The edition · General Surgery
Mesh at subcostal closure cut hernia from 38% to 8% in one trial; a transanal tube may help only without a stoma
A double-blind trial of prophylactic mesh after open hepatobiliary surgery, a Cochrane review that splits the transanal tube by stoma status, and two observational studies on leak training and robotic complex cholecystectomy.
The edition in brief
Today's surgery edition closes on a single-centre, double-blind randomised trial from Seville (JAMA Surgery, 9 September): in 139 high-risk patients having open right subcostal hepatobiliary surgery, prophylactic synthetic mesh at closure lowered radiological incisional hernia at 24 months from 37.5% to 8.1%, with no rise in surgical site occurrences, complications or pain. It is one centre with about a third lost to 24-month imaging, but the effect is large. The lead is an updated Cochrane review (22 September) of transanal tubes after rectal cancer resection: four RCTs, 1318 patients. Overall leak was very uncertain (RR 0.88, 0.46 to 1.72), re-intervention for leak may fall (RR 0.32, 0.10 to 1.00), and the effect split by stoma status — possibly helpful without a diverting stoma, possibly harmful with one (RR 2.38, 1.00 to 5.69). EAGLE-2 (BJS, 27 August), a cohort of 2875 right colectomies in 60 countries, found surgeons who had completed a free digital safe-anastomosis course had fewer leaks (9.1% vs 16.4%; adjusted OR 0.56), an association rather than proof. A single-centre cohort (JAMA Surgery, 1 September) found laparoscopic complex elective cholecystectomy associated with more unplanned ERCP or radiological intervention than robotic (OR 4.24, 1.24 to 14.52) at similar total cost. The pearl is on documenting a stoma decision.
Transanal tube after rectal resection: the answer depends on whether there is a stoma
Consider a transanal tube only for an unprotected rectal anastomosis; do not add one when a diverting stoma is already in place.
EAGLE-2: surgeons who took a free anastomosis course had fewer leaks after right colectomy
Make the free EAGLE safe-anastomosis training routine for anyone performing right colectomy; it is cheap and its association with fewer leaks is large.
Complex elective cholecystectomy: laparoscopy associated with more downstream ERCP and drains than robotic
Where a robot is available, reserve it for complex elective cholecystectomy; routine gallbladders gain nothing and cost more.
Write down why you did or did not defunction
Put the reason for the stoma decision in the operation note, not just the decision.
Prophylactic mesh at subcostal closure reduced incisional hernia from 38% to 8%
For patients with two or more hernia risk factors having open subcostal hepatobiliary surgery, add prophylactic mesh to the closure.
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