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Backgrounds: Laparoscopic surgery is widely used in abdominal emergency surgery (AES), and the possibility of extending this approach to the more recent robotic surgery (RS) arouses great interest. The slow diffusion of robotic technology mainly due to high costs and the longer RS operative time when compared to laparoscopy may represent disincentives, especially in AES. This study aims to report our experience in the use of RS in AES assessing its safety and feasibility, with particular focus on intra- and post-operative complications, conversion rate, and surgical learning curve. Our data were also compared to other experiences though an extensive literature review. Methods: We retrospectively analysed a single surgeon series of the last 10 years. From January 2014 to December 2023, 36 patients underwent urgent or emergency RS. The robotic devices used were Da Vinci Si (15 cases) and Xi (21 cases). Results: 36 (4.3%) out of 834 robotic procedures were included in our analysis: 20 (56.56%) females. The mean age was 63 years and 30% of patients were ≥ 70 years. 2 (5.55%) procedures were performed at night. No conversions to open were reported in this series. According to the Clavien-Dindo classification, 2 (5.5%) major complications were collected. Intraoperative and 30-day mortality were 0%. Conclusions: Our study demonstrates that RS may be a useful and reliable approach also to AES and intraoperative laparoscopic complications when performed in selected hemodynamically stable patients in very well-trained robotic centers. The technology may increase the minimally invasive use and conversion rate in emergent settings in a completely robotic or hybrid approach. [ABSTRACT FROM AUTHOR]

Emergency general surgeons often provide care to severely ill patients requiring surgical interventions and intensive support. One of the primary drivers of morbidity and mortality is perioperative bleeding. In general, when addressing life threatening haemorrhage, blood transfusion can become an essential part of overall resuscitation. However, under all circumstances, indications for blood transfusion must be accurately evaluated. When patients decline blood transfusions, regardless of the reason, surgeons should aim to provide optimal care and respect and accommodate each patient's values and target the best outcome possible given the patient's desires and his/her clinical condition. The aim of this position paper was to perform a review of the existing literature and to provide comprehensive recommendations on organizational, surgical, anaesthetic, and haemostatic strategies that can be used to provide optimal peri-operative blood management, reduce, or avoid blood transfusions and ultimately improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. Methods: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. Results: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. Conclusions: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception. [ABSTRACT FROM AUTHOR]

Background: Laparoscopy is widely adopted across nearly all surgical subspecialties in the elective setting. Initially finding indication in minor abdominal emergencies, it has gradually become the standard approach in the majority of elective general surgery procedures. Despite many technological advances and increasing acceptance, the laparoscopic approach remains underutilized in emergency general surgery and in abdominal trauma. Emergency laparotomy continues to carry a high morbidity and mortality. In recent years, there has been a growing interest from emergency and trauma surgeons in adopting minimally invasive surgery approaches in the acute surgical setting. The present position paper, supported by the World Society of Emergency Surgery (WSES), aims to provide a review of the literature to reach a consensus on the indications and benefits of a laparoscopic-first approach in patients requiring emergency abdominal surgery for general surgery emergencies or abdominal trauma. Methods: This position paper was developed according to the WSES methodology. A steering committee performed the literature review and drafted the position paper. An international panel of 54 experts then critically revised the manuscript and discussed it in detail, to develop a consensus on a position statement. Results: A total of 323 studies (systematic review and meta-analysis, randomized clinical trial, retrospective comparative cohort studies, case series) have been selected from an initial pool of 7409 studies. Evidence demonstrates several benefits of the laparoscopic approach in stable patients undergoing emergency abdominal surgery for general surgical emergencies or abdominal trauma. The selection of a stable patient seems to be of paramount importance for a safe adoption of a laparoscopic approach. In hemodynamically stable patients, the laparoscopic approach was found to be safe, feasible and effective as a therapeutic tool or helpful to identify further management steps and needs, resulting in improved outcomes, regardless of conversion. Appropriate patient selection, surgeon experience and rigorous minimally invasive surgical training, remain crucial factors to increase the adoption of laparoscopy in emergency general surgery and abdominal trauma. Conclusions: The WSES expert panel suggests laparoscopy as the first approach for stable patients undergoing emergency abdominal surgery for general surgery emergencies and abdominal trauma. [ABSTRACT FROM AUTHOR]

Patients with intra-abdominal sepsis suffer from significant mortality and morbidity. The main pillars of treatment for intra-abdominal infections are (1) source control and (2) early delivery of antibiotics. Antibiotic therapy should be started as soon as possible. However, the duration of antibiotics remains a matter of debate. Prolonged antibiotic delivery can lead to increased microbial resistance and the development of nosocomial infections. There has been much research on biomarkers and their ability to aid the decision on when to stop antibiotics. Some of these biomarkers include interleukins, C-reactive protein (CRP) and procalcitonin (PCT). PCT's value as a biomarker has been a focus area of research in recent years. Most studies use either a cut-off value of 0.50 ng/mL or an >80% reduction in PCT levels to determine when to stop antibiotics. This paper performs a literature review and provides a synthesized up-to-date global overview on the value of PCT in managing intra-abdominal infections. [ABSTRACT FROM AUTHOR]

Many countries are facing an aging population. As people live longer, surgeons face the prospect of operating on increasingly older patients. Traditional teaching is that with older age, these patients face an increased risk of mortality and morbidity, even to a level deemed too prohibitive for surgery. However, this is not always true. An active 90-year-old patient can be much fitter than an overweight, sedentary 65-year-old patient with comorbidities. Recent literature shows that frailty—an age-related cumulative decline in multiple physiological systems, is therefore a better predictor of mortality and morbidity than chronological age alone. Despite recognition of frailty as an important tool in identifying vulnerable surgical patients, many surgeons still shun objective tools. The aim of this position paper was to perform a review of the existing literature and to provide recommendations on emergency laparotomy and in frail patients. This position paper was reviewed by an international expert panel composed of 37 experts who were asked to critically revise the manuscript and position statements. The position paper was conducted according to the WSES methodology. We shall present the derived statements upon which a consensus was reached, specifying the quality of the supporting evidence and suggesting future research directions. [ABSTRACT FROM AUTHOR]

Sigmoid volvulus is a common surgical emergency, especially in elderly patients. Patients can present with a wide range of clinical states: from asymptomatic, to frank peritonitis secondary to colonic perforation. These patients generally need urgent treatment, be it endoscopic decompression of the colon or an upfront colectomy. The World Society of Emergency Surgery united a worldwide group of international experts to review the current evidence and propose a consensus guidelines on the management of sigmoid volvulus. [ABSTRACT FROM AUTHOR]

The article focuses on the rise of acute care surgery (ACS) as a specialized model of care and the challenges it faces in establishing a universal gold standard for its implementation worldwide. Topics discussed include the proposed ideal characteristics of ACS surgeons, variations in ACS systems globally, and the potential benefits of ACS in reducing time to surgery and complication rates for common conditions.

Background Telemedicine is becoming increasingly popular. The best use for it is in the field of aesthetic dermatology - where conditions are not life-threatening, and treatments can be topical and very safe. Aims In this study, we demonstrate that a simple store-and-forward telemedicine system can be applied safely to the field of aesthetic dermatology. Methods and Materials This was a prospective study was carried out in Singapore. A total of 102 patients filled up a medical questionnaire and submitted photographs via our online system. Upon submission, there was an independent doctor on the back-end who would review their medical details and their photographs and make diagnoses and recommendations based on this information. There was another doctor who examined the patients face-to-face. Diagnoses made by the online doctor and by the face-to-face doctor were compared for congruency. Results A total of 358 diagnoses were made by the face-to-face doctor from 102 patients; 346 diagnoses were made by the teleconsultation doctor. For the purpose of this study, the diagnoses made by the FTFD were presumed to be correct. There was total agreement between both doctors in 342 diagnoses, giving a concordance rate of 95.5%. There were 12 missed diagnoses by the teleconsultation doctor and four discordant diagnoses. Discussion Our system demonstrates that a store-and-forward system enables our doctor to make accurate skin diagnoses. Our system was also able to detect dangerous conditions such as melanomas, skin cancers, actinic keratosis, and other dangerous diagnoses. There were discordant or missed diagnoses. This was mostly attributed to poor photograph quality. Conclusion Emerging telemedicine technologies should be rigorously evaluated before they become widely implemented. Any system of value must uphold certain principles. It has to be fundamentally sound, safe, and clearly beneficial to the patient. With current technological limitations, the best use of such a system would be in aesthetics. [ABSTRACT FROM AUTHOR]

Background Achieving a good seal for the application of the vacuum-assisted closure (VAC) system in complex head and neck wounds is difficult. Methods A case series of 4 patients who developed postoperative orocutaneous or pharyngocutaneous fistulas were studied. A sterile green glove was used as a sealant together with the VAC system. Results With utilization of a green glove, a good seal for the VAC system was obtained. This gave ample time to cleanse the wound and allow granulation tissue to form before proceeding on to the next stage of treatment. Conclusion A green glove technique allows for a good seal for the VAC system to work, especially when applied to complex head and neck wounds. © 2016 Wiley Periodicals, Inc. Head Neck 38: E2523-E2526, 2016 [ABSTRACT FROM AUTHOR]

Melasma is a common pigmentation in Asian women. Lasers have been used to lighten melasma, although with variable outcomes and complications. In Asia, laser toning is a common technique used to safely lighten melasma. However, no large studies have been performed to validate efficacy. In our study, we demonstrate that in 38 970 Asian women, at least 35 890 patients (92.1%) had noticeable to excellent improvement in their melasma. [ABSTRACT FROM PUBLISHER]

Background The vacuum-assisted closure (VAC) system has been used to manage complicated wounds. The purpose of this study was to describe a novel technique in using the VAC system for orocutaneous fistulas. Methods A retrospective study was performed on 10 patients treated at the National Cancer Centre, Singapore, who developed postoperative orocutaneous fistulas. Hydrogum dental paste was used as a sealant together with the VAC system to close the fistulas. We used either the RENASYS or VAC ATS system with 50 mm Hg to 125 mm Hg continuous suction. Results The 10 patients developed 11 fistulas. The median age of this cohort was 67 years (range, 33-80 years). Nine patients had successful closure of their fistulas with VAC therapy whereas 1 patient had unsuccessful VAC therapy and required flap reconstruction. The median time to fistula closure was 19 days (range, 6-36 days). The median time to radiotherapy after surgery was 46 days (range, 26-62 days). Conclusion VAC therapy is an effective treatment option for orocutaneous fistulas. © 2013 Wiley Periodicals, Inc. Head Neck 36: 873-881, 2014 [ABSTRACT FROM AUTHOR]

Background: Diaphragmatic hernia (DH) presenting acutely can be a potentially life-threatening condition. Its management continues to be debatable., Methods: A bibliographic search using major databases was performed using the terms "emergency surgery" "diaphragmatic hernia," "traumatic diaphragmatic rupture" and "congenital diaphragmatic hernia." GRADE methodology was used to evaluate the evidence and give recommendations., Results: CT scan of the chest and abdomen is the diagnostic gold standard to evaluate complicated DH. Appropriate preoperative assessment and prompt surgical intervention are important for a clinical success. Complicated DH repair is best performed via the use of biological and bioabsorbable meshes which have proven to reduce recurrence. The laparoscopic approach is the preferred technique in hemodynamically stable patients without significant comorbidities because it facilitates early diagnosis of small diaphragmatic injuries from traumatic wounds in the thoraco-abdominal area and reduces postoperative complications. Open surgery should be reserved for situations when skills and equipment for laparoscopy are not available, where exploratory laparotomy is needed, or if the patient is hemodynamically unstable. Damage Control Surgery is an option in the management of critical and unstable patients., Conclusions: Complicated diaphragmatic hernia is a rare life-threatening condition. CT scan of the chest and abdomen is the gold standard for diagnosing the diaphragmatic hernia. Laparoscopic repair is the best treatment option for stable patients with complicated diaphragmatic hernias. Open repair is considered necessary in majority of unstable patients in whom Damage Control Surgery can be life-saving., (© 2023. The Author(s).)

OBJECTIVE: The purpose of this study was to demonstrate a novel, effective, and safe way to utilize the Erb:YAG laser to clear freckles in Type III/IV Asian skin. DESIGN: This was a prospective study. SETTING: The setting was a Singapore-based clinic. PARTICIPANTS: Participants included five women, aged 25 to 38 years, three with Skin Type III and two with Skin Type IV. All of them had freckles. MEASUREMENTS: Photographs were taken pretreatment and one month after laser treatment. Three independent physicians evaluated the photographs using a grading system. Patients were followed clinically for a total of six months post-laser treatment to monitor for post-inflammatory hyperpigmentation and recurrence. RESULTS: At one month post-laser treatment, all five patients were evaluated. The three independent physicians agreed that all five patients had greater than 90-percent clearance of their freckles. During the subsequent follow-up visits (up to 6 months post-laser treatment), no post-inflammatory hyperpigmentation, hypopigmentation, or recurrence was seen. CONCLUSION: The Erb:Yag laser might be considered an effective and safe treatment for freckles in Asian patients., Competing Interests: FUNDING:No funding was provided for this article. DISCLOSURES:The author has no conflicts of interest relevant to the contents of this article.

In recent years, laser toning or laser facial to treat melasma has become increasingly popular in Asia. It is common to see patients undergoing lasers three times a week, or even daily. This is part of a growing trend and is sometimes recommended in the user manuals from laser manufacturers. In our study, we report on 23 Chinese patients who had lasers performed three times a week for two consecutive months, followed by rest. All 23 of them developed bilateral confetti-like hypopigmentation at the end of two months. During the four-month follow-up and rest, 10 patients were lost to follow-up. Of the remaining 13 patients, none of them had repigmentation. We conclude that frequent laser facials or laser toning at regular intervals may result in undesirable outcomes and thus should not be performed in regular intervals., Competing Interests: FUNDING:No funding was provided for this study. DISCLOSURES:The author has no conflicts of interest relevant to the content of this article.

Objective: To demonstrate a novel low fluence combination laser technique [Erbium-doped yttrium aluminum garnet (Erb:YAG) and neodymium-doped yttrium aluminum garnet (Nd:YAG)] to effectively treat solar lentigines in type III Asian skin in a single session., Design: A prospective study., Setting: A Singapore-based clinic., Participants: Five patients (all females) were enrolled into the study. The ages ranged 35-60 years; all patients had Fitzpatrick skin type III., Measurements: Photographs were taken at baseline and at 1-month follow-up. These were reviewed by two independent physicians who were blinded to the study. Changes in pigment severity were assessed by a 5-point scale (1: Aggravation of pigment, 2: No change, 3: 25-50% improvement, 4: 51-75% improvement, and 5: 76-100% improvement)., Results: All patients received a single treatment session. At 1-month follow-up, a reduction in pigment was observed in all patients. Both physicians' reports were independently agreeable. All patients scored 5, having >90% improvement in pigment severity. No hypopigmentation, postinflammatory hyperpigmentation (PIH), or recurrence was seen., Conclusion: Low fluence combination laser is effective and safe for clearance of solar lentigines in type III Asian skin.

Objective: To demonstrate a combination laser therapy to treat Hori's nevus., Design: A prospective study., Setting: A Singapore-based clinic., Participants: Five female patients, aged 30-46 years, with bilateral malar Hori's nevus., Measurements: Photographs were taken before treatment and 1 month after laser treatment was completed. These were graded by three independent physicians. The patients were also asked to grade their treatment response subjectively. They were followed up for a total of 3 months after laser treatment to monitor recurrence., Materials and Methods: The fractional nonablative 2,940-nm Er:YAG laser with a fluence of 0.7 J/cm(2), spot size 12 mm, and frequency 15 Hz was used to perform a full-face single-pass treatment. Subsequently, a second pass and third pass over Hori's nevi were done bilaterally till the clinical endpoint of skin whitening. The 1,064-nm Q-switched (QS) Nd:YAG at a fluence of 2.0 J/cm(2), frequency 2 Hz, and 4-mm spot size was used to deliver multiple passes over Hori's nevus till erythema with mild petechiae appeared. We repeated the treatment once a week for 3 more consecutive weeks., Results: All five patients had above 80% improvement in their pigmentation and two (skin type III) achieved complete 100% clearance. Based on the patients' subjective assessments, all five of them expressed satisfaction and felt that their pigmentation had improved. There were no complications noted., Conclusion: The fractional nonablative 2940 nm Er:YAG laser and Q-switched 1064nm laser Nd:YAG combination is an effective and safe treatment for Hori's nevus.