Current practice of abdominal fascial closure: a survey of Ontario general surgeons.

OBJECTIVES: To determine the current practice of abdominal fascial closure among provincial general surgeons. The primary objective was to determine the proportion of surgeons choosing absorbable versus nonabsorbable sutures. Secondary objectives included determining knowledge and attitudes of surgeons to evidence-based medicine and concordance of current practice with level I evidence. DESIGN: A survey. SETTING: The province of Ontario. PARTICIPANTS: One hundred general surgeons. METHODS: A stratified random sample of community and academic surgeons was assembled and a questionnaire was mailed to them. Common clinical scenarios and questions pertaining to attitudes and knowledge of evidence-based medicine were included. MAIN OUTCOME MEASURES: Use of absorbable versus nonabsorbable suture material. Willingness to change current practice on evidence-based level I reports. RESULTS: Most surgeons (86%) chose an absorbable suture for abdominal fascial closure. Nonabsorbable suture was chosen by 58% of surgeons in the highly contaminated surgical scenario. Eighty-one percent of surgeons indicated they would be willing to change their current practice of fascial closure if there was evidence that the incidence of wound complications was reduced. Polyglactin (Vicryl) was the most commonly chosen suture. CONCLUSIONS: The current practice of abdominal fascial closure among Ontario general surgeons is in disagreement with the findings from a recent meta-analysis, recommending a nonabsorbable suture for a 32% relative risk reduction in the incisional hernia rate. The majority of surgeons employ a continuous absorbable closure in common surgical scenarios. A definitive randomized controlled trial comparing continuous nonabsorbable closure versus continuous absorbable closure is warranted.     

A systematic review of point-of-care abdominal ultrasound scans performed by general surgeons

BackgroundUltrasound is an established imaging modality in general surgery. With the increasing use of bedside point-of-care ultrasounds, general surgeons have been incorporating this skill into their clinical practice. This systematic review provides an up-to-date summary of the evidence for abdominal ultrasound scans performed by general surgeons to diagnose intra-abdominal pathology.MethodsTwo independent reviewers searched the PubMed database between 1 January 1980 and 1 June 2020. Articles about surgeon-performed abdominal ultrasound in adult patients were included. Studies on trauma and vascular surgery were excluded.Results26 articles met the inclusion criteria, presented as a narrative analysis. There was good evidence for the use of surgeon-performed ultrasound, particularly in gallstone-related diseases and moderate evidence for the use of ultrasound in appendicitis. Further evidence is required for point-of-care ultrasounds for other pathologies such as diverticulitis and groin hernias. Ultrasound training for general surgeons is variable with notable heterogeneity across studies.ConclusionA standardised training programme for general surgeons will greatly improve confidence and skill. There is good evidence for the use of bedside ultrasound by general surgeons in the acute and elective setting with reduced time to definitive treatment and fewer unnecessary hospital admissions.     

Endometriosis: presentation to general surgeons

We present nine cases of endometriosis presenting to general surgeons over a period of 4.5 years at Gwynedd Hospital, Bangor. A total of 83 cases of endometriosis was found on analysis of pathology records. Of these, 73 presented to gynaecologists, one to a dermatologist and nine to general surgeons. The presentation to general surgeons includes swelling related to Pfannanstiel scar (two), swelling in inguinal canal (two), umbilical nodule (one), rectal bleeding (one), recurrent abdominal pain (one), mimicking ovarian tumour (one) and presenting as pelvic peritonitis (one). Six were elective admissions and three were admitted as an emergency. All were premenopausal (range 19-49 years) women. None had any previous history of endometriosis or subfertility. Two patients with cyclical symptoms were correctly diagnosed clinically, and the others were postoperative diagnosis. Six patients required gynaecological referral and four of these required further medical treatment. None of them has required further surgical intervention in follow-up (range 4 weeks to 3 years). Endometriosis usually presents to general surgeons with deposits at extragonadal sites. Some patients may present as an emergency with abdominal pain. Endometriosis should be included in the differential diagnosis of women presenting with swellings related to umbilicus, surgical scars, inguinal canal and pelvis, especially if symptoms are cyclical. Usually, surgical excision is adequate. Selected cases require gynaecological referral and further medical therapy.     

The response of general surgeons to HIV in England and Wales.

The prevalence of HIV in the UK has been estimated to be 1 in 1000 of the population. Surgeons are at particular risk of occupational transmission from infected blood. To determine the effect of HIV on surgical practice we sent a questionnaire to 681 general surgeons in England and Wales; 450 replied (66%). Of those who replied, 42% were aware of having operated on an HIV-infected patient at least once, and 28 had recognised self-injury in such circumstances; 79% attempted to identify HIV-infected patients preoperatively, though many depended on clinical suspicion alone, which is known to be unreliable. Of those who had operated on a seropositive patient, 90% reported taking special precautions to avoid blood contact and minimise sharps injuries for such cases. The majority wore double gloves, eye protection and fluid-resistant gowns, but only a minority reported changes in surgical technique. Half had made no changes in procedures or technique when operating on patients not identified as being at risk of HIV infection. Among a wide variety of comments made by the surgeons, the commonest was a call for facilitation of HIV testing prior to surgery. This survey indicates that surgery on HIV-infected patients is not restricted to specialist centres. We review the means of identifying HIV-infected patients, the precautions that can be taken to minimise HIV transmission during surgery, and the possible influences of HIV status on surgical decisions.(ABSTRACT TRUNCATED AT 250 WORDS)     

Rhabdomyosarcoma. Presentation of a case with abdominal localization]

The Authors report a case of rhabdomyosarcoma observed in a 17-year-old boy. They emphasize that this rare form has an extremely rapid evolution, and in this case was also in an unusual site and of abnormal size. The difficulty of an early diagnosis and the impossibility of radical surgery are also underlined.     

Early analgesic treatment regimens for patients with acute abdominal pain: a nationwide survey among general surgeons

Introduction

Early pain relief in patients with acute nontraumatic abdominal pain in emergency departments has been discussed for years. Some randomized trials have addressed this issue but conclusive data are lacking. In this study, we assessed the current treatment practice in German hospitals in order to evaluate the necessity of a further clinical trial.

Methods

An online survey containing 27 questions was sent to general and visceral surgeons at attending level using a mailing list provided by the Professional Board of German Surgeons (BDC) using a standard interview software. The questionnaire collected demographic data, current treatment policies about frequency of early analgesia, types of pain medication, and opinions about their use and effects.

Results

Four hundred ninety-five completed questionnaires were returned. Many surgeons were cautious about early analgesia in the emergency department. Forty-five percent of the surgeons would provide analgesia prior to diagnosis to the majority of patients. Within the departments, differing opinions existed regarding the analgesic treatment (41 %). Thirty-two percent of all the respondents knew about a false diagnosis after early analgesia. There was heterogeneity in the estimation of the impact of pain medication on masking of clinical symptoms. A randomized controlled trial would be supported by the majority of respondents. As influencing factors for withdrawing early analgesia, we found the examiner being over 40 years of age (p?<?0.05), low experience with the clinical picture of acute abdominal pain (p?<?0.05), high estimation of the masking of clinical findings (p?<?0.001), and knowing about a false diagnosis after early analgesia (p?<?0.001) to be significant.

Conclusion

Discordance in the analgesic treatment regimens in patients with acute abdominal pain still exists in German hospitals. The topic remains subject of frequent discussions. More high quality data are needed before a clear guideline can be given for implementation in clinical routine management.     

Creating an emergency general surgery service enhances the productivity of trauma surgeons, general surgeons and the hospital

BACKGROUND: Several models that integrate trauma and emergency general surgery (EGS) have been proposed to provide a diverse and challenging operative practice for trauma surgeons and improve recruitment. In July 2002, our institution established a 24/7 EGS consult service, staffed primarily by critical care/trauma surgeons (CCTS). The objective of this report was to evaluate the impact of this new service on CCTS, general surgeons (GS) and the hospital. METHODS: All admissions to CCTS and GS from July 1, 2000 to June 30, 2003 were reviewed by querying hospital and physician databases for demographics, diagnoses, operative intervention(s), and resource utilization. Data were analyzed using nonparametric methods. RESULTS: [See ]. 9,405 admissions were identified, with GS and EGS admissions increasing over time. In July 2002, EGS became a separate service and captured 26% of GS admissions. Hospital-wide trauma admissions remained stable despite a slight decrease in trauma admissions to CCTS. A decrease in trauma operations by CCTS was offset by an increased EGS operative volume. EGS included "bread and butter" GS procedures including appendectomies and cholecystectomies and complex surgical procedures. EGS patients were often sicker with more than 50% requiring ICU admission compared with GS admissions of which only 10% required ICU care.(Table is included in full-text article.) CONCLUSIONS: Departmental restructuring to include an EGS service: 1) increased CCTS volume despite decreased CCTS trauma admissions and operations; 2) increased elective GS volume; 3) generated increased use of ICU and operating room resources; and 4) demonstrated that CCTS with broad operative GS backgrounds and critical care knowledge can effectively staff an EGS service.     

Childhood abdominal tuberculosis

Two children presented with abdominal tuberculosis. Because of the nonspecific clinical features, the diagnosis required a high index of clinical suspicion. Fine-needle aspiration (FNA) under ultrasonographic guidance allowed an early definitive diagnosis and bacteriological confirmation to guide chemotherapy. Both patients responded well to antituberculous chemotherapy.     

Venous thromboembolism prophylaxis used by consultant general surgeons in Scotland.

BACKGROUND: Venous thromboembolism (VTE) is a common source of morbidity and mortality in general surgical patients. Guidelines have been produced to help guide doctors through the complex issue of VTE prophylaxis. This study intended to examine the use of VTE prophylaxis amongst general surgeons in Scotland, with reference to nationally produced guidelines. METHOD: A postal questionnaire was sent to all consultant general surgeons in Scotland. They were asked to give their opinion on the best means of VTE prophylaxis in six different clinical scenarios. The responses were evaluated with reference to the guidelines from the Scottish Intercollegiate Guidelines Network (SIGN). RESULTS: A 69% response rate was achieved. There was a wide variance in the suggested prophylaxis in each of the scenarios. With reference to SIGN guidelines, 35% of responses represented undertreatment, 16% overtreatment and 49% appropriate treatment. CONCLUSION: Despite the publication of VTE guidelines, there is still a wide variety of opinions amongst consultant general surgeons with regards to VTE prophylaxis. Many of the responses were not consistent with such guidelines and represent suboptimal prophylaxis for patients.