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BACKGROUND Inguinal hernia repair is one of the most common operations performed worldwide with most of the burden of these occurring in low- or middle-income countries (LMICs). There has been much research investigating the most effective method of hernia repair in resource-rich countries, however very little has been done to determine the most cost-beneficial method of hernia repair in LMICs. METHODS A systematic review of the English literature through PubMed and Scopus was conducted according to the PRISMA statement. RESULTS Twenty-eight studies met the inclusion criteria of which 17 were randomised controlled trials and 11 were systematic reviews. Three areas of investigation were established from the literature search, namely operative method and type of mesh used (where applicable). Open-mesh procedures were shown to be less costly and have shorter operative times than laparoscopic methods. People who underwent laparoscopic hernia repair regularly returned to normal activities earlier than those who had open-mesh procedures. However, there was no other difference in complication rates between these two methods. Recent investigations have revealed that sterilised synthetic mosquito net was similar to hernia-specific meshes whilst significantly reducing cost. CONCLUSION We postulate that the most cost-beneficial method of hernia repair for implementation in LMICs is using open-mesh procedures with sterilised mosquito net under local anaesthetic. Further cost-benefit research is required in this area.

BACKGROUND Haemorrhoidal rubber band ligation (RBL) is a well-established, safe and cost-effective treatment for bleeding haemorrhoids. It is generally well tolerated; however, some patients may require narcotic analgesia or even admission to hospital for pain management. This comparative cohort study reports on the difference in peri-procedural analgesia administration and post-operative recovery time between patients who received local anaesthetic (LA) infiltration in addition to RBL, compared with patients treated only with RBL. METHODS Consecutive patients with haemorrhoids treated over a 3-month period with LA infiltration in addition to RBL were compared to a consecutive control group who received RBL alone in the preceding 3 months. Clinical data were collected prospectively for LA group and retrospectively for the control group. Data collected included analgesia administered during the procedure and in recovery, as well as the mean time to discharge. RESULTS A total of 32 patients treated with LA infiltration following RBL for haemorrhoids were compared with 22 patients who were treated with RBL alone. There was a reduction in the administration of intra-procedural parecoxib in the LA group (P

Background: The use of intraperitoneal local anaesthetic (IPLA) can be used to modulate visceral nociception after abdominal surgery; however, this technique is not routinely used in open abdominal surgery. The aim of this systematic review was to appraise the clinical effects of IPLA in open abdominal surgery for metachronous outcomes including pain, metabolic response to surgery and gastrointestinal function. Methods: A comprehensive search was conducted independently without language restriction. Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager Version 5.0 software. Postoperative clinical and metabolic outcomes of randomized controlled trials comparing IPLA versus no IPLA or placebo solution were used for meta-analysis. Results: Twelve trials were identified including eight randomized trials in gastrointestinal and gynaecological surgery. Post-operative pain was reduced but not opioid use. There was blunting of postoperative hyperglycaemia. There was no difference in post-operative cortisol response. Return of bowel function appeared to be quickened, although meta-analysis was not possible. Conclusion: The use of IPLA is safe and appears to have clinical benefits. However this technique has not been studied in optimized perioperative settings. Trials are needed to evaluate this method of visceral blockade further after major abdominal surgery.

Background: Where surgery has been preferred, the torn Achilles tendon (AT) has most commonly been repaired under general or spinal anaesthetic (GA). Repair using local anaesthetic (LA) has been reported, but does not appear to be widely used. Methods: We retrospectively reviewed 87 patients, following open repair using either GA or LA at Nelson Hospital, 2001–2005. Calf strength and ankle range of motion (ROM) were assessed. Subjective pain and function were assessed using the American Academy of Orthopaedic Surgeons Foot and Ankle Questionnaire. Complications, time off work and sport, time in theatre, and hospital were recorded. Results: Fifty-nine tendons were repaired under GA (68%) and 28 under LA (32%). Outcomes were similar for each group. There was no significant difference in strength and ROM. Foot and Ankle Questionnaire scores were similar. Total theatre time averaged 57 min for GA and 37 min for LA (P = 0.01). LA repairs (82%) were performed as a day case compared with 10% of the GA repairs (P = 0.01). LA patients had a quicker return to work. GA complications included two deep vein thromboses and two pulmonary emboli. One patient from each group had a re-rupture. Conclusion: A repair of the acutely ruptured AT under LA is at least as effective as repair under GA with regard to function, long-term pain and patient satisfaction. LA repair results in significant cost savings due to less theatre time, fewer anaesthetic costs, and a shorter hospital stay.

Background: Postoperative pain relief is of importance to both patients and surgeons. One of the simpler techniques is infiltration of the surgical incision with long acting local anaesthetic. The literature is confusing, with numerous reports attesting to the value of this approach and a similar number disputing the demonstrable benefits. Methods: A prospective, ‘blinded’, randomized trial was undertaken involving 18 females undergoing uncomplicated bilateral sapheno-femoral ligation. They received intraoperative bupivacaine infiltration into one or the other of their groin incisions. Postoperatively these patients were asked to assess a number of variables relating to their postoperative pain, each patient thereby acting as their own control. Results: There was no significant difference in the postoperative pain experience between groins infiltrated with bupivacaine and those not infiltrated. Two patients developed wound infections and both of these occurred on the sides which had been infiltrated with bupivacaine, however this was not statistically significant. There was no difference found in pain experience with respect to pre- versus post-incision infiltration. Conclusion: Intraoperative wound infiltration with bupivacaine is widely employed as a method of minimizing postoperative pain. This study was unable to demonstrate a benefit of employing the technique in terms of a reduction in the patient’s perception of pain. By having each patient act as their own control, we have avoided one of the major deficiencies of previous studies, namely, interpatient variability in assessment and perception of pain.

Background: The aim of the present paper was to evaluate the return to work and return to driving of a cohort of patients undergoing arthroscopic subacromial decompressions ± arthroscopic acromioclavicular joint excision. Methods: Arthroscopic subacromial decompressions ± arthroscopic acromioclavicular joint excision were performed in 68 patients between February 2000 and November 2000. All patients had symptoms of subacromial impingement ± acromioclavicular joint arthrosis for more than 6 months that had not settled with conservative treatment. All had positive local anaesthetic injection tests. All patients were followed up at 3 weeks and 3 months postoperatively. Their Constant−Murley score was measured preoperatively and at 3 weeks and 3 months postoperatively. Patients were asked to record when they had returned to work and when they had returned to driving. Results: Only one non-manual worker did not return to work within 6 weeks. Eighty-five per cent of manual workers returned to manual work within 3 months. Fifty-one patients held driving licences. The average time to return to driving was 28.9 days. Average preoperative Constant−Murley scores were 47.5 (20−67). At 3 weeks postoperation average Constant−Murley scores were 66.8 (40−92), and at 3 months 76.5 (48−99).

Anal stricture is an uncommon but well recognized complication following haemorrhoidectomy. Twenty-seven (3.8%) out of 704 (500 elective and 204 emergency) cases of haemorrhoidectomy performed at the Singapore General Hospital over a 24 month period had clinical evidence of anal stricture post-haemorrhoidectomy. Of the 27 cases, 15 had haemorrhoidectomy as an elective procedure while 12 had it performed as an emergency procedure (chi 2 = 3.26, 1 d.f., P > 0.05, not significant). The mean interval between surgery and presentation of anal stricture was 6 weeks (range 3-12 weeks). Eighteen of the patients were managed by anal dilatation in the outpatient clinic combined with bulk laxatives and a local anaesthetic agent. The other nine patients required a minor surgical procedure comprising either a lateral internal sphincterotomy (five) or an anoplasty (four) procedure. All patients were well, following treatment. None of these patients developed a recurrent stricture at follow up 3 months after treatment. It was concluded that although anal stricture following haemorrhoidectomy is rare, it should be detected and treated early in order to avoid pain and suffering, and treatment is usually successful.

Purpose To assess the efficacy of ‘Pinch Grafting’ on chronic ulcers, many which are vascular in origin (Arterial or Venous). Retrospectively and prospectively our experience will be presented. Methodology Over the last ten years chronic leg ulcers (15 cases a year) have been grafted in North West Regional Hospital, Mersey Campus, Tasmania. Age of these patients extends from 56 to 91 with a median age of 79. Most of these cases are grafted as outpatients and some of them done in wards, while the patient is admitted for other comorbid problems. Pinch grafts are done invariably with local anaesthetic. Pricking the anesthetized area (donor area) with a 22 needle a disc of 2–3 mm skin is tented and sliced by a no 20 blade, keeping tangential to skin surface. Discs are placed on the floor of prepared ulcers 4–5 mm apart. Many cases remain ambulant. Results 95% of the grafts take on 1st attempt and another 3% on the second attempt. No patient had any limitation for their comorbid problems. It was very easy to do: most junior staff of the team can do the procedure successfully. Conclusion Pinch skin grafts have been used for many of these patients with encouraging results. Pinch Grafting is a cost effective tool for healing chronic ulcers. 1 Factors influencing wound healing are multiple. 2 No particular dressing material is outstanding. 3 Pinch graft for chronic ulcers is a very practical and effective treatment. 4 Patient acceptance is high. 5 Very cost effective. 6 Can be given to GPs to use it as a primary care tool.

Purpose Doctors graduating from medical school are immediately faced with performing many clinical procedures. This study aimed to assess whether the introduction of a new procedural skills course for final year students increased their confidence in performing these skills at qualification. Methods Students attending the final year procedural skills course were asked to complete a pre-course, post-course and end of year questionnaire scoring their confidence and experience in each of the procedures. Fifteen skills were taught in a simulated setting including; instrument handling, suturing, knot tying, local anaesthetic administration, plaster application, rectal examination, male catheterisation, nasogastric tube insertion, arterial blood sampling and lumbar puncture. Results The questionnaires were completed satisfactorily by 60, 64 and 93 students at the precourse, postcourse and end of year times respectively. There was a significant improvement in confidence for the 15 skills taught at the postcourse and end of year assessments over the precourse values (p

All patients referred to the University Department of Surgery in Wellington with anorectal abscess were managed by simple de Pezzer drainage. The catheter used was between 3-5 mm in diameter and was inserted when possible under local anaesthetic. Ninety-seven patients have presented with anorectal abscess. After exclusion of those patients with intersphincteric abscess, 91 have been managed in this way with a male : female ratio of 2.8 : 1. a perianal abscess was present in 76 patients. General anaesthesia was necessary in 18 patients and 16 of these patients were admitted to hospital. Twelve patients were admitted for underlying medical problems. One patient had Crohn's disease. Over half of the patients had symptoms which had lasted for 4 days or less and 22 patients had antibiotics prescribed by their local practitioners. There was no past history of anorectal sepsis in 75 patients. Sixty-two of the catheters were removed in less than 15 days. Of the patients who were drained under local anaesthetic only eight said that the pain was so intolerable that they would opt for a general anaesthetic in the future. Thirty-five patients returned to their normal activities or work within 5 days and 68 were back at work 14 days after drainage. One abscess was inadequately drained. Twenty-two patients developed fistulae within the follow-up period. It is suggested that this simple technique is safe and reliable, is well tolerated by patients, results in minimal hospitalization and an early return to work.

Summary. 1. An improved arm-to-arm transfusion device is offered which provides for a continuous stream and avoids other disadvantages associated with syringes. 2. It is possible in a high percentage of cases to transfuse a pint of blood within six minutes of running time. 3. If cutting down on and canalization of donor's vein are permitted, the operation is easy and always successful. 4. The so-called speed shock to the recipient has not been observed. 5. The machine offers excellent alternative uses both as an aspirator and for massive injection of local anaesthetic, and of course in determining the flow and injection of citrated blood.