Hernia and Abdominal Wall Reconstruction for the Colorectal Surgeon.

Hernia remains a challenge for the colorectal surgeon both in regard to prevention of hernia, that is a common entity following colorectal surgery and in managing hernia which is often made more challenging by the co-existence of a significant colorectal-specific problem. This review outlines the extent of hernia as a problem for the colorectal surgeon and highlights contemporary approaches to dealing with patients who require both colorectal and complex hernia surgery.

Laparoscopic repair of an obturator hernia; a case report of a contemporary surgical technique.

INTRODUCTION AND IMPORTANCE: Small bowel obstruction secondary to an obturator hernia is a rare presentation associated with high mortality. Prior to the development of laparoscopic surgery, a laparotomy would have been the management technique of choice for this rare presentation. CASE PRESENTATION: An elderly female with a bowel obstruction secondary to an obturator hernia presented via the Emergency Department. A laparoscopic approach with the use of a haemostatic gauze plug was performed to repair the defect. CLINICAL DISCUSSION: The evolution of surgical techniques, particularly with laparoscopy has resulted in overall benefits regarding patient outcomes. These benefits include lower post operative morbidity, shorter length of stay and decreased post operative pain. This report discusses a laparoscopic approach and the use of a gauze plug to manage an emergent small bowel obstruction secondary to an obturator hernia. CONCLUSION: The use of a haemostatic gauze agent is an alternate and potentially advantageous approach for an obturator hernia repair in the emergency setting.

Use of fluorescence imaging and indocyanine green during colorectal surgery: Results of an intercontinental Delphi survey.

BACKGROUND: Fluorescence imaging with indocyanine green is increasingly being used in colorectal surgery to assess anastomotic perfusion, and to detect sentinel lymph nodes. METHODS: In this 2-round, online, Delphi survey, 35 international experts were asked to vote on 69 statements pertaining to patient preparation and contraindications to fluorescence imaging during colorectal surgery, indications, technical aspects, potential advantages/disadvantages, and effectiveness versus limitations, and training and research. Methodological steps were adopted during survey design to minimize risk of bias. RESULTS: More than 70% consensus was reached on 60 of 69 statements, including moderate-strong consensus regarding fluorescence imaging's value assessing anastomotic perfusion and leak risk, but not on its value mapping sentinel nodes. Similarly, although consensus was reached regarding most technical aspects of its use assessing anastomoses, little consensus was achieved for lymph-node assessments. Evaluating anastomoses, experts agreed that the optimum total indocyanine green dose and timing are 5 to 10 mg and 30 to 60 seconds pre-evaluation, indocyanine green should be dosed milligram/kilogram, lines should be flushed with saline, and indocyanine green can be readministered if bright perfusion is not achieved, although how long surgeons should wait remains unknown. The only consensus achieved for lymph-node assessments was that 2 to 4 injection points are needed. Ninety-six percent and 100% consensus were reached that fluorescence imaging will increase in practice and research over the next decade, respectively. CONCLUSION: Although further research remains necessary, fluorescence imaging appears to have value assessing anastomotic perfusion, but its value for lymph-node mapping remains questionable.

Retrospective analysis of a Bi-National Colorectal Cancer Audit to characterize stage II colon cancer patients who were offered adjuvant chemotherapy.

BACKGROUND: Adjuvant chemotherapy for stage II colon cancer is a controversial area with treatment often reserved for patients with high-risk clinicopathological features. The aim of this study was to characterize which patients with stage II disease were offered adjuvant chemotherapy in an Australian and New Zealand setting. METHODS: Data was retrospectively collected from the prospectively maintained Bi-National Colorectal Cancer Audit. Data from all patients with their first episode of stage II colon cancer from January 2007 to January 2019 were included. RESULTS: A total of 3763 patients were identified in the Bi-National Colorectal Cancer Audit database with stage II colon cancer, of which 715 were offered chemotherapy (19%). Patients were at significant greater odds of being offered chemotherapy for stage II disease if they were <55 years old, from an urban area, discussed in a multidisciplinary team (MDT) meeting, had a greater operative urgency, a lower American Society of Anesthesiologists score, had a T4 tumour or had less than 12 lymph nodes harvested. CONCLUSION: In Australia and New Zealand the appropriate patients with high-risk features are more likely to be offered chemotherapy in line with current guideline recommendations; however, this may not be the case for regional patients. A large proportion of patients were not discussed at MDT meeting- given the decision to provide adjuvant chemotherapy for stage II disease remains a controversial area, and the likely small survival benefit offered by adjuvant chemotherapy, appropriate patient selection is critical and best discussed in an MDT setting.

Does indocyanine green improve the evaluation of perfusion during laparoscopic colorectal surgery with extracorporeal anastomosis?

BACKGROUND: There has been recent interest in indocyanine green (ICG) to assess anastomotic perfusion in colorectal surgery. We describe our experience using ICG when performing laparoscopic segmental colorectal resections with extracorporeal anastomotic technique and a highly standardized approach for clinically assessing blood flow. METHODS: We recruited 20 consecutive patients to undergo segmental laparoscopic resection and determined an appropriate point to transect mesentery proximally confirming pulsatile arterial flow at this level. Once confirmed, we did a further perfusion study using ICG to ascertain if this would change intraoperative decision-making. RESULTS: Twenty segmental colonic resections were assessed in nine female and 11 male patients aged 26-91 years. ICG administration was safe with no adverse outcomes documented. ICG demonstrated anastomotic perfusion in all cases. We observed no cases wherewith pulsatile blood flow at the cut edge of the mesentery, ICG showed inadequate perfusion at this level. We did find in 25% of cases ICG showed perfusion beyond the cut edge of the mesentery to a distance of up to 2.5 cm. CONCLUSION: ICG perfusion is safe and straightforward to carry out. However, when pulsatile arterial bleeding is demonstrated clinically it does not add anything to assessment of perfusion in our study. Furthermore, in 25% of cases perfusion can be demonstrated beyond the cut edge of the mesentery up to a distance of 2.5 cm. This raises the possibility that an organ well perfused with ICG may have less than ideal blood flow when assessing for this with a view to constructing an anastomosis.

Clostridium colitis: challenges in diagnosis and treatment.

BACKGROUND: Clostridium difficile infection (CDI) has been reported to occur with increasing frequency and with more severe presentations being encountered. This article presents data from The Alfred Hospital highlighting the increased incidence, the increased severity and the broader clinical presentations observed. A case series highlights a variety of clinical scenarios that provided diagnostic and management challenges. We additionally describe a novel form of treatment for fulminant colitis. METHODS: A retrospective review of C. difficile toxin (CDT)-positive and culture-positive cases was performed at The Alfred Hospital (2010-2012). Six cases are then presented as a case series to highlight the broad and atypical types of presentations one may encounter. Finally, a novel method for managing fulminant colitis operatively is presented. RESULTS: A fourfold increase in cases of toxin-positive and culture-positive cases was noted over the initial 14 months of the period of analysis, the rate of cases detected then plateaued. This increase could not be explained by increased testing being undertaken. It is also not associated with increased usage of antibiotics nor with increased patient numbers being treated. CONCLUSION: CDI can present in various clinical forms. In our hospital, the number of cases of toxin-positive and culture-positive detection is increasing. A low threshold is required to identify and adequately treat patients with CDI. Fulminant colitis can be managed successfully with the creation of a diverting loop ileostomy, colonic washout and subsequent antegrade colonic vancomycin enemas.

Delayed onset diffuse lamellar keratitis following enhancement LASIK surgery.

BACKGROUND: Diffuse lamellar keratitis (DLK) is a relatively uncommon complication of the refractive procedure, laser-assisted in situ keratomileusis (LASIK). If detected and diagnosed in a timely fashion, it can be treated and should resolve with minimal sequelae. If untreated, or misdiagnosed and treated incorrectly, there may be loss of visual acuity. Optometrists should be familiar with this condition, its signs, symptoms and correct treatment protocol. CASE HISTORY: A 58-year-old male Caucasian developed delayed onset diffuse lamellar keratitis, seemingly in the absence of an epithelial defect, 25 days following an enhancement LASIK procedure to his right eye. The DLK in this patient is delayed longer than typically reported in the literature. Subsequent management with topical steroids was complicated as the patient was a steroid responder and developed a markedly raised intraocular pressure that was managed with a topical anti-glaucoma agent. The diagnosis, pathogenesis and issues relevant to the treatment of this condition are discussed. CONCLUSION: Optometrists, particularly those actively participating in the shared care of refractive surgery patients, must be familiar with diffuse lamellar keratitis so that diagnosis is not delayed. As the number of cases of refractive surgery in Australia increases, optometrists will encounter this condition more frequently.

Assessment of the role of a student-led surgical interest group in surgical education.

BACKGROUND: We describe the development of a medical student surgical interest group, its initial evaluation, and future plans. The Surgical Students Society of Melbourne was formed in August 2008 by a group of senior medical students from the University of Melbourne. The Surgical Students Society of Melbourne seeks to provide additional surgical teaching and professional development for students interested in a career in surgery. It also aims to provide junior doctors with leadership and teaching opportunities to meet the requirements of the Royal Australasian College of Surgeons for application to the Surgical Education and Training program. Its program also addresses contemporary workforce issues, such as women in surgery and rural surgery. The society runs a weekly teaching program during the semester and procedural and careers workshops throughout the year. METHODS: A survey of students attending the teaching program was conducted by means of written and online questionnaires. RESULTS: The results suggest that the society has been successful in augmenting surgical education and providing opportunities to improve procedural skills, but also highlighted areas of the program that may be improved, including aspects of surgical professional development and role modeling. CONCLUSIONS: The Surgical Students Society initiative was generally very well received by students and shows great potential as a means for augmenting surgical education at the medical student level.