The Safety and Feasibility of Laparoscopic Surgery for Very Low Rectal Cancer: A Retrospective Analysis Based on a Single Center’s Experience

In this work we intend to validate the long-term oncologic outcomes for very low rectal cancer over the past 20 years and to determine whether laparoscopic procedures are useful options for very low rectal cancer. A total of 327 patients, who electively underwent laparoscopic rectal cancer surgery for a lesion within 5 cm from the anal verge, were enrolled in this study and their long-term outcomes were reviewed retrospectively. Of 327 patients, 70 patients underwent laparoscopic low anterior resection (LAR), 164 underwent laparoscopic abdominal transanal proctosigmoidocolectomy with coloanal anastomosis (LATA), and 93 underwent laparoscopic abdominoperineal resection (APR). The conversion rate was 1.22% (4/327). The overall postoperative morbidity rate was 26.30% (86/327). The 5-year disease free survival (DFS), 5-year overall survival (OS), and 3-year local recurrence (LR) were 64.3%, 79.7%, and 9.2%, respectively. The CRM involvement was a significant independent factor for DFS (p = 0.018) and OS (p = 0.042) in multivariate analysis. Laparoscopic APR showed poorer 5-year DFS (47.8%), 5-year OS (64.0%), and 3-year LR (17.6%) than laparoscopic LAR (74.1%, 86.4%, 1.9%) and laparoscopic LATA (69.2%, 83.6%, 9.2%). Laparoscopic procedures for very low rectal cancer including LAR, LATA, and APR could be good surgical options in selective patients with very low rectal cancer.

Intra- and inter-observer reproducibility of r-ASRM endometriosis classification system and its components, using edited videotaped laparoscopic procedures

Several classification systems have been proposed for endometriosis but the search for the ideal system is ongoing. While the most commonly used system has historically been r-ASRM, this system is not fit for purpose, particularly for deep endometriosis. In order to explore strategies to devise a new system and learn from problems with the existing ones, this study was designed to assess the reproducibility of each component in r-ASRM and its total score using videotaped laparoscopic procedures. Two surgeons independently scored 64 edited videos of laparoscopic endometriosis procedure, twice. Using the Kappa statistic, the agreement of the scores given was analyzed. r-ASRM showed a moderate inter-observer agreement (ƙ = 0.503) and good intra-observer agreement (ƙ = 0.774 and 0.682 for scorer 1 and 2 respectively) for overall disease staging. The agreement for each component of the system, however, was highly variable. The least agreement was observed for the peritoneum with ƙ = 0.157 and ƙ = 0.362 respectively for inter-observer and intra-observer. The lowest intra-observer agreement was seen for cul-de-sac for scorer 2 (ƙ = 0.382). Whilst the overall rASRM shows acceptable agreement between two scorers, this agreement seems to be the product of inconsistent scoring for each component.

An Overview of Analysis of Learning Curve of Laproscopic Procedures in General Surgery Residents in Khyber Teaching Hospital, Peshawar

Aim: An Overview of Analysis of Learning Curve of Laparoscopic Procedures in General Surgery Residents in Khyber Teaching Hospital, Peshawar. Methodology: A descriptive KAP (knowledge attitude and practice) study was conducted in Khyber teaching hospital (KTH) from January 2021 to March 2021. A total of 24 surgical residents of 3rd and 4th year residency working in different surgical units were part of the study. Experience of residents performing procedures under supervision, assistance or by means of observation was recorded by a self administered questionnaire. Results: A number of 24 surgical residents of 3rd and 4th year residency of general surgery were part of the study. Frequency of 3rd yr residents was 13(54.2%) and that of 4th yr was 11(45.8%). Number of 6(25%) observed basic laparoscopy, 8(33%) advanced procedures and 10(41.7%) observed both types of procedure. 23(95.8%) participants were regularly briefed on principles of laparoscopy and 21(87.5%) strongly agreed upon the need of video simulation sessions. According to 22(91.7%) participants instrument handling was the most difficult part to learn. And 17(70.8%) participants laparoscopy enhances visualization of disease process. 18(75%) participants said that it improves postoperative recovery and 20(83.3%) were of opinion that it minimizes hospital stay. 16(66.7%) residents stated it has a steep learning curve. All participants agreed that it is necessary to assist large number of procedures to attain confidence of performing laparoscopic procedures. Conclusion: The study showed that almost all residents were in favor of the use of laparoscopic procedures rather than open surgeries. Keywords: Laparoscopy, learning curve

Laparoscopic Castration Using Bipolar Forceps vs. Orchiectomy in Dogs: A Comparison of Two Techniques

This paper aimed to study the feasibility of a new laparoscopic castration technique in male dogs, evaluate the pain associated with it, and compare it with the classical orchiectomy. Surgical times, pain scores, blood and salivary cortisol, and CRP were recorded and compared between the two groups. The use of high-frequency bipolar forceps allowed quick and uneventful laparoscopic procedures. The laparoscopic group had significantly lower pain scores, cortisol, and PCR values than the orchiectomy group. No complications were seen in any group. Our results suggest that this laparoscopic castration is a safe and beneficial surgical alternative to traditional orchiectomy in dogs.

SP4.1.2 Appendicitis during the COVID pandemic – Are we seeing more complicated presentations?

Aims Studies have suggested a decrease in emergency presentations of appendicitis during the COVID-pandemic along with a nationwide fall in non-COVID related presentations to A&E. We therefore hypothesised that those treated for appendicitis had later presentations resulting in increasing incidence of ‘complicated appendicitis’ and post-operative complications. Methods We retrospectively analysed all patients ≥16years, undergoing emergency appendicectomy during 3-month period of UK national lockdown (pandemic cohort). Data was compared to the same period one year previously (pre-pandemic cohort). Primary endpoint was nature of appendicitis (uncomplicated or complicated). Secondary endpoints were operative approach, LOS and post-operative complications. Statistical analysis was performed using Fisher’s Exact Test. Results A total of 31 patients (median age 35years) underwent emergency appendicectomy in the pre-pandemic cohort and 30 patients in the pandemic group (median age 37). 9/31 (29%) and 18/30 (60%) were found to have complicated appendicitis in each group respectively (p = 0.021). Open procedures took place in 2/31 pre-pandemic, and 12/29 (4 of which were converted from laparoscopic procedures) in the pandemic cohort (p = 0.002). Median LOS was 2 in each group, though the pandemic cohort had a much wider range (0-7 vs 0-25 days). Post-operative complications occurred in 1/31 and 5/30 patients respectively (p = 0.104) with 1 mortality within 30 days. Conclusions Despite overall volume and demographics of patients remaining the same, the COVID-19 pandemic has resulted in a statistically significant increase in complicated presentations of appendicitis to our hospital. Subsequently this has resulted in increasing incidence of open operations and post-operative complications.

TP10.2.5Investigating the impact of early COVID-19 policies on Emergency Surgical service at a District General Hospital

Aims On the 23rd March 2020, the UK introduced measures to curb the spread of coronavirus disease 19 (COVID-19). We aimed to investigate the impact of government and Royal College measures on the acute surgical take. Materials and Methods Retrospective analysis was performed for patients referred to the acute surgical take between 2nd March 2020 and 5th April 2020. Data were analysed in two groups; ‘pre-COVID measures’ cohort (prior to 23rd March 2020) and ‘post-COVID measures’ cohort (on or after 23rd March 2020). Demographics, Early Warning Score (EWS) at referral, blood results, radiological investigations, antibiotic use, diagnosis, operative and outcome data were compared. Results 465 patient referrals were included. Mean admissions per day reduced by 39.9% (p = 0.01) in the post-COVID measures’ cohort compared with the pre-COVID measures cohort. Disease severity increased, with white cell count (WCC) increasing by 14% (p = 0.02) and C-reactive protein (CRP) by 34% (p = 0.04). Laparoscopic procedures decreased by 86.4% (p < 0.01). The proportion of admissions requiring operative management showed no significant change, with 26% in pre-COVID measures verse 23% in post- COVID measures (p = 0.91). Short term morbidity, mortality and length of stay outcomes also demonstrated no significant change. Conclusion Fewer patients were referred following the implementation of government and Royal College guidance, however these patients demonstrated greater disease severity. Guidance likely modified patients help seeking behaviours and delayed presentation time. Surgeons demonstrated good compliance to Royal College guidance by reducing laparoscopic procedures, however operative management rates remained constant.