Amyand’s hernia : a case report

The presence of vermiform appendix, whether normal or inflamed in the inguinal hernia, is referred to as Amyand’s hernia. This is rare occurring in about 1% of inguinal hernias in adults. This is a report of Amyand’s hernia, which presented as a component along with partially necrotic omentum with metastasis in a 75 year old male patient. Appendicectomy followed by hernia repair using synthetic mesh was performed with an uneventful recovery.peer-reviewe

The Preservation of Cued Recall in the Acute Mentally Fatigued State: A Randomised Crossover Study.

The objective of this study is to investigate the impact of acute mental fatigue on the recall of clinical information in the non-sleep-deprived state. Acute mental fatigue in the non-sleep-deprived subject is rarely studied in the medical workforce. Patient handover has been highlighted as an area of high risk especially in fatigued subjects. This study evaluates the deterioration in recall of clinical information over 2 h with cognitively demanding work in non-sleep-deprived subjects.A randomised crossover study involving twenty medical students assessed free (presentation) and cued (MCQ) recall of clinical case histories at 0 and 2 h under low and high cognitive load using the N-Back task. Acute mental fatigue was assessed through the Visual Analogue Scale, Stanford Scale and NASA-TLX Mental Workload Rating Scale.Free recall is significantly impaired by increased cognitive load (p < 0.05) with subjects demonstrating perceived mental fatigue during the high cognitive load assessment. There was no significant difference in the amount of information retrieved by cued recall under high and low cognitive load conditions (p = 1).This study demonstrates the loss of clinical information over a short time period involving a mentally fatiguing, high cognitive load task. Free recall for the handover of clinical information is unreliable. Memory cues maintain recall of clinical information. This study provides evidence towards the requirement for standardisation of a structured patient handover. The use of memory cues (involving recognition memory and cued recall methodology) would be beneficial in a handover checklist to aid recall of clinical information and supports evidence for their adoption into clinical practice

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice

Multicentre observational cohort study of NSAIDs as risk factors for postoperative adverse events in gastrointestinal surgery

Introduction: Non-steroidal anti-inflammatory drugs (NSAIDs) are recommended as postoperative analgesia by the Enhanced Recovery After Surgery Society. Recent studies have raised concerns that NSAID administration following colorectal anastomosis may be associated with increased risk of anastomotic leak. This multicentre study aims to determine NSAIDs' safety profile following gastrointestinal resection. Methods and analysis: This prospective, multicentre cohort study will be performed over a 2-week period utilising a collaborative methodology. Consecutive adults undergoing open or laparoscopic, elective or emergency gastrointestinal resection will be included. The primary end point will be the 30-day morbidity, assessed using the Clavien-Dindo classification. This study will be disseminated through medical student networks, with an anticipated recruitment of at least 900 patients. The study will be powered to detect a 10% increase in complication rates with NSAID use. Ethics and dissemination: Following the Research Ethics Committee Chairperson's review, a formal waiver was received. This study will be registered as a clinical audit or service evaluation at each participating hospital. Dissemination will take place through previously described novel research collaborative networks

A two year retrospective review of Laparoscopic versus open Appendicectomy in perforated appendix in Hospital Ipoh (June 2006-May 2008)

Appendicectomy is one of the most common general surgical procedures performed all over the world in the surgical department. Since its description by McBurney in 1894 the open approach has become the standard surgical intervention for appendicitis, remaining virtually unchanged for 100 years owing to its proven efficacy and safety. Laparoscopic appendicectomy on the other hand was first performed by Semm in 1983 (Litynski, G.S. 1999).But its popularity increased steadily throughout the 1990s. However, unlike cholecystectomy, the benefits of the laparoscopic approach have not been as apparent for appendicectomy, even more so in perforated appendicitis. Many early randomized trials failed to show any overall benefit for laparoscopy and others at best parity between the 2 procedures. Current studies however indicate a shift in favour of laparoscopy, probably due to the increase in laparoscopic exposure at all levels of surgical training. The aim of this study is to compare certain parameters between Laparoscopic appendicectomy with open appendicectomy. xii RESULTS: Two hundred and five patients with perforated appendicitis were reviewed. Fifty-six patients had laparoscopic appendicectomy and one hundred and forty nine patients had open appendicectomy. The median age in the laparoscopic group was 28 and the open group was 30. The difference in the median age groups was not statistically significant .The p value is 0.310. The mean (s.d) operating time for laparoscopic appendicectomy was 69 minutes (29 minutes).The mean operating time for the open group was 63 minutes (28 minutes). This study showed that there was no significant difference in the mean length of operating time between the two methods. The p value is 0.669. The mean (s.d.) length of hospital stay for the patients in the laparoscopic group was 3.5days (1.6 days). In the open group the mean length of hospital stay was 3.1 days (1.9 days). This was statistically not significant (p=0.382).There was also no statistical significance in the duration the patients took to tolerate orally and for the temperature to settle in both the groups. There were a total of six patients with the surgical site infection and seven who had readmission. Although all 6 patients with surgical site infection were from the open group and none in the laparoscopic group this was not statiscally significant. p = 1.000. Five patients in the laparoscopic group and two in the open group were readmitted within a week of their respective surgeries for ileus. This difference was also not statistically significant with a p value of 1.000.The mean (s.d.) amount of analgesia used in laparoscopic appendicectomy was 387.5mg (259.4mg) . The mean (s.d.) for the use of analgesia in the open group was 274.5mg (204.3mg) for the open group. This was statistically significant where p = 0.006. CONCLUSION: There is no clinically significant difference between laparoscopic appendicectomy and open appendicectomy for perforated appendicitis

Laparoscopic appendicectomy at the Aga Khan Hospital, Nairobi

Objective: To evaluate our experience of laparoscopic appendicectomy at the Aga Khan Hospital, Nairobi over a six year period from the inception of the technique and to assess its advantages and disadvantages. Design: Case series study. Setting: The Aga Khan Hospital, Nairobi. Patients: One hundred and six cases operated on from May 1996 to June 2002. Main outcome measures: Clinical presentation, age and sex demographics, average hospital stay, operating time, intra-operative and post-operative complications and outcome. Results: There was a female preponderance with a female to male ratio of 2:3:I. Mean age was 30.6 years. There was a slightly more number of patients with recurrent appendicitis as opposed to the acute form. Totally laparoscopic procedure was in 39.6% of the cases, laparoscopic assisted in 45.3%. The conversion rate to an open procedure was 15.1%. Post operative port-site infection was 8.5%. No mortality was reported in these series. However there was one case which required re-operation following significant port site haemorrhage. Mean post-operative hospital stay was 2.2 days. Conclusion: Laparoscopic appendicectomy is a safe procedure in well trained hands. The major advantages are less morbidity and excellent cosmesis. Discovery of other intraabdominal pathologies is possible through laparoscopy as opposed to classical appendicectomy

The association between prior appendicectomy and/ or tonsillectomy in females and subsequent pregnancy rate: A cohort study

OBJECTIVE: To study pregnancy rates after appendectomy and/or tonsillectomy. DESIGN: Population-based cohort study using the United Kingdom (U.K.) primary health care–based Clinical Practice Research Datalink (CPRD). SETTING: Not applicable. PATIENT(S): Female patients who underwent appendectomy, tonsillectomy, or both from 1987 to 2012 and appropriate comparators. INTERVENTION(S): Timed follow-up until first pregnancy after surgery. The association between prior surgery and subsequent pregnancy was determined with the use of Cox regression models. MAIN OUTCOMES AND MEASURE(S): Pregnancy rate and time to first pregnancy after surgery. RESULT(S): The analyses included 54,675 appendectomy-only patients, 112,607 tonsillectomy-only patients, 10,340 patients who had both appendectomy and tonsillectomy, and 355,244 comparators matched for exact age and practice from the rest of female patients in the database. There were 29,732 (54.4%), 60,078 (53.4%), and 6,169 (59.7%) pregnancies in the appendectomy-only, tonsillectomy-only, and both appendectomy tonsillectomy cohorts, respectively versus 155,079 (43.7%) in the comparator cohort during a mean follow-up of 14.7 ± 9.7 years. Adjusted hazard ratios (HRs) for subsequent birth rates were 1.34 (95% confidence interval [CI] 1.32–1.35), 1.49 (95% CI 1.48–1.51), and 1.43 (95% CI 1.39–1.47), respectively. Time to pregnancy was shortest after both appendectomy and tonsillectomy followed by appendectomy only and then tonsillectomy only compared with the rest of the population. CONCLUSIONS(S): Appendectomy and/or tonsillectomy was associated with increased subsequent pregnancy rates and shorter time to pregnancy. The effect of the surgical procedures on the pregnancy outcome was cumulative

Development of a proficiency-based virtual reality simulation training curriculum for laparoscopic appendicectomy

This paper was presented at the 10th Annual Academic Surgical Congress (ASC), 3–5 February 2015 in Las Vegas, NV, USA.Background: Proficiency-based virtual reality (VR) training curricula improve intraoperative performance, but have not been developed for laparoscopic appendicectomy (LA). This study aimed to develop an evidence-based training curriculum for LA. Methods: A total of 10 experienced (>50 LAs), eight intermediate (10–30 LAs) and 20 inexperienced (<10 LAs) operators performed guided and unguided LA tasks on a high-fidelity VR simulator using internationally relevant techniques. The ability to differentiate levels of experience (construct validity) was measured using simulator-derived metrics. Learning curves were analysed. Proficiency benchmarks were defined by the performance of the experienced group. Intermediate and experienced participants completed a questionnaire to evaluate the realism (face validity) and relevance (content validity). Results: Of 18 surgeons, 16 (89%) considered the VR model to be visually realistic and 17 (95%) believed that it was representative of actual practice. All ‘guided’ modules demonstrated construct validity (P < 0.05), with learning curves that plateaued between sessions 6 and 9 (P < 0.01). When comparing inexperienced to intermediates to experienced, the ‘unguided’ LA module demonstrated construct validity for economy of motion (5.00 versus 7.17 versus 7.84, respectively; P < 0.01) and task time (864.5 s versus 477.2 s versus 352.1 s, respectively, P < 0.01). Construct validity was also confirmed for number of movements, path length and idle time. Validated modules were used for curriculum construction, with proficiency benchmarks used as performance goals. Conclusion: A VR LA model was realistic and representative of actual practice and was validated as a training and assessment tool. Consequently, the first evidence-based internationally applicable training curriculum for LA was constructed, which facilitates skill acquisition to proficiency.Pramudith Sirimanna and Marc A. Gladma

Single port/incision laparoscopic surgery compared with standard three-port laparoscopic surgery for appendicectomy : a randomized controlled trial

Acknowledgments The authors thank John Norrie for advice regarding the reporting of the study, and clinical staff in the Department of General Surgery, Aberdeen Royal Infirmary, for helping with the conduct of the study. This work was supported by a Grant from the Chief Scientist Office (CSO) of the Scottish Government Health Directorates (Grant Number reference CZG/2/498). Jonathan A. Cook held a Medical Research Council, UK, training fellowship (G0601938) while this research was undertaken. The Health Services Research Unit is funded by the CSO of the Scottish Government Health Directorates. The views expressed in this paper are those of the authors and may not necessarily be shared by the funding bodies. The study was overseen by an Advisory Group comprising Professor Marion Campbell (Director, Health Services Research Unit, Aberdeen), Professor John Norrie (CHaRT Director) and Professor Craig Ramsay (Health Care Assessment Programme Director, Health Services Research Unit, Aberdeen). Professor W. Alastair Chambers was the independent chair of the Trial Steering Committee. Contributing surgeons to the SCARLESS study (in alphabetical order): Bassam Alkari, Emad Aly, Norman Binnie, Duff Bruce, Jan Jansen, Peter King, Tim MacAdam, Aileen McKinley, Terry O’Kelly, Ken Park, Abdul Qadir. The National Health Service provided support through the contribution of the following research nurses: Anu Joyson, Hazel Forbes, and Julie Shotton.Peer reviewedPublisher PD