Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Variations in the Anatomical Structures of the Guyon Canal

Background: Compression neuropathy of the ulnar nerve at the Guyon canal is commonly seen by hand surgeons. Different anatomical variations of structures related to the Guyon canal have been reported in the literature. A thorough knowledge of the normal contents and possible variations is essential during surgery and exploration. Objectives: To review the recognized anatomical variations within and around the Guyon canal. Methods: This study is a narrative review in which relevant papers, clinical studies, and anatomical studies were selected by searching electronic databases (PubMed and EMBASE). Extensive manual review of references of the included studies was performed. We also describe a case report of an aberrant muscle crossing the Guyon canal. Results: This study identified several variations in the anatomical structures of the Guyon canal reported in the literature. Variations of the ulnar nerve involved its course, branching pattern, deep motor branch, superficial sensory branch, dorsal cutaneous branch, and the communication with the median nerve. Ulnar artery variations involved its course, branching pattern, the superficial ulnar artery, and the dorsal perforating artery. Aberrant muscles crossing the Guyon canal were found to originate from the antebrachial fascia, pisiform bone, flexor retinaculum, the tendon of palmaris longus, flexor carpi ulnaris, or flexor carpi radialis; these muscles usually fuse with the hypothenar group. Conclusion: The diverse variations of the contents of the Guyon canal were adequately described in the literature. Taking these variations into consideration is important in preventing clinical misinterpretation and avoiding potential surgical complications. </jats:sec

Surgical Treatment for Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is an epithelial tumor derived from hepatocytes; it accounts for 80% of all primary liver cancers and ranks globally as the fourth leading cause of cancer-related deaths. HCC treatment is a multidisciplinary and a multimodal task, with surgery in the form of liver resection and liver transplantation (LT) representing the only potentially curative modality. However, there are variable opinions and discussions about applying these surgical options and using other supporting treatments. This article is a narrative review that includes articles published from 1984 to 2013 located by searching scientific databases such as PubMed, SCOPUS, and Elsevier, with the main keyword of hepatocellular carcinoma in addition to other keywords such as liver transplantation, liver resection, transarterial chemoembolization, portal vein embolization, bridging therapy, and downstaging. In this review, we focus mainly on the surgical treatment options offered for HCC, in order to illustrate the current relevant data available in the literature to help in applying these surgical options and to use other supporting treatment modalities when appropriate