Fundus-first transumbilical single-incision laparoscopic cholecystectomy with a cholangiogram: a feasibility study.

BACKGROUND: An increasing number of techniques are emerging in the literature describing single-incision laparoscopic cholecystectomy (SILC). The advent of a new surgical approach is a reminder of the increase in bile duct injuries in the past when laparoscopic cholecystectomy was first introduced. With this in mind, the authors describe a safe and reproducible approach to SILC. METHODS: Between August 2008 and August 2009, 20 patients with symptomatic gallbladder disease underwent SILC using a totally transumbilical fundus-first approach with an intraoperative cholangiogram. Data including pain scores were collected prospectively. RESULTS: In this initial series, the median operative time was 103 min (range, 55-177 min), including the time for two patients undergoing additional procedures at the time of surgery. Intraoperative cholangiograms were completed for 18 of 19 patients. Additional ports were required in four patients for safe completion of the procedure. The mean pain score 12 h postoperatively was 2.5 on a visual analogue scale with a range of 0-10. There was no morbidity or mortality. CONCLUSION: According to the findings, SILC with an intraoperative cholangiogram can be performed safely using a fundus-first approach. However, for SILC to become the operation of choice for the treatment of gallbladder disease, evidence is required to demonstrate its advantage over laparoscopic cholecystectomy.

Day-surgery laparoscopic cholecystectomy: factors influencing same-day discharge.

BACKGROUND: Day-surgery laparoscopic cholecystectomy (LC) should be the procedure of choice in patients with symptomatic gallstone disease. This article assesses feasibility, patient outcome and predictive factors for successful day-case laparoscopic cholecystectomy. METHOD: A retrospective analysis of our prospective database of 176 patients following laparoscopic cholecystectomy in a day-surgery unit was performed. A telephone interview was conducted within 24 h after discharge and again after 3 weeks. RESULTS: Of the 176 cases included in this study, 74% had biliary colic, cholecystitis (16%), pancreatitis (8%), and jaundice (2%). In addition to LC, nine patients (5.1%) underwent laparoscopic bile duct exploration and ten (5.7%) had an additional procedure performed. Eighty-six percent of the patients were discharged the same day. Multivariate analysis identified risk factors affecting same-day discharge, including age greater than 50 years and intraoperative complications. Bile duct exploration reduced the odds of discharge but did not reach significance. Postoperative telephone interviews identified high patient satisfaction with 86% of respondents recommending LC as a day-surgery procedure. CONCLUSION: Day-surgery LC is a safe procedure with an acceptable rate of patient discharge. However, intraoperative complications or age over 50 years adversely affected the same-day discharge rate and as such should be taken into consideration when planning day-case laparoscopic cholecystectomy.

Nurses', midwives' and health visitors' involvement in cross-boundary working within child health services.

BACKGROUND: Cross-boundary working is a key policy objective. Cross-boundary working provides the foundation for high quality provision across child health services and is imperative for an effective child protection system and the support of children and young people with health needs. METHODS: Two participative conferences were attended by 113 stakeholders utilizing the World Café focus group method. Most (87%) of the sample were nurses, midwives or health visitors. RESULTS: Many examples of cross-boundary working were identified across the different areas of practice. Remarkably few transdisciplinary examples were identified in contrast to the number of inter-agency examples. Intra-organizational boundaries across the health service were also noted. CONCLUSIONS: Considerable cross-boundary working was reported but transdisciplinary working is not yet well established across all areas of child health provision.