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Background: The COVID‐19 pandemic disrupted the provision of surgical services in Australia. To prepare for a surge of COVID‐19 patients, elective surgery was mandatorily reduced or ceased at multiple timepoints in Australian states between 2020 and 2022. Operative exposure is a critical component of surgical training in general surgery, and readiness for practice is an ongoing priority. However, the impact of COVID‐19 on operative exposure in Australian General Surgical Trainees (AGST) has not been quantified. Methods: This study was a retrospective longitudinal cohort study using de‐identified operative logbook data for Australian General surgical Trainees (AGST) from the Royal Australasian College of Surgeons (RACS) Morbidity and Audit Logbook Tool (MALT) system between February 2019 and July 2021. Bivariate analysis was used to determine the impact of COVID‐19 on general surgical trainees' exposure to operative surgery and trainees' operative autonomy. Results: Data from 1896 unique 6‐month training terms and 543 285 surgical cases was included over the data collection period. There was no statistically significant impact of the COVID‐19 pandemic on AGST operative exposure to major, minor operations, endoscopies, or operative autonomy. Conclusions: The impact of COVID‐19 on surgical trainees globally has been significant. Although this study does not assess all aspects of surgical training, this data demonstrates that there has not been a significant impact of the pandemic on operative exposure or autonomy of AGST. [ABSTRACT FROM AUTHOR]

Background: Somatic Symptom Disorder is a psychiatric diagnosis that describes the experience of physical symptoms and associated distress, that is disproportionate to recognized organic pathology. Somatic symptom severity (SSS) may be associated with some surgical diagnoses; particularly the complex pain associated with pancreatitis, or the diagnostic ambiguity of undifferentiated abdominal pain (UAP). We aimed to estimate the prevalence of SSS in different diagnostic groups in surgical inpatients with abdominal pain; and to estimate the magnitude and direction of any association of SSS, anxiety and depression. Methods: Cross sectional analysis (n = 465) of adult admissions with non‐traumatic abdominal pain, at a tertiary hospital in Australia. We estimated SSS with the Patient Health Questionnaire‐15 (PHQ‐15), depression with the Patient Health Questionnaire (PHQ‐9) and anxiety with the General Anxiety Disorder (GAD‐7), at standard cut‐points ≥ 10; comparing acute pancreatitis (n = 20), chronic pancreatitis (n = 18) and UAP (n = 64) versus other causes of abdominal pain. Results: Somatic symptoms were common, 52% having moderate and 19.6% severe SSS. There was an association between moderate SSS and pancreatitis (OR 2.11, 95% CI 1.05–4.25) and depressive symptoms and chronic pancreatitis (OR = 3.47, 95% CI 1.31–9.24). There was no significant association between the four mental health categories and UAP. Conclusions: SSS and psychological comorbidity were common in a surgical inpatients admitted for abdominal pain and equally represented across most diagnostic sub‐groups. However, the pancreatitis sub‐group had greater proportions with clinically significant SSS and depression, suggesting that they have a higher requirement for psychological assessment and intervention. [ABSTRACT FROM AUTHOR]

Background: Plating techniques for the fixation of foot fractures can utilize pre‐contoured region‐specific plates or non‐anatomic non‐specific mini‐fragment plating systems, however there is limited published data describing complication rates. Methods: This study reviewed the complication rates and performed a cost analysis of 45 foot fractures that had fixation with the use of mini‐fragment non‐anatomic implants, comparing them to a series from the same centre fixed using anatomic implants and the published literature. Results: Complication rates seemed equivalent. Cost analysis demonstrated that non‐anatomic implants were more expensive on average. Conclusions: Non‐anatomic mini‐fragment fixation is an appropriate method for use in a variety of foot trauma situations, with comparable complication rates to pre‐contoured implants, although the potential for cost savings has not been realized in this patient cohort. [ABSTRACT FROM AUTHOR]

Objectives: Right hemicolectomy is a common colorectal operation for resection of cancers of the right colon. The ileocolic anastomosis may be created using a stapled end‐to‐side, stapled side‐to‐side or handsewn technique. Anastomotic leak and post‐operative bleeding are uncommon but serious causes of morbidity and mortality, while post‐operative ileus contributes to prolonged length of stay. The aim of this study was to evaluate differences in short‐term outcomes between different anastomotic configurations following right hemicolectomy for colon cancer. Methods: We conducted a retrospective study using data from the Bowel Cancer Outcomes Registry (BCOR), including 94 hospitals across Australia and New Zealand, of all patients who underwent right hemicolectomy or extended right hemicolectomy for colon cancer with formation of a primary anastomosis between 2007 and 2021. Results: We included 8164 patients in the analysis. There was no significant difference in rates of anastomotic leak and anastomotic bleeding based on anastomotic technique. A stapled end‐to‐side anastomosis was associated with a lower rate of post‐operative ileus than stapled side‐to‐side anastomosis (6.5% vs. 7.2%; P = 0.03). Conclusion: Both handsewn and stapled anastomosis techniques may be utilized for oncologic right hemicolectomy, with comparable rates of anastomotic leak and post‐operative bleeding. Stapled end‐to‐side anastomosis resulted in lower rates of prolonged ileus compared to stapled side‐to‐side anastomoses. [ABSTRACT FROM AUTHOR]

Background: Soft tissue lower limb reconstruction often requires free tissue transfer. We investigated whether the target vessels used for micro‐vascular anastomosis in the lower limb influences microsurgical outcomes. Methods: Data from Plastic Surgery Departments of a major tertiary hospital in the United Kingdom (Leeds General Infirmary, LGI) and Australia (Princess Alexandra Hospital, PAH) were retrospectively analysed. Patients who underwent lower limb free flap reconstruction using the posterior (PTA) or anterior tibial artery (ATA) were included. Patient demographics, free flap and microvascular anastomosis details were analysed. Primary outcome was flap failure. Secondary outcome was return to theatre. Results: Two hundred and thirty‐four free flaps were included (PAH 115; LGI 119). 60% were muscle flaps. Eighty‐one percent of patients were male, with trauma the cause in 82%. PTA was used for microsurgical anastomosis in 70% of cases. Venae comitantes were preferred (96%) for venous anastomosis. PTA group showed a higher proportion of patients with trauma as the mechanism of injury. ATA group was more likely to have an end‐to‐end arterial anastomosis configuration. Total flap loss was 3.8%. There was no clinically significant difference in flap failure or return to theatre using ATA versus PTA. Conclusions: Incidence of lower limb free flap failure is low (<5%) and not influenced by use of ATA versus PTA for microsurgical anastomosis. The choice of target vessels for microsurgical reconstruction of the lower limb should be predicated upon factors other than aversion to one or another vessel. If all other microsurgical considerations are equal, the surgeon can exercise personal preference. [ABSTRACT FROM AUTHOR]

Background: Major trauma activation is a process that mobilizes personnel and resources required to care for severely injured patients. Exsanguinating truncal trauma patients require an additional response beyond major trauma activation aimed at expediting haemorrhage control. To address this requirement, 'Code Crimson' (CC) activation was developed. Our aim was to examine the performance of CC activation as a process measure in the identification and management of patients with exsanguinating truncal trauma. Methods: Retrospective cohort study (2010–2015) of all adult patients who underwent operative intervention within 6 h of arrival for truncal trauma was performed. Patients were classified into: (i) major haemorrhage (assessment of blood consumption score ≥2, base deficit ≥5 and/or transfusion ≥5 U of red blood cells pre‐/intra‐operatively), or (ii) no major haemorrhage. We evaluated the proportion of patients with/without major haemorrhage in which a CC was activated as well as time to operating theatre across groups. Results: A total of 210 patients were included with a median Injury Severity Score of 20 (interquartile range (IQR) 9–29) and overall mortality of 13%. Eighty‐nine patients were classified as major haemorrhage and 61 patients underwent CC activation. The majority of CC activations (92%) fulfilled major haemorrhage criteria (sensitivity 63%, specificity 96%). Time to theatre was lower in those with CC activation with median time of 23 min (IQR 15–39.5) versus non‐CC with median of 95 min (IQR 43–180, P < 0.001). Conclusion: CC was primarily activated in patients with major haemorrhage and led to a decrease in time to theatre for patients with operative truncal trauma. [ABSTRACT FROM AUTHOR]

Background Acute surgical units have gained favour in Australia and New Zealand. However, there is a lack of evidence regarding their effectiveness in regional centres. We aim to investigate the effect of the introduction of the Acute General Surgical Unit ( AGSU) on the outcomes for patients undergoing emergency appendicectomies or cholecystectomies in a regional hospital. Methods AGSU was introduced in March 2012. We conducted a retrospective comparison analysis of patients admitted 2 years prior to and 2 years after the introduction of AGSU. Primary outcomes included length of stay, time to theatre, after hours and overnight operating. Secondary outcomes included negative appendicectomy rate, conversion to open cholecystectomy and bile duct injuries. Results No difference was seen between pre and post- AGSU introduction in median time to theatre in the appendicectomy group (8.00 h versus 9.24 h) or cholecystectomy group (17.63 h versus 17.75 h). Additionally, there was no difference between median length of stay in the appendicectomy group (47.52 h versus 48.00 h) or the cholecystectomy group (71.50 h versus 70.67 h). Night operating was significantly reduced in the positive appendicectomy group (4.4% versus 9.1%, P = 0.027) and the overall cholecystectomy group (0.43% versus 3.4%, P = 0.035), however overall after hours operating remained equivalent. Conclusions The introduction of the AGSU unit led to a significant reduction in overnight operating, which may improve patient outcomes and surgeon satisfaction. Length of stay and time to theatre did not change. Future directions include further research into the impact of theatre access on emergency surgery outcomes. [ABSTRACT FROM AUTHOR]

Background Mini C-arm image intensifiers ( IIs) are promoted to permit lower radiation dose than traditional IIs with a lower purchase price and without the need for a radiographer, saving time. In real-world usage, radiation dose is not always lower. Methods A retrospective review of prospectively collected data for 620 children undergoing forearm fracture reduction in theatre was undertaken. Imaging was performed with the Fluoroscan mini C-arm or a comparison traditional II. Radiation dose and theatre time were recorded. Results There was no significant difference in radiation dose as measured by dose-area product (0.013 versus 0.014 Gy.cm2, P = 0.22). We noted an inverse association between operator experience and radiation dose. The mini C-arm allowed a shorter procedure time (26 versus 30 min, P < 0.001) and theatre time (13 versus 16 min, P < 0.001). Re-displacement rates were similar (1.3 versus 2.2%). The Fluoroscan is AU$120 000 cheaper to purchase and AU$35 283 cheaper to run per year than the comparison II. Consultants had a 14% lower dose-area product (0.012 versus 0.014 Gy.cm2, P < 0.001) and 18% shorter screening time (8 versus 9.8 s, P < 0.001) than registrars. Conclusion The Fluoroscan mini C-arm II does not demonstrate a radiation saving during closed reductions of paediatric forearm fractures but allows shorter procedures and theatre time with similar re-displacement rates. The purchase price is lower than a traditional II. We noted that operator experience reduces radiation dose. [ABSTRACT FROM AUTHOR]

Background Patients taking warfarin are often given interim anticoagulation in the perioperative period. Institutional guidelines that use low-molecular-weight heparin ( LMWH) 'bridging' while the international normalized ratio (INR) is sub-therapeutic are often based on the American College of Chest Physicians Anticoagulation Guidelines. Purpose This study aims to identify if patients at a tertiary referral hospital were anticoagulated in line with these guidelines, and the incidence and nature of bleeding and thromboembolic complications. Methods A retrospective review of the Alfred Hospital General Surgical and ' Hospital at Home' databases was conducted, identifying patients who underwent elective general surgical procedures and received bridging anticoagulation with enoxaparin. Demographics, indication for anticoagulation, bleeding and thromboembolism rates were recorded. Thromboembolic risk was estimated. Results The study identified 108 patients. Three-quarters of all patients were anticoagulated with LMWH doses in accordance with the guidelines. Thirty of the 108 patients suffered bleeding complications. This group was younger, weighed less, received higher doses of enoxaparin and were at higher predicted risk of thromboembolism than non-bleeding patients. Wound haematoma, rectal bleeding and intra-abdominal bleeding were the most frequent complications. The peak time of bleeding was 3.5 days after surgery. Twelve patients returned to theatre, 13 were readmitted and 3 received blood transfusion. One patient suffered pulmonary emboli on the first post-operative day. Conclusion LMWH bridging therapy when prescribed appropriately is associated with low rates of inpatient thromboembolism in elective general surgical patients within our institution, but an unexpectedly high rate of bleeding complications. [ABSTRACT FROM AUTHOR]

Background The aim of this study was to audit the blood transfusion practice throughout the Epworth Healthcare Hospitals for patients undergoing primary total hip replacement ( THR). We determined if blood-saving techniques were having an impact on the risk of allogenic blood transfusion and which patients were at risk of receiving allogenic blood transfusion. Methods This study uses a retrospective audit of 787 patients who had undergone primary THR surgery at three Melbourne hospitals: Epworth Richmond, Epworth Eastern and Epworth Freemasons in 2010. Patient demographics, transfusion requirements and blood-conserving techniques were recorded. Results One hundred and eighty (23%) patients received allogenic blood transfusion and 18 (2.3%) patients received autologous blood transfusion. On multivariate analysis, preoperative anaemia (odds ratio ( OR) 4.7, P < 0.0001), female gender ( OR 3.1, P < 0.0001) and patient age ( OR 1.07 per year of age increase, P < 0.0001) were shown to be significantly associated with higher risk of allogenic blood transfusion. Use of spinal anaesthetic was found to be associated with lower risk of transfusion ( OR 0.6, P = 0.0180) compared with general anaesthetic alone. Cell saver, acute normovolaemic haemodilution and re-infusion drain tube usage did not have a significant impact on reducing the risk of allogenic blood transfusion. Conclusion Identification of patients at risk of blood transfusion, correction of preoperative anaemia and a restrictive transfusion policy are important factors to consider in effective perioperative blood management. [ABSTRACT FROM AUTHOR]

Introduction Various techniques have been described to try and reduce the rate of anastomotic leak following pancreaticoduodenectomy, which remains a challenge for pancreatic surgeons worldwide. We outline a technique to reinforce the pancreatic anastomosis with a double layer of fibrin glue between suture lines. Methods Our technique for pancreatic anastomosis is described in detail. A review of consecutive pancreaticoduodenectomies by a single surgeon ( NAC) since introduction of fibrin glue anastomosis reinforcement was compared with a historical control cohort performed by the same surgeon. Results Thirty-two consecutive pancreaticoduodenectomies were undertaken between March 2008 and March 2012 by a single surgeon, 30 patients had fibrin glue augmentation of the pancreatico-gastrostomy anastomosis. Median length of stay was 12 days. There were no pancreatic leaks or mortality since adopting fibrin glue for the pancreatic anastomosis; however; this single surgeon series is not large enough to provide statistical evidence of a difference since glue was adopted. Discussion Our results since the incorporation of this step in pancreaticoduodenectomy are encouraging. Selective use of glue is worthy of consideration in difficult cases, although confirmation of a reduction in pancreatic leak rate is not yet established, and we advocate a multi-institution randomized controlled trial to explore this. [ABSTRACT FROM AUTHOR]

The Association of Southeast Asian Nations ( ASEAN) Mutual Recognition Arrangement ( MRA) on medical practitioners' agreement will become a reality in the year 2015. Doctors registered in one ASEAN country will be given reciprocal recognition in another country under this agreement. Rapid and excessive movement of human resources between countries in a short span of time is undesirable and can be destabilizing. The surgical fraternity in the ASEAN countries should plan for a common surgical curriculum, a common examination and an ASEAN Board of Surgery so that standards of future trainees in different countries are comparable. The curriculum should take into consideration the diversity of the countries in socio-economic development. Ideally, it should be based on a public health approach to bring affordable quality surgical care to the masses in an efficient and effective manner. [ABSTRACT FROM AUTHOR]

Background: A delay in the diagnosis of developmental dislocation of the hip has many long-term consequences. This retrospective study was undertaken in order to establish an incidence of late-presenting developmental dislocation of the hip in Western Australia, and investigate possible causes for missed diagnoses. Method: Data were collected retrospectively from 1 January to 31 December 2010. Theatre records were searched for operative descriptions including the words 'arthrogram hip', 'EUA hip', 'closed reduction hip', 'open reduction hip' and 'spica'. Medical records were checked to establish the demographic details and background history of cases identified. Delayed diagnosis of developmental dysplasia of the hip (DDH) was defined as a dislocated hip requiring operative reduction, diagnosed at age greater than 3 months. Results: Seventeen children with 21 dislocated hips were identified. Age at diagnosis ranged from 6 months to 5 years. Girls accounted for 88.2% (15/17) and the left hip was involved two-thirds of the time (14/21). Bilateral dislocations were found in four children. Conclusion: This study has identified an incidence of late-presenting developmental hip dislocation of approximately three times the previously established rate. Possible reasons for this are explored. Additional retrospective audit is now underway, and changes are already in place to ensure that infants with DDH born in Western Australia are identified and treated as early as possible. [ABSTRACT FROM AUTHOR]

The technique of thyroid surgery has continued to evolve over the last 200 years. Sutureless thyroidectomy is one of the recent developments in surgical technique and is made possible by the use of vessel sealing devices. The most frequently used devices include a bipolar coagulation device (Ligasure Precise) and ultrasonic dissecting shears (Harmonic Scalpel FOCUS). The use of this technology is safe with minimal morbidity and has been shown in numerous studies to significantly decrease operative time. Over 3000 thyroid and parathyroid procedures, both open and minimally invasive, have been performed with vessel sealing devices within the University of Sydney Endocrine Surgery Unit since the technology was introduced in 2005. This manuscript discusses the technique of sutureless thyroidectomy focusing on points of difference in comparison with conventional thyroidectomy using ligatures or clips. [ABSTRACT FROM AUTHOR]

Surgical dislocation of the hip has been developed to deal with the problems causing femoroacetabular impingement (FAI). This is a relatively recent procedure that was historically reserved for larger areas specializing in hip surgery. We hypothesized that surgical dislocation can be used for symptomatic FAI in a typical Australasian tertiary orthopaedic centre with acceptable results. This prospective study reviews the results of 53 surgical dislocations in this setting, looking particularly at functional outcomes and early complications. There were significant improvements in the Western Ontario and McMaster University Osteoarthritis Index score at 1, 2, 3 and 4 years post-operatively. Western Ontario and McMaster University Osteoarthritis Index scores increased by 23, 28, 34 and 35 points, respectively ( P ≤ 0.0039). There was no significant improvement in hip range of motion. There were two (4%) early failures with conversion to total hip arthroplasty, and no cases of post-operative avascular necrosis of the femoral head. We believe that as the diagnosis of FAI and conservative non-arthroplasty surgery of the hip gains wider acceptance, it will become a procedure that should be offered to all appropriate patients in an attempt to delay or limit total hip arthroplasty in this young age group. [ABSTRACT FROM AUTHOR]

Surgical trainees' operating theatre (OT) experiences significantly influence their ability to attain key professional competencies. A measure of trainees' satisfaction with this learning environment would allow recognition of characteristics of highly successful teaching venues and threats to trainee development. Our study aimed to validate the Surgical Theatre Educational Environment Measure (STEEM) and use it to explore Australasian surgical trainees' satisfaction with OT learning. In a cross-sectional study, the STEEM was distributed electronically to all 1500 Royal Australasian College of Surgeons trainees in Australia and New Zealand. Trainee satisfaction was gauged using Likert-type items, an overall satisfaction measure and content analysis of free-text comments. The STEEM's psychometric properties were evaluated using exploratory factor analysis. Three hundred fifty-six responses were received. The STEEM's original subscales were not supported by the data; empirically grounded subscales were identified for further analysis. Most trainees were satisfied with their OT environment and satisfaction was higher in senior than junior trainees. Trainees' relationship with their supervisor correlated most strongly with overall satisfaction. Less positively, only half of trainees report discussing their operative role with their supervisor prior to surgery. The a priori STEEM subscales could not be replicated by factor analysis. We developed an empirically grounded instrument capable of identifying areas of trainee concern. The majority of trainees reported high levels of satisfaction. The revised instrument has potential to complement other sources of information to facilitate surgical supervisors' difficult task of optimizing trainees' compatibility with their OT learning environments. [ABSTRACT FROM AUTHOR]

Background: Acute compartment syndrome is a serious and not uncommon complication of limb trauma. The condition is a surgical emergency, and is associated with significant morbidity if not managed appropriately. There is variation in management of acute limb compartment syndrome in Australia. Methods: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma were developed in accordance with Australian National Health and Medical Research Council recommendations. The guidelines were based on critically appraised literature evidence and the consensus opinion of a multidisciplinary team involved in trauma management who met in a nominal panel process. Results: Recommendations were developed for key decision nodes in the patient care pathway, including methods of diagnosis in alert and unconscious patients, appropriate assessment of compartment pressure, timing and technique of fasciotomy, fasciotomy wound management, and prevention of compartment syndrome in patients with limb injuries. The recommendations were largely consensus based in the absence of well-designed clinical trial evidence. Conclusions: Clinical practice guidelines for the management of acute limb compartment syndrome following trauma have been developed that will support consistency in management and optimize patient health outcomes. [ABSTRACT FROM AUTHOR]

Heuristics are rules of thumb. Rarely described in surgical or other publications, they are an essential part of safe and expert performance. This study translates such implicit or procedural knowledge into explicit or declarative knowledge, with a view to improving both training and retraining of surgeons in the steps of dissection. Tools used include ordinary observation accompanied by introspection, and study of operative videos. Validation of the value of such heuristics is yet to be achieved. [ABSTRACT FROM AUTHOR]

Cardiothoracic surgical operations are complex procedures. Involved are an enormous number of steps that need to be carried out consistently, accurately (as the margin for error in cardiothoracic surgery is small) and in a time-efficient manner – thus the need for repetition in their performance to achieve excellence. Encompassed within the steps is a range of skills – motor and decision-making. The motor skills span from the gross of median sternotomy and thoracotomy, to the fine of coronary anastomoses. It is the challenge of all of this that I believe entices most prospective cardiothoracic surgeons into training, having already witnessed the difference in the ability of surgeons at surgical heuristics as beautifully described by Michael Patkin. Further, the chase for the ‘perfect operation’ I believe also is what keeps cardiothoracic surgeons enthralled for a career. As a comment, what will be presented is a personal perspective and should be seen as such – to quote Patton ‘if everyone is thinking alike, then somebody isn’t thinking’. Now surgery in general is made of movement systems as already mentioned, but critically layered upon by intellect and information. This affects the decision-making process throughout an episode of care – preoperatively, intraoperatively and postoperatively. To contemplate surgical heuristics, the two then, the movement systems and the decision-making process, must be discussed individually and then brought together in the end, for it is the gel that determines patient outcomes and then becomes the science to our craft. [ABSTRACT FROM AUTHOR]

Two cases of postoperative colorectal anastomotic mucosal membrane completely occluding the lumen of the bowel are described. Although an unusual event, patency may be readily re-established by an endoscopic double-illumination technique. [ABSTRACT FROM AUTHOR]

Background An ageing population and advances in medical management often requires spinal surgeons to increasingly operate on patients older than 80 years. The ability to predict complications and mortality rates would allow discrimination of which octogenarians are able to safely undergo spinal surgery. Therefore, the aims of this study were to determine whether comorbidities and extent of surgery were associated with complications in this age group, in addition to which comorbidity and physical status assessment scales were best associated with the development of complications following spinal surgery. Methods A retrospective cohort study was performed. Comorbidities and physical health status were analysed using the American Society of Anesthesiologists ( ASA) physical illness rating, Charlson Comorbidity Index ( CCI) and the Cumulative Illness Rating Scale for Geriatrics ( CIRS-G) score. Complications and extent of operation were sourced from patient records. The association between comorbidities/extent of operation and complications was analysed using negative binomial regression analysis. Results A total of 54 patients were included in our study (22 elective and 32 emergency); 38 patients suffered at least one complication (14 elective and 24 emergency, including six deaths). Increased CIRS-G and CCI scores were associated with increased incidence of total complications in the elective cohort. Increased number of operated spinal levels was also associated with complications. Conclusion Elective spinal surgery can be safely performed in well selected patients over 80 years of age. However, extent of surgery, CIRS-G and CCI scores were associated with increased complications from spinal surgery in octogenarians. [ABSTRACT FROM AUTHOR]