The number of female trainees is on the rise, and so too are the issues surrounding fertility and barriers to family planning. Over the past decade, studies of surgical residents across the United States have demonstrated a strong prevalence of fertility challenges. Strenuous training requirements have American female surgical trainees delaying pregnancy, having fewer children, and reporting increased rates of pregnancy complications, infertility, and use of assistive reproductive technology. Similarly, a survey of British surgical trainees showed over a quarter of trainees felt unsupported by their department during pregnancy, while almost a quarter of both of male and female trainees experienced difficulty in arranging parental leave. Our recent article investigated how our long training programmes are affecting Australasian surgical trainees’ ability to start families, particularly when compared with other specialities. While we acknowledge there are limitations to online surveys, the results of this survey of 1099 doctors demonstrated that surgeons, when compared with physicians and GPs, are experiencing greater challenges in balancing work and family, across multiple areas of fertility and child-caring. Surgical training occurs in the prime reproductive years and as a consequence, when many trainees finally complete their training, they are living the real-world consequences of reduced fertility because of their age. This highlights the critical need for a cultural change that’s becoming increasingly important as the surgical workforce demographic changes. Training bodies are in a prime position to provide solutions to the many obstacles surgical trainees face in family planning. There are several ways the colleges and hospitals can support a more equitable future for its members who want to pursue parenthood.

Objective To describe the incidence of infertility, pregnancy complications, and breastfeeding practices among Australian and New Zealand doctors and identify factors associated with increased pregnancy complication rates. Methods A survey of ANZ doctors using an online questionnaire during November 2021. Results One thousand ninety-nine completed responses were received. The median age of female doctors at the time of their first child was 32.4. Fertility testing was undertaken by 37%, with 27% having in vitro fertilization. More than 60% of respondents delayed family planning due to work. Pregnancy loss occurred in 36% of respondents, and 50% suffered a pregnancy complication. There were significant differences between specialists, with surgeons working longer hours before and after pregnancy, but having greater access to maternity leave than general practitioners. Conclusion Female doctors delay starting and completing their family due to work-related demands and structural biases in career progression, which may result in higher infertility and pregnancy complication rates.

Background Electronic consultations (eConsults) are an increasingly used form of telemedicine that allows a nonspecialist clinician to seek specialist advice remotely without direct patient-specialist communication. Surgical clinics may see benefits from such forms of communication but face challenges with the need for intervention planning. Objective We aimed to use the Quadruple Aim Framework to integrate published knowledge of surgical outpatient eConsults with regard to efficacy, safety, limitations, and evolving use in the era of COVID-19. Methods We systematically searched for relevant studies across four databases (Ovid MEDLINE, Embase, Scopus, and Web of Science) on November 4, 2021, with the following inclusion criteria: English language, published in the past 10 years, and data on the outcomes of outpatient surgical eConsults. Results A total of 363 studies were screened for eligibility, of which 33 (9.1%) were included. Most of the included studies were from the United States (23/33, 70%) and Canada (7/33, 21%), with a predominant multidisciplinary focus (9/33, 27%). Most were retrospective audits (16/33, 48%), with 15% (5/33) of the studies having a prospective component. Conclusions The surgical eConsult studies indicated a possible benefit for population health, promising safety results, enhanced patient and clinician experience, and cost savings compared with the traditional face-to-face surgical referral pathway. Their use appeared to be more favorable in some surgical subspecialties, and the overall efficacy was similar to that of medical subspecialties. Limited data on their long-term safety and use during the COVID-19 pandemic were identified, and this should be the focus of future research.

Metastatic involvement of the gallbladder is uncommon. We report a case of an 84-year-old male who presented with acute cholecystitis secondary to metastatic urothelial carcinoma (UC). An 84-year-old man presented with right upper quadrant pain and a positive Murphy's sign on the background of known metastatic UC. He was diagnosed with acute cholecystitis and underwent laparoscopic cholecystectomy. His postoperative period was complicated by a cardiac event, and he died 2 days later. Histology of the gallbladder revealed extensive infiltration by nested malignant epithelioid proliferation, consistent with UC. This case demonstrates that although uncommon, UC may metastasize to unusual sites, including the gallbladder. This serves as a reminder for surgeons to consider metastatic disease as a cause for acute cholecystitis.

De Garengeot hernia is defined as a femoral hernia containing the appendix, which can be normal or inflamed. It is a rare condition, comprising of about 1% of all diagnosed hernias. Patients typically present with symptoms of incarceration. There is no consensus on the management of patients with De Garengeot hernia and concurrent appendicitis. To date, less than 100 reports have been published in literature and only a few discussed the use of mesh in an infected femoral field. An 81-year-old female presented to our emergency department with a 3-day history of lower abdominal pain associated with mild nausea. Abdominal examination revealed tenderness in the right femoral region and an incarcerated femoral hernia was suspected. She proceeded to an abdominal computed tomography (CT), which confirmed the suspected diagnosis of a femoral hernia containing appendix without radiological signs of bowel obstruction (Fig. 1). Within an hour, the patient was transferred to the operating theatre and intraoperative inspection revealed a femoral canal containing a sac which had a vermiform appendix as its content, demonstrating a De Garengeot hernia. The fixation involved a high approach with a longitudinal incision extending downwards overlying the hernia sac. The sac was 2 × 3 cm in size with surrounding tissue oedema. The opened sac identified inflamed tip of appendix. Subsequently, the retroperitoneal plane was dissected and peritoneum opened to deliver the appendix under vision. Exploration revealed a healthy base of appendix and an incarcerated tip of appendix herniating through femoral defect of about 0.5 cm in diameter (Fig. 2). There was no perforation. Standard appendicectomy was performed with ligation of base end mesoappendix using absorbable sutures. The extended incision allowed the suture ligation of the sac and a mesh plug was inserted into the femoral ring. The patient made an uneventful recovery and was discharged 2 days later with oral antibiotics for 5 days. There have been no postoperative complications at 8-week follow-up. The first case of appendicitis within a femoral hernia was reported by Rene Jacques Croissant De Garengeot, an 18th century Parisian surgeon who performed the appendicectomy and primary hernia repair in 1731. This hernia is extremely rare ranging from 0.5 to 3.3%, while only 0.13% contain an acutely inflamed appendix. Other rare hernia containing the appendix is the Amyand’s hernia seen in the inguinal region reported in 1% of cases. De Garengeot hernia is often misdiagnosed as incarcerated femoral hernia and the diagnosis of appendicitis is often only made intraoperatively. It is postulated that the signs of appendicitis are not evident clinically because of the local response related to the inflammation within the confined femoral space. A CT scan in our case had demonstrated the appendix within the hernia sac, but only three published cases of CT diagnosed De Garengeot hernia are documented in literature. This further demonstrates the dilemma surrounding this diagnosis, as the surgical treatment for this condition may be more challenging than anticipated based on the patient’s clinical presentation.

Groin hernia repairs (GHRs) are among the commonest general surgical procedures in the Western population. The introduction of minimally invasive surgery has prompted the development of laparoscopic totally extraperitoneal and trans‐abdominal preperitoneal hernia repairs. We aimed to determine the hernia treatment trends in Australia over the last 15 years.

Journal Surgical Education SE001 DEVELOPING AND MAINTAINING MASTERY AS A SURGEON