JODS 29.4 November 2019

Dave Bunting

The results of a YouGov survey of surgeons commissioned by the Royal College of Surgeons of England was published last week reporting that 68% surgeons are considering early retirement due to pensions tax regulations, 64% surgeons have been advised to work fewer hours in the NHS and 69% consultant surgeons have reduced the amount of time spent working in the NHS as a result of pension tax rules. Aa a result, NHS waiting lists will inevitable increase. It is vital therefore that day case surgery services - which account for the vast majority of procedures performed in the UK – are utilised effectively to maximise productivity within an environment of reduced operating sessions. In addition, the Royal College of Emergency Medicine recently published an analysis suggesting the NHS will require 4000 additional beds this winter to avoid ‘corridor care’ and keep bed occupancy at a safe level. It is well understood that effective use of day case surgery is one way of reducing the demand on inpatient beds, therefore, it is vital we prioritise and protect day surgery services.

BADS continues to work closely with a number of national organisations including the Royal Colleges, Getting it Right First Time (GiRFT), the Model Hospital. BADS also co-hosts a number of national and regional meetings in association with external organisations such as Health Care Conferences UK (HCUK). A conference on Developing Your Daycase General Surgery Service (BADS/HCC) is being held at the Studio Conference Centre, Birmingham on Tuesday 21^st January and a conference on Daycase hip replacement surgery is being held at the De Vere Conference Centre, London on Monday 27^th January. Further details can be found in this edition of JODS. BADS members are eligible for a 25% discount on registration fees for these events.

It is a pleasure of mine to be able to introduce several new members of the BADS Council. I welcome Mr Adam Kimble, Mrs Karen Harries, Mr Shaun Clee, Mr Edward Dunstan, Mr Stamatios Karavolos and Mr Richard Parkinson. Please take the time to find out more about them and the qualities they bring to BADS Council in the New Council Members section of this edition.

JODS has been working with the BADS legal advisers to strengthen its position with regards to copyright of published material to provide the necessary protection for the benefit of authors and the journal alike. All future submissions must now be accompanied by the copyright transfer agreements for each named author. Full details can be found in the guidelines for authors included in this publication and accessible via the BADS website here:

https://daysurgeryuk.net/en/resources/guidelines-for-authors/

This edition of JODS contains scientific articles on regional anaesthesia provided by Anaesthesia Associates in day case hysterectomy; a case report of a subcapsular liver haematoma following day case laparoscopic cholecystectomy together with review of differential diagnoses and a report of a completed audit cycle demonstrating improvement in the documentation of operation notes with the use of a dedicated operation note proforma.

Finally, preparations for the Annual Conference being held at the Cardiff City Hall on 25^th and 26^th June are progressing well. Please put the dates in your diary and book your study leave now! Abstract submissions will open on 1^st January so now is the time to think about getting your project data recorded and analysed in preparation to submit your work.

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Kim Russon

In September the Anaesthesia and Perioperative Medicine GIRFT (Get It Right First Time) team visited my Trust, which was very enlightening. For those of you not familiar with GIRFT, it began as a pilot within Orthopaedics led by Professor Tim Briggs an orthopaedic surgeon. Variation in practice was identified which was thought to be impacting on quality of care and patient outcomes, so the programme was rolled out nationally with the intention to “identify areas of good practice and agree where changes can be made”. GIRFT is working through the specialities and has published a number of specialty reports available via their website. Day surgery has been identified as an area with significant national variation.

From the perspective of having GIRFT visit my Trust it was a positive experience. GIRFT expect representation from clinicians, managers and the Executive team. The data presented was little bit out of date, but it was based on the Trust’s HES data so needed to be considered. If the data is not presenting what you are expecting, then you need to look at how it is being recorded and how it is being submitted. It is your Trust’s data.

Based on GIRFT data and Model Hospital data, BADS has identified there is wide national variation in day case rates for Anterior Cruciate Ligament reconstruction and thus are planning a joint BADS / HCC conference “From ACLr to Total Knee replacement as day case” on 30th April 2020 in London. Members of the GIRFT team will be presenting at our Joint BADS /HCC conference on Day case General Surgery in Birmingham on 21^st January 2020 and our annual conference in June in Cardiff, discussing variation and how it might be addressed. I am looking forward to hearing from them and hope you will consider joining us.

The Model Hospital is a way of monitoring your hospital’s day case rates. This is provided by NHS Improvement and is accessible by anyone who has an NHS email address. Dr Mary Stocker, past president of BADS, has been working very closely with the Model Hospital team and the latest version has been launched this week which maps to the BADS Directory of Procedures 6th Edition. The day surgery module can show your overall rates, by speciality, by procedure and show how your rates compare nationally. This information is based on HES data so ensuring you Trust data is correct is key. Are your patients planned / listed as a day case and then successfully go home the same day and recorded as such?

In the last couple of months BADS has received the very sad news of the deaths of Dr Lawrence Rowe, who was pivotal in the development of the current BADS website and Professor Paul Jarrett, who was a founder member of the society and a past president. BADS is hugely indebted to them and further detail of their remarkable work can be found on the BADS website. My thanks to Dr Anna Lipp who has written Dr Rowe’s obituary published in this edition of JODS which is to be shared with SIVA (Society of Intravenous Anaesthesia) where he also had a huge involvement. Professor Jarrett’s obituary will be published in the next edition of JODS. I extend my condolences to their families at this sad time.

In addition to the new council members whose biographies you can read in this edition of JODS, I would like to welcome 3 co-opted members: Mr Richard Parkinson (British Orthopaedic Association), Dr Stamatios Karavolos (Royal College of Obstetrics & Gynaecology) and Mr. Andrei Tanase (Association of Surgeons in Training).

My thanks to everyone for promoting and progressing day surgery and all the best for the rest of 2019.

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BADS would like to thank its Strategic Alliance Partners for supporting the organisation and the BADS Annual Conference.

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Howard Cox Heart of England NHS Foundation Trust

Abstract: Anaesthesia Associates (AA) formally known as Anaesthesia Practitioner (AP) and up until 1st of July 2019 Physicians’ Assistants’ in Anaesthesia (PA(A)) have been working in a qualified capacity within the National Health Service (NHS) since January 2007. This group of anaesthetic professionals can now take on a number of extended roles beyond qualification such as regional anaesthesia. One such enhanced role includes delivery of spinal anaesthesia within a day case and short stay surgical care setting. Anaesthesia Associates are involved in spinal anaesthesia for short stay elective Gynaecology cases. This study focuses on AA clinical work and outcome measures for Length of Stay (LOS) in conjunction with anaesthetic and surgical complications, at a single centre NHS Hospital.

Introduction

Qualified Anaesthesia Associates (AAs) have been working in the National Health Service (NHS) since January 2007. The scope of practice has been governed by the Royal College of Anaesthetists (RCoA) ‘Supervision statements’ [1]. It is acknowledged by the RCoA that AA scope of practice has change and diversified following robust local governance and educational frameworks (seen here is the example of the ‘Spinal Anaesthesia’ Governance and education policy within Heartlands, Good Hope and Solihull [HGS] formally known as Heart of England Trust {HEFT}). This group of anaesthetic professionals can now take on a number of extended roles such as regional anaesthesia. One such enhanced role includes delivery of spinal anaesthesia within a day case and sort stay surgical care setting. Anaesthesia Associates administer spinal anaesthesia for short stay elective Gynaecology cases within the University Hospital Birmingham (UHB) Trust and at Good Hope Hospital (GHH) site. This study focuses on AA clinic work and outcome measures of length of stay (LOS), as well as anaesthetic and surgical complication for elective hysterectomy patients.

Aims

To identify if LOS for elective gynaecology hysterectomy patients and anaesthetic/surgical complication rates are adversely affected when patients receive an anaesthetic administered by an AA. Identifying if the patient receiving the anaesthetic, either under spinal or general anaesthesia (GA) and or a combination of the both had any effect on outcome measures.

PA-(A) Spinal governance and training package within HGS:

Methods

Once the researcher’s data clearance was authorised the study period determined ran from 1st of January 2017 until the 31st of December 2018. It focused on the gynaecology theatres at GHH and the three sessions each week where the AA cover working in a 2 to1 model. The 2 to1 model allows one consultant anaesthetist to supervise two AAs in adjacent theatres in the delivery of anaesthesia [2].

Using the hospitals electronic theatre logbook known as ‘Concerto’, the researcher was able to identify if the AA was the primary anaesthetic provider and if the list was covered in a 2 to1 supervising capacity. The researcher could obtain the patients procedure and two groups were identified, one for laparoscopic hysterectomy and the other for open hysterectomy cases. A further detail on the type of hysterectomy performed was not determined in this study. The patients recruited for this study were all elective patients, who had received pre-operative assessment in the nurse-led clinic. All patients had capacity to consent for procedures themselves and were over 18 years of age.

The researcher then utilised the electronic discharge summery to obtain the LOS and identify if there were any surgical or anaesthetic complication which contributed to an increase in LOS. Re-admission rates were not recorded in this study as these were classed as separate episodes.

In total the researcher recruited 93 patients undergoing hysterectomy, receiving their anaesthetic from an AA within the study period time frame. The American Society of Anaesthesiologist (ASA) grade of the 93 recruit patients was as such; ASA 1, 15 cases, ASA 2, 59 cases and ASA 3, 19 cases.
The researcher undertook a literature review and reviewed text over a 10-year period from 2009 to present using EMBASE, MEDLINE, NICE guidelines and Royal College of Obstetricians and Gynaecologists data bases.

Results

Open Hysterectomy
To consider the open hysterectomy procedure first, of the 40 cases 15 had a GA only and 25 had a combination of spinal and GA the mean LOS for GA only was 53 hours with and the mean LOS in the spinal and GA group was 48 hours. The ASA breakdown for this cohort ASA 1, 2 cases, ASA 2, 23 cases and ASA 3, 15 cases. Patient information literature in the NHS suggests patients should expect on average a 1 – 4 day LOS in hospital [3].

Complication rates in the open hysterectomy group identified 4 cases where discharge was delayed above 53 hours. The complications were 2 cases, who had post-operative infection and 2 had post-operative bleeding. This identified a complication rate of 1.6%. Research from ‘The International journal of Obstetrics & Gynaecology’ [4] Suggests In a study of 239 patients the mean LOS for open hysterectomy could be 96 hours and the complication rate of 4.9%. Such findings are also supported by a study of 181 patient’s states with a mean LOS of 72 hours for abdominal hysterectomy and 48 hours for vaginal hysterectomy [5].

There were no reported anaesthetic complications in this patient cohort and no evidence to suggest that the use of AA had led to an increase in LOS or complication.

Laparoscopic Hysterectomy
The analysis of the patients who were converted from laparoscopic to open hysterectomy was considered separately. There were 53 patients in this cohort, of which 41 patients had a GA + Spinal and 12 patients had just a GA. Mean LOS for the GA + Spinal group was 18 hours and the mean LOS for the GA only group was 16 hours.

There were two complications including one case of post-operative nausea and vomiting (PONV) resulting in a LOS of 24 hours and one wound infection resulting in a LOS of 54 hours.
There is little difference in LOS when complaining anaesthetic types. The review of literature identified the laparoscopic technique associated with the shortest LOS [5],[6] & [7]. There was however one anaesthetic complication of PONV which demonstrated and anaesthetic complication rate of 2.3% or 1.8% if the laparoscopic converted cases are counted within that figure
Conversion from Laparoscopic to open Hysterectomy
Of the total number of patients undergoing laparoscopic hysterectomy (53), 11 of these were converted to an open hysterectomy. All patients in this group had a GA + Spinal combination.

The mean LOS for this group was 20 hours with one significant post-operative complication of wound infection which resulted in a LOS of 40 hours. The conversion rate from laparoscopic to open hysterectomy during the study time period was 5.8%.

In a study of laparoscopic hysterectomy reviewing 1051 cases, a conversion rate of 5% is described [8] and further study of 1534 patients suggests a conversion rate of 4.6% [9] & [10].

Conclusions

The researcher did identify one anaesthetic complication relating to PONV within the laparoscopic group. Looking at this complication and relating this to the total number of patients is the study this represent a complication rate of 1.07%.

The researcher on reviewing the electric discharge information did not identify any procedural complication from the Spinal and GA techniques. The researcher did not review each written anaesthetic record for each study patient so potential records of anaesthetic procedural difficulties could have been missed by the researcher. It is also understood by the researcher that potentially all the spinals were not administered by the AA. This acknowledgement is balanced against the researcher’s ability to identify intermediate and major anaesthetic complications which were documented in the electronic discharge information.

The supervision of AA within this study timeframe follows guidelines laid down by the RCoA [1]. The AA workings within HGS also adhere to locally developed supervision and calling criteria guidelines which govern AA practice which is included in the conclusion. Seen here is the example of the, [‘Guidance for Consultant Anaesthetist supervising Anaesthetic Practitioner.’ policy within Heartlands, Good Hope and Solihull [HGS] formally known as Heart of England Trust {HEFT}].

This study helps to identify and showcase the versatility of the AA profession in the delivery of extended anaesthetic services and how the 2 to 1 model of working as suggested by the RCoA [1] is both a safe and effective workforce solution.

The study also supported existing literature trends that laparoscopic hysterectomy is associated with reduced LOS which is not anaesthetic technique dependent.

References

PA-(A) Supervision and limitation of scope of Practice (May 2011 revision) http://www.rcoa.ac.uk
Planning the introduction and training for Physician’s’ Assistant (Anaesthesia) 2016 https://www.rcoa.ac.uk
Hysterectomy NHS2019. .
Length of stay for hysterectomies in one large DGH-what role does this have in enhanced recovery? Haldane K. BJOG: An International Journal of Obstetrics and Gynaecology 2016;123:201.
Using international data to set benchmarks for morbidity outcomes after hysterectomy. Pandit Meghana J. International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 2016;133(1):84-88.
A retrospective benchmark audit to evaluate length of stay by route of hysterectomy Tomlinson F. Gynaecological Surgery 2015;12(1).
Predictors of length of stay after vaginal hysterectomy Kruger P.F. Journal of Minimally Invasive Gynaecology 2015;22(6):-.
Minilaparotomy vs. laparoscopic hysterectomy: comparison of length of hospital stay. Perron-Burdick Misa Journal of minimally invasive gynaecology 2014;21(4):619-623.
J Keurentjes, J M Briet, H Geertruida and J.E>.Mouritis. (2018)Surgical Endoscopy (2018) Volume 32(2) pages 1021-1026.
The Journal of Minimally Invasive Gynaecology A R H Andries, D Mathijis, M D Blikkendaal, W V Z Erik & F W Jansen (2012) https://doi.org/10.1016/j.jmig.2012.09.06.

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Louise Dunphy Frimley Health NHS Foundation Trust

Email: louise.dunphy1@nhs.net

Laparoscopic cholecystectomy is the gold standard treatment for symptomatic cholelithiasis. Complications can occur including haemorrhage, iatrogenic bile duct injury, gallbladder perforation, conversion to an open procedure and choledocholithiasis postoperatively. Subcapsular liver haematoma is a rare, life-threatening complication occurring after laparoscopic cholecystectomy. Anatomical variations, pseudoaneurysms, the use of NSAIDs, haemangioma and iatrogenic liver damage have been suggested as possible risk factors. There is a paucity of cases reported. Depending on the time of onset of the patient’s symptoms, treatment can vary from expectant to surgical management. The authors present the case of a 79-year-old female presenting to the Emergency Department one day following a laparoscopic cholecystectomy with right upper quadrant abdominal pain and hypovolaemic shock. Further investigation with a CT confirmed the diagnosis of a subcapsular liver haematoma. She underwent right hepatic artery embolization. This paper will provide an overview of the aetiology, risk factors, clinical presentation, investigations and management of a subcapsular liver haematoma. It offers an important clinical reminder of maintaining a high index of clinical suspicion in patients presenting with acute onset abdominal pain and hypovolaemic shock following a laparoscopic cholecystectomy. A cystic duct stump leak due to improper clip placement, spontaneous clip displacement, ischaemic necrosis and elevated common bile duct pressures should also be considered in the differential diagnosis in patients presenting with hypovolaemic shock following cholecystectomy. An infected haematoma should also be considered in patients presenting to the Emergency Department a few weeks after surgery with abdominal pain and signs of sepsis.

Subcapsular liver haematoma, described as a blood collection under the Glisson capsule is a rare life-threatening occurrence after laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography [ERCP] or colonoscopy. It can also occur in pregnancies complicated by HELLP Syndrome [haemolysis, elevated liver enzymes and low platelets] and pre-eclampsia. It is also associated with trauma, coagulopathies, hypoxia, maternal diseases and placental lesions. Patients typically present with right upper quadrant pain which may include signs of shock if the bleeding is severe. A high index of clinical suspicion is requiring to render the diagnosis to prevent morbidity and mortality.

Presentation

79-year-old female presented to the Emergency Department, with acute onset of right upper quadrant abdominal and epigastric pain. Her medical history included hypertension, GORD, hypothyroidism, chronic renal impairment and hypercholesterolaemia. Her medications included levothyroxine 50mcgs od, lansoprazole 30mg gastro-resistant tablets, pyridoxine 50 mgs od and bendroflumethiazide 10 mgs od. Further investigation with an ultrasound scan of her abdomen showed a thin-walled gallbladder with several mobile gallstones. She underwent an elective day case laparoscopic cholecystectomy, Hem-o-lok clips were used and haemostasis was achieved. Histopathology showed features of chronic cholecystitis with cholelithiasis. One day post-surgery, she presented to the Emergency Department with acute onset confusion, abdominal pain and distension. She was hypotensive [BP 70/50mmHg] and tachycardic [heart rate 110 bpm]. On examination, guarding was elicited in the right upper quadrant.

Investigations

Her venous blood gas confirmed a raised lactate of 4.3mmol/l and a haemoglobin of 104g/l. Haematological investigations confirmed a raised CRP of 129mg/L, Table 1. Her chest radiograph showed atelectasis at the left base with no evidence of sub-diaphragmatic free air. Her urine dip was negative. She commenced treatment with intravenous anti-microbial therapy [amoxicillin, metronidazole, gentamicin] for suspected intra-abdominal sepsis. Further investigation with a CT abdomen and pelvis showed a large haematoma in the gallbladder bed extending down to the right paracolic gutter (Figure 1). There was a linear streak of high attenuation within the porta hepatis at the site of the cystic artery. The appearances were suggestive of a leaking cystic artery stump, although the hepatic artery itself was not clearly visualised. A small volume of fluid was noted in the pelvis. Her clotting was deranged and she received 10mgs of vitamin K IV, tranexamic acid 1g IV and three units of FFP.

Figure 1. Further investigation with a CT abdomen and pelvis showed a large haematoma in the gallbladder bed
extending down to the right paracolic gutter.

Table 1. Haematological investigations confirmed a raised CRP of 129mg/L.

Differential diagnosis

The clinical impression was of a cystic duct stump leak due to improper clip placement, clip displacement or a subcapsular liver haematoma. Further investigation with a pre-contrast CT was recommended to determine an active bleed as the clips made interpretation difficult. Pre contrast, arterial phase and delayed phase images of her abdomen and pelvis were performed. A large subcapsular collection extending along the medial inferior border of the liver, apparently extending from the gallbladder fossa was noted. Arterial phase images showed the hepatic artery lying close to and abutting the two blushes of contrast again raising the suspicion of active focal bleeding (Figure 2). Note was also made of a variation of the coeliac axis. Two main branches were the left gastric and hepatic artery. The splenic artery appeared to arise off the left gastric artery. There was a tiny accessory vessel just arising after the origin of the coeliac axis. This extended towards the right adrenal gland. Subphrenic fluid represented subcapsular haemorrhage. Two small blushes of contrast were demonstrated suspicious for contrast extravasation from an active bleeding point. A repeat blood gas confirmed a drop in her haemoglobin to 71 g/l. She was transfused two units of packed red blood cells. She was transferred to the Intensive Care Unit for further observation. She required an infusion of metaraminol to maintain her blood pressure. She was self-ventilating and no respiratory support was required. Her haemoglobin remained stable and no further transfusions were required.

Figure 2. Arterial phase images showed the hepatic artery lying close to and abutting the two blushes
of contrast again raising the suspicion of active focal bleeding.

Treatment

As her intermittent haemorrhage persisted, prophylactic embolization was performed. Under fluoroscopic guidance, a right renal, coeliac and selective hepatic angiogram was performed. The right hepatic artery was embolised with 710-1000 micro polyvinyl alcohol particles until stasis was achieved distal to the point of origin of the gastroduodenal artery. Despite antimicrobial therapy her high inflammatory markers persisted [WCC 17x10⁹/L and CRP 342mg/L]. A CT Abdomen/pelvis with contrast was performed. Compared to her previous CT, an evolving right hepatic large haematoma was observed. Her anti-microbial therapy was changed to ertapenem. Under US guidance, the right hepatic complex collection was punctured using a 19G needle to obtain dark red fluid, a sample of which was sent for MC&S. In view of her sepsis, a 12F drain was inserted and placed on free external drainage. Her pus cultured Escherichia coli, Table 2.

Table 2. His pus sample cultured Escherichia coli.

Outcomes

As her inflammatory markers improved, her anti-microbial therapy was down-stepped to levofloxacin and metronidazole. She developed hypoactive delirium, hyperkalaemia [6.5mmol/L], hyponatraemia [124 mmol/l], hypomagnesemia [0.65 mmol/L] and hypophosphatemia [0.68mmol/l] resulting in a prolonged hospital stay. She was reviewed by the dietician and commenced total parenteral nutrition to maintain her calorie intake. Her electrolyte imbalance was caused by her dehydration and thiazide diuretics. She commenced treatment with melatonin modified release tablets 2mg od. Further investigation with a CT Head showed generalised involutional change predominantly affecting the temporal lobes. Her drain was removed after three weeks and an interval CT of her abdomen and pelvis two months later showed a significant reduction in the size of her haematoma. She was discharged home uneventfully after one month.

Discussion

Approximately 12-15% of the UK adult population have gallstones, with up to 4% becoming symptomatic every year. [1] More than 45,000 cholecystectomies are performed annually in the UK. Since the advent of laparoscopic cholecystectomy in the 1990s, it has become the gold standard for the management of symptomatic cholelithiasis. Large cohort studies have reported complication rates of 2-6% following laparoscopic cholecystectomy. [2] These complications include haemorrhage, gallbladder perforation, common bile duct injuries and conversion to an open procedure. Other risks include a subhepatic abscess, iatrogenic bile duct injury and choledocholithiasis postoperatively. [3] Bleeding occurs in <1%. [2] The anatomical sites most commonly affected include the gallbladder bed after its removal, sites of introduction of trocars, the cystic artery, falciform ligament and haemorrhage from a ruptured liver capsule. [2] In the open cholecystectomy era, cystic duct stump leaks were rarely reported. In the era of LC, improper clip placement, spontaneous clip displacement, ischaemic necrosis and elevated common bile duct pressures have been implicated as the cause, occurring in 0.12% of cases. Cystic duct stump leaks can be prevented by a high index of suspicion for postoperative complications and by prompt and appropriate intervention.

A subcapsular liver haematoma, described as a blood collection under the Glisson capsule is an extremely rare, life-threatening complication after laparoscopic cholecystectomy, with only a few cases reported in the literature. [4] Spontaneous haemorrhage of liver parenchyma following normal manipulation of the gallbladder and liver intraoperatively has also been described. This traction may be adequate to cause haemorrhage of a vulnerable haemangioma or surrounding liver parenchyma. It may occur early [up to 24 hours after surgery], presenting with acute onset upper right quadrant pain and hypovolaemic shock if the liver capsule has ruptured. Peritonism may be elicited on physical examination. It can also occur several weeks after the operation presenting with non-specific abdominal pain and a fluid collection on USS. An infected haematoma may present with pyrexia, abdominal pain and sepsis. Bacterial translocation from the gut is thought to be the cause of this superimposed infection. [5] It also occurs in <2% of pregnancies complicated by HELLP Syndrome [haemolysis, elevated liver enzymes and low platelets] and pre-eclampsia. It is also associated with trauma from a difficult labour or a breech presentation, hypoxia, coagulopathies, maternal diseases and placental lesions. In a neonate, it may present with poor feeding, listlessness, pallor, jaundice, tachypnoea and tachycardia. Other causes may include amyloidosis, rupture of hepatocellular carcinoma, adenoma, focal nodular hyperplasia or a haemorrhagic cyst. It is also a rare complication after endoscopic retrograde cholangiopancreatography [ERCP] with a paucity of cases in the literature. Iatrogenic puncture of a peripheral intrahepatic biliary tree resulting in laceration of small parenchymal vessels by an endoscopic guide wire may explain this phenomenon. [6] Acute onset of abdominal pain associated with hypotension and tachycardia after ERCP should raise the clinical suspicion of intrahepatic bleeding with Glisson’s capsule distension. Acute fascioliasis, a food-borne transmitted zoonosis caused by the liver trematode F. hepatica can manifest with a subcapsular liver haematoma, resulting from destruction of blood vessels during the intra hepatic migration of the immature parasites. Other risk factors for its development include the use of diclofenac, aspirin and ketorolac, a non-steroidal anti-inflammatory injection used for perioperative pain management. [7] Intra-operatively, the capsule of the liver can be damaged when dissecting off the gallbladder. Liver traction should be minimized through careful trocar placement while still allowing a critical view of safety to prevent visceral injury. A hepatic haemangioma has also been suggested as an aetiological risk factor. Anatomical variations involving the hepatic vascular system occurring in 12% of individuals, may result in slow bleeding post operatively. [8] Furthermore, the presence of a pseudoaneurysm is considered a risk factor. They have also been described after a liver biopsy, trauma to the abdomen and following the oral contraceptive pill. [9] CT is the investigation of choice for evaluating liver trauma as it has a high sensitivity [95%] and specificity [99%] for detecting liver injuries. [10] Abdominal ultrasound can also help to delineate the lesion, rule out a rupture and aid in serial follow up.

Displacement of a surgical clip from the cystic duct stump should also be considered in the differential diagnosis in patients presenting with haemorrhagic shock following a cholecystectomy. It has become common practice to place at least 2 clips on the proximal side of the cystic duct [CD] for insurance. Despite this practice, there are numerous reports of laparotomies in which a clipless CD has been identified as the cause of a patient’s bile peritonitis. [11][12] Necrosis of the CD stump proximal to the applied clips has also been reported as a cause of a cystic duct stump leak. Ischaemic necrosis caused by devascularization of the CD has also been implicated. [13] It has also been hypothesized that retained common bile duct stones can lead to excess pressure in the biliary tree leading to either perforation of the CD or displacement of the surgical clips. The average time to detection of a CDSL is 3-4 days post operatively. Individuals present with right upper quadrant abdominal pain [80%], nausea or vomiting [35%] and pyrexia [30%]. A leucocytosis is described in 70%. [14] The most successful imaging modality for correctly diagnosing CDSLs is ERCP, followed by MRCP. Endoscopic retrograde cholangiopancreatography is also the primary treatment modality in most postoperative biliary leaks, diminishing delay in therapy once the diagnosis has been confirmed. If a CDSL is found, a sphincterotomy should be performed and a stent placed, with care taken to evaluate for retained CBD stones. Radiologically guided drainage of the biloma has also been used in treating CDSLs. Percutaneous transhepatic biliary drainage has been demonstrated to be effective in CDSLs in small series. [15] The majority of cystic duct stump leaks heal spontaneously when bile is shunted past the defect. Percutaneous or endoscopic coil embolization, fibrin glue, and gelatin sponge injection are alternative approaches for refractory cases. Immediate development of a subscapular haematoma is a potentially life-threatening event due to hypovolaemic shock. Urgent evacuation of the haematoma using percutaneous drainage under ultra-sound guidance may be required. A relaparotomy or re-laparoscopy is required in haemodynamically unstable patients. In cases of a small haematoma in a stable patient, conservative management is appropriate. Treatment with broad spectrum antibiotics is initiated in cases of an infected haematoma. Although subcapsular haematoma is a very rare occurrence following a laparoscopic cholecystectomy it should be considered in the differential diagnosis in patients presenting with abdominal pain and signs of shock. A prompt diagnosis is required to prevent morbidity and mortality.

References

Gill MS et al. Cholecystectomy audit: waiting time, readmissions and complications. Gut, 2015, 64 [S1], A402.
De Castro SM, Reekers JA, Dwars BJ. Delayed intrahepatic subcapsular haematoma after laparoscopic cholecystectomy. Clin Imaging, 2012, 36: 629-31.
Duca S, Bala O, Al-Hajjar N, Lancu C, Puia JC, Munteanu D et al. Laparoscopic Cholecystectomy: incidents and complications. A retrospective analysis of 9542 consecutive laparoscopic operations.
Liu QF, Bian LL, Sun MQ, Zhang RH, Wang WB, Li YN et al. A rare intrahepatic subcapsular haematoma: a case report and literature review. BMC Surgery, 2019, 19:3.
Shea JA, Healey MJ, Berlin JA et al. Mortality and complications associated with laparoscopic cholecystectomy. A meta-analysis. Ann Surg 1996, 224:609-20.
Orellana F, Irarrazaval J, Galindo J, Balbontin P, Manríquez L, Plass R et al. Subcapsular hepatic hematoma post ERCP: a rare or an underdiagnosed complication? Endoscopy, 2012;44, Suppl. 2.
Vuilleumier H, Halkic N. Ruptured subcapsular haematoma after laparoscopic cholecystectomy attributed to ketorolac-induced coagulopathy. Surg Endosc 2003,17; 659.
Duric B, Ignjatovic D, Zivanoic V. New aspects in laparoscopic cystic artery anatomy. Acta Chir Iugosl, 2000: 47: 105-7.
Davis TJ, Berk RN. Benign hepatic lesions in women taking oral contraceptives. Gastrointst, Radiol, 1977, 2, 213-219.
Ahmed N, Vernick JJ. Management of liver trauma in adults. J Emerg Trauma Shock. 2011;4 [1]: 114-9.
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Cite this article as: https://bads.co.uk/for-members/journal-of-one-day-surgery-jods/?id=1857#collapse6

Matthew Flynn CT2 Surgical Department Mater Infirmorum, Belfast
Samuel Lakey Medical Student, Queens University Belfast
David Dick Specialist Registrar Antrim Area Hospital

Correspondence

Mr Matthew Flynn, ENT Department Craigavon Area Hospital, 68 Lurgan Rd, Portadown, Craigavon BT63 5QQ Email: Matthew.Flynn@southerntrust.hscni.net

Keywords: Operation notes, Documentation, Day Case, Surgical procedures

Conflict of Interests: No conflict of interests or sources of funding to disclose.

Abstract

Aims: Good operation notes are a key component of “Good Surgical Practice,” where specificity can help future treating clinicians and in medico-legal cases. This audit aimed to improve the quality of operation notes against standards set by the Royal College of Surgeons (RCS) in Good Surgical Practice (2014).

Methods: Retrospective review of case notes in a day case procedure unit dealing with local anaesthetic excisions. Change of practice was achieved by dissemination of preliminary audit results, introduction of a checklist at the point of operation note completion and education of relevant clinicians. The audit was repeated following intervention.

Results: Recording of procedure time rose from 0% to 100%, logging of operative findings and operative diagnosis improved from 80% to 100% and a detailed postoperative note from 60% to 94%. Date, name of procedure, closure technique and signature were recorded 100% of the time in both rounds of analysis.

Conclusion: Education and efficient record prompts lead to improvement over time in operation notes, demanding systemic reform of standard proformae currently in use. Further longitudinal studies could be done to determine if the improvement is sustained over time.