Emergency laparotomy at St Olav's Hospital, Trondheim. / Akutte laparotomier ved St. Olavs hospital.

BACKGROUND: Emergency laparotomies are associated with higher mortality and longer hospital stays than elective laparotomies. The purpose of this study was to survey patient characteristics, hospital care pathways, and mortality for patients undergoing emergency laparotomy at St Olav's Hospital, Trondheim. MATERIAL AND METHODS: This is a retrospective cohort study of all patients over 18 years of age who underwent emergency laparotomy at St Olav's Hospital, Trondheim, between 1 January 2015 and 1 April 2020. Patients were selected based on National Emergency Laparotomy Audit inclusion and exclusion criteria. Surgeries due to trauma or appendicitis were excluded, as were those for gynaecological or vascular aetiology. Patient and surgery characteristics, as well as date of death, were retrieved from electronic medical records. RESULTS: A total of 939 patients with a median (interquartile range) age of 68 years (54-76) were included. Intestinal obstruction was the primary indication for surgery in 488 (52.0 %) patients, followed by perforation in 220 (23.4 %) and ischaemia in 85 (9.1 %). In all, 788 (83.9 %) patients underwent emergency surgery within the timeframe scheduled. The median postoperative hospital stay was 10 days (6-18) and 30-day mortality was 8.2 %. INTERPRETATION: Although caution should be exercised when comparing findings between studies, our results suggest that the quality of treatment at St Olav's Hospital, Trondheim, is on a par with that at similar institutions. At the same time, the study provides an opportunity to identify areas for improvement in the provision of emergency surgery.

Rates of caesarean section and total volume of surgery in Sierra Leone: a retrospective survey.

BACKGROUND: Surgical services are essential components of health-care systems. Monitoring of surgical activity is important, but resource demanding. Simpler tools to estimate surgical volume, particularly in low-income countries, are needed. Previous work hypothesises that the relative frequency of caesarean sections, expressed as a proportion of total operative procedures, could serve as a proxy measure of surgical capacity. We aimed to establish nationwide and district-wide rates of surgery and caesarean sections, and to explore correlations between districts rates for caesarean sections and corresponding rates for total volume of surgery in Sierra Leone in 2012. METHODS: A nationwide, exhaustive, retrospective, facility-based study of all surgical providers and surgical procedures was performed in Sierra Leone. Between Jan 14, and May 20, 2013, four teams of 12 medical students collected data on the characteristics of the institutions and of the surgeries performed in 2012. Data were retrieved from operation, anaesthesia, and delivery logbooks. FINDINGS: Of 60 facilities performing surgery, complete annual data for 2012 was collected from 58 (97%) institutions. 24 152 surgical procedures identified, gave a national rate of 400 surgeries per 100 000 inhabitants (district range 32-909 per 100 000 [IQR 95-502 per 100 000]). National caesarean section rate was 2·1% (district range 0·3-4·0% [IQR 0·8-2·1]). District caesarean sections rate significantly correlated with the rate of total surgical procedures per 100 000 population (p<0·01). With known caesarean section rate, total volume of surgeries per 100 000 can be calculated with the equation: -9·8 + 4·68 × caesarean sections per 100 000. INTERPRETATION: The close correlation between rate of caesarean section and population rates of total volume of surgery at district level in Sierra Leone indicates that rate of caesarean section should be further explored as a proxy indicator for overall surgical volume in low performing settings. By collecting data from three sources, missing procedures was considered less likely. FUNDING: Norwegian University of Science and Technology.

Met and unmet needs for surgery in Sierra Leone: A comprehensive, retrospective, countrywide survey from all health care facilities performing operations in 2012.

BACKGROUND: Understanding a country's baseline operative actors and capacity is critical to improving the quality of services and outcomes. The aim of this study was to describe all operative providers and national operative production, to evaluate district and nationwide population rates for operations, and to estimate unmet operative need in Sierra Leone. METHODS: A nationwide, exhaustive, retrospective, facility-based study of operative actors and surgical procedures was performed in Sierra Leone. Between January and May 2013, 4 teams of 12 medical students collected data on the characteristics of the institutions and of the operations performed in 2012. Data were retrieved from the log books of operations, anesthesia, and delivery. RESULTS: A total of 24,152 operative procedures were identified, equal to a national rate of 400 operative procedures per 100,000 inhabitants (district range 32-909/100,000, interquartile range 95-502/100,000). Hernia repair was the most common operative procedure at 86.1 per 100,000 inhabitants (22.4% of the total national volume) followed by cesarean delivery at 80.6 per 100,000 (21.0% of the total). Private, nonprofit facilities performed 54.0% of the operations, compared with 39.6% by governmental and 6.4% by private for-profit facilities. More than 90% of the estimated operative need in Sierra Leone was unmet in 2012. CONCLUSION: The unmet operative need in Sierra Leone is very high. The 30-fold difference in operative output between districts also is very high. As the main training institution, operative services within the governmental sector need to be strengthened. An understanding of the existing operative platform is a good start for expanding operative services.

Motion tracking in the liver: validation of a method based on 4D ultrasound using a nonrigid registration technique.

PURPOSE: Treatments like radiotherapy and focused ultrasound in the abdomen require accurate motion tracking, in order to optimize dosage delivery to the target and minimize damage to critical structures and healthy tissues around the target. 4D ultrasound is a promising modality for motion tracking during such treatments. In this study, the authors evaluate the accuracy of motion tracking in the liver based on deformable registration of 4D ultrasound images. METHODS: The offline analysis was performed using a nonrigid registration algorithm that was specifically designed for motion estimation from dynamic imaging data. The method registers the entire 4D image data sequence in a groupwise optimization fashion, thus avoiding a bias toward a specifically chosen reference time point. Three healthy volunteers were scanned over several breathing cycles (12 s) from three different positions and angles on the abdomen; a total of nine 4D scans for the three volunteers. Well-defined anatomic landmarks were manually annotated in all 96 time frames for assessment of the automatic algorithm. The error of the automatic motion estimation method was compared with interobserver variability. The authors also performed experiments to investigate the influence of parameters defining the deformation field flexibility and evaluated how well the method performed with a lower temporal resolution in order to establish the minimum frame rate required for accurate motion estimation. RESULTS: The registration method estimated liver motion with an error of 1 mm (75% percentile over all datasets), which was lower than the interobserver variability of 1.4 mm. The results were only slightly dependent on the degrees of freedom of the deformation model. The registration error increased to 2.8 mm with an eight times lower temporal resolution. CONCLUSIONS: The authors conclude that the methodology was able to accurately track the motion of the liver in the 4D ultrasound data. The authors believe that the method has potential in interventions on moving abdominal organs such as MR or ultrasound guided focused ultrasound therapy and radiotherapy, pending the method is enabled to run in real-time. The data and the annotations used for this study are made publicly available for those who would like to test other methods on 4D liver ultrasound data.

A retrospective study evaluating the use of Permacol™ surgical implant in incisional and ventral hernia repair.

BACKGROUND: The outcome of incisional and ventral hernia repair depends on surgical technique, patient, and material. Permacol™ surgical implant (crosslinked porcine collagen) has been used for over a decade; however, there are few data on outcomes. This study is the largest retrospective multinational study to date to evaluate outcomes with Permacol™ surgical implant in the repair of incisional and ventral hernias. METHODS: Data were collected retrospectively on 343 patients treated for 213 incisional and 130 ventral hernias. Data evaluated included patient demographics, wound classification, surgical technique, morbidity, and recurrence rates. RESULTS: Median follow-up time was 649 days (max: 2857), median age 57 years (range 23-91), and BMI 32 kg/m(2) (range 17.6-77.8). Two or more comorbidities were present in 70% of patients. Open surgery was performed in 220 (64%) patients. Permacol™ surgical implant was used as an underlay (250), sublay (39), onlay (37), or inlay (17). Surgical techniques included component separation (89; 25.9%), modified Stoppa technique (197; 57.4%), and Rives-Stoppa (17; 5.0%). CDC Surgical Wound Classification was Class I (190), Class II (103), Class III (28), and Class IV (22). Complications were seen in 40.5% (139) of the patients, with seroma (19%) and wound infection (15%) as the most common. Mesh removal occurred in 1 (0.3%) patient. Kaplan-Meier analysis demonstrated that the probabilities for hernia recurrence at one, two, and three years were 5.8%, 16.6%, and 31.0%, respectively. CONCLUSIONS: Permacol™ surgical implant was shown to be safe with relatively low rates of hernia recurrence. CLINICAL TRIAL REGISTRATION NUMBER: NCT01214252 (http://www.clinicaltrials.gov).

Laparoscopic ultrasound: a survey of its current and future use, requirements, and integration with navigation technology.

BACKGROUND: Laparoscopic ultrasound (LUS) increases surgical safety by allowing the surgeon to see beyond the organ surface, by visualizing vascular structures and by improving surgical precision of tumor resection. A questionnaire-based survey was used to investigate the current use and future expectations of LUS technology. METHODS: A questionnaire consisting of 26 questions was distributed manually at four different conferences (60% at the European Association for Endoscopic Surgery (EAES) conference, Stockholm 2008). The answers were summarized with descriptive statistics and nonparametric tests at a significance level of 0.05. RESULTS: The questionnaire was answered by 177 surgeons from 40 different countries (85% from Europe). Of these surgeons, 43% use ultrasound during laparoscopic procedures. Generally, more LUS users are found at university hospitals than at general community hospitals. Surgeons use LUS primarily in procedures related to the liver (67% of the surgeons who use LUS), but LUS also is used in other procedures related to the pancreas, biliary tract, and colon. In a 5-year perspective, 82% of surgeons believe in an increased use of LUS, and 79% of surgeons also think that the use of LUS combined with navigation technology will increase and that the most important requirements for such a system are good image quality, easy interpretation, and a high degree of precision. CONCLUSIONS: Although the surgeons believe LUS has advantages, only 43% of the respondents reported using it. The surveyed surgeons were largely positive toward an increased use of LUS in a 5-year perspective and believe that LUS combined with navigation technology will contribute to improving the surgical precision of tumor resection.

Degree of adhesions after repair of incisional hernia.

BACKGROUND AND OBJECTIVES: Laparoscopic treatment of incisional hernias reduces surgical traumas and postoperative pain. It requires intraperitoneal placement of a foreign body that might cause adhesions, leading to postoperative complications. The aim of this study was to improve reliability of ultrasound in quantitatively estimating adhesions to exploit the other advantages of ultrasound, such as availability and versatility. METHODS: The ultrasound examination was performed by using a hand-held 3.5 MHz curved linear probe. The image data were analyzed prior to scan conversion. Two square regions of interest were defined, one in the abdominal wall and one in the underlying bowels. A cross correlation-based algorithm tracked each region by using a time span of 3 frames. Subtracting the 2 displacement functions from each other yielded a relative displacement function, indicating the degree of bowel adhesions. This was compared with the intraoperative findings. RESULTS AND CONCLUSIONS: The method was proven to be a rapid and robust method for quantitatively estimating the degree of bowel adhesions. It is limited to evaluation of adhesions between bowel and abdominal wall. However, this ultrasound technique could assist in the safe placement of ports prior to redo laparoscopic surgery.

[3-D navigation in laparoscopic surgery]. / Tredimensjonal navigasjon i laparoskopisk kirurgi.

BACKGROUND: The main drawback with the laparoscopic approach is that the surgeon lacks the possibility to palpate vessels, tumours and organs during surgery. Furthermore, the laparoscope only provides a surface view of organs. There is a need for more advanced visualization that enhances the view to include information below the surface of the organs when the procedure is planned and for control and guidance during treatment. MATERIAL AND METHODS: We propose 3-D navigation technology based on preoperatively acquired MR or CT data used in combination with a laparoscopic navigation pointer. The pointer has an attached position tracker which enables the surgeon to interactively control the display of images prior to and during surgery. RESULTS: We have used this technology during treatment of four patients with adrenal tumours. Preoperative registration of images of the patients was performed within two minutes with an average accuracy of 7.1 mm. 2-D and 3-D visualizations interactively controlled by the pointer were used both for planning and for guidance of the surgical procedures. INTERPRETATION: The pointer was a useful tool in image guidance of laparoscopic surgery in the reported cases both for planning the approach in detail and for guidance. We believe abdominal 3-D image guidance using a laparoscopic navigation pointer has a large potential for improving laparoscopic surgery, especially in cases where vessels and anatomical relations might be difficult to identify using only a laparoscope. Accordingly, this new technology will increase safety and facilitate successful laparoscopic surgery.