Abstract Introduction During Covid-19 many staff members were redeployed to the Intensive Care Unit (ICU) with little opportunity to train in the new skills they would require. One such skill was the transfer of a critically ill, and contagious, patient from ICU; a risky and complicated procedure which requires planning, preparation, risk assessment, situational awareness and, ideally, experience. To assist our colleagues in this skill an existing ICU transfer course has been adapted to cover the Covid-19 situation, or any similar contagious pandemic, in patient transfer. Methods An in-situ simulation method was chosen as the most realistic method of immersing our participants into the environment of ICU and to highlight real-life complexities and issues they may face. A multidisciplinary training session was devised so that novice anaesthetists, ACCPs and nurses could learn together, reflective of the usual team. Human factors such as communication, team leadership, task management and situational awareness are the focus of the post-simulation debrief, and human factors sheets have been created to guide the participants in analysing these skills. Pre- and post-simulation confidence, knowledge and attitudes will be assessed using validated appraisal tools and questionnaires to gather both quantitative and qualitative data about the experience. Discussion Multidisciplinary training is often difficult to arrange, due to the different requirements, processes, and procedures each department demands. A hidden blessing of Covid-19 is the realisation that this barrier can be broken, for the benefit of our patients and colleagues alike, and training sessions like this implemented.

Introduction: The technique of closing the appendiceal stump using linear titanium stapler clips is being used more and more frequently in laparoscopic surgery, despite the good practice in the use of resorbable single endoloop vicryl ligatures and/or the non-resorbable plastic hem-o-lok clips. No light has been shed on potential undesirable effects on the haemathological profile of the use of titanium stapler clips. This experimental study aimed at establishing any possible undesirable effect of linear titanium stapler clips and single resorbable vicryl endoloop ligatures on the blood cells in rats following appendectomy. Methods: A total of 70 adult rats were used, divided into a control group (n = 10), and two experimental groups (n = 30 + 30). The appendices were removed from the rats in the first experimental group using titanium stapler clips and in the second experimental group the appendiceal stump using resorbable endoloop vicryl ligatures was closed. In both experimental groups three sub-groups with ten animals each were formed, from which peripheral blood from a tail vein on days 7, 28 and 60 was removed postoperatively, in order to assess the usual haematological parameters. Stained blood smears were also analysed in order to establish any poikilocytotic erythrocytes present. Results: In the first experimental group, with the titanium stapler clips, more than 25 % neutrophils were found on day 7, which is a significantly different result (p < 0.05) to the control group. In the second experimental group, there were more neutrophils than in the titanium stapler clips group, especially on days 7 and 60 and the results of these two sub-groups differ statistically significantly, p < 0.05. Hypochromia was found in the endoloop vicryl ligatures group, as well as in the titanium stapler clips sub-group on day 28, due to lower haemoglobin values which were significantly different to the control group, p < 0.05. Moderate levels of annulocytes, spherocytes and stomatocytes were found in most experimental groups. Conclusion: The results of this study favour the use of linear titanium stapler clips over resorbable single endoloop vicryl ligatures, because a less unfavourable effect was established on the blood cells of the experimental rats with their use.

Background and Objectives: Titanium DS clips are made to secure the appendiceal stump during laparoscopic appendectomy. The assumption is that they behave like stapler clips in the body, being made from titanium. However, the construction and weight of DS clips differs from staplers. Their biocompatibility may have implications for their clinical use. Methods: One hundred and twenty rats were randomized into four experimental groups: in the first group the appendiceal stump was secured by Vicryl® ligature, in the second by linear staplers, in the third by Hem-o-lok® plastic clips, and in the fourth by DS titanium clips. Ten animals from each group were sacrificed 7, 28, and 60 days post-surgery. Histopathological data and adhesion formation were assessed. Results: On postoperative day 7, a statistically significant difference was found in the occurrence of inflammation between the Hem-o-lok® and stapler groups. The adhesion score was significantly higher in the Vycril® and Hem-o-lok® in comparison to the DS and stapler groups. On postoperative day 28, a statistically significant difference was found in the occurrence of inflammation between the Vycril® and stapler groups. The adhesion score was significantly higher in the Vycril® than in the DS and stapler groups. On postoperative day 60, there were no statistical differences between any of the groups. The adhesion score was significantly higher in the Hem-o-lok® group in comparison to the DS and stapler groups. Conclusion: Staplers and DS clips have advantages over other methods of securing the appendiceal stump, because of their high biocompatibility and lower adhesion score.

Background COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts’ opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. Methods Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. Results A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. Conclusion The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems.

In contrast to classical appendectomy where the appendiceal stump is secured by a single or double ligature, in laparoscopic appendectomy various ways of securing the stump are mentioned. Each of these methods has advantages and disadvantages. Since different possibilities exist for closing the stump, it is very important to find the optimum method for closure of the appendiceal stump, bearing in mind their simplicity, biocompatibility and price. The aim of this review article has been to present the problem of securing the base of the appendix during laparoscopic appendectomy.

Acute colonic diverticulitis is one of the most common clinical conditions encountered by surgeons in the acute setting. An international multidisciplinary panel of experts from the World Society of Emergency Surgery (WSES) updated its guidelines for management of acute left-sided colonic diverticulitis (ALCD) according to the most recent available literature. The update includes recent changes introduced in the management of ALCD. The new update has been further integrated with advances in acute right-sided colonic diverticulitis (ARCD) that is more common than ALCD in select regions of the world.

Introduction: In this study we wanted to examine the hormonal responses due to stress exposure during laparoscopic cholecystectomy with standard (12-15 mm / Hg) (LCSP) and low (6-8 mm / Hg) (LCLP) intraabdominal pressure and open cholecystectomy (OC), with particular emphasis on stress hormone responses. Aim: Determination of adrenocorticotropic hormone (ACTH) and cortisol stress hormones before and after laparoscopic cholecystectomy with standard and low insufflation pressure, determination of ACTH and cortisol values before and after open cholecystectomy and comparison of ACTH and cortisol values between the patient sub-groups. Methods: In a prospective study conducted between July 2016 and February 2018, we involved 110 patients which were divided into two groups: 70 patients with laparoscopic cholecystectomy (LC) and 40 patients with open cholecystectomy (OC). The first group of patients was further divided into two subgroups of 35 patients, (subgroup LC with standard and subgroup LC with low intraabdominal pressure). All patients met the preset inclusion and exclusion criteria of the study. There were no statistically significant differences in the demographic characteristics of patients between the investigated groups. The stress hormones determined were adrenocorticotropic hormone (ACTH) and cortisol. Results: During the first, second and seventh day postoperative day (POD),ACTH values were significantly lower (p <0.0001) in LCLP than in LCSP and OC groups. This was also the case for comparison in LCSP and OC groups. By comparing LC and OC groups during first, the second and seventh POD, there was a significant difference (p <0.0001) in the ACTH levels. The concentration of this hormone was higher in the OC group in all three cases. The first, second and seventh POD were also statistically significant (p <0.0001) in cortisol values and between LC and OC groups there was an increase in cortisol levels in patients operated by open method. There was also a significant difference (p <0.0001) in cortisol values measured between LCLP and LCSP groups in the investigated days. Cortisol levels were higher in patients in the LCSP group. Conclusion: During open and laparoscopic cholecystectomy the response of the body to stress increased. The stress response of the organism during laparoscopic cholecystectomy was less than during open cholecystectomy. The stress response of the organism during laparoscopic cholecystectomy with low insufflation pressure ( 6-8mmHg) was less than during laparoscopic cholecystectomy with standard insufflation pressure (12-15mmHg).

This study aimed to evaluate the effect of preoperative carbohydrate oral (CHO) loading on the postoperative metabolic and inflammatory response, perioperative discomfort and surgical clinical outcomes in open colorectal surgery compared with a conventional fasting protocol. Fifty patients were randomly allocated to either the intervention group (CHO), to receive preoperative oral carbohydrate supplementation, or the control group (FAST), to undergo preoperative fasting. Insulin resistance, insulin sensitivity, the Glasgow Prognostic Score (GPS) and IL-6 levels were analysed at 06 h on the day of surgery (T1), 6 h after surgery (T2) and at 06 h on postoperative day 1 (T3) and postoperative day 2 (T4). Thirst, hunger, dry mouth, weakness, anxiety and pain were assessed using the visual analogue scale (VAS) prior to anaesthesia induction and at 0–4, 4–8, 8–12 and 12–24 h after surgery. Surgical clinical outcomes included the return of gastrointestinal function, time to independent ambulation and postoperative discharge day. Postoperative insulin resistance was 30% lower (p < 0.03) and insulin sensitivity was 15% higher (p < 0.05) in the CHO group than in the FAST group. The GPS was lower in the CHO group at T1 (p < 0.001), T3 (p < 0.01) and T4 (p < 0.004). IL-6 serum levels were lower at the analysed postoperative time points in the CHO group (p < 0.001). The VAS well-being score was lower in the intervention group (p < 0.001); however, the VAS pain score was not significantly different between the groups. The evaluated surgical outcomes appeared earlier in the CHO group (p < 0.001). A preoperative CHO drink reduced the postoperative metabolic and inflammatory response and improved subjective well-being and surgical clinical outcomes but did not diminish the VAS pain score.

BackgroundTiming and adequacy of peritoneal source control are the most important pillars in the management of patients with acute peritonitis. Therefore, early prognostic evaluation of acute peritonitis is paramount to assess the severity and establish a prompt and appropriate treatment. The objectives of this study were to identify clinical and laboratory predictors for in-hospital mortality in patients with acute peritonitis and to develop a warning score system, based on easily recognizable and assessable variables, globally accepted.MethodsThis worldwide multicentre observational study included 153 surgical departments across 56 countries over a 4-month study period between February 1, 2018, and May 31, 2018.ResultsA total of 3137 patients were included, with 1815 (57.9%) men and 1322 (42.1%) women, with a median age of 47 years (interquartile range [IQR] 28–66). The overall in-hospital mortality rate was 8.9%, with a median length of stay of 6 days (IQR 4–10). Using multivariable logistic regression, independent variables associated with in-hospital mortality were identified: age > 80 years, malignancy, severe cardiovascular disease, severe chronic kidney disease, respiratory rate ≥ 22 breaths/min, systolic blood pressure < 100 mmHg, AVPU responsiveness scale (voice and unresponsive), blood oxygen saturation level (SpO2) < 90% in air, platelet count < 50,000 cells/mm3, and lactate > 4 mmol/l. These variables were used to create the PIPAS Severity Score, a bedside early warning score for patients with acute peritonitis. The overall mortality was 2.9% for patients who had scores of 0–1, 22.7% for those who had scores of 2–3, 46.8% for those who had scores of 4–5, and 86.7% for those who have scores of 7–8.ConclusionsThe simple PIPAS Severity Score can be used on a global level and can help clinicians to identify patients at high risk for treatment failure and mortality.