Landmark Papers In General Surgery Flashcards
2.1 Surgical skin prep
Prospective multi-centre RCT. Overall wound infx rate: CHG 9.5% vs iodine 16.1%
Surgical wound 4.2 vs 8.6%
Darouiche, R.O., Wall, M.J., Jr, Itani, K.M.F., et al. (2010) Chlorhexidine–alcohol versus povidone– iodine for surgical-site antisepsis. New England Journal of Medicine, 362, 18–26.
2.2 Venous thromboembolism (VTE) prophylaxis
Multi-centre RCT.
HSQ 5000 U 2h preop and q8 post op vs no ppx
24.6% DVT in control vs 7.7% in HSQ group
No significant intraop differences in hemorrhage
Kakker, V.V., Corrigan, T.P., Fossard, D.P., et al. (1975) Prevention of fatal postoperative pulmonary embolism by low doses of heparin: an international multicentre trial. Lancet, 306, 45–64.
2.3 Intravenous fluid therapy after major abdominal surgery
A prospective single-institution RCT.
Liquid- and solid- phase gastric emptying, passage of flatus, first BM, and hospital stay all took longer in standard 3L/day group compared to 2L/day fluid-restriction group after undergoing routine colorectal surgery
There were significantly more complications in the standard group than in the restricted group (7 versus 1, p = 0.01). Complications included peripheral oedema, hyponatraemia, vomiting, confusion, and wound and respiratory infections.
Lobo, D.N., Bostock, K.A., Neal, K.R., et al. (2002) Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection: a randomised controlled trial. Lancet, 359, 1812–18.
2.4 Abdominal wall closure
◆ Krukowski et al. concluded that absorbable polydioxanone is preferable to non-absorbable suture because of a decreased wound infection rate.
◆ The most recent study by Bloemen et al. concludes that either type of suture can be used, as it does not appear to have a bearing on incisional hernia rate.
Krukowski, Z.H., Cusick, E.L., Engeset, J., and Matheson, N.A. (1987) Polydioxanone and polypropylene for closure of midline abdominal incisions: a prospective comparative clinical trial. British Journal of Surgery, 74, 828–30.
Bloemen, A., van Dooren, P., Huizinga, B.F., and Hoofwijk, A.G.M. (2011) Randomised clinical trial comparing polypropylene or polydioxanone for midline abdominal wall closure. British Journal of Surgery, 98, 633–9.
2.5 Symptomatic groin hernias
A single-centre retrospective cohort study.
The cumulative probability of hernia strangulation was greatest in the first 3 months for both inguinal and femoral hernias. Therefore the authors concluded that patients with a short history of herniation should be referred urgently to hospital and given priority on the waiting list.
Gallegos, N.C., Dawson, J., Jarvis, M., and Hobsley, M. (1991) Risk of strangulation in groin hernias. British Journal of Surgery, 78, 1171–3.
2.6 Asymptomatic groin hernias
Chung et al. concluded from their study that the majority of asymptomatic hernias develop pain over time, and therefore surgical intervention is recommended.
Fitzgibbons et al. concluded that observation only is a reasonable option for men with an asymptomatic hernia because of the low risk of acute strangulation.
Chung, L., Norrie, J., and O’Dwyer, P.J. (2011) Long term follow up of patients with a painless inguinal hernia from a randomized clinical trial. British Journal of Surgery, 98, 596–9.
Fitzgibbons, R.J., Giobbie-Hurder, A., Gibbs, J.O., et al. (2006) Watchful waiting vs repair of inguinal hernia in minimally symptomatic men: a randomized clinical trial. JAMA, 295, 285–92.
2.7 Laparoscopic versus open groin hernia repair
The three trials discussed here confirmed that laparoscopic repair was associated with a shorter length of hospital stay and quicker return to normal activities. Some studies also reported less chronic pain with the laparoscopic procedure. However, there are serious risks associated with the laparoscopic approach which do not occur during open surgery. The cost of laparoscopic surgery has been shown to be significantly greater than that of open surgery, even without the use of disposable instruments.
MRC Laparoscopic Hernia Trial Group (1999) Laparoscopic versus open repair of groin hernia: a randomised comparison. Lancet, 354, 185–90.
Neumayer, L., Giobbie-Hurder, A., Johansson, O., et al. (2004) Open mesh versus laparoscopic mesh repair of inguinal hernia. New England Journal of Medicine, 350, 1819–27.
Arvidsson, D., Berndsen, F.H., Larsson, L.G., et al. (2005) Randomized clinical trial comparing 5-year recurrence rate after laparoscopic versus Shouldice repair of primary inguinal hernia. British Journal of Surgery, 92, 1085–91.
2.8 Local or general anaesthesia for groin hernia repair
O’Dwyer et al. concluded that there are no differences in patient recovery after LA or GA hernia surgery.
Nordin et al. felt that LA had substantial advantages over GA/regional anaesthesia.
In summary, it appears that good outcomes can be achieved with LA in non-specialist hernia centres. Therefore LA should be offered as an option to patients with uncompli- cated groin hernias.
O’Dwyer, P.J., Serpell, M.G., Millar, K., et al. (2003) Local or general anesthesia for open hernia repair: a randomized trial. Annals of Surgery, 237, 574–9.
Nordin, P., Zetterström, H., Gunnarson, U., and Nilsson, E. (2003) Local, regional or general anaesthesia in groin hernia repair: a multicentre randomised trial. Lancet, 362, 853–8.
2.9 Chronic pain after groin hernia surgery
Callesen et al. concluded that chronic pain was a significant problem after open groin hernia surgery and may be predicted by the severity of early post-operative pain.
Cunningham et al. noted that standard open hernia repair was associated with long- term pain and numbness in more than 10% of patients. They also concluded that the most common type of pain following hernia surgery is somatic pain, which can be reproduced on pressure. Cunningham et al. described a different type of pain at the medial insertion of the inguinal ligament and attributed this to the insertion of sutures under tension in this area. They also recommended that the surgeon should avoid placing sutures directly into the periosteum of the pubic tubercle.
Callesen, T., Bech, K., Kehlet, H. (1999) Prospective study of chronic pain after groin hernia repair. British Journal of Surgery, 86, 1528–31.
Cunningham, J., Temple, W., Mitchell, P., et al. (1996) Cooperative hernia study. Pain in the postrepair patient. Annals of Surgery, 224, 598–602.
2.10 The Lichtenstein repair
The authors concluded that the primary cause of recurrence post inguinal hernia repair is the approximation of normally unopposed tissues. This creates tension on the suture which is ‘a clear violation of basic surgical principles’. The new technique was simple, rapid, less painful, safe, and effective.
Lichtenstein, I.L., Shulman, A.G., Amid, P.K., Montllor, M.M. (1989) The tension-free hernioplasty. American Journal of Surgery, 157, 188–93.
2.11 Open versus laparoscopic incisional hernia repair
All three studies were randomized controlled clinical trials.
◆ Although less frequent, more serious complications including bowel perforation were recorded in the laparoscopic surgery groups.
◆ Surgical site infection was less common at 8 weeks in the laparoscopic group—5.6% versus 23.3% (Itani et al.).
◆ Laparoscopic surgery was associated with less pain and a faster return to normal activities in one study (Itani et al)
◆ Carbajo et al. and Itani et al. noted that laparoscopic incisional/ventral hernia repair was quicker and had a shorter length of stay than open surgery
Carbajo, M.A., Martin del Olmo, J.C., Blanco, J.L. et al. (1999) Laparoscopic treatment vs open surgery in the solution of major incisional and abdominal wall hernias with mesh. Surgical Endoscopy, 13, 250–2.
Asencio, F., Aguilo, J., Peiro, S., et al. (2009) Open randomized clinical trial of laparoscopic versus open incisional hernia repair. Surgical Endoscopy, 23, 1441–8.
Itani, K.M., Hur, K., Kim, L.T., et al. (2010) Comparison of laparoscopic and open repair with mesh for the treatment of ventral incisional hernias: a randomised trial. Archives of Surgery, 145, 322–8.
2.12 Antibiotic prophylaxis in inguinal hernia repair
meta-analysis of RCTs.
Post-operative infection rate was higher in the placebo group than in the antibiotic group (2.89% versus 1.38%).
The authors conclude that antibiotic prophylaxis reduces post-operative infection by 50% in patients undergoing mesh hernioplasty.
Sanabria, A., Dominguez, L.C., Valdivieso, E., and Gomez, G. (2007) Prophylactic antibiotics for mesh inguinal hernioplasty: a meta-analysis. Annals of Surgery, 245, 392–6.
2.13 Surgery for ingrown toenails
All these early studies concluded that phenol cauterization compares favourably with non- phenol procedures whether the whole nail is avulsed or the nail edge is simply excised. The addition of topical antibiotics is not justified.
Andrew et al. and Bos et al. reported a high rate of recurrence in patients undergoing phe- nol cauterization. This figure was higher (2%) than in other observational studies at that time. The authors felt that the application of phenol for 3 minutes may have been too brief. In addition, nail-bed haemorrhage may have ameliorated the action of the phenol. They suggested that phenol be applied for a longer period of time and that absolute haemostasis is essential before application.
Grieg et al. reported a significant level of post-operative infection in the phenol cauter- ization group. Although phenol is itself an antiseptic, this study highlighted the relevance of tissue injury and the potential for infective complications with this caustic agent.
Andrew, T. and Wallace, W.A. (1979) Nail bed ablation—excise or cauterise? A controlled study. British Medical Journal, 1, 1539.
Grieg, J.D., Anderson, J.H., Ireland, A.J., and Anderson, J.R. (1991) The surgical treatment of ingrowing toenails. Journal of Bone and Joint Surgery, British Volume, 73, 131–3.
Bos, A.M.C., van Tilburg, A., van Sorge, A.A., and Klinkenbijl, J.H.G. (2007) Randomized clinical trial of surgical technique and local antibiotics for ingrowing toenail. British Journal of Surgery,
94, 292–6.
2.14 Surgical volume and patient outcome
retrospective US-based observational study (level 2c evi- dence) assessing the mortality associated with six cardiovascular procedures and eight types of major cancer resection
Data from more than 2.5 million procedures were examined.
◆ A reduction in mortality in all 14 procedures was seen in high-volume institutes
compared with low-volume institutes.
◆ The most marked differences in adjusted mortality rates between the highest- and lowest-volume centres were seen for oesophagectomy (mortality of 8.4% in high- volume centres versus 20.3% in low-volume centres), pancreatic resection (3.8% versus 16.3%), and repair of non-ruptured aortic aneurysm (3.9% versus 6.9%).
◆ A less significant difference in mortality was seen for other procedures such as coronary artery bypass grafting and nephrectomy.
Birkmeyer, J.D., Siewers, A.E., Finlayson, E.V.A., et al. (2007) Hospital volume and surgical mortality in the United States. New England Journal of Medicine, 346, 1128–37.
3.1 Active observation
2 Prospective case series in Scottish hospitals with
acute abdominal pain. 1 in kids, 1 in all comers.
◆ The authors reported that no patient who was observed appeared to suffer any detrimental effects from delay in operation
◆ None of the patients in the later study with non-specific abdominal pain were readmitted within the year following the study
Jones, P.F. (1976) Active observation in management of acute abdominal pain in childhood. British Medical Journal, 2, 551–3.
Thomson, H.J. and Jones, P.F. (1986) Active observation in acute abdominal pain. American Journal of Surgery, 152, 522–5.
