Surgery

Surgical experience and identification of errors in laparoscopic cholecystectomy (2023)

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Type of publication:
Journal article

Author(s):
Humm, Gemma L; Peckham-Cooper, Adam; *Chang, Jessica; Fernandes, Roland; Gomez, Naim Fakih; Mohan, Helen; Nally, Deirdre; Thaventhiran, Anthony J; Zakeri, Roxanna; Gupte, Anaya; Crosbie, James; Wood, Christopher; Dawas, Khaled; Stoyanov, Danail; Lovat, Laurence B.

Citation:
British Journal of Surgery. 2023 Aug 23. [epub ahead of print]

Abstract:
BACKGROUND: Surgical errors are acts or omissions resulting in negative consequences and/or increased operating time. This study describes surgeon-reported errors in laparoscopic cholecystectomy. METHODS: Intraoperative videos were uploaded and annotated on Touch SurgeryTM Enterprise. Participants evaluated videos for severity using a 10-point intraoperative cholecystitis grading score, and errors using Observational Clinical Human Reliability Assessment, which includes skill, consequence, and mechanism classifications. RESULTS: Nine videos were assessed by 8 participants (3 junior (specialist trainee (ST) 3-5), 2 senior trainees (ST6-8), and 3 consultants). Participants identified 550 errors. Positive relationships were seen between total operating time and error count (r2 = 0.284, P < 0.001), intraoperative grade score and error count (r2 = 0.578, P = 0.001), and intraoperative grade score and total operating time (r2 = 0.157, P < 0.001). Error counts differed significantly across intraoperative phases (H(6) = 47.06, P < 0.001), most frequently at dissection of the hepatocystic triangle (total 282; median 33.5 (i.q.r. 23.5-47.8, range 15-63)), ligation/division of cystic structures (total 124; median 13.5 (i.q.r. 12-19.3, range 10-26)), and gallbladder dissection (total 117; median 14.5 (i.q.r. 10.3-18.8, range 6-26)). There were no significant differences in error counts between juniors, seniors, and consultants (H(2) = 0.03, P = 0.987). Errors were classified differently. For dissection of the hepatocystic triangle, thermal injuries (50 in total) were frequently classified as executional, consequential errors; trainees classified thermal injuries as step done with excessive force, speed, depth, distance, time or rotation (29 out of 50), whereas consultants classified them as incorrect orientation (6 out of 50). For ligation/division of cystic structures, inappropriate clipping (60 errors in total), procedural errors were reported by junior trainees (6 out of 60), but not consultants. For gallbladder dissection, inappropriate dissection (20 errors in total) was reported in incorrect planes by consultants and seniors (6 out of 20), but not by juniors. Poor economy of movement (11 errors in total) was reported more by consultants (8 out of 11) than trainees (3 out of 11). CONCLUSION: This study suggests that surgical experience influences error interpretation, but the benefits for surgical training are currently unclear.

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Pre-Assessment Information (2022)

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Type of publication:
Service improvement case study

Author(s):
*Rachael Bollands, *Rachel Bladen, *Rachel Hanmer, *Paul Adams, *Jemima Hughes

Citation:
SaTH Improvement Hub, September 2022

Abstract:
Patients are required to have an information pack following their assessment to share the required information prior to surgery. A QR code was generated to share this information reducing time spent creating the packs to release additional time for patient care.

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Health and Wellbeing (2022)

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Type of publication:
Service improvement case study

Author(s):
*Andrena Weston, *Lisa Baker-Murray, *Alison Mattey, *Steve Turner, *Claire Oborn, *Theatre Teams- RSH and PRH, *Sabeena Khanna

Citation:
SaTH Improvement Hub, June 2022

Abstract:
In order to improve the Health and Wellbeing, vacancy rates and reduce sickness within Theatres, a number of interventions were trialled.

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Stepped-wedge randomized controlled trial of laparoscopic ventral mesh rectopexy in adults with chronic constipation (2021)

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Type of publication:
Conference abstract

Author(s):
Grossi U.; *Lacy-Colson J.; Brown S.; Cross S.; Eldridge S.; Scott S.M.; Taheri S.; Knowles C.

Citation:
Colorectal Disease. Conference: 16th Scientific and Annual Meeting of the European Society of Coloproctology, ESCP 2021. Virtual. 23(Supplement 2) (pp 3), 2021. Date of Publication: October 2021.

Abstract:
Aim: Effectiveness of laparoscopic ventral mesh rectopexy (LVMR) in patients with defecatory disorders secondary to internal rectal prolapse (IRP) is poorly evidenced. A UK-based multicentre randomized controlled trial (RCT) was designed to determine the clinical efficacy of LVMR compared to controls at medium-term follow-up. Method(s): A stepped-wedge RCT design permitted observer-masked data comparisons between patients awaiting LVMR with those who had undergone surgery.Adult participants with radiologically confirmed IRP refractory to conservative treatment were randomized to 3 arms with different delays before surgery. Efficacy outcome data were collected at equally stepped time points (12, 24, 36, 48, 60, and 72 weeks). Clinical efficacy of LVMR compared to controls was measured as a 1.0-point reduction in PAC-QOL and PAC-SYM scores at 24 weeks. Secondary outcome measures included 14-day diary data, GAD7, PHQ9, St Marks incontinence score, PISQ12, CC-BRQ, and BIPQ. Result(s): Of 42 eligible patients, 28 (67%) females were randomized from 6 institutions. Nine were assigned to the T0 arm, 10 to T12, and 9 to T24. There were no substantial differences in baseline characteristics between the 3 arms. Compared to baseline, significant reduction in PAC-QOL and PAC-SYM scores were observed at 24 weeks post-surgery (-1.09 [95%CI -1.76, -0.41], P = 0.0019, and -0.92 [-1.52, -0.32], P = 0.0029). As opposed to PAC-QOL (-1.38 [-2.94, 0.19], P = 0.0840 at 72 weeks), improvements in PAC-SYM scores persisted to 72 weeks (-1.51 [-2.87, -0.16], P = 0.0289). Compared to baseline, no differences were found on secondary outcomes, except for significant improvements on CC-BRQ and BIPQ at 24 and 48 weeks. Conclusion(s): There was evidence of a short-term effect of LVMR for IRP up to 36 weeks. Improvements in quality of life declined over follow-up up to 72 weeks.

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Bariatric surgeons' experiences of working in the first year of the pandemic (2023)

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Type of publication:
Journal article

Author(s):
Graham Y.N.H.; Mahawar K.; Singhal R.; Madhok B.; Yang W.; *Riera M.; Martinez-Duartez P.; Pouwels S.; Sharma M.; Hayes C.

Citation:
Obesity Science and Practice. 9(4) (pp 329-336), 2023. Date of Publication: August 2023.

Abstract:
Background: The first year of the Covid-19 pandemic saw drastic changes to bariatric surgical practice, including postponement of procedures, altered patient care and impacting on the role of bariatric surgeons. The consequences of this both personally and professionally amongst bariatric surgeons has not as yet been explored. Aim(s): The aim of this research was to understand bariatric surgeons' perspectives of working during the first year of the pandemic to explore the self-reported personal and professional impact. Method(s): Using a retrospective, two phased, study design with global participants recruited from closed, bariatric surgical units. The first phase used a qualitative thematic analytic framework to identify salient areas of importance to surgeons. Themes informed the construction of an on-line, confidential survey to test the potential generalizability of the interview findings with a larger representative population from the global bariatric surgical community. Finding(s): Findings of the study revealed that the first year of the pandemic had a detrimental effect on bariatric surgeons both personally and professionally globally. Conclusion(s): This study has identified the need to build resilience of bariatric surgeons so that the practice of self-care and the encouragement of help-seeking behaviors can potentially be normalized, which will in turn increase levels of mental health and wellbeing.

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Global Level of Harm experienced by Bariatric Surgeons for Bariatrics surgical interventions: An exploration of predictors (2022)

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Type of publication:
Conference abstract

Author(s):
Cheruvu C.; Bangash A.H.; Isik A.; Parmar C.; Galanis M.; Yang W.; Kok J.H.H.; *Bandyopadhyay S.K.; Di Maggio F.; Atici S.D.; Abouelazayem M.; Viswanath Y.K.S.

Citation:
British Journal of Surgery. Conference: AUGIS Annual Scientific Meeting. Aberdeen United Kingdom. 109(Supplement 9) (pp ix17-ix18), 2022. Date of Publication: December 2022.

Abstract:
Background: COVID-19 pandemic has taken the world by surprise with the depth and breadth of its effect on all walks of life, bariatric surgery being no exception. With the scientific literature hitherto unable to comment and ascertain the influence of the COVID-19 pandemic on bariatric surgery and the level of harm experienced by bariatric surgeons, we- TUGS 'Level of Harm' collaborative group- attempted to gauge the effect of the said pandemic on bariatrics surgery specifically vis a vis the level of harm experienced by bariatric surgeons due to the pandemic. Method(s): A virtual questionnaire- developed on both: Google forms and Survey Monkey- was circulated via TUGS social media platforms to reach bariatric consultant surgeons, fellows and residents practising throughout the world in a bid to explore the influence of the COVID-19 pandemic on their surgical practice including but not limited to the annual surgical volume including re-do surgeries volume and postoperative complications. Moreover, they were also requested to categorise their respective level of harm vis a vis bariatric surgical interventions they undertake. After de-identification of the data, SPSS (V.26) was adopted to undergo statistical analysis. After exploring the dataset by descriptive analyses, the Chi-square test was applied to pursue the association of categorical variables with the reported level of harm. A double-sided p-value of less than 0.05 was considered statistically significant. Result(s): 16.8% of the respondents (21/125) indicated no harm vis a vis bariatrics surgery work whereas a comparative 18.4% of the respondents (23/125) reported moderate harm with significant worsening of symptoms. None of those who indicated less than 10% increase in surgery waitlisted patients being subjected to endoscopic interventions (0/14) reported Moderate Harm for bariatrics surgery work with significant worsening of symptoms whereas 1 in every 3 of those who indicated between 10% to 25% increase in surgery waitlisted patients being subjected to endoscopic interventions (5/15) reported such level of harm for bariatrics surgery work. (p < 0.001) Upon exhaustive sub-group analysis, it was uncovered that 33.6% of bariatrics surgical professionals perceived no harm (no evidence of change in clinical condition) during gastric band or related surgery work with only 4% perceiving Moderate Harm (significant worsening of symptoms/ comorbidities control/ minor increase in medications) for such surgical interventions. All of those who reported No harm for gastric band or related surgical work reported that Single anastomosis duodeno-ileal bypass (SADI-S) accounts for 10% of their practice whereas none of those who indicated that SADI-S accounts for more than 10% of their practice reported No harm for such surgical work. (p = 0.019) Conclusion(s): The global snapshot illustrates a trend of low harm vis a vis bariatrics surgery work in surgical professionals practising in the private sector with a lesser number of patients developing COVID-19 postoperatively and no postoperative COVID-19 related mortality. The patient being subjected to endoscopic intervention portends a higher level of harm for bariatrics surgical work- strict adherence to criteria and safety protocols being a logical inference. For gastric band and related surgery work, preoperative COVID-19 testing appears to be influenced by confounders in its effect on the surgeon's level of harm for the said interventions warranting further exploration. SADI-S, at a cut-off of 10%, exhibits strong interaction with the surgeon's level of harm for gastric band insertion and relation surgery work. Women surgical professionals came out to exhibit equivalent mental resilience and technical prowess at par with their male colleagues when it came to bariatrics surgical intervention

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Evaluating the perceptions of workplace-based assessments in surgical training: a systematic review (2022)

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Type of publication:
Systematic Review

Author(s):
Mughal Z.; *Patel S.; Gupta K.K.; Metcalfe C.; Beech T.; Jennings C.

Citation:
Annals of the Royal College of Surgeons of England. (no pagination), 2022. Date of Publication: 14 Nov 2022. [epub ahead of print]

Abstract:
INTRODUCTION: Workplace-based assessments (WBAs) are intended to maximise learning opportunities in surgical training. There is speculation as to whether mandatory assessments in this form contribute to a tick-box culture. The objective of this review was to investigate surgical trainees' attitudes towards WBAs. METHOD(S): This systematic review of qualitative studies was performed in accordance with the PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) statement. The literature was searched on the Medline, Embase, PubMed and Web of Science databases on 22 March 2022. RESULT(S): Sixteen studies were included in the review, mostly carried out on users of the Intercollegiate Surgical Curriculum Programme portfolio in the UK. Trainees felt that WBAs were educationally useful, providing opportunity for feedback, but this was overshadowed by a pressure to reach a set annual quota for WBAs and achieve high scores. Other themes included inaccurate recording of WBAs, the role of WBAs as formative or summative assessments, engagement and accessibility of trainers, and lack of time to complete WBAs. CONCLUSION(S): Negative perceptions about WBAs were widespread among surgical trainees despite a recognition of their capacity to facilitate learning. This review supports the recent removal of the annual quota for WBAs in UK surgical training programmes.

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Resection and primary anastomosis is safe in selected patients with perforated diverticulitis: A cohort study (2022)

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Type of publication:
Conference abstract

Author(s):
*Dowdeswell M.; *Chang J.; *Rajalingam V.; *Wolos M.; *McCloud J.; *Cheetham M.

Citation:
British Journal of Surgery. Conference: Association of Surgeons of Great Britain and Ireland Annual Congress, ASGBI 2022. Liverpool United Kingdom. 109(Supplement 5) (pp v30-v31), 2022. Date of Publication: 2022.

Abstract:
Aims: Historically, the preferred procedure for perforated diverticular disease is Hartmann's procedure (Hp). Although reliably achieving source control, it's associated with a high rate of post-operative complications and a stoma which of ten becomes permanent. We reviewed our experience of patients undergoing Hp vs primary anastomosis (PA) for perforated diverticulitis. Method(s): All patients undergoing emergency resectional surgery for perforated diverticulitis between March 2015 and Jan 2021 were identified from The Hospital Episode Statistics (HES) data. Demographics were collected and The patient groups were case matched for age and Charleson Comorbidity Index (CCI), Computed Tomography (CT) appearance and intraoperative contamination data. Post-operative morbidity/mortality data was compared. Result(s): 105 patients were included. 15 patients had PA (without diversion) and 90 Hp. In The PA cohort were10 males, median age 52 (range 27-76). There were no anastomotic leaks. 30-day morbidities were superficial wound dehiscence (1) and early incisional hernia (1). Median post-operative stay was 9 days (range 5-25). Hp control group (age below 76, Charlson score 10and below, Hinchey 1-3 intraoperatively). Included 58 patients, 26 males, median age 60.5 (range 30-76). Median post-operative stay was 10.5 days (range 5-227). 2 patients required re-operation. 5 patients developed wound infections. At the time of the study 18 patients have undergone reversal, 6 are On active waiting-list for reversal. There was a single 30-day mortality (post-discharge). Conclusion(s):We have shown that PA is safe in selected cohort of patients and have identified that over 50% of patients undergoing Hp could have been considered for PA.

The potential for day case total parathyroidectomy in patients with secondary hyperparathyroidism (2022)

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Type of publication:
Conference abstract

Author(s):
*McDonald S.; *Al-Saadi N.; *Chang J.; *Neophytou C.; *Houghton A.

Citation:
British Journal of Surgery. Conference: Association of Surgeons of Great Britain and Ireland Annual Congress, ASGBI 2022. Liverpool United Kingdom. 109(Supplement 5) (pp v106), 2022. Date of Publication: 2022.

Abstract:
Aims: Hypocalcaemia is a common complication after parathyroidectomy for secondary hyperparathyroidism (SHpT) and is of ten The cause of a prolonged hospital stay post operatively. Although there is no current guidance on targets for total parathyroidectomy for SHpT, current guidance recommends a day-case rate of 90% for patients undergoing Surgery for primary hyperparathyroidism. Our centre has developed a safe protocol which allows us to perform total parathyroidectomies as a day-case procedure in patients with SHpT. This protocol, developed in conjunction with The renal physicians, involves giving The patients alpha calcidol pre-operatively for 5 days, to minimise The incidence of hypocalcaemia, and close monitoring of The calcium levels post operatively, to permit safe discharge. Method(s): We carried out a single centre retrospective study on all patients who underwent a total parathyroidectomy for SHpT between February 2005 and May 2021. All The patients received The alpha calcidol regimen pre-operatively. Data on patient baseline characteristics, peri-operative calcium, potassium and PTH levels, length of hospital stay, operative procedure details, hospital readmission and 30-day morbidity were collected. Result(s): 49 patients underwent a total parathyroidectomy during The study period. 67% of patients were discharged on day 0 or on day 1 post-operatively. Reasons for prolonged hospital stay in The remaining patients included refractory hyperkalaemia requiring dialysis, complications secondary to anaesthesia, as well as hypocalcaemia in a few cases. No patients required readmission during The 30-day post-operative period. Conclusion(s): Day-case Surgery for SHpT can be achieved safely with a pre-operative regimen of alpha calcidol and close monitoring of calcium levels post-operatively.

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Safety of in-hospital delay to appendicectomy in acute appendicitis: A retrospective study (2022)

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Type of publication:
Conference abstract

Author(s):
Claydon O.; Down B.; *Kumar S.

Citation:
British Journal of Surgery. Conference: Association of Surgeons of Great Britain and Ireland Annual Congress, ASGBI 2022. Liverpool United Kingdom. 109(Supplement 5) (pp v72), 2022. Date of Publication: 2022.

Abstract:
Aims: In many hospitals the availability of operating theatres and access to senior surgical and anaesthetic support diminishes during night hours. Therefore urgent surgery is sometimes postponed until the following morning rather than performed overnight, if judged to be safe. We aim to determine if a delay to laparoscopic appendicectomy in cases of acute appendicitis of over 12 hours, analogous to an overnight delay, is correlated to worse patient outcomes. Our primary outcome was delayed discharge from hospital. Our secondary outcomes were appendicitis severity, conversion, and post-operative complications. Method(s): We undertook a retrospective review of The medical records of patients who underwent laparoscopic appendicectomy at a UK district General hospital between 01/01/2018 and 30/08/2019. For each patient clinical and demographic information; and times of hospital admission, surgery, and discharge; were collected. Delayed discharged was defined as 'time to discharge' >24 hours. Result(s): 506 patients were included. In 144 patients (28.5%) 'time to surgery' was under 12 hours; in 362 patients (71.5%) 'time to surgery' was over 12 hours. 362 patients (71.5%) had a delayed discharge. 303 patients (59.9%) had Simple appendicitis; 143 patients had severe appendicitis (28.3%); 60 patients had a macroscopically normal appendix (11.9%). No statistically significant association between 'time to surgery' and delayed discharge, appendicitis severity, conversion or 30 day re-presentations was observed. Conclusion(s): Time from admission to start of appendicectomy did not affect patient outcomes. Short in-hospital delays to appendicectomy, for example an overnight delay, may be safe in certain patients, taking account of clinical judgement.