Delayed Perforation of the Large Bowel due to Thermal Injury during Laparoscopic Cholecystectomy

From FUSE to a hands-on electrosurgery course using a cadaveric model

INTRODUCTION

Surgical procedures in contemporary practice frequently employ energy-based devices, yet comprehensive education surrounding their safety and effectiveness remains deficient. We propose an innovative course for residents that aims to provide basic electrosurgery knowledge and promote the safe use of these devices.

METHODS

We developed a simulated training course for first-year general surgery and orthopedic residents. First, a survey was conducted regarding their knowledge perception about energy devices. The course consisted of two online theoretical sessions, followed by three in-person practical sessions. First-year residents performed three video-recorded attempts using a cadaveric model and were assessed through a digital platform using the Objective Structured Assessment of Technical Skill (OSATS), a Specific Rating Scale (SRS), and a surgical energy-based devices scale (SEBS). Third-year residents were recruited as a control group.

RESULTS

The study included 20 first-year residents and 5 third-year residents. First-year residents perceived a knowledge gap regarding energy devices. Regarding practical performance, both OSATS and checklist scores were statistically different between novices at their first attempt and the control group. When we analyzed the novice's performance, we found a significant increase in OSATS (13 vs 21), SRS (13 vs 17.5), and SEBS (5 vs 7) pre- and post-training scores. The amount of feedback referred to skin burns with the electro-scalpel reduced from 18 feedbacks in the first attempt to 2 in the third attempt (p-value = 0.0002). When comparing the final session of novices with the control group, no differences were found in the SRS (p = 0.22) or SEBS (p = 0.97), but differences remained in OSATS (p = 0.017).

CONCLUSION

This study supports the implementation of structured education in electrosurgery among surgical trainees. By teaching first-year residents about electrosurgery, they can acquire a skill set equivalent to that of third-year residents. The integration of such courses can mitigate complications associated with energy device misuse, ultimately enhancing patient safety.

Post-operative complications of cholecystectomy: what the radiologist needs to know

Cholecystectomy is one of the most performed surgical procedures. The safety of this surgery notwithstanding, the sheer volume of operations results in a notable incidence of post-cholecystectomy complications. Early and accurate diagnosis of such complications is essential for timely and effective management. Imaging techniques are critical for this purpose, aiding in distinguishing between expected postsurgical changes and true complications. This review highlights current knowledge on the indications for cholecystectomy, pertinent surgical anatomy and surgical technique, and the recognition of anatomical variants that may complicate surgery. The article also outlines the roles of various imaging modalities in identifying complications, the spectrum of possible postsurgical anatomical changes, and the implications of such findings. Furthermore, we explore the array of complications that can arise post-cholecystectomy, such as biliary system injuries, gallstone-related issues, vascular complications, and the formation of postsurgical collections. Radiologists should be adept at identifying normal and abnormal postoperative findings to guide patient management effectively.

Massive parietal defect with multiple enteroatmospheric fistulae after thermal injury abdomen in a metal industry accident: Case report of a rare survivor

In industrial foundries, raw metal is heated almost up to its melting point and then passed through the rolling mill to mould it into a desired shape. Contact with hot machinery or the hot metal can cause severe deep burns. When such thermal injury involves the abdominal wall, complex bowel injury can occur, leading to life-threatening abdominal sepsis. We report successful management of a patient with abdominal wall defect and multiple open fistulae. Severe thermal injury of the anterior abdominal wall may be associated with latent bowel injuries and abdominal compartment syndrome. A low threshold for surgery and re-look surgery may prevent complications.

Unusual cause of gas complicating a biloma, postcholecystectomy

A 50-year-old man presented to the emergency department with abdominal pain, vomiting and fever. He had been admitted 6 months ago with acute cholecystitis when he underwent endoscopic retrograde cholangiopancreatography (ERCP) to remove ductal gallstones. Elective cholecystectomy was performed 3 days prior to the current admission. CT demonstrated a fluid and gas containing collection in the gallbladder fossa, biliary gas and free intra-abdominal gas. ERCP revealed a retained common bile duct gallstone and leakage from the cystic duct remnant. We postulate that the gas within the collection originated from intrahepatic gas post-ERCP or from a gas forming organism. The free intra-abdominal gas originated from the collection rather than an intraoperative bowel injury. This complicated case highlights an unusual appearance of a common complication. It demonstrates the importance of discussion with the clinical team to ensure that an accurate diagnosis is made and the correct treatment is provided.

Lack of awareness among surgeons regarding safe use of electrosurgery. A cross sectional survey of surgeons in Pakistan

Objective

To assess our surgeons perceptive regarding the safe usage of electrosurgical devices.

Method

ology: This cross sectional survey was carried out at two hospitals, A cancer hospital and a public sector general hospital. Consultants, fellows and senior residents (Resident year 3rd and year 4th) on the surgical floor were requested to fill up the questionnaire. Calculations were performed with Statistical Package for the Social Sciences (SPSS 20) for Windows version 20 statistical software. Data was described using median with minimum and maximum value for quantitative variables. For categorical variables, number of observations and percentages were reported. The study is complied with hospital guidelines on research involving human subjects.

Results

Out of 80 questionnaires 52 were filled and returned. 12 consultants, 16 fellows/Senior registrars and 24 senior residents filled their questionnaires. For the sake of anonymity no information was obtained regarding the level of training and experience. Total 12 questions were asked. An expert level was set for a score above 10/12. A moderate level was set at 8/12. A score of less than 8 was considered unsafe for using electrosurgical devices. Only 6 (11.5%) participants had an expert level of understanding. 16 (30.7%) had moderate understanding. 30 (57.7%) were considered unsafe regarding use of electrosurgical devices. 85% participants were not aware of the correct mode of current to use for coagulating vessels. 69% of surgeons would use electrocautery to control staple line bleeds. 67% participants weren't aware of the correct placement of dispersive electrode. 60% couldn't identify a safe device for use in patients with a pacemaker. 46% of surgeons would cut a dispersive electrode to fit it on a child. 69% believed that harmonic scalpel was a bipolar cautery. 61% couldn't differentiate between RFA and Microwave Ablation. 63% didn't know how to handle an operating room fire.

Conclusion

In these two hospitals, high level of ignorance noticed regarding the procedure and indications of basic electrosurgical equipment which needs raising awareness and further training.

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The first study to show the lack of understanding of electrosurgical devices among surgeons in Pakistan.

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Study was performed in 2 hospitals and included consultants, fellows and residents

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A survey was distributed and questions pertinent to the use of electrosurgical devices were asked.

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Surgical residents, fellows and consultants were equally unaware of how these devices work.

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Study highlights the need to start training courses for these devices.

Clinical Impact of Iatrogenic Small Bowel Perforation Secondary to Laparoscopic Cholecystectomy: A Single-center Experience

OBJECTIVE

Bowel, vascular, and biliary injuries during laparoscopic cholecystectomy (LC) have to be addressed with high priority. The focus of this study was on small bowel injury (SBI) and its impact on clinical management.

METHODS

We report 5 cases of SBI in a retrospective database of 2062 consecutive LC between January 2004 and December 2017.

RESULTS

We report isolated iatrogenic SBI in 0.24% (5 of 2062) after LC. We identified 3 cases with SBI associated with the technique of Hasson or related problems with intraoperative relaxation toward the end of the LC. All 5 patients needed at least 1 reoperation. There was no mortality in this series and all patients with iatrogenic SBI got discharged from the clinic in good health. Nevertheless, 3 of 5 patients (60%) with SBI filed a law suit.

CONCLUSIONS

Isolated iatrogenic SBI is a rare but dreaded complication after LC with high impact on patient's health and prone for medicolegal claims. Strict precaution on thorough relaxation throughout the operation, meticulous handling of closing technique of the fascial layer and "eternal vigilance" are mandatory to reduce risks of SBI after LC.

Fundamental Use of Surgical Energy (FUSE): An Essential Educational Program for Operating Room Safety

Operating room (OR) safety has become a major concern in patient safety since the 1990s. Improvement of team communication and behavior is a popular target for safety programming at the institutional level. Despite these efforts, essential safety gaps remain in the OR and procedure rooms. A prime example is the use of energy-based devices in ORs and procedural areas. The lack of fundamental understanding of energy device function, design, and application contributes to avoidable injury and harm at a rate of approximately 1 to 2 per 1000 patients in the US. Hundreds of OR fires occur each year in the US, some causing severe injury and even death. Most of these fires are associated with the use of energy-based surgical devices.In response to this safety issue, the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) developed the Fundamental Use of Surgical Energy (FUSE) program. This program includes a standardized curriculum targeted to surgeons, other physicians, and allied health care professionals and a psychometrically designed and validated certification test. A successful FUSE certification documents acquisition of the basic knowledge needed to safely use energy-based devices in the OR. By design FUSE fills a void in the curriculum and competency assessment for surgeons and other procedural specialists in the use of energy-based devices in patients.

Delayed jejunal perforation after laparoscopic cholecystectomy

Bowel perforation is a rare complication of laparoscopic cholecystectomy, which if left undiagnosed can have fatal consequences. In addition, isolated small bowel perforation is extremely rare and should be considered in patients presenting with sudden onset abdominal pain in the postoperative period. A 57-year-old male with symptomatic gallstones underwent urgent laparoscopic cholecystectomy and was discharged home on postoperative day (POD) 1 without complications. He presented to the emergency department on POD 11 complaining of sudden onset abdominal pain. A CT scan did not confirm a diagnosis and he was admitted for observation. On post admission day 2, he became significantly peritonitic and laparotomy revealed jejunal perforation. Bowel resection with hand-sewn anastomosis was completed and he was discharged on POD 10. Follow-up at 6 weeks revealed no further issues. We review the literature on small bowel perforation post laparoscopic cholecystectomy.

Face validation of the Virtual Electrosurgery Skill Trainer (VEST©)

BACKGROUND

Electrosurgery is a modality that is widely used in surgery, whose use has resulted in injuries, OR fires and even death. The SAGES has established the FUSE program to address the knowledge gap in the proper and safe usage of electrosurgical devices. Complementing it, we have developed the Virtual Electrosurgery Skill Trainer (VEST(©)), which is designed to train subjects in both cognitive and motor skills necessary to safely operate electrosurgical devices. The objective of this study is to asses the face validity of the VEST(©) simulator.

METHODS

Sixty-three subjects were recruited at the 2014 SAGES Learning Center. They all completed the monopolar electrosurgery module on the VEST(©) simulator. At the end of the study, subjects assessed the face validity with questions that were scored on a 5-point Likert scale.

RESULTS

The subjects were divided into two groups; FUSE experience (n = 15) and no FUSE experience (n = 48). The median score for both the groups was 4 or higher on all questions and 5 on questions on effectiveness of VEST(©) in aiding learning electrosurgery fundamentals. Questions on using the simulator in their own skills lab and recommending it to their peers also scored at 5. Mann-Whitney U test showed no significant difference (p > 0.05) indicating a general agreement. 46% of the respondents preferred VEST compared with 52% who preferred animal model and 2% preferred both for training in electrosurgery.

CONCLUSION

This study demonstrated the face validity of the VEST(©) simulator. High scores showed that the simulator was visually realistic and reproduced lifelike tissue effects and the features were adequate enough to provide high realism. The self-learning instructional material was also found to be very useful in learning the fundamentals of electrosurgery. Adding more modules would increase the applicability of the VEST(©) simulator.

Impact of a hands-on component on learning in the Fundamental Use of Surgical Energy™ (FUSE) curriculum: a randomized-controlled trial in surgical trainees

BACKGROUND

While energy devices are ubiquitous in the operating room, they remain poorly understood and can result in significant complications. The purpose of this study was to estimate the extent to which adding a novel bench-top component improves learning of SAGES' Fundamental Use of Surgical Energy™ (FUSE) electrosurgery curriculum among surgical trainees.

METHODS

Surgical residents participated in a 1-h didactic electrosurgery (ES) course, based on the FUSE curriculum. They were then randomized to one of two groups: an unstructured hands-on session where trainees used ES devices (control group) or a goal-directed hands-on training session (Sim group). Pre- and post-curriculum (immediate and at 3 months) assessments included knowledge of ES (multiple-choice examination), self-perceived competence for each of the 35 course objectives (questionnaire), and self-perceived comfort with performance of seven tasks related to safe use of ES. Data expressed as median[interquartile range], *p < 0.05.

RESULTS

56 (29 control; 27 Sim) surgical trainees completed the curriculum and assessments. Baseline characteristics, including pre-curriculum exam and questionnaire scores, were similar. Total score on the exam improved from 46%[40;54] to 84%[77;91]* for the entire cohort, with higher immediate post-curriculum scores in the Sim group compared to controls (89%[83;94] vs. 83%[71;86]*). At 3 months, performance on the exam declined in both groups, but remained higher in the Sim group (77%[69;90] vs 60%[51;80]*). Participants in both groups reported feeling greater comfort and competence post-curriculum (immediate and at 3 months) compared to baseline. This improvement was greater in the Sim group with a higher proportion feeling "Very Comfortable" or "Fully Competent" (Sim: 3/7 tasks and 28/35 objectives; control: 0/7 tasks and 10/35 objectives).

CONCLUSIONS

A FUSE-based curriculum improved surgical trainees' knowledge and comfort in the safe use of electrosurgical devices. The addition of a structured interactive bench-top simulation component further improved learning and retention at 3 months.

Imaging in laparoscopic cholecystectomy--what a radiologist needs to know

Laparoscopic cholecystectomy is the gold standard treatment option for cholelithiasis. In order to properly assess for the complications related to the procedure, an understanding of the normal biliary anatomy, its variants and the normal postoperative imaging is essential. Radiologist must be aware of benefits and limitations of multiple imaging modalities in characterizing the complications of this procedure as each of these modalities have a critical role in evaluating a symptomatic post-cholecystectomy patient. The purpose of this article is describe the multi-modality imaging of normal biliary anatomy and its variants, as well as to illustrate the imaging features of biliary, vascular, cystic duct, infectious as well as miscellaneous complications of laparoscopic cholecystectomy. We focus on the information that the radiologist needs to know about the radiographic manifestations of potential complications of this procedure.

Common uses and cited complications of energy in surgery

BACKGROUND

Instruments that apply energy to cut, coagulate, and dissect tissue with minimal bleeding facilitate surgery. The improper use of energy devices may increase patient morbidity and mortality. The current article reviews various energy sources in terms of their common uses and safe practices.

METHODS

For the purpose of this review, a general search was conducted through NCBI, SpringerLink, and Google. Articles describing laparoscopic or minimally invasive surgeries using single or multiple energy sources are considered, as are articles comparing various commercial energy devices in laboratory settings. Keywords, such as laparoscopy, energy, laser, electrosurgery, monopolar, bipolar, harmonic, ultrasonic, cryosurgery, argon beam, laser, complications, and death were used in the search.

RESULTS

A review of the literature shows that the performance of the energy devices depends upon the type of procedure. There is no consensus as to which device is optimal for a given procedure. The technical skill level of the surgeon and the knowledge about the devices are both important factors in deciding safe outcomes.

CONCLUSIONS

As new energy devices enter the market increases, surgeons should be aware of their indicated use in laparoscopic, endoscopic, and open surgery.

A feasibility and dosimetric evaluation of endoscopic radiofrequency ablation for human colonic and rectal epithelium in a treat and resect trial

BACKGROUND

Endoscopic radiofrequency ablation (RFA) has been used effectively for ablation of foregut disorders and also may have a role in treating colonic pathology. This study aimed to assess the feasibility of delivering RFA to locations within the colon and to determine a range of safe treatment parameters.

METHODS

Patients undergoing left hemicolectomy or proctocolectomy were evaluated. Focal RFA using a colonoscope-mounted device was delivered to normal segments of the colon and rectum within the planned surgical resection specimen. Endoscopic accessibility and feasibility of delivering heat energy to the colon and rectum were assessed as well as the maximum incurred histologic depth of ablation in relation to the number of applications (2 or 4) and the energy density (12, 15, or 20 J/cm2).

RESULTS

A total of 51 ablation zones in 16 patients had available histopathology. None of the sites receiving two applications demonstrated serosal layer alteration compared with 15% of the sites receiving four applications (p=0.11). Muscularis propria alterations were seen in 25% of the two-application sites and 63% of the four-application sites (p<0.05). Increasing energy density from 12 to 20 J/cm2 did not correlate with a deeper ablation effect.

CONCLUSIONS

Endoscopic RFA is capable of delivering therapy to the distal colon. Injury is limited to the muscularis propria or less depth when no more than two ablations are applied regardless of the energy density used. Based on these feasibility and dosimetry results, the authors will continue investigation using these and smaller energy doses to initiate trials ultimately with patients who have suitable mucosal and submucosal disorders of the lower gastrointestinal tract including chronic, nonulcerated hemorrhagic radiation proctitis and angiodyplasia.

Monopolar electrosurgery on the extrahepatic bile ducts during laparoscopic cholecystectomy: an experimental controlled trial

INTRODUCTION

The purpose of this study is to investigate the occurrence of thermal injury in the extrahepatic bile ducts when monopolar electrosurgery is used to perform dieresis of the cystic duct and cystic vessels in laparoscopic cholecystectomy.

METHODS

Female pigs (n=40) of the Large White breed were separated into 2 groups of 20 animals. In the experimental groups, dieresis of the cystic duct and cystic vessels was performed with monopolar electrosurgery using a hook-like dissector using a power setting of 20 W, whereas in the control group this procedure was performed with a pair of Metzenbaum scissors disconnected from any kind of thermal energy source. Occurrence of distal thermal injury was evaluated on 2 occasions, on the 3rd and 28th days postoperatively. It consisted of exploratory laparotomy, cholangiography and both macroscopic and microscopic examination of the surgical specimen, which included cystic duct stump, hepatic duct and choledochus.

RESULTS

The presence of distal thermal injury, classified as second degree, 1.2 mm in the portion near the clipping area, was observed in only one of the cystic duct stumps after microscopic examination, without statistical significance. No thermal injury was observed in the extrahepatic bile ducts.

CONCLUSIONS

Monopolar electrosurgery produced negligible thermal injury in the extrahepatic bile ducts after laparoscopic cholecystectomy.