Implementation of ambulatory surgery in a university hospital: an audit comprising 873 general surgery cases

The Ambulatory Surgery Centre of the Lausanne University Hospital was established in 1995 as a multispeciality unit comprising general surgery, plastic surgery, otorhinolaryngology, orthopaedics and urology. In its first 3 years of activity 873 general surgery procedures were performed, including biopsies, laparoscopies, inguinal hernia repair and vein stripping. An audit of these cases revealed an overall morbidity of 1%, a rate of non-planned admissions of 0.6%, no re-admissions within 30 days, and that 95% of patients were satisfied with their care. These results demonstrate the feasibility of implementing ambulatory surgery in a teaching hospital and encourage the expansion of this practice.     

The reminiscences of a plastic surgeon during World War II.

The experiences of the author while an Officer in the South African Medical Corps are related. During the battle of Britain he was attached to the R.A.M.C. and observed the work of pioneers in modern military plastic surgery. On his return to South Africa, he set up the Brenthurst Military Red Cross Hospital for Plastic Surgery and dealt with many thousands of allied battle casualties--South African, British, French, and Polish. The injuries treated included aircraft and tank burns, facial destructions (particularly the nose and eyes), extensive facial fractures, and limb amputations. Various procedures are mentioned. The first plastic surgical journal in English, The Brenthurst Papers, was produced describing these innovations.     

Evolution of the Emergency Management of Severe Burns (EMSB) course in the UK.

The principle of the 'golden hour' is now well established and forms the basis of a growing number of instructional courses teaching a systematic approach to the management of major trauma. In April 1997, the EMSB course, developed by the Australian and New Zealand Burn Association, was adopted by the British Burn Association to meet the needs of health professionals dealing with major burn injuries in this country. The experience of the first 13 courses following the introduction of EMSB is discussed and the course is recommended as a requirement for the training of UK plastic surgeons and plastic surgery nurses.     

Gunpowder, the Prince of Wales's feathers and the origins of modern military surgery

Background: The history of military surgery claims many forebears. The first surgeon‐soldiers were Homer's Machaon and Podalirius, followed a thousand years later by the Roman surgeons‐general, Antonius Musa and Euphorbus; and later, e.g. Ambrose Paré, John Hunter and Sir John Pringle; and the 19th century innovators, Dominique‐Jean Larrey (France), Friedrich von Esmarch (Prussia) and the Russian, Nikolai Pirogoff. The singular feature that distinguished modern military surgery from its earlier practice was the use of gunpowder. It was one of two inventions (the other was printing) that by the empowerment of individuals, lifted Western humankind from the medieval to the modern era. Methods: Research of primary and secondary archives. Results and conclusion: Gunpowder was first used in European warfare at Algeceras (1344–1368). Hitherto, the destruction of tissue had been the result of (relative) low‐energy wounding with tissue damage caused by incisional or crushing wounds. The founder of modern surgery, Master John of Arderne (1307–1380), wrote of his experience gained as a military surgeon on the battlefield at Crecy (1346). Following Crecy, Arderne was the only chronicler who described the origins of the Prince of Wales's feathers as a royal and later commercial symbol, and the motto ‘Ich Dien’, ‘I serve’, as that of hospitals in the Western World. Later advances in military surgery incorporated both clinical experimentation and the innovation of new systems of pre‐hospital battlefield care.     

Franti?ek Burian (September 17, 1881–October 15, 1965) and the beginning of plastic surgery in Czechoslovakia

In the Czech Republic, plastic surgery is inseparably related to the name of its initiator and founder, Franti?ek (Francis) Burian, who not only laid the foundations of this branch in Czechoslovakia, but also influenced many contemporary plastic surgeons. Burian spent 6?years as a military surgeon in the Balkan wars and in World War I. Up until World War I, only separate plastic operations by excellent surgeons were mentioned. The experience gained from the First World War led to an undreamed-of development in plastic surgery and to the need for specialisation. It was during the First World War that European plastic surgery was formed as a special branch. Burian probably opened the first department of plastic surgery in the world at the Jedli?ka Institute in 1927. In 1932, after operating for 5?years, the department of plastic surgery at the Jedli?ka Institute was granted the status of a separate clinic.     

The Scientific Contributions of British Plastic Surgeons to the Revue de Chirurgie Plastique and the Revue de Chirurgie Structive, Brussels (1931–1938)

In 1931, Maurice Coelst, M.D. from Brussels started the publication of the first international journal of plastic surgery ever published: the Revue de Chirurgie Plastique (1931-1934), which eventually became the Revue de Chirurgie Structive (1935-1938). In 1936, he established the first European Society of Structive Surgery, which held its first congress in Brussels. Further congresses were held in London in 1937 and in Milan in 1938. It is the collaboration and the participation of British plastic surgeons in this Society, this journal, and these meetings that I want to stress, because I am firmly convinced that these documents fill a gap in the history of Plastic Surgery in Great Britain, since--as far as I know--no detailed information concerning this period was ever published in Plastic Surgery literature.     

The selection of patients for breast reduction: should health commissions have a say?

Selective or restrictive access policies operate for breast reduction, despite proven benefits. The rationale for these policies, in particular the requirement of psychiatric assessment prior to a plastic surgical consultation, as an aid to patient selection by the health commission, was examined in 57 general practice referrals to a plastic surgical unit. In 22 cases, these policies deterred the patient or GP from pursuing the referral further. Sixteen cases were funded by the health commission directly, 16 patients required psychiatric or orthopaedic referrals, and three patients were refused funding outright. The decision to fund, reject or refer to a non-plastic-surgical specialist was not statistically related to the patients' symptoms. Non-plastic-surgical assessment resulted in referral for a plastic surgical opinion in 15 of 16 patients. We conclude that these selective policies are unsatisfactory, since patient management is not related to symptoms and the use of non-plastic-surgical opinions by the health commission as an aid to rationing is of little benefit.     

A funding model for a psychological service to plastic and reconstructive surgery in UK practice.

Appearance related distress in both clinical and general populations is associated with the increasing identification of surgery as a solution, leading to referrals for cosmetic surgery and pressure on NHS resources. Cosmetic surgery guidelines are designed to control this growing demand, but lack a sound evidence base. Where exceptions are provided on the basis of psychological need, this may recruit patients inappropriately into a surgical pathway, and creates a demand for psychological assessment which transfers the resource problem from one service to another. The model described below evaluates the impact of a designated psychology service to a plastic surgery unit. Developing an operational framework for delivering cosmetic guidelines, which assesses patients using clearly defined and measurable outcomes, has significantly reduced numbers of patients proceeding to the NHS waiting list and provided a systematic audit process. The associated cost savings have provided a way of funding a psychologist within the plastic surgery service so that psychological assessment becomes routine, alternative methods of treatment are easily available and all patients have access to psychological input as part of the routine standard of care.     

Incomplete excision of basal cell carcinoma: a prospective multicentre audit.

The audit of incomplete excision of basal cell carcinoma can be used as a parameter for clinical governance in plastic surgery units. However, there are no national standards, and all the previous reports from the UK have been retrospective and from regional units only. This 1 year prospective audit was undertaken simultaneously in the plastic surgery units of three different categories of hospital: a regional plastic surgery unit (University Hospital of South Manchester), a supraregional cancer hospital (Christie Hospital) and a district general hospital (Royal Bolton Hospital). A total of 757 lesions were excised from 600 patients, with 34 lesions (4.5%) being incompletely excised. The incidences of incomplete excision were similar in the regional unit (3.2%) and the district general hospital (3.1%), but higher in the supraregional cancer hospital (7.5%). The commonest site for incomplete excision was the eyebrow, followed by the postauricular area, the nose and the temple. There were no statistically significant differences in the distributions of the age and sex of the patients, the site and size of the lesions or the methods of repair between the three hospitals. However, there were significant differences in the distribution of syndromal, multiple and recurrent lesions, the grade of surgeon, and the clinical and histological subtypes. When the various confounding factors were adjusted by logistic regression, the variables most likely to have affected the incidence of incomplete excision were found to be grade of surgeon, minimal excision margin and histological subtype.     

Penetrating Missile Injuries During the Iraqi Insurgency

INTRODUCTION

Since the invasion of Iraq in 2003, the conflict has evolved from asymmetric warfare to a counter-insurgency operation. This study investigates the pattern of wounding and types of injuries seen in casualties of hostile action presenting to a British military field hospital during the present conflict.

PATIENTS AND METHODS

Data were prospectively collected on 100 consecutive patients either injured or killed from hostile action from January 2006 who presented to the sole coalition field hospital in southern Iraq.

RESULTS

Eighty-two casualties presented with penetrating missile injuries from hostile action. Three subsequently died of wounds (3.7%). Forty-six (56.1%) casualties had their initial surgery performed by British military surgeons. Twenty casualties (24.4%) sustained gunshot wounds, 62 (75.6%) suffered injuries from fragmentation weapons. These 82 casualties were injured in 55 incidents (mean, 1.49 casualties; range 1–6 casualties) and sustained a total 236 wounds (mean, 2.88 wounds) affecting a mean 2.4 body regions per patient. Improvised explosive devices were responsible for a mean 2.31 casualties (range, 1–4 casualties) per incident.

CONCLUSIONS

The current insurgency in Iraq illustrates the likely evolution of modern, low-intensity, urban conflict. Improvised explosive devices employed against both military and civilian targets have become a major cause of injury. With the current global threat from terrorist bombings, both military and civilian surgeons should be aware of the spectrum and emergent management of the injuries caused by these weapons.     

Telemedicine for acute plastic surgical trauma and burns.

Visual images can enhance communication over a distance. In the UK, plastic surgery provides services over large distances by a 'hub and spoke' model. Telemedicine could help to increase the efficiency of service for plastic surgery patients. Telemedicine, along with the impending Electronic Patient Record system could combine to improve communication, patient triage, record keeping, audit and could lead to a better quality of clinical care. Another benefit could be significant cost savings. We report our experience of the introduction of telemedicine to a Regional Plastic Surgery Service. Our first study compared assessments from images and patient examinations, which gave us confidence in the use of images [Jones SM, Milroy C, Pickford MA. Telemedicine in acute plastic surgical trauma and burns. Ann R Coll Surg Engl 2004;86:239-42]. We proceeded to a 10-week evaluation of all 973 referrals to our unit. We found that the system was used for a wide variety of injuries and for 42% of the 452 patients where the system was available. Initial resistance was overcome by the ease of use of the system, with both receiving and referring clinicians reporting benefits. The third phase was a 12-week prospective cohort study of 996 patients comparing the referrals with and without the telemedicine system. The system was available for 389 patients, and used for 243 patients (63%). The groups were analysed by a chi squared test and confidence interval calculation. We demonstrated a significant difference in the initial management of patients, with 10% more being booked directly to our Day Surgery Unit. There was a decrease in number of occasions when we were unable to accept a patient due to a lack of capacity. We found no change in the patients being managed with telephone only advice. We found that telemedicine is a valuable method of providing useful preliminary information in the referral process for injured patients and often significantly modifies their treatment and/or management plan. This has implications for the use of Information Technology resources and potentially the delivery of healthcare in relation to the management of injured patients.     

Swiss physicians and their contribution to surgery of the hand]

The origins of five important Swiss contributions to plastic and hand surgery since the last third of the 19th century are described: free grafting of the epidermis (J.L. Reverdin), a pollicization (C. Roux), de Quervains's stenosing tendovaginitis, Secrétan's oedema and the first voluntary movable artificial hand (S. Stodola and F. Sauerbruch). These contributions are related to the development of general surgery. Their history illustrates the advantages which may result from prolonged contact and exchange between members of different cultures.     

Psychiatric assessment of patients with self-inflicted lacerations to the wrist and forearm admitted to a nonpsychiatric ward: the experience of a regional plastic surgery unit.

In 1984, the Department of Health (DoH) recommended that all patients with deliberate self-harm (DSH) must have a mental assessment before discharge. DSH patients, especially those with lacerations to wrist and forearm, are a regular source of admission to plastic surgery units. In Northern Ireland, the regional plastic surgery service is provided at the Ulster Hospital, which does not have an on-site psychiatric department. Consequently, it was often difficult to arrange a psychiatrist assessment for these patients on the ward even when the assessment was required urgently. The objective of this study was to develop and validate a protocol that would ensure that these patients were assessed and followed up for their mental health as recommended by the DoH. In the absence of clear guidelines from the DoH and utilising the existing arrangement between Accident and Emergency (A&E) and the psychiatric services, all referring A&E departments were instructed at the time of referring patients with DSH to wrist and forearm to arrange a psychiatric examination before transferring the patient to the plastic surgery unit. Data were collected retrospectively (August 2002-October 2002) and prospectively (November 2002-October 2003) and comprised demographic features, previous history of self-harm, conduct of the patient in A&E and the ward, length of stay in the hospital and various aspects of psychiatric assessment and follow-up. In total, 42 referrals were made during the period studied. The average age was 28 years with a male to female ratio of 2:1. The average hospital stay was two days. Despite difficulties, our practice was found effective in ensuring psychiatry assessment and follow-up without risking the patient's physical health. The study also highlighted the need for collaboration between plastic surgeons and psychiatrists to improve services in regards to DSH patients.     

The early history of cardiac surgery in Stockholm

Cardiac surgery in Stockholm grew on a sound foundation of well-developed general thoracic surgery. The portal figure is Clarence Crafoord (1899-1983) who already in 1927 had succeeded with the Trendelenburg pulmonary embolectomy operation. He went on to develop lung surgery in general. With foresight he stimulated the chemists of Karolinska Institute to purify heparin, first for prophylaxis against venous thromboembolism and later for use with the heart-lung machine. In 1944 he became the first surgeon to successfully operate on patients with coarctation of the aorta. With Viking Olov Bjork and Ake Senning the heart-lung machine was improved, finally allowing its clinical use in a patient operated in 1954 for a myxoma of the left atrium, with long-term survival. This was the first successful use of the heart-lung machine in Sweden and the second in the world. He and his coworkers, first at the Sabbatsberg hospital and from 1957 at the Karolinska hospital made major contributions to cardiology and radiology, apart from the progresses in cardiac surgery. Contributions such as pressure recording from the left atrium by needle puncture in 1950, the Senning operation for transposition of the great arteries and the first use of a totally implantable cardiac pacemaker in 1958 are indeed medical history.     

Plastic surgery and the specialists

Because of its extensive development plastic surgery has become an indispensable surgical unit in the general hospital.The relationship of this surgery to other specialities must be based on its definite indications.The manifold problems involved in the prevention and treatment of deformities caused by automobile and industrial accidents as well as by burns can be properly handled only by those thoroughly familiar with plastic surgery procedures.The successful reconstruction of highly hypertrophic and atrophic prolapsed breasts is at present assured by the method of subcutaneous transposition of the gland with mastopexy.Plastic repair in otorhinolaryngology as a rule should not be attempted by nose and throat specialists, and the association of plastic surgery with the laryngological service in a general hospital should be avoided. The end-results in rhinoplasties are uniformly successful if this surgery is performed aseptically and with proper skill.Intricacies of plastic repair in the paraorbital region are due to the different types of skin grafts required in a relatively limited area, and the great functional importance of the eyelids. Cicatricial contractions around the eyelids are the most common indications for this surgery.Cleft lip and cleft palate, repaired at an early age, should in the majority of cases be followed by a satisfactory end-result.A variety of skin conditions such as nevi, hemangiomas, lymphangiomas, large hairy moles, extensive pigmentation and scars can be successfully eradicated by plastic procedures, followed, if necessary, by the application of physical agents such as x-ray and radium. A great economic waste will thus be avoided.     

Post-CABG Deep Sternal Wound Infection: A Retrospective Comparative Analysis of Early versus Late Referral to a Plastic Surgery Unit in a Tertiary Care Center

Background  Deep sternal wound infections (DSWI) following median sternotomy are initially treated by the cardiothoracic surgeons and are referred to a plastic surgical unit late in the course of time. Methods  This is a retrospective review done in a tertiary care teaching institute from January 2005 to June 2018 and the data of 72 patients who had DSWI out of 4,214 patients who underwent median sternotomy for coronary artery bypass grafting (CABG) was collected with respect to the duration between CABG and presentation of DSWI as well as time of referral to a plastic surgery unit. We defined early referral as < or equal to 15 days from presentation and late referral as > 15 days. Both groups were compared with respect to multiple parameters as well as early and late postoperative course, postoperative complications, and mortality. Results  The early group had 33 patients, while the late group had 39 patients. The number of procedures done by the cardiothoracic team before referral to the plastic surgery unit is significant ( p = 0.002). The average duration from the presentation of DSWI to definitive surgery was found to be 16.58 days in the early group and 89.36 days in the late group. The rest of the variables that were compared in both the groups did not have significant differences. Conclusion  There is no statistical difference between early and late referral to plastic surgery in terms of mortality and morbidity. Yet, early referrals could lead to highly significant reduction in total duration of hospital stay, wound healing, and costs. Early referral of post-CABG DSWIs to Plastic surgeons by the cardiothoracic surgeons is highly recommended.     

Day of surgery cancellations after nurse-led pre-assessment in an elective surgical centre: the first 2 years

We describe a nurse-led pre-assessment system at an elective surgical centre. A targeted referral system was used by trained nurses to direct referrals to a supervising consultant anaesthetist or to the surgical team. Of 2726 patients pre-assessed in the first 2 years, 105 patients (3.9%) were cancelled or postponed for medical optimisation after pre-assessment. There were 137 cancellations (5.0%) on the day of surgery, despite pre-assessment, but only 36 were for anaesthetic or medical reasons. Only eight of these 36 were considered a 'failure' of the pre-assessment system. These results are much better than the cancellation rate of about 11% in the Trust as a whole. There were 18 transfers of patients postoperatively from the elective centre to another hospital. A review suggested that four of these transfers could have been reasonably predictable from the patients' medical history. We conclude that a pre-assessment clinic has an important role to play in minimizing cancellations on the day of surgery and also in reducing the number of patients transferred to other hospitals. This last conclusion has an important implication for the planning of systems in hospitals that perform only elective surgery.     

Immediate breast reconstruction in the West Midlands: a survey of current practice.

Immediate reconstruction (IR) of the breast following mastectomy is not available to all appropriate patients. Previous studies have examined general surgeons attitudes toward reconstruction but have not assessed how these translate into surgical practice. We investigated the current rates of referral for, and availability of, IR across the West Midlands region.A postal questionnaire was sent to all breast surgery units in the region. Out of 20 units 19 responded. Units where IR was performed in-house were likely to have more breast surgeons (2.3 vs. 1.5, p=0.0106), and a higher annual workload (222 new cases vs. 174). Only two of 19 surgeons said they did not discuss IR with appropriate patients. Selection criteria in the other units included age, lack of co-morbidity, favourable pathology, smoking habit, and in one unit, only small-breasted women were offered IR. IR is performed in 13 of 19 units. Reconstructive procedures range from implants to deep inferior epigastric artery perforator (DIEP) flaps; the surgery is performed by breast and plastic surgeons together in seven units, breast surgeons alone in five and plastic surgeons alone in one. Six units do not carry out reconstruction. These units referred between two and 10 patients (average five) for IR in 2001. Units where some types of IR were available referred between three and 35 patients for surgery not performed in-house, and there was no relationship between complexity of surgery available in-house and referral rates. Reasons for low referral rates included: surgeons' attitudes; geographical isolation; long waiting times for plastic surgical opinion and for surgery; and loss of control of patients' management. Although surgeons' attitudes in the West Midlands are generally positive toward IR, availability and referral rates vary widely. Reconstructive surgeons should encourage referrals by increasing contact with general surgeons to overcome logistical problems and by ensuring appropriate systems for referral exist.     

2-Week wait referrals in suspected skin cancer: Does an instructional module for general practitioners improve diagnostic accuracy?

The two-week wait (2WW) scheme in the United Kingdom for suspected skin cancer has been criticised for having low pick up rates, with a high proportion of clinically benign lesions being referred as suspicious.We studied the referral patterns of skin cancer to our hospital under the 2WW initiative, and aimed to quantify the effect of a targeted continuing medical education (CME) module on improving diagnostic accuracy.All referrals to our hospital (dermatology and plastic surgery) under the 2WW rule were audited between July and September 2006. A targeted CME module was sent to GPs describing and illustrating common lesions. After 11 months, all 2WW referrals were prospectively studied between August and October 2007. The main outcome measure was the percentage of correctly referred squamous cell carcinomas (SCCs) and melanomas.237 referrals were made between July and August 2006, and 223 referrals between August and October 2007. The proportion of appropriately referred skin cancers (SCCs and melanomas) was 23.2% before CME, and 20.6% after CME. There were no differences in pick up rates before and after the CME amongst suspected SCCs (21.1% vs. 29.7%) or melanomas (24.6% vs. 15.1% respectively). Referrals to Plastic Surgery were more likely to be confirmed histologically as melanomas or SCCs (23.6% and 33.7% respectively) than those made to Dermatology (17.5% and 15.3% respectively).The proportion of correctly suspected skin malignancies under the 2WW initiative remains low despite education. A targeted CME module sent to GPs fails to improve pick up rates. There is a need for continuing dermatology training amongst referring physicians.