Safe percutaneous suprapubic catheterisation

INTRODUCTION

We describe our technique of percutaneous suprapubic catheter insertion with special reference to steps that help to avoid common complications of haematuria and catheter misplacement.

METHODS

The procedure is performed using a stainless steel reusable trocar under local infiltrative anaesthesia, usually at the bedside. After clinical confirmation of a full bladder, the trocar is advanced into the bladder through a skin incision. Once the bladder is entered, the obturator is removed and the assistant inserts a Foley catheter followed by rapid balloon inflation. Slight traction is applied to the catheter for about five minutes. Patients with previous lower abdominal surgery, an inadequately distended bladder or acute pelvic trauma do not undergo suprapubic catheterisation using this method.

RESULTS

The procedure was performed in 72 men (mean age: 42.4 years, range: 18–78 years) with urinary retention with a palpable bladder. The average duration of the procedure was less than five minutes. No complications were noted in any of the patients.

CONCLUSIONS

Trocar suprapubic catheter insertion is a safe and effective bedside procedure for emergency bladder drainage and can be performed by resident surgeons. The common complications associated with the procedure can be avoided with a few careful steps.     

Laparoscopy for Penetrating Thoracoabdominal Trauma: Pitfalls and Promises

Background:

How should the stable patient with penetrating abdominal or lower chest trauma be evaluated? Evolving trends have recently included the use of diagnostic laparoscopy. In September 1995 we instituted a protocol of diagnostic laparoscopy to identify those patients who could safely avoid surgical intervention.

Design:

Prospective case series.

Materials and Methods:

Hemodynamically stable patients with penetrating injuries to the anterior abdomen and lower chest were prospectively evaluated by diagnostic laparoscopy, performed in the operating room under general anesthesia, and considered negative if no peritoneal violation or an isolated nonbleeding liver injury had occurred. If peritoneal violation, major organ injury or hematoma was noted, conversion to open celiotomy was undertaken.

Results:

Seventy consecutive patients were evaluated over a two-year period. The average length of stay (LOS) following negative laparoscopy was 1.5 days, and for negative celiotomy 5.2 days. There were no missed intra-abdominal injuries following 30 negative laparoscopies, and 26 of 40 laparotomies were therapeutic. The technique also proved useful in evaluation of selected blunt and HIV+ trauma vic-tims with unclear clinical presentations. However, while laparoscopy was accurate in assessing the abdomen following penetrating lower chest injuries, significant thoracic injuries were missed in 2 out of 11 patients who required subsequent return to OR for thoracotomy.

Conclusions:

Laparoscopy has become a useful and accu-rate diagnostic tool in the evaluation of abdominal trauma. Nevertheless, laparoscopy still carries a 20% nontheraputic laparotomy rate. Additionally, significant intrathoracic injuries may be missed when laparoscopy is used as the pri-mary technique to evaluate penetrating lower thoracic trauma.     

Use of laparoscopy in trauma at a level II trauma center

Background and Objectives:

Enthusiasm for the use of laparoscopy in trauma has not rivaled that for general surgery. The purpose of this study was to evaluate our experience with laparoscopy at a level II trauma center.

Methods:

A retrospective review of all trauma patients undergoing diagnostic or therapeutic laparoscopy was performed from January 2004 to July 2010.

Results:

Laparoscopy was performed in 16 patients during the study period. The average age was 35 years. Injuries included left diaphragm in 4 patients, mesenteric injury in 2, and vaginal laceration, liver laceration, small bowel injury, renal laceration, urethral/pelvic, and colon injury in 1 patient each. Diagnostic laparoscopy was performed in 11 patients (69%) with 3 patients requiring conversion to an open procedure. Successful therapeutic laparoscopy was performed in 5 patients for repair of isolated diaphragm injuries (2), a small bowel injury, a colon injury, and placement of a suprapubic bladder catheter. Average length of stay was 5.6 days (range, 0 to 23), and 75% of patients were discharged home. Morbidity rate was 13% with no mortalities or missed injuries.

Conclusions:

Laparoscopy is a seldom-used modality at our trauma center; however, it may play a role in a select subset of patients.     

Diagnostic and therapeutic value of laparoscopy for small bowel blunt injuries: A case report

INTRODUCTION

Small bowel injuries after blunt abdominal trauma represent both a diagnostic and a therapeutic challenge. Early diagnosis and prompt treatment are necessary in order to avoid a dangerous diagnostic delay. Laparoscopy can represent a diagnostic and therapeutic tool in patients with uncertain clinical symptoms.

PRESENTATION OF THE CASE

We report the case of a 25-year-old man, haemodynamically stable, admitted for acute abdominal pain a few hours after a physical assault. Giving the persistence of the abdominal pain and the presence of free fluids at the computed tomography examination, an exploratory laparoscopy was performed.

DISCUSSION

At the laparoscopic exploration, an isolated small bowel perforation was found, 60 cm distal from the ligament of Treitz. The injury was repaired by laparoscopic suturing and the patient was discharged home at postoperative day 3 after an uneventful postoperative course.

CONCLUSIONS

Laparoscopy represents a valuable tool for patients with small bowel blunt injuries allowing a timely diagnosis and a prompt treatment.     

A giant adrenal cyst difficult to diagnose except by surgery

Introduction

Adrenal cysts represent rare clinical entities. Although surgical indications are well defined, pitfalls arise from the failure to establish an accurate preoperative diagnosis. Cystic lesions of other abdominal organs especially the pancreas complicate the diagnostic field.

Presentation of case

We present the case of a giant adrenal cyst in a young female causing diagnostic dilemma. Imaging studies revealed a large cystic lesion of uncertain origin located between the spleen and the tail of the pancreas. It was decided to perform a laparotomy which confirmed the presence of an adrenal cyst and enucleation of the cyst was performed. Examination at one year confirmed no complications.

Discussion

Adrenal cysts should always be included in the differential diagnosis of cystic abdominal lesions.

Conclusion

When the preoperative diagnosis is uncertain, surgical intervention can be both diagnostic and therapeutic.     

Minimally Invasive Surgery in Pediatric Trauma: One Institution's 20-Year Experience

Background:

Minimally invasive surgery (MIS) for trauma in pediatric cases remains controversial. Recent studies have shown the validity of using minimally invasive techniques to decrease the rate of negative and nontherapeutic laparotomy and thoracotomy. The purpose of this study was to evaluate the diagnostic accuracy and therapeutic options of MIS in pediatric trauma at a level I pediatric trauma center.

Methods:

We reviewed cases of patients aged 15 years and younger who had undergone laparoscopy or thoracoscopy for trauma in our institution over the past 20 years. Each case was evaluated for mechanism of injury, computed tomographic (CT) scan findings, operative management, and patient outcomes.

Results:

There were 23 patients in the study (16 boys and 7 girls). Twenty-one had undergone diagnostic laparoscopy and 2 had had diagnostic thoracoscopy. In 16, there were positive findings in diagnostic laparoscopy. Laparoscopic therapeutic interventions were performed in 6 patients; the remaining 10 required conversion to laparotomy. Both patients who underwent diagnostic thoracoscopy had positive findings. One had a thoracoscopic repair, and the other underwent conversion to thoracotomy. There were 5 negative diagnostic laparoscopies. There was no mortality among the 23 patients.

Conclusions:

The use of laparoscopy and thoracoscopy in pediatric trauma helps to reduce unnecessary laparotomy and thoracotomy. Some injuries can be repaired by a minimally invasive approach. When conversion is necessary, the use of these techniques can guide the placement and size of surgical incisions. The goal is to shift the paradigm in favor of using MIS in the treatment of pediatric trauma as the first-choice modality in stable patients.     

Role of the trauma-room chest x-ray film in assessing the patient with severe blunt traumatic injury

Objectives

To examine the accuracy of standard trauma-room chest x-ray films in assessing blunt abdominal trauma and to determine the significance of missed injuries under these circumstances.

Design

A retrospective review.

Setting

A regional trauma unit in a tertiary-care institution.

Patients

Multiply injured trauma patients admitted between January 1988 and December 1990 who died within 24 hours of injury and in whom an autopsy was done.

Intervention

Standard radiography of the chest.

Main Outcome Measures

Chest injuries diagnosed and recorded by the trauma room team from standard anteroposterior x-ray films compared with the findings at autopsy and with review of the films by a staff radiologist initially having no knowledge of the injuries and later, if injuries remained undetected, having knowledge of the autopsy findings.

Results

Thirty-seven patients met the study criteria, and their cases were reviewed. In 11 cases, significant injuries were noted at autopsy and not by the trauma-room team, and in 7 cases these injuries were also missed by the reviewing radiologist. Injuries missed by the team were: multiple rib fractures (11 cases), sternal fractures (3 cases), diaphragmatic tear (2 cases) and intimal aortic tear (1 case). In five cases, chest tubes were not inserted despite the presence (undiagnosed) of multiple rib fractures and need for intubation and positive-pressure ventilation.

Conclusions

Significant blunt abdominal trauma, potentially requiring operative management or chest-tube insertion, may be missed on the initial anteroposterior chest x-ray film. Caution must therefore be exercised in interpreting these films in the trauma resuscitation room.     

Vesical calculus formation on non-absorbable sutures used for open inguinal hernia repair

INTRODUCTION

Iatrogenic injuries to the urogenital tract are rare, with the bladder being the organ most affected. We describe a case of a vesical calculus that formed on non-absorbable sutures that were used to repair an inguinal hernia.

PRESENTATION OF CASE

A 45-year-old male presented with frank haematuria and dysuria 2 years following an open left inguinal hernia repair. A CT urography showed a vesical calculus adherent to the left anterio-lateral wall of the bladder. Cystoscopy revealed that the calculus formed on non-absorbable sutures. Cystolapaxy was performed followed by cystoscopic excision of the sutures. The patient''s post-operative course was uneventful.

DISCUSSION

Foreign bodies in the urinary bladder always act as a nidus for formation of a calculus. Iatrogenic bladder injuries are common during hernia repair. It is however rare for sutures used to repair an inguinal hernia to involve the urinary bladder wall. The patient most likely had a full bladder at the time of hernia repair or the bladder was part of the contents of the hernia sac.

CONCLUSION

This case illustrates the need to ensure that the bladder is empty prior to pelvic surgery and for surgeons to have a good understanding of inguinal anatomy to avoid injuring the contents of the hernia sac.     

Transvesical NOTES: Survival Study in Porcine Model

Background and Objectives:

The optimal access route and method for natural orifice transluminal endoscopic surgery (NOTES) has not been established. A transvesical approach, with its low rate of peritoneal contamination, is an effective clean portal of entry, but a safe urinary bladder closure has been a challenge. We developed a new technique for a safe, pure transvesical NOTES approach.

Methods:

Four female piglets were used in the study. With the pigs under anesthesia, a flexible cystoscope (15Fr) was used to make an endoscopic cystotomy; diagnostic peritoneoscopy of the abdominal quadrants was done with biopsies and hemostasis. At the end, a Vicryl loop was pushed to close the bladder incision while the incision edges were pulled inwards. The pigs were euthanized after 2 wk, and necropsies were performed.

Results:

No bowel injury was noted in any of the 4 pigs. Satisfactory bladder closure was done in 2 pigs, while a partial closure was achieved in 1 case. In the postoperative period, the pigs showed no signs of pain or distress, voided normally, and had a good appetite. On necropsy, we noted healed cystotomy incisions, no intraabdominal adhesions, and no adhesions at the site.

Conclusion:

Our new technique for endoscopic cystotomy overcomes previously reported risks for bowel injuries. Using this route gives good spatial orientation and access to all quadrants, including the pelvis. Biopsies with good hemostasis can be easily achieved. Lack of intraperitoneal changes postoperatively indicate that this procedure may be safe for humans.     

A cross-sectional study of knife injuries at a London major trauma centre

INTRODUCTION

No national recording systems for knife injuries exist in the UK. Understanding the true size and nature of the problem of knife injuries is the first stage in reducing the burden of this injury. The aim of this study was to survey every knife injury seen in a single inner city emergency department (ED) over a one-year period.

METHODS

A cross-sectional observational study was performed of all patients attending with a knife injury to the ED of a London major trauma centre in 2011. Demographic characteristics, patterns of injury, morbidity and mortality data were collected.

RESULTS

A total of 938 knife injuries were identified from 127,191 attendances (0.77% of all visits) with a case fatality rate of 0.53%. A quarter (24%) of the major trauma team’s caseload was for knife injuries. Overall, 44% of injuries were selfreported as assaults, 49% as accidents and 8% as deliberate self-harm. The highest age specific incident rate occurred in the 16–24 year age category (263/100,000). Multiple injuries were seen in 19% of cases, of which only 81% were recorded as assaults. The mean length of stay for those admitted to hospital was 3.04 days. Intrathoracic injury was seen in 26% of cases of chest trauma and 24% of abdominal injuries had a second additional chest injury.

CONCLUSIONS

Violent intentional injuries are a significant contributory factor to the workload of the major trauma team at this centre. This paper contributes to a more comprehensive understanding of the nature of these injuries seen in the ED.     

An unusual cause of small bowel obstruction caused by a Richter's-type hernia into the urinary bladder

INTRODUCTION

The authors present an unusual case of small bowel obstruction in a 62-year-old man.

PRESENTATION OF CASE

A 62-year-old man with a background of transitional cell carcinoma (TCC) of the bladder presented to the emergency department with abdominal pain, distension, vomiting and had not opened his bowels for three days. 3 weeks previously he had a repeat Transurtheral resection of bladder tumour (TURBT), during which there was an iatrogenic perforation of the bladder. A CT scan of the abdomen and pelvis revealed small bowel obstruction but did not identify a cause. At laparotomy the cause of the obstruction was identified as a section of the small bowel that had partially herniated into the bladder, via the perforation. The defect was repaired and the patient made an uneventful recovery.

DISCUSSION

Herniation of the bowel into a defect in the bladder wall is a rare event with only 6 previous cases reported in the literature. It can cause signs and symptoms of bowel obstruction.

CONCLUSION

In patients with known bladder perforations who present with symptoms and signs of bowel obstruction, bowel herniation into the bladder should be considered. Early surgical intervention may be necessary if the patient is clinically unwell with appropriate symptoms and signs and imaging does not provide conclusive answer.     

Ovarian torsion in puerperium: A case report and review of the literature

INTRODUCTION

Ovarian torsion (OT) is a rare cause of acute abdominal pain that requires prompt recognition and treatment during puerperium. Diagnosis of OT can be challenging due to nonspecific clinical features and uncommon objective findings. The management of OT is often delayed because of diagnostic uncertainty. Early and timely recognition and prompt intervention are crucial to preserve ovarian function and to minimize morbidity.

PRESENTATION OF CASE

We report a 29-year-old postpartum woman who presented to the emergency department (ED) with severe right flank pain, nausea and anorexia initially considered as renal colic. After further investigation, OT caused by large mucinous cyst was diagnosed. Right-sided salpingo-oophorectomy was performed due to hemorrhagic ovary and huge cystic mass causing ischemic OT.

DISCUSSION

OT is often diagnosed based on the clinical presentation, including severe, sharp, sudden onset of unilateral lower abdominal pain and tenderness with a palpable laterouterine pelvic mass and nausea/vomiting. Emergency surgical intervention should be performed if OT is suspected to confirm the diagnosis and uncoil the twist to prevent ovarian damage.

CONCLUSION

In conclusion, emergency physicians should be aware of the possibility of OT in postpartum women. Therefore, early and timely surgical intervention should be undertaken.     

Erect chest radiography in the setting of the acute abdomen: essential tool or an unnecessary waste of resources?

INTRODUCTION

It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain.

PATIENTS AND METHODS

A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospec-tively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care.

RESULTS

A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant.

CONCLUSIONS

The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This would lead to less radiation exposure, reduce delays to diagnosis, and provide significant financial savings.     

Repair of Bochdalek hernia in an adult complicated by abdominal compartment syndrome,gastropleural fistula and pleural empyema: Report of a case

INTRODUCTION

Bochdalek''s diaphragmatic hernia (BDH) rarely developed symptomatic in adulthood but mostly required an operation. In adult BDH cases, long-term residing of the massive intraabdominal organs in the thoracic cavity passively causes loss of domain for abdominal organs (LOD).

PRESENTATION OF CASE

A 63-year-old man presented at our institution complaining of sudden left upper quadrant abdominal pain. Chest radiography showed a hyperdense lesion containing bowel gas in the left pleural space. Computed tomography revealed a dilated bowel above the diaphragm and intestinal obstruction suggestive of gangrenous changes. These findings were consistent with the diagnosis of incarcerated BDH and an emergency laparotomy was performed. Operative findings revealed the hypoplastic lung, lack of hernia sac, and location of the diaphragmatic defect, which indicated that his hernia was true congenital. Organs were reduced into the abdominal cavity, and large defect of the diaphragm was repaired with combination of direct vascular closure and intraperitoneal onlay mesh reinforcement using with expanded polytetrafluoroethylene (ePTFE) mesh. On the postoperative day 1, the patient fell into the shock and was diagnosed to have abdominal compartment syndrome (ACS). Conservative therapies were administered, but resulted in gastropleural fistula and pleural empyema, which required an emergency surgery. Mesh extraction and fistulectomy were performed.

DISCUSSION

A PubMed search for the case of ACS after repair of the adult BDH revealed only three cases, making this very rare condition.

CONCLUSION

In dealing with adult BDH, possible post-repair ACS should be considered.     

Laparoscopy and natural orifice surgery: first entry safety surveillance step

Background and Objective:

We are sharing information regarding the surveillance of the first entrance port in laparoscopic and natural orifice transvaginal endoscopy surgeries. However, we are not analyzing techniques or other surgical findings.

Method:

In this study, 160 women with previous abdominal pelvic surgeries underwent laparoscopic surgery, 145 patients underwent transvaginal Minilaparoscopy Assisted Natural Orifice Surgery (hybrid), and 3 patients underwent pure natural orifice transvaginal endoscopic surgery (pure). For those patients who had laparoscopy and hybrid procedures, the surveillance was from a laparoscope or gastroscope placed in a secondary port. Surveillance in pure cases was done using a gastroscopic retro view to see the pouch of Douglas.

Results:

The laparoscopic procedures were gynecological procedures. The hybrid procedures included gynecological procedures as well as appendectomies and cholecystectomies; the pure procedures were cholecystectomies. There were a few minor vascular and bowel injuries in the laparoscopy group. There were no injuries in the transvaginal hybrid or pure procedures groups.

Conclusion:

The surveillance of the first entrance port can be an effective precautionary step. The cumulative experience suggests that using such surveillance in cases involving patients with prior surgery may assist in recognizing complications that might otherwise be missed.     

Military General Surgical Training Opportunities on Operations in Afghanistan

INTRODUCTION

In the UK, general surgical specialist trainees have limited exposure to general surgical trauma. Previous work has shown that trainees are involved in only two blunt and one penetrating trauma laparotomies per annum. During their training, nearly half of trainees will not be involved in the surgical management of liver injury, 20% will not undertake a trauma splenectomy and only a quarter will see a trauma thoracotomy. Military general surgical trainees require training in, and exposure to, the surgical management of trauma and specifically military wounding patterns that is not available in the UK. The objective of this study was to determine whether operative workload in the sole British surgical unit in Helmand Province, Afghanistan (Operation HERRICK) would provide a training opportunity for military general surgical trainees.

PATIENTS AND METHODS

A retrospective theatre log-book review of all surgical cases performed at the Role 2 (Enhanced) treatment facility at Camp Bastion, Helmand Province on Operation HERRICK between October 2006 and October 2007, inclusive. Operative cases were analysed for general surgical trauma, laparotomy, thoracotomy, vascular trauma and specific organ injury management where available.

RESULTS

A total of 968 operative cases were performed during the study period. General surgical procedures included 51 laparotomies, 17 thoracotomies and 11 vascular repairs. There were a further 70 debridements of general surgical wounds. Specific organ management included five cases of liver packing for trauma, five trauma splenectomies and four nephrectomies.

CONCLUSIONS

A training opportunity currently exists on Operation HERRICK for military general surgical specialist trainees. If the tempo of the last 12 months is maintained, a 2-month deployment would essentially provide trainees with the equivalent trauma surgery experience to the whole of their surgical training in the UK NHS. Trainees would gain experience in military trauma as well as specific organ injury management.     

Bladder neck closure and suprapubic catheter placement as definitive management of neurogenic bladder

Objective

Surgical management for neurogenic bladder may require abandonment of the native urethra due to intractable urinary incontinence, irreparable urethral erosion, severe scarring from previous transurethral procedures, or urethrocutaneous fistula. In these patients, bladder neck closure (BNC) excludes the native urethra and provides continence while preserving the antireflux mechanism of the native ureters. This procedure is commonly combined with ileovesicostomy or continent catheterizable stoma, with or without augmentation enterocystoplasty. Alternatively, BNC can be paired with suprapubic catheter diversion. This strategy does not require a bowel segment, resulting in shorter operative times and less opportunity for bowel-related morbidity. The study purpose is to examine preoperative characteristics, indications, complications, and long-term maintenance of renal function of BNC patients.

Methods

A retrospective review of medical records of 35 patients who underwent BNC with suprapubic catheter placement from 1998 to 2007 by a single surgeon (LKL) was completed.

Results

Neurogenic bladder was attributable to spinal cord injury in 71%, 23% had multiple sclerosis, and 9% had cerebrovascular accident. Indications for BNC included severe urethral erosion in 80%, decubitus ulcer exacerbated by urinary incontinence in 34%, urethrocutaneous fistula in 11%, and other indications in 9%. The overall complication rate was 17%. All but two patients were continent at follow-up. Forty-nine per cent of patients had imaging available for review, none of which showed deterioration of the upper tracts.

Conclusions

Our results suggest that BNC in conjunction with suprapubic catheter diversion provides an excellent chance at urethral continence with a reasonable complication rate.     

Emergency Intraperitoneal Onlay Mesh Repair of Incarcerated Spigelian Hernia

Background and Objectives:

Spigelian hernia is a rare cause of incarcerated ventral abdominal hernia that may pose a diagnostic dilemma. However, with the increasing utilization of double contrast computed tomography (CT) for undiagnosed small bowel obstruction in a virgin abdomen, more such cases are being diagnosed with increasing confidence. Furthermore, with the rapid expansion of the indications for minimal access surgery in emergency situations, these rare emergencies are increasingly tackled using a laparoscopic approach leading to swift patient recovery and discharge.

Methods:

We present the case of an emergency intraperitoneal onlay mesh (IPOM) repair of Spigelian hernia, causing acute small bowel obstruction in a 55-year-old man with liver disease and ascites that was diagnosed using a CT scan. We conducted a search of Medline, Embase, Science Citation Index, Current Contents, PubMed, and the Cochrane Database to review the history of laparoscopic repair of Spigelian hernia and its various advancements, which are briefly presented here.

Results:

The hernia was successfully reduced using laparoscopy, revealing a moderate-size defect in the linea semilunaris. The hernial defect was repaired with a composite mesh that was tacked into position. The patient was discharged from the hospital on the second postoperative day.

Conclusions:

Spigelian hernia in an emergency setting can be easily and swiftly repaired using the IPOM method utilizing a composite mesh.     

The use and effectiveness of cadaveric workshops in higher surgical training: a systematic review

INTRODUCTION

The aim of this systematic review is to describe the use of cadavers in postgraduate surgical training, to determine the effect of cadaveric training sessions on surgical trainees'' technical skills performance and to determine how trainees perceive the use of cadaveric workshops as a training tool.

METHODS

An electronic literature search was performed, restricted to the English language, of MEDLINE®, Embase™, the Cumulative Index to Nursing and Allied Health Literature (CINAHL®), Centre for Agricultural Bioscience (CAB) Abstracts, the Educational Resources Information Center (ERIC™) database, the British Education Index, the Australian Education Index, the Cochrane Library and the Best Evidence in Medical Education website. Studies that were eligible for review included primary studies evaluating the use of human cadaveric surgical workshops for surgical skills training in postgraduate surgical trainees and those that included a formal assessment of skills performance or trainee satisfaction after the training session.

RESULTS

Eight studies were identified as satisfying the eligibility criteria. One study showed a benefit from cadaveric workshop training with regard to the ability of trainees to perform relatively simple emergency procedures and one showed weak evidence of a benefit in performing more complex surgical procedures. Three studies showed that trainees valued the experience of cadaveric training.

CONCLUSIONS

Evidence for the effectiveness of cadaveric workshops in surgical training is currently limited. In particular, there is little research into how these workshops improve the performance of surgical trainees during subsequent live surgery. However, both trainees and assessors hold them in high regard and feel they help to improve operative skills. Further research into the role of cadaveric workshops is required.     

SUPRAPUBIC LAPAROSCOPIC CHOLECYSTECTOMY: TECHNIQUE AND PRELIMINARY RESULTS

Background

The minimally invasive abdominal surgery has evolved to reduce portals, culminating with a single incision and natural orifice operation. However, these methods are still expensive, difficult to implement and with questionable aesthetic results.

Aim

To present the standardization and preliminary results of a technique for performing laparoscopic suprapubic access by the principle which was called the Supra Pubic Endoscopic Surgery for cholecystectomy.

Method

The average body mass index of patients, the mean operative time, clinical data of the postoperative complications and quality of life were prospectively studied. The operation incisions consisted of: A) umbilical for instrumental dissection and clipping; B) in the right groin for handling and gallbladder gripping; C) suprapubic for the camera. With the patient in reverse Trendelenburg and left lateral decubitus, the operation flew by the camera trocar in C, proceeding with dissection and isolation of the biliary pedicle, identification of cystic duct and artery, with usual instrumentation. Transcystic intraoperative cholangiography was performed in all cases in which there were indications. The procedure was completed with clipping and sectioning of the cystic duct and artery, retrograde resection of the gallbladder and extracting it by the umbilical trocar incision under direct vision.

Results

Thirty patients undergone this surgical procedure between March and June 2012 and were evaluated. The mean age was 40.7 years and the indications were typical biliary colic in 18 cases (60 %), cholecystitis in five cases (16.6 %), biliary pancreatitis in one case (3.3%); polyp in three cases (10%) and obstructive jaundice at three cases (10%). The average body mass index was 27.8 (23.1-35.1) and surgical time ranged between 24 and 70 minutes.

Conclusion

The technique proved to be feasible and safe , with no significant complications, and satisfactory cosmetic results.