Primary closure versus vertical rectus abdominis myocutaneous (VRAM) flap closure of perineal wound following abdominoperineal resection-a systematic review and meta-analysis.

PURPOSE/AIM: Perianal wound healing and/or complications are common following abdominoperineal resection (APR). Although primary closure is commonly undertaken, myocutaneous flap closure such as vertical rectus abdominis myocutaneous flap (VRAM) is thought to improve wound healing process and outcome. A comprehensive meta-analysis was performed to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. METHODS: PubMed, MEDLINE, EMBASE, and Cochrane Central Registry of Controlled Trials were comprehensively searched until the 8th of August 2023. Included studies underwent meta-analysis to compare outcomes of primary closure versus VRAM flap closure of perineal wound following APR. The primary outcome of interest was perineal wound complications, and the secondary outcomes were abdominal wound complications, dehiscence, wound healing time, length of hospital stay, and mortality. RESULTS: Ten studies with 1141 patients were included. Overall, 853 patients underwent primary closure (74.8%) and 288 patients underwent VRAM (25.2%). Eight studies reported on perineal wound complications after APR: 38.2% (n = 263/688) in the primary closure group versus 32.8% (n = 80/244) in the VRAM group. Perineal complication rates were statistically significantly lower in the VRAM group versus primary closure ((M-H OR, 1.61; 95% CI 1.04-2.49;

A double-blind, placebo-controlled randomised trial of intraparenchymal administration of local anaesthetic in elective breast augmentation.

INTRODUCTION: Several methods of controlling pain post-bilateral breast augmentation (BBA) have been described. BBA is frequently performed as a day case procedure; therefore, a simple effective method of controlling pain in the immediate post-operative period is desired. METHODS: We conducted a prospective, double-blinded, placebo-controlled randomised study of 20 women undergoing BBA. Women were randomly assigned to receive intraparenchymal infiltration intra-operatively prior to implant placement with either local anaesthetic (LA) (chirocaine) or normal saline. The primary outcome was post-operative pain scores immediately, and at 6 h. Our secondary endpoint was post-operative narcotic consumption. RESULTS: Twenty patients were included in this study. The average pain score in the immediate post-operative period was 3.4 in the control group versus 0.7 in the treatment group (p = 0.013). In 6 h post-operatively, the average pain score was 2.4 in the control group versus 0.9 in the treatment group (p = 0.03). Sixty-six percentage of patients in the control arm required post-operative opiates compared with 27% in the treatment group (p = 0.17) CONCLUSION: This randomised controlled trial demonstrates a technique of intraparenchymal infiltration of LA that significantly reduces post-operative pain scores after BBA.

Aesthetic surgery training in a changing healthcare environment.

Aesthetic surgery is a rapidly evolving sub-speciality, both technologically and conceptually. It is therefore critical that plastic surgery training coincides with this rapid evolution. Recent fiscal limitations in public health provision and trainee working-time legislation may impact the delivery of high quality aesthetic surgery training. There is an urgent need to address the delivery of aesthetic training in current training paradigms in Ireland and we propose a number of strategies to obliterate the learning curve.

Intraneural ganglion cyst involving the tibial nerve-a case report.

Intraneural ganglia are rare non-neoplastic cysts that are caused by an accumulation of thick mucinous fluid. This occurs within the epineurium of peripheral nerves, which is encased in a dense fibrous capsule. The most common presentation of this tumour is local and/or radiating pain. Involvement of the tibial nerve is extremely uncommon, with less than 18 reported cases in the literature. We present a case of an intraneural tibial nerve ganglion cyst in a young male. We also discuss the current literature and proposed pathogenesis and treatment of this rare entity.

Zone calculation as a tool for assessing performance outcome in laparoscopic suturing.

BACKGROUND: Simulator performance is measured by metrics, which are valued as an objective way of assessing trainees. Certain procedures such as laparoscopic suturing, however, may not be suitable for assessment under traditionally formulated metrics. Our aim was to assess if our new metric is a valid method of assessing laparoscopic suturing. STUDY DESIGN: A software program was developed to order to create a new metric, which would calculate the percentage of time spent operating within pre-defined areas called "zones." Twenty-five candidates (medical students N = 10, surgical residents N = 10, and laparoscopic experts N = 5) performed the laparoscopic suturing task on the ProMIS III(®) simulator. New metrics of "in-zone" and "out-zone" scores as well as traditional metrics of time, path length, and smoothness were generated. Performance was also assessed by two blinded observers using the OSATS and FLS rating scales. This novel metric was evaluated by comparing it to both traditional metrics and subjective scores. RESULTS: There was a significant difference in the average in-zone and out-zone scores between all three experience groups (p < 0.05). The new zone metrics scores correlated significantly with the subjective-blinded observer scores of OSATS and FLS (p = 0.0001). The new zone metric scores also correlated significantly with the traditional metrics of path length, time, and smoothness (p < 0.05). CONCLUSION: The new metric is a valid tool for assessing laparoscopic suturing objectively. This could be incorporated into a competency-based curriculum to monitor resident progression in the simulated setting.

A simple technique for intubating the mouth during OGD in patients with previous neck radiation.

Trismus and microstomia are commonly associated complications of neck irradiation. In recent years we are seeing an increase in the number of patients with various head and neck cancers being treated with radiotherapy. This can pose a significant challenge in performing oesophagogastroduodenoscopy (OGD) in this cohort of patients. We describe a novel technique for intubating the mouth during OGD in patients with previous neck radiation. Instead of placing a standard mouthpiece, we place the barrel of a 5 mm syringe, which is cut in half, into the patient's mouth. This method allows easy passage of the gastroscope, where the mouth opening is limited by trismus from prior radiation. It also serves to protect the patient's teeth during OGD. Successful intubation with a gastroscope is possible in patients with severe trismus using our novel technique.

The impact of aptitude on the learning curve for laparoscopic suturing.

BACKGROUND: Within surgery, several specialties demand advanced technical skills, specifically in the minimally invasive environment. METHODS: Two groups of 10 medical students were recruited on the basis of their aptitude (visual-spatial ability, depth perception, and psychomotor ability). All subjects were tested consecutively using the ProMIS III simulator until they reached proficiency performing laparoscopic suturing. Simulator metrics, critical error scores, observed structured assessment of technical skills scores, and Fundamentals of Laparoscopic Surgery scores were recorded. RESULTS: Group A (high aptitude) achieved proficiency after a mean of 7 attempts (range, 4-10). In group B (low aptitude), 30% achieved proficiency after a mean of 14 attempts (range, 10-16). In group B, 40% demonstrated improvement but did not attain proficiency, and 30% failed to progress. CONCLUSIONS: Distinct learning curves for laparoscopic suturing can be mapped on the basis of fundamental ability. High aptitude is directly related to earlier completion of the learning curve. A proportion of subjects with low aptitude are unable to reach proficiency despite repeated attempts.

Is the skillset obtained in surgical simulation transferable to the operating theatre?

BACKGROUND: Simulated surgical training offers a safe and accessible way of learning surgical procedures outside the operating room. Training programs have been developed using simulated laboratories to train surgical trainees to proficiency outside the operating room. Despite the global enthusiasm among educators to enhance training through simulation-based learning, it remains to be elucidated whether the skill set obtained is transferrable to the operating room. METHODS: Using standardized search methods, the authors searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Web-Based Knowledge, as well as the reference lists of relevant articles, and retrieved all published randomized controlled trials. RESULTS: Sixteen randomized controlled trials involving 309 participants were identified to be suitable for qualitative analysis using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The mean Consolidated Standards of Reporting Trials score was 16 (range, 12-22). The studies showed considerable clinical and methodologic diversity. Operative time improved consistently in all trials after training and was the only objective parameter measurable in the live setting. Studies that used the Objective Structured Assessment of Technical Skills as their primary outcome showed improved scores in 80% of trials, and studies that used performance indicators to assess participants all showed improved scores after simulation training in all of the trials, with 88% showing statistical significance. CONCLUSIONS: The current literature consistently demonstrates the positive impact of simulation on operative time and predefined performance scores. However, these reproducible measures alone are insufficient to demonstrate transferability of skills from the laboratory to the operating room. The authors advocate a multimodal assessment, including metrics, the Objective Structured Assessment of Technical Skills, and critical step completion. This may provide a more complete assessment of operative performance. Only then can it be concluded that simulation skills are transferable to the live operative setting.

Does aptitude influence the rate at which proficiency is achieved for laparoscopic appendectomy?

BACKGROUND: The attainment of technical competence for surgical procedures is fundamental to a proficiency-based surgical training program. We hypothesized that aptitude may directly affect one's ability to successfully complete the learning curve for minimally invasive procedures. The aim was to assess whether aptitude has an impact on ability to achieve proficiency in completing a simulated minimally invasive surgical procedure. The index procedure chosen was a laparoscopic appendectomy. STUDY DESIGN: Two groups of medical students with disparate aptitude were selected. Aptitude (visual-spatial, depth perception, and psychomotor ability) was measured by previously validated tests. Indicators of technical proficiency for laparoscopic appendectomy were established by trained surgeons with an individual case volume of more than 150. All subjects were tested consecutively on the ProMIS III (Haptica) until they reached predefined proficiency in this procedure. Simulator metrics, critical error scores, and Objective Structured Assessment of Technical Skills (OSATS) scores were recorded. RESULTS: The mean numbers of attempts to achieve proficiency in performing a laparoscopic appendectomy for group A (high aptitude) and B (low aptitude) were 6 (range 4 to 7) and 14 (range 10 to 18), respectively (p < 0.0001). Significant differences were found between the 2 groups for path length (p = 0.014), error score (p = 0.021), and OSATS score (p < 0.0001) at the initial attempt. CONCLUSIONS: High aptitude is directly related to a rapid attainment of proficiency. These findings suggest that resource allocation for proficiency-based technical training in surgery may need to be tailored according to a trainee's natural ability.