Since the last issue of the Annals, the following letters have been published on our website <http://www.rcseng.ac.uk/publications/eletters/>:
letter . 2007 May;89(4):393. doi: 10.1308/003588407X187649
letter Ann R Coll Surg Engl. 2007 May;89(4):393. doi: 10.1308/003588407X187649
There is a persistent misunderstanding of what constitutes an incarcerated or an irreducible hernia. This is evident not only among surgeons but also in commonly used reference textbooks.
The term incarceration derives from Old French incarceration, from Middle Latin incarcerationem, from incarcerare (imprison), from in- (in) plus carcer (prison, an enclosed space).
We reviewed 19 surgical textbooks. In 13, the term incarcerated was not mentioned at all: the term irreducible was used in preference. In others, the two terms were used interchangeably, with no distinction between the two. In no textbook was there any clarification of the two terms. On this basis, we propose the term incarceration be dropped from nomenclature of hernia description, and that the terms reducible, irreducible (+/− obstruction) and strangulated be used in preference.
Uberrimae fidei (of the utmost good faith)
letter Ann R Coll Surg Engl. 2007 May;89(4):393. doi: 10.1308/003588407X187649
I read with interest the article by A Abdul-Ghani and his colleagues and would like to make the following comments:
The success rates of the authors are appreciable and the audit is well structured. The authors have recommended left lateral position in the view that it would permit day-case treatment. We have been operating, with special interest, on patients with pilonidal sinus in the prone position and all of them are discharged home on the same day. Prone position not only gives an excellent exposure compared to the lateral position but also allows better access to raise the flaps if the pilonidal tract is found to extend over a wider area.
Prophylactic dose of antibiotics at the time of induction is more than sufficient to prevent infection. Routine use of antibiotics is not required and we would appreciate any evidence available otherwise.
Footnotes
Comment on Abdul-Ghani AKM, Abdul-Ghani AN, Ingham Clark CL. Day-care surgery for pilonidal sinus. Ann R Coll Surg Engl 2006; 88: 656–658. doi: 10.1308/003588406X149255
Ann R Coll Surg Engl. 2007 May;89(4):393. doi: 10.1308/003588407X187649
I recognise that the traditional approach for pilonidal sinus is to operate with patients in the prone position. However, this does pose difficulties for the anaesthetists, especially if the patient has a high body mass index and may reduce the risk of the patient getting home the same day as the procedure.
In my experience the lateral position has provided excellent exposure, especially if the upper buttock is lifted and taped to the cylindrical body restraint during the dissection part of the procedure. It is also perfectly possible to raise lateral flaps prior to closure in this position. The other advantage is that there is no pooling of any blood at the bottom of the wound and therefore one is better able to ensure that one does not transgress any lateral tracts but rather is able to excise them completely.
Regarding the use of antibiotic treatment to cover pilonidal sinus surgery, there has been a prospective randomised control trial that showed that five-day antibiotic treatment was associated with a much smaller number of post-operative wound infections than single-dose antibiotic prophylaxis.1
I hope that this letter helps contribute to the ongoing debate.
Reference
- 1.Chandhuri A. Single-dose metronidazole vs 5-day multi-drug antibiotic regimen in excision of pilonidal sinuses with primary closure: a prospective, randomized, double-blinded pilot study. Int J Colorectal Dis. 2006;21:688–692. doi: 10.1007/s00384-005-0064-7. [DOI] [PubMed] [Google Scholar]
letter Ann R Coll Surg Engl. 2007 May;89(4):393. doi: 10.1308/003588407X187649
We were interested by the surgical technique described by Jayasekera et al, regarding the use of a cortical screw and Kocker's forceps to aid the extraction of the trapezium during trapezectomy. We agree that the procedure they advocate simplifies the excision of this bone. However, we have found that one can improve this and get better control of the bone by using the tap and T-handle found on a small fragment set rather than a screw. This is introduced having, as with the screw technique, drilled the bone. We have used a similar method during excision of the scaphoid and mid carpal fusions and proximal row carpectomies.
Footnotes
Ann R Coll Surg Engl. 2007 May;89(4):393. doi: 10.1308/003588407X187649
We read with interest the use of a bone tap during trapezectomy described by Bitsiadou et al. We commend them on their wider and successful application of this technique. An advantage with our method is that it does not risk damage to a reusable surgical instrument. We wonder if in less experienced hands their technique may risk tap failure due to bending or breakage, as the tap is subjected to repeated bending moments during multiple procedures.
letter Ann R Coll Surg Engl. 2007 May;89(4):393. doi: 10.1308/003588407X187649
I was delighted to see your editor's comments in the February 2007 issue of the Bulletin.
I too was disappointed that the communications section of the MRCS examination failed to be suitably discriminatory. I taught on the College communications course in Bristol and while there were some wonderful examples of great communicators among the junior surgical delegates there were also one or two people who, by any measure, would have failed an appropriate examination. It seems a great shame that we do not have a sufficiently powerful tool in place to maintain the necessary high standards.
It may be that as surgeons we feel uncertain of this role and may feel more confident in vigorously examining a candidate on surgical anatomy than we do on assessing their ability to listen appropriately or empathise (we are all aware of the usual jibes about the communicating surgeon being a contradiction in terms!). However, as in all branches of medicine, communication is the core of good practice and in surgery it is even more necessary as the nature of our profession reduces the time we spend with our patients in the clinical setting, requiring our skills in this area to be even more finely tuned.
I recently presented the results of a survey on communication skills in senior doctors at our Trust, which was read at the European Association for Communication in Healthcare in Basel, 2006. This study identified a high degree of importance given to communication skills by senior medical and surgical staff, but this was not reflected in any continuing postgraduate education in the subject. There was also a worryingly high percentage of senior doctors who felt that their skills improved naturally with age despite the fact that there is no evidence to support this. This is likely to mitigate against surgical consultants engaging in communications skills education of their own; nor indeed giving it much emphasis in the training of their juniors.
Nevertheless, we cannot afford to be complacent as there is plenty of evidence that senior clinicians are failing in this regard. A recent study from the National Clinical Assessment Service, reviewing failing doctors from all fields, revealed 89% had significant skill deficits including communication and teamwork. These skills, or lack of them, are having an impact in our profession but they can be taught and measured and so I would strongly support the College in its attempt to institute a robust system of training and assessment in the earliest stage of the surgical trainees' career.
A course along the ATLS® lines may be a more powerful tool and more acceptable to the trainee than trying to incorporate it in the traditional MRCS format.
Footnotes
Comment on Thomas WEG. The future of surgical training. Ann R Coll Surg Engl (Suppl) 2007; 89: 78.