The surgical metaverse.

Recent developments have seen acceleration in the development of virtual reality (VR) and augmented reality (AR) technology. Through these developments, the metaverse has emerged. Within the metaverse, users create an avatar to experience an immersive, interactive extended reality. Current front-runners in its implementation are the financial, communication and entertainment sectors. This technology, however, is receiving greater recognition in the medical world, with national and international surgical bodies acknowledging the benefits that VR and the metaverse will have on surgical training and patient care. Its versatility means that we are likely to see VR related technology become intimately woven into the fabric of surgery in the next two decade. In this article, the impact of the metaverse on the surgical field will be discussed.

The role of imaging in the diagnosis of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study.

Acute appendicitis is one of the most common general surgical emergencies worldwide; however, its diagnosis remains challenging, with a high proportion of negative appendicectomies. The purpose of this study was to investigate the benefit of routine use of pre-operative imaging for the evaluation of suspected appendicitis. This retrospective cohort study included all cases of appendicectomies performed for suspected acute appendicitis during the first and second peaks of the COVID-19 pandemic, between March 2020 and February 2021. The control group included all cases of appendicectomies performed for suspected acute appendicitis in the previous 12 months (March 2019-February 2020). One hundred and four patients underwent appendicectomy in the study group, compared to 209 in the control group, with similar gender distribution but a significantly higher median age in the study group (33 vs. 28, p = 0.001). The two groups had similar rates of perforation and similar median white cell count (WCC) and CRP. Imaging was used in 80.77% of the patients in the study group, compared to 61.72% in the control group (p = 0.001), with 55.77% of patients in the study group undergoing CT scans. Despite this, the negative appendicectomy rate (NAR) in the two groups did not differ significantly (11.54% vs. 15.79%, p = 0.320). The increase in the use of imaging for the diagnosis of acute appendicitis during the COVID-19 pandemic did not lead to a significantly lower negative appendicectomy rate. Registration: The study was pre-registered at ClinicalTrials.gov (NCT05205681).

Straight-to-test colonoscopy: Has it improved the detection of colorectal cancer? A 7- year review.

AIM: Early diagnosis of colorectal cancer (CRC) improves outcome. Straight-To-Test (STT) pathway was introduced in Whittington Hospital in 2012. The aim was to reduce the time to first oncological treatment and minimise unnecessary outpatient clinic appointments. However, this pathway has added significant burden to the trust in terms of number of procedures to be done.We assessed the diagnostic yield and the effectiveness of this pathway in improving the time to diagnosis of colorectal cancer. We also performed a cost-effective analysis and discussed the current literature along with interventions to further improve the benefits of STT investigations. METHOD: This is a prospectively collected data of all patients who underwent STT examinations in a single centre from January 2012 till December 2018. The parameters collected were patient details, procedures performed, findings and discharge plan. We also performed a cost-effective analysis. RESULTS: A total 1648 (90.8%) of patients identified suitable for STT pathway underwent colonoscopy or flexible sigmoidoscopy. From this, 764 (50.2%) patients had diagnosed pathology and CRC was detected in 50(3%) of the patients. We also estimated annual savings of £ 21,599.54 (£151,196.76 in seven years). Patients on the STT pathway took 25 days to obtain results as compared to 40 days in the standard pathway. The decision to take the patient off the cancer pathway was shortened by 3 weeks. CONCLUSION: STT pathway has proven to be safe and cost-effective means of investigation. However, further improvement is needed in the implementation to make it a sustainable. mode of investigation in long run and increase the pickup rate of colorectal cancer through STT.

A cohort study of 30 day mortality after NON-EMERGENCY surgery in a COVID-19 cold site.

BACKGROUND: Two million non-emergency surgeries are being cancelled globally every week due to the COVID-19 pandemic, which will have a major impact on patients and healthcare systems. METHODS: During the peak of the pandemic in the United Kingdom, we set up a multicentre cancer network amongst 14 National Health Service institutions, performing urological, thoracic, gynaecological and general surgical urgent and cancer operations at a central COVID-19 cold site. This is a cohort study of 500 consecutive patients undergoing surgery in this network. The primary outcome was 30-day mortality from COVID-19. Secondary outcomes included all-cause mortality and post-operative complications at 30-days. RESULTS: 500 patients underwent surgery with median age 62.5 (IQR 51-71). 65% were male, 60% had a known diagnosis of cancer and 61% of surgeries were considered complex or major. No patient died from COVID-19 at 30-days. 30-day all-cause mortality was 3/500 (1%). 10 (2%) patients were diagnosed with COVID-19, 4 (1%) with confirmed laboratory diagnosis and 6 (1%) with probable COVID-19. 33/500 (7%) of patients developed Clavien-Dindo grade 3 or higher complications, with 1/33 (3%) occurring in a patient with COVID-19. CONCLUSION: It is safe to continue cancer and urgent surgery during the COVID-19 pandemic with appropriate service reconfiguration.

Gastro-Colic Fistula After Sleeve Gastrectomy Leak: Our Experience with this Rare Complication.

BACKGROUND: Sleeve gastrectomy (SG) is one of the commonest bariatric procedure performed worldwide (Asian Journal of Endoscopic Surgery 7:314-6, 2014). Leaks reported in 1 to 7% of cases are difficult to manage after SG. Leaks can be graded into acute (within 7 days), early (within 1-6 weeks), late (after 6 weeks) and chronic (after 12 weeks) (Asian Journal of Endoscopic Surgery 7:314-6, 2014). Oesophageal stents can be used for acute leaks. Gastro-colic fistula (GCF) is a rare complication following a chronic leak after SG (Asian Journal of Endoscopic Surgery 7:314-6, 2014). We would like to share our experience of a rare and challenging case of GCF after SG leak. METHOD: Prospectively collected data in our tertiary bariatric centre was retrieved. RESULTS: A 31-year-old female with body mass index (BMI) of 46.2 kg/m2 with history of bipolar disorder had an uneventful SG. On sixth day post-operatively, she presented to other unit with lower chest pain and had a computed tomography (CT) scan which was normal. At 6-week follow-up (FU), she had lost 44% excess weight loss (EWL) and complained of epigastric pain and reflux. CT scan showed collection with active leak in SG. This was successfully treated with partially covered stent placement. Imaging confirmed control of leak. Ten days later, endoscopic removal of the stent was successfully done. At 6-month FU, she had 86% EWL. At 1-year FU, she had 102% EWL with complain of reflux despite being on proton pump inhibitor (PPI). There were no nutritional parameter concerns. There was no history of diarrhoea. CT scan showed GCF (Image 1). OGD confirmed the findings and the site was tattooed. Colonoscopy was equivocal, and no clear fistula visualised which would explain the lack of diarrhoea. Operation was planned with colorectal team after multidisciplinary team discussion. At laparoscopy (Video 1), GCF was identified between SG and splenic flexure at the site of the previous leak. Adhesinolysis was done with a combination of blunt, sharp and energy device and the gastric sleeve and the splenic flexure were mobilised. The fistulous tract was isolated, divided and excised with Endo GIA tristapler taking partial lumen of colon. Intra-operative oesophagogastroduodenoscopy (OGD) showed no leak and colonoscopy showed no leak or narrowing of the lumen and showed healthy tissue. Post-operative recovery was uneventful. She was closely monitored by the bariatric dietician throughout the journey. At 6-month FU, she regained weight under close supervision, had EWL of 88% and is doing well. CONCLUSION: SG leaks can add long-term morbidity. Stent can be used successfully to treat SG leak if used judiciously. There should be low threshold for investigating patients with EWL of > 100% for anatomical complications like stricture, fistula or kink in the gastric sleeve. We wanted to make the bariatric fraternity aware of a rare late (> 12 weeks) complication of gastro-colic fistula after successfully treated SG leak. Limited literature is published about this rare complication and its management which ranges from conservative management to stent placement to surgical intervention (Asian Journal of Endoscopic Surgery 7:314-6, 2014; Clinical Case Reports 6:1342-1346, 2008; Surgery for Obesity and Related Diseases 6:308-12, 2010). It can be dealt with successfully with minimally invasive technique by a multidisciplinary team in an experienced tertiary bariatric unit.

Systematic Review of Pelvic Exenteration With En Bloc Sacrectomy for Recurrent Rectal Adenocarcinoma: R0 Resection Predicts Disease-free Survival.

BACKGROUND: The management of recurrent rectal cancer is challenging. At the present time, pelvic exenteration with en bloc sacrectomy offers the only hope of a lasting cure. OBJECTIVE: The purpose of this study was to evaluate clinical outcome measures and complication rates following sacrectomy for recurrent rectal cancer. DATA SOURCES: A search was conducted on Pub Med for English language articles relevant to sacrectomy for recurrent rectal cancer with no time limitations. STUDY SELECTION: Studies reported sacrectomy with survival data for recurrent rectal adenocarcinoma. MAIN OUTCOME MEASURE: Disease-free survival following sacrectomy for recurrent rectal cancer was the main outcome measured. RESULTS: A total of 220 patients with recurrent rectal cancer were included from 7 studies, of which 160 were men and 60 were women. Overall median operative time was 717 (570-992) minutes and blood loss was 3.7 (1.7-6.2) L. An R0 (>1-mm resection margin) resection was achieved in 78% of patients. Disease-free survival associated with R0 resection was 55% at a median follow-up period of 33 (17-60) months; however, none of the patients with R1 (<1-mm resection margin) survived this period. Postoperative complication rates and median length of stay were found to decrease with more distal sacral transection levels. In contrast, R1 resection rates increased with more distal transection. LIMITATION: The studies assessed by this review were retrospective case series and thus are subject to significant bias. CONCLUSION: Sacrectomy performed for patients with recurrent rectal cancer is associated with significant postoperative morbidity. Morbidity and postoperative length of stay increase with the level of sacral transection. Nevertheless, approximately half of patients eligible for rectal excision with en bloc sacrectomy may benefit from disease-free survival for up to 33 months, with R0 resection predicting disease-free survival in the medium term.

Improving the diagnostic stage of the suspected colorectal cancer pathway: A quality improvement project.

We aimed to improve the lead-time and the patient experience of the diagnostic stage of the suspected colorectal cancer pathway. This project worked within the constraints of limited resources and an austere environment. The core team included a project manager trained in quality improvement methodologies. Senior and Fleming's planned change model was used as the overall framework. Baseline data supported the case for change and highlighted targets for improvement. A stakeholder workshop employed social movement theory, lean thinking, experience-based design and patient stories to engage influential leaders and secure support and commitment. Solutions that arose from the workshop were then researched. A "Genchi Genbutsu" ethos took the team to Northumbria to learn about another unit's pathway innovations. Subsequently, our new pathway employed solutions aimed at increasing the proportion of patients who went straight-to-test. Consensus on the design was achieved using Schein's process consultation theory. Implementation of the new pathway resulted in a significant reduction in the median time from referral to endoscopy from 26 days to 14 days (P<0.001), and a significant increase in the proportion going straight-to-test from 6% to 43%. Changes to improve patient experience were also implemented, however data to evidence this has not yet been collected. Going forward, further standardisation is required and issues around sustainability need to be tackled. This project exemplified, amongst others, the value of working from data from the beginning and a comprehensive early stakeholder engagement.

Heated IntraPEritoneal Chemotherapy (HIPEC) for Patients With Recurrent Ovarian Cancer: A Systematic Literature Review.

BACKGROUND: Despite advances in surgical oncology, most patients with primary ovarian cancer develop a recurrence that is associated with a poor prognosis. The aim of this review was to establish the impact of Heated IntraPEritoneal Chemotherapy (HIPEC) in the overall survival of patients with recurrent ovarian cancer. METHODS: A search of PubMed/MEDLINE databases was performed in February 2015 using the terms "recurrent ovarian cancer," "cytoreductive surgery/cytoreduction," and "heated/hyperthermic intraperitoneal chemotherapy." Only English articles with available abstracts assessing the impact of HIPEC in patients with recurrent ovarian cancer were examined. The primary outcome measure was overall survival, whereas secondary outcomes included disease-free survival and HIPEC-related morbidity. RESULTS: Sixteen studies with 1168 patients were analyzed. Most studies were Level IV, with 4 studies graded as Level III and 1 Level II. Cisplatin was the main chemotherapeutic agent used, but variations were observed in the actual technique, temperature of perfusate, and duration of treatment. In patients undergoing cytoreductive surgery and HIPEC, the overall survival ranged between 26.7 and 35 months, with disease-free survival varying between 8.5 and 48 months. Heated IntraPEritoneal Chemotherapy seems to confer survival benefits to patients with recurrent disease, with a randomized controlled study reporting that the overall survival is doubled when cytoreductive surgery is compared with cytoreductive surgery and chemotherapy (13. 4 vs 26.7 months). Heated IntraPEritoneal Chemotherapy-related morbidity ranged between 13.6% and 100%, but it was mainly minor and not significantly different from that experienced by patients who only underwent cytoreduction. CONCLUSIONS: Cytoreductive surgery and HIPEC seem to be associated with promising results in patients with recurrent ovarian cancer. Large international prospective studies are required to further quantify the true efficacy of HIPEC and identify the optimal treatment protocol for a maximum survival benefit.

The diagnostic yield of preoperative staging computed tomography of the thorax in colorectal cancer patients without hepatic metastases.

BACKGROUND: National UK guidelines recommend preoperative computed tomography (CT) examination of the chest for all patients with colorectal cancer (CRC) as identification of thoracic metastatic disease may influence treatment plans. The diagnostic yield of this approach for patients without radiological evidence of hepatic metastases remains unclear. The aim of this study was to establish the impact upon treatment of chest CT examination for CRC patients without metastatic liver disease. PATIENTS AND METHODS: All patients diagnosed with CRC without liver metastases disease between December 2006 and December 2013 in a single institution were identified from a prospectively recorded departmental database. Data collected included patient demographics, disease stage and chest CT findings. RESULTS: There were 358 CRC patients (183 male, 175 female, median age 70 years, range 24-96 years) without liver metastases. Colon cancer accounted for 68% of cases with 32% of patients diagnosed with rectal cancer. The majority of patients (n=292, 81.6%) had no evidence of thoracic pathology during the study period. Lung metastases were identified in five (1.4%) patients, one of them subsequently diagnosed with benign pulmonary nodule. In 61 (17.0%) patients the lung nodules were classified as intermediate with only three subsequently reclassified as pulmonary metastases (n=1) or primary lung cancer (n=2). CONCLUSION: In the absence of liver metastases, CRC rarely spreads to the lung. Consequently, preoperative chest CT examination for patients without evidence of liver metastases may not be necessary in the majority of patients. Future studies are required to identify patients at high risk for pulmonary metastases who may benefit from this preoperative investigation.

Perforated duodenal diverticulae: importance for the surgeon and gastroenterologist.

We present the case of a 78-year-old woman who was admitted for an elective left hemicolectomy for diverticular disease. Two days following the elective procedure, bilious fluid was noted in her pelvic drain. The patient returned to theatre, where a perforated duodenal diverticulum was excised and the defect primarily repaired. The patient then developed a low output enterocutaneous fistula which was treated conservatively with nasojejunal feeding and resolved spontaneously.

Caecal volvulus following abdominoplasty: a tale of caution.

We present a case of a 30-year-old woman with a gangrenous right colon secondary to caecal volvulus, diagnosed postabdominoplasty. To our knowledge, this is the first case recorded in the literature. An emergency right hemicolectomy was performed and the patient had an unremarkable recovery. Given the severity of this incident, the diagnosis of caecal volvulus postabdominoplasty requires a high index of suspicion to allow prompt diagnosis and treatment.

Establishing a regional enterocutaneous fistula service: the Royal London hospital experience.

BACKGROUND: The development of enterocutaneous fistula (ECF) is one of the most challenging complications encountered in colorectal surgery. Currently, only two supra-regional centres are nationally designated in the United Kingdom to treat ECF patients. The aim of this study was to assess clinical outcome measures following the implementation of an ECF service at The Royal London Hospital. METHODS: All patients diagnosed with enterocutaneous fistula between December 2005 and November 2011 were recruited to the study. Clinical outcomes analysed included successful ECF closure, number of surgical procedures required for successful ECF closure, re-fistulation rates and morbidity/mortality data. RESULTS: 41 patients (20 M:21 F) of median age 54 years (range, 16-81) were studied. Patients had undergone a median of 4 (range, 1-18) operations prior to referral. Eleven fistulas (27%) healed spontaneously. Of the remaining 30 patients, 5 (17%) died before surgery due to uncontrollable sepsis and 6 (20%) refused surgical intervention and were managed conservatively. Nineteen patients (63%) underwent definitive surgical repair requiring a median of 1 (range, 1-2) operations, with recurrent fistulation reported in 4 patients (21%). No intra-operative mortality was encountered. Two (11%) patients died postoperatively due to cardio-respiratory complications. CONCLUSIONS: These data compare favourably with outcome measures reported by designated national centres, suggesting ECF patients can be safely managed closer to home in regional units that have the appropriate expertise. Nevertheless, management of this condition remains critically dependent upon a dedicated multidisciplinary team approach.

Dynamic MRI (dMRI) as a guide to therapy in children and adolescents with persistent full thickness rectal prolapse: a single centre review.

INTRODUCTION: Full thickness rectal prolapse (FTRP) tends to be self-limiting in children and is usually managed expectantly. However, it may persist and therefore requires surgical correction. There is no consensus upon operative management, and no one procedure has uniformly good outcomes. The aim of this study was to determine whether pre-operative diagnostic dMRI findings might help identify the operative approach best suited to the anatomical abnormality of the individual child. METHODS: A retrospective review of ten children with persistent FTRP who had been evaluated pre-operatively with dMRI between 2002 and 2010 was performed. In this preliminary work, MRI findings were not used to direct surgical management. Data collected included: age at presentation, underlying medical conditions, timing and findings of dMRI (specifically, descent of rectum from pubococcygeal (PC) line on straining), timing and type of surgery, surgical outcomes, and length of follow-up. RESULTS: Ten children (two female) with a median age of 11 years 2 months (range 8-15 years) with FTRP refractory to conservative treatment underwent diagnostic pre-operative dMRI. Median perineal descent from PC line on straining during dMRI was 3.5 cm (range 1-4 cm). Three of the seven children with severe descent initially underwent a Delorme's procedure, and all required surgical revision. Five with severe descent and one with moderate descent achieved a cure following rectopexy. Two patients with mild descent underwent a Delorme's procedure. One achieved a cure, and the other developed recurrence. Of the ten patients, seven had no prolapse at the last clinic review, and three have persisting symptoms. Median follow-up was 3.5 years (range 1-6). CONCLUSION: The findings from this small study favour rectal suspension techniques for surgical management of moderate to severe perineal descent on dMRI. Delorme's procedure should only be applied to those with mild descent. Pre-operative dMRI assessment may have a potential role in guiding surgical intervention for children. However, future prospective studies will be required to confirm this assertion.

Prospective randomized double-blind study of temporary sacral nerve stimulation in patients with rectal evacuatory dysfunction and rectal hyposensitivity.

OBJECTIVE: Prospective randomized double-blind placebo-controlled crossover trial of 14 female patients (median age 52 [30-69] years) with proctographically defined evacuatory dysfunction (ED) and demonstrable rectal hyposensitivity (elevated thresholds to balloon distension in comparison with age- and sex-matched controls). BACKGROUND: Sacral nerve stimulation (SNS) is an evolving treatment for constipation. However, variable outcomes might be improved by better patient selection. Evidence that the effect of SNS may be mediated by modulation of afferent signaling promotes a role in patients with ED associated with rectal hyposensation. METHODS: SNS was performed by the standard 2-stage technique (temporary then permanent implantation). During a 4-week period of temporary stimulation, patients were randomized ON-OFF/OFF-ON for two 2-week periods. Before insertion (PRE), and during each crossover period, primary (rectal sensory thresholds) and secondary (bowel diaries, constipation, and GIQoL [gastrointestinal quality of life] scores) outcome variables were blindly assessed. RESULTS: Thirteen patients completed the trial. Following stimulation, defecatory desire volumes to rectal balloon distension were normalized in 10 of 13 patients (PRE: mean 277 mL [234-320] vs ON: 163 mL [133-193] vs OFF: 220 mL [183-257 mL]; P = 0.006) and maximum tolerable volume in 9 of 13 (PRE: mean 350 mL [323-377] vs ON: 262 mL [219-305] vs OFF: 298 mL [256-340 mL]; P = 0.012). There was a significant increase in the percentage of successful bowel movements (PRE: median 43% [0-100] vs ON: 89% [11-100] vs OFF: 83% [11-100]; P = 0.007) and Wexner constipation scores improved (PRE: median 19 [9-26] vs ON: 10 [6-27] vs OFF: 13 [5-29]; P = 0.01). There were no significant changes in disease-specific or generic quality of life measures. Eleven patients progressed to permanent stimulation (9/11 success at 19 months). CONCLUSIONS: Most patients with chronic constipation secondary to ED with rectal hyposensitivity responded to temporary SNS. The physiological results presented support a mechanistic role for rectal afferent modulation.

Fecal incontinence in men: coexistent constipation and impact of rectal hyposensitivity.

BACKGROUND: The pathophysiology of fecal incontinence in men is poorly established. OBJECTIVE: The aim of this study was to assess the coexistence of constipation and determine the impact of rectal sensorimotor dysfunction in males with fecal incontinence. SETTING: This study was conducted at a tertiary referral center. PATIENTS: Included were adult male patients referred for the investigation of fecal incontinence over a 5-year period who underwent full anorectal physiology testing and completed a standardized symptom questionnaire. INTERVENTION: Standardized symptom questionnaires were fully completed, and anorectal physiologic test results (including evacuation proctography) were evaluated. MAIN OUTCOME MEASURES: : The primary outcomes measured were the frequency of symptoms of associated constipation, the association of blunted rectal sensation (rectal hyposensitivity) with symptoms, and other physiologic measures. RESULTS: One hundred sixty patients met the inclusion criteria, and 47% of these patients described concurrent constipation. Fifty-four patients (34%) had sphincter dysfunction on manometry, only 19 of whom had structural abnormalities on ultrasound. Overall, 28 patients (18%) had rectal sensory dysfunction, 26 (93%) of whom had rectal hyposensitivity. Patients with rectal hyposensitivity were more likely to subjectively report constipation (77%) in comparison with patients with normal rectal sensation (44%; p = 0.001), allied with decreased bowel frequency (19% vs 2%; p = 0.003) and a sense of difficulty evacuating stool (27% vs 8%; p = 0.008). Cleveland Clinic constipation scores were higher in patients with rectal hyposensitivity (median score, 13 (interquartile range: 8-17) vs normosensate, 9 (5-13); p = 0.004). On proctography, a higher proportion of patients with rectal hyposensitivity had protracted defecation (>180 s; 35% vs 10%; p = 0.024) and incomplete rectal evacuation (<55% of barium neostool expelled, 50% vs 20%; p = 0.02). LIMITATIONS: : This study was limited by the retrospective analysis of prospectively collected data. CONCLUSIONS: Only one-third of incontinent men had sphincteric dysfunction. Other pathophysiologies must therefore be considered. Nearly half of patients reported concurrent constipation, and one-sixth had rectal hyposensitivity, which was associated with higher frequencies of both symptomatic and objective measures of rectal evacuatory dysfunction. In the majority of adult males, fecal incontinence may represent a secondary phenomenon.

Selection matters-a regional survey of UK consultant opinion on selection into postgraduate surgical and medical training.

BACKGROUND AND AIMS: Recent changes to postgraduate training in the United Kingdom have led to considerable debate regarding selection processes for specialist training (ST) positions. A survey of the opinion of a group of consultants on the relative importance of selection criteria for entry into the first year of specialist training (ST 1) was conducted. METHODS: An electronic questionnaire was sent to the e-mail addresses of all consultants at 4 hospitals in London with a request to rank order the importance of specific selection criteria when assessing (1) a candidate's suitability for entry into ST 1, (2) the fairest shortlisting mechanism, and (3) whether an interview should be a necessity for appointment. RESULTS: Of 657 consultants successfully contacted, 212 (32%) replied. Previous specialty-specific experience gained during foundation (intern-level) training was considered the most important criteria in assessing suitability for entry into ST 1 with additional research degrees second most important. A conventional curriculum vitae (CV) was considered the fairest way of shortlisting candidates, whereas a nationalized final undergraduate examination (Final MB) was least favored. Ninety-five percent of respondents felt that an interview was essential for appointment to ST 1. CONCLUSIONS: Consultants place the most emphasis on previous specialty-specific experience and additional research degrees when considering selection for ST 1, bringing into question the generic nature of foundation training. Consultants preferred to maintain some subjective controls over purely objective markers in the selection process. Thus, there is little support for a nationalized ranked examination as a shortlisting tool, and an interview is recognized as essential for appointment to ST 1. There is a need to build on these preliminary findings by conducting further investigations before changes to selection methodology are implemented.

Diagnostic peritoneal lavage and ultrasonography for blunt abdominal trauma: attitudes and training of current general surgical trainees.

OBJECTIVE: It has been suggested that diagnostic peritoneal lavage is now obsolete in UK hospitals with access to either skilled ultrasonography or emergency physician or surgeon-performed focused abdominal sonography in trauma. Diagnostic peritoneal lavage continues to be advocated and taught on Advanced Trauma Life Support courses. The aim of this study was to evaluate the experiences and attitudes of general-surgery trainees in one UK training region towards diagnostic peritoneal lavage and focused abdominal sonography in trauma in managing blunt abdominal trauma. METHODS: An anonymous postal piloted questionnaire was sent to all 66 general surgery specialist trainees in one UK training region between January and March 2005. RESULTS: Out of 40 replies to the questionnaire (response rate 61%), 53% and 38% of surgical trainees had either never performed or never observed a diagnostic peritoneal lavage during their training. Thirteen trainees (33%) felt diagnostic peritoneal lavage to be obsolete and would never contemplate using it; 15 trainees (37%) might consider using diagnostic peritoneal lavage if computed tomography or ultrasonography were unavailable. Ten trainees (25%) felt that diagnostic peritoneal lavage had been superseded by computed tomography. Only 12 trainees (30%) had worked in a UK hospital with access to facilities for focused abdominal sonography in trauma and only seven trainees (18%) had received any training or experience in focused abdominal sonography in trauma. CONCLUSIONS: Surgical trainees in one UK training region lack skills in both diagnostic peritoneal lavage and focused abdominal sonography in trauma for managing blunt abdominal trauma and are therefore reliant upon the availability of prompt, skilled radiological assistance or emergency physician-provided focused abdominal sonography in trauma.