be provided by the EGS with input from upper GI/HPB surgeons (when required) with acceptable morbidity and a satisfactory outcome. *Median.

Evaluation of a Novel Laparoscopic Cholecystectomy Curriculum With the Use of Animal Models and Live Operating.

BACKGROUND: Despite wide recognition of the benefits of simulation training, there is no established model for the teaching of laparoscopic cholecystectomy. The authors developed a replicable, intensive 2-day proficiency-based curriculum, to include simulation and live operating, designed to be practical to both attend and organize. The primary objective of this study was to evaluate this curriculum for improved procedural confidence, measured by participant self-evaluation. Secondary outcomes were objective improvement in technical skills in accordance with the Objective Structured Assessment of Technical Skills (OSATS) scale and trainee self-assessment scores. METHODS: The course consisted of lectures, operating on a sheep hepatobiliary model through a laparoscopic box trainer, and live operating on female patient volunteers. It was attended by eight junior registrars. Precourse data collated included demographic information, experience, and procedural confidence scores using a visual analog scale. Performance on an animal model and live patient was assessed by experts using the OSATS score. Procedural confidence was re-evaluated after each task, as well as self-assessment of speed, accuracy, and overall performance. RESULTS: Procedural confidence scores improved by a mean of 12% (P < 0.001). All trainees demonstrated sustained objective improvement in technical skills (P < 0.001). The overall mean OSATS score increased by 18%. Significant improvement was observed after performing the procedure on an animal model (P < 0.001); however, no further significant improvement was observed with live operating. No significant difference was found on trainee self-assessment scores, in any category. CONCLUSIONS: The study describes a successful curriculum model for the teaching of laparoscopic cholecystectomy, to include procedural and technical skill acquisition, in addition to the refinement and development of procedural confidence. Importantly, this was carried out in a safe environment with direct transferability to the operating theater.

The important role of in-situ simulation in preparing surgeons for the COVID-19 pandemic.

BACKGROUND: Effective training is vital when facing viral outbreaks such as the SARS Coronavirus 2 (SARS-CoV-2) outbreak of 2019. The objective of this study was to measure the impact of in-situ simulation on the confidence of the surgical teams of two hospitals in assessing and managing acutely unwell surgical patients who are high-risk or confirmed to have COVID-19. METHODS: This was a quasi-experimental study with a pretest-posttest design. The surgical teams at each hospital participated in multi-disciplinary simulation sessions to explore the assessment and management of a patient requiring emergency surgery who is high risk for COVID-19. The participants were surveyed before and after receiving simulation training to determine their level of confidence on a Visual Analog Scale (VAS) for the premise stated in each of the nine questions in the survey, which represented multiple aspects of the care of these patients. RESULTS: 27 participants responded the pre-simulation survey and 24 the one post-simulation. The level of confidence (VAS score) were statistically significantly higher for all nine questions after the simulation. Specific themes were identified for further training and changes in policy. CONCLUSION: In-situ simulation is an effective training method. Its versatility allows it to be set up quickly as rapid-response training in the face of an imminent threat. In this study, it improved the preparedness of two surgical teams for the challenges of the COVID-19 pandemic.

Emotional Intelligence Predicts Accurate Self-Assessment of Surgical Quality: A Pilot Study.

BACKGROUND: Self-assessment is fundamental in surgical training. Accuracy of self-assessment is superior with greater age, experience, and the use of video playback. Presently, there is scarce evidence in the literature regarding predictors for a surgical trainee's aptitude for self-assessment. The objective of this study was to investigate whether emotional intelligence or visual-spatial aptitude can predict effective self-assessment among novice surgeons performing laparoscopic appendectomy (LA). MATERIALS AND METHODS: Eighteen novice trainees performed a simulated LA, and two aptitude measures were evaluated: (1) emotional intelligence questionnaire and (2) visual spatial ability test. Self-assessment of their performance was conducted using the Objective Assessment of Surgical and Technical Skills global rating scale and ranking five subtasks of the procedure in order of quality of performance after watching a playback of their LA. Two blinded experts (senior consultant surgeons, performed >100 LAs) assessed surgical quality using the same scoring system. Candidates were ranked into higher and lower aptitude groups for the two aptitude measures. Spearman's rank correlation coefficient was calculated to identify if either of the two groups demonstrated greater agreement between self and expert assessment in relation to the two aptitude measures. RESULTS: Participants with a higher degree of emotional intelligence demonstrated significant agreement with expert assessment (r = 0.73, P = 0.031). CONCLUSIONS: Emotional intelligence can predict better self-assessment of surgical quality after performing a simulated LA. This may facilitate early identification of individuals who might require mentoring or guidance with self-assessment as well as contribute to selection criteria.

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.

Right-sided diaphragmatic hernia causing gastric outlet obstruction 1 month after trauma.

Diaphragmatic hernias arising from trauma are rare, and scarcely present in a delayed manner. This case report highlights a case of delayed presentation of a right-sided post-traumatic hernia in a woman in her early 70s following a fall. The aim of this report is to shed light on the diagnostic peculiarities and management. The woman presented with a 3-day history of abdominal pain and coffee-ground vomiting. This followed a fall a month ago. CT confirmed the diagnosis of a gastric outlet obstruction secondary to a right-sided diaphragmatic rupture. At surgery, the herniated abdominal contents were reduced, and the diaphragmatic defect was fixed. The postoperative recovery was unremarkable, and the patient was discharged on day 4. This case highlights that diaphragmatic hernias should be considered as differential diagnoses following recent trauma.

Accuracy of Self-Estimated BMI in the Context of Telephone Assessment Before Elective General Surgery.

Background This study aimed to determine if self-estimated body mass index (BMI) from telephone consultation was accurate and useful for surgical planning prior to elective general surgery. Methods A prospective cohort study was performed under a single surgeon at a district general hospital in the United Kingdom. Estimated BMI was collected from consecutive patients attending a pre-operative telephone consultation. Actual BMI was measured on the day of surgery and compared. Patient age and gender were also collected. Results Data were collected from 124 participants (median age 59 years, 49.2% male). A total of 33 participants under-estimated, 53 over-estimated, and 38 accurately estimated their BMIs. The median change in BMI was 0.0 (IQR -0.1, 0.3, p = 0.003). The median change in males was 0.0 (-0.1, 0.2, p = 0.479) compared to 0.1 (0.0, 0.7, p = 0.002) in females. Those with an actual BMI > 29.9 had a significantly higher median change (0.2 {0.0, 1.1}) compared to those with BMI ≤ 29.9 (0.0 {-0.2, 0.1}; p <0.001). Only two patients could have required a change in surgeon on the day of the procedure and this was not statistically significant (p = 0.500). Conclusions Self-estimated BMI, collected via telephone consultation, is a suitable method for assessing patients for surgical planning ahead of elective general surgery procedures, particularly for males. However, it is important to be aware that those with higher BMIs, particularly females, may underestimate their BMIs.

Patient satisfaction with general surgery telephone consultations during the COVID-19 pandemic: a single surgeon experience.

BACKGROUND: COVID-19 pandemic accelerated the development and use of telemedicine in surgical practice. Here we set out to understand patient satisfaction with the use of telephone consultation in the general surgical clinic and preference over face-to-face consultation. METHODS: A prospective cohort study was carried out for consecutive patients seen in a general surgery telephone clinic by a single surgeon in a district general hospital in the UK from 1st September 2021 to 10th March 2022. Demographic data was collected from electronic patient records. At the end of the consultation patients were asked to: 1) score their satisfaction with the telephone consultation on a 5-point Likert Scale; and 2) whether they preferred telephone consultations to face-to-face appointments. It was noted if a patient required a further face-to-face consultation in addition to the telephone consultation. RESULTS: The study included 245 patients who were reviewed by telephone consultation. Most patients (59.6%; N.=146) gave the telephone consultation the highest satisfaction score with a further 31% (N.=76) scoring it as a 4 out of 5. Only 2.8% of patients said they would have preferred a face-to-face consultation and gave a median satisfaction score of 2 (IQR 2-3) compared to 5 (IQR 4-5) in those who preferred telephone consultations (P<0.001). CONCLUSIONS: Telemedicine is associated with high levels of patient satisfaction regardless of patient age or gender. Lower rates of satisfaction are associated with the need for further face-to-face follow-up. If telemedicine is to remain a permanent part of surgical practice, disease specific protocols for its use are required.

Dysphagia due to spontaneous hyperinflation of a swallowable intragastric balloon.

A 49-year-old woman presented as an acute admission with persistent vomiting and an inability to tolerate both solids and liquids. Five weeks prior to the admission she had an Elipse swallowable intragastric balloon placed into her stomach as an aid to weight loss. This type of balloon stays inflated inside the stomach for 16 weeks before disintegrating and passing through the gastrointestinal tract. Observations and blood parameters were unremarkable but abdominal radiograph indicated that the balloon had undergone spontaneous hyperinflation-a rare complication. At gastroscopy, the balloon was found to fill the entire stomach volume causing dysphagia. The balloon was punctured endoscopically, contents suctioned and remnants retrieved through the gastroscope. The patient commenced oral intake the following day and was discharged home with no further symptoms at 12-week follow-up.

Outcomes on mesh fixation vs non-fixation in laparoscopic totally extra peritoneal inguinal hernia repair: a comparative study.

OBJECTIVES: Inguinal hernia repair is one of the most common general surgical procedure, and laparoscopic approach gained popularity over the open approach. This study aimed to compare the clinical effects of TEP inguinal hernioplasty with or without mesh fixation. The primary outcome was acute post-operative pain. MATERIAL AND METHODS: A retrospective comparative study on a prospectively collected data was conducted in a large DGH in England between Janu- ary 2017 and December 2019 on 47 patients. The patients were divided into two groups. In group A, mesh fixation was performed with absorbable tackers and in group B no fixation was performed. Patients were followed up to 18 months postoperatively. Data was collected on post-operative pain, cost, recurrences and time taken to return to normal activities. Patients with lower midline scar and complicated inguinal hernias were excluded. RESULTS: Out of the 47 patients 53% (n= 25) were in group A and 47% (n= 22) in group B. All the patients in both groups were male. The mean postopera- tive pain score at 72h in group A was 7.12 (SD 1.13) and 4.91 (SD 1.23) in group B (p <0.001). Group B patients have taken shorter time to return to normal activities in comparison to group A (p <0.001), while recurrence (2%) rate is higher in group B (p> 0.05). CONCLUSION: Pain and time taken to return to normal work postoperatively were significantly less in the non-fixation group. The study recommends non-fixation over fixation as it is feasible, cost-effective, causes less post-operative pain and no differences in terms of recurrences.

Unusual fistula demonstrating the need for an early cholecystectomy.

A 79-year-old man developed a spontaneous cholecystocutaneous fistula 12 months after an initial episode of acute cholecystitis. A laparoscopic cholecystectomy procedure was twice abandoned due to extensive adhesions and active disease, limiting safe dissection of Calot's triangle. Abdominal collections formed and a spontaneous cholecystocutaneous fistula developed. Imaging revealed an 11 cm calculus and erosion of the fundus of the gall bladder through the sheath. Definitive management was achieved with a laparoscopic assisted open cholecystectomy.

Perceived barriers to medical leadership training and methods to mitigate them in the undergraduate medical curriculum: A mixed-methods study of final-year medical students at two medical schools.

INTRODUCTION: Effective leadership is vital for high-quality healthcare. Despite progress in leadership development for junior doctors, studies reflect perceptions that junior doctors feel underprepared for leadership. This study aims to understand medical students' perceptions about barriers to effective leadership training and how to mitigate these. METHODS: This was a mixed-methods study utilising focus group interviews structured using four trigger questions. Qualitative narrative responses underwent quantitative inductive coding applied by two independent coders. Commonly occurring codes underwent thematic analysis to understand underpinning themes. RESULTS: Thirty-one students were interviewed from King's College London (n=24) and St George's, University of London (n=7). Cohen's kappa statistic of inter-rater reliability was 0.73. The priority areas were the equity of teaching, implemented approaches and methods of assessing competency. The study presents a driver diagram summarising findings. CONCLUSION: This study presents medical students' perceptions about barriers to effective leadership training in current undergraduate curriculum and interventions to mitigate these.

Self-Assessment of Surgical Skills: A Systematic Review.

OBJECTIVE: Self-assessment is fundamental in surgical training to enhance learning in the absence of trainer feedback. The primary objective of this review was to assess the factors that influence accuracy of self-assessment at technical skills across all surgical specialties. The secondary objective was to assess whether there are any innate factors or attributes to predict those that will carry out effective self-assessment. DESIGN: A systematic review was carried out in accordance with PRISMA guidelines. A search strategy encompassing MEDLINE, EMBASE, ERIC, WHO, and the Cochrane database was conducted to identify studies investigating self-assessment at any surgical task. Quality was assessed using the Newcastle-Ottawa scale. A summary table was created to describe specialty, participants, task, setting, assessment tool, and correlation coefficient between self and expert assessment. The review protocol was registered in PROSPERO. RESULTS: Of 24,638 citations, 40 met inclusion criteria. In total 1753 participants performed 68 procedures. Twenty-six studies investigated skills in general surgery with the remaining 14 in various other surgical specialties. Accuracy of self-assessment is superior in those with greater experience and age, and with use of retrospective video playback. Accuracy tends to be reflected by overestimation of performance. Stressful environments reduce accuracy. There is limited evidence in the literature regarding predicting traits for those who will carry out accurate self-assessment. CONCLUSIONS: The ability to perform accurate self-assessment is an important skill in surgical training, with accuracy being influenced by a multitude of factors. The use of self-assessment from retrospective video playback may be of benefit in surgical training curricula to enhance learning of technical skills. Further studies are required to define predictors of good self-assessment, which will strengthen recruitment and mentoring to assist trainee learning.

Introducing a reserve waiting list initiative for elective general surgery at a District General Hospital.

Cancelled operations represent a significant burden on the National Health Service in terms of theatre efficiency, financial implications and lost training opportunities. Moreover, they carry considerable physical and psychological effects to patients and their relatives. Evidence has shown that up to 93% of cancelled operations are due to patient-related factors. An analysis at our District General Hospital revealed that approximately 18 operations are cancelled on the day of surgery each month. This equates to 27 hours of allocated operating time valued by the trust as £67 500, not being used effectively. This retrospective quality improvement report aims to reduce unused theatre time due to cancelled elective operations in general surgery theatres-thereby improving theatre efficiency and patient care. To ascertain the baseline number of cancelled operations, an initial review of theatre cases was undertaken. Further review was then completed after implementation of two improvements-a short notice surgical waiting list and fast track pre-assessment clinics. The results showed that implementation of the reserve surgical waiting list reduced unused operating time by an average of 2.25 hours per month. By further adding in the fast track preassessment clinic, these figures increased to an average of 11.5 hours over the next 3 months. This precipitated a reutilisation of otherwise wasted theatre time. Economic impact of this time amounts around £28 750 a month, after implementation of both improvements. Simple protocol changes can lead to large improvements in the efficient running of theatres. The resultant change has improved patient satisfaction, led to greater training opportunities and improved theatre efficiency. Extrapolation of our results show better usage of previously underused theatre time, to the equivalent worth of £345 000. Further implementation of these improvements in other surgical specialities and hospitals would be beneficial.

Validation of a virtual reality laparoscopic appendicectomy simulator: a novel process using cognitive task analysis.

BACKGROUND: Virtual reality (VR) simulation is a vital component of surgical training with demonstrated improvements in surgical quality and clinical outcome. AIMS: To validate the LAP Mentor (Simbionix™) laparoscopic appendicectomy (LA) VR simulator with inclusion of a novel tool, Cognitive Task Analysis (CTA). METHODS: Thirty-two novices and nine experienced surgeons performed two simulated LAs. An expert-consensus questionnaire guided face validity assessment. Content validity was assessed using CTA-derived questions encompassing eight operative steps and four decision points. Construct validity was evaluated using dexterity metrics, masked assessment of surgical quality using the OSATS global rating scale, and mental workload from two validated tools: the NASA-TLX and SMEQ. Ten novices performed eight further LAs for learning curve assessment. RESULTS: Face validity was demonstrated across all domains. Considering content validity, the essential technical and non-technical steps were evident. The experienced group performed the procedure quicker (median time 361 vs. 538 s, P = 0.0039) with fewer total movements (426 vs. 641, P < 0.0001) and shorter idle time (131 vs. 199 s, P = 0.0006). This correlated with higher OSATS scores (median 33.5 vs. 22.2, P < 0.0001) and lower mental demand (NASA-TLX: 9.0 vs. 13.75, P = 0.012; SMEQ: 60 vs. 80, P = 0.0025), indicating construct validity. Learning curve data showed statistically significant improvements after the 7th session for procedure time, total movements and idle time, which correlated with reduction in mental demand. CONCLUSIONS: The LAP Mentor demonstrates face, content and construct validity for LA; thus, it can be used as an effective tool in surgical training. Task repetition leads to achievement of expert benchmarks.

Penetrating trauma causing cerebrospinal fluid leak without nerve root damage.

A 19-year-old man with a stab injury to the lower back presented with no focal neurology or haemodynamic instability. He complained of a headache that was improved by lying flat and underwent imaging to look for damage to local structures. He was found to have air in his intraspinal space. Initially this case was managed conservatively; however, 2 weeks after discharge, he presented with cerebrospinal fluid leak from his wound. This was managed with neurosurgical intervention and watertight closure of fascia. There were no further complications.