Automated analysis of intraoperative phase in laparoscopic cholecystectomy: A comparison of one attending surgeon and their residents.

OBJECTIVE: This study compares the intraoperative phase times in laparoscopic cholecystectomy performed by an attending surgeon and supervised residents over 10-years to assess operative times as a marker of performance and any impact of case severity on times. DESIGN: Laparoscopic cholecystectomy videos were uploaded to Touch Surgery™ Enterprise, a combined software and hardware solution for securely recording, storing, and analysing surgical videos, which provide analytics of intraoperative phase times. Case severity and visualisation of the critical view of safety (CVS) were manually assessed using modified 10-point intraoperative gallbladder scoring system (mG10) and CVS scores, respectively. Attending and residents' times were compared unmatched and matched by mG10. SETTING: Secondary analysis of anonymized laparoscopic cholecystectomy video, recorded as standard of care. PARTICIPANTS: Adult patients who underwent elective laparoscopic cholecystectomy a single UK hospital. Cases were performed by one attending and their residents. RESULTS: 159 (attending=96, resident=63) laparoscopic cholecystectomy videos and intraoperative phase times were reviewed on Touch Surgery™ Enterprise and analyzed. Attending cases were more challenging (p=0.037). Residents achieved higher CVS scores (p=0.034) and showed longer dissection of hepatocystic triangle (HCT) times (p=0.012) in more challenging cases. Residents' total operative time (p=0.001) and dissection of HCT (p=0.002) times exceeded the attending's in low-severity matched cases (mG10=1). Residents' total operative times (p<0.001), port insertion/gallbladder exposure (p=0.032), and dissection of HCT (p<0.001) exceeded the attending's in matched cases (mG10=2). Residents' total operative (p<0.001), dissection of HCT (p<0.001), and gallbladder dissection (p=0.010) times exceeded the attendings in unmatched cases. CONCLUSIONS: Residents' total operative and dissection of HCT times significantly exceeded the attending's unmatched cases and low-severity matched cases which could suggest training need, however, also reflects an expected assessment of competence, and validates time as a marker of performance.

Local Protocol for Management of Low-Grade Appendiceal Mucinous Neoplasm (LAMN).

The management and surveillance of low-grade appendiceal mucinous neoplasm (LAMN) is a confusing topic in the colorectal MDM. This study was aiming to provide a local protocol for our trust for such cases. From prospectively maintained database, patients who underwent appendicectomy between 2011 and 2017 were identified. Those with histological confirmation of LAMN were included. Retrospective analysis of operative notes, investigations and follow-up, return to theatres or development of pseudomyxoma peritonei (PMP) was performed. Four thousand six hundred twenty-eight patients had appendicectomy; 36 were diagnosed with LAMN. Age range was 30-88 (20 females). Fifteen had their operation as emergency and 13 elective, either for abnormal-looking appendix on CT scan or as part of elective right hemicolectomy. In 8 patients, LAMNs were diagnosed incidentally during other surgery either intraoperatively or on histology. Two patients had mucus in the peritoneal cavity (not sampled). The remaining 34 had either contained mucocele or inflamed appendix. Regarding follow-up, 28 patients had CT scans only, and 2 had ultrasound scan (USS). Two had both CT and USS. Three had CT and MRI scans. One patient did not have radiological investigations. Eighteen patients had colonoscopies (50%). Three patients had no follow-up, while 33 had 5-year follow-up. Ten patients are still currently under follow-up. None of the 36 patients required further surgeries related to LAMN, and none has developed PMP to date of the study. We have developed a local protocol based on our findings and literature review for management and surveillance of LAMN in line with national centres.

Prevascular femoral hernia and its relation with inferior epigastric vessels: a rare presentation of the femoral hernia sac.

A 61-year-old man presented to the emergency department, with a 2-week history of a painful lump on his right groin. A diagnosis of an irreducible right femoral hernia was made. As such, an urgent operation was carried out on the same day, and the patient was found to have a rare prevascular femoral hernia in which the sac was lying over the femoral vessels and split by the inferior epigastric vessels into 2 components resembling 2 trouser limbs. The hernia sac presented in a different and challenging way that necessitated meticulous dissection and full orientation of the anatomy of the femoral triangle. Complete dissection and control of the inferior epigastric vessels, and complete reduction of the sac followed by repair with a prosthetic mesh plug were performed successfully. The patient was discharged home the next day.

Ergonomics in Laparoscopic Surgery--A Survey of Symptoms and Contributing Factors.

PURPOSE: We aimed to investigate physical/cognitive symptoms experienced by clinicians undertaking laparoscopic surgery (LS) in relation to demographics, operating factors, and instruments. METHODS: Fifty trainees/consultants practicing LS in Southeast England completed a 17-question survey. Results were analyzed using nonparametric tests of metric, ordinal, and binomial data. RESULTS: Forty-five percent of respondents reported moderate/severe symptoms during long cases (>2 h). Worse neck/shoulder (N=45, P=0.01), back (N=44, P=0.002), and fatigue/irritability (N=42, P=0.02) symptoms were reported for long (vs. short) cases. Assistants reported worse back symptoms than principle operators (N=43, P=0.02, long cases). Females (vs. males), glove size ≤6.5 (vs. ≥7.0), and experience ≤5years (vs. 5 to 10, >10 y) reported worse symptoms relating to handle dimensions (N=45, P=0.004, 0.001, 0.01, respectively). Ninety-six percent believe ergonomics should be incorporated into LS courses. CONCLUSIONS: Principle and assistant surgeons experience adverse symptoms during LS; ergonomics training and handles dimensions, accommodating female surgeons, and smaller glove sizes may reduce this.

Reversed rotation of the midgut in adults--a case report.

Intestinal obstruction is a common surgical emergency. It is often due to adhesions; however, when the patient is young and has a virgin abdomen, we have to consider uncommon causes. We present a rare case of reversed rotation of the midgut as a cause for intestinal obstruction.

Accidental ingestion of a cocktail stick.

Cocktail stick (CS) ingestion injury has rarely been reported in the literature. It is a serious clinical problem with considerable morbidity and mortality, largely due to the fact that the event is unnoticed by the patient. We report a case of CS ingestion that went unrecognised by the patient and caused a perforation in the mid-small bowel. We discuss how injuries from such events can become a diagnostic challenge. The history should be re-evaluated in any undiagnosed abdominal pain which has an unclear aetiology and negative radiology.

An "all 5-mm ports" versus conventional ports approach to laparoscopic cholecystectomy and Nissen fundoplication: a randomized clinical trial.

BACKGROUND: Although needlescopic surgery may reduce postoperative pain, the use of 3-mm instruments is cumbersome and has not gained popularity. We have described an "all 5-mm ports" approach to laparoscopic cholecystectomy (LC) and Nissen fundoplication (LNF). METHODS: Selected patients were randomized to undergo LC or LNF using either the "all 5-mm ports" approach (group 1) or the conventional approach (group 2) that used two 10-mm ports and two or three 5-mm ports. The patients and investigator were blinded to the size of ports used. RESULTS: Forty patients (20 in each group) were randomized. The groups were comparable for age, sex, and type and duration of surgery. No significant reductions in analgesic requirements at 7 days or in pain scores at 4 and 24 hours postoperatively were detected with the "all 5-mm ports" approach. However, the cosmetic satisfaction scores with the body (P=0.029), incisions (P=0.015), and scars (P=0.023) 4 weeks after surgery were significantly higher in group 1. CONCLUSIONS: The "all 5-mm ports" approach to LC and LNF in selected patients did not offer clear advantages over the conventional approach in terms of postoperative pain or analgesic requirements. Nevertheless, the former approach enjoyed a superior cosmetic outcome and patient acceptability.

Laparoscopic removal of a huge gastric trichobezoar in a patient with trichotillomania.

Gastric bezoars are rare, and are commonly observed in female children with mental or emotional disorders. Large bezoars may not be suitable for endoscopic extraction and are conventionally removed at laparotomy. We present a 19-year-old girl who had trichotillomania with a symptomatic abdominal mass that represented a 17-cm gastric trichobezoar. This was removed laparoscopically through a gastrotomy in a water-impervious bag and was extracted piecemeal through a 4-cm extension of one of the port wounds. The bezoar weighed 720 g. She was discharged home on the third postoperative day and remains symptom-free at 12-month follow-up. Laparoscopic removal of large gastric trichobezoars is feasible and appears safe.

Closed blunt-trocar 5 mm-port for primary cannulation in laparoscopic surgery: A safe technique.

Primary cannulation of the peritoneal cavity is a critical part of laparoscopic surgery. The aim of this study was to evaluate the safety and applicability of a direct blunt-port primary cannulation. The peritoneal cavity was accessed by direct trocar-port insertion at sites other than the umbilicus and avoiding abdominal scars. A 5-mm port with a smooth blunt tip conical trocar was employed using a closed technique. The closed blunt trocar-port technique for primary cannulation of the peritoneal cavity was applied in 503 of 524 patients (96%) who underwent laparoscopic surgery between 2002 and 2005. Some 199 patients (38%) had abdominal scars of previous surgery. There were no major complications, but minor complications occurred in 3 patients (0.6%). No bowel or retroperitoneal vascular injuries were encountered. The closed introduction of a blunt-tipped 5-mm port, conical-trocar is a simple technique for primary cannulation in laparoscopic surgery that allows safe and rapid access to the peritoneal.

Laparoscopic versus open splenectomy for massive splenomegaly: a comparative study.

BACKGROUND: Despite the benefits of the laparoscopic approach to splenectomy, its application in patients with massive splenomegaly (splenic weight >or= 1000 g) remains controversial. In this study we evaluated the safety and feasibility of laparoscopic splenectomy for massive splenomegaly compared with open splenectomy. MATERIALS AND METHODS: One surgeon applied the laparoscopic approach to splenectomy to all comers with massive splenomegaly, while other surgeons carried out the surgery through a laparotomy. The outcomes of the two approaches were compared on an intention-to-treat basis. Results of continuous variables are shown as medians. RESULTS: Fifteen patients underwent laparoscopic splenectomy between 2000 and 2005, and 13 underwent open splenectomy between 1996 and 2003. The two groups were comparable for age, sex, American Society of Anesthesiologists score, and splenic weight (1.3 vs. 1.1 kg). There was one conversion (6.6%) to open surgery. Although laparoscopic splenectomy was associated with significantly longer operating time (175 vs. 90 minutes, P < 0.001), it carried lower postoperative morbidity and mortality (13.3 vs. 30.8% and 0 vs. 7.7%, respectively). Laparoscopic splenectomy was associated with significantly lower total dose (29 vs. 264 mg morphine-equivalent, P < 0.0001) and duration of opiate usage (1 vs. 4 days, P < 0.0001); duration of parenteral hydration (24 vs. 96 hours, P = 0.006) and more rapid resumption of oral diet (24 vs. 72 hours, P = 0.017); and a shorter postoperative hospital stay (3 vs. 10 days, P < 0.0001). CONCLUSIONS: The laparoscopic approach to splenectomy for massive splenomegaly is feasible and safe. Despite a longer operating time, the postoperative recovery following laparoscopic splenectomy is smoother, with lower morbidity and shorter postoperative hospital stay compared with open splenectomy.

Laparoscopic gastric and biliary bypass: a single-center cohort prospective study.

PURPOSE: Relief of gastric outlet and distal biliary obstruction may be accomplished by open surgery or by minimally invasive techniques including endoscopic and laparoscopic approaches. We examined the feasibility and safety of laparoscopic gastric and biliary bypass in all patients with malignant and benign disease requiring surgical relief of obstructive symptoms. MATERIALS AND METHODS: Patients with benign duodenal stricture or inoperable malignancy underwent therapeutic laparoscopic bypass surgery. Prophylactic gastric or biliary bypass was added in selected patients with nonmetastatic malignancy. RESULTS: Twenty-eight patients (17 of them female) with a median age of 67 years (range, 26-81 years) underwent 29 laparoscopic bypass procedures for malignant (n = 23) or benign (n = 6) disease. One patient who underwent a Roux-en-Y gastrojejunostomy for non-steroidal anti-inflammatory drug induced ulcer disease developed stenosis of the stoma that required laparoscopic refashioning 2 months later, accounting for the 29th procedure reported herein in 28 patients. Surgery included the construction of a single gastric (n = 16) or biliary (n = 5) bypass or a double bypass (n = 8), and an additional prophylactic bypass in 5 of 23 cancer patients (21.8%). All procedures were completed laparoscopically. The median operative time was 90 minutes (range, 60-153 minutes) and mean postoperative hospital stay was 4 days (range, 3-6 days). Complications developed following 4 procedures (13.8%) and 1 patient died (3.4%). No complications occurred in patients with prophylactic bypass. One patient required laparoscopic revision of the gastroenterostomy 2 months postoperatively, for benign disease. No recurrence of obstructive symptoms was observed in cancer patients during follow-up. CONCLUSION: Laparoscopic bypass surgery for distal biliary and gastric obstruction in patients with benign or malignant disease results in low morbidity and mortality and short postoperative hospital stay. The addition of prophylactic bypass in patients with nonmetastatic unresectable malignancy appears safe and effective.

An "all 5-mm ports" selective approach to laparoscopic cholecystectomy, appendectomy, and anti-reflux surgery.

Laparoscopic appendectomy, cholecystectomy, or anti-reflux procedures are conventionally performed with the use of one and often two 10/12-mm ports. While needlescopic or micropuncture laparoscopic procedures reduce postoperative pain, they invariably involve the use of one 10/12-mm port and the instruments applied have their ergo-dynamic shortcomings. Between September 2002 and March 2003, we have attempted an "all 5-mm ports" approach in 49 laparoscopic procedures, which included 18 of 59 laparoscopic cholecystectomies (31%), 26 diagnostic laparoscopies for suspected appendicitis (of which we proceeded to a laparoscopic appendectomy in 17 patients), and in the last 5 of 9 laparoscopic Nissen fundoplications. Conversion of one of the 5-mm ports to a 10-mm port was required in 5 of the 18 (28%) laparoscopic cholecystectomies and in 6 of the 17 (35%) laparoscopic appendectomies to facilitate organ retrieval in patients with large gallstones (>5 mm in diameter) and in obese patients with fatty mesoappendix. There were no conversions to open surgery. No significant differences in the operating time between the laparoscopic procedures performed by the all 5-mm ports approach or the conventional approach were observed. No intraoperative or postoperative complications occurred in this series. The "all 5-mm ports" approach to laparoscopic cholecystectomy and appendectomy in selected patients and to laparoscopic fundoplication appears feasible and safe. A randomised comparison between this approach and the conventional laparoscopic approach to elective cholecystectomy and fundoplication in which two of the ports employed are of the 10-mm diameter is warranted.