British Journal of Surgery

Ike, D I; Asemota, N; Jacob, A; Okorocha, C; Stamenkovic, S

doi: 10.1093/bjs/znae163.048pmid: N/A

Robotic surgery has rapidly advanced across various medical specialties over the past decade. Extensive research has confirmed the benefits of robotic surgery, leading to improved surgical outcomes and patient satisfaction. Historically, only highly experienced consultants in laparoscopic and open surgery received training in robotic surgery to the detriment of junior surgical trainees.Virtual reality simulators have introduced gamification to enhance surgical skills. Studies have shown that individuals with gaming experience, musical aptitude, and sports backgrounds exhibit improved psychomotor skills relevant to surgery, including hand-eye coordination, reaction time, and visuospatial awareness. Despite this, there is a lack of research on how gaming and musical abilities impact robotic surgical skill acquisition and learning curves.This prospective, observational, and comparative study involved 15 novice surgeons with no prior robotic experience recruited from various UK medical institutions. Participants were divided into two groups based on their video game experience.While statistical significance was not reached (p 0.26), an observed trend favoured the gaming cohort's performance (M 56.29, SD 57.85) on the robotic surgical simulator compared to the non-gamer group (M 38.41, SD 46.77) possibly due to the limited sample size. Gamers exhibited notably superior reaction time scores (p 0.037) Additionally, gamers demonstrated enhanced overall performance in spatial reasoning and the Beat Saber game, assessing hand-eye coordination, though these differences did not reach statistical significance.This study suggests that video gaming experience may provide novice surgeons with certain advantages when beginning training on the high-fidelity dVSS robotic surgical simulator. Further research with larger participant groups may confirm these findings.

Soteriou, I; Hadjixenophontos, S; Musbahi, O; Jones, G; Pouris, K; Cobb, J

doi: 10.1093/bjs/znae163.447pmid: N/A

AimRadiographic assessment is crucial for the success of a hip replacement procedure as an accurately positioned prosthesis indicates favourable long-term outcomes. This project aims to develop a novel artificial intelligence (AI)-based method that can: (1) automatically identify the presence of a hip resurfacing prosthesis in radiographs and (2) calculate the radiographic neck-shaft angle (NSA) of the prosthesis from two-dimensional plane images using both anterior-posterior (AP) and lateral x-rays with high accuracy.MethodUsing a computer vision and pattern recognition algorithm, the femur shaft and prosthesis regions were identified, and their respective angles were extracted for NSA calculation. A neural network (NN) was then trained using clinician-generated AP radiograph NSAs as ground truths and AI-generated AP and lateral NSAs as features. Spearman's correlation and Kruskal-Wallis tests were calculated to explore any significant association between the final AI-generated and clinician-generated AP x-ray NSAs. Mean absolute error (MAE) and R-squared values were calculated with and without the NN model to identify the model's accuracy and variability.ResultsThere was a statistically significant correlation between the final AI-generated AP x-ray NSAs and the clinician-generated AP x-ray NSAs (rs=0.83,p=0.00). MAE and R2 without the NN were 3.09 and 0.37 respectively. MAE and R2 with the NN were 1.94 and 0.53 respectively.ConclusionsThe results of this study demonstrate that the identification of hip resurfacing prostheses using artificial intelligence is feasible. By incorporating additional features such as the lateral NSA, the model can provide an accurate prediction of the AP radiographic NSA, closely approximating the ground truth.

Manoharan, M; Alrasad, R; Chatterjee-Woolman, S; Peeraully, R; Shepherd, G; Shenoy, M

doi: 10.1093/bjs/znae163.160pmid: N/A

IntroductionIn appendicitis, antibiotics are routinely commenced prior to consideration of operative management. The choice of initial regimen depends on local antimicrobial guidelines. The presence of resistant organisms risks development of post-operative collections.In our tertiary paediatric surgery unit, antimicrobial guidelines were changed in September 2022 to recommend co-amoxiclav instead of cefuroxime/metronidazole. This study compares incidence of post-operative collections before and after the policy change.MethodPatients who underwent appendicectomy between September 2021 and October 2023 were identified and contemporaneous data collected. Patients who had initial surgery elsewhere, interval/incidental appendicectomies or penicillin allergy were excluded. Comparison was made between patients receiving cefuroxime/metronidazole (Group 1) or co-amoxiclav (Group 2).ResultsOver the 26-month period, there were 104 patients in Group 1 (after excluding 47) and 104 in Group 2 (after excluding 46). 4 (3.8%) developed collections in Group 1 versus 13 (12.5%) in Group 2. In Group 1, 2 (50%) were treated with antibiotics alone, 1 (25%) required drain insertion and 1 (25%) had a laparotomy. In Group 2, 7 (54%) were treated with antibiotics alone, 5 (38%) required drain insertion and 1 (8%) had a laparotomy. The relative risk of developing a post-operative collection was 3.3 (p=0.023) in Group 2 versus Group 1.ConclusionsThe change in antimicrobial policy resulted in a significant increase in post-operative collections in our unit. This provides evidence that a regimen of cefuroxime/metronidazole is more effective at preventing collections and we are liaising with our Microbiology department with a view to amend the guidelines.

Abimbola, A; Quiney, G; Colucci, G

doi: 10.1093/bjs/znae163.137pmid: N/A

BackgroundMusculoskeletal (MSK) injuries are very common among laparoscopic surgeons. These injuries can result in physician burnout, early retirement, and medical/surgical treatment. The aims of this study are to identify the causes of MSK injuries in laparoscopic surgeons, the most common injuries, and strategies to prevent them.MethodFollowing the PRISMA guidelines, Medline, Embase and PubMed databases were systematically searched for relevant articles using the predefined inclusion/exclusion criteria. Data was extracted by two independent reviewers.ResultsA total of 321 papers were found, after screening 41 papers were selected for inclusion. Many study designs involved the use of biomechanical methods, surveys, and quality of life questionnaires. Studies varied drastically in their sample sizes. Results show that long periods of static postures held in non-ergonomic positions are a significant contributing factor to MSK injuries. This is more likely in laparoscopic surgery, as surgeons hold more fixed positions with more physical demand when compared with open surgery. Studies show that the most common sites for injury are the neck, back and shoulder.ConclusionsMSK injuries are an ongoing problem which is often underestimated and poorly reported. There was clear evidence in the literature that microbreaks and strength training is beneficial, and that ergonomic training should be a standard element of surgical training.

Veerappan, V; Kundu, S; Arora, H; Virk, S; Goshal, R; Gadgil, A; Raykar, M

doi: 10.1093/bjs/znae163.126pmid: N/A

AimThis scoping review aimed aims to identify challenges in delivering obstetrics care within PHCs in India, using the 6 WHO healthcare building blocks.MethodA literature search covered PubMed, MEDLINE databases, and Google Scholar. Studies published from 2012 to 2022, discussing PHC-based obstetrics care in India, were included based on predefined criteria. Title, and full-text screenings were conducted using Covidence, involving 2 reviewers for screening and 1-2 reviewers for conflict resolution. Data extraction on the 6 WHO building blocks was performed by 4 reviewers.ResultsTwenty-two studies were included for final review, mostly cross-sectional (59%), mainly from the state of Bihar (23%). Service delivery (77%) and health workforce (73%) were the most extensively discussed building blocks. Leadership and governance were the least discussed (14%). Challenges in service delivery encompassed limited antenatal care uptake, inadequate emergency obstetrics care and adjunct services, inadequate infrastructure, equipment and space and poor transport, and onward referral services. Health workforce issues included staffing levels and competency and training deficiencies in existing staff.ConclusionsThis review highlights significant challenges in obstetrics care delivery within Indian PHCs in India, primarily related to service delivery and health workforce. Our scoping review identified literature gaps within the four building blocks outside service delivery and health workforce, and geographical literature gaps from the Northeast of India. PHCs play a crucial role in the equitable delivery of obstetrics services that can reach the most underserved population across India. It is imperative that surgical and obstetrics plan strategies include primary care within them.

Aldabbagh, Y; Riaz, S; Wiffin, R; Hollingworth, M

doi: 10.1093/bjs/znae163.487pmid: N/A

AimTo investigate signs and symptoms in children and young people (CYP), with cerebrospinal fluid (CSF) shunts, presenting to a CYP emergency department (ED) with onsite paediatric neurosurgical facilities; and assess their association with 30-day shunt revision rate.MethodRetrospective analysis of CYP (<17 years old) with CSF shunts presenting to the CYP ED. Univariate and multivariate analyses were performed to assess the relationship between patient characteristics, presenting signs and symptoms, and 30-day shunt revision rate.ResultsWe analysed 107 presentations between 03/11/2021 and 25/10/2022. 42% of patients were female with a mean age of 5.64 years. The most common shunt aetiologies included tumour (30%) and intraventricular haemorrhage (30%). Vomiting (37%), reduced alertness (27%), and behaviour change (27%) were the most common symptoms. 13% of patients underwent shunt revision within 30 days of presentation. No individual sign or symptom was highly sensitive, with the most sensitive being headache (64%) and vomiting (64%). Univariate analysis demonstrated that ≥2 (two or more) previous shunt revisions, fever, pallor, headache, and surgical site swelling, were significantly more common in those who underwent shunt revision (p<0.05). However, only headache and shunt site swelling were independently predictive using multivariate analysis (p<0.05).ConclusionsCYP with CSF shunts present with complex symptomatology. Number of shunt revisions, headache, and shunt site swelling were predictive of shunt revision at 30 days. Understanding and integrating key predictors of CSF shunt failure into the diagnostic pathway is essential for improving efficiency and minimising the impact on CYP and their families.

Babikir, A; Banerjee, S; Boulton, R

doi: 10.1093/bjs/znae163.654pmid: N/A

AimThe effectiveness of immersion training in endoscopy for surgical trainees has not been documented previously and we aimed to assess the impact at a busy gastrointestinal surgical unit within London. This involved providing the surgical registrars with a week of endoscopy training every month, during which time their clinical duties would be covered by an appointed clinical leadership fellow – externally funded by HEE.MethodSurgical trainees currently rotating at Queen’s Hospital Surgical unit are each enrolled in endoscopy immersion and assigned a week per month with prior notice to hand over their clinical duties to the clinical fellow. During the immersion week, the surgical registrar is exposed to hands-on training, simulator access, and interactive sessions with experienced endoscopists.ResultsThree surgical trainees were enabled access since September 2023 to immersion training. Another trainee mentioned performing around 6-7 colonoscopies per day during immersion to a total of 65 in two weeks. A third trainee has attended a total of 8 endoscopy lists in 1 week. He competed 28 colonoscopies and 2 OGD’s, achieving TI intubation in 4, caecal intubation in 18.ConclusionsThe feedback supports the efficacy of immersion week as a valuable adjunct to traditional surgical training. Integration of immersion weeks into the curriculum can potentially optimize the training pathway for surgical registrars allowing them to achieve the required numbers for CCT and building competencies. Study leave blocks for endoscopy training could also be an alternate option.

Burton, H; Goodarzi, M; Chalmers, R

doi: 10.1093/bjs/znae163.495pmid: N/A

Ulnar collateral ligament (UCL) injuries of the thumb constitute frequent trauma presentations. While clinical assessment proves valuable, instances arise in equivocal cases where imaging aids in determining optimal management. This project aims to assess the diagnostic efficacy of ultrasound in identifying UCL injuries.A retrospective analysis was conducted utilizing online medical records system. Patients from the last five years who underwent thumb ultrasounds were identified and inclusion criteria encompassed: acute thumb injuries accompanied by ultrasounds indicative of full-thickness UCL tears and/or Stener lesions.Fifty patients who underwent ultrasounds for acute thumb injuries with UCL concerns were identified. 31 were excluded with normal results or incomplete data. The remaining 19 patients had ultrasound reported complete UCL tears and/or Stener lesions and subsequently underwent operative intervention. The average age was 38.7 years; 58% were female. The median duration from presentation to ultrasound scan was 2 days, and from presentation to surgery was 4.5 days. Eleven patients (63%) exhibited a confirmed complete UCL tear during surgery; 6 patients (37%) had a normal intact UCL. Consequently, the positive predictive value of ultrasound in detecting acute UCL tears within this cohort was 63%.It is known that accuracy of US is operator dependent and with over a third of patients in our cohort being identified as having false positive result following surgery, relying on US findings to proceed to surgery must be cautioned. It remains a valuable non-invasive investigation. For cases where the clinical picture is indeterminate, MRI is now our modality of choice.

Schenk, E; Maggs, R; Franklin, M

doi: 10.1093/bjs/znae163.035pmid: N/A

AimInclusivity and diversity of individuals from lower socioeconomic backgrounds is unequal within surgery. Diversification of the workforce is a requirement for the future of surgery to ensure high quality patient care is provided (Hassan, 2023). The School’s Engagement Session, originating with the British Hip Society and replicated with British Orthopaedic Association (BOA), aimed to introduce the idea of a career in medicine or surgery to children from non-selective state schools.MethodThree school groups, twenty-four students and three staff members, attended day three of the annual BOA conference. Highly engaging medical student presentations, industry stand activities, and hands-on consultant led surgical based stations sparked interest and provided ‘work-experience’ opportunities; an increasingly challenging pre-requisite for applicants to acquire. Resources, lunch, and room availability were all supported by the BOA.ResultsDirectly addressing students from lower socioeconomic backgrounds about a career in surgery, which many had not previously considered, stimulated their interest in this as a career. Feedback from accompanying educators, acknowledged their lack of insight regarding accessibility, and students explicitly demonstrated the positive impact of these in-person engagement events. Many students explained how this newly acquired knowledge had empowered the possibility of pursuing a medical career.ConclusionsReplication of this highly successful event demonstrated the impact of engagement with individuals from diverse backgrounds upon future surgical diversity. Nationwide reproducible events are therefore warranted to reduce inequality in medicine and surgery. Medical student through to consultant involvement with future engagement work will diversify and sustain the surgical workforce within the UK.

Babu, S; Lee, R E; Allen, S; Dowson, H

doi: 10.1093/bjs/znae163.210pmid: N/A

AimEnhanced recovery after surgery (ERAS) improves short-term post-operative outcomes by maintaining pre-operative function and reducing the stress response associated with surgery. Early post-operative mobilisation is a key component. This study sought to assess achievement of early mobilisation goals, identify barriers to mobilisation, and improve awareness of ERAS.MethodEye-catching posters were placed within view of each surgical bedspace and on the door of each bathroom. These emphasised the benefits of early mobilisation and simple steps a patient may take to improve their post-operative outcomes. Between May to July 2023 (Baseline; n=47), and August to September 2023, (Post-intervention; n=46) data were prospectively collected on adult patients who were day one post-elective or emergency general surgery.ResultsUnfamiliarity with the concept of ERAS, as well as inadequate post-operative analgesia were identified as barriers to early post-operative mobilisation. Following the implementation of ward-based educational posters, there was a 36% increase in the number of patients who were aware of the concept of ERAS (10% to 46%). 31% of patients were able to recall at least two benefits of early mobilisation as highlighted by the posters. Requests for analgesia increased by 29%. There was a 24% increase in the number of patients sitting out of bed for meals. Furthermore, completion of the recommended 4 x 60m walks also improved (77% to 87%).ConclusionsA simple ward-based intervention resulted in heightened awareness of Enhanced Recovery and the importance of early post-operative mobilisation as well as improved compliance to the local post-operative mobility goals.