Characterisation and mitigation of gas leaks at laparoscopy: an international prospective, multi-center cohort clinical trial.

INTRODUCTION: Gas leaks polluting the operating room are common in laparoscopy. Studies defining methods for sensitive leak characterisation and mechanical mitigation in real world settings are, however, lacking. METHODS: Mobile optical gas imagers (both a miniaturised Schlieren system and sensitive tripod-mounted near-infrared carbon dioxide camera (GF343, FLIR)) prospectively defined trocar-related gas leaks occurring either spontaneously or with instrumentation during planned laparoscopic surgery at three hospitals. A boutique Matlab-based analyser using sequential frame subtraction categorised leaks (class 0-no observable leak; class 1-marginally detectable leak; class 2-short-lived plume; class 3-energetic, turbulent jet). Concurrently, the usefulness of a novel vacuum-ring device (LeakTrap™, Palliare, Ireland) designed as a universal adjunct for existing standard laparoscopic ports at both abdominal wall and port valve level was determined similarly in a phase I/11 clinical trial along with the device's useability through procedural observation and surgeon questionnaire. RESULTS: With ethical and regulatory approval, 40 typical patients (mean age 58.6 years, 20 males) undergoing planned laparoscopic cholecystectomy (n = 36) and hernia repair (n = 4) were studied comprising both control (n = 20) and intervention (n = 20) cohorts. Dual optical gas imaging was successfully performed across all procedures with minimal impact on procedural flow. In total, 1643 trocar instrumentations were examined, 819 in the control group (mean 41 trocar instrumentations/procedure) and 824 in the intervention group (mean 41.2 trocar instrumentations/procedure). Gas leaks were detected during 948(62.6%) visualised trocar instrumentations (in 129-7.8%-the imaging was obscured). 14.8% (110/742) and 60% (445/742) of leaks in control patients were class 0 and 3, respectively, versus 59.1% (456/770) and 8.7% (67/772) in the interventional group (class 3 v non-class 3, p < 0.0001, χ2). The Leaktrap proved surgically acceptable without significant workflow disruption. CONCLUSION: Laparoscopic gas leaks can be sensitively detected and consistently, effectively mitigated using straightforward available-now technology with most impact on the commonest, highest energy instrument exchange leaks.

Clinical Experience of a Smart Articulating Digital Device for Transanal Minimally Invasive Surgery.

BACKGROUND: The constrained access associated with transanal minimally invasive surgery has led surgeons to deploy robotic-assisted platforms to offset inherent maneuverability limitations and, perhaps, skills deficits. IMPACT OF INNOVATION: A handheld, powered 5-mm lightweighted laparoendoscopic electromechanical digital device (HandX, HumanXtensions, Israel) with hardware and software components that convert surgical hand movements precisely to the instrument's articulating tip and enable robotic transanal minimally invasive surgery with full tip roticulation for hook diathermy and suturing. TECHNOLOGY, MATERIALS, AND METHODS: After bench and biomedical model training, HandX was used in 3 transanal minimally invasive surgery procedures (2 male patients and 1 female patient, mean age 66.3 years). The rectal lesions averaged 30 mm in maximum dimension and were located posteriorly (n = 2) and laterally (n = 1) a mean of 3 cm from the anal verge. Standard transanal minimally invasive surgery setup and instrumentation (Gelport Path, Applied Medical with Airseal, and Conmed) were used, adding the HandX device for circumferential lesion marking and hemostatic full-thickness excision as well as defect suturing where appropriate. PRELIMINARY RESULTS: All procedures were completed without undue prolongation (operating times <1 hour) despite nuisance hemorrhoidal bleeding in 1 patient. All lesions were fully excised, with 2 being T1 cancers and 1 tubulovillous adenoma with high-grade dysplasia. All patients were discharged within 48 hours postoperatively (1 experienced secondary hemorrhage on postoperative day 5). CONCLUSIONS AND FUTURE DIRECTIONS: HandX capably facilitated endoscopic robot-like instrument movement for transanal minimally invasive surgery without disrupting workflows. With time dedicated to instrument understanding and training, HandX increased dexterity with a small operating room footprint and may offer greater cost-effectiveness than other platforms.

Clinical validation of 3D virtual modelling for laparoscopic complete mesocolic excision with central vascular ligation for proximal colon cancer.

INTRODUCTION: Laparoscopic Complete Mesocolic Excision (CME) with Central Vascular Ligation (CVL) in colon cancer surgery has not been broadly adopted in part because of safety concerns. Pre-operative 3-D virtual modelling (3DVM) may help but needs validation. METHODS: 3DVM were routinely constructed from CT mesenteric angiograms (CTMA) using a commercial service (Visible Patient, Strasbourg, France) for consecutive patients during our CMECVL learning curve over three years. 3DVMs were independently checked versus CTMA and operative findings. CMECVL outcomes were compared versus other patients undergoing standard mesocolic excision (SME) surgery laparoscopically in the same hospital as control. Stakeholders were studied regarding 3DVM use and usefulness (including detail retention) versus CTMA and a physical 3D-printed model. RESULTS: 26 patients underwent 3DVM with intraoperative display during laparoscopic CMECVL within existing workflows. 3DVM accuracy was 96 % re arteriovenous variations at patient level versus CTMA/intraoperative findings including accessory middle colic artery identification in three patients. Twenty-two laparoscopic CMECVL with 3DVM cases were compared with 49 SME controls (age 69 ± 10 vs 70.9 ± 11 years, 55 % vs 53 % males). There were no intraoperative complications with CMECVL and similar 30-day postoperative morbidity (30 % vs 29 %), hospital stay (9 ± 3 vs 12 ± 13 days), 30-day readmission (6 % vs 4 %) and reoperation (0 % vs 4 %) rates. Intraoperative times were longer (215.7 ± 43.9 vs 156.9 ± 52.9 min, p=<0.01) but decreased significantly over time. 3DVM surveys (n = 98, 20 surgeons, 48 medical students, 30 patients/patient relatives) and comparative study revealed majority endorsement (90 %) and favour (87 %). CONCLUSION: 3DVM use was positively validated for laparoscopic CMECVL and valued by clinicians, students, and patients alike.

Ethical perspectives on surgical video recording for patients, surgeons and society: systematic review.

BACKGROUND: Operating-room audiovisual recording is increasingly proposed, although its ethical implications need elucidation. The aim of this systematic review was to examine the published literature on ethical aspects regarding operating-room recording. METHODS: MEDLINE (via PubMed), Embase, and Cochrane databases were systematically searched for articles describing ethical aspects regarding surgical (both intracorporeal and operating room) recording from database inception to the present (the last search was undertaken in July 2022). Medical subject headings used in the search included 'operating room', 'surgery', 'video recording', 'black box', 'ethics', 'consent', 'confidentiality', 'privacy', and more. Title, abstract, and full-text screening determined relevance. The quality of studies was assessed using Centre for Evidence-Based Medicine grading and no formal assessment of risk of bias was attempted given the theoretical nature of the data collected. RESULTS: From 1048 citations, 22 publications met the inclusion criteria, with three more added from their references. There was evident geographical (21 were from North America/Europe) and recency (all published since 2010) bias and an exclusive patient/clinician perspective (25 of 25). The varied methodology (including ten descriptive reviews, seven opinion pieces, five surveys, two case reports, and one RCT) and evidence level (14 level V and 10 level III/IV) prevented meaningful systematic grading/meta-analysis. Publications were narratively analysed for ethical thematic content (mainly education, performance, privacy, consent, and ownership) that was then grouped by the four principles of biomedical ethics of Beauchamp and Childress, accounting for 63 distinct considerations concerning beneficence (22 of 63; 35 per cent), non-maleficence (17 of 63; 27 per cent), justice (14 of 63; 22 per cent), and autonomy (10 of 63; 16 per cent). From this, a set of proposed guidelines on the use of operative data is presented. CONCLUSION: For a surgical video to be a truly valuable resource, its potential benefits must be more fully weighed against its potential disadvantages, so that any derived instruments have a solid ethical foundation. Universal, ethical, best-practice guidelines are needed to protect clinicians, patients, and society.

The impact of ursodeoxycholic acid on gallstone disease after bariatric surgery: a meta-analysis of randomized control trials.

BACKGROUND: Ursodeoxycholic acid (UDCA) is a bile acid that has been shown to reduce the formation of gallstones after significant weight loss. OBJECTIVE: This study aimed to evaluate the impact of UDCA on the incidence of gallstones after bariatric surgery. SETTINGS: An electronic search of PubMed (Medline), Cochrane Central Register of Controlled Studies (CENTRAL), Scopus (Elsevier) databases, EMBASE, CINAHL, Clinicaltrials.gov, and Web of Science. METHODS: A meta-analysis of randomized control trials was performed. The primary outcome was the incidence of gallstones after bariatric surgery. Secondary outcomes included type of operation and time interval to and characteristics associated with gallstone formation. RESULTS: Ten randomized control trials including 2583 patients were included, 1772 patients (68.6%) receiving UDCA and 811 (31.4%) receiving placebo. There was a significant reduction in gallstone formation in patients who received UDCA postoperatively (risk ratio [RR] .36, 95% confidence interval [CI] .22-.41, P < .00001). The overall prevalence of gallstone formation was 24.7% in the control group compared to 7.3% in the UDCA group. A dose of ≤600 mg/day had a significantly reduced risk of gallstone formation compared to the placebo group (risk ratio .35; 95% CI .24-.53; P < .001). The risk reduction was not significant for the higher dose (>600 mg/day) group (risk ratio .30; 95% CI, .09-1.01, P = .05). CONCLUSIONS: UDCA significantly reduces the risk of both asymptomatic and symptomatic gallstones after bariatric surgery. A dose of 600 mg/day is associated with improved compliance and better outcomes regardless of type of surgery. UDCA should be considered part of a standard postoperative care bundle after bariatric surgery.

The impact of huddles on a multidisciplinary healthcare teams' work engagement, teamwork and job satisfaction: A systematic review.

BACKGROUND: Job satisfaction and retention of healthcare staff remains an ongoing issue in many health systems. Huddles have been endorsed as a mechanism to improve patient safety by improving teamwork, collaboration, and communication in teams. AIM: This study aims to synthesises the literature to investigate the impact of huddles on job satisfaction, teamwork, and work engagement in multidisciplinary healthcare teams. METHODS: Five academic databases were searched to conduct a systematic review of peer-reviewed literature published from January 2000 to January 2020. Articles were included if they (1) featured a daily huddle, were conducted in a healthcare setting, and involved a multidisciplinary team and (2) measured variables including job satisfaction, work engagement, or teamwork. Results were reported in accordance with the systematic synthesis without meta-analysis and preferred reporting items for systematic reviews and meta-analysis guidelines. We identified 445 articles of which 12 met the eligibility criteria and are included in this review. RESULTS: All 12 included studies found a predominantly positive impact on teamwork and job satisfaction. None of the studies discussed or reported evidence of the impact of huddles on work engagement. This review highlights the value of a daily multidisciplinary healthcare team huddle in improving job satisfaction and teamwork for the healthcare staff involved. However, there is a dearth of high-quality, peer-reviewed evidence regarding the direct impact of huddles on job satisfaction, teamwork and in particular on work engagement. Further research-particularly controlled studies on adoption, implementation and outcomes for healthcare team culture-is needed to further assess this intervention.

Changing attitudes towards annual influenza vaccination amongst staff in a Tertiary Care Irish University Hospital.

BACKGROUND: Healthcare workers are encouraged annually to get vaccinated against influenza. This year in view of COVID-19 pandemic, attitudes of HCWs towards vaccination are particularly important. A cross-sectional study was completed to understand how to best encourage and facilitate the vaccination of HCWs based on the previous years' findings. METHODS: An online survey was disseminated to all hospital staff via electronic channels. The clinical audit sphinx software was used for data collection and analysis. RESULTS: The total number of responses was n = 728, almost double the rate from 2018 (N = 393). A total of 78% (N = 551) of participants were vaccinated last year. A total of 94% (N = 677) of participants reported their intention to be vaccinated this year. The main barriers listed were being unable to find time (32%, N = 36), side effects (30%, N = 33) and thinking that it does not work (21%, N = 23). The most popular suggestions for how to increase uptake were more mobile immunisation clinics (72%, N = 517) and more information on the vaccine (50%, N = 360). A total of 82% of participants (N = 590) agreed that healthcare workers should be vaccinated, with 56% (N = 405) agreeing that it should be mandatory. Of the participants who were not vaccinated last year (N = 159), 40% (N = 63) agreed that COVID-19 had changed their opinion on influenza immunisation with a further 11% (N = 18) strongly agreeing. DISCUSSION: In light of the increasing number of survey participants, more staff were interested in flu vaccination this year than ever before. The COVID-19 pandemic has had some influence on staff's likelihood to be vaccinated. Feasibility of immunisation and education posed the largest barriers to HCW vaccination.

Enhanced Recovery After Bariatric Surgery: Feasibility and Outcomes in a National Bariatric Centre.

PURPOSE: This study aimed to assess outcomes of bariatric surgical procedures after the implementation of an enhanced recovery after bariatric surgery protocol in the National Bariatric Centre in Ireland. MATERIALS AND METHODS: Data on consecutive bariatric procedures performed over a 36-month period was prospectively recorded. ERABS interventions utilized included preoperative counselling, shortened preoperative fasts, specific anaesthetic protocols, early postop mobilization and feeding, and extended post-discharge thromboprophylaxis. RESULTS: A total of 280 primary bariatric procedures were performed over a 36-month period. The primary procedures were laparoscopic sleeve gastrectomy (57.5%), laparoscopic one anastomosis gastric bypass (33.2%) and laparoscopic Roux-en-Y gastric bypass (9.3%). Mean (SD) age was 48 (± 10) years, mean (SD) preoperative BMI 49.5 (± 9) kg/m2 and 68% were female. Median ASA score was 3, and median OSMRS also 3. Over 50% of patients had a diagnosis of hypertension or OSA, and over one-third had a diagnosis of type 2 diabetes mellitus or dyslipidemia. All procedures were completed laparoscopically and 29 patients underwent a simultaneous procedure. The mean (SD) length of stay was 2.3 (± 1.4) days (median 2 days, range 2-47 days). Overall postoperative morbidity rate was 10.0% (n = 29). The 30-day readmission and reoperation rates were 3.6% and 2.5% respectively. There was no mortality recorded in this series. CONCLUSION: Implementing an ERABS protocol was feasible, safe, associated with low morbidity, no mortality, acceptable LOS and low readmission and reoperation rates. Although patients with obesity have a spectrum of disease-related complications, this should not preclude the use of an ERABS protocol in bariatric surgery.