Damage Control in Hinchey III and IV Acute Diverticulitis

Acute diverticulitis is one of the most common surgical causes of admission to Emergency Departments in Western Countries. Although most of the cases can be managed conservatively or electively, a number of them will require an emergency surgical treatment. Among these patients, an even smaller number of them will present with a full-blown catastrophic septic shock. These minorities of cases have accounted for a significant part of the overall mortality and morbidity of complicated acute diverticulitis itself. The implementation of Damage Control strategies has shown to be useful also in these septic catastrophes, where a profound derangement of physiology makes unsafe a classic approach. Damage Control, as we intend it, is not a surgical “technique.” A close collaboration between different specialties brought forth a strategy of treatment. The Surgeon, the Anesthetist, and the Intensivist are the three most involved specialists in the treatment of these cases. It is paramount for them to learn how to work side by side and in harmony, since the patients will benefit from each-one’s input in their care

Virtual Reality Simulation as a Tool to Monitor Surgical Performance Indicators: VIRESI Observational Study

Introduction: Virtual reality simulation is a topic of discussion as a complementary tool to traditional laparoscopic surgical training in the operating room. However, it is unclear whether virtual reality training can have an impact on the surgical performance of advanced laparoscopic procedures. Our objective was to assess the ability of the virtual reality simulator LAP Mentor to identify and quantify changes in surgical performance indicators, after LAP Mentor training for digestive anastomosis. Material and Methods: Twelve surgeons from Centro Hospitalar de São João in Porto (Portugal) performed two sessions of advanced task 5: anastomosis in LAP Mentor, before and after completing the tutorial, and were evaluated on 34 surgical performance indicators. Results: The results show that six surgical performance indicators significantly changed after LAP Mentor training. The surgeons performed the task significantly faster as the median ‘total time’ significantly reduced (p < 0.05) from 759.5 to 523.5 seconds. Significant decreases (p < 0.05) were also found in median ‘total needle loading time’ (303.3 to 107.8 seconds), ‘average needle loading time’ (38.5 to 31.0 seconds), ‘number of passages in which the needle passed precisely through the entrance dots’ (2.5 to 1.0), ‘time the needle was held outside the visible field’ (20.9 to 2.4 seconds), and ‘total time the needle-holders’ ends are kept outside the predefined operative field’ (88.2 to 49.6 seconds). Discussion: This study raises the possibility of using virtual reality training simulation as a benchmark tool to assess the surgical performance of Portuguese surgeons. Conclusion: LAP Mentor is able to identify variations in surgical performance indicators of digestive anastomosis

Caracterização da Formação Específica em Cirurgia Geral em 2015 – A visão dos Internos

Introduction: The general surgery residency training program has gained complexity, particularly due to laparoscopy. The Comission of General Surgery Residents (Comissão de Internos em Formação Específica em Cirurgia Geral), a chapter of Portuguese Society of Surgery (CIFECG-SPCir), aimed to characterize national general surgery residents in 2015 and evaluate their training program, through a survey. Methods: A survey regarding the subject, consisting of 40 questions, confidential and anonymous was sent via email. The statistical analysis was made with software software SPSS Statistics for Windows®, Version 21.0. Results and Discussion: The online survey was sent to 183 residents and obtained 105 answers (57,4%). The sample is mainly feminine, mean age 29 years, single and childless. The majority of residents dedicates 56 to 85 weekly hours to hospital duty, with prejudice of study time. Annually participation in courses and scientific events is almost always self-financing. There is a geographic variability of scientific work production, with more investigation involved residents in the north. The majority of surgery departments are already structured in functional units, with great organization variability without that translating to more surgeries or laparoscopic procedures. The vast majority of residents have 2 or more operating room days per week, operating more as main surgeon in elective than emergency surgeries. Laparoscopy is mainly executed by assistants and only in less than half of the procedures. The majority of the residents actively participates in outpatients assistance, mainly autonomously. A 24hours emergency rotation is the most frequent period of time per week. The probability to accomplishment the goals set by law (Portaria nº48/2011, January 26th) if higher in a secondary care hospital. The feeling of being prepared for the demands of the future is related to the number of surgeries but not emergency room shifts or study time. Conclusion: There is a wide variability of the national general surgery residency training program. An evaluation and training adequacy is being needed to face the resident and society new expectations.Introdução: A formação específica em Cirurgia Geral tem aumentado em complexidade, principalmente devido à difusão da laparoscopia. A Comissão de Internos em Formação Específica em Cirurgia Geral, Capítulo da Sociedade Portuguesa de Cirurgia (CIFECG-SPCir), teve o objetivo de caraterizar a população nacional de Internos da especialidade de Cirurgia Geral em 2015 e avaliar a sua formação específica. Métodos: Foi realizado um questionário, confidencial e anónimo, com 40 perguntas enviado por email com submissão automática após o preenchimento. Para análise estatística foi utilizado o software SPSS Statistics for Windows®, Version 21.0. Resultados e Discussão: Foram contactados 183 Internos e obtidas 105 respostas (57,4% de adesão). A amostra é maioritariamente feminina, com idade média de 29 anos, solteira e sem filhos. A maioria dos Internos desempenha 56 a 85 horas/ semanais de serviço hospitalar devido aos turnos de urgência, com prejuízo do seu tempo de estudo. Frequentam anualmente cursos e congressos maioritariamente autofinanciados. A produção de trabalho científico difere geograficamente com Internos mais envolvidos em projetos de investigação no norte do país. A maioria dos serviços está organizada em unidades funcionais, de estrutura variávele sem condicionar o maior número de cirurgias ou a maior realização de laparoscopia. A generalidade dos Internos tem pelo menos dois dias de bloco operatório/semana, operando mais frequentemente como Cirurgião na cirurgia programada do que em urgência. A laparoscopia é quase totalmente realizada pelos Assistentes e escolhida em menos de metade dos procedimentos. A maioria dos Internos participa na consulta externa de forma autónoma. Vinte e quatro horas semanais de urgência é o mais frequente entre os Internos. É mais provável cumprir os objetivos propostos na Portaria nº 48/2011, de 26 de janeiro num internato em hospital distrital. A noção de estar à altura das suas exigências futuras está diretamente relacionada com o número de cirurgias realizadas e não com as horas de estudo ou urgência. Conclusão: Existe uma grande variabilidade na formação em Cirurgia Geral nacional. Há necessidade de alterar a estrutura da avaliação e formação específica de maneira a ir ao encontro das novas expetativas do Interno e da sociedade

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Global economic burden of unmet surgical need for appendicitis

Background There is a substantial gap in provision of adequate surgical care in many low- and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially