Australian general surgical trainee experience with inguinal hernia surgery: a review of international training programmes and the learning curve.

BACKGROUND: There are no publications addressing the level of experience Australian surgical trainees achieve in inguinal hernia surgery. Internationally, some training boards have set minimum competency requirements, but this is not true in Australia. The longer learning curve for laparoscopic inguinal hernia repairs (LIHRs) compared to open inguinal hernia repairs (OIHRs) has placed greater demands on trainees. METHODS: Logbook data on OIHR and LIHR for Australian surgical trainees who graduated as fellows between 2013 and 2018 were obtained. A literature review was performed to analyse international published logbook numbers for surgical trainees from the past decade. International training board requirements, estimations of the learning curve and hernia society guidelines for each procedure were reviewed. RESULTS: In total, 7946 operations were recorded from 58 trainees. On average 49.2 OIHRs (range 13-101), 21.5 LIHRs (range 1-94) and 71.1 inguinal hernia repairs overall (range 25-129) were performed during training. The European Hernia Society recommends that at least 30-50 of each procedure be performed during training. The learning curves for LIHRs (50-100 procedures) have been shown to be longer than for OIHRs (40-64 procedures). CONCLUSION: Australian general surgical trainees are achieving adequate primary operator logbook numbers for OIHRs but are not completing the required number of LIHRs. The tailored approach to inguinal hernia repair requires skill in both open and laparoscopic repairs. This may not be possible with the current training structure in Australia.

Roux-en-Y gastric bypass and gastric sleeve surgery result in long term bone loss.

OBJECTIVES: Little is known about the long-term skeletal impact of bariatric procedures, particularly the increasingly commonly performed gastric sleeve surgery (GS). We examined bone density (BMD) change following three types of bariatric surgery Roux-en-Y gastric bypass (RYGB), GS and laparoscopic adjustable gastric banding (LAGB), compared with diet, over 36 months. METHODS: Non-randomized, prospective study of participants with severe obesity (n = 52), undergoing weight-loss interventions: RYGB (n = 7), GS (n = 21), LAGB (n = 11) and diet (n = 13). Measurements of calciotropic indices, gut hormones (fasting and post prandial) peptide YY (PYY), glucagon-like peptide 1 (GLP1) and adiponectin together with dual-X-ray absorptiometry and quantitative computed tomography scans were performed thorough the study. RESULTS: All groups lost weight during the first 12 months. Despite weight stability from 12 to 36 months and supplementation of calcium and vitamin D, there was progressive bone loss at the total hip (TH) over 36 months in RYGB -14% (95% CI: -12, -17) and GS -9% (95% CI: -7, -10). In RYGB forearm BMD also declined over 36 months -9% (95% CI: -6, -12) and LS BMD declined over the first 12 months -7% (95% CI: -3, -12). RYGB and GS groups experienced significantly greater bone loss until 36 months than LAGB and diet groups, which experienced no significant BMD loss. These bone losses remained significant after adjustment for weight loss and age. RYGB and GS procedures resulted in elevated postprandial PYY, adiponectin and bone turnover markers up to 36 months without such changes among LAGB and diet participants. CONCLUSIONS: RYGB and GS but not LAGB resulted in ongoing TH bone loss for three postoperative years. For RYGB, bone loss was also observed at LS and non-weight-bearing forearms. These BMD changes were independent of weight and age differences. We, therefore, recommend close monitoring of bone health following RYGB and GS surgeries.

Torsion of omental fibrous pseudotumour mimicking acute appendicitis.

Unusual pathologies are occasionally found at laparoscopy when appendicitis is suspected. We present a case of strangulated inflammatory fibrous pseudotumour of the omentum presenting in a similar fashion to appendicitis. The infarcted omentum was excised, facilitating prompt resolution of symptoms.

Does patient compliance with follow-up influence weight loss after gastric bypass surgery? A systematic review and meta-analysis.

Gastric bypass surgery is an effective intervention to manage morbid obesity. However, there have been suggestions that patients who do not comply to follow-up lose less weight. This study evaluated the influence of patient's follow-up compliance on weight loss post gastric bypass surgery. From the search of MEDLINE and EMBASE, four studies (n = 365) were identified and majority of these studies concluded that compliance with follow-up leads to increased weight loss. Our meta-analysis of these studies found increase in the percentage of excess weight loss (%EWL) at 1-year post gastric bypass surgery (mean difference 6.38 % %EWL, 95 % CI 1.68-11.15) when patients were compliant with follow-up. Therefore, this review found that continued long-term follow up of gastric bypass patients has the potential to increase postoperative weight loss.

Totally extraperitoneal inguinal hernia repair in patients previously having prostatectomy is feasible, safe, and effective.

BACKGROUND: The laparoscopic approach to repair of inguinal hernia has proven advantages over open repair. Repair of more technically challenging hernias, such as patients previously receiving prostatectomy, has been less studied and may not have these advantages. We aimed to compare safety, feasibility, and clinical outcomes for repairs in patients who previously underwent prostatectomy to control subjects. METHODS: We undertook a case-control study using a prospectively collected database. From 2004, all patients were routinely offered totally extraperitoneal laparoscopic repair. All patients who had a history of previous prostatectomy were identified and compared to a matched control group. Both operative and follow-up data were analyzed. RESULTS: Of 987 patients undergoing surgery during this time period, 52 prostatectomy patients were identified (44% open, 44% robotic, 3% laparoscopic) and matched to 102 control subjects. Accounting for bilateral repairs, 203 hernia repairs had been performed. Patients were well matched for age and American Society of Anesthesiologists score. Operative time was longer for prostatectomy patients (mean, 70 vs. 52 min, p < 0.0001); however, this reduced over time when comparing the first and second half prostatectomy patients (77 vs. 63 min, p = 0.144). Overall, there were no intraoperative or major postoperative complications and only one conversion (prostatectomy group). No significant differences were found for rates of minor postoperative complications, length of stay, or recurrence (n = 1, control group). No difference was observed for chronic pain, and all patients in each group reported satisfaction with surgery at contemporary follow-up. CONCLUSIONS: In experienced hands, totally extraperitoneal inguinal hernia repair for patients previously having undergone prostatectomy is safe and has equivalent outcomes to patients not having undergone prostatectomy, and is an option to open repair. Understandably, slightly longer operative times may be justified, given the benefits of early discharge and less postoperative pain after laparoscopic surgery.

Pancreaticoduodenectomy - outcomes from an Australian institution.

BACKGROUND: Operative morbidity and mortality rates have improved markedly since the first single-stage pancreaticoduodenectomy (PD) was performed by A. O. Whipple in 1940. There is a lack of published data regarding outcomes of PD from Australian centres. The aim of this study was primarily to establish post-operative morbidity and mortality rates of an Australian unit, and secondly, to investigate the value of preoperative investigation with endoscopic ultrasound and laparoscopy upon tumour stage and survival following PD. METHOD: A retrospective analysis was conducted on consecutive patients undergoing PD at St Vincent's Hospital from 1990 to 2006. Data were collected with particular reference to preoperative investigations, including endoscopic ultrasonography (EUS) and staging laparoscopy, and post-operative complications. Patient survival was determined from the hospital and consultant surgeons' records and telephone interviews with the patients' general practitioners. RESULTS: Eighty-one patients underwent PD, of which 58 were Whipple's procedures and 23 were pylorus-preserving pancreaticoduodenectomies (PPPD). Twenty-six patients had EUS, and 22 had a staging laparoscopy before PD. The post-operative morbidity rate was 55% and included intra-abdominal collections (17%), major haemorrhage (10.7%), pancreatic anastomotic leakage (9%) and delayed gastric emptying (22%). The operative (30-day) mortality rate was 1.6%. There was no survival advantage in the EUS or the laparoscopy group. CONCLUSION: EUS and laparoscopy are useful modalities in the preoperative investigation and staging of patients being considered for PD. PD is a safe procedure with acceptable complication rates when carried out in a specialist unit experienced in this operation.

Assessment of laparoscopic psychomotor skills in interns using the MIST Virtual Reality Simulator: a prerequisite for those considering surgical training?

Selection for surgical training in Australia is currently based on assessment of a structured curriculum vitae, referral reports from selected clinicians and an interview. The formal assessment of laparoscopic psychomotor skill and ability to attain skills is not currently a prerequisite for selection. The aim of this study was to assess the innate psychomotor skills of interns and also to compare interns with an interest in pursuing a surgical career to interns with those with no interest in pursuing a surgical career. Twenty-two interns were given the opportunity to carry out tasks on the Minimal Invasive Surgical Trainer, Virtual Reality (Mentice, Gothenburg, Sweden) Simulator. The candidates were required to complete six tasks, repeated six times each. Scores for each task were calculated objectively by the simulator software. Demographic data were similar between the two groups. Although some candidates who were interested in pursuing a surgical career performed poorly on the simulator, there was no significant difference when comparing the two groups. The Minimal Invasive Surgical Trainer, Virtual Reality (Mentice) Simulator provides an objective and comparable assessment of laparoscopic psychomotor skills. We can conclude that interns have varying inherent ability as judged by the simulator and this does not seem to have an influence on their career selection. There was no significant difference in the scores between the two groups. Interns with and without inherent abilities have aspirations to pursue surgical careers and their aptitude does not seem to influence this decision. Surgical colleges could use psychomotor ability assessments to recruit candidates to pursue a career in surgery. Trainees needing closer monitoring and additional training could be identified early and guided to achieve competency.

Biliary tract injury in laparoscopic cholecystectomy: results of a single unit.

BACKGROUND: Laparoscopic cholecystectomy was introduced into Australia in early 1990. Its rapid increase in acceptance was, however, tempered by reports of an increased incidence of bile duct injury. The aim of this study was to report on the incidence of biliary tract injuries in a single unit, comment on the way they were managed and look at strategies to prevent them. METHODS: A retrospective audit was conducted on laparoscopic cholecystectomies performed between January 1992 and March 2001. The data was collated from patient medical record files and yielded a total of 1216 procedures. RESULTS: There were 899 women (74%) and 317 men (26%), with an age range of 13-92 years. Most of the procedures were performed on an elective (94%) rather than emergent basis (6%). There was one bile duct injury (0.09%) and seven bile leaks (0.63%). The single injury involved common bile duct obstruction by a misplaced clip and was successfully managed by chol-angio-enteric bypass. Of the seven bile leaks, three were from the cystic duct stump, two from the gallbladder bed, and two were unidentified, settling conservatively. Of the five patients actively treated, two underwent therapeutic laparoscopy, two proceeded to laparotomy, and one was managed successfully by endoscopic stenting. CONCLUSIONS: Single-centre studies such as this are important in ensuring that standards of surgery are maintained in a community setting.