Giant Intrahepatic Subcapsular Haematoma: A Rare Complication following Laparoscopic Cholecystectomy-A Case Report and Literature Review.

We report on a 59-year-old female with symptomatic cholelithiasis on a background of morbid obesity who underwent an elective LC with an uncomplicated intraoperative course; however, she experienced a refractory hypotension within one hour postoperatively with an acute haemoglobin drop requiring fluid resuscitation and blood transfusion. A triphasic computed tomography scan revealed a large intrahepatic subcapsular haematoma (ISH) measuring 21 cm × 3.1 cm × 17 cm surrounding the lateral surface of the right hepatic lobe without active bleeding. She was managed conservatively with serial monitoring of haemoglobin and haematoma size. A follow-up ultrasound scan after eight weeks confirmed complete resolution of the haematoma. Giant ISH is a fairly rare, but life-threatening complication following LC which merits special attention. This case demonstrates the necessity of close postoperative monitoring of patients undergoing LC and considering the possibility of ISH, although being rare event, in those who experience a refractory postoperative hypotension. It also highlights the decisive role of diagnostic imaging in securing a timely and accurate diagnosis of post LC-ISH.

Correction to: Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial.

In the original publication, one of the co-author 'M. Riaz' details were missed to include in the author group. The complete author group should read as A. Mughal, A. Khan, J. Rehman, H. Naseem, M. Riaz, R. Waldron, M. Duggan, W. Khan, K. Barry, I. Z. Khan.

Laparoscopic-assisted transversus abdominis plane block as an effective analgesic in total extraperitoneal inguinal hernia repair: a double-blind, randomized controlled trial.

PURPOSE: Laparoscopic inguinal hernia repair has facilitated early mobilization. Management of post-operative pain is paramount in these day case procedures. The aim of this study was to compare laparoscopic-assisted transversus abdominis plane (TAP) block with periportal local anaesthetic infiltration in managing post-operative pain. METHODS: A double-blind, randomized controlled trial was conducted with patients undergoing elective laparoscopic inguinal hernia repair (January 2016-October 2017). The intervention group received laparoscopic-assisted TAP block with 30 ml 0.25% Bupivacaine. The control group received 15ml of 0.5% Bupivacaine at the periportal sites. Primary outcome measure was assessment of post-operative pain scores using numerical rating on visual analogue scale (VAS) at rest and on coughing at 3 h. Efficacy of TAP block was assessed as reduction in mean pain scores in the order of 2 points using the VAS. RESULTS: 60 (57 males and 3 females) were enrolled; 30 patients were randomized to each group. Patient demographics, anaesthetic and surgical times were similar in both groups. Mean pain scores were significantly reduced in the intervention group at 3 (3.1 vs 1.1 p < 0.001) and 6 h (4.1 vs 1.7 p < 0.001) at rest and on coughing at 3 (4.8 vs 2.1 p < 0.001) and 6 h (5.4 vs 3.0 p < 0.001). Patient satisfaction was higher (8.0 vs 6.8 p < 0.001) and rescue analgesic requirements (169.4vs 71.3 p < 0.001) lower in the intervention group. CONCLUSIONS: This analysis has demonstrated the therapeutic benefit of laparoscopic-assisted TAP block in initial post-operative pain management for patients undergoing elective laparoscopic inguinal hernia repair.

The pharmacokinetics of cytarabine administered subcutaneously, combined with prednisone, in dogs with meningoencephalomyelitis of unknown etiology.

The objective of this study was to describe the pharmacokinetics (PK) of cytarabine (CA) after subcutaneous (SC) administration to dogs with meningoencephalomyelitis of unknown etiology (MUE). Twelve dogs received a single SC dose of CA at 50 mg/m2 as part of treatment of MUE. A sparse sampling technique was used to collect four blood samples from each dog from 0 to 360 min after administration. All dogs were concurrently receiving prednisone (0.5-2 mg kg-1 day-1 ). Plasma CA concentrations were measured by HPLC, and pharmacokinetic parameters were estimated using nonlinear mixed-effects modeling (NLME). Plasma drug concentrations ranged from 0.05 to 2.8 µg/ml. The population estimate (CV%) for elimination half-life and Tmax of cytarabine in dogs was 1.09 (21.93) hr and 0.55 (51.03) hr, respectively. The volume of distribution per fraction absorbed was 976.31 (10.85%) ml/kg. Mean plasma concentration of CA for all dogs was above 1.0 µg/ml at the 30-, 60-, 90-, and 120-min time points. In this study, the pharmacokinetics of CA in dogs with MUE after a single 50 mg/m2 SC injection in dogs was similar to what has been previously reported in healthy beagles; there was moderate variability in the population estimates in this clinical population of dogs.

Prospective validation of neutrophil-to-lymphocyte ratio as a diagnostic and management adjunct in acute appendicitis.

BACKGROUND: No optimal biomarker exists that accurately diagnoses appendicitis or predicts severity, estimates post-operative complications or total length of hospital stay (LOS). AIM: To prospectively validate the utility of neutrophil-to-lymphocyte (NLR) ratio in predicting the severity of appendicitis, LOS, and 30-day complication rates. METHODS: Patients who were admitted with a provisional diagnosis of acute appendicitis over a period of 18 months (Oct 2014-April 2016) were included. Patient demographics and blood results were prospectively collected. Details of imaging, operative intervention, severity of appendicitis, length of stay, and 30-days post admission complications were recorded. Recommended cut-off values of NLR and C-reactive protein for severity of appendicitis were determined using receiver operating characteristic analysis (ROC). These cut-off values were compared with C-reactive protein levels. Mann-Whitney test was performed to assess the correlations between LOS and 30-day complications to NLR. RESULTS: Four hundred fifty-three patients were included in the study; 55.2% (n = 245) were female with mean patient age of 23 years. Two-thirds (n = 281, 62.03%) underwent operative management. Histologically, appendicitis was confirmed in 214 (76%) patients. A NLR of >6.36 or CRP of >28 were statistically associated with complicated acute appendicitis, with a median of one extra hospital day (p < 0.0001). Mean NLR was statistically higher in patients with post-operative complications (14.42 vs. 7.29 for simple appendicitis group, p < 0.001). CONCLUSION: This confirms previous reports that NLR is a simple, readily available adjunct in predicting severity of appendicitis. Additionally, it can aid delineating severe appendicitis that should proceed to surgery without substantial delay.

Adherence to clinical guidelines and the potential economic benefits of admission avoidance for acute uncomplicated diverticulitis.

BACKGROUND: The treatment paradigm for acute diverticulitis is changing. There is an increasing trend towards managing patients with uncomplicated diverticulitis in the community. AIMS: The aim of this study was to analyse how acute diverticulitis is managed in our institution and also to analyse national data pertaining to treatment of acute diverticulitis. METHODS: A prospective database of all patients admitted to our institution over a 2-year period (2014-2016) with acute diverticulitis was maintained. Severity of disease, treatment received and average length of stay (LOS) were analysed for all patients. Contemporaneous hospital inpatient enquiry (HIPE) data was interrogated to analyse current management for acute diverticulitis at a national level. RESULTS: One hundred twenty-six patients were admitted to our institution with acute diverticulitis during the study period (inpatient stay = €1277/night). Of patients, 59.5% had uncomplicated diverticulitis while 40.5% had complicated disease. The median LOS was 4 (range 1-34) days and 8 (range 2-51) days in the uncomplicated and complicated group, respectively. Based on HIPE data, there were 11,357 patients with uncomplicated diverticulitis and 526 patients with complicated diverticulitis admitted to Irish hospitals in the year 2015. Nationally, the median LOS for those with uncomplicated diverticulitis was 3 (range 1-142) days and for those with complicated diverticulitis the median LOS was 7 (range 1-308) days. Projected total cost for hospital stay nationally for uncomplicated diverticulitis amounted to €43.5 million for the year 2015. CONCLUSIONS: At present, uncomplicated diverticulitis in Ireland is not being managed as per evidence-based guidelines. Changing practice could result in significant cost savings for surgical departments.

Undergraduate basic surgical skills education: impact on attitudes to a career in surgery and surgical skills acquisition.

INTRODUCTION: Basic surgical skills modules in medical education are effective in teaching skills and increasing confidence among students approaching surgery. However, these modules are not delivered universally and their effect on the professional development of graduates has not been established. We aimed to assess the impact of a 10-week basic surgical skills module on attitudes and technical skills of first year medical students compared to interns. METHODS: Eighteen students participated and were assessed using a 4-part questionnaire. Technical skills were assessed by observing students perform a basic interrupted suture, using the objective structured assessment of technical skills (OSATS) tool. Fourteen interns were recruited. RESULTS: Students were more confident in surgical scrubbing (mean score 4.0 vs. 2.86, p = 0.001), and performing a basic suture (4.05 vs. 1.93, p = 0.000), more enthusiastic about assisting with an operation (4.5 vs. 3.0, p = 0.001) and more likely to consider a career in surgery (4.16 vs. 2.28, p = 0.000). Technical skills were greater in the student group (mean score 30.8 vs. 19.6, p = 0.001). Five interns had taken part in surgical skills modules as undergraduates. Their technical skills were significantly higher compared to interns who had not (n = 9) (28.8 vs. 14.5, p = 0.006), and they were more likely to consider a career in surgery (3.6 vs. 1.5, p = 0.036). CONCLUSION: The introduction of surgical skills teaching to the undergraduate medical curriculum has a positive impact on students' attitudes towards surgery and accelerates basic technical skills development. Consideration should be given to development of a standardised undergraduate core curriculum in basic surgical skills teaching.

A national evaluation of the management practices of acute diverticulitis.

INTRODUCTION: Diverticulitis is a common surgical admission that presents with a wide range of symptoms and severity. Overall there has been a shift to conservative management practices, including the consideration of non-antibiotic treatment approaches in select cases. METHODS: A national survey of all consultant surgeons evaluating their practices was performed. Reasons for changes in management, use of radiological imaging, role of non-antibiotic treatment approaches and indications for elective surgical management were evaluated. RESULTS: Response rate for this survey was 67.7% (n = 67/99). An overwhelming 92.5% stated that computed tomography imaging was routinely used to investigate acute presentations. Interestingly, 22.4% stated they would consider a non-antibiotic treatment approach in uncomplicated diverticulitis. Main reasons for adopting this approach was low inflammatory markers with short duration of symptoms. Co-amoxiclav was the most common antibiotic used for acute diverticulitis, with considerable variability in duration of treatment. Additionally, there was considerable heterogeneity regarding how many recurrences were necessary before surgical management was required. CONCLUSION: This review highlights substantial variation in the management of diverticulitis across Ireland. Shifts to non-antibiotic treatment approaches for uncomplicated cases are observed, but less so than in Northern Europe. National guidelines are required to establish uniform treatment protocols including indications for surgical resection.

Shaped-bolus protocol reduces contrast medium volume in abdominal CT while maintaining image quality.

AIM: To prospectively assess whether bolus shaping to exponentially decrease the contrast medium injection rate leads to alteration in image validity or renal function. MATERIALS AND METHODS: In this prospective study, patients alternatively received 100 ml contrast medium versus 75 ml via bolus shaping. Image quality was assessed via measurement of attenuation values in the aorta, liver, and spleen and also blinded subjective assessment of image sharpness, low contrast detectability, image noise, and overall quality. Renal function was assessed by change in creatinine levels up to 72 hours post-contrast medium administration. RESULTS: Of 190 abdominal computed tomography (CT) studies performed in the 3-month period, 98 received the 75 ml dose. There was no significant difference in renal function or objective image quality with a significant improvement in image sharpness in the 100 ml group. CONCLUSIONS: By using bolus-shaping software, it is possible to maintain objective image quality while reducing the contrast medium load to the patient. This has significant implications regarding clinical practice in decreasing cost and risks associated with iodinated contrast media.

Magnitude of non-operative surgical emergency admissions; service implications for surgical and radiological practice.

BACKGROUND: Financial sustainability is an area of sharp ongoing focus across the broad spectrum of the Irish Health Service. Recent attention has been drawn to the financial implications of non-operative surgical admissions, suggesting that some of these may be unnecessary. AIMS: In this study, we aim to determine the volume of emergency surgical admissions to Mayo University Hospital (MUH), in particular, to identify the scale of non-operative admissions and to assess the wider inherent implications for acute hospital services. METHODS: An electronic handover system for emergency surgical admissions was introduced in MUH in September 2014. All surgical admissions from September 1st 2014 to August 31st 2015 were identified from this prospectively maintained database. HIPE (Hospital Inpatient Enquiry) data were not used in this study. Theatre logbooks confirmed those patients who required operative intervention. RESULTS: 1466 patients were admitted as emergencies during the study period. 58 % (850) were male and median age was 48 years (0-100). Average length of stay was 5 days (range 1-125). 327 patients (22.3 %) required operative intervention. The most commonly performed procedure was appendicectomy (52.5 %). 48 (3.3 %) patients were transferred to other hospitals. 131 (8.9 %) admissions related to the acute urological conditions. Of the 1466 admissions, 546 underwent a CT scan, while 342 patients proceeded to ultrasound. CONCLUSION: Almost 80 % of all surgical emergency admissions were discharged without undergoing a formal operative procedure while generating a significant workload for the radiology department. Changes in working practices and hospital network structures will be required to reduce the burden of non-operative emergency admissions.

Management of paediatric acute appendicitis in the general hospital setting: a national survey of preferred surgical technique.

BACKGROUND: The advent of laparoscopic surgery has facilitated the management of acute appendicitis in the adult population. In the paediatric population (<12 years), management varies according to institution and/or consultant expertise. The aim of this study was to analyse consultant preference for laparoscopic versus open appendicectomy in the management of acute appendicitis in children under 12 years presenting to general hospitals. METHODS: A 15-point questionnaire was distributed to 81 consultant surgeons identified from the specialist register of the Irish Medical Council and practicing as general surgeons outside of specialist paediatric centres. RESULTS: A response rate of 83 % (67/81) was obtained. Of the 67 surgeons surveyed, 11 (16 %) had formal paediatric training. Sixty percent (40/67) of surgeons expressed a preference for the open technique. The median frequency of on-call rota was >1 in 5 (32/67) and only 3 % (2/67) claimed that the on-call commitment influenced decision-making regarding surgical approach. The average minimum age (9.3 years, range 1-14) and average minimum weight (25 kg, range 12-70) at which the operating surgeon would perform a laparoscopic appendicectomy were also recorded. Thirty percent (20/67) of consultant general surgeons had immediate access to specialist paediatric laparoscopic equipment. DISCUSSION: This study has shown wide variability amongst consultant general surgeons when considering open versus laparoscopic appendicectomy in children under 12 years. Restricted access to specialist paediatric laparoscopic equipment, combined with declining exposure to paediatric surgical training, may continue to limit the numbers of paediatric laparoscopic appendicectomies performed in the general setting.

Sedation for gastroscopy: Is it an adequately understood and informed choice?

INTRODUCTION: Sedation uptake rates for oesophagogastroduodenoscopy (OGD) vary greatly. Issues concerning adequate information and consent have been raised. Additionally, patient comprehension of sedation options is inconsistent. METHODS: A closed ended questionnaire was created and delivered to assess patient understanding regarding sedation prior to OGD. The questionnaire was based on British Society of Gastroenterology guidelines. RESULTS: One hundred and eleven patients were recruited. 90 % of the sedated and 73 % of the unsedated patients were satisfied with their respective decisions (OR 0.283, *p = 0.01). 65 % were unaware of basic differences between conscious sedation and general anesthesia, and 37 % were unaware that driving is permitted after having throat spray alone. The most informed of the age groups had the lowest uptake of sedation and the least informed had the highest uptake. CONCLUSION: The decision to undergo gastroscopy with or without sedation is not a sufficiently informed one. This study highlights the need for the widespread dissemination of good quality information to inform patients better regarding sedation prior to OGD.

Unusual osseous metastases from rectal adenocarcinoma: a case report and review of the literature.

INTRODUCTION: Rectal adenocarcinoma typically metastasizes to the liver. When osseous spread occurs, it is most commonly detected in the vertebrae and pelvis. Distal osseous spread is unusual and may be the first presentation of the carcinoma. We present a review of the current literature on unusual osseous rectal adenocarcinoma metastases and highlight a case of a scapular lesion as the first presentation of rectal carcinoma from our institution. MATERIALS AND METHODS: A Pubmed search using keywords 'rectal carcinoma metastases,' 'colorectal cancer metastases' and 'skeletal metastases' was performed. RESULTS: Twenty-four cases were identified (54 % male, mean age at diagnosis 61 ± 16 years). The most common site was the mandible, followed by the foot. In four cases, the metastasis was the first presentation of the carcinoma. Mean time from resection of the primary tumour to osseous metastases diagnosis of skeletal metastases was 26 ± 17 (SD) months. Mean time from diagnosis of skeletal metastases to death was 3.2 (±2.8) months. CONCLUSION: Rectal adenocarcinoma osseous metastases located distal to the pelvis and/or vertebrae are rare and associated with a poor prognosis. Unusual bony lesions should raise an index of suspicion for distal carcinoma, including rectal carcinoma.

Utilisation of Clinical Networks to Facilitate Elective Surgical Workload; A Preliminary Analysis.

Clinical networks have potential to increase elective surgical workload for benign conditions in non-cancer centres. The aims of this study were to determine outcomes for elective laparoscopic cholecystectomy in our unit and to evaluate early experience in managing benign surgical workload referred from the tertiary centre within our clinical network. An analysis of cholecystectomies performed at Mayo General Hospital was conducted (2003-2013). A review of elective procedures more recently referred from Galway University Hospital (GUH) waiting lists was also conducted. 1937 consecutive cholecystectomies were performed with an overall laparoscopic conversion rate of 1.7% (33/1875). The total major complication rate was 0.93% (18/1937). 151 selected procedures originating from GUH have been performed since December 2013 without adverse events. Laparoscopic cholecystectomy can be performed in significant volume in the general hospital environment. This and other appropriate benign surgical procedures may be performed outside of tertiary units according to network agreements.

Operative surgical yield from general surgical outpatient clinics; time to change the way we practice?

The aim of this study was to compare the number of patients attending surgical outpatient clinics in a general hospital to the number of resulting elective procedures scheduled in a single year. Patients initially assessed at private consulting rooms are not included in this study. The number of surgical outpatient appointments issued in 2011 totalled 6503 with non-attendances running at 1489 (22.9%). The number of elective surgical theatre cases performed in 2011 (i.e. the surgical yield from that period) came to 1078 with an additional 1470 patients referred for endoscopy and 475 patients referred for minor operations. Operative surgical yield from the currently structured outpatient clinic model is low, with the number of theatre cases coming to only 16.58% of the original number of outpatient appointments issued. Recommendations for the improvement of outpatient services are made. These findings are relevant in the context of streamlining access to surgical services.

Higher surgical training opportunities in the general hospital setting; getting the balance right.

BACKGROUND: The general hospital can play an important role in training of higher surgical trainees (HSTs) in Ireland and abroad. Training opportunities in such a setting have not been closely analysed to date. AIMS: The aim of this study was to quantify operative exposure for HSTs over a 5-year period in a single institution. METHODS: Analysis of electronic training logbooks (over a 5-year period, 2007-2012) was performed for general surgery trainees on the higher surgical training programme in Ireland. The most commonly performed adult and paediatric procedures per trainee, per year were analysed. RESULTS: Standard general surgery operations such as herniae (average 58, range 32-86) and cholecystectomy (average 60, range 49-72) ranked highly in each logbook. The most frequently performed emergency operations were appendicectomy (average 45, range 33-53) and laparotomy for acute abdomen (average 48, range 10-79). Paediatric surgical experience included appendicectomy, circumcision, orchidopexy and hernia/hydrocoele repair. Overall, the procedure most commonly performed in the adult setting was endoscopy, with each trainee recording an average of 116 (range 98-132) oesophagogastroduodenoscopies and 284 (range 227-354) colonoscopies. CONCLUSIONS: General hospitals continue to play a major role in the training of higher surgical trainees. Analysis of the electronic logbooks over a 5-year period reveals the high volume of procedures available to trainees in a non-specialist centre. Such training opportunities are invaluable in the context of changing work practices and limited resources.

Beware the ischiorectal abscess.

INTRODUCTION: Ischiorectal abscesses have been shown to form sinuses with various deep structures but continuity with the spinal canal is extremely rare. PRESENTATION OF CASE: A previously healthy sixty-five year old man presented emergently with rectal pain, weight loss and recurrent severe tension headaches. He had systemic sepsis and resultant coagulapathy (INR 3.4) which precluded investigation of neurological symptoms by lumbar puncture. MRI rectum demonstrated a well circumscribed fluid collection with direct connection to the spinal canal and containing meningeal tissue. It extended inferiorly to the right ischiorectal fossa and abutted the natal cleft. A radiological diagnosis of ischiorectal abscess which had become continuous with a previously existing anterior sacral myelomeningocoele (ASM) was made. He was treated with broad spectrum antibiotics and a neurosurgical opinion was sought. He remained clinically unwell (septic and coagulopathic) until the abscess fistulated through the perianal skin, draining pus mixed with clear fluid (likely CSF) at which point he improved systemically. DISCUSSION: Few general surgeons would be faced with acute management of complicated ASM. Paucity of literature made application of evidence based medicine difficult. In fit healthy patients surgery is the mainstay of treatment as myelomengingoceles do not regress spontaneously. Conservative management is associated with up to 30% mortality (largely due to bacterial meningitis). The patient in this case was adamant that he did not consent to definitive surgical intervention. CONCLUSION: This case highlights challenges encountered in the management of complicated ASM in a general hospital.

Life after the cancer strategy: analysis of surgical workload in the general hospital setting.

BACKGROUND: The National Cancer Strategy heralded a major reorganisation of the delivery of cancer services in Ireland. As a result of this policy, cancer care was centralised to eight centres. The impact of this strategy on hospitals no longer providing cancer services has not been analysed to date. AIM: The aim of this study was to examine the impact of centralisation of cancer services on surgical workload at Mayo General Hospital. METHODS: Data pertaining to all surgical procedures performed in 2007 (prior to the introduction of the National Cancer Strategy) and 2011 were obtained using the Hospital Inpatient Enquiry system. Histopathology reports and theatre registers were also analysed to ensure accuracy of the data. RESULTS: The numbers of elective and emergency surgical admissions during 2007 and 2011 were broadly similar (2,581 vs. 2,662). One hundred and thirty-five oncological procedures (colorectal and breast) were carried out in 2007 compared with 50 (colorectal) in 2011. This represents a 63% reduction in cancer surgery workload following the implementation of the National Cancer Strategy. There was a concomitant increase in surgery performed for benign conditions (laparoscopic cholecystectomy and hernia repair), which coincided with the innovative introduction of 43 ring-fenced surgical in-patient beds in June 2010. CONCLUSION: This study demonstrates the impact of the centralisation of cancer services on surgical workload in a non-cancer centre. Our results show that there continues to be a role for general hospitals in the provision of elective surgical services. Hospital network arrangements have the potential to facilitate such developments.