CLosure of Abdominal MidlineS Survey (CLAMSS): A national survey investigating current practice in the closure of abdominal midline incisions in UK surgical practice.

AIM: Incisional herniation (IH) is a frequent complication following midline abdominal closure with significant associated morbidity. Randomized controlled trials have demonstrated that the small bites technique (SBT) and prophylactic mesh augmentation (PMA) may reduce IH compared to mass closure techniques, but data are lacking on their implementation in contemporary surgical practice. This survey aimed to evaluate the use of the SBT and PMA and to identify factors associated with their adoption. METHOD: Between 22 January 2023 and 16 March 2023, consultant surgeons across the UK were asked to complete a 25-question survey on closure of an elective primary midline incision. RESULTS: Responses were received from 267 of 675 eligible surgeons (39.6%) in 38 NHS Trusts. Respondents were evenly split between tertiary centres (47.6%) and district general hospitals (49.4%). SBT and PMA were used by 19.9% and 3.0% of respondents, respectively. Compared to other techniques, surgeons using the SBT were more likely to close the anterior aponeurotic layer only, use single suture filaments, 2-0 gauge sutures and sharp needle points and routinely dissect abdominal layers to aid closure (all p < 0.001). Attendance at lectures/conferences on SBT (p = 0.043) and basing practice on available evidence (p < 0.001) were independently associated with use of the SBT. The commonest barriers to adopting SBT were a perceived lack of evidence (23.8%) and belief that personal IH rates were low (16.8%). CONCLUSION: A minority of UK consultant surgeons have adopted the SBT or PMA. Practice change should be driven by more widespread dissemination of current evidence and procedural information.

A comparative study on analgesic and non-analgesic outcomes of inter pleural analgesia compared to thoracic epidural analgesia in open pancreatico-duodenectomy.

Backgrounds/Aims: Thoracic epidural analgesia (TEA) is an established analgesic method in open Kausch-Whipple pancreaticoduodenectomy (KWPD). Although, it can cause hemodynamic instability and neurological complications. Inter pleural analgesia (IPA) is an alternative option. We aim to evaluate the effectiveness of IPA versus TEA after KWPD. Methods: We retrospectively studied the efficacy of IPA against TEA in patients, operated by a single surgeon. The primary outcome was the analgesic efficacy and secondary outcomes were analgesia-related complications, inotrope use, and duration. Results: Forty patients (TEA, 22; IPA, 18) were included. Both groups were well matched for patient characteristics, type, and duration of surgery. TEA was associated with higher analgesia-related complications (n = 8, 36.4% vs. n = 1, 5.6%; p = 0.027). TEA complications included analgesia not working (n = 4), leakage (n = 2), refractory hemodynamic instability (n = 1), and lower limb anaesthesia (n = 1). One patient in the IPA group encountered leakage. TEA was associated with longer inotrope requirement (35 vs. 18 hours; p = 0.047). There was no significant difference in intensive care unit (ITU) admission rate (81.8% vs. 77.8%; p > 0.999), median ITU stay (3 vs. 2 days, p = 0.385), or hospital stay (11 days in both groups). Conclusions: In open KWPD, IPA is not inferior to TEA in its efficacy of pain control. IPA was associated with less analgesia-related complications and shorter inotrope requirements. However, this was a small retrospective study. Larger randomized controlled trials are needed to study the effectiveness of IPA.

Use of prophylactic mesh during initial stoma creation to prevent parastomal herniation: a systematic review and meta-analysis of randomised controlled trials.

AIM: Parastomal hernia (PSH) is a common complication following stoma creation. Previous reviews found mesh reinforcement during initial stoma creation beneficial in reducing PSH incidence. Since then, several multicentre randomised controlled trials (RCTs) produced widely ranging results rendering previous findings debatable. This current review assessed whether combining the latest larger multicentre RCTs would alter the previous findings. METHODS: The Cochrane Library, MEDLINE and Embase were searched from the respective dates of inception until 15 January 2021. RCTs were included if they compared mesh with no mesh during initial stoma creation in adult patients to prevent PSH. Included RCTs were summarised narratively and meta-analysed to estimate the relative risk (RR) of PSH incidence (primary analysis), peristomal complications and PSH repair (secondary analyses). Several subgroup analyses were performed, including mesh type (synthetic/biologic), surgical technique (open/laparoscopic) and mesh position (sublay/intraperitoneal). RESULTS: Thirteen RCTs were included in the primary meta-analysis (1070 patients); PSH incidence was reduced in patients with mesh compared with patients without mesh at maximal follow-up (RR = 0.54; 95% CI 0.39-0.77; I2  = 67%; P < 0.01). The number of PSH repairs was fewer in patients who had mesh (RR = 0.63; 0.35-1.14; I2  = 6%; P = 0.39), with no difference in peristomal complications (RR = 0.96; 0.55-1.70; I2  = 0%; P = 0.71), comparing with no mesh. Subgroup analyses suggested that placing synthetic mesh using an open sublay technique might be more beneficial. CONCLUSIONS: Prophylactic mesh reinforcement during initial stoma creation reduces PSH incidence and potentially its repair, without an increase in peristomal complications. However, substantial heterogeneity among included RCTs limits confidence in the results.

Granulocytic sarcoma: An uncommon cause of systemic inflammatory response syndrome.

Granulocytic sarcoma rarely arises from adrenal glands. Its necrosis can lead to systemic inflammatory response syndrome (SIRS), causing clinical difficulty in diagnosis without imaging and both biochemical and histological analysis. Compressive effects of the tumor may mask its source, and therefore, prompt resuscitation, symptom control, and investigation are vital in preventing clinical deterioration.

Deliberate practice on a virtual reality laparoscopic simulator enhances the quality of surgical technical skills.

INTRODUCTION: Virtual reality (VR) simulation provides unique training opportunities. This study evaluates whether the deliberate practice (DP) can be successfully applied to simulated laparoscopic cholecystectomy (LC) for enhancement of the quality of surgical skills. METHODS: Twenty-six inexperienced surgeons underwent a training program for LC on a VR simulator. Trainees were randomly allocated to 1 of 2 specific protocols of 10 sessions comprising a total of 20 LCs. For each session, the control group performed 2 LCs separated by 30 minutes of occupational activities; the DP group were assigned 30 minutes of DP activities in between 2 LCs. Each participant then performed 2 LCs on a cadaveric porcine model. Quantitative parameters were recorded from the simulator and a motion tracking device; qualitative assessment utilized validated rating scales. RESULTS: Twenty-two subjects completed training. Learning curves on the VR simulator were significant for time taken and number of movements in both groups. The DP group was slower from the third LC (1373 vs. 872 seconds, P = 0.022) and utilized more movements from the seventh (942 vs. 701, P = 0.033). Global rating scores improved significantly in both groups over repeated LCs. The DP group revealed higher scores than control from tenth (19.5 vs. 14, P = 0.014) until the twentieth LC (22 vs. 16, P = 0.003). On the porcine model, the DP group also achieved higher global rating scores (25.5 vs. 19.5, P = 0.002). CONCLUSIONS: VR training improved dexterity for both groups, and led to transfer of skill onto a porcine LC model. The DP group achieved higher quality, and demonstrated superior transfer onto real tissues.