Day-only laparoscopic cholecystectomy in a regional teaching hospital

Background: Day‐only laparoscopic cholecystectomy (DOLC) has been demonstrated to be a safe and feasible procedure. The aim of the present study was to introduce DOLC to a busy teaching hospital without a separate day‐surgery facility, to identify any problems associated with early discharge, and to determine patient satisfaction. Methods: Over a 2‐year period, all patients undergoing elective laparoscopic cholecystectomy under one surgeon were prospectively studied. Patients satisfying criteria for DOLC were offered the procedure. All patients were sent anonymous satisfaction surveys postoperatively. Results: One hundred and one patients underwent elective laparoscopic cholecystectomies and 41 of these patients were booked for DOLC. Thirty‐three (80%) were successfully discharged the same day and there were no complications related to early discharge. Only two of eight unplanned admissions were because of postoperative pain or nausea. Thirty‐two (78%) of DOLC patients replied to our survey and of those, 24 (78%) were satisfied with their length of stay. The extra strain placed on day‐stay ward resources was reflected in patient survey comments on their care. Conclusions: Our findings support the evidence that DOLC is safe and feasible. However, in a busy teaching hospital with tight budget constraints and no separate day‐surgery facility we found many patients satisfied with their length of stay but not always with the quality of care they received on the day‐stay ward. The latter was insufficiently equipped to handle procedures of this complexity. So although in theory DOLC has many advantages, we are unable to institute this as routine practice at this time.     

Rare causes of abdominal pain: a primer for the admitting general surgeon

The broad uptake of the acute surgical unit (ASU) model of surgical care in Australia has resulted in general surgeons becoming increasingly involved in the management of patients with acute abdominal pain (AAP), some of whom will be labelled as having non-specific abdominal pain (NSAP) (Kinnear N, Jolly S, Herath M, et al. The acute surgical unit: An updated systematic review and meta-analysis. review. Int. J. Surg. 2021;94:106109; Lehane CW, Jootun RN, Bennett M, Wong S, Truskett P. Does an acute care surgical model improve the management and outcome of acute cholecystitis? ANZ J. Surg. 2010;80:438-42). NSAP patients lack a clear diagnosis of surgical pathology based on standard clinical, laboratory and imaging work-up, although they may require ASU admission for pain control and assessment. This article provides a review of uncommon conditions, presenting as AAP, that could possibly be mis-labelled as NSAP, with a focus on aspects of the presentation that may aid diagnosis and management including specific demographic features, clinical findings, key investigations and initial treatment priorities for ASU clinicians. Ultimately, most of the conditions discussed will not require surgical intervention, however, they require a diagnosis to be made and initial treatment planning before on-referral to the appropriate specialty. For the on-call general surgeon, some knowledge of these conditions and an index of suspicion are invaluable for the prompt diagnosis and efficient management of these patients.     

Minor operations performed under local anaesthetic in a day surgery unit

Minor ‘lumps and bumps' requiring operation under local anaesthetic constitute a significant number of referrals each month to general surgical clinics. These patients have often remained on hospital waiting lists for more than 1 year. A new system for managing these cases is presented whereby: (i) a large throughput of ‘clinical material' is available for supervised teaching of both medical students and junior trainees; (ii) patients are operated upon safely and efficiently; (iii) the waiting list time can be significantly reduced; and (iv) the patient has an overall satisfactory hospital ‘experience'.     

Reflections on surgery as a career and its future

This report is the gist of a paper read by J.E.C. at the 90th Annual Meeting of the Japanese Surgical Society, Sapporo, Japan, 1990     

Single visit surgery for pediatric ambulatory surgical procedures: a satisfaction and cost analysis

Background

Single visit surgery (SVS) consists of same-day pre-operative assessment and operation with telephone post-operative follow-up. This reduces family time commitment to 1 hospital trip rather than 2–3. We began SVS for ambulatory patients with clear surgical indications in 2013. We sought to determine family satisfaction, cost savings to families, and institutional financial feasibility of SVS.

Basic knowledge of a microwave tissue coagulator and its clinical applications

A microwave tissue coagulator originally developed to control hemorrhage during hepatic resection has recently found widespread use in the field of minimally invasive surgery. This surgical tool is based on the principle that by radiating a 2450-MHz (12-cm wavelength) microwave from a monopolar antenna within tissue, the heat generated will be limited to within the electromagnetic field generated around the antenna, leading to coagulation of protein in that field. It is therefore possible to use this monopolar antenna as a surgical electrode. The coagulation field is determined by the relationship between the wavelength frequency, tissue-specific permittivity, antenna length, waveform and output, and duration of the irradiation. Since this technique has been applied to devise a new method of hepatectomy, it has also found use in various other surgical fields, such as gastrointestinal tract endoscopic surgery, laparoscopic surgery, and percutaneous surgery. It has also enhanced therapeutic results, notably in cancer therapy. Received for publication on Sept. 6, 1997; accepted on Jan. 6, 1998     

机器人辅助神经鞘瘤切除日间手术一例报道

神经鞘瘤是一种常见的后纵隔占位性病变,通常发生于脊神经根,具有一定的恶变可能性。临床上对于后纵隔占位性病变,若无禁忌证,均应考虑外科治疗。手术方式根据肿瘤的大小和位置分为开胸手术以及胸腔镜手术。尽管后纵隔肿瘤切除术通常被认为是一种安全的、低风险的手术,但患者术后仍需要住院观察。随着手术机器人技术的开发,机器人辅助手术可以保护周围组织减少术后出血的可能性,以达到日间手术的标准。本文介绍了一例接受机器人辅助后纵隔肿瘤切除日间手术的患者,手术效果满意,患者在24h内顺利出院。     

Enhanced recovery programmes in hepatobiliary and pancreatic surgery: a systematic review

INTRODUCTION

The terms ‘enhanced recovery after surgery’, ‘enhanced recovery programme’ (ERP) and ‘fast track surgery’ refer to multimodal strategies aiming to streamline peri-operative care pathways, to maximise effectiveness and minimise costs. While the results of ERP in colorectal surgery are well reported, there have been no reviews examining if these concepts could be applied safely to hepatopancreatobiliary (HPB) surgery. The aim of this systematic review was to appraise the current evidence for ERP in HPB surgery.

METHODS

A MEDLINE® literature search was undertaken using the keywords ‘enhanced recovery’, ‘fast-track’, ‘peri-operative’, ‘surgery’, ‘pancreas’ and ‘liver’ and their derivatives such as ‘pancreatic’ or ‘hepatic’. The primary endpoint was length of post-operative hospital stay. Secondary endpoints were morbidity, mortality and readmission rate.

RESULTS

Ten articles were retrieved describing an ERP. ERP protocols varied slightly between studies. A reduction in length of stay was a consistent finding following the incorporation of ERP when compared with historical controls. This was not at the expense of increased rates of readmission, morbidity or mortality in any study.

CONCLUSIONS

The introduction of an ERP in HPB surgery appears safe and feasible. Currently, many of the principles of the multimodal pathway are derived from the colorectal ERP and distinct differences exist, which may impede its implementation in HPB surgery.     

Incidence and predictors of post-thyroidectomy hypocalcaemia in a tertiary endocrine surgical unit

Background

Post-thyroidectomy hypocalcaemia is a common complication with significant short and long term morbidity. The aim of this study was to determine the incidence and predictors of post-thyroidectomy hypocalcaemia (as defined by a corrected calcium <2.1 mmol/l) in a tertiary endocrine surgical unit.

Methods

A total of 238 consecutive patients who underwent completion or bilateral thyroid surgery between 2008 and 2011 were included in this retrospective study. Clinical and biochemical data were obtained from electronic and hard copy medical records.

Results

The incidence of post-thyroidectomy hypocalcaemia on first postoperative day (POD1) was 29.0%. There was variation in the incidence of hypocalcaemia depending on the timing of measurement on the first postoperative day. At six months following surgery, 5.5% of patients were on calcium and/or vitamin D supplementation.Factors associated with post-thyroidectomy hypocalcaemia were lower preoperative corrected calcium (p=0.005) and parathyroid gland (PTG) auto-transplant (p=0.001). Other clinical factors such as central lymph node dissection, inadvertent PTG excision, ethnicity, preoperative diagnosis and Lugol’s iodine were not associated with post-thyroidectomy hypocalcaemia.

Conclusion

The incidence of post-thyroidectomy hypocalcaemia was underestimated by 6% when only POD1 measurements were considered. The timing of measurement on POD1 has an impact on the incidence of post-thyroidectomy hypocalcaemia. Auto-transplantation and lower preoperative calcium were associated with post-thyroidectomy hypocalcaemia.     

单中心23年胆道外科腹腔镜手术的围手术期安全性分析

目的分析解放军总医院23年间收治胆道外科行腹腔镜手术患者的围手术期情况,探讨腹腔镜手术在胆道外科应用中的安全性。 方法根据相关纳入标准回顾性分析解放军总医院胆道外科1992年4月至2014年12月期间收治的连续11 419例腹腔镜手术患者的临床资料,进而分析其围手术期并发症发生和严重程度情况。选取同期行开腹手术的患者资料作为对照进行对比分析,比较两组患者之间围手术期和术后并发症情况。 结果(1)解放军总医院胆道外科1992年4月至2014年12月23年间收治的行腹腔镜手术患者共11 419例,占同期胆道外科手术患者的56.33%。(2)在所有患者中,围手术期死亡患者2例,病死率为0.02%;发生并发症患者43例,并发症发生率为0.38%。在所有并发症中,最常见的依次为胆瘘、切口感染和腹腔感染,发生率分别为0.18%、0.05%和0.05%,其中60.42%的并发症为Ⅱ级并发症,V级致死性并发症占4.17%。(3)腹腔镜手术并发症患者中构成比最高的疾病是胆囊良性疾病和肝外胆管结石,分别占58.14%和25.58%。(4) 对于胆囊良性疾病而言,腹腔镜手术的术中出血量、手术时间、术后住院时间、并发症发生率、病死率均优于开腹手术[(15.6±26.1)ml、(1.1±0.5)h、(2.1±1.8)d、25例(0.22%)、1例(0.01%)] vs [(136.1±168.2)ml、(1.7±0.8)h、(9.8±5.4)d、25例(0.22%)、80例(4.42%)](P<0.01)。对于肝外胆管结石患者而言,腹腔镜手术的术中出血量、术后住院时间和并发症发生率方面优于开腹手术[(44.4±46.1)ml、(5.4±5.7)h、11例(3.24%)] vs [(142.5±125.0)ml、(13.0±9.1)h、(9.8±5.4)d、84例(13.29%)](P<0.01)。 结论随着腹腔镜技术在胆道外科的推广和发展,其在胆囊良性疾病和肝外胆管结石中的应用最为广泛,围手术期效果明显优于开腹手术。     

Laparoscopic sleeve gastrectomy as day-case surgery: a review of the literature

Day-case surgery (DCS) in digestive surgery is a hot topic, and new indications for DCS in the field of gastrointestinal surgery have recently been described. Laparoscopic sleeve gastrectomy (LSG) has become a popular bariatric procedure in recent years. LSG is a reproducible, standardized procedure with a short operating time and possibly simple perioperative management. It therefore meets the criteria to be performed as a DCS procedure. Recently published series of LSG as DCS have demonstrated its feasibility. In this review on LSG performed as DCS, we focused on the management of risks associated with DCS and the results of such type of management. A literature search was conducted in the PubMed and Embase databases. Six studies were selected, comprising a total of 6227 patients. Most published series were retrospective single-center studies. Inclusion criteria were similar between most studies (primary sleeve gastrectomy for most series, patients with a body mass index ≥40 kg/m² or a body mass index ≥35 kg/m² in the presence of co-morbidities), while exclusion criteria were based on literature data for some studies (using series on risk factors for morbidity and mortality after Roux-en-Y gastric bypass) and personal experience for other series. The mortality rate of LSG as DCS ranges 0%–.08%, while the overall complication rate ranges 0%–10%. The unplanned overnight admission rate after LSG ranges .8%–8%. The unscheduled hospitalization rates range 2.1%–8.5%. LSG performed as DCS is feasible with good results, but cannot be proposed for all patients. Good selection is necessary in others to avoid increased risk of morbidity and mortality.     

应用超声刀行小切口甲状腺开放手术146例

目的探讨应用超声刀行小切口甲状腺开放手术的方法及可行性。方法 2008年3月至2010年2月,146例甲状腺良性肿瘤患者行小切口甲状腺开放手术。结果所有手术均成功,切口长度为2～4 cm,手术时间65～120 min,术中出血量5～68 ml,术后未出现手术并发症。结论应用超声刀行小切口甲状腺开放手术具有良好的美容效果,并且可以明显减少术中出血量、缩短手术时间及降低术后并发症的发生率,增加手术安全性,缩短腔镜甲状腺手术的学习曲线。     

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目的 设计一种全新的治疗胃粘膜或粘膜下病变的腹腔镜手术方法。方法 三个穿刺套管均通过腹壁及胃壁穿刺置入胃腔，在胃腔内采用腹腔镜器械通过监视器图像进行手术。结果 8例中，6例早期胃癌，1例粘膜下平滑肌瘤，1例巨大息肉，均未出现并发症，亦无中转开腹。结论 对于纤维胃镜无法治疗的胃粘膜或粘膜下病变，采用腹腔镜胃腔内手术其方法简便、安全、可行。