ASiT Innovation Summit E-Posters

doi:10.1308/rcsann.2026.0029

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

6 Enhancing ENT induction with conversational avatars: improving confidence and satisfaction in epistaxis care

Abstract

Aim

Traditional induction modules for resident doctors starting ENT rotations are passive, offering limited interaction. We developed an interactive, speech-driven AI avatar induction module for managing epistaxis and evaluated its impact on trainees’ confidence and satisfaction. We aim to determine whether participant engagement and satisfaction is higher with interactive AI avatars.

Method

A prospective single-group study recruited twelve resident doctors, who completed baseline surveys rating their self-confidence and satisfaction with prior induction methods. Following a 10-minute interactive avatar-led epistaxis tutorial and structured viva, post-module surveys reassessed confidence and measured satisfaction with the interactive experience. Differences between pre- and post-course survey data were assessed using the Wilcoxon rank-sum test, with p < 0.05 deemed significant.

Results

All participants completed pre- and post-course satisfaction surveys. In the participant group, 58.3% had no prior ENT experience, and 50% had no AI experience. Self-confidence scores did not improve significantly. However, there was a significant increase in engagement (median increase of 1.0 on the 5-point scale; p < 0.001) and general satisfaction with the induction module (median increase of 2.5; p = 0.007).

Conclusions

An AI avatar-delivered induction course substantially increased resident doctors’ self-reported engagement and was well received. Furthermore, AI based induction models are no difference in delivering content compared to traditional induction methods. AI avatar tutors show promise as scalable tools in surgical education, but further refinement—especially in assessment, feedback, and objective performance measures—is warranted to optimise effectiveness.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

7 How have generic large language models progressed in their ability to write clinical letters and manage patients in the virtual fracture clinic?

Amy Smith ^1,^✉, James Brock ¹, Rana Anss ¹, Charles Kimberley ¹, Claire Joyner ¹, Francesca Solari ¹, Tariq Yasin ¹, Arwel Poacher ¹

Abstract

Aim

To evaluate the progression of large language models (LLMs) and their ability to write clinic letters and management plans for common orthopaedic scenarios.

Method

Fifteen clinical scenarios were generated and GPT-4, Chat-GPT and GPT-3 were single prompted to write clinic letters and management plans. Letters were assessed for readability using the Readable Tool. Accuracy of letters and management plans were assessed by six independent blinded orthopaedic consultants.

Results

Readability was compared using Flesch-Kincade Grade Level (GPT-4:9.11;(SD 0.98);ChatGPT:8.77 (SD 0.918);GPT-3:8.47 (SD 0.982)), Flesch Readability Ease (GPT-4:34.26 (SD 7.91);ChatGPT:58.2 (SD 4.00);GPT-3,59.3 (SD 6.98)). GPT-4, Chat-GPT and GPT-3 produced accurate letters (Mean = 8.75/10 (SD 0.96), 8.7/10 (SD 0.60), 7.3/10 (SD 1.41)) respectively. GPT4 and Chat-GPT had a significantly increased letter accuracy compared to GPT-3 (p = 0.024, p = 0.019). Consultant-rated accuracy comparisons across 4.0, 3.5 and 3.0 revealed that ChatGPT-4 exhibited the highest accuracy for management plans (9.08/10 95%CI, 8.25-9.9). This represents a statistically significant progression of the ability of a large language model to provide accurate management plans from GPT-3 6.84 (95% CI, 5.41-8.27), to ChatGPT 7.63 to GPT4 (p < 0.0001).

Conclusions

This study shows that next generation LLMs are effective for generation of clinic letters which are readable and accurate. Further, LLMs can produce generic management plans that are often accurate, demonstrating their evolving improvement. Given these findings a specific LLM trained on accurate and secure healthcare data could be an excellent streamlining tool for clinicians in high demand areas such as virtual fracture clinics.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

39 The perfect AI research assistant: are ScholarGPT references more reliable than ChatGPT references?

Bisher Tulimat ^1,^✉, Omar Kiwan ², Mohammed Al-Kalbani ², Amr Musa ¹, Omar Edlebi ¹, Tyler Munro ²

Abstract

Aim

Artificial Intelligence (AI) is rapidly transforming academic research. However, concerns remain regarding the accuracy of AI-generated citations, particularly with ChatGPT. ScholarGPT, a newer model designed for academic use, has not yet been systematically evaluated. This study compares the reference accuracy of ScholarGPT and ChatGPT in medical literature.

Method

Fifty references were generated by each model, 40 related to orthopaedics and 10 to plastic surgery, across 10 query rounds. For each reference, the PubMed ID (PMID) and Digital Object Identifier (DOI) were requested. Each reference was manually verified to determine whether the article exists, and if the PMID and DOI were correct. Subspecialty categorisation was also performed.

Results

ScholarGPT achieved 100% accuracy, with all 50 references containing correct PMIDs and DOIs. In contrast, only 21 (42%) of ChatGPT’s references had both a correct PMID and DOI. Additional errors included 3 references with valid DOIs but incorrect PMIDs, 24 with valid PMIDs but incorrect DOIs, and 2 with both incorrect. No fabricated articles were found. ScholarGPT also demonstrated a more diverse topic distribution, while 88% of ChatGPT’s references were non-specific.

Conclusions

ScholarGPT significantly outperformed ChatGPT in generating accurate and verifiable academic references. While ChatGPT did not fabricate references, it frequently misattributed identifiers, posing risks to research integrity. ScholarGPT proved to be a highly reliable reference tool in medical research, offering accurate PMIDs and DOIs across all outputs. These findings support its use for generating references in academic and clinical settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

52 The role of artificial intelligence and machine learning applications in emergency surgery: a systematic review of diagnostic accuracy and clinical outcomes

Safa Baqar ^1,^✉, Adel Hamed ², Mohammed Elsaiegh ³

Abstract

The integration of AI into emergency surgical care represents a significant advancement in modern medicine. This field has developed rapidly.

We aim to evaluate the effectiveness of machine learning in identifying emergency patients and the effectiveness of AI methods in diagnosing them compared to conventional methods. We also aim to assess AI's capability in predicting complications and the need for surgical intervention.

The systematic review included research papers published between 2015 and 2025. Two independent reviewers analyzed articles following the Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, screening titles from five significant databases (PubMed, Web of Science, Scopus, Cochrane, and Embase).

This systematic review identified 19 eligible studies from an initial pool of 2791 publications. The results showed the significance of the application of AI across five key areas of emergency surgery: appendicitis management (five studies), emergency abdominal surgery risk assessment (five studies), acute abdominal pain and triage (two studies), bowel obstruction (four studies), and acute conditions of the gallbladder and mesenteric vessels (three studies). Machine learning models demonstrated promising accuracy rates compared to conventional methods in all the different aspects. This systematic review highlights the promising impact of AI and machine learning across emergency surgery domains. The models demonstrated remarkable accuracy (72-98%) across various applications. Most notably, AI tools showed superior performance in acute abdominal pain triage and risk assessment compared to conventional methods, suggesting their potential to enhance clinical decision-making in emergency surgical settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

93 AI-assisted cystoscopy for bladder cancer: current evidence and clinical potential (2020–2025)

Mazen Alsharief ^1,^✉, Abdullah Alawadi ¹

Abstract

Aim

White-light cystoscopy (WLC) is the gold standard for bladder cancer detection, but up to 20% of tumours are missed, particularly flat and small lesions [1,2]. Artificial intelligence (AI) has been proposed to improve diagnostic accuracy and reduce interobserver variability.

Method

Literature from 2020–2025 was reviewed for studies applying AI to cystoscopic detection of bladder tumours.

Results

Deep learning methods such as convolutional neural networks (CNNs) achieved area under the curve (AUC, a diagnostic accuracy measure) values up to 0.99 [3]. Sensitivities between 90% and 96% and specificities above 90% were consistently reported in validation datasets [4,5]. A multicenter trial using a residual network (ResNet)-based system demonstrated accuracy of 93.9% and sensitivity of 95.4% in real time [6]. Blue-light cystoscopy combined with AI further increased sensitivity over WLC alone [7]. Data augmentation improved robustness across institutions [8]. A prospective trial achieved sensitivity of 96% with stable specificity [9]. Reviews confirm AI reduces operator fatigue and interobserver variation [10,11].

Conclusions

From 2020–2025, AI-assisted cystoscopy demonstrated high sensitivity and specificity for bladder tumour detection, surpassing WLC alone [3–7]. Prospective randomised studies remain limited, but current evidence supports AI integration to reduce recurrence risk by improving lesion detection [1,2,10,11].

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

94 Risk-stratification machine learning (AI) models for microscopic haematuria (2020–2025)

Mazen Alsharief ^1,^✉, Abdullah Alawadi ¹

Abstract

Aim

Microscopic haematuria (MH) is present in up to 13% of adults, but urinary tract malignancy is detected in only 2–5% [1,2]. Risk-stratification models using machine learning (ML) may improve diagnostic pathways.

Method

Studies from 2020–2025 developing or validating ML-based risk prediction in MH were reviewed.

Results

Random forest algorithms achieved AUC 0.85 for cancer detection [3]. Gradient boosting reduced unnecessary cystoscopies by 30% while maintaining sensitivity at 95% [4]. Integration of urinary biomarkers increased predictive accuracy to AUC 0.9 [5]. A prospective cohort study validated ML calculators in 500 patients, outperforming guideline-based pathways [6]. Cost-effectiveness modeling showed ML reduced healthcare burden by up to 25% [7]. Reviews concluded ML consistently outperformed American Urological Association (AUA) guideline risk criteria [2,8].

Conclusions

Between 2020–2025, ML-based risk stratification for MH demonstrated superior accuracy over guideline-based approaches [3–6]. Adoption could reduce unnecessary invasive testing while maintaining cancer detection rates [1,2,7,8].

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

172 Bias in surgical artificial intelligence models: a systematic review of algorithmic fairness and surgical outcome

Marcus Owen Tsang ^1,^✉, Yiu Ka Nathaniel Leung ²

Abstract

Introduction

The integration of artificial intelligence (Al) into surgical care has demonstrated improvements in precision, efficiency and patient outcomes. However, persistent disparities across demographic groups raise concerns about systematic algorithmic biases affecting minority populations. This review examines the scope of these risks, the ethical implications of AI in surgery, and potential mitigation strategies.

Method

A scoping review was conducted using peer-reviewed literature from 2022 to 2024. Studies were included if they addressed bias in surgical AI or decision-support systems relevant to demographic disparities.

Results

Of 141 studies identified, 46 met the inclusion criteria. Bias was frequently tied to limited demographic representation in training datasets and insufficient reporting of variables such as race, ethnicity and socioeconomic status. This gap is attributed to inconsistent use of key fairness metrics, including statistical parity and equal opportunity, with limited consensus on surgical applicability.

Reviews highlighted the persistent underreporting of demographic data in AI training datasets and clinical validation, underscoring the lack of equity-focused evaluation in most clinical decision-support systems. Furthermore, most machine learning models function as “black boxes”, offering limited transparency for surgeons to assess health disparity risks.

Emerging frameworks such as HEAAL (Health Equity Assessment Across the AI Lifecycle) and JustEFAB (Justice, Equity, Fairness, and Anti-Bias) aim to promote transparency and equity throughout the AI development lifecycle, but widespread clinical adoption and validation remain limited.

Conclusions

Al is increasingly applied in the surgical field, but ethical and surgical implications demand scrutiny, and widespread adoption should be preceded by transparent, comprehensive evaluations of how demographic differences are addressed.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

199 BASSGPT: a grounded retrieval augmented generation large language model for spine surgery patients

Sayan Biswas ^1,^✉, Ved Sarkar ², K Joshi George ¹

Abstract

Aim

The cornerstones for disseminating information to patients includes physical patient leaflets and direct recommendations from healthcare professionals. The pre-, peri and post operative period for patients undergoing any type of spine surgery is often characterised by increased levels of health anxiety, and as such sources of reliable information and reassurance are necessary. Thus, the aim of this study was to create a reliable chatbot that patients undergoing spine surgery could utilise at any point in their journey to gain further information from.

Method

All patient leaflets were first concatenated into a single PDF file. A local server was created where a large language model (LLM) was able to read the PDF file and generate answers to the questions asked by the users. GPT-3.5-turbo was used as the test LLM, and its performance was evaluated against the state of the art GPT-4. This pipeline was then deployed as a website accessible via private access for the local trust.

Results

BASSGPT was developed as a custom retrieval augmented generation (RAG) LLM for spine surgery patients. A custom website was created where patients could interact with the chatbot. The performance of the LLM was evaluated on RAG specific metrics: context_recall: 0.9444, context_precision: 1.0000, context_entity_recall: 0.5771, faithfulness: 0.9444, answer_relevancy: 0.9371, context_relevancy: 0.1554, context_utilization: 1.0000.

Conclusions

The impact of such LLMs on enhancing patient care is continually growing. Models like ours that demonstrate low rates of hallucinations and high rates of context specific answers have the potential to improve patient health anxieties and allow faster dissemination of information.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

213 Evaluating ChatGPT-4's performance on the FRCS urology part a examination

Abdul-Hadi Kafagi ^1,^✉, Abdul Rhaman Kafagi ²

Abstract

Introduction

Large language models (LLMs) such as ChatGPT-4 are transforming medicine, but their performance in surgical examinations remains uncertain. ChatGPT-3.5 previously failed the Fellow of the Royal College of Surgeons (FRCS) Urology Part A exam (35%). We evaluated whether ChatGPT-4, with improved reasoning and accuracy, could meet the passing standard.

Method

ChatGPT-4 was tested on 240 FRCS Part A questions, aligned with the 2023 syllabus and structured into two mock exams. Accuracy and response times were benchmarked against expert standards.

Results

ChatGPT-4 achieved 74.5% (179/240), exceeding the pass mark, and completed the exam in 14.5 minutes (3.64 seconds per question vs ∼1 minute for humans). Domain performance varied: high in radiology (92.3%), stone disease (90%), urinary tract infections (89.5%), and basic sciences; low in paediatric (44.4%) and female urology (50%). Subspecialty gaps reflected likely training data limitations.

Conclusions

ChatGPT-4 successfully passed a high-stakes surgical exam, demonstrating rapid and accurate knowledge application. However, static knowledge, hallucination risk, and opaque reasoning constrain reliability. Its efficiency raises questions about the validity of current assessment formats and highlights the need to prioritise uniquely human competencies such as procedural skills, judgment, and ethics. Future models integrating multimodal data and real-time updates could improve clinical utility. While valuable as an educational adjunct, ChatGPT-4 should complement, not replace, human expertise in surgical practice.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

462 Intraoperative AI-enhanced optical/spectroscopic imaging in glioma surgery: a pooled analysis

Jesvin T Sunny ^1,^✉, Kriisan Manoharasundaram ¹, Neima Ebrahimian-Roodbari ¹, Sreevishnu Kalaga ¹, Kalista Lam ², Kevin Tsang ¹

Abstract

Objective

Over the past five years, artificial intelligence (AI) has gained traction in neurosurgery, particularly in neuro-oncology. This study evaluates the diagnostic accuracy and intraoperative utility of AI-enhanced Raman spectroscopy, stimulated Raman histology, and confocal laser endomicroscopy in glioma surgery through a pooled analysis of recent clinical studies.

Method

Eight peer-reviewed studies (2019–2024) involving 475 glioma patients undergoing resection with AI-assisted intraoperative optical technologies were analysed. Sensitivity, specificity, diagnostic accuracy, and input-to-interpretation time were extracted. Weighted means were calculated with inter-study variance.

Results

Six studies reported mean interpretation times of 1.9 ± 0.4 minutes from image or signal acquisition to tissue classification. Pooled sensitivity for glioma tissue was 93.5% (range 89.1–97%), while specificity for non-glioma tissue averaged 87.1% (82–92.3%). Deep convolutional neural networks demonstrated superior diagnostic accuracy compared with traditional machine learning approaches (94.6% vs 88.9%, p = 0.017). Notably, in studies without frozen section as the comparator, AI-enhanced Raman spectroscopy and stimulated Raman histology achieved concordance with final histopathology in 91–94% of cases.

Conclusions

AI-enhanced intraoperative optical and spectroscopic imaging provides consistently high diagnostic accuracy with rapid (∼2 min) interpretation times, reinforcing its value as a surgical adjunct in glioma resection. Beyond complementing intraoperative decision-making, these technologies show potential as an alternative to frozen section analysis, particularly in resource-limited settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

3 Trans-nasal oesophagoscopy: does it have a role in diagnosing malignant disease?

Jessica Larwood ^1,^✉

Abstract

Aim

Trans-nasal oesophagoscopy (TNO) is an alternative to oesophago-gastro-duodenoscopy (OGD) and direct laryngoscopy/oesophagoscopy. Unlike these procedures, TNO is routinely performed awake in the outpatient clinic. The purpose of our study is to determine whether biopsies taken through TNO reliably diagnose malignancy.

Method

Retrospective cohort study of patients who underwent TNO with biopsy at our institution August 2022 - November 2023. For each patient, demographic data, biopsy results and diagnosis were recorded. For patients with a final diagnosis of malignancy, the biopsy taken during TNO was recorded as adequate, inadequate, or indicative of diagnosis.

Results

61 patients had biopsies taken during TNO August 2022 - November 2023. Of the 61 patients, 16 were diagnosed with malignancy, and the remaining 45 had benign pathology. Of the 16 patients with malignancy, 11 were correctly diagnosed by biopsies taken during TNO. 1 patient had a biopsy taken during TNO that revealed SCC-in situ, and went on to have a formal diagnosis of invasive SCC. Biopsies taken during TNO from 4 patients were inadequate for diagnosis; these patients required further investigations. In our cohort, the sensitivity of TNO and biopsy for malignancy was 0.8.

Conclusions

Biopsies taken through TNO reliably diagnose malignancy; of the 16 patients with confirmed malignancy, 12 were either correctly diagnosed (11) or had an indicative diagnosis (1) using TNO. These patients were able to avoid general anaesthetia, sedation, and hospital admission. TNO is a valid alternative to OGD/direct oesophagoscopy/laryngoscopy for diagnosis of head and neck malignancy; with reliable results and logistic and clinical benefits.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

8 Mesorectal nodal threat to the circumferential resection margin predicts outcomes comparable to tumour-related CRM involvement in rectal cancer

May Thu Zin ^1,^✉, Oluwafemi Coker ², Khurram Rais ¹, Beenish Alam ¹, Shamsa Saleem ¹, Christopher Ray ¹

Abstract

Aim

Circumferential resection margin (CRM) involvement is a key predictor of local recurrence in rectal cancer. While tumour-related CRM threat is well studied, the prognostic impact of CRM threat from mesorectal lymph nodes (LN) is less defined. This study compares oncological outcomes between tumour- and LN-related CRM threat.

Method

A retrospective cohort of MRI-staged, non-metastatic rectal cancer patients diagnosed between January–December 2019 across WOSCAN was analysed. Patients were classified as: CRM-clear (CRM-C), CRM threatened by tumour only (CRM-T), or CRM threatened by lymph nodes only (CRM-LN). Outcomes were compared for 3-year local recurrence, metastasis, and disease-free survival (DFS).

Results

Of 261 patients, 151 were CRM-C, 85 CRM-T, and 25 CRM-LN. Among curatively treated cases, local recurrence rates were similar: CRM-T 4.7% vs CRM-LN 4.0%. Three-year metastatic progression was 12.9% vs 12.0%, respectively. DFS was 30.6% (CRM-T) and 40.0% (CRM-LN). Neoadjuvant therapy followed by surgery improved outcomes in both groups, with complete clinical response achieving excellent local control. CRM-C patients had the most favourable results.

Conclusions

Mesorectal nodal CRM threat carries a comparable oncological risk to tumour-related CRM involvement. These findings support incorporating nodal CRM threat into neoadjuvant treatment decision-making to optimise long-term outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

22 Long-term angiographic outcomes and clinical durability of endovascular treatment for indirect carotid–cavernous fistulas: a retrospective study

Sajjad Saghebdoust ^1,^2,^3,^✉, Daniel Kheradmand ², Samira Zabihyan ², Mohammad Hossein Mirbolouk ², Humain Baharvahdat ^4,^2,³

Abstract

Aim

To assess the immediate and long-term safety and efficacy of various endovascular treatment (EVT) strategies for managing indirect carotid-cavernous fistulas (CCFs).

Method

A retrospective review of electronic health records was conducted to identify patients with indirect CCFs who underwent EVT between 2013 and 2024. Data collected included demographics, clinical presentation, CCF characteristics, procedural details, and clinical and radiological outcomes. Comparative analyses were performed across endovascular approaches and embolic agents.

Results

Thirty-nine patients were included. EVT achieved technical success in 37 cases (94.8%). Immediate complete fistula obliteration was observed in 92.3%, with 18 patients (46.2%) treated using coiling alone, 12 (30.7%) with combined coiling and liquid embolic agents (LEAs), and 9 (23.1%) with LEAs alone. At ≥6 months follow-up, angiographic cure was confirmed in all patients. Procedure-related complications occurred more frequently in the LEA group versus the coiling group (28.6% vs 16.7%; p > 0.05). New cranial nerve (CN) palsies were significantly more common following LEA embolization compared to coiling (23.8% vs 5.6%; p < 0.05), with full recovery in 76.9% of cases. One patient experienced intracranial hemorrhage, and another suffered an ischemic stroke due to Onyx migration into the internal carotid artery. Ocular symptoms improved in 87.1% of patients.

Conclusions

Endovascular treatment offers high rates of angiographic and clinical cure in patients with indirect CCFs. Coiling appears to confer a lower risk of CN palsy compared to LEAs, supporting its role as a safer embolic option. Despite select complications, most patients experienced substantial long-term symptomatic improvement.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

31 Does the timing of ankle fracture surgery influence post-operative length of stay (LoS) and surgical complications

Farwa Raza ^1,^✉, Roderick Kong ¹, Shariff Hazarika ¹

Abstract

Aim

Ankle fractures are the third most common fracture, associated with high care costs and extended hospital stay. The delays in surgery can be attributed to a lack of trauma theatre availability and soft tissue swelling.

We aimed to assess whether the timing of surgery influences overall and post-operative length of stay (LoS) and complications.

Method

A retrospective review of 142 patients between August 2020-2021 admitted for ankle ORIF surgery with follow-up of at least 12 months, using the local database.

Time between admission and surgery was categorised within 48 hrs, 48-120hrs, > 120hrs. A comparison was made for demographic variables, injury characteristics, significant comorbidities, time to surgery, length of stay, and post-operative complications.

Results

According to the Kruskal-Wallis test, a significant difference was observed in the median overall and postoperative length of stay between the time to surgery groups, with the lowest at 48 hours and the highest at more than 120 hours.

Age was the only demographic factor associated with a significant increase in LOS as per Multivariate regression model.

12% of patients incurred a post-op complication; however, there was no association between time to surgery and a complication.

Conclusions

This large-scale study demonstrated no significant correlation between demographics, fracture pattern, and postoperative complications. However, a strong correlation was found between prolonging time to surgery and overall LOS and post-operative LOS. The study supports the drive for early surgical management of ankle fractures and local resource planning, within 48 hours of admission, to promote early mobilisation and discharge planning to reduce overall costs.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

48 A prospective observational study comparing retrorectus and anterectus mesh placement in incisional hernia repair

Havil Stephen Alexander Bakka ^1,^✉, Prathibha Kamepalli ², Kayaththery Varathan ³, Adele Zacken ⁴, Tharaga Kirupakaran ⁵, Daniel I Koshy ⁶, Sanjeevi Bharadwaj ⁷

Abstract

Background

Incisional hernias are a frequent complication following abdominal surgeries, significantly contributing to morbidity. Surgical repair using mesh placement has become the standard of care, with ongoing debates regarding the optimal anatomical plane for mesh placement. Even though the retrorectus plane advocated by Rives and Stoppa has become the choice of plane for most surgeons, it is not without recurrence. This prospective observational study compares the outcomes of incisional hernia repair using anterectus versus retrorectus mesh placement techniques.

Method

A total of 60 patients were enrolled from April 1, 2022, to April 1, 2024, at NRI Medical College & General Hospital, Vijayawada, India, divided equally into two groups. Group A included patients who underwent retrorectus hernioplasty, while Group B had anterectus hernioplasty. Parameters evaluated include epidemiological data, defect size, content, mesh size, operative time, postoperative pain, drain output, postoperative complications, hospital stay, recovery time, and recurrence rates.

Results

Results demonstrated a statistically significant advantage of the retrorectus approach with reduced operative time (160 ± 16 min vs. 216 ± 28 min; p < 0.0001), lower postoperative pain scores, decreased drain output, shorter hospital stays (5.6 ± 0.6 days vs. 15.7 ± 6.6 days; p < 0.0001), and fewer wound complications after a mean follow-up period of (17.4 +/- 4.7) months in group A and (18.3+/- 4.7) months in group B. Neither group had recurrences during the follow-up period.

Conclusions

This study concludes that retrorectus hernioplasty is superior to anterectus hernioplasty with less postoperative morbidity, shorter hospital stays, and accelerated patient recovery.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

95 Critical review of ICD-9 to ICD-10 system-based complication codes for measuring postoperative surgical complications using large administrative datasets

Radhe Shantha Kumar ^1,^✉, Tarsicio Uribe-Leitz ², George Molina ², Rachel Adler ², Clancy J Clark ³

Abstract

Aim

The 2015 transition from ICD-9 to ICD-10 in the U.S. aimed to improve diagnostic and procedural precision. However, no validated methodology exists for translating complication codes, posing a barrier to longitudinal surgical outcomes research. This study evaluates a structured approach to map ICD-9 to ICD-10 complication codes for high-risk operations including esophagectomy, pancreaticoduodenectomy, and hepatectomy.

Method

We developed an 8-step process using the CMS General Equivalence Mappings (GEMs), incorporating manual review and clinical adjudication. ICD-9 codes representing complications including cardiovascular, gastrointestinal, pulmonary, renal, infectious, systemic, intraoperative, wound-related, blood transfusion, and postoperative interventions were mapped to ICD-10 and classified as exact, approximate, or mismatch. This framework was applied to the National Inpatient Sample to evaluate postoperative complications before and after implementation of ICD-10.

Results

148 ICD-9 codes mapped to 774 ICD-10 codes. Clinical review identified 63.3% as exact, 33.9% as approximate, and 2.8% as mismatched. The proportion of postoperative complications declined for esophagectomy (50.6% to 44.5%, p < 0.0001), increased for pancreatectomy (44.3% to 46.4%, p < 0.01), and were unchanged for hepatectomy (33.4% to 32.8%, p = 0.53) across the ICD-9 to ICD-10 transition. For all operations, length of stay and in-hospital mortality were also lower in the ICD-10 era (all p < 0.05).

Conclusions

ICD-10 implementation improves capture of specific complications and reflects evolving perioperative care. However, significant discrepancies in code translation underscore the need for validated methods. Our proposed mapping framework enables reliable complication tracking across coding eras and is globally relevant, including the UK, as it prepares for the ICD-10 to ICD-11 transition.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

102 Comparison of short-term clinical outcomes between robotic, minimally invasive and open esophagectomy in esophageal cancer surgery: systematic review

Kayaththery Varathan ¹, Adele Zacken ², Praveen Surya Ravichandran ², Havil Stephen Alexander Bakka ^3,^✉, Mustafa Albayati ¹, Uzair Khan ⁴

Abstract

Background

Esophageal cancer is an aggressive disease traditionally managed with open esophagectomy (OE), a procedure associated with high morbidity and mortality. Minimally invasive esophagectomy (MIE) and robot-assisted minimally invasive esophagectomy (RAMIE) have emerged as alternatives, offering benefits such as reduced blood loss, shorter hospital stay, and quicker recovery. RAMIE additionally provides surgeons with three-dimensional visualization and improved ergonomics.

Objectives

This systematic review compares short-term outcomes of OE, MIE, and RAMIE, focusing on operative time, blood loss, anastomotic leak, recurrent laryngeal nerve injury, hospital stay, and mortality.

Method

Electronic databases (Cochrane, PubMed, EMBASE, PsychInfo, UpToDate, and OpenGrey) were searched using defined criteria. Eligible articles were assessed using the Newcastle-Ottawa Scale for non-randomised studies and the Cochrane Risk of Bias 2 tool for randomised controlled trials.

Results

Fifteen full-text articles involving 10,414 esophagectomy cases were included. Nine studies compared MIE with OE, four compared MIE with RAMIE, one compared RAMIE with OE, and one assessed all three. Most reported reduced blood loss and shorter hospital stay for MIE and RAMIE relative to OE, though operative time was generally longer. No consistent evidence supported reductions in anastomotic leak or recurrent laryngeal nerve injury. Four studies reported conversions to open surgery, with three specifying reasons.

Discussion

Both MIE and RAMIE appear safe and effective alternatives to OE, particularly for reducing blood loss and hospital stay. Further large-scale randomised controlled trials are warranted to evaluate long-term survival and quality of life outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

104 Content and face validity of a novel homemade laparoscope and laparoscopic camera navigation model: a pilot study

Kayaththery Varathan ¹, Adele Zacken ², Havil Stephen Alexander Bakka ^3,^✉, Tharaga Kirupakaran ⁴, Mustafa Albayati ¹, Uzair Khan ⁵, Sanjeevi Bharadwaj ¹

Abstract

Introduction

Laparoscopic surgery, introduced just over a century ago, has surpassed open surgery in popularity. While training resources exist for mastering laparoscopic skills, little emphasis is placed on camera navigation, a task that can limit surgical performance regardless of the surgeon’s expertise. This study aimed to validate homemade 0° and 30° laparoscopes and camera navigation models.

Method

Low-cost laparoscopes and navigation models were constructed. Eighteen participants with no prior camera handling experience completed three tasks with the 0° laparoscope (camera navigation, in-line orientation, opposite-line orientation) and one task with the 30° laparoscope (camera navigation). Performance times were recorded, and participants completed face- and content-validity questionnaires for both instruments and models.

Results

The homemade 0° and 30° laparoscopes cost £25 and £20, respectively, while the models totalled £2,760. Questionnaire scores indicated acceptable realism, with the lowest averages being 7.5 for laparoscopes and 6.9 for models. For the 0° laparoscope, average navigation time was 267 seconds; in-line orientation (61 seconds) was completed faster than opposite-line orientation (151 seconds). For the 30° laparoscope, mean navigation time was 134 seconds.

Conclusions

The homemade laparoscopes were inexpensive and, combined with the models, proved effective training tools for camera navigation. Improvements in model design may enhance cost-effectiveness and realism. Future studies should involve larger participant groups, assess long-term skill retention, and incorporate construct validity testing across novice, intermediate, and expert surgeons.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

134 Evaluation of high ligation operation in varicocele as regard to semen parameters, testicular functions and postoperative complications

David Safwat Thabet Abdelnour ^1,^2,^✉, Mohamed Mahfouz ¹, Wadie Boshra ¹, Peter Farag ²

Abstract

Background

Varicocele is the most common surgically correctable cause of male infertility and is associated with impaired semen quality and testicular dysfunction.

Objective

This study aimed to evaluate the outcomes of high ligation varicocelectomy (Palomo technique) in terms of semen parameters, testicular hormonal function, and postoperative complications.

Method

A prospective clinical study was conducted on 40 patients with clinically and Doppler-confirmed varicocele at Ain Shams University Hospital between March and October 2017. Indications for surgery included primary infertility, chronic scrotal pain, or both. Pre- and postoperative assessments included semen analysis, serum levels of LH, FSH, and testosterone, in addition to monitoring for complications such as recurrence, hydrocele, persistent pain, and testicular atrophy.

Results

The average operative time was 60 minutes for unilateral and 90 minutes for bilateral procedures, decreasing with surgical experience. Thirty-seven patients completed postoperative follow-up. Semen analysis revealed significant improvement in sperm concentration, motility, and morphology after surgery. Serum FSH levels decreased, and testosterone levels increased significantly postoperatively, while LH levels showed no significant change. No cases of recurrence or testicular atrophy were reported. Postoperative complications included wound infection in 7.5% of patients, transient headache in 10%, persistent pain in 5%, and hydrocele in 5%.

Conclusions

High ligation varicocelectomy is a safe and effective surgical option for patients with varicocele-associated infertility. The procedure improves semen quality and testicular endocrine function with minimal complications and no recurrence or testicular atrophy. Further large-scale studies are recommended to validate these results.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

228 Trends in the microbiological profile of prosthetic joint infections: are pathogens getting more sophisticated?

Emmanuel Oladeji ¹, Patrick Okonkwo ^1,^✉, Onyeka Omerenma ¹, Mohammad Alhashash ¹, Oghofori Obakponovwe ¹

Abstract

Background

Understanding the microbiological agents responsible for prosthetic joint infections (PJIs) and their antimicrobial susceptibility is critical for guiding empirical prophylaxis and initial treatment. This information is continually evolving, making it crucial to update local data regularly. This study analysed recent trends in causative microorganisms and their antimicrobial susceptibility patterns.

Method

We conducted a single-centre, ten-year retrospective cohort study of consecutive patients aged ≥18 years diagnosed with PJI between January 2014 and January 2024. Data were retrieved from a prospectively maintained database and patients’ electronic records. Extracted variables included demographic information and microbiological findings, including isolated organisms, polymicrobial infections, culture-negative status, and antimicrobial susceptibility.

Results

Eighty-seven patients were included (mean age 72 ± 10.8), 48 with hip and 39 with knee replacements. Seventy per cent had acute or subacute haematogenous infections. Staphylococcus aureus and coagulase-negative staphylococci were the most common pathogens, accounting for 58.6% of cases (p < 0.01). Gram-negative organisms were identified in 37.6% of culture-positive cases, particularly in acute infections (42.6% vs 23.1%). Twenty-seven cases were polymicrobial, more frequent in acute (34.4%) than chronic (23.1%) disease. Over time, isolation of Gram-negative organisms and polymicrobial infections increased. Complete antibiotic susceptibility was found in 60% of isolates, while multidrug resistance occurred in 19.5%.

Conclusions

Empiric prophylaxis and treatment regimens for PJIs must be tailored to the increasing prevalence of Gram-negative pathogens and polymicrobial infections, taking into account the local resistance patterns of the pathogens.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

250 Laparoscopy: a comprehensive approach for diagnosis and treatment of abdominal pain

Kulsum Maula ^1,^✉, Md Mustafizur Rahman ², Mohammad Emrul Hasan Khan ³, Md Nazmul Hasan ⁴, Md Nadim Ahmed ²

Abstract

Background

Laparoscopy is a minimally invasive technique for visualisation of the peritoneal cavity without creating large abdominal incisions. It has changed the treatment of abdominal pain in both emergency and elective settings. Many patients undergo exploration according to the conventional investigation; many are treated conservatively and discharged. However, in most cases, patients return with a recurrence or more definitive symptoms of pathology.

Aim

This study aims to evaluate the role of laparoscopy in the diagnosis and treatment of abdominal pain where clinical symptoms and routine investigations are inconclusive.

Method

A prospective, cross-sectional study was conducted over six months (March–August 2016). Thirty patients with undiagnosed abdominal pain, despite clinical examination and routine investigations, and who consented to laparoscopy, were included through purposive sampling.

Results

After laparoscopy, 93.0% (28) of cases had a definitive diagnosis, while 6.67% (2) of cases had no obvious pathology. At the time of diagnosis, 66.67% (20) of patients underwent laparoscopic surgery, and in 3.33% (1) of cases, they required conversion to laparotomy to treat the condition. Laparoscopic biopsy was taken in 16.67% (4) cases. In 3.33% (1) of the cases, a complication was observed related to laparoscopic port infection. The average hospital stay was 3.73 days, and the average operation time was 65 minutes.

Conclusions

Abdominal pain can be accurately, quickly and efficiently managed with laparoscopy. This procedure decreases the number of avoidable laparotomies while also improving diagnostic accuracy. Thus, physicians should consider diagnostic laparoscopy as the first invasive test for people with unknown abdominal pain.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

266 Prevalence, characterisation, and clinical impact of anaemia in patients with intermittent claudication: a retrospective analysis

Jae Seon Hong ^1,^✉, Grace Loy ¹, Ashwin Sivaharan ¹, Sarah Sillito ¹, Sandip Nandhra ^1,², Tamer El-Sayed ¹

Abstract

Aim

This study aims to investigate anaemia characteristics and clinical outcomes in patients with intermittent claudication.

Method

A retrospective analysis of 403 consecutive patients with intermittent claudication attending a tertiary vascular clinic over three months in 2023 was conducted. Primary outcomes included anaemia prevalence, characterisation, treatment patterns, and 24-month clinical outcomes: chronic limb-threatening ischaemia progression, major amputation, mortality, and symptom improvement following anaemia treatment.

Results

Among 403 patients, 307 (76.2%) underwent anaemia investigation, revealing anaemia in 54 patients (17.6% of investigated; 13.4% of total cohort). Male predominance was evident (77.8% vs 68.4% in non-anaemic, p = 0.187), with peak prevalence in males aged 70-79 years (32.3% vs 12.5% in <50 years, p < 0.001). Normocytic normochromic anaemia predominated (79.6%), while iron deficiency was identified in only 11.1%, though limited iron studies (33.3% of anaemic patients tested). Treatment gaps were substantial: 77.8% received no anaemia treatment despite potential benefits. Oral iron therapy demonstrated trends towards symptom improvement (70.0% vs 37.9% in untreated, OR = 3.82, 95% CI: 0.65-22.4, p = 0.141; NNT=3.1). Anaemia correlated weakly by significantly with bilateral claudication (66.7% vs 52.2%, p = 0.003). Survival analysis revealed significant composite endpoint differences (log-rank p = 0.045), with trends toward increased amputation risk (5.6% vs 2.4%, RR = 2.33, 95% CI: 0.52-10.4) and mortality (11.1% vs 6.3%, RR = 1.79, 95% CI: 0.68-4.71) in anaemic patients.

Conclusions

Anaemia affects one in five intermittent claudication patients and represents a significant treatment gap with 77.8% receiving no therapy. Iron therapy shows promise for symptom improvement (NNT=3.1), while anaemia associates with worse clinical outcomes. Systematic screening and treatment protocols warrant implementation in vascular practice.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

276 Two techniques,one goal: a prospective study on early postoperative outcomes between stapled and hand-sewn gastrojejunostomy in distal gastric cancer

Syeda Mehbuba Joty ^1,^✉, Ferdous Alam ¹, SM Syyed-Ul-Alam Sunny ¹, Noshin Saiyara ², Ashok Kumar Sarker ³

Abstract

Aim

To compare the efficacy and safety during early post-operative period after Stapled and Hand-Sewn Gastrojejunostomy in Distal Gastric Cancer.

Method

This prospective comparative study was conducted in the Department of General Surgery at Enam Medical College and Hospital and Shaheed Suhrawardy Medical College and Hospital, Dhaka, Bangladesh, from September 2022 to August 2024. A total of 120 patients undergoing gastrojejunostomy for operable distal (antrum & pylorus) gastric cancer were enrolled and divided into two groups: Group A (stapled, n = 60) and Group B (hand-sewn, n = 60). Baseline demographic, intraoperative and early postoperative outcomes were analyzed and compared using appropriate statistical tests.

Results

Baseline characteristics such as age, sex, BMI and ASA grades were similar between groups (p > 0.05). The stapled group had significantly shorter operative time (140.5 ± 15.2 vs. 165.3 ± 18.6 minutes, p < 0.001) and anastomotic time (18.2 ± 3.4 vs. 32.5 ± 5.6 minutes, p < 0.001). Time to appear bowel sound, initiation of oral intake and length of hospital stay were significantly improved in the stapled group (p < 0.01). Although surgical site infection and anastomotic leakages were slightly lower in the stapled group, the differences were not statistically significant. Clavien-Dindo complication grading showed comparable safety profiles in both groups.

Conclusions

Stapled gastrojejunostomy offers significant advantages in operative efficiency and early postoperative recovery without increasing complication rates, suggesting it may be a preferred technique for selected patients with distal gastric cancer.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

297 Bucks bites: a retrospective review of a single centre experience of bites to the hand

Vidhya Lingamanaicker ^1,^✉, Christopher Bricogne ¹, Colleen Lim ¹, Rebecca Shirley ¹

Abstract

Introduction

Animal and human bites can lead to severe infection and morbidity. The British Society for Surgery of the Hand (BSSH) guidelines recommend surgical debridement within 24 hours to prevent complications. This review reports clinical outcomes and assesses guideline compliance in a UK plastic surgery centre.

Method

In a 3 month period, 63 patients presenting with animal and human bites to the hand and their notes were reviewed. Data included demographics, bite type, time to debridement and admission duration.

Results

The median patient age was 49 years (IQR 36-63). Bite cases included 47 dogs, 13 cats,1 human and 2 other animals. Median time from injury to debridement was 2 days (IQR 1-3). 42.9% (n = 27) of patients received debridement within 24 hours, in compliance with BSSH guidelines. 19% (n = 12) required hospital admission for median 2.5 days (IQR 1-3), totalling 41 bed-days. Smoking was observed more frequently in admitted patients (25% vs 17.6%). Non-compliance with 24-hour guidelines occurred in 58.3% of cases requiring admission. Delays to debridement were due to late patient presentation and emergency department to surgical review time.

Conclusions

Bite injuries impose a considerable burden on plastic surgery services, with 41 total bed-days over three months. BSSH guideline non-compliance of 58.3% with delays to primary debridement as well as smoking were associated with increased admission rates and prolonged stays. Pathway optimisation targeting earlier presentation and expedited surgical review are needed to improve patient outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

316 Mean serum PSA levels before and after TURP: insights from BPH patients.

Kanwal Naz ^1,^2,^✉, Vikram Seetlani ², Mushtaq Hussain ^3,²

Abstract

Introduction

Benign prostatic hyperplasia (BPH) is an age-related condition characterised by progressive prostate enlargement. Ageing is associated with microvascular changes, inflammation, and oxidative stress, all of which contribute to BPH development. Prostate-specific antigen (PSA) levels are commonly elevated in BPH and may decrease following surgical intervention. This study aimed to evaluate mean serum PSA levels before and after transurethral resection of the prostate (TURP) in patients with BPH.

Method

An observational study was conducted over six months, from February to July 2022. Patients diagnosed with BPH who met inclusion criteria were enrolled. Informed consent was obtained. Serum PSA levels were measured preoperatively and reassessed on postoperative days 30 and 90. Data were analyzed to compare pre- and postoperative PSA levels, with statistical significance set at p < 0.05.

Results

Patient ages ranged from 55–75 years (mean 69.5). The mean preoperative PSA level was 9.35 ± 6.22 ng/mL. On day 90 after TURP, the mean PSA level decreased to 5.28 ± 3.68 ng/mL, reflecting a mean reduction of 4.07 ± 2.54 ng/mL. This reduction was statistically significant (p = 0.0001).

Conclusions

TURP is associated with a significant reduction in mean serum PSA levels at 90 days postoperatively. PSA may serve as a useful biomarker for evaluating the completeness of resection and postoperative monitoring in patients undergoing TURP for BPH.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

332 Exploring patient narratives on diaphragm dysfunction: a social media listening study

Sofia G Villavicencio Clayton ^1,^2,^✉, Amrita Bajaj ³, Rachael A Evans ^4,⁵, Edward J Caruana ^2,⁵

Abstract

Aim

Despite its significant impact, diaphragm dysfunction is often under-recognised and poorly understood by patients, who increasingly turn to online platforms for support and information. This study aims to systematically analyse patient-generated content with the objective of identifying prevalent concerns and information needs to inform patient-centred education and clinical communication strategies.

Method

A qualitative content analysis was conducted on patient-generated posts across four dedicated Facebook support groups between 1st July 2024 and 30th June 2025. Only data that was freely and publicly available was used.

Results

808 posts were reviewed, of which 27.6% (223) were excluded for lack of diaphragm-specific content. 72.4% (585) posts were included for thematic analysis. 36% (291) of initial posts were shared by women, with no gender data available for 46.2% (373) entries. Posts generated an average engagement of 9.0 (IQR 5-18) comments and 2.0 (IQR 1-4) likes. Among identified users 54.8% (443) posts were anonymous; contributors were primarily US-based (74.5%;272) with a small UK contingent (11.2%;41).

Information needs clustered around “Symptom Recognition” 23.1% (131) and “Treatment Options” 21.1% (120), followed by “Second Opinions & Access to Specialist Care” 14.1% (80) and “Diagnostic Pathways” 12.9% (73). Shortness of breath 16.5% (16) and pain 13.4% (13) were the most frequently reported out of 15 symptoms.

Conclusions

Patients with diaphragm dysfunction primarily seek information on understanding symptoms and treatment options. There is a perceived lack of reliable, accessible resources. This highlights a need for structured stakeholder engagement in the field to understand patient concerns and uncertainties and deliver this through appropriate pathways and resources.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

338 Technological versus clinical monitoring in breast reconstruction: a systematic review and meta-analysis

Amenah Dhannoon ^1,^✉, Zhen Yu Wong ¹, Alexander Zargaran ², Afshin Mosahebi ²

Abstract

Background and Aim

Monitoring of free flaps in breast reconstruction is critical for timely detection of vascular compromise and salvage of threatened flaps. This systematic review and meta-analysis aimed to evaluate whether technological monitoring provides advantages over clinical inspection in breast free flap reconstruction.

Method

A systematic search was conducted across major databases according to PRISMA guidelines. Eligible studies compared technological monitoring with clinical monitoring in breast reconstruction. Data on flap outcomes, reoperations, salvage, complications, and timing of re-exploration were extracted. Pooled risk ratios (RRs) and mean differences were calculated using a random-effects model.

Results

Seven retrospective cohort studies encompassing 4,157 breast free flap reconstructions (2,041 technological vs 2,116 clinical) were included. Technologies evaluated included tissue oximetry, implantable Doppler, microdialysis, and venous couplers. Pooled analyses showed no significant differences in fat necrosis (RR 0.99, 95% CI 0.67–1.48), partial flap loss (RR 0.89, 95% CI 0.41–1.94), or total flap loss (RR 0.68, 95% CI 0.22–2.11) between groups. The incidence of flap compromise requiring intervention was comparable (RR 1.06, 95% CI 0.71–1.59). However, technological monitoring significantly improved flap salvage success (RR 1.67, 95% CI 1.20–2.34) and enabled earlier return to theatre by approximately 24 hours (p < 0.01).

Conclusions

Technological monitoring does not reduce overall rates of flap loss compared with clinical inspection but improves salvage success and expedites re-exploration. These findings suggest that while clinical monitoring remains reliable and cost-effective, technological devices may offer additional benefit in selected settings by enhancing timely intervention.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

358 Complete versus incomplete percutaneous oblique distal closing wedge osteotomy for bunionette (Tailor’s Bunion) deformity correction: a comparative study

Sanjana Mehrotra ^1,^✉, Ayla Newton ², Mohamed Wasim Shaffe Ahamed ³, Lilanthi Wickramarachchi ³, Mohamed Sayed Yousef ³, Peter Lam ⁴, Thomas L Lewis ³, Robbie Ray ³

Abstract

Aim

There is increasing interest in the use of minimally invasive osteotomy techniques for bunionette (Tailor’s bunion) correction. This study investigated clinical and radiographic outcomes following unfixed, minimally invasive oblique distal diaphyseal osteotomy for bunionette correction, and compared results between complete and incomplete osteotomy groups.

Method

Forty-three feet (mean age 54.2 ± 17.1) underwent minimally invasive oblique distal osteotomy for bunionette correction by a single surgeon over four years. The primary outcome was significant postoperative callus formation (>150% of 5th metatarsal shaft width). Secondary outcomes included radiographic parameters [4th–5th intermetatarsal angle (IMA), metatarso-phalangeal angle (MPA)] and Patient-Reported Outcome Measures (PROMs) of Manchester-Oxford Foot Questionnaire (MOxFQ), EQ-5D-5L, and visual analogue scale (VAS) pain (minimum 12-month follow-up).

Results

Thirty patients had complete osteotomy, 13 had incomplete osteotomy with intact lateral cortex. In the complete group, 60% (p = .0003) showed callus >150% of the metatarsal width at 6 weeks, decreasing to 19% (p = .31) at 6 months and 0% (p = 1) at 12 months. All PROMs except EQ-5D-5L VAS improved significantly (p < .05). IMA and MPA decreased significantly postoperatively in both groups (p < .001). No significant radiographic or clinical differences were found between complete and incomplete osteotomies at follow-up.

Conclusions

Unfixed, minimally invasive oblique distal osteotomy for bunionette correction is safe and effective, significantly improving radiographic and clinical outcomes. Whether or not the osteotomy is complete does influence callus formation but does not significantly affect the radiographic or clinical outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

407 Reamed vs unreamed intramedullary nailing for fragility fractures of the proximal femur – a retrospective study

Sanjana Mehrotra ^1,^✉, Chiraag Pandya ², Meera Dackombe ², Dorin Iftinca ², Henry Lincoln ², Kathryn Virgo ², Kevin Wembridge ²

Abstract

Aim

Intramedullary fixation is a common treatment for proximal femur fractures but is associated with longer operative times and increased blood loss. These patients often have capacious femoral canals, and the decision to ream is surgeon-dependent, with little supporting evidence. This study compares operative time, transfusion rates, length of stay, and mortality between reamed and unreamed femoral nailing in fragility fractures of the proximal femur.

Method

A retrospective review was conducted of fragility fractures of the proximal femur (A2, A3, subtrochanteric) treated with intramedullary nailing at Rotherham District General Hospital (2022–2024). Exclusions were diaphyseal, atypical, and pathological fractures. Outcomes included operative time, transfusion rates, length of stay, complications, and mortality at 1, 6, and 12 months. Statistical analysis used χ² or Student’s t-test, significance set at 0.05.

Results

65 patients were included (37 reamed, 28 unreamed). Mean operative time was longer in the reamed group (107 vs 81 min, p = 0.003). Transfusion was required in 32 vs 16 patients (p = 0.01), with mean units transfused 2 vs 1.4 (p = 0.01). Length of stay was 18 vs 14 days (p = 0.05). There were no significant differences in age, Charlson Comorbidity Index, complications, or mortality at any time point.

Conclusions

Both methods are effective, but unreamed nailing was associated with shorter operative times, fewer transfusions, and shorter stay, without increased complications or mortality. These findings support considering unreamed nailing in frail elderly patients.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

425 Ten-year outcomes of bladder stone management at a UK tertiary centre: a retrospective data analysis

Neehar Shetty ^1,^✉, Joshua Xu ², Stephanie Croghan ¹, Tobias Page ¹, Alistair Rogers ¹

Abstract

Aim

We aimed to retrospectively analyse complications and outcomes of bladder stone treatment at a tertiary UK centre over 10 years, addressing the lack of large published datasets in this area.

Method

A retrospective review was conducted for all patients undergoing cystolithopaxy between January 2014 and December 2024. Demographic, operative, and post-operative data were collected.

Results

A total of 661 patients were included (87.3% male; median age 71 years). Of these, 21.4% had a neurogenic bladder and 35.6% were managed with a long-term catheter prior to surgery. Median stone number was 2 and median size 2 cm. Simultaneous bladder outlet procedures were performed in 1.6%, while 12.5% required one subsequently.

Operative techniques shifted over time:

2014–2018 (n = 274): 54.7% laser, 31.0% stone punch, 7.7% washout/stent grasp, 2.9% open, 2.2% PCCL.
2019–2023 (n = 343): 73.2% laser, 18.7% stone punch, 6.4% washout/stent grasp, 0.3% open, 0.9% PCCL.

Laser power was documented in 278 cases (median 30W, range 1–120W). Stone clearance was achieved in 97% after a single procedure. Median length of stay was 1 day (0–67), with 34% day-case and 37% next-day discharge. Complications were infrequent (7.0% Clavien-Dindo I, 0.9% II, 0.9% III; none grade IV–V).

Conclusions

Cystolithopaxy using higher laser power settings than typically employed in renal stone surgery is safe and effective, offering high clearance rates with low morbidity. This evolution has markedly reduced the need for stone punch and almost eliminated open cystolithopaxy.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

433 Safe and feasible in a low-income setting: complications of ultrasound-guided PCN assessed with the Modified Clavien System

Mushtaq Hussain ^1,^2,^✉, Muhammad Danial Iqbal ², Ahmad Waleed ², Tanzeel-Ur-Rahman Gazder ²

Abstract

Introduction

Percutaneous nephrostomy (PCN) is widely used for urgent upper urinary tract decompression but carries recognised risks. The Modified Clavien Classification System (mCCS) provides a standardised method of reporting surgical complications. This study evaluated the frequency and severity of PCN-related complications in a tertiary Centre within a low-income country.

Method

An observational study was conducted on patients aged 16–70 years who underwent ultrasound-guided PCN between August 2022 and February 2023. Demographics, comorbidities, and clinical variables were recorded. Patients were followed for 15 days post-procedure, and complications were categorised using the mCCS. Data were analyzed using descriptive statistics and chi-square testing for associations.

Results

Ninety patients were included (59% male, mean age 50.2 ± 14.7 years). Grade I complications were seen in 41.1%, grade II in 8.9%, grade IIIa in 12.2%, and grade IVa in 1.1% of cases, while 36.7% had no complications. Most events were minor and manageable. Higher-grade complications were rare, and no significant associations were observed with age, sex, BMI, insertion side, or comorbidities (p > 0.05).

Conclusions

Ultrasound-guided PCN proved to be a safe and effective procedure, with the majority of complications being low grade. In the context of a low-income country, these findings are reassuring, demonstrating that safe outcomes can be achieved despite resource constraints. The use of mCCS enables transparent and comparable reporting, supporting quality improvement and benchmarking across diverse healthcare settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

446 Evaluating the role of adjuvant chemotherapy in post-resection outcomes of pancreatic cancer

Marta Chacon Garcia ^1,^✉, Thrshegan Theivendrampillai ¹, Adam Frampton ^1,²

Abstract

Aim

Pancreatic cancer carries a poor prognosis despite potentially curative surgery and chemotherapy. This study aimed to assess the impact of adjuvant chemotherapy on survival outcomes following surgical resection.

Method

A retrospective analysis was conducted on 128 patients who underwent surgical resection for pancreatic cancer between 2016 and 2019 at a single institution. The median age was 69 years; 51 were female and 77 male. Follow-up ranged from 1 to 60 months. Histological subtypes included pancreatic ductal adenocarcinoma (PDAC, 66%), cholangiocarcinoma, ampullary, and duodenal cancers.

Results

PDAC patients had the poorest overall survival (OS), with a median OS of 25.7 months, while ampullary cancer had the best outcome (median OS 41.3 months; P = 0.07, not significant). Univariate analysis showed that incomplete adjuvant chemotherapy was associated with poorer OS in PDAC patients (P = 0.012).

Adjuvant chemotherapy was initiated in 79% of patients, and 58% completed treatment. A total of 9.5% declined chemotherapy, while 11.5% were unfit due to prolonged postoperative recovery. Patients who did not receive adjuvant chemotherapy had significantly worse OS (P = 0.0016).

Conclusions

The majority of patients commenced adjuvant chemotherapy, with over half completing treatment—aligning with existing literature. A small proportion declined or were unfit for therapy. These findings underscore the importance of preoperative counselling to emphasise the role of multimodal treatment in improving survival following pancreatic cancer resection.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

456 Does prior endoscopic management influence success of anterior urethroplasty?

Mushtaq Hussain ^1,^2,^✉, Kanwal Naz ², Syed Saeed Abidi ²

Abstract

Introduction

Male urethral stricture is a common urological problem, often initially managed with dilatation or direct visual internal urethrotomy (DVIU). While these procedures may delay definitive repair, their effect on subsequent urethroplasty outcomes remains debated. This study assessed whether prior instrumentation influences the success of anterior urethroplasty.

Method

A prospective cohort study was conducted between August 2021 and February 2022. Sixty-six male patients with anterior urethral stricture were enrolled and divided into two groups: Group A (no prior instrumentation) and Group B (history of dilatation or DVIU). All underwent anterior urethroplasty. Operative findings, blood loss, duration, fibrosis, and postoperative outcomes were recorded. Success was defined as a maximum urine flow (Qmax) > 15 ml/s on uroflowmetry at 3 months without need for further intervention. Statistical analysis was performed with chi-square testing.

Results

Trauma was the most common cause of stricture (Group A 81.8%, Group B 60.6%). Patients with prior instrumentation had greater intraoperative challenges, including increased bleeding (200–500 ml in 66.7% vs 15.2%, p < 0.001), longer operative times (≥2 h in 78.8% vs 12.1%, p < 0.001), and higher rates of fibrosis (75.8% vs 3.0%, p < 0.001). Despite this, urethroplasty success rates were similar: 96.9% in Group A and 87.9% in Group B (p = 0.163).

Conclusions

Prior dilatation or DVIU increases operative difficulty by lengthening strictures and causing fibrosis but has minimal impact on urethroplasty success when performed by experienced surgeons. These findings support early referral for definitive repair rather than repeated instrumentation.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

300 Acute otitis media in children with cleft lip and/or palate: a narrative synthesis of the literature

Kurchi Mitra ^1,², Sanjana Nair ^3,^✉, Maliha Kazi ¹, Sophie Butterworth ⁴, Jason Powell ^2,¹

Abstract

Aim

Disorders of the middle ear are common in children. Certain paediatric populations report a higher incidence, including children with cleft lip and/or palate (CL+/-P). Otitis media with effusion (OME) or glue ear has been extensively researched in this group. However, the burden of acute otitis media (AOM), which shares numerous risk factors and aetiological pathways, remains under-recognised and inconsistently reported. This narrative review aims to explore the current evidence regarding the prevalence, suggested pathophysiology, and management options for AOM in children with CL+/- P.

Method

A literature search was conducted using Medline (from 1946), Embase (from 1974), and the Cochrane Library via Ovid Online. Search terms included “cleft lip”, “cleft palate”, “acute otitis media”’, and related synonyms. Initial results identified 465 records, which were screened independently by two reviewers, after which a total of 25 studies were included.

Results

Despite variability in the reported prevalence, children with CL+/- P are more susceptible to AOM compared to the general population and experience a longer-lasting disease course. The heterogeneity in study design and terminology used to define otitis media in the literature adds to the complexity in interpretation. A wide variety of management strategies have been proposed; however, data on the effectiveness of these treatment strategies is limited.

Conclusions

Further research is warranted to establish evidence-based management pathways for this vulnerable group, recognising the crucial role of otolaryngologists within cleft multidisciplinary teams. This is essential in helping safeguard hearing and speech outcomes and help improve quality of life in children with CL+/-P.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

11 Pre-MDT flow project

Amina Akhtar ¹, Daniel Andreyev ¹, Krishmitha Jothy Govindaraju ^1,^✉, Pauline McCulloch ¹, Noel Thin ¹, Lee Dvorkin ¹, Romesh Navaratnam ¹

Abstract

Introduction

Since the launch of the National Cancer Plan in 2000, Multidisciplinary Team (MDT) discussions have become the gold standard for cancer management. However, increasing patient volumes and the growing complexity have made MDTs increasingly time-consuming and resource-intensive. This led to the introduction of the Pre-MDT meeting for patients scheduled for the colorectal MDT. This involves reviewing patients beforehand to ensure all necessary investigations are completed prior to the formal MDT discussion. The objective was to streamline the MDT process.

Method

A retrospective analysis was conducted, of MDT meetings before and after the implementation of the Pre-MDT system in late 2023. The following metrics were assessed: time to staging CT, colonoscopy, rectal MRI, formulation of the initial treatment plan, and time to treatment. Patients on surveillance pathway were excluded from the analysis.

Results

Following the introduction of Pre-MDT meetings, waiting times for key investigations reduced significantly. The average time to staging CT decreased from 39.3 to 23.4 days. Similarly, the average time to colonoscopy was reduced from 33.8 to 23.3 days. Patients requiring rectal MRI, the mean wait time dropped from 62.7 to 42.8 days. Importantly, the mean time to MDT decision-making also decreased from 91.9 to 59.9 days.

Conclusions

Introduction of Pre-MDT meetings led to faster completion of essential investigations, enabling more timely clinical decision-making and earlier initiation of treatment. Additionally, it improved efficiency of MDT discussions, thereby minimizing delays caused by incomplete investigations. The results of this project will guide us to create a standardised pathway, replicable for other departments of trusts.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

27 Forging a new frontier in neurosurgical research: a replicable leadership model for building research capacity in a low- and middle-income country setting

Sajjad Saghebdoust ^1,^2,^✉, Ali Fathi Jouzdani ², Mohammad Reza Rouhbakhsh Zahmatkesh ², Reza Zare ²

Abstract

Introduction

High-volume surgical centers in low- and middle-income countries (LMICs) represent a significant, yet often untapped, source of clinical research potential. In May 2021, our tertiary neurosurgery referral center in Eastern Iran, serving 10 million people, had no formal research program. This initiative aimed to build a sustainable, high-impact neurosurgery research enterprise from the ground up, led by the hospital's first-ever research fellow.

Method

A novel leadership model was implemented, fusing the clinical credibility of a top-ranked medical graduate with strategic management principles from a Healthcare MBA. This involved: 1) Securing competitive funding to ensure resource stability; 2) Establishing and leading a collaborative, non-hierarchical Multidisciplinary Team (MDT) including neurology, neuroradiology, and neuropsychology; 3) Fostering a research culture through dedicated mentorship; and 4) Creating sustainable infrastructure by establishing the region’s first patient registries for epilepsy and awake craniotomy surgery.

Results

Within three years, a dormant research environment was transformed into a productive academic unit. The team successfully disseminated research at prestigious international forums, including the EANS, IESS, and INNC congresses between 2022 and 2025. This work received significant peer recognition, culminating in a “Best Presentation Award” for our region's largest study on cavernoma-related epilepsy. The established registries now provide a foundational asset for long-term, data-driven research.

Conclusions

This initiative demonstrates that targeted leadership, combining clinical insight with management science, can successfully overcome systemic barriers to build a thriving research program in a resource-limited setting. This journey provides a replicable blueprint for empowering clinical champions and developing sustainable research capacity in LMICs globally.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

139 Early-stage innovation: artificial intelligence in flap perfusion assessment and monitoring

Mohammed Shakir ^1,^✉

Abstract

Aim

To explore the emerging role of artificial intelligence (AI) in flap perfusion assessment and monitoring, with a focus on early-stage innovations that may transform reconstructive outcomes.

Method

A narrative review of early feasibility studies and technical reports was conducted using PubMed and Google Scholar (2015–2025). Relevant literature on AI combined with indocyanine green (ICG) angiography, thermal imaging, near-infrared spectroscopy (NIRS), and wearable sensor platforms was synthesised. Outcomes of interest included accuracy of perfusion prediction, time to detection of flap compromise, and potential advantages over standard monitoring techniques.

Results

Preliminary studies suggest that AI-enhanced imaging can identify subtle perfusion deficits earlier than conventional clinical monitoring. Models trained on ICG angiography and thermal imaging datasets demonstrate high sensitivity in predicting ischaemic zones. Pilot work using AI-linked NIRS sensors shows promise for continuous, non-invasive monitoring with automated alerts. Reported benefits include earlier recognition of flap compromise, reduced reliance on operator expertise, and potential integration with telemedicine platforms. However, current evidence is limited to small series, single-centre prototypes, and retrospective data, with no randomised trials or standardised algorithms.

Conclusions

AI-assisted flap monitoring represents an early but exciting innovation in reconstructive surgery. While existing studies confirm feasibility, robust validation and cost-effectiveness analyses are lacking. Integration of AI into intraoperative imaging and postoperative monitoring may provide earlier detection of flap compromise, enhance patient safety, and support more efficient reconstructive workflows.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

176 Evaluating the role of simulation-based medical teaching on teaching core competencies in undergraduate surgical education: interim results of a randomised control trial

Aimee Brennan ^1,^2,^✉, Czara Kennedy ^1,², Hilary Coyle ¹, Philip McEntee ², Katherine Egan ^1,², John Cronin ³, Waqas Butt ^1,², Helen Heneghan ^1,²

Abstract

Aim

Undergraduate medical education still largely follows traditional structures, revolving around a mixture of didactic lecture-based teaching and clinical placement. Simulation-based education offers a safe, immersive environment to bridge theory and practice, yet evidence at the undergraduate surgical level remains limited. This study aims to evaluate the impact of simulation based medical teaching on the management of an acutely ill surgical patient at undergraduate level.

Method

This single-centre randomised controlled trial involved medical students during their core surgical module at St. Vincent’s University Hospital, UCD. Students were randomised to receive (1) didactic teaching only (control) or (2) didactic plus structured weekly simulation sessions (intervention). Simulations focused on common critically ill surgical presentations with structured debriefing. The primary outcome was competence in a structured OSCE station assessed by blinded examiners. Secondary outcomes included confidence and satisfaction, measured via validated surveys.

Results

Seventy-six students were randomised equally between the two study arms. Interim analysis demonstrated a trend toward higher OSCE performance in the simulation group compared with controls. Students in the intervention group reported greater confidence in managing acutely ill surgical patients, particularly in decision-making and team communication. Survey feedback consistently described the sessions as engaging, relevant, and highly valuable in bridging theory and practice. Satisfaction scores were significantly higher among students who participated in simulation.

Conclusions

Early findings strongly support the role of simulation-based teaching as an effective and highly valued adjunct to traditional methods. These results suggest that simulation should be formally integrated into undergraduate surgical curricula to better prepare students for clinical practice.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

189 Pilot evaluation of an AI-powered medication assistant for detecting drug–drug interactions in hospitalised patients

Roshan Ajeet Singh ^1,^✉, Wymin Sivakumar ¹, Derek B Hennessy ¹

Abstract

Aim

Polypharmacy is common and increases the risk of drug–drug interactions (DDIs). AI-driven prescribing assistants may improve detection accuracy and efficiency, particularly for severe interactions. We evaluated the performance of an AI medication assistant in detecting DDIs during a ward-based pilot.

Method

Nineteen inpatient medication lists were assessed using the AI tool. The number of medications, review time, and flagged DDIs were recorded. Interactions were categorised as green (moderate), yellow (cautionary), or red (severe). Independent clinicians verified flagged interactions, and confirmation rates were calculated.

Results

156 medications were reviewed across 19 cases (median 8, range 3–14 per case). The median review time was 31 seconds (IQR 23–47). The AI flagged a median of 2 DDIs per case (IQR 1–3; range 0–11), giving 49 potential interactions overall: 35 green, two yellow, and 12 severe. Both yellow alerts were confirmed, relating to central nervous system depression. Clinician review confirmed eight severe interactions, judged three as theoretical but pharmacologically valid, and downgraded one to non-severe, equating a positive predictive value of 92% when including theoretical risks. Severe alerts involved gastrointestinal bleeding, QT prolongation, and electrolyte imbalance. Theoretical alerts flagged hepatotoxicity with paracetamol or enoxaparin combinations. 6 of 19 patients (32%) had at least one true severe interaction.

Conclusions

The AI medication assistant showed high accuracy and efficiency in detecting severe DDIs in real-world ward use. All true severe interactions were identified, while false positives were uncommon and largely theoretical. These findings support a larger-scale evaluation to determine the impact on prescribing safety.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

252 From simulation to surgery: validating the chicken sternal cartilage model as a transitional tool in rhinoplasty training

Cheuk Ying Kyleen Kiew ^1,^✉, Anuska Shah ¹, Rananjay Singh ¹, Duncan Atherton ²

Abstract

Aim

This study aimed to evaluate the educational impact of a previously reported chicken sternal cartilage model for rhinoplasty simulation training by assessing changes in participant confidence, skill acquisition and the perceived realism and utility of the model.

Method

A prospective, single-cohort study was conducted with 20 medical students participating in a half-day rhinoplasty workshop which included a didactic lecture and a supervised practical session using the model. Pre- and post-workshop surveys assessed self-reported confidence and knowledge using 5-point Likert scales. Technical skills were evaluated by experienced surgeons using the Objective Structured Assessment of Technical Skills (OSATS) tool.

Results

Following the workshop, participants demonstrated significant improvements in theoretical knowledge (mean score 1.55 to 3.70, p < 0.01) and confidence in performing rhinoplasty (1.35 to 3.65, p < 0.01). OSATS scores showed consistent improvements across global, task-specific, and procedure-specific domains, including septal exposure (4.06 ± 0.93) and safe dissection (3.81 ± 1.05). Realism (4.45 ± 0.51) and overall experience (4.6 ± 0.60) were rated highly, with 100% of participants agreeing it facilitated skill acquisition.

Conclusions

The chicken sternal cartilage model is a valuable, realistic, accessible and cost-effective tool for rhinoplasty simulation. It significantly improves novice trainees’ knowledge, confidence, and technical skills in a controlled environment. Integrating this model into surgical curricula could bridge the gap between theoretical learning and clinical practice, particularly in early surgical training and in resource-limited settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

261 Progressive, low-cost simulation models to enhance undergraduate microsurgery exposure: a student-led conference

Rananjay Singh ^1,^✉, Cheuk Ying Kyleen Kiew ¹, Ameen Mahmood ¹, Anuska Shah ¹, Hasan Zaidi ¹, Tarek Kutaiman ¹, Vimal Gokani ²

Abstract

Aim

Microsurgery is a cornerstone of modern reconstructive practice but remains largely absent from undergraduate curricula, with students citing limited exposure and high training costs as key barriers. This study evaluated the educational impact of a hands-on, low-cost microsurgery conference on medical student confidence, knowledge, and skill acquisition.

Method

Thirty-three medical students attended a one-day conference combining consultant-led lectures with five progressive hands-on workshops, ranging from basic dexterity exercises to simulated nerve coaptation and vascular anastomosis on chicken thigh models. Delegates trialled magnification using loupes, smartphones, and microscopes. Pre- and post-conference surveys assessed knowledge, confidence, technical competence, and perceptions. Data were analysed using paired Wilcoxon signed-rank tests.

Results

72.7% of delegates reported no prior formal microsurgical exposure. Pre-conference knowledge and technical confidence were low across all domains (mean 1.44-2.08), with significant improvements observed post-conference in every area (all p < 0.001). Confidence in performing key technical skills, including chicken femoral artery anastomosis, increased from 1.47 ± 0.94 to 3.39 ± 1.20. OSATS scores corroborated these findings, with significant gains in knot technique, dissection, and coaptation (all p < 0.01). Simulation models were rated highly for realism and educational value (mean 4.1-4.2). Career interest in reconstructive surgery remained strong (4.03 ± 0.84), though perceptions of accessibility were moderate (2.69 ± 1.21).

Conclusions

A structured, student-led microsurgery conference significantly enhanced medical students’ confidence, technical knowledge, and skill acquisition. Adoption of low-cost progressive simulation models provides a reproducible, scalable, and accessible platform to democratise early exposure to microsurgery and support the next generation of reconstructive surgeons.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

283 Improving the induction experience for plastic surgery resident doctors through digital resources

Maysha Nowrin ^1,^✉, Angus McMillan ¹, William Clay ¹, Sharmila Jivan ¹

Abstract

Aim

When resident doctors rotate into new posts, unfamiliarity with departments, specialities, or hospitals can lead to significant anxiety. Typically, inductions are delivered in person, with little provision to revisit new material. We developed a novel approach to departmental induction to enhance the quality of trainee experiences.

Method

Experienced residents created 5-minute video presentations on documentation, plastic surgery acute pathology, and clinical skills. Videos were shared via Microsoft® Teams and linked to QR codes displayed on posters in the department. New residents received links prior to starting and could access the material at any time. An online survey was distributed to evaluate accessibility, usefulness and confidence levels before and after using the resources.

Results

Twelve resident doctors, FY2 to ST3+, completed the survey. Analysis showed residents found the videos helpful in easing their transition into the department. Confidence in identifying and managing common presentations increased. 71% felt the induction experience was better than other induction experiences they have had.

Conclusions

Utilising digital platforms increases familiarity with their new department and improves trainee experience, leading to increased confidence and quicker assimilation into the department. New residents add to the library of videos, giving them the opportunity to teach and add to their portfolios. Wider adoption of this approach across different departments has the potential to streamline information uptake and facilitate smoother transitions into clinical practice.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

296 Scalpel meet DIY: bridging the gap between simulation and surgical fidelity

Nicole Salgado Fernandez ^1,^✉, Guglielmo Piozzi ², Jim Khan ²

Abstract

Aim

Commercial suturing pads offer basic functionality for beginners but lack the realism of cadaveric or animal tissue. This project aimed to develop an affordable, high-fidelity suturing model—Sutura-Kaizen_TM—to enhance training accessibility for medical students.

Method

The model was evaluated through surveys distributed at multi-level surgical courses, involving participants ranging from medical students to consultants. Feedback was collected on robustness, aesthetics, suturing ease, and comparison to existing low-cost alternatives.

Results

Among 59 respondents, 51% were medical students, 32% surgical trainees, and 17% consultants. Robustness was positively noted by 88%, with only 6 responses indicating concerns on frailty. Regarding suturing ease, 50% found the model easy to use, 40% were neutral, and the remainder reported difficulty or did not respond. The model was described as “Beginner-Friendly” by 62.7% of participants, and 76.3% recommended it over current market options.

Conclusions

The Sutura-Kaizen_TM model demonstrates strong potential as a cost-effective, realistic alternative for suturing practice. Its positive reception across experience levels suggests value in early surgical education. Further validation and refinement are warranted to optimise its utility in broader training contexts.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

321 Novel method for successful placement of double lumen urodynamics catheters in men who are difficult to catheterise

Oluwabukola Olaitan ^1,^✉, Pravisha Ravindra ¹, Jaskarn Rai ¹

Abstract

Aim

Urodynamic studies are indicated in some men with lower urinary tract symptoms with an unclear diagnosis, previous surgery, planned surgery or neuropathic background. Insertion of a standard double-lumen urodynamic catheter can be complicated by prostatic enlargement, high bladder neck and/or urethral or bladder neck stricture. In our practice, we utilise a previously undescribed technique which can be used by urologists and trained specialist nurses for successful placement of urodynamic catheters in patients who are difficult to catheterise.

Method

When initial conventional blind passage of the urodynamic catheter is unsuccessful, a flexible cystoscope is used to navigate the urethra. A standard PTFE guidewire is passed through the flexible cystoscope into the bladder. A note is made of the length of scope (χ cm) in the bladder when the end is at the bladder neck just before it is removed, leaving the guidewire in the bladder. χ cm of an adjustable length ureteral peel-away access sheath is then passed over the guidewire and the inner dilator and guidewire removed. The remaining external sheath is then peeled away until the external urethral meatus, and the urodynamic catheter inserted through the sheath until the end is in the bladder. The remainder of the external sheath is then completely peeled away and removed, leaving the end of the urodynamic catheter in the bladder.

Conclusions

This technique has been successfully used in our department for carrying out urodynamic studies in patients who may otherwise be unable to benefit from the clinical information gleaned from the study.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

364 Neuroendoscopic trans-ventricular cyst drainage prior to tumour resection using a two-staged approach for cystic craniopharyngioma: a case-based review

Saeed Javid ^1,^✉

Abstract

Introduction

Craniopharyngiomas are rare, benign suprasellar tumours causing up to 3% of adult brain tumours. They present with symptoms of raised intracranial pressure, visual impairment, and endocrine dysfunction. They are classified into the more common adamantinomatous, and less common papillary tumours. Cystic variants may cause obstructive hydrocephalus, necessitating urgent intervention.

Case presentation

This video case-based review presents the case of a 61-year-old male, who presented with a two-month history of headaches, cognitive decline, and visual changes. Imaging revealed a large 2.8 × 2.2 × 2.2 cm suprasellar mass with cystic components extending into the third ventricle - consistent with a craniopharyngioma, causing bilateral foraminal obstruction and acute hydrocephalus. An urgent right frontal endoscopic septum pellucidostomy, cyst drainage, and ventriculoperitoneal shunt insertion achieved rapid symptomatic relief. Histopathology confirmed a WHO Grade 1 adamantinomatous craniopharyngioma. Following neurological stabilisation, a planned second-stage extended transsphenoidal resection achieved near-total removal. Postoperative radiotherapy was delivered to tumour residuum. Endocrine sequelae, including hypopituitarism and diabetes insipidus, were managed with hormone replacement. At one-year follow-up, the patient remained radiologically stable with no recurrence.

Discussion

A review of current literature further supports neuroendoscopic transventricular cyst aspiration as a temporising measure in cyst-dominant craniopharyngiomas, particularly in the setting of acute hydrocephalus. This strategy offers rapid decompression, symptom relief, facilitating safer, elective definitive surgery. However, as a sole intervention it is rarely curative, and recurrence risk remains high without subsequent resection and/or radiotherapy.

Conclusions

A planned, two-stage approach combining neuroendoscopic decompression with definitive tumour control represents a safe and effective management strategy for giant craniopharyngiomas.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

384 Adaptation of glue injection needle for haemorrhoidal sclerotherapy

Paras Batra ^1,^✉, Abhiram Sharma ¹

Abstract

Aim

Injection sclerotherapy with 5% phenol in oil remains an established treatment for early haemorrhoidal disease. Traditionally, this has required a dedicated haemorrhoidal injection needle, which is no longer available. Hence, we propose a new method of using the glue needle for the same.

Method

We describe an innovative adaptation using a 21G glue injection needle (InjectorForce Max, Olympus) introduced through a flexible sigmoidoscope for submucosal delivery of 5% oily phenol. Patients are positioned in lithotomy or left lateral decubitus, and sclerosant is injected at standard sites (3, 7, and 11 o’clock) under direct endoscopic visualisation. Aspiration is performed prior to injection to avoid intravascular administration.

Results

This approach ensures safe and accurate delivery of sclerosant with enhanced visual control. Readily available endoscopic equipment allows widespread adoption. The rigid needle design facilitates controlled submucosal injection. Direct endoscopic guidance reduces the risk of misplacement and improves safety.

Conclusions

Use of a glue injection needle via flexible sigmoidoscope represents a safe, practical, and readily available alternative to traditional haemorrhoidal injection needles. This innovation combines the proven efficacy of sclerosant therapy with the precision of endoscopic visualisation, supporting its role as a valuable adaptation in current practice.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

387 Has Optilume drug-coated balloon urethral dilatation for recurrent urethral strictures expanded our treatment options: a narrow follow-up snapshot

Neehar Shetty ^1,^✉, Ishtiakul Rizvi ¹, Jonathan Barclay ¹

Abstract

Aim

Optilume drug-coated balloon (DCB) urethral dilatation is a novel treatment for treating recurrent urethral strictures, combining mechanical dilation alongside intra-lesional paclitaxel delivery. We report our tertiary centre’s initial experience of patient treatment and review early outcomes.

Method

Electronic records were reviewed for all patients who underwent Optilume procedures between 2023–2024. Data collected included demographics, operative details, and follow-up outcomes.

Results

A total of 26 patients underwent Optilume, with only one intraoperative failure of dilation. Patients had a median of three prior endoscopic interventions (range 1–11). Twenty patients (80%) had required at least one endoscopic procedure within the last five years (mean 2.5; range 1–8). Pre-dilation was performed in 56%. All patients were able to discontinue intermittent self-catheterisation (ISC) post-procedure. Post-procedure flow testing showed an average Qmax of 16.8 mL/s and PVR of 56.4 mL; all patients achieved Qmax >10 mL/s and PVR <100 mL. Six-month follow-up was available for 19 patients, showing a recurrence-free rate of 79%, with no emergency presentations.

Conclusions

Our early outcomes are consistent with the ROBUST III trial, which reported a 74.6% six-month recurrence-free rate. Optilume appears to be a safe and effective option for a difficult patient cohort, which can delay, or possibly even replace, formal urethroplasty, as well as removing the need for repeated instrumentation. Longer-term follow-up is needed to see whether these encouraging results are sustained.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

477 Hearing preservation surgeries in management of endolymphatic sac decompression – a dying surgery in ENT?

Sarah Menezes ^1,^✉, Sreeshyla Basavaraj ¹

Abstract

Aim

To highlight the decline of endolymphatic sac decompression in the UK and encourage renewed awareness and increased training for this procedure.

Introduction

Ménière’s disease is a disorder, thought to result from endolymphatic fluid accumulation, causing disabling vertigo episodes with progressive hearing loss and tinnitus. Lifetime prevalence is estimated at 34–190 per 100,000. When medical therapy fails, endolymphatic sac decompression has been considered the first-line surgical option, endorsed in BMJ Best Practice.

Method

Telephone inquiries and discussions with ENT colleagues revealed that only four surgeons in the UK currently perform this decompression, three of whom have since retired.

Results

In personal series of 40 cases perform in the Isle of Wight, three required revision surgery, none developed hearing loss. These results align with international literature demonstrating safety and effectiveness, which reports vertigo control rates of 75–94% and hearing preservation in 70–88% of patients following endolymphatic sac decompression by Garcia et al in 2017. Huang’s 3,000 cases and Bento’s long-term study of 95 patients, confirm that vertigo can be effectively controlled while preserving hearing in most cases.

Conclusions

Endolymphatic sac decompression is safe and can be performed without any additional infrastructure, expect surgical skill. There are few remaining surgeons, minimal trainee exposure, the procedure might disappear as senior practitioners retire. Given its favourable safety profile and potential for hearing preservation, the loss of surgical expertise may limit treatment options for patients with refractory disease. It is vital for us to look at rest of the world and skills level rather than local or regional practices.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

20 Transformational leadership and team engagement in the neurosurgical operating theatre: a prospective, video-recorded observational study

Sajjad Saghebdoust ^1,^2,^✉, Ali Fathi Jouzdani ², Ghasem Soltani ³, Reza Zare ²

Abstract

Introduction

Strong leadership underpins safe, efficient surgical care, yet the influence of distinct leadership styles on neurosurgical teams remains undefined. In organizational theory, transactional leaders focus on tasks and compliance, whereas transformational leaders inspire, motivate, and foster engagement beyond baseline expectations.

Method

We prospectively video-recorded ten consultant neurosurgeons during complex cranial and spinal procedures. Two blinded raters (an organizational psychologist and a neurosurgical researcher) scored each surgeon’s leadership style using the Multifactor Leadership Questionnaire (MLQ). Independently, trained observers—also blinded to MLQ results—coded surgeon behaviors via the Surgical Leadership Inventory (SLI) and documented team behaviors (information sharing, cooperative actions, voice behaviors). Poisson regression models assessed associations between MLQ scores and observed behaviors, adjusting for operative duration and total behavior counts.

Results

Transactional leadership scores were uniformly moderate across the cohort (MLQ range 2.33–2.71), while transformational leadership varied substantially (1.92–3.73). Importantly, each one-point increase in transformational leadership was associated with more than a threefold rise in team information-sharing and nearly a fivefold rise in team voice behaviors (both p < 0.0001). Leaders with higher transformational scores also exhibited almost ten times more supportive behaviors and experienced over an elevenfold reduction in negative behaviors (both p < 0.0001).

Conclusions

Our findings provide a validated framework for assessing neurosurgical leadership and demonstrate that transformational leaders elicit markedly improved team engagement and supportive interactions in the operating room. Embedding transformational leadership training within neurosurgical curricula may enhance operative efficiency, team cohesion, and patient safety.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

21 Unmasking post-operative delirium in elderly neurosurgical patients: a closed-loop clinical audit to improve screening at a tertiary teaching hospital

Sajjad Saghebdoust ^1,^2,^✉, Ali Fathi Jouzdani ², Mohammad Reza Rouhbakhsh Zahmatkesh ², Reza Zare ²

Abstract

Introduction

Postoperative delirium (POD) is a frequent and severe complication in elderly neurosurgical patients, associated with increased morbidity, mortality, and healthcare costs, yet it remains profoundly under-diagnosed. This audit aimed to improve the rate of formal delirium screening in this high-risk population.

Method

A closed-loop clinical audit was conducted at the Neurosurgery Department of Taleghani Teaching Hospital. The standard was set at 100% of patients aged >65 years to be screened for delirium daily for the first three postoperative days using the 4 ‘A's Test (4AT). A baseline audit reviewed 50 consecutive patient notes. A multifaceted intervention was implemented, including mandatory 4AT screening integrated into nursing charts and targeted staff education. A re-audit of 50 patient notes assessed the impact.

Results

Baseline screening compliance with a validated tool was 4% (2/50). Most patients with documented altered mental status (n = 12) were described with non-specific terms like “confused.” Following the intervention, formal 4AT screening compliance increased to 88% (44/50) (p < 0.001). The rate of appropriate investigations (e.g., infection screen, metabolic panel) for patients with positive delirium screens increased from 8% (1/12) to 86% (12/14) (p < 0.001).

Conclusions

The implementation of a multifaceted quality improvement initiative, centered on the mandatory use of the 4AT tool, dramatically improved the detection and initial investigation of postoperative delirium in elderly neurosurgical patients. This demonstrates that systemic process changes can effectively bridge the evidence-practice gap in managing this critical patient safety issue.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

33 Restrictive bariatric surgery in focus: what’s next for endoscopic sleeve gastroplasty and laparoscopic sleeve gastrectomy

Swapnil Tripathi ^1,^2,^✉, Avinash Ray ³, Yash Sinha ¹, Saleem Noormohamed ¹, Alastair Reid ¹

Abstract

Aim

To systematically review and synthesise evidence from randomised controlled trials (RCTs), meta-analyses, and registry data comparing ESG and LSG in terms of weight loss efficacy, safety, recovery time, and impact on obesity-related comorbidities.

Method

A systematic search was conducted across PubMed, Embase, Scopus, and Cochrane Library for studies published between January 2020 and July 2025. Inclusion criteria were RCTs, meta-analyses, and registry-based studies reporting comparative outcomes for ESG and LSG. Data extraction focused on total body weight loss (TBWL), excess weight loss (EWL), complication rates, recovery time, and hormonal/metabolic changes. Risk of bias was assessed using Cochrane RoB 2, and certainty of evidence was graded using GRADE methodology.

Results

LSG demonstrated superior long-term EWL (60–70%) and TBWL (25–30%) at 2–5 years (1–3). ESG showed moderate efficacy with TBWL of 13–16% and EWL of 35–45% at 12 months, sustained up to 3 years. ESG had lower serious adverse event rates (<2%) and faster recovery (2–3 days) compared to LSG (5–10% adverse events; 2–6 weeks recovery). Both procedures improved glycaemic control, hypertension, and NAFLD, with LSG showing greater metabolic remission. Hormonal analyses revealed distinct patterns: LSG reduced ghrelin and increased PYY and adiponectin; ESG preserved ghrelin levels and improved insulin secretory dynamics.

Conclusions

ESG offers a safe, outpatient alternative to LSG with moderate efficacy and rapid recovery. LSG remains superior in long-term weight loss and metabolic impact. ESG may serve as a complementary option in tiered obesity management. Further head-to-head trials and mechanistic studies are warranted.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

51 Bariatric surgeries outcomes on geriatric age group: a retrospective study in Egypt

Michael Fahem ^1,^✉, Anasimone Zaki ², Cathrine Antonious ³, Mohamed abdelghani ², Peter Ayoub ⁴

Abstract

Introduction

Laparoscopic bariatric surgeries (LBS), especially sleeve gastrectomy, are widely performed globally, representing 46% of procedures across 51 countries. These surgeries significantly improve obesity-related comorbidities such as hypertension, diabetes, and sleep apnea. Candidates typically have a BMI ≥35, or ≥30 with associated conditions. Outcomes in geriatric patients (≥60 years in Egypt) are comparable to younger adults, with high satisfaction rates.

Aim

To evaluate one-year outcomes after LBS, focusing on remission of hypertension (HTN), diabetes mellitus (DM), obstructive sleep apnea (OSA), and gastroesophageal reflux disease (GERD), along with patient satisfaction and psychological effects.

Method

This is a retrospective analysis of patients from multiple Egyptian centers. Categorical variables were summarised as frequencies and percentages; continuous data were presented as mean (SD) or median (IQR) based on distribution (Shapiro-Wilk test). Chi-square and independent t-tests were used for comparisons.

Results

A total of 61 patients (47 females, 14 males) were included. Procedures included sleeve gastrectomy (47.5%), single anastomosis gastric bypass (47.5%), and Roux-en-Y bypass (4.9%). Preoperative comorbidities included HTN (70.5%), DM (42.6%), GERD (59%), and OSA (36.1%). At 12 months, remission rates were high: HTN 95.3%, DM 96.2%, GERD 91.7%, and OSA 100% (p < 0.001). Psychological disorders were present in 24.6%, not significantly different from expected rates. Mean BMI reduction was 15.2 kg/m² (p < 0.001). Satisfaction was high (86.9%, p < 0.001).

Conclusions

LBS provides excellent outcomes in elderly patients, with high satisfaction and significant remission of major comorbidities.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

174 The factors influencing the conversion from laparoscopic to open cholecystectomy at Muhimbili National Hospital

Esra Mohamed ^1,^✉

Abstract

Aim

To evaluate factors associated with conversion from laparoscopic to open cholecystectomy among patients undergoing laparoscopic cholecystectomy at Muhimbili National Hospital, Tanzania.

Method

A hospital-based retrospective cross-sectional study was conducted in the Department of Surgery, Muhimbili National Hospital, Dar es Salaam, Tanzania. Records of 230 patients who underwent laparoscopic cholecystectomy between 2023 and 2024 were reviewed. Data on demographics, comorbidities, operative indications, preoperative imaging, intraoperative findings, surgeon experience, and outcomes were collected and analysed.

Results

Of the 230 patients, 77.8% were female, with a mean age of 47.8 years. The most common comorbidity was hypertension. Cholelithiasis accounted for 89.1% of operative indications. Preoperative imaging predominantly included ultrasonography (62.1%) and MRCP (18.1%). Intraoperative findings correlated with preoperative gallbladder assessment in 40.4% of cases, while extensive adhesions were observed in 29.6%. The overall conversion rate to open cholecystectomy was 9.2%. Significant predictors of conversion included higher patient body weight (p = 0.04), surgeon experience level (p = 0.02), and intraoperative findings (p = 0.001).

Conclusions

Conversion from laparoscopic to open cholecystectomy at Muhimbili National Hospital was influenced by patient weight, surgeon experience, and intraoperative pathology. More experienced surgeons demonstrated lower conversion rates. Inflammatory changes, contracted gallbladders, and extensive adhesions were strongly associated with conversion. Optimising surgeon training and preoperative patient assessment may reduce conversion rates in similar LMIC settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

242 Pelvic floor reconstruction with retroverted uterus after extralevator abdominoperineal excision for rectal carcinoma: cost effective technique in select women useful in low- and middle-income countries

Shiva Pratap Unnenahalli Visweswaraiah ^1,^2,^✉, Gigi Varghese ^1,²

Abstract

Background

Primary closure of levator cuff for closing the perineal defect after ExtraLevatorAbdominoPerineal Excision (ELAPE) is technically not possible due to complete excision of the levator at its origin. ELAPE is associated with poor wound outcomes in terms of breakdown and perineal herniation. The large pelvic floor defect is bridged by local/distant flap or biological mesh which requires additional expertise and adds cost (biological mesh) to the procedure in resource strained countries. We describe an economical technique to address the pelvic defect using retroverted uterus to bridge the gap in 29-year-old female with T4N2M0 low rectal poorly differentiated adenocarcinoma who had neoadjuvant long course chemoradiotherapy.

Technique

ELAPE done in prone-jack-knife position. The retroverted uterus was used to bridge the defect and secured to pelvic sidewall as well using non-absorbable interrupted sutures. The post-operative course was uneventful and there were no perineal surgical site complications on follow up for up to 15 months.

Discussion

Retroverted uterus to bridge the pelvic defect after ELAPE is a cost effective and feasible technique in resource poor settings. This technique is not novel however best applicable only in post-menopausal women and in select pre-menopausal women who have completed neo adjuvant chemoradiotherapy and who had completed family (as in this case report). Positional menstruation, dyspareunia can be issues in pre-menopausal women.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

324 Diagnostic pitfalls in endemic regions: MEST mimicking hydatid disease

Mushtaq Hussain ^1,^2,^✉, Kanwal Naz ², Naveed Mahar ²

Abstract

Introduction

Mixed epithelial and stromal tumour (MEST) of the kidney is a rare neoplasm, representing only 0.2% of renal tumours. It typically occurs in females and often mimics other cystic renal pathologies. This case highlights the diagnostic challenges of MEST in a resource-limited setting, where hydatid disease is common.

Method

A 37-year-old female presented with right lumbar pain for three months. Laboratory evaluation revealed mild neutrophilia and borderline Echinococcus antibody titres. Ultrasound and CT imaging showed a multiloculated cystic renal lesion with daughter cysts, suggesting hydatid disease. The patient underwent nephron-sparing surgery with excision of the mass, and the specimen was sent for histopathology.

Results

Gross examination revealed a large encapsulated, multilocular cystic lesion. Microscopy showed biphasic proliferation with cystically dilated tubules embedded in spindle cell stroma, consistent with MEST. No atypia or necrosis was observed. The postoperative course was uneventful, and at six months follow-up the patient remained asymptomatic with no recurrence on imaging.

Conclusions

MEST of the kidney is a rare entity that can closely mimic hydatid disease, particularly in endemic regions. Accurate diagnosis requires histopathological confirmation, as imaging alone may be misleading. This case underlines the importance of considering MEST in the differential diagnosis of cystic renal masses and demonstrates the value of nephron-sparing surgery in management.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

436 Gender representation among surgeons working in low-income countries affected by conflict and war: a scoping review

Abdul Baseer Wardak ^1,^✉, Eilene Basu ²

Abstract

Aim

Global surgical data from Low-income countries (LICs) affected by war, especially in gender representation, amongst surgeons working in such low-resource, increasingly hostile environments, remains unsatisfactory. This study aims to understand better the extent of gender imbalances and barriers faced by underrepresented genders in all the surgical fields from the LICs affected by war.

Method

We conducted a scoping review by searching PubMed, Google Scholar, Medline, and grey literature databases like WHO, UN, MSF, ICRC, and other surgical organizations using key phrases such as “Gender disparity in Surgery”, “Low-income countries”, “affected by conflict”, and “war”. We included primary research studies, news articles, and reports. Data was extracted based on the stipulated inclusion criteria of key phrases and countries listed in the World Bank's directory of FY26 Fragile and Conflict-Affected States.

Results

We found that only three relevant studies showed statistical data about female surgeons from these regions. Syria had 37.3% female surgeons, sub-Saharan Africa had one-tenth of the surgical workforce, and Lebanon had only 1.63%. The preliminary results indicate minimal relevant data about other regions, no data about surgical specialty-based gender representation, and the remaining genders. Thematic synthesis showed recurring themes of 1) safety concerns, 2) influence of society, 3) cultural barriers, and 4) harassment.

Conclusions

Gender representation in surgery, especially in LICs devastated by war, has been typically overlooked in research. More inclusive practices in global surgical care are the need of the hour, by studying the intersection between conflict and limited resources to address the barriers for gender under-representation in surgery.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

2 Assessing the yield: investigating the incidence of significant findings on flexible sigmoidoscopies in patients with PR bleeding

Jessica Quimpo ^1,^✉, Muhammadtaaha Syed ¹, Umar Iftikhar ¹, Sophie Rushbrook ², Aditi Rane ³, Faddy Kamel ¹

Abstract

Introduction

Anorectal bleeding affects approximately 10% of adults in the UK and is most associated with benign colorectal conditions, such as haemorrhoids. Current guidelines from the European Society of Coloproctology and NICE CKS recommend endoscopic visualisation of the anal canal for patients presenting with new rectal bleeding to assess the condition and exclude other pathologies. The aim of this quality improvement project was to evaluate whether patients with fresh PR bleeding underwent flexible sigmoidoscopy, and to determine the incidence of significant findings requiring further investigation.

Method

Data from 99 patients seen in a general surgery clinic for PR bleeding between November 2023 and November 2024 were reviewed, with inclusion/exclusion criteria applied. This study excluded cases referred via 2-Week Wait pathway, and patients with suspected or known malignancy.

Results

All patients underwent flexible sigmoidoscopy. Results showed that 9% of patients had polyps, the majority presented with benign pathologies, including haemorrhoids (69.7%). 5% of patients required a full colonoscopy for further investigation of polyps.

Conclusions

The findings suggest the potential for over-investigation in cases of fresh PR bleeding where benign colorectal disease is most likely. Risk stratification could enhance referral specificity, avoiding unnecessary procedures, reducing costs, and improving patient satisfaction while maintaining diagnostic efficacy.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

10 The abscess pathway and how much it cost the NHS in a single centre

Yuki Julius Ng ^1,^2,^✉, Alshibshoubi Muhammad ¹, Chiara Rossi ¹, Maha Tariq ¹, Eleanor Carney ¹, Katrina Butcher ¹

Abstract

Aim

Operating theatres has been conservatively estimated to cost the NHS at a median of £16 min^-1 with a range of £12–20 min^-1 in 2011. The price tag to run operating theatres is expensive and therefore patient selection should be further scrutinised especially for simpler cases that may be done on the bedside such as abscesses. We aimed to provide a local recommendation and assess the expenditure of abscesses from 2021 to 2025.

Method

A 6-month retrospective review of abscesses was done in our trust which provided insights to develop a recommendation. We further collected data on types of abscesses done in the operating theatres from 2021 to 2025. The expenditure of abscesses was extrapolated over the years. These expenditures were adjusted to inflation rates with 3 different inflation rate indices, namely consumer product index (CPI), medical CPI and Hospital and Community Health Services Index.

Results

It is estimated that the trust has cumulatively spent a total median expenditure of £914,077 for abscesses in the department of General Surgery. According to the recommendations made, 48.6%(n = 188) were considered inappropriate. Inappropriate expenditure was £440,857 with a range of £326,190–657,641. If compared to the maximum cost of abscess treatment at Same Day Emergency Care (SDEC), which is £20 per patient without adjustment to inflation, it would cost just £3760 for the 188 patients.

Conclusions

The recommendations of this study could potentially save a median expenditure of £440,857 by treating patients in SDEC instead of the operating theatres.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

24 Enhancing patient and family education in post-operative neurosurgical care: a structured quality improvement initiative to reduce complications and improve satisfaction at a tertiary care center

Sajjad Saghebdoust ^1,^2,^✉, Ali Fathi Jouzdani ², Mohammad Reza Rouhbakhsh Zahmatkesh ², Reza Zare ²

Abstract

Introduction

The post-operative period for neurosurgical patients carries high risks of complications and readmission. Patient and family education can mitigate these risks, yet delivery is often inconsistent. This quality improvement project aimed to design, implement, and evaluate a structured, multi-faceted education program to reduce 30-day unplanned readmissions and improve discharge communication satisfaction in a referral centre.

Method

A prospective pre-/post-intervention study (January–July 2023) used the Plan-Do-Study-Act framework. Adult elective cranial neurosurgery patients were included. The pre-intervention cohort (n = 112) received standard care. Following a one-month training period, the post-intervention cohort (n = 108) received an educational bundle comprising a standardised low-literacy Farsi information packet with visual aids, structured pre-discharge counseling using the Teach-Back method, and a scripted follow-up phone call at 48–72 hours. Primary outcomes were 30-day unplanned readmission rate and patient satisfaction (HCAHPS-aligned). Secondary outcome was 30-day surgical site infection (SSI) rate.

Results

Groups were comparable in demographics and clinical characteristics. Thirty-day unplanned readmission fell from 17.0% to 6.5% (p = 0.015); SSI rate from 8.9% to 2.8% (p = 0.041).Satisfaction improved significantly: patients reporting physicians “Always” explained clearly rose from 67.0% to 88.9% (p < 0.001); provision of written “red flag” symptom information from 34.8% to 94.4% (p < 0.001); and mean self-management understanding from 3.5 to 4.6/5 (p < 0.001).

Conclusions

Implementing a structured, multi-component patient education bundle significantly reduced readmissions and SSIs, and enhanced satisfaction and understanding. This model offers a feasible, effective framework for improving neurosurgical care quality and safety in resource-constrained settings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

25 An improving quality in healthcare initiative: enhancing interdisciplinary communication during neurosurgical patient handovers using a standardised protocol

Sajjad Saghebdoust ^1,^2,^✉, Ali Fathi Jouzdani ², Soheil Saghebdoust ³, Reza Zare ²

Abstract

Introduction

Effective communication is a cornerstone of patient safety in neurosurgery, where unstructured patient handovers are a significant source of medical errors. Communication failures during these critical transitions pose a substantial risk. At Taleghani Teaching Hospital, observed inconsistencies in the interdisciplinary handover process prompted a project to improve the continuity and safety of care.

Method

A quality improvement project with a pre-post interventional design was conducted in the Neurosurgery Department of Taleghani Teaching Hospital from August to November 2024. A multidisciplinary team implemented the Taleghani Neurosurgical Handoff Protocol (TNHP), a standardised checklist integrating SBAR and I-PASS frameworks. The primary outcome was the Handoff Completeness Score. Secondary outcomes included staff satisfaction, handover-related communication errors, and handover duration.

Results

Following the intervention, the mean Handoff Completeness Score increased significantly from 7.5 to 13.8 out of 15 (p < 0.001). Staff-reported satisfaction with handover safety and efficiency improved markedly; the percentage of staff rating the process as “safe” or “very safe” increased from 18.0% to 66.7% (p < 0.001). Post-handover clarification calls, a proxy for communication errors, were also substantially reduced.

Conclusions

Implementing a standardised, evidence-based handover protocol produced significant improvements in the quality, safety, and efficiency of communication in a busy neurosurgical service. This initiative shows that a structured approach can effectively mitigate handover risks, enhance team collaboration, and foster a stronger culture of safety.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

28 Is it still PHPT? Evaluating normohormonal presentations in severe hypercalcaemia

Timia Raven-Gregg ¹, Yousuf Sabah ¹, Vlad Micu ^1,^✉, Richard Egan ¹

Abstract

Aim

Severe hypercalcaemia (serum calcium >3.0 mmol/L) is a serious biochemical abnormality with a broad differential diagnosis. Presentations with normal parathyroid hormone levels can create diagnostic uncertainty and therefore compromise patient management. We investigated patient diagnoses and outcomes following episodes of severe hypercalcaemia.

Method

We retrospectively analysed 250 patients with serum calcium >3.0 mmol/L identified from biochemistry records (2022/23). Parathyroid hormone (PTH) levels were reviewed and stratified, and underlying diagnoses and investigations were interrogated as well as patient outcomes.

Results

PTH levels were recorded in 64% of patients; 30% were normohormonal, 34% had high PTH and 36% had suppressed PTH levels. Overall, the mortality rate was 51%, 79% died within 12-months. Within the normohormonal cohort, 22 patients had primary malignancy, 8 patients were under the care of the renal team, 5 had orthopaedic conditions, and only 3 patients were diagnosed with primary hyperparathyroidism. Other diagnoses included pituitary adenoma (n = 1), milk-alkali syndrome (n = 1), legionella infection (n = 1), sarcoidosis (n = 1), cardiac event (n = 1), and spontaneous bowel perforation (n = 1). In four patients, no cause was found despite investigation.

Conclusions

In this study, hypercalcaemia is associated with poor short-term prognosis. A small proportion of patients with hypercalcemia and normal PTH may be considered to have primary hyperparathyroidism. This study highlights the importance of prompt endocrine workup and careful interpretation of “normal” PTH values in the context of severe hypercalcaemia.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

30 Optimising outcomes in geriatric emergency laparotomy: a quality improvement initiative for consistent COTE consultant review

Kulsum Maula ^1,^✉, John Vu ¹, Colette Thompson-Reil ¹, Roy Miller ²

Abstract

Introduction

The National Emergency Laparotomy Audit (NELA) aims to improve care quality for patients undergoing emergency laparotomy, providing high-quality comparative data. NELA states that all COTE (Care of the elderly) patients should undergo a COTE review in the perioperative period. However, Current NELA data shows: 1 in 5 have a frailty assessment; 1 in 3 are reviewed by a geriatrician; average length of stay = 15.2 days. At this hospital, COTE reviews are conducted on an ad hoc basis, with no formal integration into General Surgery.

Aim

To review COTE patients who underwent emergency General Surgery from April 2023 to April 2024, to assess local adherence to NELA guidance.

Method

This was a retrospective audit conducted over 1 year. Seventy patients who met the inclusion criteria were included in the study (out of 289 COTE General Surgery patients). Patient cohort was identified through the main theatre clerk.

Inclusion Criteria

All emergency laparotomy and laparoscopy procedures, including: adhesiolysis; Hartmann’s procedures; bowel resections.

Results

Only 4% of patients received a COTE review in the perioperative period, significantly below the national average of 33%. However, 65% had a Clinical Frailty Score recorded—exceeding the NELA-reported 20%. Patients without a COTE review had higher 30-day mortality and longer hospital stays.

Conclusions

This audit highlights a gap in current practice. While logistical barriers exist, we recommend allocating a dedicated COTE consultant to General Surgery patients meeting NELA criteria. Increasing team awareness of NELA recommendations is essential. A re-audit is planned in six months to assess progress and impact.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

34 Saving time for ENT doctors with innovative emergency on-call bag

Peter Eves ^1,^✉, Syed Wajih Ul Hassan ¹

Abstract

Aim

First on-call ENT doctors lost a lot of time whilst on call due to returning to the outpatient clinic for emergency equipment. We decided to introduce an ENT on-call bag that would contain everything required. Our goal was to reduce the time wasted by 95%.

Method

We first established interest in the project and collected baseline data through a survey. All first on-call doctors who responded felt the situation was frustrating and unprofessional. We found an appropriately sized bag that was ergonomic and was easily accessible. We established where the bag would be kept and introduced the innovation. After a month of use we re-surveyed the relevant doctors. Clarity over what exactly should be kept in the bag, as well as who and when the bag would be restocked clearly was an issue. This was resolved by recruiting the nursing axillaries who stock the clinic room to also stock the bag using a checklist. After a further month a final survey was completed.

Results

Time lost was reduced by 85 minutes per doctor per month to 2 minutes, representing a 97.6% reduction, exceeding our aim. No significant loss in nursing axillary time was noted.

Conclusions

We saved 9 hours 45 minutes of first-on-call doctors’ time per month and also reduced the likelihood of expensive equipment loss. The use of a bag for equipment may also appear more professional to patients. If this project was successful in our ENT department it may be of value in other units/specialties.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

37 Circumcised foreskin – to routinely send or not send for histopathological analysis?

Charles Ojo ^1,^✉, Laura McAuley ¹

Abstract

Introduction and Aim

Routine histopathological analysis of circumcised foreskin remains debated, with studies both supporting and opposing the practice. To date, there is no British Association of Urological Surgeons (BAUS) policy addressing whether foreskin specimens should be routinely submitted for histopathological analysis. We aimed to evaluate whether histopathological examination of circumcised foreskin altered patients’ management, in order to assess the value of routine submission.

Method

Following clinical governance approval, a list of patients who underwent circumcision in Southern Trust, Northern Ireland from October 2024 to March 2025 was retrieved (n = 50). Each patient’s electronic medical records was examined for intra-operative findings, histopathology results and subsequent changes in trajectory of care.

Results

48 patients had no clinical suspicion of cancer - histopathology showed “inflammation not Balanitis-Xerotica-Obliterans (BXO)” in 26 cases, BXO in 12 cases, and no histopathology was requested in 10 cases. Two patients were clinically suspected to have penile cancer; in both, histopathology was performed and confirmed malignancy. Those without cancer were discharged whilst patients with penile cancer were referred to specialist penile cancer team for further management.

Conclusions

Clinicians’ suspicion of malignancy accurately guided histopathology requests in the two cases where cancer was suspected, demonstrating satisfactory diagnostic acumen. In the 76% of patients where cancer was not suspected, histopathology was still performed and none had cancer - they were all discharged. Our findings suggest that in the absence of suspicious clinical features, routine histopathological analysis rarely changes care and may represent unnecessary use of resources. Selective submission, guided by clinical judgement appears safe and more cost-effective.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

70 Assessing referral appropriateness for torus (buckle) and minimally displaced clavicle fractures to a paediatric virtual fracture clinic

Edward Roberts ^1,^✉, Laura Deriu ²

Abstract

Aim

Local guidance supports first-contact discharge with safety-netting for torus (buckle) and minimally displaced clavicle fractures (MDCF). Nevertheless, our Virtual Fracture Clinic (VFC) reports referrals for these injuries, resulting in avoidable costs.

Method

Retrospective audit of all paediatric VFC referrals at a large UK teaching hospital during June–September 2023 and June–September 2024. Electronic records (PPM+) identified children with torus fracture or MDCF discharged at VFC without additional intervention; cases needing further management were excluded. Primary outcomes: (i) proportion of all VFC referrals that were buckle/clavicle fractures (BFC). Secondary outcome: overall share of ED-originating BFC among all VFC referrals. An exploratory cost analysis quantified associated resource use, using only time-driven costing.

Results

2023 (n = 1,050): 9.52% BFC: 5.05% of all VFC referrals were ED-originating BFC (53 contacts)—2024 (n = 1,174): 8.52% BFC: 4.94% were ED-originating BFC (58 contacts). The per-case processing cost under current practice (consultant: 5 minutes; CNS: 8 minutes; admin: 5 minutes; £60, £25, and £12 per hour) was approximately £9.33. The July–September workload, therefore, consumed £494 in 2023 and £541 in 2024, plus 4.42/7.06/4.42 hours (consultant/CNS/admin) in 2023 and 4.83/7.73/4.83 hours in 2024.

Conclusions

A persistent gap between protocol and practice generates avoidable VFC cost and staff time burden. Quantifying this burden supports prevention of inappropriate ED-VFC referrals through reinforcement of existing guidance, refreshed safety-netting, more explicit red-flag criteria, and focused ED teaching, while monitoring unplanned reattendance and outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

103 Comparison of ward round notes before and after the introduction of an electronic note system

Gianluca Fiorentini ^1,^✉, Rebecca Wharry ¹, Michael Stokes ¹

Abstract

Introduction

On 8 May 2025 the Western Health and Social Care Trust became the final trust in Northern Ireland to transition from a paper-based system to an electronic system. This review assessed ward round compliance against predefined standards, both prior to and following the implementation of an electronic note system.

Method

A retrospective review examining ward round notes compiled across three Trauma and orthopaedic wards was conducted over the course of a week, preceding the introduction of an electronic note taking system. A month following deployment of the electronic system the retrospective review process was repeated. The RCS Edinburgh guidelines for the key components of a surgical ward were utilised to establish our criteria.

Results

Following implementation, increased compliance was observed across several points; time (94% to 100%), observations (45% to 97%), overnight updates (33% to 70%), plan (97% to 100%) and who documented the note (52% to 100%). A decline was observed in naming of the ward round lead (100% to 92%) and documentation of diagnosis (97% to 85%). Overall compliance demonstrated an average increase from 77% to 93% following the introduction of the electronic notes system.

Conclusions

This audit has demonstrated an overall improvement in the quality of ward round notes within our trauma and orthopaedic department subsequent to the introduction of an electronic note taking system. This was an anticipated result and in keeping with current literature.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

148 Audit of testicular torsion management, comparison with BAUS FIX-IT guidance

Milad Shaheen ^1,^✉, Toby Murray ¹, Akinlolu Oluwole-ojo ¹, Panagiotis Papikinos ¹

Abstract

Introduction

Testicular torsion is a time-critical urological emergency requiring exploration ideally within 6 hours to maximise salvage. The British Urology Researchers in Surgical Training (BURST) and BAUS published the FIX-IT consensus guidelines in 2022 to standardise best practice in scrotal exploration. We conducted a retrospective audit at our hospital comparing local practice with FIX-IT standards.

Method

A retrospective review of all scrotal explorations between April 2024–April 2025 was performed. Data were obtained from theatre logs and operation notes, assessing demographics, intra-operative findings, management, and documentation of bell clapper deformity. Outcomes were benchmarked against FIX-IT recommendations.

Results

105 cases were reviewed, including 15 confirmed torsions. All but one torsion underwent bilateral orchidopexy; however, in equivocal cases, unilateral fixation was often performed without contralateral exploration. Overall, 26% (28/105) of cases deviated from FIX-IT, mainly due to omission of contralateral exploration. Documentation was inconsistent, with bell clapper deformity recorded in only 3.8% of operation notes.

Discussion

Strengths included timely exploration, with only one orchidectomy required due to late presentation. Areas for improvement include adherence to FIX-IT guidance and comprehensive operative documentation. Limited recording of anatomical findings may compromise future care and medico-legal defensibility.

Quality Improvement

A digital operative template for scrotal exploration is being developed to standardise documentation, improve compliance with FIX-IT, and enhance communication of intra-operative findings. Re-audit is planned within 6 months.

Conclusions

Timeliness of intervention was good, but adherence to consensus standards was variable. Implementation of a structured proforma should sustainably improve both practice and documentation, aligning with national guidance.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

151 The financial and strategic impact of accurate coding in elective orthopaedic surgery: a retrospective audit

Rukayya Usman ^1,^✉, Hosain Hadi ¹, Canan Metin ¹, Ezidinma Nwankwo ¹, Mihaela Piciorea ¹, Mina Samir ¹, Abid Mahmood ², Satish Janipireddy ¹, Mike Kurer ¹

Abstract

Aim

Healthcare Research Group (HRG) codes are essential tools used by NHS hospitals and funding bodies for governance and financial planning. These codes depend on accurate documentation of procedures, patient comorbidities, social history, and inpatient journeys. This project evaluated the implications of improving coding accuracy in elective orthopaedic cases.

Method

A retrospective review of elective orthopaedic cases, including minor to major procedures, at North Middlesex University Hospital NHS Trust. Clinical documentation (notes, discharge summaries, referral and operation notes, and anaesthetic pre-assessment records) was analysed for information on procedures, comorbidities, Body Mass Index, inpatient journey, mobility, and social history. This data was provided to the hospital's coding team to generate revised HRG codes, which were compared with the originals to calculate changes in tariff income.

Results

A total of 144 elective orthopaedic cases from April 2024 to April 2025 were reviewed. Of these, 51% (74) had missing information affecting the HRG tariff, leading to a recovered income of £76,000, an average uplift of £1,027 per corrected case. 88% (65/74) were arthroplasty cases, with the remaining nine non-arthroplasty cases contributing £9,000. Most discrepancies were due to under-reported comorbidities and BMI, which influence the complication/comorbidity score used in HRG calculation.

Conclusions

This study underscores the value of robust communication between clinical and coding teams. Accurate documentation of Body Mass Index and comorbidities significantly affects HRG coding in elective orthopaedics. Conducted before the financial year-end, this exercise led to a substantial remuneration uplift for the Trust enabling reinvestment, improved governance, and strategic planning to enhance patient care.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

152 Closed-loop audit to improve trauma care by adhering to the guidelines for attendance and documentation of trauma calls in one of London’s major trauma centres

Htoo Htet Linn ^1,^✉, Clara Calero Pages ¹, Kriisan Manoharasundaram ¹, Daniel Frith ¹

Abstract

Aim

Adherence to NICE and local trauma guidelines can reduce morbidity, mortality, and healthcare costs. Accurate documentation of attendance and roles during trauma calls is vital for guideline compliance, quality assurance, and medico-legal accountability. This closed-loop audit aimed to evaluate and improve adherence to trauma call attendance, documentation, and specialty involvement to facilitate timely management and trauma care delivery.

Method

The first cycle was conducted over two weeks in November 2024 at St Mary’s Hospital, London, a major trauma centre. Data collected retrospectively from pre-alert forms and electronic patient records. Data points included trauma type (code red/black/neuro), specialty attendance, sign-in sheet completion, and admission details, with performance analysed between in-hours and out-of-hours. A second cycle was undertaken in January 2025 following interventions.

Results

In the first cycle, sign-in sheets were completed in 69% of trauma calls, and the admitting surgical specialty was present in 55%. Documentation and attendance were significantly poorer out of hours. Barriers included limited familiarity with electronic systems, and equipment-related issues were identified. These were addressed through staff education, emails, and a presentation at the Major Trauma Audit Day. In the second cycle, specialty sign-in completion reached 90%, and admitting surgical specialty was present in 73% of trauma calls, with marked enhancement in out-of-hours performance.

Conclusions

This audit identified persistent gaps in trauma call documentation, with incomplete records risking care delivery, compliance, and medico-legal accountability. Following interventions, substantial improvements were achieved. For further progress, we proposed introducing automated sign-in systems, standardised documentation templates, and addressing barriers via staff surveys.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

154 A closed-loop clinical audit to improve perioperative dexamethasone stewardship in supratentorial tumour surgery

Sajjad Saghebdoust ^1,^2,^✉, Soheil Saghebdoust ³, Ali Fathi Jouzdani ¹, Reza Zare ¹

Abstract

Aim

Dexamethasone is widely used perioperatively in brain tumour surgery to manage vasogenic oedema. However, its use is associated with significant morbidity and lacks robust evidence to guide practice, resulting in considerable variation. This audit aimed to improve adherence to evidence-based dexamethasone stewardship guidelines in patients undergoing supratentorial tumour surgery.

Method

A prospective, two-cycle, closed-loop clinical audit was conducted at Razavi Hospital’s Neurosurgery Department. Cycle 1 (March–August 2019) assessed baseline adherence to predefined standards for dexamethasone dosing, tapering, and monitoring. A multifaceted quality improvement intervention was then introduced, including departmental education, a standardised Electronic Health Record (EHR) order set with “soft-stop” alerts, a prescribing checklist, and automated clinical pharmacist reviews for prolonged prescriptions. Cycle 2 (September 2019–February 2020) re-evaluated practice post-intervention.

Results

A total of 305 patients were audited (Cycle 1: n = 150; Cycle 2: n = 155), with comparable baseline characteristics. Post-intervention, adherence to appropriate preoperative dosing (≤16 mg/day) rose from 75% to 95% (p < 0.001). Documentation of discharge tapering plans increased from 35% to 95% (p < 0.001), and daily glycemic monitoring compliance improved from 55% to 98% (p < 0.001). These process enhancements correlated with reduced adverse outcomes: perioperative hyperglycemia (>10 mmol/L) decreased from 40% to 22% (p = 0.008), and 30-day surgical site infections fell from 6.0% to 1.9% (p = 0.045).

Conclusions

A structured, multidisciplinary dexamethasone stewardship program, integrating EHR tools and pharmacy oversight, significantly improved guideline adherence and reduced steroid-related complications. Such initiatives should be considered standard practice in neuro-oncology to enhance patient safety.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

158 A quality improvement project to improve ward round documentation using the Heidi health application

Amna Qamar ^1,^✉, Maired Kelly ¹, Robert Maweni ¹, Ayeshah Abdul-Hamid ¹

Abstract

Introduction and Aim

Accurate and timely documentation during surgical ward rounds is critical for ensuring patient safety, effective multidisciplinary communication, and continuity of care. In high-demand surgical settings, resident doctors often experience delays in completing documentation due to competing clinical priorities. This quality improvement project aimed to assess whether an AI transcription tool, Heidi, could reduce documentation time in a busy ENT department within a tertiary centre.

Method

Baseline data on time taken to complete conventional ward round documentation were collected over a four-day period. The Heidi AI tool was then implemented to transcribe real-time discussions during ward rounds and automatically format the information using a structured template adapted from the SHINE Surgical Ward Round Toolkit. Documentation times using the AI system were recorded over a subsequent four-day period. Pre- and post-Heidi ward round documentation times, measured in minutes, were compared using the Mann-Whitney U test.

Results

The implementation of Heidi led to a statistically significant reduction in documentation time compared to conventional methods. The median time taken to document reduced from 5.00 minutes (IQR 4.00, 7.00) to 2.13 minutes (IQR 1.82, 2.75). P value < 0.001 deemed this reduction to be statistically significant.

Conclusions

Using AI tools can not only improve timeliness of clinical records but also free resident doctors from scribing duties, allowing greater participation in patient care and enhancing educational opportunities. This intervention demonstrated the potential of AI-assisted documentation to improve workflow efficiency and patient flow while supporting resident doctor training and reducing administrative burden in a surgical setting.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

159 Improving operative note documentation through low-cost interventions: a closed-loop audit in general surgery

Anurag Agarwal ^1,^✉, Vignesh Balasubaramaniam ¹, Umair Hassan ¹, Nik Abdullah ¹

Abstract

Aim

Operative notes are essential medico-legal documents that directly impact patient safety, continuity of care, and communication among healthcare professionals. This audit aimed to evaluate and improve the quality of operative note documentation in the general surgery department, benchmarked against the Royal College of Surgeons (RCS) England 2014 guidelines.

Method

A prospective closed-loop audit was conducted on 50 randomly selected operative notes in each cycle. Cycle 1 reviewed notes from July 2024, and Cycle 2 from March 2025. Documentation was assessed against RCS standards using a structured proforma covering 19 parameters. Following Cycle 1, targeted interventions were introduced: placement of guideline signboards in surgeons’ rooms, theatre staff involvement in prosthesis sticker documentation, and immediate electronic uploading of operative notes.

Results

Cycle 1 demonstrated an overall compliance of 86.8%, with deficiencies most notable in prosthesis documentation, estimated blood loss, and postoperative care instructions. After implementing the interventions, Cycle 2 showed a marked improvement, with compliance rising to 97.8%. Prosthesis documentation and completeness of operative details improved significantly, although variability persisted in recording estimated blood loss and postoperative instructions. Overall compliance in Cycle 2 exceeded international benchmarks reported in the literature (79–87%).

Conclusions

Simple, low-cost interventions can significantly improve operative note documentation. These measures enhance patient safety, communication, and medico-legal reliability. Sustained improvement will require continued feedback to surgeons, reinforcement of RCS guidelines, and integration of electronic systems, with a re-audit planned to ensure long-term adherence.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

160 Evaluating BOAST 4 compliance during the establishment of a regional plastic surgery unit: a two-cycle audit

Omar Kiwan ^1,^✉, Arash Rafie ², Mohammed Al-Kalbani ¹, Mazhar Nasim ³, Susie Yao ³

Abstract

Aim

A plastic surgery unit was established in 2021 within a major trauma center to manage regional open limb fractures. This audit evaluated compliance with BOAST 4 standards in the unit’s second and third years and assessed the impact of service changes introduced after cycle 1.

Method

We retrospectively reviewed all acute open limb fractures from October 2022 to September 2023 (cycle 1) and October 2023 to September 2024 (cycle 2). Data included the timing and mechanism of injury, joint orthoplastic presence, and timings for antibiotic administration, debridement, and definitive closure. Compliance with BOAST 4 standards was measured for these key domains. Following cycle 1, several interventions were introduced to improve adherence, including documentation proformas, sharing results with orthoplastic colleagues, and a poster promoting plastics involvement at theatre briefing.

Results

Cycle 1 included 55 patients. Median antibiotic time was 102 minutes, with 28% compliance. Orthoplastic presence at debridement was 81%. 70% of patients underwent debridement within 24 hours, and 4% of high-energy fractures met the 12-hour target. Definitive closure within 72 hours was achieved in 92%.

Cycle 2 included 98 patients. Median antibiotic time was 74 minutes, with 33% compliance. Joint orthoplastic presence was 67% overall and 82% for lower limb fractures. Debridement within 24 hours improved to 86% and 19% of high-energy fractures met the 12-hour target. Definitive closure within 72 hours was achieved in 90%.

Conclusions

The unit demonstrated progressive alignment with BOAST 4 standards, supported by targeted interventions. Persistent challenges in managing high-energy fractures highlight the need for further service development.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

162 Improving safeguarding in paediatric burns: implementing the BuRN tool in outpatient clinics

Caitlyn Thomas ^1,^✉, Olivia Hartrick ¹, Charlotte Bowman ¹, Hannah Willett ¹, Zoe Avent ¹, Sophie Connett ¹, Alexandra Murray ¹

Abstract

Background

Burns are common injuries in children. With around 1 in 10 due to maltreatment, early recognition and escalation are vital. The Burn Risk assessment for Neglect or abuse Tool (BuRN-tool) is validated in emergency departments, but its role in clinics is unclear. This project aimed to improve identification of maltreatment in paediatric burns by introducing the BuRN tool in outpatient practice.

Method

A full cycle Plan-do-Study-Act (PDSA) cycle was conducted in the paediatric plastic surgery clinic at Stoke Mandeville Hospital. Baseline safeguarding documentation and escalation rates were measured retrospectively from electronic records over one week. During the intervention week, BuRN tool forms were completed for new patients by two specialist nurses. The facilitator attended clinics to reduce barriers and reinforced use with brief reminders. Outcome measures included the proportion of patients with safeguarding documentation and those escalated via safeguarding pathways. Staff experiences were explored through informal interviews.

Results

60 patients were seen at baseline and 51 during intervention. Safeguarding documentation improved from 28% to 55% overall, and from 31% to 69% in new patients. Staff concerns rose from 7% to 12%, and escalations from 2% to 4%. Despite the small sample size and clinician variation, staff interviews suggested the BuRN Tool provided valuable support, particularly for less experienced clinicians. Reported barriers included paperwork and limited time.

Conclusions

The BuRN tool improved safeguarding documentation and escalation. While experienced nurses used clinical judgement, it offered a useful framework for newer staff. Despite sample, duration, and workload limits, wider adoption could strengthen safeguarding practice.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

167 Assessing general surgery admissions - opportunities for next day acute surgical unit review

Dawood Mahmoood ^1,^✉, Akhtar Mahmood ¹, Paul Cromwell ¹

Abstract

Aim

To evaluate overnight General Surgery admissions at Galway University Hospital, identify patients suitable for next-day review in the Acute Surgical Assessment Unit (ASAU), and explore opportunities to optimise patient flow and bed utilisation without compromising safety.

Method

A retrospective audit was performed over a three-month period (November 2024 – January 2025). Data from daily handovers of emergency surgical admissions were reviewed. Patients were assessed against predefined ASAU criteria: age, ambulatory status, clinical stability, absence of systemic sepsis, pain severity.

Results

Across the study period, 384 admissions were recorded: 121 in November, 122 in December, and 141 in January. Of these, 26 patients (6.7%) were retrospectively deemed suitable for ASAU review: 13 (10.7%) in November, 5 (4.0%) in December, and 8 (5.6%) in January. Common diagnoses included non-specific abdominal pain, uncomplicated appendicitis, mild cholecystitis, diverticulitis, and soft tissue abscesses—conditions typically safe for ambulatory reassessment. Gender distribution varied, with male predominance in November (61.5%) and January (62.5%), and female predominance in December (80%), reflecting higher rates of biliary pathology in females. Mean time to imaging was often delayed until the following day (13.3 h in November, 14.0 h in December, 11.9 h in January), further supporting the feasibility of ASAU-based review.

Conclusions

A meaningful proportion of overnight surgical admissions could be safely redirected to ASAU review the next day (6.7%). Introducing a formal ASAU triage pathway, improving access to next-day imaging, and ensuring early senior input at admission may reduce avoidable overnight stays, alleviate bed pressures, and safeguard elective surgical capacity.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

178 Sustainable surgery in practice: an audit of reusable vs single-use gowns

Mohammed Al-kalbani ^1,^✉, Tyler Munro ², Adam El Khouja ³, Ayah Assadi Shekrobat ³, Omar Kiwan ¹

Abstract

Aim

Single-use gowns generate significant waste. Reusable gowns produce just one-third of the carbon footprint of single-use gowns and demonstrate a 28% reduction in energy use, 30% reduction in greenhouse gas emissions, 41% reduction in water use, and 93% reduction in solid waste. The Intercollegiate Green Theatre Checklist highlights the use of reusable gowns as a key sustainability measure. Evidence indicates reusable gowns do not increase surgical site infection (SSI) risk. This audit was undertaken at a district hospital to evaluate the introduction of reusable gowns and their effect on SSI rates and outcomes.

Method

An audit was conducted in December 2024 in a single theatre, primarily involving general surgery and gynaecology procedures. Morning surgeries used single-use gowns, and afternoon surgeries used reusable gowns. Patient records were reviewed three months later to identify SSIs. Data was analysed using chi-square testing. Patients with incomplete records or high baseline SSI risk were excluded.

Results

Seventy-three patients were included. 28 cases used single-use gowns and 45 used reusable gowns. SSIs occurred in 3 patients (10.7%) in the single-use group and 4 patients (8.9%) in the reusable group. Chi-square analysis showed no significant difference in infection rates (p = 0.797).

Conclusions

This audit found no evidence of increased SSI risk with reusable gowns. Their use aligns with the Intercollegiate Green Theatre Checklist and offers clear sustainability benefits. While limited by a small sample size, single-centre design, and non-random gown allocation, the findings support the implementation of reusable gowns as a safe and environmentally sustainable alternative to disposable gowns.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

179 Audit of flexor tendon injury management: a three-cycle review of compliance with BSSH guidelines

Daniel Eaton ^1,^✉, Alexandra Sebastiao ¹, Hannah Cook ¹, Lola Giwa ¹, Katerina Kyprianou ¹, Vikram Sharma ¹, Mo Akhavani ¹

Abstract

Aim

This audit evaluates departmental compliance with the 2023 British Society for Surgery of the Hand (BSSH) guidelines for flexor tendon repair.

Method

Three audit cycles were conducted for patients undergoing primary repair of open flexor tendon injuries at a tertiary centre between September 2024 and May 2025. Variables included demographics, time to assessment, surgery, and hand therapy (HT), as well as infection and rupture rates. Results were analysed and presented after each cycle to guide improvements. To reduce delays, referral to HT was streamlined from email to an electronic request, trialled and refined during subsequent cycles.

Results

Cycle A: 45 patients, 9-75 (mean 35) years. 91 tendons repaired, 9 ruptures, 3 infections. 2.4 days assessment wait, 2.8 days surgery wait, 4.5 days HT wait.

Cycle B: 55 patients, 5-68 (mean 32) years. 111 tendons repaired, 10 ruptures, 4 infections. 1.8 days assessment wait, 2.1 days surgery wait, 5.3 days HT wait.

Cycle C: 60 patients, 1-69 (mean 36) years. 104 tendons repaired, 5 ruptures, 4 infections. 1.3 days assessment wait, 2.6 days surgery wait, 4.1 days HT wait. Assessment time improved from 2.4 to 1.3 days. Surgery remained within the 4-day target, and HT met the 5-day target in Cycles A and C. Rupture rates declined from 9.8% to 4.8%; infection rates varied, whilst remaining under 7.5%.

Conclusions

The audit demonstrated overall compliance with BSSH flexor tendon repair guidelines, with improved surgical assessment and referral processes. Further work is needed to achieve the 1-day target for initial assessment.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

182 Landmark-guided knee injections: a cost-effective alternative to ultrasound in outpatient clinics

Sangeetha Baskar ¹, Saphalya Pattnaik ^1,^✉

Abstract

Aim

Knee osteoarthritis (OA) is a major cause of disability, with intra-articular corticosteroid injections frequently used when conservative measures fail. While ultrasound (US)-guided injections are often considered more accurate, they contribute to longer waiting times, higher costs, and increased demand on radiology services. Landmark-guided injections, delivered in orthopaedic outpatient clinics, may represent a safe and cost-effective alternative.

Method

A closed-loop audit was undertaken at a London district general hospital, comparing US-guided and clinic-based landmark-guided injections across two cycles: a retrospective review (Jan–Dec 2023) and a prospective cycle (May–Dec 2024). Data on waiting times, procedure volumes, and costs were extracted from electronic records and NHS coding systems.

Results

In 2023, 391 US-guided injections had an average waiting time of 16.2 weeks, compared to 182 clinic-based injections with a 15-week wait. By 2024, 346 US-guided and 234 clinic-based injections were performed, with US waiting times reduced to 9 weeks. Cost analysis demonstrated an annual saving of approximately £96,000 when emphasising clinic-based procedures. Importantly, no adverse events were recorded following landmark-guided injections.

Conclusions

Clinic-based landmark-guided injections offer a safe, efficient, and significantly cheaper alternative to US-guided procedures. Wider adoption of this approach could relieve radiology pressure, shorten waiting times, and generate meaningful cost savings for the NHS without compromising patient care.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

185 Radiological and functional outcomes after fixation: the relevance of Soong grades

Saphalya Pattnaik ^1,^✉, Mohamed Khalid ¹, Gur Aziz Singh Sidhu ²

Abstract

Aim

Volar locking plate (VLP) fixation is widely used in managing distal radius fractures (DRFs). The Soong classification, which grades volar plate prominence, is primarily recognised for its association with flexor tendon complications. However, its role in predicting radiological alignment and functional recovery following fixation remains uncertain. This study assessed whether Soong grade correlates with restoration of radial parameters and patient-reported outcomes.

Method

A retrospective review was conducted of patients undergoing VLP fixation for DRFs between January and July 2023 at a district general hospital. Forty-four patients met the inclusion criteria. Demographic data, fracture characteristics, surgical factors, and patient-rated outcomes were collected. Radiographic parameters, including radial height and radial inclination, were measured pre- and postoperatively. Soong grade (0–2) was determined from postoperative radiographs.

Results

The cohort had a mean age of 53.5 years, with 73% female predominance. Most fractures were intra-articular (88.6%) and dorsally angulated (79.5%). Soong Grade 0 (n = 23) demonstrated the best radiographic outcomes, with mean postoperative radial height of 13.6 mm and inclination of 26.4°, alongside the highest mean functional score (74.1). Grade 1 (n = 14) showed moderate restoration (radial height 12.1 mm, inclination 26.4°; outcome score 65.3), while Grade 2 (n = 7) had the lowest restoration (radial height 11.7 mm, inclination 24.3°; outcome score 61.5). One patient with Grade 2 required plate removal due to flexor tendon irritation.

Conclusions

Higher Soong grades were associated with progressively poorer radiological alignment and functional recovery. These findings reinforce the importance of meticulous plate positioning to minimise prominence, optimise anatomical correction, and reduce postoperative complications.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

187 Periprosthetic joint infections in arthroplasty: local audit against national standards

Saphalya Pattnaik ^1,^✉, Mothana Gawad ¹, Gur Aziz Singh Sidhu ²

Abstract

Aim

Periprosthetic joint infection (PJI) is one of the most serious complications after total hip and knee arthroplasty, leading to significant patient morbidity, multiple reoperations, and increased healthcare costs. This study aimed to determine the incidence, microbiology, and risk factors for PJI in a district general hospital (DGH), with comparison to national benchmarks.

Method

A retrospective audit was conducted of all primary total knee (TKA) and total hip arthroplasties (THA) performed between April 2022 and September 2023 within Lewisham and Greenwich NHS Trust. Patients were followed for one year postoperatively. Demographic, clinical, operative, and microbiological data were reviewed for patients who developed surgical site infections (SSIs) or PJIs.

Results

A total of 588 procedures were performed (310 TKAs, 278 THAs). Seven deep infections were identified (5 TKAs, 2 THAs), giving rates of 1.6% and 0.7% respectively (p = 0.455). The mean time to presentation was 91 days (range 15–307). Staphylococcus aureus accounted for most cases (5/7), all flucloxacillin-sensitive, with Group B Streptococcus and Serratia marcescens isolated in one case each. Patients with infections were more likely to have high BMI (>30 kg/m²) and ASA grade ≥3. Operative factors included procedures exceeding two hours and reported issues with laminar theatre airflow.

Conclusions

Infection rates at this DGH were within national averages, but obesity, ASA grade, and prolonged operative time emerged as key risk factors. Strengthening perioperative optimisation and addressing environmental factors, particularly theatre airflow, represent important local quality improvement targets to reduce PJI incidence.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

192 An Audit evaluating environmental and financial impacts of intra-operative intravenous (IV) paracetamol use, and implementation of a policy document to transition from intra-operative IV paracetamol use to pre-operative oral paracetamol use, for elective surgical patients at St Vincent’s Hospital, Sydney

Sofia Zulueta ^1,^✉

Abstract

Aim

Analyse intra-operative intravenous (IV) paracetamol use in theatres at St Vincent’s Hospital Sydney, assessing both cost and environmental impact. Implementation of a policy document, transitioning elective surgical patients from intra-operative IV paracetamol to pre-operative oral paracetamol administration.

Method

IV paracetamol usage in theatres from January to December 2023 was assessed via pharmacy records. Associated costs & environmental impacts were calculated, then compared to those of oral paracetamol. A policy document initiating pre-operative oral paracetamol in elective surgical patients was created, including clear inclusion and exclusion criteria. Education was provided to nursing and medical staff prior to policy implementation.

Results

In 2023, 3,178 IV paracetamol orders were placed for intra-operative use, costing $4044.26 AUD. Transitioning to oral paracetamol would have cost between $31.78 and $444.92 AUD. Environmentally, 1 g of oral paracetamol produces 38 g CO2 emissions (gCO2), while IV formulations emit 310–628 gCO2. Therefore, 2023 intra-operative IV use generated 1,682,872 gCO2. This is equivalent to 11% of total annual electricity & stationary fuel CO2 emissions at St Vincent’s Hospital Sydney. Switching to oral would reduce this to 120,764 gCO2, representing a substantial reduction in emissions.

Conclusions

IV paracetamol is significantly more expensive and environmentally harmful than oral alternatives, despite equivalent clinical efficacy. A policy has now been implemented at St Vincent’s Hospital Sydney initiating pre-operative oral paracetamol for elective surgical patients, effectively reducing costs and carbon emissions associated with intra-operative IV paracetamol use. Further recommendations include re-auditing intra-operative IV paracetamol use over the following year and intervention compliance.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

193 A scalable consultant-led pathway for paediatric burns: one-week review with routine laser Doppler flowmetry

Georgios Rafail Floros ^1,^✉

Abstract

Introduction

Delayed healing in paediatric burns is associated with hypertrophic scarring. British Burns Association guidance recommends smaller burns heal within 21 days. We audited outcomes in our unit and used process-mapping to identify modifiable delays, with the aim of designing a pathway centred on consultant review within one week and routine laser Doppler flowmetry (LDF) to refine depth assessment and enable earlier grafting decisions.

Method

A retrospective review of paediatric outpatient burns managed at Mid Yorkshire Teaching Hospitals over six months in 2024 was undertaken. Data included %TBSA, mechanism, days to healing, grafting, and scar outcomes. Healing was categorised as ≤14, 15–21, and >21 days. Cases >21 days were process-mapped to locate system delays and inform a proposed consultant-led, LDF-supported pathway.

Results

Two hundred seventy-one patients were included. Median healing time was 10 days; 77% healed ≤14 days, 14% in 15–21 days, and 9% > 21 days. Six patients underwent grafting, with several decisions made ≥4 weeks post-injury. Hypertrophic scarring was documented in 16/18 patients followed in scar clinic, almost entirely among those healing >14 days. Process-mapping highlighted late consultant review and delayed graft decisions as key, modifiable contributors to prolonged healing.

Conclusions

We propose a consultant-led outpatient paediatric burns clinic ensuring review within one week of injury, with routine LDF alongside clinical assessment to standardise depth estimation and fast-track grafting by two weeks when indicated. This audit-driven redesign is reproducible and scalable across NHS trusts, with clear potential to reduce prolonged healing and hypertrophic scarring. Re-audit is planned following implementation.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

195 Optimising indications for foreskin histopathology post-circumcision: a quality improvement initiative

Antoni Bochinski ^1,^✉, Rishabh Ray ¹, Ellie Keeling ¹, Jaskarn Rai ¹

Abstract

Introduction

Sending foreskin specimens for histopathological analysis post-circumcision varies among operators and Trusts. This QIP aimed to evaluate the frequency of malignant changes in circumcision specimens over 18 months at our Trust and assess the potential to reduce unnecessary analyses.

Method

Data from 537 circumcision patients were retrospectively analysed from December 2022 to April 2024. Only patients operated on by the Adult Urology team were included. Pre-operative clinical findings, clinic letters and pathology results were reviewed to retrieve data. Histology results were categorised as: ‘Normal,’ ‘Benign,’ ‘BXO,’ ‘Infective,’ and ‘Malignant.’ Patients with ‘Malignant’ findings were further reviewed for preoperative clinical suspicion.

Results

Of 415 adult patients, 364 (87.71%) had histopathological analysis. Findings were: ‘Normal’ 6 (1.45%), ‘Benign’ 184 (44.34%), ‘BXO’ 152 (36.63%), ‘Infective’ 2 (0.48%), and ‘Malignant’ 20 (4.82%). Among ‘Malignant’ cases, 2 were incidental penile intraepithelial neoplasia (PeIN) fully excised and placed on active surveillance. The remaining 18 had preoperative malignant diagnoses.

Conclusions

Our QIP demonstrates that only 2 incidental findings (0.5%) altered management. However, in both cases PeIN was fully excised and did not show recurrence in subsequent follow up. Avoiding histopathological analysis for ‘Normal,’ ‘Benign,’ and ‘BXO’ specimens (82.41% of cases) could save up to £51,300 annually without compromising patient care. This supports a more selective approach to specimen analysis. A robust financial analysis was proposed.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

196 STEP-up for surgery: a simulation-based teaching and enrichment programme for resident doctors starting surgical rotations

Grace Slater ^1,^✉, Katherine Watson ¹, Ioana Iftimie-Nastase ¹

Abstract

Aim

Resident doctors in surgery often face anxiety and intimidation which hinder learning, engagement and clinical competency. Many lack sufficient procedural training and understanding of their responsibilities. A lecture-based general surgery bootcamp reduced apprehension and tackled misconceptions but imposed high cognitive load. Simulation-based teaching fosters autonomy and emotional self-regulation. Compared to traditional approaches, this improves long-term competence, patient outcomes and learner satisfaction. STEP-up aimed to develop the surgical bootcamp into a learner-centred simulation-based programme to improve confidence and competence of foundation doctors commencing general surgery rotations.

Method

Incoming foundation doctors attended one day of practical teaching including simulation, clinical skills and wellbeing sessions. Pre- and post-session questionnaires assessed objective and subjective measures of confidence and competence using 5-point Likert scales. Scores ≥3 were considered positive. Results were compared with outcomes from lecture-based bootcamp.

Results

STEP-up resulted in improvements in all of 24 assessed parameters, including knowledge, prescribing, and practical skill proficiency. Learners reporting pre-rotation apprehension reduced from 88% to 33%. Confidence improved in specialty-specific parameters, including wound, drain and stoma care. Objective assessment of venous thromboembolism prophylaxis was improved. 100% learners felt positively about learning by simulation. Lecture-based bootcamp achieved similar improvement in confidence and knowledge, but produced smaller improvements in procedural competencies.

Conclusions

Simulation-based teaching via STEP-up was effective in preparing foundation doctors for surgical rotations. Teaching compared favourably to lecture-based bootcamp and was highly valued. These findings support adoption of learner-centred simulation-based strategies. Further work will assess transferability across departments and explore whether tackling deterrents can improve access and diversity within surgery.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

202 Do we adequately counsel patients on the substantial consequences of radical pelvic cancer surgery for bladder, bowel and sexual function?

Daria Ditri ^1,^✉, Gunn Pungpapong ¹, Sadaf Ghaem-Maghami ^1,², Marcus Drake ^1,²

Abstract

Aim

To understand the impact of radical pelvic surgery on bladder, bowel and sexual function using electronic communication to improve discussion and documentation, with an aim to identify whether radical surgery affects quality-of-life with long-term implications.

Method

We carried out a two-cycle, single centre audit using data from electronic records of 51 women who underwent radical pelvic surgery for cancer. Results were presented locally, followed by three rounds of email intervention over four months to all clinicians advising increased post-operative discussion and documentation of pelvic organ dysfunction prior to the reaudit of 48 patients.

Results

Post-intervention, discussion of bladder dysfunction post-operatively increased from 35% to 81% and discussion of bowel dysfunction post-operatively from 45% to 88% There was no improvement in the rate of post-operative discussion of sexual dysfunction: 2% before- vs 0% after intervention. Pre-operative counselling regarding bladder and bowel function remained low at 48% (vs 37% in 1^st cycle) and 42% (vs 35% in 1^st cycle) respectively. Sexual function discussions pre-operatively decreased from 14% to 4% in the 2^nd cycle.

Conclusions

We have shown that simple, low-resource email intervention increased documentation of post-operative bladder and bowel dysfunction discussions, enabling more patients to receive interventions aimed at reducing morbidity. However, at this stage, changes are often irreversible. Pre-operative counselling remained poorly documented. Essential discussions regarding sexual function are scarce at both the pre-operative and post-operative stages. In future, interventions should shift focus to pre-operative counselling, ensuring patients understand the potential long-term implications of radical pelvic surgery for quality-of-life and, particularly, sexual dysfunction.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

205 Audit of ePROMs uptake and patient-reported outcomes following penectomy and nodal surgery

Mahin Chowdhury ^1,^✉, Clare Hodgson ¹, Vijay Sangar ¹

Abstract

Introduction

Patient-reported outcome measures (PROMs) provide valuable insights into recovery, quality of life, and complications. However, uptake of electronic PROMs (ePROMs) in urological oncology remains poorly documented, limiting follow-up strategies and counselling. This single-cycle audit assessed ePROMs uptake and trends in outcomes following partial or total penectomy, inguinal lymph node dissection (ILND), or sentinel node biopsy over two years.

Patients and Method

All patients undergoing partial/total penectomy or ILND at The Christie Hospital between 01/01/22 and 31/12/23 were included. PROMs were reviewed retrospectively at defined intervals. Outcomes included urinary and sexual function, mobility, and psychological impact. Uptake, completeness, and trends over time were analysed with respect to procedure and question type.

Results

A total of 167 patients were identified; 99 (59%) completed at least one ePROM, and 32 (19%) completed both pre- and postoperative questionnaires. Uptake declined with time: 0–3 months (n = 84), 3–6 months (n = 46), 6–9 months (n = 34), 9–12 months (n = 24). Frequently omitted questions related to sexual health (erectile dysfunction, libido, ejaculation disorders), penile size, and bowel symptoms. Psychological and functional domains were more consistently completed.

Conclusions

This audit demonstrates early uptake of ePROMs after penectomy and nodal surgery but marked attrition beyond six months. Sensitive sexual health and body image domains were most often omitted, suggesting barriers to disclosure. Strategies such as targeted counselling, streamlined questionnaires, and digital reminders have potential to improve engagement. Greater uptake and completeness of ePROMs are vital to assess survivorship outcomes and guide service improvements in penile cancer care.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

212 Evaluation of the knowledge and confidence of foundation doctors in catheter and drain management

Qian Zhang ^1,^✉, Joshua Rabinowitz ¹

Abstract

Aim

Pathology relating to catheters and nephrostomies are encountered frequently by Foundation Doctors with minimal Urology experience. While basic catheterisation is taught in medical school, confidence remains low resulting in limited ‘parent team’ management and increased Urology referrals. Foundation teaching feedback highlights the demand for interactive, face-to-face teaching, applicable to real life scenarios. This was a single centre QIP aimed at improving Foundation Doctors’ knowledge of catheters and nephrostomies.

Method

PDSA Cycles were completed in collaboration with the Post Graduate Medical Education Department. Data were collected using pre and post intervention questionnaires. Four teaching sessions on catheters and nephrostomies with physical and visual aids were delivered to Foundation Doctors. Data were analysed using Microsoft Excel.

Results

Thirty-eight doctors participated. Mean knowledge and confidence improved across all domains scored 0-2. Knowledge improved by 0.942 for differences between 2-way and 3-way catheters, 0.742 for 3-way catheter indications, 0.793 for SPCs, 0.904 for SPC advantages, 0.655 for nephrostomy indications, and 1.04 for advantages. Confidence improved by 0.985 for continuous bladder irrigation, 0.309 for urethral catheterisation, 0.844 for SPC exchange and 0.680 for nephrostomy aspiration. Awareness of Tiemann tip indications rose to 97.3% by 83%. SPC anatomical knowledge increased by 68.3%. Lumen size and name identification improved by 50.6% and 72.7%. 100% of participants found the teaching beneficial. Limitations include lack of long-term data on knowledge, confidence levels and patient outcomes.

Conclusions

Practical teaching in catheters and nephrostomies improves Foundation Doctor knowledge and confidence. Similar teaching sessions could lead to reduced urology referrals and improved inpatient care.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

217 Evaluating colonoscopy rescope requests: service burden and clinical justification

Debora Joseph ^1,^✉, Benjamin Stubbs ¹

Abstract

Aim

Colonoscopy is the gold standard for diagnosing colorectal cancer. Unnecessary repeat procedures increase service burden, costs and patient risk. This audit assessed the frequency and appropriateness of rescope requests against Joint Advisory Group (JAG) recommendations.

Method

An audit of FIT-positive and FIT-negative colonoscopies performed between July–December 2024 was conducted using the HICCS database and consultant judgement reviews. Data collected included pathology detected, clinicians performing index scopes, rescope requests, appropriateness, and who performed the rescopes.

Results

In six months, 462 FIT-positive colonoscopies were performed, with a polyp detection rate consistently above 32% and exceeding 50% in some months. Forty (8.7%) cases resulted in a rescope request; 82.5% were deemed reasonable, and 17.5% were deemed unreasonable. Among 165 FIT-negative scopes (average polyp detection rate 32.5%), 14 (10.3%) rescope requests were made, of which 71.4% were reasonable and 28.6% unreasonable. The majority of all requests came from in-sourced external consultants and clinical endoscopists.

Conclusions

The majority of rescope requests were due to inadequate bowel preparation or the failure to remove polyps detected during the index scope. JAG does not establish a formal rescope rate as part of its key performance indicators. Colonoscopy performed by in-house consultants resulted in the lowest rescope rates, and over-reliance on in-sourcing and clinical endoscopists may have a negative impact on rescope rates.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

224 FAST in name, slow in practice: a QIP to improve trauma care in line with ATLS/ETC

Ganga Gurung ¹, Christopher Singh ^1,^✉, Catello Landolfi ¹

Abstract

Background

FAST (Focused Assessment with Sonography in Trauma) is a cornerstone of trauma assessment, recommended by ATLS and ETC guidelines for rapid detection of intraperitoneal, pericardial, and pleural free fluid in blunt and penetrating trauma. Despite guideline endorsement, FAST is inconsistently performed in many Emergency Departments (EDs), limiting timely decision-making. This project aimed to identify barriers to guideline-adherent FAST use and inform practical interventions to improve compliance, clinician competency, and patient care.

Method

A two-part quality improvement project was conducted. Thirty-five ED clinicians were surveyed regarding training, confidence, competence, and barriers to FAST. Separately, 67 trauma cases meeting activation criteria (July–December 2024) were retrospectively reviewed for FAST utilization, documentation, operator grade, and supervision.

Results

Survey revealed significant gaps: 69% of clinicians lacked formal FAST training, 57% reported low confidence, 80% lacked competence in interpretation, and 91% reported inadequate supervision. Barriers included limited training (69%), time pressures (49%), and equipment constraints (29%). Patient review showed FAST was performed in only 4.5% of eligible trauma cases, exclusively by middle-grade clinicians. Eighty-three percent of staff expressed interest in structured workshops, and proformas were suggested to standardise documentation and workflow.

Conclusions

FAST scans remain underutilised in the ED despite guideline recommendations. Planned interventions include hands-on workshops for all grades, structured senior supervision, standardised proformas, and visual reminders. These targeted measures represent a practical and scalable approach to improve adherence to ATLS and ETC standards, enhance clinician competency, and optimise trauma patient care. Re-audit is scheduled in 3–4 months to assess impact.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

226 Reducing inappropriate post-operative laxative prescribing following elective colorectal surgery: a clinical audit

Nikita Jha ^1,^✉, Suha Ugur ¹, Victoria Leeper ¹, Anjay Talwar ¹

Abstract

Aim

To quantify the prevalence of inappropriate laxative prescriptions following elective colorectal surgery, assess outcomes after removing laxatives from the standard prescribing bundle, and implement measures to reduce unnecessary prescribing. Currently, there is no formal guidance supporting routine laxative use post-operatively. The 2018 ERAS Society guidelines mention laxatives but do not recommend their standardised use, and existing studies show inconsistent benefits with small sample sizes.

Method

A retrospective clinical audit was conducted at a district general hospital. Pre-intervention data were collected from 08/01/2024 to 08/09/2024, and post-intervention data from 01/05/2025 to 16/06/2025. Patient records were reviewed for age, length of stay (LOS), laxative prescriptions, administration, and 30-day morbidity. The intervention involved removing laxatives from the standard post-operative prescribing bundle.

Results

Twenty-eight patients were included in the pre-intervention audit, and twenty-three post-intervention. Laxative prescribing fell from 86% to 39% (p = 0.0001); administration dropped from 28% to 11% (p = 0.005). Median LOS decreased from 7 to 4 days (p = 0.03). No complications were attributed to laxative omission. Post-intervention 30-day morbidity decreased (17% vs 39%, p = 0.1), with no increase in ileus or anastomotic leaks.

Conclusions

Routine laxative use post-colorectal surgery is not evidence-based and may be unnecessary. Removal from standard prescribing significantly reduced inappropriate use without adverse outcomes. Though some studies suggest earlier gastrointestinal recovery, they show no impact on LOS or return of oral diet and are limited by small samples. Continued audit and staff education are recommended.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

231 Evaluation of clinical practise in relation to BOAST 11 guidelines: supracondylar humeral fractures in children

Arif Khan ^1,^2,^✉, Zarafshan Bhatti ³

Abstract

Aim

Supracondylar humeral fractures are the most common elbow fractures in children and can lead to serious complications if not managed appropriately. The British Orthopaedic Association Standards for Trauma (BOAST) 11 guidelines provide recommendations to standardise care and improve outcomes. This audit assessed local compliance with BOAST 11 standards.

Method

A retrospective audit was conducted of children diagnosed with supracondylar humeral fractures between January 2022 and July 2025. Electronic patient records were reviewed for adherence to BOAST 11 standards, including documentation of neurovascular status (radial pulse, capillary refill, nerve function), operative details (K-wire size, fixation technique), and post-operative care. Data were extracted using a standardised collection sheet.

Results

Compliance varied across standards. Documentation of a full neurovascular assessment at presentation and pre-operatively was very low, at 4% (2/56), and post-operative neurovascular monitoring was documented in 25% (14/56). Urgent surgical management in cases of vascular compromise (100%, 4/4) and use of at least two K-wires for stabilization (100%, 53/53) achieved full compliance. Most patients (87%, 46/53) underwent surgery on the day of injury unless delay was indicated. Moderate compliance was observed for documentation of ulnar nerve protection (60%, 12/20), use of 2 mm wires (66%, 35/53), and intraoperative stability assessment (76%, 42/55). Documentation of post-operative radiographs and wire removal timing was achieved in 46% (26/56).

Conclusions

Operative standards were generally well met, but neurovascular documentation remained inconsistent. Implementation of a standardised proforma and targeted education is planned, with re-audit to assess improvement and ensure compliance with BOAST 11 guidelines.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

239 Evaluating the presence of recycling information on medical packaging

Ashwini Tittawella ^1,^✉, Colton Bohonos ¹, Jack McDermott ¹, Derek Hennessey ¹

Abstract

Aim

Global concern for environmental sustainability highlights the need for improved waste management practices. However, medical device packaging often lacks disposal instructions, leading potentially recyclable materials to be diverted to landfill or clinical waste. This study evaluates how effectively medical packaging informs healthcare workers about disposal methods, likely impacting waste management.

Method

A total of 100 medical devices were randomly selected from a flexible cystoscopy suite and urology theatre. Included items featured either primary (direct-contact) or secondary (external) packaging. Observed data was collected on the presence of recycling or waste disposal information and any additional environmental guidance. Frequencies and proportions were calculated.

Results

Products from over 35 manufacturers were assessed. Over 80% of packaging failed to indicate recyclability. Fewer than 8% of non-recyclable-labelled products offered further disposal or environmental guidance. More than half the packaging consisted of potentially recyclable paper or plastic. Where recycling information was present, it was most often conveyed through a symbol. Ten clinical supply categories were identified: endourological supplies (22%), surgical & procedural instruments (16%), surgical packs & drapes (6%), PPE (12%), lubricants & antiseptics (10%), wound care (8%), general consumables (10%), cleaning & hygiene products (8%), diagnostics (2%), and sutures (2%)- reflecting a focus on urology and surgical care.

Conclusions

There is a significant lack of disposal guidance on medical packaging, contributing to avoidable incineration or landfill waste. Existing instructions are sparse and often unclear. Manufacturers should adopt clearer labelling to support healthcare workers in improving recycling and sustainable waste management.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

248 Beyond the orchidectomy: benchmarking testis cancer care against ANZUP standards in a high-volume Australian centre

Penny Grudgings ^1,^✉, Abdullah Al-Khanaty ¹, Beatrice Hornstein Lasry ¹

Abstract

Aim

Testicular cancer is the most common solid malignancy in young men, with cure rates over 95% when managed appropriately. High-quality care depends on timely staging, tumour marker assessment, and multidisciplinary team (MDT) input. ANZUP guidelines specify staging CT before orchidectomy, repeat markers 7–10 days post-operatively, and MDT review for all cases. We benchmarked peri-operative processes at a high-volume Australian cancer centre against these standards.

Method

A retrospective audit of 39 consecutive orchidectomy patients (2023–2025) was performed. Data included demographics, histology, laterality, staging CT timing and findings, pre- and post-operative markers, and MDT discussion.

Results

Median age was 34 years (range 19–80). Laterality was left 56%, right 36%, bilateral 8%. Histology: seminoma 52%, mixed germ cell tumour 21%, pure NSGCT 14%, sex cord–stromal 10%, metastatic melanoma 2%. Staging CT was performed pre-operatively in most cases (median –6 days, IQR –11 to –1). Findings: no metastatic disease in 31/39 (79%), retroperitoneal lymphadenopathy 3 (8%), pulmonary nodules 5 (13%), several longstanding and stable. Pre-operatively, markers were elevated in AFP 18%, β-hCG 23%, LDH 28% (maxima 296, 1693, 550). First post-orchidectomy markers were obtained at a median of 23 days (IQR 18–35, range 1–250). Of 9 patients with elevated markers, 7 (78%) had delayed checks >14 days, beyond the ANZUP 7–10 day window. MDT discussion occurred in 93%, reflecting strong capture.

Conclusions

At this centre, staging CT and MDT review were guideline-concordant, but marker reassessment was delayed. Standardising early post-operative markers and universal MDT review are key quality improvement priorities.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

251 Optimising the transurethral resection of bladder tumour (TURBT) pathway: introducing a clinician-led scheduling system

Lauren McGeoghan ^1,^✉, Jessica Morrow ¹, David Curry ¹, Patrick Keane ¹

Abstract

Aim

Delays in the diagnosis and management of bladder cancer can adversely affect patient outcomes, particularly in high-risk and muscle-invasive cases. A retrospective review of 160 patients on the TURBT pathway in the Belfast Trust identified inefficiencies, including prolonged timelines from initial referral to surgery. This quality improvement (QI) project aimed to streamline the pathway, reduce delays, and improve case prioritisation.

Method

A multidisciplinary QI initiative was launched, focussing on documentation optimisation at initial assessment, altering the need for pre-op assessment, and the introduction of a clinician-led scheduling system for active management of the waiting list.

Audit Cycle 1 (June–October 2024, n = 73) captured baseline data, followed by Audit Cycle 2 (November 2024–February 2025, n = 87) to assess the impact of pathway changes. Timelines were benchmarked against NICaN guidelines of a 62-day target. Evaluation criteria included referral-to-surgery intervals, pre-operative assessment (POA) triage, procedure selection, and rate of ‘fast track’ identification for high-risk cases.

Results

Post-intervention, average weekly TURBT cases increased from 3.5 to 6. Timeline improvements were observed across key pathway stages. Active waiting list management and POA triage enabled more efficient theatre scheduling. Clinician-led booking resulted in a 22% procedure alteration rate, ensuring appropriate prioritisation and resource use of theatre sites. ‘Fast track’ identification increased to 18%, including 2 muscle invasive bladder cancers and 1 metastatic case. Safety netting revealed 12 patients initially misclassified or missed.

Conclusions

The clinician-led TURBT pathway significantly improved scheduling efficiency and prioritisation. Continued audits and pathway surveillance are essential to sustain improvements.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

253 Shaping surgical futures: insights into specialty life through the Surgical Specialty Spotlight Series, a global teaching initiative for tomorrow’s surgeons

Praveen Subbiah ^1,^✉, Akshay Vinoo ², Aalia Uddin ³

Abstract

Aim

Medical students and junior doctors often have limited exposure to surgical subspecialties and uncertainty about training pathways. The Surgical Speciality Spotlight Series, developed by the Surgical Society of International Doctors (SSID), aimed to provide authentic insights into specialty life and improve career clarity for early-career doctors worldwide.

Method

A structured series of interactive webinars was delivered across four subspecialties: neurosurgery, plastic surgery, cardiothoracic surgery, and paediatric surgery. Each session was led by surgical trainees and included an overview of “a week in the life” of a surgeon, portfolio development, and the UK application process, with opportunities for live Q&A. Pre- and post-session surveys (5-point Likert scales) assessed knowledge, confidence, and career clarity. Qualitative feedback was also collected.

Results

Across the series, 280 participants attended. Mean self-rated understanding of specialty careers improved from 2.3 to 4.1/5, and knowledge of the UK application process increased from 2.0 to 3.9/5. Confidence in managing basic emergencies (1.9→3.6/5) and expectations at junior level (2.2→3.8/5) also improved. The proportion of participants “very likely/likely” to pursue a surgical career rose from 40% to 72%. Feedback described the sessions as informative, practical, and inspiring, with requests for expanded portfolio and interview preparation.

Conclusions

The Surgical Specialty Spotlight Series significantly enhanced awareness of surgical careers and training pathways. This innovative, trainee-led teaching model provided global reach and authentic insights into specialty life, empowering medical students and junior doctors and shaping the aspirations of tomorrow’s surgeons.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

254 Day-case solutions: re-designing paediatric trauma services

Abra Zahid ^1,^✉, Priyatma Khincha ¹, Jared McSweeney ¹, James Bedford ¹, Clare Rivers ¹

Abstract

Aim

Paediatric minor trauma constitutes significant operative workload in Paediatrics Plastic Surgery. In a large tertiary center, cases were previously assessed in A&E and treated on emergency operating lists. This resulted in prolonged waiting times, repeated cancellations, and considerable disruption for patients. A dedicated trauma service was proposed to deliver standardised care and improve operational efficiency, enhance patient experience, whilst improving resident doctor training.

Method

The minor trauma pathway was designed collaboratively with clinical leaders, operational teams, and resident doctors. A dedicated weekday trauma clinic and regular trauma theatre lists were introduced, and a standard operating procedure (SOP) was developed. Trauma coordination was delegated to operations Team, reducing resident administration burden and improving patient flow.

Results

Data collected for January(pre-change) and April(post-change) showed that emergency department waiting times decreased from 2.27 to 1.38 hours whilst surgical cancellations dropped from 1 in 13 to 1 in 8. Average fasting time for pediatric patients was reduced from 9.228 to 8.167 hours. The proportion of patients treated on emergency theatre lists reduced by 58% which led to increase in the time from injury to surgery from 2.6 to 3.17 days.

Conclusions

The introduction of structured pediatric minor trauma pathway led to improvements in patient care, reduced emergency department waiting times, fewer surgical cancellations, shorter fasting periods, and more efficient use of theatre resources. There was increase in time to surgery as more patients were managed on day lists rather than emergency lists. Resident doctor work became more predictable enabling improved planning of training activity.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

259 Improving practice in acute diverticulitis: an audit of antibiotic use and endoscopic follow up against ESCP guidelines

G Balamurugan ^1,^✉, Ailsa Innes ², Mark Heads ¹, Francesca Peters ², Daya Singh ¹

Abstract

Aim

To assess compliance with European Society of Coloproctology (ESCP) guidelines on antibiotic stewardship and endoscopic follow-up in acute diverticulitis and evaluate the impact of targeted interventions on clinical practice.

Method

A two-cycle audit was conducted across two centres. The first cycle was a retrospective review of patients diagnosed with acute diverticulitis between August 2023 and January 2024. Following the dissemination of findings and educational sessions, a prospective re-audit was undertaken from July to December 2024. Data on demographics, disease classification, antibiotic use, imaging, and endoscopic follow-up were collected and compared.

Results

In the first cycle (n = 138, median age 58 years), 91 patients had uncomplicated and 47 had complicated diverticulitis. Antibiotics were prescribed in 90% of uncomplicated cases, including 56% who received intravenous therapy and 34% oral therapy, despite guideline recommendations for selective use. Endoscopic follow-up was completed in 44.7% of patients with complicated diverticulitis. In the second cycle (n = 141, median age 60 years; 92 uncomplicated, 49 complicated), antibiotic stewardship improved substantially. Intravenous use decreased to 24%, oral prescribing increased to 54%, and 22% were managed without antibiotics. Inappropriate prescribing in patients without high-risk features fell from 37% to 20%. Endoscopic follow-up in complicated diverticulitis rose to 70.7%, reflecting better alignment with ESCP guidance.

Conclusions

This closed-loop audit demonstrated that targeted education improved compliance with ESCP guidelines. Reductions in unnecessary intravenous antibiotic use and improved endoscopic follow-up support the value of audit-driven quality improvement in diverticulitis management.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

264 Boosting theatre performance and productivity in elective surgery through audit and feedback

G Balamurugan ^1,^✉, Layla Sayyadi ¹, Rimshah Taswar ¹, Jamie Tomlin ², Daya Singh ¹

Abstract

Aim

To evaluate factors influencing theatre timings and performance in elective general surgery and assess the impact of targeted multidisciplinary feedback on efficiency and documentation, benchmarked against Getting It Right First Time (GIRFT) recommendations.

Method

A retrospective audit was conducted of elective general surgery sessions between November 2023 and January 2024 at a district general hospital. Data included briefing and debrief times, sign-out documentation, start delays, and session overruns. GIRFT recommendations were used as the benchmark for start timings and productivity. Results were presented at clinical governance meetings with anaesthesia, surgery, and theatre teams. A prospective re-audit was undertaken from May to July 2025.

Results

The first cycle analysed 116 sessions. Delayed starts occurred in 76.3% of sessions. Documentation of delay reasons was present in 55.2%. Session overruns occurred in 50.9% of lists, with documented reasons in just 8.3%. Briefings lasted a median of 9 minutes for morning lists and 6 minutes for afternoon lists. Sign-out and debrief compliance were 97.4% and 94%, respectively. In the second cycle (131 sessions), delayed starts reduced to 47.1%. Documentation of delay reasons increased to 88.6%. Session overruns fell to 30.3%, with documentation improving to 64.8%. Briefing durations were shortened, reflecting more focused discussions. Compliance with sign-out improved to 99%, and debrief timings reached 96%, surpassing audit standards.

Conclusions

This closed-loop audit demonstrated improved adherence to GIRFT recommendations following targeted feedback. Reductions in delayed starts and overruns, alongside better documentation, highlight the value of audit-driven multidisciplinary interventions in boosting elective theatre productivity.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

270 Necessity Of surgical revascularization of the diagonal artery during isolated CABG: outcomes in patients managed without diagonal grafting

Eiran Gannon ^1,^✉, Machaela Miskell ¹, Alan Soo ¹

Abstract

Aim

To determine whether diagonal artery (DA) stenosis is associated with mortality or postoperative morbidity in patients undergoing isolated CABG where the diagonal was not grafted.

Method

Single-centre retrospective cohort study (2018–2023) conducted in Galway University Hospital. Consecutive adults undergoing isolated CABG were classified by pre-operative angiography as DA stenosis ≥50% or <50%. Outcomes were all-cause mortality to last follow-up (primary), 30-day and 1-year mortality, and hospital length of stay (LOS).

Results

Of 230 patients, 71 (31%) had DA stenosis ≥50% and 159 (69%) had <50%. The ≥50% group was modestly older with more hypertension and diabetes. Mortality to last follow-up was 16.9% (12/71) with ≥50% versus 11.3% (18/159) with <50% (p = 0.29). Early outcomes did not differ (30-day 0 vs 2 deaths; 1-year 2 vs 4). Postoperative morbidity was comparable, with no suggestion of a longer LOS in the ≥50% cohort (medians ∼9–10 days in both groups). In an exploratory severity check confined to patients with stenosis, ≥ 70% did not confer higher mortality than the 50-69% group (1/22 [4.5%] vs 11/49 [22.4%]), so greater stenosis severity does not appear to explain the longer-term difference.

Conclusions

In isolated CABG performed without diagonal grafting, DA stenosis ≥50% was not associated with higher early mortality or longer postoperative stay. The small, non-significant difference in longer-term mortality did not intensify with ≥70% stenosis, suggesting other clinical factors more likely explain the numerical gap. These data support the short-term safety of omitting diagonal grafting and justify larger, risk-adjusted, time-to-event studies to clarify any long-term effect.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

291 A prospective closed-loop audit of patient-reported experience measures (PREMs) in urodynamic studies

Praveen Subbiah ^1,^✉, Farah Nurin Qasrina ², Aakash Pai ²

Abstract

Aim

To evaluate patient-reported experience measures (PREMs) during urodynamic testing, benchmark outcomes against national standards, and determine whether a structured information-based intervention could improve patient satisfaction and reduce pre-procedural anxiety.

Method

In the first audit cycle, 50 consecutive patients undergoing urodynamic studies at our unit completed a structured questionnaire assessing leaflet provision, anxiety before and during the procedure, pain, embarrassment, overall satisfaction, and willingness to repeat. Data were compared with British Association of Urological Surgeons (BAUS) and NHS standards. Following identification of deficits, a targeted intervention was introduced: mandatory provision of written information leaflets at booking, clinic packs to ensure availability, QR-code links to digital leaflets on appointment letters, and prominent information stands in waiting areas. A second prospective cycle of 50 patients was then undertaken.

Results

In cycle 1, leaflet provision was 62%. Mean anxiety scores were 3.08/5 before and 2.38/5 during, giving an overall score of 2.73/5 (5.46/10), which failed the <5/10 standard. Overall satisfaction was high at 4.49/5, with 76% awarding 5/5, and willingness to repeat exceeded 60%. In cycle 2, leaflet provision improved to 100%. Overall anxiety fell to 2.2/5 (4.4/10), now within standard. Satisfaction rose to 4.7/5, with 94% willingness to repeat.

Conclusions

This closed-loop audit demonstrates that consistent, multimodal pre-procedural information delivery significantly reduces anxiety, enhances satisfaction, and ensures compliance with national guidance. Ongoing reinforcement of these strategies is recommended to sustain improvements in patient experience.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

293 Improving catheter documentation in a tertiary urological centre: a quality improvement project

Murray MacKay ^1,^✉

Abstract

Background

The insertion of catheters carries significant risks, including traumatic injury upon insertion or removal and catheter associated urinary infections (CAUTIs). Structured documentation of reason for insertion, size/type of catheter and volume of water in the balloon is recommended by NICE and helps to reduce these risks and promote good catheter care.

Aim

To improve the documentation of catheters, and its accuracy, through the implementation of a structured questionnaire in a tertiary urological centre.

Method

Patients undergoing catheter insertion were identified using on-call lists. All patients over a two week period had their notes analysed for documentation of catheter insertion, and adherence to NICE guidelines, as mentioned above. A brief education session was held, and posters were placed to encourage the use of structured proformas to document catheterisation across the urology department. A re-audit was then carried out to evaluate the impact.

Results

Prior to the implementation of the structured catheter questionnaire only 55% (n = 15/27) of catheters had all parameters documented and only 26% (n = 7/27) inserted were recorded using a structured format. Following the structured format being implemented 77% (n = 17/22) of all catheters were correctly documented; the same percentage was documented using a structured format. Notably of all catheters which were recorded using a structured format 82% were correctly documented.

Conclusions

The use of a structured format significantly improved catheter recording and its accuracy. Wider implementation of these structures may help to reduce the risk of CAUTIs and traumatic injuries by promoting thorough catheter care and informed clinical review.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

298 Assessing staff attitudes towards sustainability in operating theatres

Charvi Bhargava ^1,^✉, Seema Bhargava ², Pallavi Marghade ²

Abstract

Aim

Staff views and adherence to green measures are critical factors in enabling a green theatre. Our study explored theatre staff’s views on sustainability, their awareness of green plans, and attitudes toward introducing new green measures in hospitals, particularly operating theatres.

Method

We conducted a survey amongst 34 theatre staff at Basildon University Hospital via Microsoft forms assessing: views on improving sustainability, staff awareness of green initiatives, green practice adherence at work, support from employer and views on introducing new green initiatives in theatre.

Results

Most participants recognised their responsibility towards sustainability, both professionally and personally, positively engaging in simple conservation measures such as taking public transport, correct waste disposal, resource conservation, etc. However, awareness of NHS sustainability plans was limited, with many expressing a need for more support to encourage green practice. Staff showed mixed support for proposed sustainability measures, with some (e.g., reusable textiles, improved waste management) viewed more positively than others (e.g., the ‘Rub don’t Scrub’). Reported barrier’s to implementing green measures included, lack of support, awareness from staff, resistance to change and cost effectiveness.

Conclusions

This survey highlights that most theatre staff felt responsible for improving sustainability and recognised the importance of creating a greener theatre environment. Although, there is some engagement and effort in sustainable measures presently, systemic barriers and staff awareness limits the implementation of current and new green measures. Therefore, introducing training, providing incentives for adopting green practice and creating supportive policies is vital i to implement green theatre measures and improve sustainability.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

301 Implementing a change of gloves and instruments prior to abdominal wound closure in general surgery to reduce rates of surgical site infection

Lorcan Purser ^1,^✉

Abstract

Aim

To assess current practice regarding glove and instrument change prior to abdominal wound closure in contaminated cases, and to evaluate whether simple departmental interventions could improve compliance.

Method

A prospective audit was conducted over two two-week cycles between January and May 2025. Eligible operations were defined as those involving abdominal incisions ≥5 cm with any degree of contamination (excluding c-sections). During cycle one, adherence to glove and instrument change prior to wound closure was recorded. Between cycles, audit findings were presented to the department and educational interventions were introduced. These included posters in theatre, email reminders, and education highlighting evidence from the Cheetah trial, which demonstrated a 13% reduction in surgical site infections with this practice. A second two-week audit cycle was then performed.

Results

In cycle one, only 1 of 17 eligible operations (6%) involved a change of gloves and instruments before closure. After departmental education, cycle two demonstrated no improvement, with 1 of 8 eligible operations (12.5%) demonstrating adherence. Feedback from colleagues indicated broad support for the intervention, however, this did not translate into a measurable behavioural change during the audit period.

Conclusions

Despite strong evidence and departmental awareness, this audit highlights the difficulty of achieving practice change in surgery. Educational interventions alone were insufficient to improve compliance. Sustained improvement is likely to require stronger measures, such as integration into the WHO checklist or departmental policy, to overcome barriers to implementation.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

303 Audit of the oesophago-gastric cancer diagnostic pathway at UHDB NHS foundation trust

Zohal Sohrabi ^1,^✉

Abstract

Aim

The Faster Diagnosis Standard (FDS) was introduced by NHS England replacing the previous 2-week-wait target. The FDS outlines that cancer should be either ruled out or diagnosed within 28 days of referral. This audit assesses the timeliness of the oesophago-gastric cancer diagnostic pathway at University Hospitals of Derby and Burton (UHDB) NHS Foundation Trust against the FDS 28-day best practice timed pathway standards.

Method

Data was collected for 50 patients who received a diagnosis of oesophago-gastric cancer at UHDB between March and September 2024. Timings for each stage of the diagnostic pathway (OGD, CT, MDT discussions, PET, staging laparoscopy/EUS, outpatient (OP) clinic) were compared against the targets suggested by FDS. Factors that could impact timeliness of the diagnostic pathway were also analysed.

Results

41.5% of patients were seen in OP clinic within 28 days of referral (median 31 days). The 7-day targets for OGD and CT were met in 28.6% and 14.0% of patients respectively. 5% of patients undergoing PET met the 21-day target (median 28 days). None met the 27-day target for staging laparoscopy/EUS (median 39 days). Patients with curative intent experienced longer waits to OP clinic (median 33 days) than those with palliative intent (median 26 days).

Conclusions

Timeliness across all stages of the diagnostic pathway was poor compared to the FDS 28-day best practice timed pathway. Specifically, patients requiring a PET scan and those on a curative treatment pathway faced longer waits. These findings will inform recommendations to improve timeliness of the oesophago-gastric diagnostic pathway at UHDB.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

305 Virtual fracture clinic improves BOAST compliance, patient outcomes, and delivers cost savings in lower socio-economic areas

Rania Khan ^1,^✉, Hosain Hadi ¹, Abid Mahmood ², Afnan Backer ¹, Shahnawaz Khan ¹, Henry D Atkinson ¹

Abstract

Background

Lower socio-economic regions face higher pressures on emergency services. Virtual services may reduce demand on secondary care. We assessed the effect of virtual fracture clinics (VFC) on BOAST compliance, patient-reported outcomes and hospital metrics in an inner-city setting with high social deprivation.

Method

A closed-loop prospective audit compared outcomes from January to December 2024 (pre-VFC) to February to March 2025 (post-VFC). Metrics included BOAST 72-hour breaches, discharge rates, did-not-attend (DNA) rates, surgical conversion rates, patient satisfaction, and projected cost savings.

Results

New attendances fell from 45 to 27/day. VFC assessed 18 patients daily, discharging 32.3%, saving 155 appointments. Required face-to-face (F2F) clinic slots reduced by 40.9%, (from 110 pre-VFC to 65 post-VFC). F2F DNA rates fell from 23.5% (n = 863) pre-VFC to 8.3% (n = 26) post-VFC; VFC calls DNA rates were 1.2% (n = 9). Pre-VFC, 9.8% of surgical and emergency cases were incorrectly triaged to fracture clinic, reducing to 1.2% post-VFC. BOAST 72-hour breaches decreased from 37.4% (n = 2449) to 14.5% (n = 70). 84% of patients preferred VFC over waiting in F2F clinic, with wait times exceeding 90 minutes. Projected annual cost savings from reduced attendance exceeded £100,000.

Conclusions

VFC improved BOAST compliance, reduced non-urgent fracture clinic attendances and DNA rates. Urgent cases were expedited to on-call pathways. There were exceptional operational cost savings. VFC led to earlier consultant-level decision-making in patient care, preventing harm and redistributing departmental resources to patient benefit. This audit demonstrated VFC to be a successful model despite high levels of deprivation and one of the largest cohorts of non-English-speaking patients in the UK.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

309 Open abdomen management in trauma and emergency surgery: a two-year audit

Aslesha Deshraju ^1,^✉, Orla Freeman ¹, Htoo Linn ¹, Lalin Navaratne ¹

Abstract

Aim

Management of the open abdomen remains one of the most challenging scenarios in acute care surgery, associated with considerable morbidity and mortality. This audit aimed to describe indications, closure methods, and short-term outcomes for patients requiring open abdomen at a major trauma centre in London.

Method

A retrospective audit was conducted at St Mary’s Hospital, a tertiary referral and major trauma centre, over a two-year period, from August of 2023 to August of 2025. Data were collected on indication for laparostomy, closure technique at index procedure, and patient outcomes.

Results

Thirty-four patients underwent open abdomen management. Indications were emergency general surgery (44%), trauma (29%), and complications of vascular surgery (26%). Index temporary closure methods included Abthera (71%), fascial closure (12%), VAC dressing (12%) and Opsite “sandwich” (3%), 3% of which were undocumented. Overall mortality was 23.5% (n = 8), with three patients dying before relook laparotomy.

Conclusions

This audit demonstrates the significant burden of open abdomen within a major trauma centre, with nearly one-quarter mortality. Abthera was the most frequently used closure technique, consistent with international practice across all specialties. These findings provide a benchmark for outcomes and underscore the value of ongoing audit in refining management strategies.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

312 Reducing surgical site infections: SSI bundle implementation at Wrexham Maelor Hospital

C Battersby ¹, M Pereira ¹, T A Ravindran ^1,^✉, S - ¹, O Sogaulu ¹, D Idama ¹, Y Garbutt ¹

Abstract

Aim

Surgical site infection (SSI) is a common post-operative complication that increases patient morbidity and healthcare costs through prolonged hospital stay, antibiotic use, reoperation, and frequent dressing changes. This study aimed to evaluate the impact of implementing an evidence-based SSI bundle on infection rates in general surgery at Wrexham Maelor Hospital and to identify patient factors associated with increased SSI risk.

Method

A local audit was undertaken in 2020 to determine SSI incidence in upper gastrointestinal and colorectal surgery at Wrexham Maelor Hospital. In response, an SSI bundle checklist was introduced alongside the WHO surgical safety checklist. The bundle incorporated evidence-based measures including clean closure instruments, use of plus sutures, glove changes and more. A re-audit was conducted in 2023 to evaluate outcomes following implementation.

Results

The re-audit demonstrated a reduction in SSI rates from 24.5% to 9.8% following introduction of the bundle, compared with the national average of 10.4%. Analysis also revealed that patients with a body mass index >25 and those aged >65 years had a higher risk of developing SSI.

Conclusions

The WHO surgical checklist is widely standardised, but there remains scope for enhancement to maximise patient care and reduce complications. This audit demonstrated a measurable improvement in SSI rates following integration of additional evidence-based practices. Continued adoption and reinforcement of these measures at a local level may further reduce SSI incidence and improve patient outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

315 More is better

Rahul Menon ^1,^✉, Louise Smith ¹, Holly Ansell ¹, Achyuth Menon ¹

Abstract

Aim

Colonoscopy is the gold standard for diagnosing colorectal cancer, enabling histological confirmation. At our trust, avoidable repeat colonoscopies were identified as a significant cause of delays in the fast-track cancer pathway, particularly due to inadequate histological sampling. Our study aimed to evaluate the extent of the issue, causes for delays and reduce the number of repeat procedures needed.

Method

Patients diagnosed with colorectal cancer between January 2023–May 2024 were retrospectively reviewed. Those undergoing diagnostic colonoscopy were identified and reasons for repeat procedures recorded, focusing on inadequate biopsy sampling. In March 2025 we changed our protocol: endoscopists were advised to take 12 biopsies as standard, double the number suggested in current literature. Patients diagnosed between March–July 2025 were then reviewed to assess the impact of this intervention.

Results

From January 2023–May 2024, 74 patients underwent diagnostic colonoscopy; 26% required a repeat procedure. Of these, 34% were specifically due to inadequate biopsy sampling. Following the protocol change, 25 patients underwent colonoscopy in March 2025; 28% required repeats due to insufficient sampling, reflecting partial implementation. Between April–July 2025, after full implementation, 52 patients were scoped, and no repeats occurred due to inadequate sampling. No adverse effects were reported from increasing the number of biopsies.

Conclusions

Doubling biopsy numbers from six to twelve eliminated repeat colonoscopies due to inadequate histological sampling. Given the absence of complications or additional resource burden, we recommend adoption of 12 biopsies as the standard of care to improve diagnostic efficiency and patient outcomes in colorectal cancer nationally.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

322 Audit of microbiological analysis and clinical utilisation of organ perfusion fluid in renal transplantation

Samuel Amo-Afful ^1,^✉, Ahmed Adelmageed ², Raphael Uwechue ²

Abstract

Aim

To assess local practice in the microbiological testing of abdominal organ transport fluid (OTF) in renal transplantation, with reference to the UK Standards for Microbiology Investigations (SMI B 62), which recommend routine culture of OTF to inform clinical decision-making.

Method

We retrospectively reviewed 128 renal transplant cases performed at the Queen Alexandra Hospital between January 2024 and May 2025. Data was collected using the patient electronic records (Minestrone, VitalData). The analysis focused on the submission of OTF for microbiological culture, the frequency and nature of positive results, and whether findings influenced patient management.

Results

Perfusion fluid was sent for analysis in 70% (n = 89) of cases. Nine samples (7%) grew organisms: seven were considered contaminants requiring no intervention, while two resulted in antimicrobial treatment following microbiology advice. Donor types included 43% donation after brain death (DBD), 30% donation after circulatory death (DCD), and 27% living donors. Delayed graft function (DGF) was observed in 49% of recipients. The findings suggest variable adherence to national guidance and some gaps in documentation of actions taken in response to positive cultures.

Conclusions

We recommend the development of local protocols aligned with UK SMI B 62 to support consistent interpretation and integration of OTF microbiology findings into post-transplant care.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

327 Apixaban use peri-operatively in orthopaedics

Hermione Jemmett ^1,^✉, Nivar Saleh ¹

Abstract

Aim

Apixaban is a frequently used DOAC in orthopaedic patients. In the peri-operative period, recommendations advise to withhold apixaban 24hrs pre-operatively and restart 48hrs post-operatively barring contraindications. Delayed re-initiation resulted in longer hospital stays, thromboembolic events and medication errors.

Method

A retrospective two-cycle audit was conducted on orthopaedic patients admitted on apixaban who underwent emergency surgery. We evaluated adherence to post-operative apixaban guidelines. Data was collected over 3 weeks on timing of apixaban discontinuation and reinitiation. The first intervention paired team education, posters and admissions checklist modifications. The second intervention added a specific section on restarting apixaban to post-operative and daily review proformas to sustain improvements.

Results

Initial data revealed that of 27 patients admitted on apixaban within a one-month period, 70.3% (n = 16) had their apixaban inappropriately withheld for >48hrs. Only one patient (3.7%) had it correctly restarted within 48 hours post-operatively. Following the first intervention, over a 3-week period (n = 12), adherence improved with only 16.7% (n = 2) having had their apixaban incorrectly restarted beyond the 48hr guideline without a medical reason. 33.3% (n = 4) had apixaban correctly restarted, the remaining patients (n = 6) had apixaban withheld for >48hrs appropriately. Following the second intervention, 80% (n = 8) were correctly restarted Day 2 post-operatively, the remaining 20% (n = 2) were restarted on Day 3. This resulted in 167% increase in adherence to guidelines.

Conclusions

These interventions significantly improved adherence to apixaban guidelines post-operatively. Given its importance in the long-term health outcomes of patients, restarting apixaban should continue to be an important consideration in the post-operative period.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

329 Beyond the scan: accuracy and limitations of mpMRI in prostate cancer diagnosis

Kanwal Naz ^1,^✉, Ayokunle Adenipekun ¹, Mushtaq Hussain ², Sarvpreet Ubee ¹, Amerdip Birring ¹, Adel Shafik ¹

Abstract

Introduction

Multiparametric MRI (mpMRI) is central to the assessment of suspected prostate cancer, guiding biopsy decisions and risk stratification. While highly valued in clinical pathways, its sensitivity for clinically significant disease remains debated. This audit evaluated the diagnostic accuracy of mpMRI against histology from Local Anesthetic Transperineal (LATP) biopsy.

Method

A retrospective audit was conducted of 126 patients who underwent mpMRI followed by LATP biopsy between January and March 2025. MRI findings were classified as high, intermediate, or low probability for malignancy. Histology served as the reference standard. Diagnostic accuracy was calculated using a confusion matrix, with “high-probability MRI” defined as a positive test.

Results

Among 84 patients with high-probability MRI, 85.7% (72/84) had malignancy confirmed on biopsy. In the intermediate group (28 patients), 78.6% (22/28) had cancer, including five cases missed on targeted cores but detected in non-targeted samples. In the low-probability group (14 patients), 42.9% (6/14) had malignancy; two of these had clinically significant disease (Gleason 4 + 4 and 4 + 5). Several patients in this group also had recognised risk factors such as family history or Afro-Caribbean ethnicity.

Conclusions

mpMRI demonstrated strong predictive value when reported as high probability, but clinically significant cancers were also identified in intermediate and low-probability groups. Reliance on MRI alone risks under diagnosis, and biopsy remains essential in selected patients.

Recommendations

Multidisciplinary review of indeterminate cases, further training in MRI interpretation, and assessment of interobserver variability are recommended to enhance diagnostic accuracy.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

331 Enhancing handover and continuity of care: a closed-loop audit of digital documentation in thoracic surgery at a teaching hospital

Amirah Adlina Binti Abdul Aziz ^1,^✉, Ghaith Qsous ¹, Alina Akhter ¹, Hariz Azhari Bin Nor Azam ¹

Abstract

Aim

This closed-loop audit aimed to improve the quality and accessibility of digital documentation in the thoracic surgery department to enhance handover, continuity of care, discharge summaries, and, ultimately, patient safety.

Method

A retrospective audit of 20 patients was undertaken across two cycles. Documentation on the trust's digital platform was assessed against the Royal College of Physicians (RCP) ward round best practice guidance (2012), the General Medical Council (GMC) Good Medical Practice requirements for accurate, contemporaneous records, and additional local thoracic unit standards (drain status, anticoagulation, imaging, and blood results). Domains assessed included diagnosis, procedure, current issues, past medical history, drain status (suction, output, air leak), imaging, blood results, antibiotics, anticoagulation status, and plans. Following the first cycle, departmental teaching was delivered and a structured digital template was introduced to guide ward staff. The second cycle repeated the assessment using identical criteria.

Results

Post-intervention, documentation quality improved significantly across key domains: diagnosis (33% to 100%), procedure (77% to 100%), current issues (22% to 73%), suction application (33% to 71%), air leak status (22% to 77%), anticoagulation status (0% to 100%), and blood results (22% to 67%). Plans remained consistently documented (100%).

Conclusions

Departmental teaching and a structured template substantially improved compliance with established documentation standards. This intervention supported safer handover, clearer discharge letters, and enhanced patient care and safety, demonstrating a sustainable approach to improving digital record-keeping in thoracic services.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

344 LIVER study – liver injury vigilance, evaluation and response: evaluating liver trauma surveillance in high-grade injuries: a retrospective analysis of compliance, intervention rates and outcomes at St Mary’s major trauma centre

Georgios Karagiannidis ¹, Evie Banham ^2,^✉

Abstract

Aim

High-grade hepatic trauma (AAST Grades IV–V) poses significant challenges in trauma care. The standard practice of non-operative management (NOM) exists for stable patients but the necessity and timing of surveillance imaging (re-imaging), particularly contrast-enhanced CT remains unclear. The detection of delayed complications, such as pseudoaneurysms or bile leaks, through imaging remains controversial for patients who remain asymptomatic. The absence of UK-based data creates challenges for following guidelines especially after the Trauma Audit and Research Network (TARN) shutdown in 2024.

Method

A retrospective cohort analysis examined 209 adult patients who received AAST Grade IV–V liver injuries at St Mary’s Major Trauma Centre from January 2019 to October 2024. The main study outcome measured the frequency and timing of surveillance imaging procedures. The study evaluated two additional outcomes which included intervention rates and mortality rates. The study evaluated imaging compliance against institutional protocols which require triple-phase CT scans between 48–72 hours for all high-grade injuries and a 6-week ultrasound for penetrating trauma patients.

Results

The 209 patients (mean age 52.4 years; 75% male) included 82% Grade IV and 18% Grade V liver injuries. Most injuries resulted from blunt trauma incidents. Re-imaging conducted on 74% of patients but only 52% completed the full imaging protocol. The practice of re-imaging resulted in major management alterations which required additional interventional radiology or surgical procedures for 21% of patients. The hospital death rate reached 5.3%.

Conclusions

High-grade liver trauma patients experienced significant changes in their clinical treatment because of surveillance imaging procedures. The implementation of imaging protocols showed restricted compliance especially when it came to outpatient follow-up procedures.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

346 From white-top to red-top: a simple change improving urine culture accuracy in ureteroscopy

Maelle Collangettes ^1,^✉, Randeep Dhariwal ¹, Vimoshan Arumuham ¹

Abstract

Aim

To evaluate intra-operative urine sample collection accuracy before and after introducing boric acid preservative containers. Accurate perioperative urine cultures are essential in flexible ureteroscopy to detect urinary tract infections (UTIs) and guide antibiotic use. At our institution, samples were often collected in white-top containers lacking preservative, risking bacterial overgrowth, mixed growths, and unreliable results. Red-top containers with boric acid preservative prevent this by stabilising specimens during transport, thereby improving culture reliability.

Method

This single-centre quality improvement study retrospectively analysed flexible ureteroscopy cases across two time periods: June–December 2024 (pre-intervention) and April–June 2025 (post-intervention). The intervention comprised provision of red-top containers in theatres, process changes to ensure availability, and targeted staff education. Outcomes measured were container type used and urine culture results, with data extracted from electronic patient records.

Results

Pre-intervention, 61 intra-operative urine samples were collected; 12 (19.7%) used red-top containers. Post-intervention, 40 samples were collected; 39 (97.5%) were red-top. Correct container use therefore improved from 19.7% to 97.5%, representing a highly significant process change.

Conclusions

Introducing boric acid preservative containers, supported by staff education and theatre workflow changes, led to a marked and sustained improvement in correct intra-operative urine sample collection. Whilst culture positivity did not significantly differ by container type (likely due to small sample size and case-mix), standardised specimen handling remains crucial for diagnostic reliability, reducing contamination, and promoting safe antibiotic stewardship. Ongoing monitoring and reinforcement are required to maintain compliance and ensure the benefits of this change.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

347 Standardising flexor tendon repair documentation and enhancing patient communication: a two-cycle audit and qi project

Harry Phillips ^1,^✉

Abstract

Aim

To assess compliance with BSSH guidelines for flexor tendon repair and improve the quality of operative documentation and patient information.

Method

We conducted a two-cycle audit. Cycle 1 (July–November 2024) was a retrospective review of electronic patient records (EPR). Following this, we introduced a standardised operative note template, provided QR codes at admission to streamline access to patient information, and presented findings at an audit meeting to address delays in theatre and hand therapy. Cycle 2 (December 2024–March 2025) was a prospective review of patients undergoing flexor tendon repair.

Results

Cycle 1 included 22 patients: 68% underwent surgery within four days, 86% had the repair technique documented, 73% had the level of laceration recorded, 50% had pulley documentation, 64% were seen by hand therapy within five days, and 9% received written postoperative information. Key issues were delay to theatre and therapy, incomplete documentation, and limited patient information.

Cycle 2 included 19 patients. Documentation improved to 100% for all key points, 100% received patient information via QR codes, and 100% were reviewed by hand therapy. However, only 33% were operated on within four days.

Conclusions

Smartphrases within the EPR significantly improved documentation, and QR codes were a simple, effective method of delivering patient information from the first visit. However, accessibility remains a challenge, particularly for patients with limited digital access or literacy. Integration into induction materials has helped sustain improvements. Delays to theatre reflected systemic pressures and remain a target for further work.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

350 Low diagnostic yield of the two-week wait pathway for testicular cancer: is there a role for pre-referral ultrasound?

Mushtaq Hussain ^1,^✉, Kanwal Naz ², Debashis Sarkar ¹

Abstract

Introduction

The two-week wait (2WW) referral pathway aims to expedite cancer diagnosis. For testicular cancer, NICE guidelines mandate urgent referral based on clinical suspicion alone, without pre-referral imaging. While this maximises sensitivity, it may also result in a high proportion of benign referrals. This audit evaluated the diagnostic yield of the 2WW pathway and considered the potential role of primary care ultrasound.

Method

A retrospective audit of 100 consecutive 2WW referrals for suspected testicular cancer was conducted at a tertiary NHS urology clinic between June 2023 and May 2025. Data included patient age, final diagnosis, and use of pre-referral ultrasound. Malignancy detection rate was compared against the expected benchmark of 5–10%.

Results

Only 1% of patients underwent ultrasound before referral. Malignancy was confirmed in three patients (3%): one seminoma, one non-seminomatous germ cell tumour, and one high-grade B-cell lymphoma. The remaining 97% had benign diagnoses, most commonly hydrocele (41%) and epididymal cyst (26%). The malignancy detection rate (3%) was lower than the expected benchmark.

Conclusions

The 2WW pathway for testicular cancer demonstrates a low diagnostic yield, with the vast majority of referrals representing benign disease. Limited access to pre-referral ultrasound contributes to unnecessary referrals, increased service burden, and avoidable patient anxiety. Integrating scrotal ultrasound in primary care could improve triage, reduce inappropriate urgent referrals, and better align with NHS diagnostic priorities.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

362 Optimizing hand trauma management in a tertiary NHS plastic surgery department: a quality improvement initiative aligned with UK prevalence data and BSSH guidelines

Shimul Dey ^1,^✉

Abstract

Aim

Hand trauma is a significant burden on the UK healthcare system. The BSSH provides crucial guidelines for the timing of surgical intervention to improve patient outcomes. This project evaluates compliance with these guidelines at University Hospitals Coventry and Warwickshire (UHCW) NHS Trust and proposes solutions to systemic challenges.

Method

A retrospective audit of 148 hand trauma cases managed between January 1st and March 31st, 2025, was conducted. The primary objective was to assess adherence to BSSH timeframes: within 24 hours for open fractures/joints/bites, within 4 days for other open injuries, and within 7 days for closed fractures.

Results

Overall compliance for surgical intervention was 83%, exceeding the 80% target and showing an improvement from the previous cycle's 73%. While open soft tissue injuries showed high compliance (89-97%), delays were noted for open fractures (64% compliance) and closed fractures (67% compliance), with surgical fixation for the latter at just 50%. The median time from decision taken for surgical intervention to surgery was 42.7 hours.

Conclusions

Despite overall progress, persistent delays in managing complex injuries like fractures highlight systemic bottlenecks. Strategic interventions are needed to improve patient outcomes and reduce the estimated £287 million annual cost of hand trauma in the UK. Recommendations include increasing dedicated trauma list capacity, enhancing daily clinic capabilities, and implementing targeted education and regular audits.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

373 Treatment outcomes following intravesical onabotulinum toxin a (Botox) Injection: a retrospective cohort study

Philip Abolanle ^1,^✉, Thomas Richards ¹, Paulette Hussain ¹, Coral Seymour ¹, Rebecca Saunders ¹, Maike Eylert ¹

Abstract

Aim

Intravesical onabotulinum toxin A (Botox) is widely used for refractory overactive bladder symptoms following comprehensive clinical assessment and urodynamic testing. This study evaluates its efficacy, urinary tract infection and catheterization outcomes.

Method

We conducted a retrospective review of 193 patients who received Botox in 2024 at the Urology Department of a District General Hospital in South Wales. Statistical tests including Chi-square, Fisher’s Exact Test, and likelihood ratios were used to assess for significant associations.

Results

The cohort was predominantly female (85%) with a median age of 62 years. 77% of patients suffered from idiopathic detrusor overactivity (IDO) and 21% had neurogenic detrusor overactivity (NDO) with 78.3% undergoing repeat treatments during this period. Most patients (66.2%) were not on any concomitant bladder medications. Overall, 82.4% reported good effects, with no significant difference in response rates across indications (χ² = 3.82, p = 0.28), and only 3% of patients required dosage escalation. Incidence of urinary tract infection in the cohort was low (4.7%), though higher in diabetic patients (11.5%) without statistical significance (χ² = 3.195, p = 0.074; Fisher’s p = 0.105). Only 18% of patients needed to use catheters as a sequela and this need was not significantly associated with Botox dosage in either IDO or NDO groups. Duration of effect reported was most commonly 6–12 months.

Conclusions

Botox therapy demonstrates high efficacy and safety across overactive bladder subtypes, with minimal UTI risk and no significant dose-related catheter burden. These findings support its continued use in diverse patient populations.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

383 Risk stratification post radical nephrectomy: an evaluation of Leibovich Score in clear cell renal cell carcinoma (ccRCC) report

Kevin Xuan Hong Tang ^1,^✉, Mohamed Alnoomani ¹, Mohamed Ibrahim ¹, Omar Allat ¹, Amr Emara ¹

Abstract

Aim

The Leibovich Score is a risk stratification tool which classifies and guides the follow up protocol for patients with ccRCC post radical nephrectomy. A closer surveillance and higher frequency of computed tomography imaging are recommended monitoring high risk patients based on Leibovich Scoring. Risk stratification and the reporting of Leibovich Score is thus a key indicator for referral for adjuvant therapy. The aim of this audit is to evaluate the risk stratification and histology reporting of Leibovich Score in ccRCC patients post radical nephrectomy.

Method

A retrospective review of histology reports, clinical letters and multidisciplinary outcomes of patients who underwent radical nephrectomy from January 2021 to March 2024 in two mid and north Hampshire Hospitals was conducted. Papillary renal cell carcinoma, chromophobe renal cell carcinoma, renal oncocytoma and benign renal cysts were excluded. Referrals for adjuvant therapy were evaluated as well.

Results

46 out of 80 renal cell carcinoma patients were diagnosed with ccRCC (57.5%). 14 patients were classified as low risk, followed by 21 patients as intermediate risk and 11 as high risk. Only 32.6% of the histology reports commented on the Leibovich score of ccRCC. Of these 46 patients, 7 (15.2%) were referred for adjuvant therapy (Pembrolizumab) based on multidisciplinary meeting reports.

Conclusions

This audit underscores the importance of reporting Leibovich Score and risk stratification in patients with ccRCC, which potentially affects the follow up protocol and pathway of care. Collaboration with local histopathologists is recommended to improve reporting standards for optimised care for those patients.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

393 a lower limb free flap enhanced dangling protocol initiative at a major trauma centre: introducing LEAP-ER (Lower Limb Enhanced Accelerated Pathway-Early Recovery) protocol

Shimul Dey ^1,^✉, Rehnuma Hossain ¹, David Wallace ¹

Abstract

Aim

This initiative was aimed to provide a standardised care pathway with the development of an easy-to-use proforma to support a lower limb free flap dangling protocol at a major trauma center. The goal was to establish an enhanced recovery pathway to reduce the length of stays (LoS) for patients undergoing these procedures.

Method

A retrospective observational audit was conducted from August 2024 to July 2025, including all lower limb free flap reconstruction cases at a major trauma center during that period. Data was collected from the hospital's electronic patient records (EPR) and was presented in Departmental meeting to initiate easy to follow proforma for lower limb free flap reconstruction patients.

Results

A total of 21 patients were included in the audit. The median age was 44.23 years, with an average hospital stay of 27 days. The median day for starting dangling was 4.3 days post-operation. The flap survival rate was 81% (17 out of 21 patients). It was approved by Departmental Clinical Governance to introduce a 3 days dangling initiative.

Conclusions

The project enabled us to establish a protocol for lower limb free flap dangling. The use of the proforma is aimed at aiding an enhanced patient recovery and reducing the length of hospital stays. Future objectives include a prospective audit in six months to monitor the effectiveness of the new protocol.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

395 Reducing delays to PEG insertion in postoperative head and neck cancer patients: a quality improvement project at Oxford University Hospitals

Danish Malik ^1,^✉, Shayndhan Sivanathan ¹, Sarah Shaw ¹, Satheesh Prabhu ¹

Abstract

Introduction

Major oral cancer resections and reconstructions are complex procedures with long, often unpredictable recoveries. In some cases, the need for PEG frequently emerges only postoperatively due to delayed recovery or extensive resections. These patients, though otherwise medically fit for discharge, remain hospitalised awaiting PEG, delaying recovery, burdening families, and affecting patient flow in a scarce bed capacity unit.

Method

We conducted a retrospective review of head and neck cancer patients on Blenheim Ward, Churchill Hospital, between January 2024 and May 2025 who required PEG insertion postoperatively. NHS records provided data on demographics, surgical details, PEG indication, and time from decision to insertion.

Results

Five cases were identified, all involving major resections with bilateral neck dissections and tracheostomy. Indications included extensive resections and severe postoperative dysphagia. Median delay from decision to PEG insertion was 33 days (range 12–37), attributed to limited external booking capacity. This resulted in 138 excess bed days, costing £47,610, without conferring additional clinical benefit.

Conclusions

Unpredictable postoperative PEG requirements expose patients to avoidable inpatient stays, undermining recovery and independence. We established an onsite PEG referral pathway in collaboration with the Upper GI team that enabled patients to be discharged earlier with a PEG, facilitating rehabilitation in the community and maximising their chance of regaining functional independence. This patient-centred, cost-saving initiative offers a scalable model for cancer centres nationwide to improve outcomes and efficiency.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

412 Reducing catheter duration to improve recovery in hip fracture patients: a two-cycle audit

Malin White ^1,^✉, Jonathan Dimitry ¹, Ahmad Diab ¹, Suharto Chatterjee ¹

Abstract

Introduction

Hip fracture is a common surgical emergency with high morbidity and resource demands. Perioperative urinary catheterisation is often necessary but can delay mobilisation, increase complications, and prolong hospital stay. We evaluated the impact of a targeted catheter-reduction intervention on practice and outcomes in hip fracture patients at Pilgrim Hospital, Boston, UK.

Method

Two audit cycles were performed. Cycle 1 (retrospective) included 56 patients admitted between February–March 2024. Cycle 2 (prospective) included 45 patients admitted between May–June 2025 following implementation of a multifaceted intervention comprising: ward-based teaching, daily catheter review on ward rounds, and visual prompts for the multidisciplinary team. Data collected included demographics, fracture type, operation, comorbidities, catheter duration, trial without catheter (TWOC) date, and length of stay (LOS). Outcomes were compared using t-tests, ANOVA, and regression analysis adjusting for confounders.

Results

Documentation of catheter review dates improved from 15% to 40%, while inappropriate TWOC delays fell from 31.8% to 8%. Among catheterised patients, mean catheter duration decreased from 11.6 ± 11.1 days to 4.2 ± 2.7 days. LOS reduced by 26.9% in catheterised patients (18.5 to 13.6 days, p = 0.12) and 16.1% in non-catheterised patients (13.1 to 11.0 days, p = 0.33). Multivariable regression confirmed catheterisation independently prolonged LOS by ∼7 days (p = 0.044), though the intervention effect was not statistically significant after adjustment.

Conclusions

A simple, multidisciplinary intervention significantly improved catheter practice and reduced catheter duration, with associated reductions in LOS. These findings highlight the potential for low-cost service changes to enhance perioperative recovery and discharge efficiency in hip fracture patients.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

416 Bloodless victory: a two-cycle audit to reduce the use of routine group and save testing in day case laparoscopic cholecystectomy

Jeeva Karuniya Sundarraj ^1,^✉, Eve Watt ¹, Rahee Mapara ¹, Erin McIlveen ¹

Abstract

Aim

Laparoscopic cholecystectomy is a common procedure with low morbidity and mortality, although major hemorrhage is a rare complication. Routine preoperative G&S sampling is widely undertaken to facilitate transfusion if required. This audit aimed to evaluate the incidence of transfusion and assess the financial and environmental impact of routine G&S testing.

Method

A two-cycle retrospective audit was performed at a single institution. Cycle 1 reviewed all LCs between July 2024 and January 2025, prior to intervention. Cycle 2 examined LCs performed in August–September 2025 following introduction of a reduced G&S policy. Demographic data, bleeding risk, G&S frequency, transfusion, cost, and carbon footprint were analyzed.

Results

Cycle 1: 191 patients, median age 51 years, 81% female, 19 with increased bleeding risk. A total of 193 G&S samples were obtained; no cross-matching or transfusions occurred. Estimated cost was £4,180 over 6 months, with a carbon impact equivalent to 3,435 petrol-car miles.

Cycle 2: 41 patients (median age 52; 14 male, 27 female), 6 with increased bleeding risk. 23 G&S samples were taken; no cross-matching or transfusions occurred. Compared with Cycle 1 practice, this represents a saving of ∼£399 and 328 carbon miles.

Conclusions

No patient in either cycle required perioperative transfusion despite extensive preoperative G&S testing. Routine G&S for LC appears unnecessary in low-risk patients, and its omission offers measurable financial and sustainability benefits, with an estimated £8,360 saved annually. Further work is required to eliminate routine testing, while retaining targeted G&S for higher-risk patients.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

418 Leveraging electronic patient record technology to optimise Oakland score use in lower gastrointestinal bleeding

Faraaz Khan ^1,^✉, Andrew Emmanuel ¹

Abstract

Aim

The Oakland score was introduced in the first UK national guidelines on acute lower gastrointestinal bleeding (LGIB) by the British Society of Gastroenterology to stratify patients and guide the management of major and minor bleeds. We audited the use of this risk score and implemented strategies to improve compliance, including raising awareness and integrating a calculator into the electronic patient record (EPIC systems).

Method

Pre-intervention data were initially collected from the electronic patient record from October 2024 to March 2025 with patients presenting with LGIB identified. Documentation of the Oakland score and management of LGIB patients was assessed and scores retrospectively calculated in absent cases. Departmental interventions included an education session in April 2025 and the introduction of an integrated calculator into the EPIC system in June 2025 to support ease of use during on-call shifts.

Results

A total of 69 patients presenting with LGIB were identified during the initial data collection of which 68 cases represented stable bleeds. The Oakland score was documented in only 5 instances. There were 52 recorded cases of major LGIB however only 27 of these patients were admitted for inpatient monitoring or further investigations. In contrast, only 1 of 17 patients retrospectively classified as ‘minor’ bleeds was admitted, the majority did not receive outpatient investigations. Use of the Oakland score improved following departmental interventions.

Conclusions

Using modern technologies to improve workflow efficiency, departmental interventions including education and electronic patient record calculator integration have led to increased familiarity and uptake of the Oakland score to manage LGIB.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

419 Optimising on-call workflow in general surgery through EPIC-integrated handover Tools

Faraaz Khan ^1,^✉, Musallam Al-Akash ¹

Abstract

Aim

Maintaining patient safety is ensured by timely reviews and safe handover from the on-call to ward teams. The Royal College of Surgeons recommends that emergency patients are reviewed by an on-site consultant at least once every 24 hours. We identified limitations with our on-call workflow which relied upon manually updated, separate online word documents. We now utilise inbuilt tools within our electronic patient records (EPIC systems) for a safer and more reliable handover.

Method

The workflow system was assessed by recording the number of patients admitted under General Surgery, timing of consultant review and instances where patients were not appropriately handed over from on-call to ward teams leading to delay in clinician review. Departmental surveys were conducted in parallel to gain feedback on the on-call workflow. Interventions included a departmental introduction of the use of integrated EPIC tools alongside in person handovers in November 2024, followed by an online departmental webinar in February 2025.

Results

In October 2024, 141 patients were admitted under general surgery of which 72% were reviewed by a consultant whilst 5% had no clinical review within 24 hours post admission. Over 85% of responding clinicians did not feel confident in knowing which patients required consultant review or formal handover to the respective ward team and had concerns for the safety of handovers. The introduction of a workflow system which uses readily available electronic tools has had a positive impact.

Conclusions

Integrated electronic tools improve efficiency and safety of patient handover during surgical takes and ensure appropriately timed inpatient reviews.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

421 An audit of the management of tetanus-prone wounds in hand trauma patients at a UK plastic surgery unit

Vidhya Lingamanaicker ^1,^✉

Abstract

Introduction

Tetanus-prone wounds are a common presentation in the hand and a tetanus status assessment and treatment should be delivered as per UK Health Security Agency (UKHSA) guidelines. The aim of this audit was to study the management of tetanus-prone hand trauma at a UK Plastic Surgery unit in comparison to these guidelines.

Method

Electronic medical records of patients referred to Hand Trauma clinic with tetanus-prone wounds were collected over a 4 week period. Documentation of tetanus status and provision of a reinforcing dose of the vaccine were studied. First cycle results were discussed at a local meeting alongside dissemination of UKHSA guidelines. Following this, the second cycle studied patients over a further 4 week period.

Results

80 patients with tetanus-prone wounds were included in the first cycle. 10% (n = 8) of patients did not have a documented tetanus status and did not receive booster prophylaxis. Human tetanus immunoglobulin was not administered to any patient. In the second cycle, 117 patients attended clinic with tetanus-prone wounds. All patients (n = 117) were found to have an up to date tetanus vaccination status documented or were administered a reinforcing dose of the vaccine following injury as per guidelines.

Conclusions

This audit has demonstrated that following clinician education, there was 100% compliance in this unit with national management of tetanus-prone hand trauma. Administration of tetanus immunoglobulin in patients with unknown tetanus status was not reflected in clinical practice and this requires further study.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

430 Complications and diagnostic accuracy of local anaesthetic transperineal prostate biopsy: a 6-month single-centre audit

Jasmine Derex-Briggs ^1,^✉

Abstract

Aim

To evaluate the safety profile of local anaesthetic transperineal prostate biopsy with prophylactic antibiotic cover and assess the diagnostic accuracy of multiparametric MRI (mpMRI) compared with biopsy outcomes.

Method

We retrospectively reviewed men undergoing local anaesthetic transperineal prostate biopsy at our hospital between January and June 2023. Patients undergoing repeat biopsy for active surveillance were excluded. Data collected included demographics, PSA, use of prophylactic antibiotics, MRI PIRADS score, biopsy histology, and complications. Complications were classified by re-attendance, re-admission, and Clavien–Dindo grading. MRI diagnostic performance was assessed against biopsy using PIRADS thresholds of ≥3 and ≥4.

Results

Fifty-seven men underwent first-time transperineal biopsy (median age 69 years, PSA 6.2 ng/mL). Prostate cancer was detected in 39 (68%), most with Gleason ≥7 disease. Complications were rare, with only one case of urinary retention requiring admission and no post-biopsy infection. All men had pre-biopsy MRI. Using PIRADS ≥3, sensitivity was 98% with poor specificity, while PIRADS ≥4 achieved sensitivity 69% and specificity 75%. MRI lesion laterality concordance with histology was 98%.

Conclusions

Local anaesthetic transperineal biopsy with prophylactic antibiotic cover for first-time patients was safe, with minimal morbidity and high cancer detection. mpMRI was highly sensitive at PIRADS ≥3 but more clinically balanced at PIRADS ≥4. PSA density further improved discrimination, and MRI lesion localisation closely matched histology. In the next audit cycle, we will review outcomes without prophylactic antibiotics to evaluate whether antibiotic cover is necessary in this setting.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

432 Patient experience of urodynamic studies: a first-cycle audit against BAUS standards

Sarankan Sriranganathan ^1,^✉, Irfan Kar ¹, Adel Shaikh Hasan ¹, Mohammad Alomari ¹

Abstract

Aim

To evaluate patient experience of urodynamic studies (UDS) against the BAUS Essential In-House Audit Framework (2018) and identify areas for service improvement.

Method

A first-cycle audit was conducted on 51 consecutive patients undergoing UDS. Immediately post-procedure, patients completed the BAUS patient experience questionnaire. Data collected included anxiety (before and during the test), pain, embarrassment, satisfaction, provision of information leaflets, willingness to repeat, and recommendation of the service. Results were analysed descriptively and compared with BAUS standards (satisfaction >60%, willingness to repeat >60%, mean anxiety <5/10).

Results

Of 51 patients, 60.8% were male and 39.2% female. All patients received an information leaflet (100%). Mean anxiety before UDS was 3.04/5 (target <2.5), while mean anxiety during the test was 2.20/5, meeting the BAUS threshold. Mean pain and embarrassment scores were 2.18/5 and 1.8/5 respectively. The mean satisfaction score was 4.71/5. Satisfaction ≥4/5 was reported by 92.2% (target >60%), willingness to repeat by 95.9% (target >60%), and 98.0% would recommend the service. Overall satisfaction and willingness exceeded BAUS benchmarks, but anticipatory anxiety remained above the recommended level.

Conclusions

This first-cycle audit shows excellent outcomes for satisfaction and willingness to repeat UDS, exceeding BAUS standards. Elevated pre-test anxiety was the main gap identified. We plan to implement an enhanced counselling package, including a standardised staff script, leaflet provision at referral, and a pilot patient information video. A re-audit is planned to measure the impact of these interventions, completing the BAUS audit cycle.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

78 Early outcomes of robotic radical cystectomy: initial single-centre experience

Jonathan McAdam ^1,^✉, Andrew McAdam ¹

Abstract

Aim

To evaluate the feasibility, peri-operative outcomes, and early follow-up of robotic radical cystectomy (RRC) during the initial adoption phase at a single UK centre.

Method

A retrospective review was performed of the first five consecutive patients undergoing RRC. Data collected included demographics, tumour characteristics, operative details, pathological outcomes, complications, and follow-up. Complications were graded using the Clavien–Dindo classification.

Results

Five patients (3 male, 2 female) with a median age of 62 years underwent RRC. Indications included muscle-invasive bladder cancer (n = 2), BCG-unresponsive disease (n = 2), and high-risk NMIBC (n = 1). All patients were ASA grade II. Median operative time was 460 minutes and median estimated blood loss was 350 ml. Ileal conduit diversion was performed in all cases, with no conversions to open surgery. Pathological outcomes were pT2a (n = 1), pTa (n = 1), pTX (n = 2), and one awaited result. Median lymph node yield was 7, with no nodal involvement, and all surgical margins were negative. Median length of stay was 7 days. No peri-operative complications, readmissions, or 30-day mortality occurred. Median follow-up was 2 months, with no recurrences recorded.

Conclusions

Robotic cystectomy was introduced safely within our centre, with acceptable peri-operative and early oncological outcomes. Operative times reflect the early learning curve, but morbidity was minimal. These results support the feasibility of establishing a robotic cystectomy programme in a new unit, with ongoing data collection required to determine long-term efficacy.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

86 Optimizing robotic pyeloplasty: a QIP of an efficient elective service model in a district general hospital

Ashwin Paul Bobby ^1,^✉, Claire Luke Krishnan ¹, Khaled Hosny ¹

Abstract

Aim

To reduce robotic pyeloplasty average waiting time to under 90 days by December 2025 through a dedicated elective service, using existing robotic capacity, strict patient selection, and a 24-hour discharge model.

Method

Details of patients that underwent elective robotic pyeloplasty between March 2017 and January 2021 (pre-intervention group) and between January 2023 and October 2024 (post-intervention group) were collected. The criteria for suitability of patients undergoing the new elective service were ASA grade 1 or 2, WHO performance status 0, no prior surgeries, no recurrent PUJ obstructions, and a maximum of one renal pelvis stone. Data such as waiting times, symptom status, MAG-3 renogram results, complications, hospital stay duration, and recurrence rates were compared between pre- and post-intervention groups.

Results

Post-intervention, 32 patients underwent surgery. Average hospital stay reduced significantly from 2.8 days pre-intervention to 1.66 days post-intervention. Initial post-intervention waiting times were prolonged due to backlog clearance (average 252 days) but subsequently showed a marked improvement, with the most recent cases operated within approximately two weeks (15 days). Complication rates remained low and comparable pre- and post-intervention. Recurrence rate post-intervention was 6.25% compared to 4% in the pre-intervention group.

Conclusions

The new elective robotic pyeloplasty service effectively reduced hospital stay and significantly improved waiting times following the initial backlog clearance. This model demonstrates potential scalability and could be extended regionally to enhance timely patient care across the integrated care board (ICB).

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

314 The Scottish robotic colorectal surgery pilot training programme (RCTP) – reflections on implementing a collaborative programme specific for colorectal trainees

Yousef Abduldaiem ^1,^✉, Muhammed Bilal Akbar ¹, Vithya Vera ¹, Adarsh Shah ¹, Claire Carden ¹

Abstract

Aim

Robotic-assisted-surgery is increasingly adopted across the UK. Variability in access, absence of a national curriculum, and competing demands between consultant upskilling and trainee education remain barriers to training. ACPGBI called for structured frameworks to ensure equity, safety, and competence. Subsequently, we reflect on the implementation, feasibility, and outcomes RCTP.

Method

NHS Tayside was selected as the pilot site due to established robotic activity and experienced Robotic colorectal surgeons, including a proctor, delivering training. In collaboration with NES, RCSEd, Intuitive, and NHS Tayside, a structured programme was introduced based on Intuitive’s 4-phase model. The TPD nominated senior trainees (ST6+) with satisfactory ARCP, colorectal interest, and willingness to train outside core commitments. Training incorporated simulation, wet labs, supervised console operating, and regular feedback to monitor progression.

Results

Six trainees commenced in March 2024. In 12 months, two trainees achieved training certification, one is completing phase 4, and three await wet lab training(phase 3) before progressing. Senior trainees advanced rapidly, some reaching phase 4 within six months. Key enablers included simulation access, consistent skilled theatre teams, and competency benchmarking. The very positive feedback cited expert faculty and small-group teaching as drivers of proficiency

Conclusions

This programme demonstrates that a structured, collaborative robotic training pathway can deliver trainee certification and ARCP Rectal Resection requirements, alongside consultant training. Success depends on motivated trainers and trainees, high-fidelity simulation, first-assist access, and strong healthcare-industry partnership. The ACPGBI statement (2025) has endorsed the need for such frameworks, validating the programme’s design and outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

47 Mesh repair versus no-mesh repair for the management of acute and elective femoral hernia: a systematic review and meta-analysis comparing the perioperative outcomes

Ahmed Abdalgany ^1,^✉, Hashem Malkawi ¹, Mohammed Abdelgawa Abdelgawad ¹, Hussein Najjar ¹

Abstract

Aim

The objective of this meta-analysis is to compare mesh repair versus no-mesh repair in the management of acute and elective femoral hernia repair.

Method

Different studies comparing mesh repair versus no-mesh repair in the management of femoral hernia were selected from the medical electronic databases and meta-analysis and was conducted in accordance with the guidelines of the Cochrane Collaboration using statistical software Rev Man version 5.

Results

Four retrospective studies and one prospective study were included on 537 patients reporting the incidence of recurrence, surgical site infection, complications and length of hospital stay were included. In the random effect model analysis, the length of hospital stay was lower in the mesh group but with significant statistical heterogeneity [standardised mean difference (SMD) −0.34, 95%, CI (−1.78, −1.11), Z = 0.46, P = 0.65]. However, the variables of hernia recurrence, surgical site infection and total complications were in favour of mesh group despite no statistically significant difference between both groups and without any statistical heterogeneity among the included studies [Risk Ratio (RR) 0.50, 95%, CI (0.25, 1.02), Z = 1.91, P = 0.06], [RR0.95, 95%, CI (0.35, 2.57), Z = 0.10, P = 0.92], [Risk Ratio(RR) 0.99, 95%, CI(0.56,1.74), Z = 0.05, P = 0.96].

Conclusions

This systematic review indicates that mesh repair of the femoral hernia does not offer any superiority over no-mesh repair of the femoral hernia. Due to the paucity of the RCTs and significant heterogeneity among the compared variables, a major multicentre RCT is needed to validate these findings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

91 Management of carpal tunnel syndrome: a network meta-analysis

Dimitris Challoumas ¹, Nathan Edgar ¹, Brendan Barrett ¹, Emily Ihlbrock ^1,^✉, Nachika Ibekewe ¹, Ali Ahmad ¹, Alexander Tham ¹, David Munn ¹, Stella Polzer ¹, Rob Sinnerton ¹

Abstract

Aim

This network meta-analysis of randomised controlled trials (RCTs) compared the efficacy of various interventions for managing carpal tunnel syndrome (CTS).

Method

As part of a broader umbrella review, we included all systematic reviews of RCTs focused on CTS management. The primary outcome was the Boston Carpal Tunnel Questionnaire (BCTQ), analysed through its two subscales: Symptom Severity Scale (SSS) and Functional Severity Scale (FSS). Interventions supported by at least two RCTs were included. Analyses were performed separately for short-term (≤12 weeks) and mid-term (13–52 weeks) outcomes. Surface under the cumulative ranking (SUCRA) curves ranked treatments, while treatment class tables summarised comparisons. The GRADE tool assessed the certainty of evidence, and both clinical and statistical significance were considered when comparing interventions.

Results

Of 113 eligible RCTs covering 66 interventions, 92 RCTs representing 16 interventions were included in the network meta-analyses. For CTS of any severity, corticosteroid injection with splinting ranked highest for short-term FSS, and endoscopic surgery for short-term SSS. At mid-term, extracorporeal shock wave therapy (ESWT) ranked highest for both SSS and FSS. In cases of mild-moderate CTS, platelet-rich plasma (PRP) injections ranked highest in the short term, while ESWT was most effective mid-term for both BCTQ subscales. Placebo or no treatment consistently ranked last. All interventions except splinting alone were superior to placebo at mid-term for CTS of any severity.

Conclusions

Non-surgical treatments, especially PRP and ESWT, show strong potential in managing CTS, particularly in mild to moderate cases. These findings support prioritising non-invasive approaches before considering surgery.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

97 Exploring the new horizon: a systematic review of artificial intelligence (AI) in urology

Prasenjit Bhowmik ^1,^✉, Banan Osman ¹

Abstract

Introduction

Artificial Intelligence (AI) has emerged as a transformative tool in the field of urology, ranging from cancer diagnostics to surgical innovation. While early studies suggest improved diagnostic and predictive accuracy, the extent of clinical integration and validation remains uncertain. The aim of this study was to systematically review the recent literature to evaluate the applications, performance, and limitations of AI in urology, with a focus on oncology, functional diagnostics, endourology, and surgical innovation.

Method

A systematic search of PubMed, Scopus, and Web of Science was performed for studies published recently. Eligible studies evaluated AI applications in urological practice, including imaging, pathology, predictive modelling, and surgical guidance. Titles, s, and full texts were independently screened by two reviewers. Data were extracted and synthesised according to PRISMA guidelines.

Results

A review of recent studies on AI applications in urology highlights significant advancements in prostate cancer, demonstrating high diagnostic accuracy in MRI interpretation and pathology slide analysis. In urothelial carcinoma, AI models improved risk stratification and recurrence prediction. Applications in endourology and robotic surgery highlighted potential in stone detection and intraoperative guidance. A smaller number of studies addressed benign urological conditions like urodynamics, incontinence prediction, and lower urinary tract symptom assessment. Common limitations included small sample sizes, retrospective design, and lack of external validation.

Conclusions

AI demonstrates significant promise in urology, particularly in prostate cancer detection and outcome prediction. However, most studies remain exploratory, with limited clinical translation. To enable safe adoption, future work should prioritise prospective, multicentre validation, clinical integration, and clear regulatory frameworks.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

137 Topical stem cell sprays and suspensions for post-burn wound healing: a systematic review of emerging regenerative therapies

Mohammed Shakir ^1,^✉

Abstract

Aim

To systematically evaluate the evidence on topical stem cell sprays and suspensions in post-burn wound healing, focusing on cell sources, delivery methods, clinical outcomes, and safety.

Method

A systematic review was conducted according to a predefined PICO framework. Databases (PubMed, Embase, Cochrane Library) were searched up to April 2025 for human studies evaluating spray or suspension-based stem cell therapies for burn wounds. Eligible studies included RCTs, cohort studies, and case series (≥5 patients). Data on study design, population, intervention, outcomes, and follow-up were extracted. Narrative synthesis was applied due to heterogeneity.

Results

Twenty-five studies were included: RCTs (n = 7), cohort studies (n = 14), and case series (n = 4), with sample sizes 10–150. Interventions involved keratinocyte-based sprays (e.g., ReCell®) and mesenchymal stem cell (MSC) suspensions (bone marrow, adipose, umbilical cord). Outcomes consistently showed accelerated epithelialisation (6–10 days vs 10–14 with standard grafts), reduced donor site morbidity, improved pigmentation, and lower hypertrophic scarring. Patient satisfaction was higher in spray-treated groups. Safety was favourable, with no serious adverse events reported; however, long-term follow-up and standardised scar assessments were limited. MSC-based sprays demonstrated promising regenerative effects (angiogenesis, immunomodulation, ECM remodelling) but remain largely in early clinical translation.

Conclusions

Topical stem cell-based sprays are a promising regenerative therapy for burns, offering faster healing and reduced morbidity compared to conventional grafting. Keratinocyte-based systems such as ReCell® are already in practice, while MSC sprays show strong experimental potential. Larger multicentre RCTs with standardised outcomes and long-term follow-up are required before widespread clinical adoption.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

141 Evaluating the effectiveness of personalised video-based coaching for the acquisition of surgical skills in minimally invasive surgery; a systematic review and meta-analysis

Peter Bery ^1,^✉

Abstract

Aim

To evaluate whether personalised video-based coaching (VBC) is more effective than the traditional Master-Apprentice Model for acquiring minimally invasive surgical (MIS) skills using validated surgical skills checklists.

Method

A systematic search was conducted in Embase, MEDLINE, CENTRAL, Web of Science, Google Scholar, Opengrey.eu and ClinicalTrials.gov (1990–July 2023). Forward and backward citation tracing was also performed. Eligible studies assessed personalised VBC as an adjunct or comparator to conventional teaching, with outcomes measured on validated surgical checklists. Data were synthesised using an inverse variance random-effects model, reported as standardised mean difference (SMD).

Results

Of 7,021 studies screened, nine met inclusion criteria, comprising 204 participants ranging from medical students to surgical trainees. All interventions involved personalised post-procedural video feedback tailored to trainee performance. Meta-analysis demonstrated a strong effect size in favour of VBC (SMD 1.14; 95% CI 0.81–1.47; p < 0.00001). Subgroup analyses by training setting (simulation and operating theatre) showed consistent benefit. Sensitivity analysis, excluding high-risk-of-bias studies, confirmed significant findings (SMD 1.13; 95% CI 0.73–1.53).

Conclusions

This review provides evidence that personalised VBC is a highly effective adjunct for MIS training across both simulated and clinical settings. Compared to traditional apprenticeship, VBC accelerates skill acquisition with large effect sizes. Further research should explore its role in developing non-technical competencies and in continuing professional development for senior surgeons.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

145 Exploring the role of perioperative dexamethasone in pancreaticoduodenectomy: helpful adjunct or hidden risk? A meta-analysis

Mishkat Shehzad ^1,^✉, Syed Muhammad Moaaz Bin Sultan ¹, Muhammad Anzal Imran ¹, Aaes Nizami ²

Abstract

Background

Pancreaticoduodenectomy is a technically demanding abdominal surgery, with alarming complication rates despite the recent advances in healthcare. Dexamethasone is frequently administered for the prevention of postoperative nausea and vomiting and is routinely used in pancreatic surgeries. However, its broader influence on outcomes following pancreaticoduodenectomy has never been systematically assessed, representing a critical gap in perioperative optimization. This meta-analysis aims to evaluate the perioperative effects of dexamethasone following pancreaticoduodenectomy.

Method

A systematic search of PubMed, Google Scholar, and the Cochrane Library was conducted up to August 2025. Eligible studies included clinical trials and cohort studies reporting perioperative dexamethasone use in patients undergoing pancreaticoduodenectomy. Excluded studies comprised non-clinical research, reviews, s, and duplicate publications. Four studies (one RCT, one prospective, and two retrospective cohorts) met the inclusion criteria.

Results

A total of 2,631 patients were analysed (912 received dexamethasone, 1,719 served as controls). No significant differences were observed for postoperative pancreatic fistula (RR 0.99), 30-day mortality (RR 1.05), or reoperation (RR 0.77). Delayed gastric emptying showed a non-significant trend towards increased risk (RR 1.13, 95% CI 0.96–1.34; p = 0.14; I² = 0%), while infectious complications suggested a possible reduction (RR 0.87, 95% CI 0.67–1.14; p = 0.31; I² = 61%), though neither result was statistically significant.

Conclusions

No reduction in surgical morbidity was demonstrated. In the context of the already high complication burden of pancreaticoduodenectomy, its continued routine use should now be questioned. Large, high-quality RCTs are urgently required to clarify whether antiemetic benefits justify potential surgical risks.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

175 Clinical outcomes of hip hemiarthroplasty in patients with Parkinson’s Disease following femoral neck fractures: a systematic review

Eimear Roche ^1,^✉, Colin Murphy ¹

Abstract

Background

Hip fractures represent a significant cause of morbidity and mortality, particularly in the elderly population. Current guidelines recommend hemiarthroplasty as treatment of intracapsular neck of femur fractures. However, concomitant illnesses, such as Parkinson’s Disease (PD), can adversely affect the clinical outcomes of hip hemiarthroplasty.

Method

A systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, utilising the PubMed, MEDLINE, and Scopus databases. Included studies were full-text publications in the English language, which looked at adult patients with Parkinson’s Disease who underwent hip hemiarthroplasty for femoral neck fracture.

Result

Six studies met the inclusion criteria and included 11,532 patients diagnosed with Parkinson’s Disease who underwent hip hemiarthroplasty. The average follow-up period was 15 months (range 3–36.5 months). Postoperative dislocation was the most reported adverse outcome among those with Parkinson’s Disease, with 5 out of 6 studies reporting an increased dislocation rate ranging from 2-8%. Two studies reported higher requirements for revision surgery in PD patients. Three studies indicated an increased mortality risk in patients with PD, while two studies found no significant difference.

Conclusions

This systematic review demonstrates that patients with Parkinson's Disease face significantly higher risks of postoperative complications, particularly dislocation, compared to non-PD patients following hip hemiarthroplasty. Surgeons must carefully consider these inferior outcomes when planning surgical interventions for PD patients and ensure comprehensive preoperative counselling regarding associated risks.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

181 Absorbable versus non-absorbable sutures for facial skin cancer closure: a systematic review of patient-reported outcome measures

Noor Kaur ^1,^✉, Anirban Mandal ²

Abstract

Aim

Facial skin cancer excision requires closure techniques that balance cosmetic results with optimal tumour margins. Although non-absorbable sutures remain standard practice, absorbable sutures may offer comparable outcomes while avoiding the inconvenience of suture removal at clinic follow-up. This systematic review evaluates clinical outcomes and patient-reported outcome measures (PROMs), comparing absorbable and non-absorbable sutures in facial skin cancer surgery, outlining plans to inform evidence-based clinical decision making on future suture selection.

Method

A systematic search of MEDLINE, Embase, and trial registries (2000–2025) identified RCTs, meta-analyses, and qualitative studies involving adults undergoing facial closure after skin cancer excision. Inclusion criteria encompassed direct comparison of absorbable versus non-absorbable sutures and reporting of PROM, complication, or cosmetic data.

Results

Four studies met inclusion criteria. Two split-scar RCTs (Rosenzweig et al., Moran et al.) and one meta-analysis (Malhotra et al.) reported no statistically significant differences in blinded cosmetic outcomes between absorbable (poliglecaprone-25, polyglactin 910) and non-absorbable (polypropylene, nylon) sutures at up to four months’ follow-up. Complication rates, including infection and dehiscence, were low and comparable. Rosenzweig et al. found 85% of scars had no visible difference. A qualitative study (Ashraf et al.) suggested patient preference for avoiding suture removal and follow-up visits, though quantitative PROM data remains limited.

Conclusions

Absorbable sutures appear to deliver cosmetic results equal to non-absorbable in facial skin cancer surgery, with the added benefit of sparing patients suture removal at follow-up. A meta-analysis will be conducted and included upon completion of our retrospective cohort study to further strengthen current evidence.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

268 The role of pre-operative systemic corticosteroids in functional endoscopic sinus surgery: a systematic review and meta-analysis

Kujani Wanniarachchi ^1,^✉, James Morris ¹, Dhruv Patel ¹, Tareq Omer ¹, Darren Yap ²

Abstract

Introduction

Functional Endoscopic Sinus Surgery (FESS) is widely used to improve symptoms and quality of life for patients with Chronic Rhinosinusitis. Many centres prepare patients for FESS using preoperative corticosteroids to improve surgical field visibility (SFV) and reduce total intraoperative blood loss (TBL). However, this also confers a significant risk of side effects, including insomnia, mood disorders, weight gain, gastric irritation and osteoporosis. We sought to evaluate the efficacy of this approach with regard to intraoperative and postoperative surgical outcomes through a systematic review and meta-analysis.

Method

This review was prospectively registered with PROSPERO (CRD42023412361) and adhered to PRISMA reporting guidelines. Systematic searches of MEDLINE, CENTRAL and EMBASE in March 2025 identified studies comparing preoperative systemic corticosteroids to placebo in patients undergoing FESS. Random-effects meta-analyses were conducted to generate restricted maximum-likelihood estimates for the TBL, SFV, and preoperative Lund-Mackay scores in the treatment and placebo cohorts. Study quality was evaluated using the Cochrane Collaboration’s tool for assessing risk of bias.

Results

The systematic search identified 3,047 unique papers; 10 eligible papers, comprising 761 patients, were included in our final analyses. Meta-analysis revealed no significant difference between the TBL, SFV, duration of surgery, or pre-operative Lund-Mackay scores in patients treated with pre-operative corticosteroids compared to controls (p < .05 for each).

Conclusions

Further randomised controlled trials need to be conducted to determine the benefit of systemic corticosteroids prior to FESS. Given the side effect profile associated with systemic, but not topical, corticosteroids, we encourage clinicians to critically evaluate the route of administration when considering corticosteroids before FESS.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

278 The role of testosterone in lower urinary tract symptoms: help or harm? – systematic review

Prasenjit Bhowmik ^1,^✉, Banan Osman ¹

Abstract

Background

Lower urinary tract symptoms (LUTS) are common in aging men, usually associated with benign prostatic hyperplasia (BPH). Because the prostate is androgen-sensitive, concerns persist that testosterone replacement therapy (TRT) may worsen LUTS or accelerate BPH progression. Conversely, hypogonadism may contribute to LUTS through metabolic, vascular, and inflammatory mechanisms. This review evaluated the relationship between endogenous testosterone, TRT, and LUTS in adult men.

Method

A systematic search of PubMed, Embase, and the Cochrane Library was conducted by following PRISMA 2020 guidelines. Eligible studies included randomised controlled trials, cohort studies, and meta-analyses assessing baseline testosterone, TRT, and LUTS outcomes. The primary endpoint was the change in validated symptom scores (IPSS or AUA-SI). Secondary endpoints included urinary flow rate (Qmax), post-void residual (PVR), prostate volume, prostate-specific antigen (PSA), and adverse events such as acute urinary retention (AUR) or BPH surgery.

Results

Observational studies suggested an inverse association between endogenous testosterone and LUTS severity, although age and comorbidities confounded results. Controlled trials showed that TRT did not worsen LUTS compared with placebo and often provided modest improvements in IPSS, particularly in hypogonadal men with metabolic syndrome or obesity. Prostate volume and PSA rose slightly but remained comparable to placebo. Qmax improved modestly, while PVR was unchanged. Incidence of AUR and surgery was low and not increased with TRT.

Conclusions

Evidence indicates that physiologic TRT does not exacerbate LUTS and may yield modest symptom benefit in selected hypogonadal men. Careful patient selection and monitoring remain essential, while long-term studies are needed to clarify effects on disease progression.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

317 The impact of artificial intelligence on clinical outcomes in general surgery: a systematic review and meta-analysis

Muhammad Harris Siddique ^1,^✉

Abstract

Aim

To perform a systematic review and meta-analysis evaluating the impact of artificial intelligence (AI)–driven tools on clinical outcomes, complication prediction accuracy, and intraoperative efficiency in general surgery.

Method

A comprehensive literature search of PubMed, Scopus, and Web of Science was undertaken for original studies published between January 2020 and May 2025. Inclusion criteria mandated studies of AI applications in diagnostic support, surgical phase recognition, complication risk prediction, or workflow optimization with a minimum cohort size of 50 patients. Two independent reviewers screened titles, s, and full texts, with discrepancies resolved by consensus. Data on predictive performance, intraoperative error rates, operative times, and postoperative outcomes were extracted. Risk of bias was assessed using the Newcastle–Ottawa Scale. A random-effects meta-analysis was conducted to calculate pooled effect sizes for complication prediction accuracy and operative time reduction. Heterogeneity was evaluated with the I² statistic.

Results

Fourteen studies encompassing 6,320 surgical cases met inclusion criteria. AI algorithms improved complication prediction accuracy by a pooled 24.7% (95% CI 21.3–28.1) compared with standard risk models. Intraoperative error rates decreased by 16.9% (95% CI 14.2–19.6). AI-assisted systems achieved a mean operative time reduction of 28.5 minutes (95% CI 22.7–34.3). Heterogeneity was moderate (I² = 52–68%) across outcomes.

Conclusions

AI-driven tools significantly enhance predictive accuracy, reduce intraoperative errors, and shorten operative duration in general surgery. Further high-quality, multicenter trials with standardised reporting are required to validate these findings and support clinical integration.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

330 Systematic review of strategies to minimise extraction site pain after laparoscopic sleeve gastrectomy

Mahmudul Hasan Nahid ^1,^✉, Mehnaj Noor ², Aravind Adarsh Padmanaban ³, Naveed Hossain ⁴, Tanvir Hossain ³

Abstract

Aim

Laparoscopic sleeve gastrectomy (LSG) is one of the most widely performed bariatric operations, yet extraction site pain remains a notable postoperative concern. Despite the use of diverse surgical techniques and analgesic regimens, an optimal strategy has not been firmly established. This systematic review aimed to evaluate interventions for managing extraction site pain following LSG, focusing on surgical approaches and analgesic techniques.

Method

A comprehensive search of PubMed, Embase, Scopus, and CINAHL was undertaken using keywords including “extraction site pain,” “LSG,” “port-site pain,” and “analgesia.” Eligible studies were RCTs and cohort studies published between 2015 and 2025 that assessed postoperative pain management strategies in LSG. The primary outcome was pain intensity at 24 hours, measured by the Visual Analog Scale (VAS). Secondary outcomes included postoperative complications, cosmetic satisfaction, and length of hospital stay. Screening and data extraction were performed independently by two reviewers. Risk of bias was assessed using RoB 2 for RCTs and ROBINS-I for observational studies.

Results

Nine studies met the inclusion criteria (five RCTs, four cohort studies), enrolling 1,200 patients. Single-incision laparoscopic surgery (SILS) and reduced-port methods consistently demonstrated lower VAS scores at 24 hours. Port-site infiltration and epidural analgesia were more effective than intravenous analgesia. SILS and reduced-port techniques also shortened hospital stay and improved cosmetic satisfaction. Complication rates were low, with no significant intergroup differences.

Conclusions

Port-site infiltration with bupivacaine and epidural analgesia appears most effective for postoperative pain control in LSG. SILS and reduced-port techniques may provide additional benefits, though large multicentre RCTs are needed for validation.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

334 Impact of reduction mammaplasty on body mass index: a systematic review and meta-analysis

Wei Yu Fong ^1,^✉, Zhen Yu Wong ², Ryan Faderani ³, Muholan Kanapathy ³, Afshin Mosahebi ³

Abstract

Introduction

The current evidence remains inconclusive regarding weight changes following reduction mammaplasty, with some studies reporting modest postoperative weight loss and others showing weight regain over time. To clarify these discrepancies, we performed a systematic review and meta-analysis of BMI outcomes in patients undergoing breast reduction.

Method

A comprehensive literature search was conducted in accordance with PRISMA guidelines to identify studies reporting preoperative and postoperative BMI in adult and adolescent reduction mammaplasty patients. Two reviewers independently screened, extracted data, and assessed study quality. Pooled mean BMI change was calculated using a DerSimonian-Laird random-effects model.

Results

Ten studies encompassing 986 patients met inclusion criteria. Follow-up durations ranged from one to six years. The pooled analysis demonstrated an overall postoperative decrease in BMI of 1.6 kg/m² (95% CI, 1.12–2.27; p < 0.001). Among adults, larger resection volumes were associated with greater early BMI reductions; however, long-term outcomes depended primarily on baseline BMI: obese adults were more likely to sustain weight loss or maintain reduced BMI over several years, whereas leaner patients often returned to or exceeded their preoperative weight. In contrast, adolescent patients frequently experienced postoperative BMI increases despite larger resections. Across all cohorts, absence of dietary counselling and regular exercise was consistently linked to weight regain.

Conclusions

Reduction mammaplasty yields a modest but statistically significant reduction in BMI, particularly in adults with higher baseline BMI and larger resections. Further well-designed studies with larger sample sizes are needed to confirm these findings and to identify patient-specific predictors of weight outcomes.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

341 Operative versus conservative management of nailbed injuries: a systematic review and meta-analysis

Amenah Dhannoon ^1,^✉, Zhen Yu Wong ¹, Alexander Zargaran ², Afshin Mosahebi ²

Abstract

Introduction

Nailbed injuries are a frequent cause of fingertip trauma, and debate continues regarding whether operative repair or nonoperative management yields superior outcomes. This review and meta-analysis aimed to compare these two approaches in terms of complications and clinical outcomes.

Method

Following PRISMA guidelines, we searched MEDLINE, Embase, and Cochrane CENTRAL through March 2025 for studies comparing formal operative repair (nail removal with suture, pinning) versus nonoperative management (trephination, splint nail preservation with dressing, adhesive, observation) in nailbed injuries. Two reviewers independently extracted data on outcomes of interest. Pooled risk ratios (RR) and 95% confidence intervals (CI) were calculated via a DerSimonian–Laird random-effects model, with heterogeneity assessed by I².

Results

Six studies (one adult, five paediatric; total n = 317) met inclusion criteria. Meta-analysis showed no significant difference in infection risk (pooled RR 0.82, 95% CI 0.31–2.17; I² = 0%) or reoperation (pooled RR 0.87, 95% CI 0.31–2.40; I² = 0%). Operative repair carried higher risks of nail deformity (pooled RR 2.18, 95% CI 1.14–4.16; I² = 0%) and overall complications (pooled RR 1.83, 95% CI 1.02–3.29; I² = 0%). Functional outcomes including range of motion, pain, patient satisfaction, and QDASH scores were excellent across both strategies. Nonoperative management required shorter time and incurred lower cost.

Conclusions

Clinical outcomes appear comparable between operative and nonoperative management, but nonoperative approaches offer logistical advantages. Well-designed randomised trials with standardised cost and patient-reported measures are needed to confirm these findings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

357 CONSORT compliance in prostatectomy randomised control trials: a systematic review

Praveen Subbiah ^1,^✉, Gul Rukh Khan ², Sebastian Mitchell ³, Mohammed Jameel ⁴

Abstract

Aim

To evaluate adherence to the CONSORT 2017 extension for Non-Pharmacological Treatments (CONSORT-NPT) in randomised controlled trials (RCTs) of prostatectomy, and to identify reporting gaps that may limit reproducibility and clinical applicability.

Method

A systematic review was conducted across PubMed, Embase, MEDLINE, CENTRAL, and Web of Science for RCTs on prostatectomy published between January 2017 and March 2025. Reporting quality was assessed using the 25-item CONSORT-NPT checklist. Risk of bias was appraised with Cochrane RoB 2.0, and certainty of evidence with the GRADE framework. Descriptive statistics summarised adherence, while exploratory analyses evaluated associations with journal impact factor and author count.

Results

Of 3958 records screened, 38 RCTs met inclusion. The mean CONSORT adherence was 71%, with wide heterogeneity. Strong compliance was seen for structured s (92%) and study objectives (100%). However, essential domains were underreported: allocation concealment (53%), blinding (26–45%), trial registration (47%), and funding disclosure (21%). Most studies were single-centre (71%) and rated low-to-moderate certainty on GRADE. Risk of bias was frequent in outcome measurement and selective reporting. No significant correlation was observed between adherence and journal impact factor (p = 0.09) or author number (p = 0.80).

Conclusions

Prostatectomy RCTs demonstrate only moderate adherence to CONSORT-NPT, with persistent gaps in transparency and methodological rigour. These deficiencies threaten reproducibility and weaken evidence guiding prostate cancer surgery. Future trials should integrate CONSORT at the design stage, mandate checklist use in submission, and prioritise multicentre, internationally representative studies to ensure robust, reliable, and generalisable findings.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

388 Dual mobility versus large femoral head in primary and revision total hip arthroplasty: a meta-analysis of outcomes

Abdelrahman Ibrahim ^1,^✉, Amr Selim ¹, Christina Dwebeng ¹, Zain Choudhary ¹, Sachin Singal ¹, Mohamed Ahmed ¹, Khadija Khamdan ¹, Musab Al-musabi ¹, Geraint Thomas ¹

Abstract

Aim

To conduct a systematic review and meta-analysis to evaluate the impact of implant choice on postoperative outcomes in patients undergoing Total Hip Arthroplasty (THA).

Method

We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, and ClinicalTrials.gov. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases.

Results

We identified 20 studies (2 RCTs, 18 non-randomised) for inclusion, with a total of 140,481 patients (16,059 DM; 125,026 LFH). The analysis revealed that LFH constructs were associated with a significantly higher risk of dislocation compared to DM in both primary THA (OR: 4.93, P < 0.001) and revision THA (OR: 2.02, P < 0.001). The overall risk of all-cause revision was significantly higher with LFH (OR: 1.60, P < 0.001), as was the risk of revision for aseptic loosening (OR: 1.92, P = 0.006) and periprosthetic fracture (OR: 1.60 in primary, P = 0.04; OR: 3.44 in revision, P = 0.04). There were no statistically significant differences in PJI or postoperative HHS.

Conclusions

Meta-analysis of the best available evidence demonstrated that Dual Mobility (DM) constructs are associated with a significantly lower risk of dislocation, periprosthetic fractures, revision for PPF, and revision for aseptic loosening in patients undergoing primary THA. This protective effect was comprehensive, as DM was also associated with a lower risk of dislocation and all-cause re-revision in the revision setting, representing a considerable decrease in implant-related morbidity. However, longer-term implant survival requires further investigation.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

390 The impact of smoking on outcomes following anterior cruciate ligament reconstruction: a systematic review and meta-analysis

Abdelrahman Ibrahim ^1,^✉, Musab al-musabi ¹, Rakan Kabariti ¹, Muaaz Tahir ¹, Roger Wade ¹

Abstract

Background

The influence of smoking on postoperative outcomes following Anterior Cruciate Ligament (ACL) reconstruction is a topic of ongoing scientific discussion and uncertainty. Our aim was to conduct a systematic review and meta-analysis to compare the outcomes between smokers and non-smokers undergoing this procedure.

Method

We conducted a systematic search of electronic information sources, including MEDLINE, EMBASE, CINAHL, CENTRAL, ClinicalTrials.gov, and bibliographic reference lists. We applied a combination of free text search and controlled vocabulary search adapted to thesaurus headings, search operators, and limits in each of the above-mentioned databases. Primary outcome parameters included surgical site infections, ACL graft rupture, revision rates, and patient-reported outcome measures (PROMs).

Results

We identified 24 comparative studies including a total of 672,241 patients, of whom 69,113 were in the smoker group and 603,128 were in the non-smoker group. The analysis revealed that smoking was associated with a significantly higher risk of surgical site infections (OR 1.40, P = 0.01). Smokers also reported significantly worse PROMs on the IKDC score (MD −5.38, P < 0.00001) and multiple KOOS subscales. There was no statistically significant difference between the two cohorts for ACL graft rupture or all-cause revision rates.

Conclusions

Smoking appears to be associated with a higher risk of surgical site infections following ACL reconstruction and is linked to significantly poorer functional PROMs.

Ann R Coll Surg Engl. 2026 Feb 25;108(Suppl 1):S18–S64.

420 Laparoscopic versus endoscopic strategies for common bile duct stones: a systematic review and network meta-analysis of randomised trials

Ali Akbar Shah ^1,^✉

Abstract

Aim

Choledocholithiasis complicates 10–20% of cholecystectomies and is associated with significant morbidity. Multiple strategies exist for common bile duct (CBD) stone clearance, but the optimal approach remains unclear.

Method

A systematic review and network meta-analysis was conducted in accordance with PRISMA-NMA guidelines. PubMed, Embase and Cochrane CENTRAL were searched through May 2025 for randomised controlled trials (RCTs) enrolling adults with confirmed CBD stones, with or without grade I–II cholangitis. Four strategies were compared: ERCP followed by laparoscopic cholecystectomy (ERCP → LC), LC with laparoscopic CBD exploration (LC + CBDE), LC with intraoperative ERCP (LC + IntraOpERCP), and LC followed by ERCP (LC → ERCP). Primary outcome was stone clearance; secondary outcomes included complications, conversion, mortality, operative time, length of stay, pain, and cost.

Results

Thirty-four RCTs comprising 4,561 patients were included. LC + CBDE achieved the highest clearance rates and ranked most effective overall. Compared with LC + CBDE, ERCP → LC had higher pancreatitis (6.9% vs 1.1%; OR 5.42, 95% CI 3.13–9.37) and morbidity (17.4% vs 11.5%; OR 1.85, 95% CI 1.12–3.06). LC + IntraOpERCP reduced retained stones (3.3% vs 7.5%) but increased bile leak risk (5.2% vs 1.1%; OR 2.95, 95% CI 1.59–5.47). ERCP → LC had the shortest operative time but greater pain and higher costs. Mortality was rare and comparable.

Conclusions

Single-stage laparoscopic strategies, particularly LC + CBDE, are the most effective and safe treatments for choledocholithiasis. LC + IntraOpERCP is a viable alternative where expertise exists, whereas ERCP → LC is linked with higher morbidity and cost, and LC → ERCP is least effective.

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