Abdominal Surgery - Science topic

Thanks Matti and Tageja.

Every kind of procedures have a place in the treatment of patients and the surgeon must use the best for the patient (personalized surgery) For example ,Robotic surgery for gallbladder is not indicated for the cost and not superiority ,Some kinds of trauma due to the emergency situation, it is obvious, robotic procedure is not indicated. I think residents must learn all the kind of procedures to be used in specific situations .

= I treated a 7 yr old boy whose injury resulted from a .30 Cal deformed solid point which ricocheted from a granite wall. It penetrated his khaki trouser, scrotal skin and dartos muscle and located itself in the right testicular sac.

= Another case of a .22 Cal. solid point bullet ricochet on lagoon water fired from 500 yards on a 9 yr old. It penetrated her dress, anterior midline abdominal wall and was found sitting on top of her omentum,

= Another case was a .22 Cal ricocheted solid point bullet through the right flank of a 17 year old to lodge in his liver, right lobe. He developed and died of gas gangrene.

= Dr. Ordog, do you have studies on injuries of spent, ricocheted bullets?

Theodor Billroth *26 Apr 1829 †06 Feb 1894

Remembering giants in science, medicine and surgery - German Surgeon & Co-Founder of academic surgery

Happy Birthday

"I can not understand how someone can read receptively only"

"Only those who know the past & present of science and art, will boost their progress with awareness"

~ Theodor Billroth

I Have always used a mesh despite size in adults. usually light weight mesh and placed between the anterior and posterior sheet ideally. the reults have been very good with no removal of meshes in the last 24 months and the infection rate less that 5%.

Please de-identify the photos (remove patients name)

Do diagnostic thoracentesis, if pus, insert chest tube.

If no infection with free fluid, insert pigtail

Clotted blood or encysted, decortication

In addition to the earlier answers, recent studies suggest very early appendectomy may be associated with autoimmune disease development, including inflammatory bowel disease (IBD), rheumatoid arthritis and lupus. This is probably due to an exaggerated immune response, one that has not been adequately primed for appropriate reaction due to the absent appendix - a seat of lymphoid tissue. The 'hygiene hypothesis' applied to IBD may also be applied to this phenomenon. Further, this indicates a possible role of the appendix in "post-natal" immune tolerance, akin to the role of the thymus in-utero.

The other theory put-forth recently is the protective benefit of appendectomy in preventing neurodegenerative disease. The immune response initiated by the lymphoid tissue in the appendix each time they are stimulated result in free radicals, reactive oxygen species and other metabolic byproducts that have been implicated in the pathogenesis of neurodegenerative diseases including Parkinson's. The model of hepatic encephalopathy is a good comparison.

Maybe it is due to OR conditions and lack of standard asepsis precautions or using it in just contaminated abdominal surgeries like entrotomies. It is believed ceftriaxone was superior in contaminated operations as a prophylactic antibiotic.

But, better to remind antibiotics should never be substitutes for “surgical conscience.”

Early repair is better

I suppose it's anatomically determined by any median scar or depressed point in the middle of the abdomen less than 10cm distal to xiphoid apêndix region below clavicle.   

The changing of the titanium adaptor should always be performed with strict aseptic technique. However, since the titanium adaptor can be difficult to remove, it is always a concern that the PD nurse could accidentally contaminate the distal end of the PD catheter or the new titanium connector, thus putting the PD patient at risk for peritonitis from touch contamination.

In general, unless the titanium adaptor for some reason is obviously soiled, we would not recommend changing the adaptor routinely with each episode of peritonitis.

In the last twenty years in our emergency  hospital  we have performed only less than five DLP, I think. This extremely low number is explained because we have routinely performing FAST in the emergency department to all patients admitted with blunt  or open abdominal trauma. In some cases, when the diagnosis was uncertain we performed abdominal puncture under US guidance. Hemodinamic stable patients, in the last years, were referred to the CT scan for a thoroughly abdominal exam.

Mucocele of appendix in itself is not common. Most of the cases remain silent till they   present as acute appendicitis and diagnosis is per-op or HPE. But to such a giant lump lying asymptomatic without any mass effect or pain, and not ruptured till this size is reached, is very uncommon.

Just as today's science fiction is tomorrow's science so too is today's pharmaceutical wonder tomorrow's poison. For example, Warfarin, a rat poison will soon be phased out with the APPROPRIATE introduction of DOACs - even the term has changed! A year ago they were called NOACs! They're not novel anymore. 

Personally, I would be very wary of any loco-regional recommendations, due to the fear of starting unscientific trends and vogues. I do believe while the information you provide above might be of some relevance to the Indian society, if freely and easily available (I.e. Unadulterated spices and legumes at a price cheaper than reliable pharmaceuticals) then by all means start a well- designed randomised controlled trial, with at least 5-10 years follow up, given the vast number of compounding variables. If not, one is only able to make suggestions based on personal observation to individual patients in good faith. Faith, albeit well- intended is not science! 

Please remember, all this is an international forum of communication, and it's called research gate! In the interim, thank you for providing the linked article. I will definitely go through it to look at the quality of the data provided. 

Please remember, Charaka Samhiti, the origins of Ayurveda, lists the ethical duties of the Doctor, the nurse, the patient and the drug - the drug must do what it is expected to do! There was an ethical requirement for the doctor to study all the international literature he could get hold of, and make intelligent adjustments to his prescriptions accordingly, so the nurse-compounder could mix better potions and the patient remained trusting and the doctor respected and trustworthy. 

If one has knowledge of ancient cultural practices, and if one wishes to utilise such information in treating another - human or non-human person, I believe they are duty-bound to do so in a scientific manner!

It is not without unfortunate reason that despite an exceedingly high level of knowledge and information in the East those of us from the Western scientific community do not publish our work nor rely upon information published in Eastern journals. 

Again, Dr Reddy please do source locally relevant dietary modifications and do not rely too much on surgical techniques tried and tested in a different part of the world in an area where John Bunni will tell you there remains a lot of controversy, because colleagues "treat" using techniques on which there is little consensus data. 

Dear Deborah. We have, analogously to Your experience, in our study report speculated that, besides choosing a mesh with good ingrowth features - which excludes ePTFE and biological material - a permanent fixation is advisable in immunosuppressed organ transplanted incisional hernia patients repaired with IPOM+. Additionally, allowance of a generous overlap; advises not followed in the presented case. But we are short on scientific evidence.

Conversion to RYGB

Yes, in that case the mechanism would be as suggested by Littre

Very interesting at such low doses

Our research was looking at use for anaesthesia (sedation/ analgesia) doses, combined with propofol at different ratios

We modelled on the McFarlan regime (initial bolus dose followed by an infusion) and then reductions in the McFarlan regime thereafter, and found rates of 15-50µcg/kg/min were satisfactory up to 90 min anaesthesia in combination with propofol.

So, pure analgesia use is 60 times lower dose, albeit as part of a multimodal strategy

I don't think our work is easily applicable to your patients – awake with pure analgesia aims. The ultra-low dose numbers are very interesting though.

Do you use a loading dose? We found LD 15-16 times the per minute dose rate were useful. Again, with an aim of early loss of conscious being the aim.

Hello,

I feel you need to do a number of things;

1).  Long term TPN, the patient is young, and there are lots of successful instances when patients have be maintained on parenteral feeding long term, for example, complete intestinal failure, whilst awaiting definitive treatment, in intestinal failure units.

2). Feed through the distal stoma, this might be technically difficult but you could try passing a fine bore tube through the stoma using an endoscope, a good distance, to reduce reflux of feed back out. Reduce her intestinal secretions with octreotide 150 micrograms tds, give her St. Marks solution orally, and NO hypotonic fluids. I can send you the instructions if you need them. Replace intestinal losses IV and by adding to the TPN. Get the dieitian involved.

3). Early reversal of stoma. I would wait about 20 weeks or longer, and also site a feeding enterostomy at time of Surgery well distally.

If anything else comes to mind I will let you know.

Hope that helps,

Gurpreet Singh Ranger 

Bleeding requiring four units of blood in 24 hours or 10 units in total must be treated surgically. The laparotomy, in the absence of a reliable source of bleeding will most likely be a "blind colectomy". This still happens, though rarely, in western countries also. That for which I totally disagree with what has been done is the absolute lack of any attempt to diagnostics. An endoscopy service at Km 10 is not unattainable, plus 150 km there was a service of Angio CT. If the patient had been kept in hemodynamically stable conditions, a helicopter could transfer the patient to a center of high-volume where a diagnostic CT would be of great help. Then no one can say what would have happened, but doing so was not given any chanche the patient and the surgeon.

I quite agree with Dr. Prasanna's circumstance of moment, to maintain a conservative treatment to ensure daily evacuation of stool and occasional enema, "Primum Non Nocere".

I also feel that  u/s is an unhelpful investigation. A patent processus on its own does not warrant surgery. I only operate on the side of the hernia. Unfortunately many of our patients present to us with an u/s which had been requested by their GP.

Of course, the main stay in Roux en Y GJ is to separate the bilio-pancreatic limb from the gastrojejunal limb so as to prevent reflux biliary gastritis. It's more demanding however effective. It can be made as classical roux en Y or modified one without any jejunal division by doing simple GJ followed by entero-enteric anastomosis between the afferent and efferent jejunal limbs to the stomach and then ligating the afferent limb DISTAL to the entero-enteric anastomosis. 

In an ideal situation beyond 3-4 years  and before the 5th birthday

We are working on it

Thank you Dr. Bobowicz for your valuable comment. It is reassuring to know from that none of the lap group had thrombotic event with LMWH prophylaxis in your center.

Thank you also for bringing to our attention the important issue of giving the spinal anaesthesia during surgery and epidural analgesia in the postoperative period so the LMWH is given at the latest 12 hours prior to surgery. My question: will you restart LMWH on the same day of surgery and when? Thank you

The RCS England have published a document which includes at the end some 'quality' specifications.   

https://www.rcseng.ac.uk/healthcare-bodies/docs/published-guides/hernia     

Its not amazing, but these criteria are designed to be easily obtained using administrative databases.

Cheers

Ewen

Thanks all of you for your valuable comments. Is it possible to reduce this huge hernia in staged procedure.? There will be increased intra abdominal pressure to a dangerous levels if we attempt reduction of all contents without initially increasing the abdominal 

Maybe a  better question to ask is: do you use Stereotactic body radiotherapy (SBRT) aka Cyberknife, for treatment of any liver tumors?  There has been a wealth of experience from Asia that SBRT is as effective and less toxicity than TACE or RFA.

If a foreign body is present without doubt, it should be extracted if the surgical risk is not prohibitive. Open abdominal exploration seems the best approach. Once you have diagnosed it, you have to inform the patient about what happened and what you are intending to do to help her. Failure to do so is potentially dangerous to her and to yourself.

Never, because the peritoneum generally doesn't meet easily and small gaps will be left (which are much more dangerous than big gaps for causing internal small bowel obstruction). Its the same reason I never close mesenteric defects after segmental resection.

I agree with Darby

I THINK THAT NO PLACE FOR MAD IN MODERN SURGICAL PRACTICE...USAGE OF TOPICAL NG OR NEFIDIPINE WILL GIVE GOOD RESULTS IN ADDITION TO SALTY WARM BATHS AND STOOL SOFTENERS, TOPICAL LIDOCAINE CAN BE ADDED

I think if the burst abdomen  has the big dehiscence with bowels herniating out of it sometimes with the cough also should be taken to operation theater.collection of pockets of infected material should be drain out,the stucked bowels can sometime goes in to the obstruction so  mass closure with interrupted sutures as already said by Prasanna  will help the situation.

Your case report seems to be a case of cystic intestinal pneumatosis. Almost always is simptomatic with abdominal pain and free abdominal gas (see the attached file ), but sometime could be asymptomatic or light symptomatic. I remember two cases of CIP operated on, one symptomatic and one not. The procedure was the resection of the small bowel affected by the cystic formations. It's not so rare and affected not only elderly patients.

Very very excellent question! The same as what I want to ask.

It's true as indicated by above answers that in a broad sense, surgical quality could be evaluated by numerous layers of parameters: blood loss, postoperative recovery, pain, patient experience, you name it. I can assure you, viewing in this bird-view angle, it is impossible to evaluate surgical quality or the quality of a surgeon.

Answer my question first: what is a SURGEON? What makes you different from other physicians? What makes you proud of what you are doing?--- Yes! SURGERY! YOU ARE "FIXING" A LIVING PERSON AND SAVING LIFE WITH YOUR KNIFE AND NEEDLES!!!

A long time ago, it was said that a surgeon should have "eagle's eyes, a lion's heart, and women's hands". I was inspired by these words and struggled out of my country to come here to join the team of the best. I don't know how many of you guys still remember this verse, but I'm sure no one is paying any attention to it. However, from my "stupid" point of view, this is EXACTLY the parameters you MUST look for to qualify a surgery and a surgeon--- A profound vision into surgical science, a superior knowledge-based decision maker, and the finest skillful craftsman with prudent responsibility. This is the core parameter that decides the outcome of a surgery. This decides all other above mentioned measures. Yet you are asking: how to measure these?!

I tell you, it's very simple, but I'll ask: do you DARE and do you really CARE? All these properties boils down to only one element: "Surgical skill". If a surgeon, who loves surgery, looks at his operation from the point of view of a craftsman, he would die to make his surgery flawless. And a flawless operation will beat all the indirect measurements like hospital stay, patient feeling, what-so-ever! In such an advanced world, this is very easy to achieve: every surgery should be recorded with video and sound, then reviewed anonymously by a board of superior surgeons. Scores placed on intraoperative bleeding, intraoperative decision making, collateral damage level, surgical cleanliness, intraoperative patient status, suturing skill, tying skill, incision skill, fine movement of instruments, etc. I'll assure you, if you really do so, you will see a tremendous difference between our current attendings. You will be shocked to see why some guy is still working here! How he was selected to be a surgeon!? So answer my question: do you dare to?

Quality control by this means would be most efficient and cost-effective, because this catches problems in ahead, instead of wasting resources to "manage" them after they do occur, which though is the requirement of "evidence-based-medicine", correct? :) LOL

Unfortunately, the quality of surgeons is drifting downwards these years globally. We have a saying: " to attend to the superficials and neglect the essentials". Way too much emphasis placed on candidates' communication skills and their ability to handle textbook knowledge or even their research experiences, but ignoring the most important part of a surgeon: his potential on mastering surgical skills. We are producing more speakers instead of doers. I was told that surgical skill is not viewed as an essential part of surgery......

It largely depends on the surgeon's experience and the importance of the complication. The policy of our institution generally is to use laparoscopic access if the patient was previously operated laparoscopically. Then, if the surgeon is not able to successfully treat the complication, a open surgery conversion is advised. However, open surgery is avoided in many cases.

I agree with the notion that all surgeons should have experience with ultrasound; in fact, I think that it should be incorporated in the surgical curriculum. Eastern Virginia Medical School is leading the charge in integrating ultrasound into the medical school clinical curriculum. From a surgeon standpoint, I think that it will help with ED triaging, trauma bay, ICU evaluation, and routine floor management.

Depends on what you have and your aim. There are many published researches on mortality of elderly surgical patients. Going through some may help

Dear Jensen

Zieren et al [1] studied the quality of life after elective hernia repair by using the Short-Form 36 questionnaire and found significant improvement in preoperative quality of life regarding freedom from pain, vitality, and physical

activity. Patients with scrotal hernia suffer preoperatively from an impaired quality of life, and it is unclear whether the quality of sexual lifeis improved by hernia repair.

The International Index of Erectile Function (IIEF) is a 15-item, self-administered questionnaire to assess male erectile function in the previous 4 weeks and is used to detect treatment-related changesIIEF was used to assess quality of sexual

function[2].

Ref

1 Zieren J, Kupper F, Paul M, Neuss H, Muller JM. Inguinal hernia:

obligatory indication for elective surgery? A prospective assessment

of quality of life before and after plug and patch inguinal hernia

repair. Langenbecks Arch Surg 2003;387:417–20.

2.Ertan T, Keskek M, Kilic M, Dizen H, Koc M, Tez M. Recovery of sexual function

after scrotal hernia repair. Am J Surg. 2007 ;194:299-303.

Depends on the length of ascending colon left after resection. Have done  both without any undue consequences.

Habeeb, how much evidence do you have on that rule? Who published it and who has proven it? What about the patients characterics beyond the hernia margins (4cm in a 50KG Body are never the same as 4 cm in a 90 KG Body, etc.)

Prevention is the best.One must avoid the efferent obstruction and blind afferent loop syndrome(ALS) by adopting the basic principles of GI Surgery.However in this case one can predict coagulation disorder only in presence of a very longstanding and long loop afferent loop syndrome(chronic ALS) and not if in case it has been an early(ALS) complication of GJ in GOO.

This is an interesting but not uncomon case, particularly in the younger population. Most cases are indeed benign and usually due to inflammatory causes e.g. abscess from the appendicitis itself, associated inflammatory bowel disease, worms in certains parts of the globe, and occasional diverticulitis. There is several good reasons to perform an resection:

1) Provides pathological diagnosis of the unknown mass

2) If the tissue is inflammed, it may compromise the healing of your appendiceal stump

3) If the mass left untreated, it can precipitate subsequent small bowel obstruction

4) And very occasionally the diagnosis is malignant which will significantly change the patient's subsequent treatment, And a delay in diagnosis in this situation will be unsatisfactory. We had a patient who was diagnosed of angiosarcoma presenting with a appendiceal mass: Small intestinal angiosarcoma masquerading as an appendiceal abscess, Ann R Coll Surg Engl. 2013 Jan;95(1):e22-4. doi: 10.1308/003588413X13511609955373

Depending on comfort and expertise, ileocaecal resection should suffice, otherwise right hemi is fine too

Another relevant reference: Inflammatory cecal masses in patients presenting with appendicitis World J Surg. 1999 Jul;23(7):713-6; discussion 716

Hope this helps

Dr. Suman Das is a plastic surgeon in Flowood, Mississippi and is affiliated with multiple hospitals in the area, including River Oaks Hospital and St. Dominic-Jackson Memorial Hospital. He received his medical degree from RG Kar Medical College Calcutta and has been in practice for 47 years. He is one of 14 doctors at River Oaks Hospital and one of 7 at St. Dominic-Jackson Memorial Hospital who specialize in Plastic Surgery. He also speaks multiple languages, including Hindi/Urdu and Bengali.

And particular thanks to Dr.Raza for an article on the paraduodenal hernia downloaded! The thing is worth to read.

Hydrolipoclasy have been introduced in aesthetic market basically for the treatment of cellulite (just orange skin, or mild cellulite), supporting in the idea of removing the superficial fat, up to 1 cm below the skin surfece.

For this treatment, a high power ultrasound device (more than 20 watts per sq. inch), is needed. Besides, the ultrasound must be 3 MHZ type. Other physioterapist ultrasound are 1 MHZ, and those are not useful.

Although it is somewhat effective, these high power devices are dangerous, and may cause skin burns, so it is mandatory to use them with a temperature sensor during all the procedure.

It is clearly not a common problem but it exists. I had similar case few years ago – a male patient after PPPD who had two low-attenuating lesions in the left liver at CT, and PET-CT demonstrates hypermetabolic activity (as you can see at the attached figures below). As patient refused chemotherapy we did left hepatectomy. Histology revealed both lesions to be an inflammatory pseudotumors and the presence of marked chronic cholangitis was also noted by pathologists.

For the most number of cases, there is not any difference, so that a surgeon can choose any on the bases of other conditions, like the given patient's body mass index, comorbidity, etc. The personal experience of the surgeon does matter as well.

The interrupted or intradermal suturing do not alter the wound infectious complication's rate in either case. On the other hand, the former might be used even in case of frank abscess formation providing that a system for acitve irrigation and drainage was carefully placed and insert through the separate stab wound.

The only reliable explanation not to use the latter way of the skin closure (intradermal running suture) seems to be not to waiste time and efforts if the risque of purulent complication is too high.

There is good evidence that it is ok to operate on and perform almost all urologic procedures if a patient is on Aspirin. In my practice, I like to take patients off of aspirin if possible and I routinely discuss this with the patient's cardiologist. If the procedure is necessary in a certain amount of time (Cystectomy) and the patient cannot come off of aspirin, I will proceed with the operation. Hope that helps.

I agree that varicose vein disease is not a contraindication for abdominal surgery even in the case of elective procedures for non malignant disease. However the varicose veins are a risk factor for dvt. In my hospital we have a score chart to quantify the risk of dvt in order to select the best prevention of dvt in where varicose veins count as obesity age etc......stocking and lwmh are all excellent even combined to prevent dvt

Actually during liver resection we ask the surgeon to measure inferior cava vein diameter and its variation by intraoperative ultrasounds. We are trying to find a correlation between it and other volemia related parameters (cardiac index, central venous pressure, stroke volume variation, fluid balance)

Dear Dr Borodach..

Thank you for bringing attention to this guideline document. While going through the document, I could not find the Cruse Visual Criteria. I will be grateful if you can elaborate on this criteria and how it helps in the decision making process.

Regards, raza

we are loosing the core of disease. In strangulated inguinal, crural or incisional hernias the real problem is quoad vitam. The hernia recurrence is secondary. I confirm that is better a recurrence in an healthful patient than the risk of infected mesh. i'll read with interest the article you cited but i think that in in emergency surgery the common sense should prevail

Dear colleague,

Thank you very much for this profound answer!

Of course, I have read your article already when I asked the question, and I did not expect (and this is honour for me) that you personally were that one who give an answer.

My article on the GBA is to be published in a journal 'Annaly Khirurgicheskoy Gepatologii' (Moscow) in the end of this or in the beginning of next year, so that I invite you, in my turn, to read my article. A summary is in a docx. file below.

Thank you again!

It is not possible to make definitive recommendations

regarding treatment by PC or cholecystectomy in elderly or critically ill patients with acute cholecystitis, but pending the results of the CHOCOLATE trial, I think that in acute calculous cholecystitis, percutaneous cholecystostomy can be used like "bridge to surgery", instead the same method in acute acalculous cholecystitis can be considered, on the basis of each patient, a definitive method

I do not think that diverticular disease is the only cause of lower gastrointestinal bleeding. In emergancy settings a CT scan may be indicated only after a proctologic examination does not find other source of bleeding (haemorroids, fissures, rectal or anal polyops, solitary ulcer syndrome). Anyway, a successive colonoscopy is mandatory expecially in old patients.

The identification of a definite point of obstruction, the ‘transition zone’, with dilated small bowel loops proximal to the site of obstruction and collapsed loops distally, is the most reliable CT criterion for diagnosing small bowel obstruction .

The best studies to answer to this question come from cancer registries. In western countries, the SEER is the most accurate. Tumors are located with the same rate in the right colon, left colon and rectum.

(right colon 28%, sigmoid 23%, rectum 25%, rectosigmoid 10%: Anatomic subsite of primary colon colorectal cancer.... Cancer 2013)

Length of hospital stay is due to many factors - personal, medical and cultural. Not that it is a consequence of severity not a cause and as such would not be an appropriate parameter by which to define severity. See Petrov et al Gastroenterology 2010 for determinants of severity and Dellinger et al Ann Surg 2012 for definitions of severity.

Interesting question but to the best of my knowledge this has not been studied.

The first Dutch study was aborted because of high rate of complications, but other three study are on going. The UK CReST Trial, a second Dutch trial and a swedish trial. I think that we have to wait these results for better understanding the value of the procedure.

With such a variation in techniques and types if abdominoplasty you will probably receive as many answers as surgeons. My regime for standard abdominoplasty with rectus plication is overnight stay, clexane and TEDS till mobile, elasticated abdominal binder, mobilise semi-erect first morning post op, drains out and patient home on day one post op. Abdominal binder , ted stocking for six weeks. Micropore (paper tape) on scar for three months.

Uncomplicated acute appendicitis that you can treat without surgery, often are not acute appendicitis but someone else.

There are some crucial questions in such cases: which organ exactly is incarcerated, and wheter the incarcerated content is vital or not, and is there an infection? So in my opinion laparoscopy is the most reliable option – you can reduce the hernia, can see what is incarcerated and wheter there are signs of necrosis, and also take fluid for culture. If there is a bowel necrosis the need of resection is clear. But if it is not the problem is always whether there is an infected ascites, as there is never been a good idea to place a mech in infected conditions. So better reduce the hernia, apply external pressure of the sac, for example with gauzes and fix them with adhesive bands or folio drape. Start antibiotics keeping the guidelines for the treatment of bacterial peritonitis in cirrhosis. Do not remove ascites if not visibly purulent, no drains, as they usually caused nearly uncontrollable homeostatic disturbances due to huge amount of fluid losed. When the patient is stable and infection is controlled by antibiotics you can move back to OR and do that what you prefer. I think the laparoscopic repair is better. So the philosophy is that there is absolutely no need to address both problems – incarceration and hernia itself in one stage in a patient that is usually not fit for surgery and had severe comorbidities. The exception might be the patients requiring bowel resection.

Our hospital has used laparoscopic lavage as the treatment of choice for all cases of non fecal perforated divericulitis for the last three years with very good results. It is surprising how well it works and it has revolutionised the treatment. No stoma. Much quicker mobilisation and shorter hospital stays. For us, there is no turning back to Hartmans procedure.

This is a very important question.

There is a major push to implement DVT prophylaxis in the US. This is motivated by the so-called SCIP Core Measure Set implemented by The Joint Commission, the primary accrediting organization for hospitals.

It has been my personal experience that I have an increase in bleeding-related complications with DVT prophylaxis according to these guidelines. These include difficulties with intraoperative hemostasis, wound hematomas, and, rarely, bleeding requiring re-operation.

I have asked my colleagues informally about this and the result is universally similar. It is interesting that the SCIP Core Measure Set does not include identifying and reporting anticoagulant-related complications. The argument is usually that bleeding complications are rarely fatal and easily treated while pulmonary embolism is more likely fatal. I suppose internists all agree that bleeding is easily treated. Just call the surgeon!

Still, we need to collect all relevant data when experiments like this are imposed on a very large population.

It appears to me that the SCIP Core Measure Set is weighted toward a one-size-fits-all standard of measures that are very easy to quantify. Perhaps that is one reason why early data does not show differences in outcome between patients that meet SCIP Core Measures and those that do not. (There are other factors influencing these data as well.)

You also referenced patients coming in with ongoing anti-platelet and anticoagulant therapy. I do not know of any simple answer. It is always a trade-off between the urgency of surgery, the risk of bleeding, and the indication for the anti-platelet or anticoagulant therapy.

I've just reviewed a couple of articles; LeGoo has been used for femorodistal bypasses and there is a paper out by Davies group from London, and a couple of recent ones in the European Journal of Vascular and Endovascular Surgery. Have a look and see what you think.

In our centre both oncology and HPB surgery see every patient, even the initially unresectable patients since some of these will become respectable in the future after chemotherapy. This is important since a portal vein embolization or a staged resection can render some of these patients operable but the opportunity may be missed if surgery is not also following these patients. After the initial visits the patients are presented at HPB Tumor Board. The oncologists, surgeons, interventional radiologists, and radiation oncologists are present, every one is trying to determine how many patients can be converted to a resectable state, i.e. everyone believes that a resected patients is better off. There is no question about the patients that is resectable at presentation, barring other medical conditions they will be offered surgery. it is important that every centre bring all the parties to the table and have a discussion driven by the literature and get buy in for an in-house protocol for these patients, this may need to be done every 2-3 years. The protocol should reflect the centres strengths and attempt to boost their weaknesses.

It is better to do an early laparoscopic surgury after a short corse of medical resuscitation. But in your special poorly medical condition a percutaneous gall bladder drainage with local anesthesia is prefered.

The UK National Institute for Clinical Excellence (NICE as was) has just completed an audit of VAC therapy and fistula risk in ICU patients following the paper from Gordon Carlsson's unit published a couple of years ago

Ann Surg. 2008 Mar;247(3):440-4. doi: 10.1097/SLA.0b013e3181612c99.

Outcome of reconstructive surgery for intestinal fistula in the open abdomen.

Connolly PT, Teubner A, Lees NP, Anderson ID, Scott NA, Carlson GL.

SourceIntestinal Failure Unit, Department of Surgery, Salford Royal NHS Foundation Trust, Salford, United Kingdom.

Above 12 months. Before 1 year of age there is no need to open the external oblique aponeurosis provided you do dissect the sac high enough to avoid residual patent processus vaginalis that would end up with a recurrency in a 2 to 3 years