Who will do general surgery?

The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Advantages to patients of a single anaesthetic for more than one operation are obvious; attracting generalist surgeons, training them and ensuring they have adequate credentials remain hurdles.Martin H Bruening and Guy J Madder

Left Extended Hemihepatectomy With Preservation of Large Inferior Right Hepatic Vein: A Case Report

For hepatic function to be preserved after an extended hemihepatectomy adequate venous drainage of the remaining liver is required. Most metastases close to the confluence of the superior hepatic veins are considered unresectable because hepatic venous outflow after resection would be compromised. In 10–25% of people, the inferior right hepatic vein is of large calibre. Thus the superior hepatic veins may be sacrificed and hepatic function preserved if a large inferior right hepatic vein is present

Sclerosing Haemangiomas of the Liver: Two Cases of Mistaken Identity

We describe two cases where patients undergoing hepatic resection for metastatic disease of colorectal origin were found to have concomitant sclerosing haemangiomas. The typical radiological and histological appearances of these lesions are discussed

Technical note: Facilitating laparoscopic liver biopsy by the use of a single-handed disposable core biopsy needle

Despite the use of advanced radiological investigations, some liver lesions cannot be definitely diagnosed without a biopsy and histological examination. Laparoscopic Tru-Cut biopsy of the liver lesion is the preferred approach to achieve a good sample for histology. The mechanism of a Tru-Cut biopsy needle needs the use of both hands to load and fire the needle. This restricts the ability of the surgeon to direct the needle into the lesion utilising the laparoscopic ultrasound probe. We report a technique of laparoscopic liver biopsy using a disposable core biopsy instrument (BARD (R) disposable core biopsy needle) that can be used single-handedly. The needle can be positioned with laparoscopic graspers in order to reach posterior and superior lesions. This technique can easily be used in conjunction with laparoscopic ultrasound.M. I. Trochsler, Q. Ralph, F. Bridgewater, H. Kanhere, and Guy J. Madder

Hepatic Surgery Facilitated by a New Jet Dissector

Increasing experience with major hepatic resections has stimulated the development of improved resectional techniques and tools. A new high velocity water jet dissector is reported which offers significant advances over previously developed ultrasonic and low pressure water jet machines. It has been successfully used in 8 major hepatic resections with minimal blood loss, excellent visibility and without complications. The dissector is also of value in the exposure of intrahepatic bile ducts for biliaryenteric anastomosis

Absolute Electron Scattering Cross Sections for the CF2 Radical

Using a crossed electron-molecular beam experiment, featuring a skimmed nozzle beam with pyrolytic radical production, absolute elastic cross sections for electron scattering from the CF2 molecule have been measured. A new technique for placing measured cross sections on an absolute scale is used for molecular beams produced as skimmed supersonic jets. Absolute differential cross sections for CF2 are reported for incident electron energies of 30–50 eV and over an angular range of 20–135 deg. Integral cross sections are subsequently derived from those data. The present data are compared to new theoretical predictions for the differential and integral scattering cross sections, as calculated with the Schwinger multichannel variational method using the static-exchange and static-exchange plus polarization approximations

Painless Obstructive Jaundice Secondary to a Common Bile Duct Abscess: A Delayed Sequela of Cholecystectomy

Complications related to cholecystectomy are well described. Most occur in the early postoperative period and are recognised either at the time of, or shortly after surgery. Clinical sequelae occurring years following cholecystectomy are rare and infrequently reported. In addition, most delayed complications are related to the continuing presence or new formation of gallstones. In this paper we present a unique case of an abscess of the common bile duct wall, presenting with painless obstructive jaundice more than 30 years following an open cholecystectomy, without the presence of gallstones. The clinical presentation, investigations, and treatment are discussed with a review of other relevant reported cases in the literature

Hepatic Resection Using a Water Jet Dissector

The mortality and morbidity in major hepatic resection is often related to hemorrhage. A high pressure, high velocity water jet has been developed and has been utilized to assist in hepatic parenchymal transection. Sixty-seven major hepatic resections were performed for solid hepatic tumors. The tissue fracture technique was used in 51 patients (76%), and the water jet dissector was used predominantly in 16 patients (24%). The extent of hepatic resection using each technique was similar. The results showed no difference in operative duration (p = .499). The mean estimated blood loss using the water jet was 1386 ml, and tissue fracture technique 2450 ml (p = .217). Transfusion requirements were less in the water jet group (mean 2.0 units) compared to the tissue fracture group (mean 5.2 units); (p = .023). Results obtained with the new water dissector are encouraging. The preliminary results suggest that blood loss may be diminished

Atypical mycobacterial infection mimicking metastatic cholangiocarcinoma

Mycobacterial infections are rare in developed countries. Isolated involvement of the liver and biliary tree by mycobacterial infection is extremely rare. We report a case of a 45-year-old Caucasian female presenting with obstructive jaundice with a common bile duct stricture and multiple hypodense liver lesions raising suspicion of a metastatic cholangiocarcinoma. Percutaneous core biopsies of the liver lesions however suggested granulomatous process and histology at surgical excision confirmed this finding. Atypical mycobacteria (M. abcessus) sensitive to Amikacin were cultured from the surgical specimen proving the diagnosis. With the resurgence of tubercular and atypical mycobacterial infections in the developed world, it is important not to overlook these in differential diagnosis of various malignancies.Harsh A. Kanhere, Markus I. Trochsler, John Pierides, and Guy J. Madder

Merkel cell carcinoma metastasis to the pancreas: report of a rare case and a review of the literature

CONTEXT: Merkel cell carcinoma is a rare skin tumour which can metastasise to regional lymph nodes and occasionally to distant organs. Merkel cell carcinoma metastasis to the pancreas has been rarely reported. CASE REPORT: We describe the case of Merkel cell carcinoma metastasis to the pancreas and review the literature on this rare phenomenon. CONCLUSION: Merkel cell carcinomas metastasis should be considered as a differential in patients who present with a pancreatic mass with a previous history of Merkel cell carcinomas.Neil Bhardwaj, Sebastien Haiart, Harsh A Kanhere, Guy J Madder