The Australian and New Zealand journal of surgery最新文献

Background: Laparoscopic cholecystectomy (LC) requires expensive equipment and special training. Mini-lap cholecystectomy (MLC) has no start-up costs but no large series from a single centre has been reported as the procedure is considered hazardous because of inadequate exposure of the surgical field.

Methods: We retrospectively reviewed the outcome of 737 cholecystectomies performed through a 3-5-cm transverse subcostal incision and compared the results to published series of laparoscopic cholecystectomy.

Results: The operating time (61.6 min; range 35-130), conversion rate (4%), rate of postoperative complications (3.6%), bile duct injuries (0.3%), number of analgesic doses required (3.4; range 3-8), duration of postoperative hospital stay (1.4; range 1-15 days), and the time off work (13.3 days; range 8-61) compare well with the reported results of laparoscopic and MLC. Ninety-three per cent of the patients were followed up for a median period of 28.4 months and none developed biliary stricture.

Conclusions: Mini-lap cholecystectomy is considered a safe, viable alternative to LC in the Third World.

Background: There is concern about the exposure of orthopaedic surgeons to radiation. The aim of this study was to monitor radiation use in theatre to improve practice and to attempt to quantify the radiation dose the orthopaedic surgeon may have received.

Methods: A 6-month prospective audit of all procedures performed in the orthopaedic theatre that used fluoroscopy or radiographs was undertaken An anthropomorphic phantom was used to measure scatter and direct-skin doses. Screening times were recorded in a subsequent 6-month post at a tertiary trauma centre.

Results: Fluoroscopy or radiographs were used in 378 procedures. Fluoroscopy was used in 260 procedures with a screening time of 124 min at an average of 0.48 min per procedure. Lead aprons were worn in 99% of cases and thyroid guards in 32%. All dosimeter badges were negative. The surgeon's hand was caught in the fluoroscopy beam in 15% of procedures. The phantom recordings ranged from 13 to 210 microGy for skin dose and 0.17-0.87 microGy for scatter dose. The calculated hand exposure was less than 5% of recommended levels. In the trauma post 210 min of screening was used potentially increasing the hand exposure to one-third of recommended limits. If a printer was used to record the image, 58% of intra-operative radiographs would have been avoided.

Conclusions: Hand exposure to radiation is the limiting factor in orthopaedics. The extremity limit will only be exceeded if the hands are regularly caught in the beam. Dose-reduction gloves should be considered for high-risk procedures. A printer can reduce the need for intraoperative plain radiographs.

Background: Recent judicial decisions involving informed consent have led to some medical practitioners altering the way they obtain consent. The aim of this study was to determine the degree to which patients understood the risks associated with a surgical procedure after giving routine consent and whether providing additional detailed verbal and/or written information improved their understanding. It was further determined whether the provision of more extensive information altered patients' anxiety levels.

Methods: Patients undergoing femoral popliteal bypass or carotid surgery were randomized to obtain either routine consent only or routine consent with verbal or written or verbal and written consent. Patients undertook a pre-operative risk and complication questionnaire, a pre- and postoperative anxiety and depression evaluation and a follow-up questionnaire 6 weeks after discharge.

Results: Thirty-two patients were included in the trial. The comprehension questionnaire resulted in a correct percentage response of 48% for the routine information only, 59% with added verbal information, 59% with added written information and 55% with added written and verbal information. Twenty-five per cent of patients stated that they had a poor understanding of the risks and complications of the procedure.

Conclusions: Additional written or verbal information did not improve a patient's understanding of risks and complications of the procedure. It also did not improve patients' perceived understanding of the operation or its complications. Patients' anxiety levels were unaltered by the increase in the information they were given. The information provided to patients should be simple, easy to understand and list any possible major complications to enable the patient to determine whether to undergo or decline a procedure.

Background: Modern surgical practice is stressful and anxiety-producing. We investigated urologists health and their attitude to their own health care.

Methods: Two hundred and seventy-five Australasian urologists were surveyed to ascertain their attitudes to their physical and psychological health; 205 responses were received.

Results: Ten per cent reported serious physical illnesses. Fewer than half had their own general practitioner (GP), and fewer than one-third had seen a doctor in the previous 12 months. A majority had, at some time, prescribed themselves medication, including antibiotics, narcotic and non-narcotic analgesia and benzodiazepams. Nearly all reported that aspects of their urological practice caused them anxiety. More felt that this anxiety was the result of pressures experienced outside the operating theatre than problems directly related to performing surgery. A small number of psychological problems were reported, and fewer than 10 per cent had ever a visited a psychiatrist. It was evident that most Australasian urologists were unwilling to discuss any psychological problems that they may have. Even when a specific problem had been identified, few sought the appropriate care.

Conclusions: It would be advantageous for Australasian urologists and doctors in general to see their GP more regularly, and be more willing to discuss any psychological difficulties that they may experience.

Background: A comparative analysis of outcomes of inguinal hernia repair performed under local (LA) and general anaesthesia (GA) by a single surgeon using a standardized technique of anterior transversalis repair was performed. Ninety-three cases were examined, 56 of which were cases of LA hernia repair.

Methods: A retrospective analysis of the patient hospital record was performed with particular attention to intra-operative and post-operative analgesia requirements.

Results: An overall series complication rate of 6.5% (6/93) is reported. Only one of 56 LA patients (2%) required more than 24 h of narcotic analgesic injections compared to 11% (4/37) in the GA group (P < 0.05). The mean total postoperative parenteral narcotic requirement in the LA group was 86+/-14 mg of pethidine as compared to the GA group who had a mean total requirement of 121+/-17 mg of pethidine (P > 0.08).

Conclusions: The LA infiltration technique is an effective method for inguinal hernia repair. This series demonstrates benefits in terms of length of hospital stay and a lower incidence of postoperative parenteral narcotic analgesic requirement although when post-operative parenteral narcotics were required by the LA group of patients, the difference in mean total pethidine requirement was not statistically significant.

Background: Rural South Australia (SA), like other rural areas in Australia, faces a crisis in the medical workforce. It is also generally assumed that the same applies to rural surgical services but finding evidence to support this is scarce.

Methods: All hospitals situated outside the outer metropolitan area of SA were surveyed about surgical services (n = 57). Questions were asked about the frequency of emergency and elective theatre usage and which surgeons provided surgical services.

Results: Operating theatre facilities were in active use in 39 of the 57 hospitals studied. At the time of the study there were seven specialist general surgeons resident in rural SA. General practitioners continued to have a major input in the provision of surgical services, either by providing the general anaesthetic (34/39) or by performing the surgical procedures (26/39).

Conclusions: The Department of Surgery at the University of Adelaide is instituting various measures to counter the rural surgical workforce problem and is developing a model that serves either the individual or the two-person surgical practice. Metropolitan teaching hospitals can play an important role in supporting current rural surgeons and can foster an increased commitment to the future of rural general surgery.