The edition · General Surgery
Colon trauma: repair or anastomose most stable patients, and divert only on physiology
World Society of Emergency Surgery recommendations move colorectal trauma away from routine stomas. Plus robotic versus laparoscopic emergency cholecystectomy and bile duct injury, and axillary surgery omitted in 97% of eligible women.
The edition in brief
Today's general surgery edition ends on colorectal trauma. GRADE-based recommendations from the World Society of Emergency Surgery (JAMA Surgery, 23 September) favour primary repair or resection with anastomosis over routine diversion in most stable patients, reserve diversion for persistent vasopressor need, failure of fascial closure or compounded physiological derangement, keep proximal diversion as the default for extraperitoneal rectal injury, and limit antibiotic prophylaxis to 24 hours. Much of the evidence is observational. A propensity-matched US database study of 146,632 emergency cholecystectomies found robotic surgery associated with fewer 30-day bile duct injuries than laparoscopy (0.06% vs 0.11%; OR 0.56) and less conversion, with longer operating time; residual confounding is possible. A prospective series of 437 postmenopausal women with small, low-grade HR-positive, HER2-negative cancers and a normal axillary ultrasound omitted sentinel node biopsy in 97% after SOUND and INSEMA, with no axillary recurrence at a short median follow-up of 7.7 months. A Danish cohort found that leaving a normal appendix at diagnostic laparoscopy led to a second laparoscopy in 3.5% over five years. A nationwide survey of 9,552 ventral hernia repairs found less scar dissatisfaction after minimally invasive repair but slightly more patient-reported recurrence after laparoscopy. The pearl is the critical view of safety.
Robotic emergency cholecystectomy was associated with about half the bile duct injury rate of laparoscopy
Robotic emergency cholecystectomy was associated with fewer bile duct injuries, but the absolute gain is small and the evidence observational; the critical view of safety matters more.
Sentinel node biopsy was omitted in 97% of eligible older women after SOUND and INSEMA
In tightly selected postmenopausal women with low-risk HR-positive cancers and a normal axillary ultrasound, omitting sentinel node biopsy is feasible in nearly all.
Leaving a normal appendix at diagnostic laparoscopy led to a repeat laparoscopy in 3.5%
Leaving a normal appendix at diagnostic laparoscopy is a reasonable option; record it clearly so a future clinician knows.
Minimally invasive ventral hernia repair: less scar dissatisfaction, similar pain
For small primary ventral hernias, choose the approach with the patient's priorities in mind; pain outcomes were similar.
Do not divide anything until you have the critical view of safety
Clip and divide nothing until two, and only two, structures are seen entering the gallbladder.
Colorectal trauma: primary repair for most stable patients, diversion only on physiology
Repair or anastomose colon injuries in stable patients, and decide on a stoma by physiology rather than by the organ injured.
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