Can open cholecystectomy be taught by cadaveric simulation?

BACKGROUND: Laparoscopic cholecystectomy (LC) is the current standard of treatment for surgical gallbladder removal as it has an overall improved post-operative recovery compared to Open Cholecystectomy (OC). This has resulted in the loss of exposure to surgical trainees and the associated technical skills and decision-making required to convert to OC. The aim of this study is to provide construct validity to the proposition that cadaveric simulation can be used successfully to teach and learn open cholecystectomy. METHODS: Participants (n = 25) were surveyed on a 9-point questionnaire using a 5-point Likert scale to determine their opinion on cadaveric simulation as a tool for teaching OC. RESULTS: Overall respondents deemed the tool as highly translatable. There was no significant correlation in the responses between candidates versus tutors (P = 0.05, r = 0.51). CONCLUSIONS: The outcome of the survey revealed that participants agreed that cadaveric simulation is a positive learning tool to aid in OC.

Primary breast angiosarcoma in a postmenopausal woman: A case report.

INTRODUCTION AND IMPORTANCE: Primary angiosarcoma of the breast is a rare malignancy with an associated poor prognosis due to its high rates of reoccurrence and metastasis It is most common in females presenting in their 3rd and 4th decades with no evidence of hormonal dependency. Cases usually present with rapidly progressing non-tender breast lump. CASE PRESENTATION: A 75-year-old female referred for triple assessment of a rapidly enlarging right breast lump. The patient underwent multiple investigations for work-up and to aid in the diagnosis of a moderately differentiated angiosarcoma of the breast. CLINICAL DISCUSSION: Diagnostic dilemmas remain due to the non-specific findings on standard radiological investigations and high false-negative results on core-biopsy. Consideration should be made in those with a high clinical suspicion for magnetic resonance imaging and excisional biopsy. Although limited research, first line management of those without metastatic disease is radical surgery. CONCLUSION: Breast primary angiosarcoma is a rare entity in post-menopausal women that should be considered in the differentials of breast lumps. Standardized information is limited though current management includes local control with radical surgery. The role for neoadjuvant therapy, adjuvant radiotherapy or chemotherapy is still unclear.

Idiopathic spontaneous intraperitoneal haemorrhage: A near fatal presentation of acute abdomen requiring prompt diagnosis.

INTRODUCTION AND IMPORTANCE: Idiopathic spontaneous intraperitoneal haemorrhage is a rare and life-threatening condition that results from non-traumatic visceral artery rupture in the latter half of pregnancy and within the postpartum period [1-3]. CASE PRESENTATION: A 32 -year-old woman presented to emergency department, 14 weeks post-partum, with sharp left sided abdominal pain, nausea, and vomiting. Initial computed tomography (CT) was suggestive of non-specific colitis from transverse to descending colon of unclear cause. Six hours into admission she became haemodynamically unstable with abdominal peritonism resulting in emergency laparotomy. Intra-operative findings showed large volume haemoperitoneum with an active bleed from the middle colic artery. CLINICAL DISCUSSION: Symptoms and clinical presentation of Idiopathic spontaneous intraperitoneal haemorrhage is variable and ranges from vague abdominal pain to haemorrhagic shock. A latent period of several hours may be followed by a rapid progression of symptoms owing to rapidity of extravasation[3]. Pathogenesis has been suggested to arise from the increased physiologic demands during the intrapartum period, wherein repeated distension of vessels and increased tortuosity leads to a predisposition for rupture [4]. CONCLUSION: Diagnosis of Idiopathic spontaneous intraperitoneal haemorrhage is difficult but should be a differential in those who are post-partum presenting with abdominal pain. Patients should be assessed with CT angiography and treatment focused around aggressive resuscitation, surgical exploration, and ligation [3].

Peritoneal inclusion cysts in a young male: A case report.

INTRODUCTION AND IMPORTANCE: Peritoneal inclusion cyst is a rare benign condition with low potential for malignant transformation but high recurrence rates. Debulking surgery is the recommended first line management for these patients, however, recurrence rates are up to 50 % (Padmanabhan et al., 2020; Chapel and Husain, 2021). CASE PRESENTATION: A 26-year-old male being worked up for non-specific abdominal pain with cross-sectional imaging showing multiple multicystic lesions in the abdomen and pelvis. There was a pre-operative suspicion of Pseudomyxoma Peritonei and decision was made for diagnostic laparoscopy and biopsy. Mucin and an abnormal small bowel mesentery was found intraoperatively and sampled leading to the diagnosis of peritoneal inclusion cyst. CLINICAL DISCUSSION: Treatment of peritoneal inclusion cyst range from surveillance to aggressive treatment with complete cytoreductive surgery with involved field peritonectomy and hyperthermic intra-peritoneal chemotherapy. CONCLUSION: First line management of peritoneal inclusion cysts is for debulking surgery. Arguments for less invasive and more aggressive management has been proposed, however, further data needs to be collected to determine gold standard of treatment.

An unusual presentation of a primary lung adenocarcinoma: A case report.

INTRODUCTION AND IMPORTANCE: Lung cancer is one of the most common malignancies worldwide and common sites of metastasis are to brain, liver, adrenal glands, and bones [1]. Metastasis to the gastrointestinal (GI) tract is extremely rare (<1%) and the most common site is the small intestine [5]. CASE PRESENTATION: A 60-year-old female referred for intermittent colicky abdominal pain and diarrhoea, with cross-sectional imaging showing a distal small bowel mass with lymphadenopathy. Malignancy workup revealed an additional mediastinal mass and raised tumour marker carcinoembryonic antigen (CEA). Bronchoscopy confirmed primary lung adenocarcinoma of the mediastinal mass. Given the raised CEA, evolving obstructive symptoms, and concerns for synchronous lung and gastrointestinal primaries, the patient proceeded to have a small bowel resection leading to the diagnosis of a GI lung metastasis. CLINICAL DISCUSSION: If Symptomatic, suggested treatment of lung metastasis to the GI tract is surgical resection. Current evidence suggests that in isolated GI metastases, resection may have a therapeutic benefit and an association with overall survival rate. CONCLUSION: In patients with symptomatic or isolated GI lung metastasis, surgical resection should be considered for treatment and management of metastatic disease. The role of tumour marker CEA in primary lung adenocarcinoma is unclear.

Using a validated tool to assess whole-body cadaveric simulation course on open general and emergency surgery.

BACKGROUND: The Anatomy of Surgical Exposure (ASE) is a cadaver-based operative surgery simulation course that aims to teach techniques and exposures commonly used in open surgical operations. In this study, we used a validated tool to determine efficacy of assessing skills acquisition in the simulated environment. Our aims were to investigate if the ASE course improves the candidates' surgical performance, and to assess if the validated Objective Structured Assessment of Technical Skill (OSATS) template could be a useful tool for assessing technical skills. METHODS: Participants (n = 33) undertook supervised assessment of specific procedures at 10 cadaveric stations over a 2-year period; performance was marked using the OSATS template. This template utilizes a seven-item score to assess general and specific surgical techniques and knowledge using a 5-point Likert scale. Experienced tutors assessed each surgery for each participant; individual and comparative data over the 3-day course was used to provide each participant specific feedback at course completion. RESULTS: Average OSATS scores did not improve significantly over the 3-day OSATS course. There was a significant positive correlation observed between surgical trainees and OSATS total scores (P = 0.001, r = 0.747), number of years of post-graduation, and total OSATS scores (P = 0.001, r = 0.527). CONCLUSIONS: Our findings indicate that those on the surgical training pathway and those who had graduated earlier, had an overall higher score than those not yet on surgical training. The template was able to provide on-site specific candidate feedback by the end of the course, identifying areas of improvement of technical surgical skills.