Cutting edge blog

Correspondence to: Dr. Juri Fuchs (email: juri.fuchs@med.uni-heidelberg.de )

Department of General, Visceral, Pediatric and Transplantation Surgery

University of Heidelberg

Correspondence to: Guy J. Maddern (e-mail: guy.maddern@adelaide.edu.au)

Department of Surgery

The University of Adelaide

Correspondence to: Bing Hai (email: binghai999@163.com)

374

Dianmian Road

Nearly thirty years ago Paul Sugarbaker first published the classification and description of the techniques of peritonectomy procedures and organ resections as part of cytoreductive surgery1. Since then, Paul Sugarbaker has published numerous manuscripts, books and book chapters and produced videos on peritonectomy procedures. Some of these have been improvisations of the previous descriptions while others have been descriptions of new peritonectomy procedures that he had devised2,3,4. The description of the hepatic bridge and the clearance of the peritoneum in the tunnel created by it, clearance of peritoneal disease in an inguinal hernia, clearance of the foramen of Winslow and peritonectomy of the sub-pyloric space are some of the techniques published subsequently5,6,7,8,9,10. The most recent addition to the list was peritonectomy of the colonic mesentery published in 202111.

Paul Sugarbaker started working on the treatment of peritoneal malignancies in the early eighties and coined the term cytoreductive surgery for a surgical procedure that involved resection of all macroscopic tumor, including electrosurgical removal of the peritoneal tumor deposits, combined with administration of intraperitoneal chemotherapy12,13. The body of publications by Sugarbaker on peritonectomy procedures is the most comprehensive resource on these procedures in the literature, both in terms of the included procedures and the technical descriptions of these procedures. In 2016, Grey’s anatomy, for the first time, included a chapter on the anatomy of the peritoneum by Paul Sugarbaker14. Paul Sugarbaker has set the bar for the quality of operative surgical images published in these manuscripts. Cytoreductive surgery addresses different regions of the peritoneal cavity, and organ systems, and can appear disjointed and unstructured, especially in the setting of extensive peritoneal disease. The intraoperative images in his manuscripts are pristine, demonstrating each anatomical structure with great clarity15. This attention to detail underlines the importance of meticulous surgical technique, and the pursuit of perfection, which to those who have trained and worked with him, are his well-known hallmarks.

Paul Sugarbaker has over the years laid great emphasis on minute technical aspects of cytoreductive surgery, such as the incision and exposure of the peritoneal cavity, meticulous excision of previous surgical scars, use of high voltage electrocautery and copious lavage of the peritoneal cavity16,17,17. One of his most famous aphorisms ‘It’s what the surgeon does not see that kills the patient’ is a manuscript focusing on meticulous surgical technique to reduce peritoneal dissemination from colorectal primary tumors19. In current times, this aphorism incorporates , and underlines, the importance of ‘complete’ cytoreductive surgery which requires meticulous exploration of the abdominal cavity and identification and resection of all sites of disease. However, the original aphorism refers to another important concept that he introduced whereby he described the technique of centripetal surgery which involved starting the dissection far away from the tumor, and employing local peritonectomy procedures to contain the colorectal primary tumor19. While most of his work was on peritoneal metastases of gastrointestinal origin, the principles and concepts introduced by him are applicable to all surgical approaches for peritoneal malignancies. Another very significant Sugarbaker concept is that the peritoneum helps prevent retroperitoneal dissemination of peritoneal malignancy and is thus “the first line of defense” again peritoneal metastases20.

Tumour Boards (MDT) are swamped. Some UK centres now log more than 30 hours each month discussing colorectal cancer (CRC) cases. Yet large-language models (LLMs) such as ChatGPT could already shoulder a sizeable slice of that load.

We retrospectively audited 100 consecutive CRC cases discussed by our lower-GI MDT (September-December 2023)1 Raw patient data including surgical notes, preoperative work up, TNM staging, comorbidities and imaging summaries were uploaded to ChatGPT‑4 without prior medical interpretation. The model returned a single “best” plan for the pre‑ and (where applicable) post‑therapeutic settings (Figure 1). After that the concordance with the German S3 guideline was manually assessed by our team (Table 1)2. In the pretherapeutic discussions, complete concordance was observed in 72.5 per cent, with partial concordance in 10.2 per cent and discordance in 17.3 per cent. For post-therapeutic discussions, the concordance increased to 82.8 per cent; 11.8 per cent of decisions displayed partial concordance and 5.4 per cent demonstrated discordance. Key discordance drivers were age > 77 years (OR 1.08 per year) (Figure 2), ASA ≥ III, rectal cancer, N1 stage on the TNM Classification.

ChatGPT prompt.

Correspondence to: Catherine Arundel (email: catherine.arundel@york.ac.uk)

Correspondence to: Jinshan Liu (email: liujinshanqijiang@163.com)

Department of Gastrointestinal Surgery

Chongqing Hospital of Jiangsu Province Hospital

The impact of operating room door openings on surgical site infections (SSIs) has long been a topic of debate. Minimizing door openings – or implementing a strict zero door opening policy for certain surgical procedures - is a common recommendation in SSI prevention bundles and clinical guidelines. This recommendation is based on associations between door openings and surrogates of SSI, such as increased microbial air contamination or wound contamination. However, direct clinical evidence of an increase in SSI rates has been lacking.

Our systematic review and individual patient data meta-analysis (IPDMA) of eight observational studies including 4,412 procedures provides the first cumulative clinical data assessing the effect of the number of door openings in the operating room on SSIs across all surgical types1. Very low certainty of evidence suggested a marginal increase in SSI risk with each additional door opening per hour, patients at a higher baseline risk being more affected (Figure 1). Given the minimal observed effect on clinical outcomes and the very low certainty of the evidence, our results do not support enforcing a strict zero-door-opening policy solely for the purpose of SSI prevention.

We found it particularly relevant to examine the potential impact of door openings in clean surgeries and implant procedures, where strict zero-door-opening policies are often most rigorously enforced to minimize contamination risks. Although exogenous sources of contamination other than the patient’s own microflora are believed to play a role in infection after clean and long-duration surgery, this is primarily based on studies showing associations with surrogates such as colony forming units in wounds or operating rooms, rather than a direct effect on higher SSI rates2-4. In implant surgeries, the serious consequences of prosthetic infections, especially those linked to biofilm formation on implant surfaces, further support the rationale for stricter door-opening policies5. However, our findings suggest that the relationship between the number of door openings per hour and clinical SSI outcomes remains comparable across different wound contamination levels and implant statuses.

Correspondence to: Stephan Bischofberger (e-mail: stephan.bischofberger@kssg.ch)

Department of Surgery

Kantonsspital St. Gallen

Corresponding author: Hinpetch Daungsupawong (email: hinpetchdaung@gmail.com)

Private Academic Consultant

Phonhong

Professor Stephen Wigmore, Treasurer, BJS Foundation, interviews the 2025 BJS Award winner Professor James Shapiro.

At the heart of the Royal College of Surgeons of England lies the Hunterian Museum, a space dedicated to the history of surgery from ancient times to the present day. Many visitors are drawn to the specimens on display - over 2,000 preparations of human and animal tissue collected by John Hunter in the 1700s. However, the story of surgery is equally told through the wealth of surgical instruments in the collection, from the simplest probes to the latest minimally invasive technologies.

Mick Crumplin, a retired surgeon and Honorary Curator of Instruments at the Royal College of Surgeons of England, delves into this fascinating history in his series of 20 articles for ‘The Instrumentalist’ in the BJS. This brilliant resource reviews the origin of a wide range of instruments, some of which will be very familiar to today’s surgeons, while others are less well-known.

Liston pattern bone-cutting forceps. © 2014 All rights reserved. Courtesy of Surtex Instruments Ltd.

Correspondence to: Simon Lundström (e-mail: Simon.Lundstrom@med.lu.se)

Department of Surgery

Skåne University Hospital

Correspondence to: Ranjith Kumaran Ramu (e-mail: ranjithkumaran2009@gmail.com)

Senior Resident

Department of General Surgery

Despite an increasing emphasis on patient safety, modern surgical practice is still plagued by the occurrence of serious Adverse Events (AEs). A large proportion of these AEs are caused not by technical errors, but short comings in non-technical skills (NTS) or non-technical errors.1 NTS are the cognitive and interpersonal components of surgical professionalism including communication, decision-making, situational awareness and leadership.2 Few studies have attempted to quantify the significance of non-technical errors leading to patient harm. Those that have, only include small, non-representative cohorts, or have assessed for NTS shortcomings using heterogeneous, non-standardised, and non-comprehensive assessment methods.3-6 As a result, the true impact of non-technical errors, and information about how, when, and why these errors occur are poorly understood. Evidence to guide NTS improvement is lacking.

This study7 aimed to investigate the incidence of non-technical errors linked to patient death in a large representative Australian cohort, investigate factors associated with fatal non-technical errors, and whether the incidence of non-technical errors had changed over time. To achieve this, an 8-year retrospective audit using surgical mortality cases was conducted. Data were derived from the Australian and New Zealand Audit of Surgical Mortality (ANZASM) a mandatory, national surgical mortality audit overseen by the Royal Australasian College of Surgeons. In Australia, every surgical death is reported to ANZASM for external peer review for the purpose of identifying clinical management issues (CMI’s) that could be improved in future. CMI’s are rated on a three-tiered system with ‘area of concern’ or ‘Adverse Event’ representing the two most serious. All surgical deaths between 2012-2019 (excluding New South Wales), flagged with an area of concern or AE were included with no further exclusions. Each case was assessed using the System for Identification and Categorization of Non-technical Errors in Surgical Settings (SICNESS), a validated tool, developed by the study authors.8 The SICNESS enabled assessors to identify if a non-technical error linked to patient death had occurred, and if so, to which NTS domain it belonged.

There were 30,971 surgical deaths reported to ANZASM during the study. Of these, 3829 were flagged with an AE or Area of concern. Some 134 had insufficient information for assessment, leaving 3695 cases for review. A non-technical error linked to patient death was identified in 2354 cases (63.7%). Of the cases with non-technical errors, 1375 (58.4%) had decision making errors, 1328 (56.4%) had situational awareness errors, 357 (15.2%) had communication/teamwork errors, and 128 (5.44%) had leadership errors.

Correspondence to: Sander J. M. van Hootegem (e-mail: s.vanhootegem@erasmusmc.nl)

Department of Surgery

Erasmus Medical Centre

Correspondence to: Anyin Wang (email: Hospitalpwkedu@163.com)

Department of Gastrointestinal/Hernia Surgery

The People's Hospital of Liangping District

____________

My first significant contact with abdominal aortic aneurysm (AAA) screening was when I was appointed as a consultant surgeon in Gloucestershire in 1991. My consultant colleague, Brian Heather, had already started an AAA screening programme for 65-year-old men in Gloucestershire. The burden of managing vascular disease single-handed for a population of 350,000 was significant for him; in addition, patients with ruptured AAA were major consumers of critical care services in Gloucestershire at the time. Brian contacted all the GP surgeries in Gloucestershire asking whether (i) they were prepared to identify the 65-year-old men in their practice each year, and then (ii) to receive a visit once a year for them to be scanned. He secured the services of a research nurse, Elaine Shaw, who took a portable ultrasound scanner to the GP surgeries to do the scans. The screening programme in Gloucestershire was born in 1988 and has run ever since1.

Correspondence to: Shuting Yin (e-mail: yin13938214200@163.com)

Department of Education and Sports

Zhengdong New District

Correspondence to: Sabaretnam Mayilvaganan (drretnam@gmail.com)

Additional Professor

Department of Endocrine Surgery

Correspondence to: Chahrazed Dous

(email: douschahrazed@yahoo.com)

Tazoult City

Correspondence to: Gang Bian (e-mail: bianganglingling@163.com)

Department of Gastroenterology

Qingdao Third People's Hospital Affiliated to Qingdao University

Dominic Slade and Prita Daliya bring you the opening teaser for their upcoming podcast: Surgeons unscrubbed! A collaboration between the British Hernia Society (BHS) and BJS Academy.

In this series, Dominic and Prita will be interviewing prominent surgeons around the world and asking them questions submitted by you!

Correspondence to: Raafat Gendy (email: raafat.gendy1@nhs.net)

____

____