Carbon footprints in minimally invasive surgery: Good patient outcomes, but costly for the environment.

Advancements in technology and surgical training programs have increased the adaptability of minimally invasive surgery (MIS). Gastrointestinal MIS is superior to its open counterparts regarding post-operative morbidity and mortality. MIS has become the first-line surgical intervention for some types of gastrointestinal surgery, such as laparoscopic cholecystectomy and appendicectomy. Carbon dioxide (CO2) is the main gas used for insufflation in MIS. CO2 contributes 9%-26% of the greenhouse effect, resulting in global warming. The rise in global CO2 concentration since 2000 is about 20 ppm per decade, up to 10 times faster than any sustained rise in CO2 during the past 800000 years. Since 1970, there has been a steady yet worrying increase in average global temperature by 1.7 °C per century. A recent systematic review of the carbon footprint in MIS showed a range of 6-814 kg of CO2 emission per surgery, with higher CO2 emission following robotic compared to laparoscopic surgery. However, with superior benefits of MIS over open surgery, this poses an ethical dilemma to surgeons. A recent survey in the United Kingdom of 130 surgeons showed that the majority (94%) were concerned with climate change but felt that the lack of leadership was a barrier to improving environmental sustainability. Given the deleterious environmental effects of MIS, this study aims to summarize the trends of MIS and its carbon footprint, awareness and attitudes towards this issue, and efforts and challenges to ensuring environmental sustainability.

A 10-Year Profile of Trauma Admissions Caused by Interpersonal Violence: A Major Trauma Centre's Experience.

INTRODUCTION: This study aimed to characterise interpersonal violence victims admitted to a major trauma centre. MATERIALS AND METHODS: A retrospective cohort study of interpersonal violence victims who were admitted to our centre from 1 January 2001 to 31 December 2010 was conducted. Data were obtained from our trauma registry. RESULTS: Interpersonal violence victims constituted 444 (90.1% males and 9.9% females) out of a total of 8561 trauma admissions in the same time period. The average age was 36.6 years (range, 14 to 83 years). Majority were Chinese (53.4%) and Singaporeans (77.3%). The number of cases increased from 10 per year to 96 per year in the first 8 years, then decreased in the last 2 years (55 in year 2010). Time of injury was predominantly 0000 to 0559 hours (72.3%). Interpersonal violence mostly occurred in public spaces for both genders (88.7%). However, the number of females who were injured at home was significantly higher than males (P = 0.000). Blunt trauma (58.3%) was more common than penetrating trauma (41.7%). The average injury severity score (ISS) was 13.5 (range, 1 to 75); 34.9% of patients had major trauma (ISS >15). The average Glasgow coma scale (GCS) score was 13.5 (range, 3 to 15); 16.4% of patients had moderate-to-severe brain injury (GCS 3-8). Blunt trauma was significantly more likely to cause major trauma than penetrating trauma (P = 0.003). The sole case of firearm assault caused most morbi-mortality. Overall mortality was 4.5%. Major trauma (OR: 25.856; P = 0.002) and moderate-to-severe brain injury (OR: 7.495; P = 0.000) were independent risk factors of mortality. CONCLUSION: There has been no prior published data on interpersonal violence locally. This study is thus useful as preliminary data for future population-based studies. It also provides data for authorities to formulate preventive and intervention strategies.

Inguinal hernia repair: are the results from a general hospital comparable to those from dedicated hernia centres?

INTRODUCTION: We aimed to report the outcomes of inguinal hernia repair performed at Tan Tock Seng Hospital and compare them with those performed at dedicated hernia centres. METHODS: We retrospectively analysed the medical records and telephone interviews of 520 patients who underwent inguinal hernia repair in 2010. RESULTS: The majority of the patients were male (498 [95.8%] men vs. 22 [4.2%] women). The mean age was 59.9 ± 15.7 years. Most patients (n = 445, 85.6%) had unilateral hernias (25.8% direct, 64.3% indirect, 9.9% pantaloon). The overall recurrence rate was 3.8%, with a mean time to recurrence of 12.0 ± 8.6 months. Risk factors for recurrence included contaminated wounds (odds ratio [OR] 50.325; p = 0.004), female gender (OR 8.757; p = 0.003) and pantaloon hernias (OR 5.059; p = 0.013). Complication rates were as follows: chronic pain syndrome (1.2%), hypoaesthesia (5.2%), wound dehiscence (0.4%), infection (0.6%), haematoma/seroma (4.8%), urinary retention (1.3%) and intraoperative visceral injury (0.6%). Most procedures were open repairs (67.7%), and laparoscopic repair constituted 32.3% of all the inguinal hernia repairs. Open repairs resulted in longer operating times than laparoscopic repairs (86.6 mins vs. 71.6 mins; p < 0.001), longer hospital stays (2.7 days vs. 0.7 days; p = 0.020) and a higher incidence of post-repair hypoaesthesia (6.8% vs. 1.8%; p = 0.018). However, there were no significant differences in recurrence or other complications between open and laparoscopic repair. CONCLUSION: A general hospital with strict protocols and teaching methodologies can achieve inguinal hernia repair outcomes comparable to those of dedicated hernia centres.

Arteriovenous fistula aneurysm--plicate, not ligate.

INTRODUCTION: Arteriovenous fistula (AVF) created for haemodialysis can be complicated by aneurysm formation. CLINICAL PICTURE: Ligation of the fistula is often required to prevent aneurysmal rupture and the life-threatening haemorrhage that ensues. Other methods of treatment involve using foreign bodies like mesh and grafts. TREATMENT: We describe a new method in the treatment of this condition--plication. It involves plicating the excess free wall of the aneurysm with sutures and does not require resection or anastomosis. OUTCOME: Early results show that this method shrinks the aneurysm size and reduces the risk of haemorrhage. CONCLUSION: The AVF can continue to be used and the patient is spared the agony of having to go through the entire cycle of creating a new vascular access site.