Comparative study between purse–string suture and peritoneal disconnection with ligation techniques in the laparoscopic repair of inguinal hernia in infants and children

Background Laparoscopic hernia repair in children is becoming more popular nowadays. A lot of laparoscopic techniques were described to repair inguinal hernia in infants and children; however, there are few reports on laparoscopic disconnection of the hernia sac at internal inguinal ring (IIR) as a method for hernia repair.Purpose The objective of this study was to compare intracorporeal purse–string suturing leaving the hernia sac in continuity and laparoscopic disconnection of the hernia sac at IIR and proximal closure of the peritoneum for repair of inguinal hernia in infants and children. A randomized prospective study was carried out in the Pediatric Surgery Unit of Alexandria University Hospitals (Alexandria, Egypt) on 40 male children.Patients and methods Forty male patients (48 repairs) were randomized into two equal groups (n= 20). Group A was subjected to intracorporeal purse–string suturing around the IIR leaving the hernia sac in continuity. Group B was subjected to disconnection of the hernia sac from the parietal peritoneum at the level of IIR, followed by proximal closure of the peritoneum. Inclusion criteria were as follows: male inguinal hernia, either unilateral or bilateral, and age between 6 months and 12 years. Exclusion criteria were as follows: female inguinal hernia, hernia with undescended testicles, recurrent inguinal hernia, and previous major lower abdominal surgery. The main outcome measurement was recurrence, and secondary outcome measurements were operative time, hospital stay, intraoperative complications, postoperative hematoma, postoperative testicular atrophy, and postoperative hydrocele formation.Results There were no significant differences between the two groups as regards age, sex, and mode of presentation. All cases were completed laparoscopically without conversion. Group A showed a significantly higher rate of recurrence as well as hydrocele formation compared with group B; however, there was no difference as regards the operative time, hospital stay, and testicular atrophy.Conclusion Laparoscopic hernia repair using the peritoneal closure following disconnection of the hernia sac is a safe and feasible method for hernial repair with minimal complications. It has a lower recurrence rate compared with the purse–string suturing alone, with no added risk for injury to the vas and vessels

Transperitoneal laparoscopic pyeloplasty in children and adolescents: Long-term results

Background Open pyeloplasty has been the gold standard for the treatment of  ureteropelvic junction obstruction (UPJO) in children and young adolescents. However, the use of laparoscopy for the treatment of pyeloplasty is increasing as it has the potential to provide a better and more desirable cosmetic outcome in  addition to less postoperative pain and decreased recovery time. The aim of this study was to evaluate the long-term outcome of transperitoneal laparoscopic  pyeloplasty (TLP) for the treatment of UPJO in children and young adolescents.Patients and methods Twenty-nine patients with UPJO with 32 renal units were subjected to TLP at Al-Azhar University Hospitals, Egypt, during the period from May 2008 to December 2012. The outcome measurements of this study included operative time, internal stent placement, hospital stay, intraoperative complications, and success rates. Success is defined as both symptomatic relief and radiographic resolution of hydronephrosis at the last follow-up. Patients were followed up with intravenous urography and diethylene triamine penta-acetic acid scan at 3, 6, and 12 months regularly for both functional and morphological outcomes.Results The study included 29 patients (12 male and 17female) with 32 obstructed renal units. The mean age was  4.23 ± 2.1 years (range 3–16 years). All procedures were completed laparoscopically without conversion. The mean operative time was 143.41 ±23 min (range 110–220 min). The mean postoperative hospital stay was 4.1 days (range 3–8 days). All patients achieved full recovery without any complications. The mean follow-up period of the patients was 36.34± 5.18 months (range 22–60 months). Success rate was 96.9%. Only one case developed  recurrent UPJO and was treated with retrograde endopyelotomy and stenting.Conclusion TLP has the advantages of less postoperative pain, short hospital stay, and rapid recovery, with excellent functional and cosmetic outcomes. However, it requires advanced skill level for intracorporeal suturing and knot tying.Keywords: children, laparoscopy, long-term results, pyeloplasty, ureteropelvic junction obstructio

Reliability of hypertrophy of the contralateral testis in prediction of the status of impalpable testis

Background: The hypertrophied testis can predict the status of the impalpable contralateral one. The aim of this study was to assess the accuracy of contralateral testicular hypertrophy for predicting the presence or absence of impalpable undescended testis (UDT) in Egyptian boys.Patients and methods: This study was carried out on 204 patients with unilateral impalpable UDT who presented to the Pediatric Surgery Department, Al-Azhar University Hospitals, from July 2014 to April 2016. Only 40 patients with unilateral impalpable UDT and hypertrophy of the contralateral testes were included in this study. They were subjected to routine laboratory investigations, ultrasonography measurement of the volume of the hypertrophied testis, and diagnostic laparoscopy for the impalpable intra-abdominal testis (IAT). Both ultrasonography and laparoscopic findings were reported.Results: Out of 204 patients with unilateral impalpable UDT, only 40 patients fulfilled the inclusion criteria. Their ages ranged from 1 to 5 years, with a mean of 2.3±1.18 years. Testicular volume ranged from 0.94 to 6.33 cm3, with amean of 3.12±1.41 cm3. Diagnostic laparoscopy indicated 30 patients with vanishing testis, four patients with low IAT, and three patients with high IAT and three patients with testicular vessels and vas passing internal inguinal ring, where inguinal exploration indicated atrophic testes.Conclusion: Hypertrophied testis can predict the absence of other contralateral impalpable testis when its volume is 1.85 cm3.Keywords: hypertrophy, impalpable undescended testis, laparoscopy, reliabilit

Laparoscopic diagnostic findings in atypical intestinal malrotation in children with equivocal imaging studies

Background Atypical presentations of intestinal malrotation are more common in older children with a diagnostic and therapeutic challenge. Upper gastrointestinal (UGI) contrast study is essential for the diagnosis of the majority of cases. Recently, laparoscopy has been used in the management of malrotation. We present our experience with laparoscopic management of atypical presentations of intestinal malrotation in children, describing laparoscopic findings in these cases.Patients and methods A total of 40 patients with atypical presentations of malrotation were included in this study. The main presentations were recurrent abdominal pain, intermittent intestinal obstruction, recurrent bilious vomiting, and failure to thrive. They all were subjected to thorough history taking, clinical  examination, routine laboratory investigations, and UGI contrast study. No preoperative definitive diagnosis of malrotation was performed and all patients underwent laparoscopic evaluation.Results Forty patients (25 males and 15 females) with a mean age of 7± 2.8 years were subjected to laparoscopy. Thirty-six patients (90%) were found to have definite laparoscopic findings in the form of markedly dilated stomach and first part of duodenum, ectopic site of cecum, medial and low position of duodenojejunal  junction, congested mesenteric veins with lymphatic ectasia, generalized mesenteric lymphadenopathy, reversed relation of superior mesenteric artery and vein, and rightsided small bowel and narrow mesenteric base. Four patients had differed laparoscopic diagnosis. All the procedures were completed laparoscopically. All the patients achieved full recovery without intraoperative or postoperative complications.Conclusion Laparoscopy permits direct evaluation and treatment of undocumented malrotation in children, with equivocal UGI contrast study. These newly described laparoscopic findings are the key for the diagnosis of malrotation with atypical presentation.Keywords: Ladd’s procedure, laparoscopy, mesenteric lymphadenopathy, undocumented malrotatio

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

Background Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide.Methods A multimethods analysis was performed as part of the GlobalSurg 3 study-a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital.Findings Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3.85 [95% CI 2.58-5.75]; p<0.0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63.0% vs 82.7%; OR 0.35 [0.23-0.53]; p<0.0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer.Interpretation Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised

Laparoscopic Hernia Repair versus Open Herniotomy in Children: A Controlled Randomized Study

Background. Laparoscopic hernia repair in infancy and childhood is still debatable. The objective of this study is to compare laparoscopic assisted hernia repair versus open herniotomy as regards operative time, hospital stay, postoperative hydrocele formation, recurrence rate, iatrogenic ascent of the testis, testicular atrophy, and cosmetic results. Patients and Methods. Two hundred and fifty patients with inguinal hernia were randomized into two equal groups. Group A was subjected to laparoscopic inguinal hernia repair. Group B was subjected to open herniotomy. The demographic data were matched between both groups. Assessment of the testicular volume and duplex assessment in preoperative, early, and late postoperative periods were done. Results. All cases were completed successfully without conversion. The mean operative time for group A was minutes, minutes and minutes, for unilateral hernia, unilateral hernia in obese child, and bilateral hernia, respectively. The recurrence rate was 0.8% in group A, whereas in group B the recurrence rate was 2.4%. Conclusion. Laparoscopic hernia repair by RN is an effective line of hernia repair. It resulted in marked reduction of operative time, low rate of recurrence, no testicular atrophy, no iatrogenic ascent of the testis, and excellent cosmetic results

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

Background: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

BJS commission on surgery and perioperative care post-COVID-19

Background: Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues experiences and published evidence. Methods: In late 2020, BJS contacted colleagues across the global surgical community and asked them to describe how severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) had affected their practice. In addition to this, the Commission undertook a literature review on the impact of COVID-19 on surgery and perioperative care. A thematic analysis was performed to identify the issues most frequently encountered by the correspondents, as well as the solutions and ideas suggested to address them. Results: BJS received communications for this Commission from leading clinicians and academics across a variety of surgical specialties in every inhabited continent. The responses from all over the world provided insights into multiple facets of surgical practice from a governmental level to individual clinical practice and training. Conclusion: The COVID-19 pandemic has uncovered a variety of problems in healthcare systems, including negative impacts on surgical practice. Global surgical multidisciplinary teams are working collaboratively to address research questions about the future of surgery in the post-COVID-19 era. The COVID-19 pandemic is severely damaging surgical training. The establishment of a multidisciplinary ethics committee should be encouraged at all surgical oncology centres. Innovative leadership and collaboration is vital in the post-COVID-19 era

BJS commission on surgery and perioperative care post-COVID-19

Coronavirus disease 2019 (COVID-19) was declared a pandemic by the WHO on 11 March 2020 and global surgical practice was compromised. This Commission aimed to document and reflect on the changes seen in the surgical environment during the pandemic, by reviewing colleagues' experiences and published evidence

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit