Cutting edge blog
This section is designed to add value to the articles published in BJS and BJS Open.
If you wish to send a written (or even recorded) comment on one of the published articles, please send it to katie@bjsacademy.com.
If you wish to respond more immediately, please use social media directly by tagging @BJSurgery, @BjsOpen or @BJSAcademy
Endoscopic mastectomy meta-analysis: commentary
Ayla Carroll, Carlos Robles, Hung-Wen Lai, Lidia Blay, Piotr Pluta, Gauthier Rathat, Guillermo Peralta, Rami Younan, Giada Pozzi, Daniel Martinez Campo, Robert Milligan, Glenn Vergauwen, Paolo Carcoforo, Antonio Toesca
Division of Breast Surgical Oncology
Candiolo Cancer Institute
Comment on: Oncological, surgical, and cosmetic outcomes of endoscopic versus conventional nipple-sparing mastectomy: a meta-analysis
Kefah Mokbel, MBBS, MS, FRCS
Correspondence to: Kefah Mokbel (email: kefahmokbel2@gmail.com)
The London Breast Institute
Princess Grace Hospital
Ergonomics in the operating room is a safety imperative
Julie Hallet, MD MSc, Fahad Alam, MD MEd
The operating room (OR) is often imagined as a highly choreographed space – every step deliberate, every movement precise, and every member essential. Yet, beneath this seamless surface lies a persistent under-addressed risk to those who make it all happen: the ever-growing ergonomic hazards faced by OR teams. Our group recently reported about live observations by ergonomic experts in the OR, in “Under Pressure: Live Observation of Ergonomic Challenges in the Operating Room” published in the BJS, to shine a spotlight on some of these challenges and adds to a growing call for change.1
We observed OR teams across multiple specialties and procedures to identify common ergonomic challenges to target for improvement in future educational interventions. The findings were both revealing and concerning: surgeons leaning awkwardly to see monitors, anesthesiologists contorted around ill-placed equipment, scrub nurses reaching and twisting repeatedly to manage instruments. These were not rare occurrences, they were routine. In a single two-hour procedure, 37 near-miss tripping incidents were recorded due to poor cord management. It is not just a matter of individual minor discomforts, but systemic risks that accumulate over time, leading to musculoskeletal injuries, burnout, and ultimately threats to patient safety and the sustainability of surgical care systems.
Historically, the conversation around ergonomics in surgery has been largely focused on surgeons. Whilst important, this lens is incomplete. Poor ergonomics affects everyone in the OR: nurses, anesthesiologists, technicians, and trainees. A scrub nurse standing for hours with no anti-fatigue mat is as vulnerable as the surgeon operating with prolonged neck flexion. An anesthesiologist forced into a hunched position for intubation is as likely to suffer long-term strain as any other member of the team. Moreover, poor ergonomics doesn’t just result in discomfort. It affects communication, reaction time, and decision-making, all which affect patient safety. Increasingly, we recognize that surgical safety is not only about checklists and technique; it is also about ensuring that the people delivering care are supported, protected, and able to perform at their best.
Strengthening the evidential basis of ward-round safety interventions
Wenbo Zhao, Yuquan Chen
Correspondence to: Yuquan Chen (email: yuquan.chen@monash.edu)
School of Public Health and Preventive Medicine
Faculty of Medicine
Author response: strengthening the evidential basis of ward-round safety interventions
Ellie C Treloar, Jesse D Ey, Matheesha Herath, Guy J Maddern
Correspondence to: Guy J. Maddern (email: guy.maddern@adelaide.edu.au)
Department of Surgery
The University of Adelaide
Science in a flash: pain, anxiety, stress and sleep disturbances among surgical patients
Jetske Marije Stoop, Markus Klimek, MD, PhD, DEAA, EDIC, FESAIC
How often do surgical patients experience pain, anxiety, stress, and sleep disturbance during their hospital stay? And how severe are these symptoms? In collaboration with numerous Dutch hospitals, we set out to answer these questions, using an uncommon and innovative, but for our goals perfectly fitting method: a flash mob study.
A flash mob study is a novel research design in which data is collected on a single day, simultaneously in multiple centres. It’s an efficient way to address clinically relevant questions on a large scale – in our case the point prevalence of surgical patient pain, anxiety, stress, and sleep disturbance. But this approach also requires meticulous planning: there’s only one shot to get it right.
The preparation for the project took a year. We started by developing the methodology and drafting the study protocol, followed by compiling all necessary documents for submission to the Medical Ethics Review Committee (MERC). While awaiting approval, we reached out to all hospitals across the Netherlands. Through secretaries and outpatient clinics, we found surgeons and residents in 29 Dutch hospitals who were eager to participate and helped forming a local research team and arranging institutional approval from the hospital board.
Comment on: Assessment of nodal staging and risk factors for nodal involvement in gallbladder cancer
Wissam Benhami, Dihia Makaci, Ahmed Fouad Bouras, Chafik Bouzid
Correspondence to: Dr. Wissam Benhami (email: wissambenhami@gmail.com)
Department of General Surgery
RAHMOUNI Djilali Public Hospital (Les Orangers)
Author response: Assessment of nodal staging and risk factors for nodal involvement in gallbladder cancer
Anita Balakrishnan, Petros Barmpounakis, Nikolaos Demiris, Bodil Andersson, Alejandro Brañes, Xavier de Aretxabala, Malin Sternby Eilard, Paul Gibbs, Simon J F Harper, Emmanuel L Huguet, Asif Jah, Vasilis Kosmoliaptsis, Javier Lendoire, Siong S Liau, Shishir Maithel, Jack L Martin, Colin Noel, Raaj K Praseedom, Alejandro Serrablo, Volkan Adsay, the OMEGA Study Investigators
Correspondence to: Anita Balakrishnan (email: ab2031@cam.ac.uk)
Department of Hepatopancreatobiliary Surgery
Cambridge University Hospitals NHS Foundation Trust
Arterial resections in pancreatic cancer: measure twice, cut once
Monish Karunakaran
Correspondence to: Monish Karunakaran (email: monish3682@gmail.com)
Department of Surgical Gastroenterology
Asian Institute of Gastroenterology
Comment on: Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas
Lauren Taylor, Chris Duff, David Mowatt, James Howard, Richard Whitehouse
Correspondence to: Lauren Taylor (email: lauren.taylor6@nhs.net)
Plastic Surgery Department
Wythenshawe Hospital
Author response: Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas
Samuel J Ford, James Hodson
Correspondence to: Samuel J Ford (email: samuel.ford@uhb.nhs.uk)
University Hospitals Birmingham
Edgbaston
Immunotherapy-enhanced tumour regression in rectal cancer: should surgery be omitted?
Wenlong Qiu, Xuan Zheng, Yunpeng Wu, Yong Yang, Qian Liu
Correspondence to: Qian Liu and Yong Yang
Qian Liu (e-mail: fcwpumch@163.com)
Department of Colorectal Surgery
Organ preservation for rectal cancer patients in the era of neoadjuvant immunotherapy
Kai Pang, Xinzhi Liu, Pengfei Zhao, Hongwei Yao, Yingchi Yang, Zhongtao Zhang
Correspondence to: Zhongtao Zhang (email: zhangzht@ccmu.edu.cn)
Department of General Surgery
Beijing Friendship Hospital
Comment on: Effect of transverse versus midline periumbilical incision on incisional hernia and short-term outcomes after laparoscopic colon cancer surgery: multicentre, open-label, randomized clinical trial
Jeremy Meyer, Jonathan Douissard, Marie Burgard
Correspondence to: Marie Burgard (email: marie.burgard@web.de)
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Missing the split? Reconsidering the scope of biliary complications in the classification proposed at the BileducTx meeting
Juri Fuchs, MD, Florent Guerin, MD, PhD, Geraldine Hery, MD, Virginie Fouquet, MD, Sophie Branchereau, MD, PhD
Department of General, Visceral, Pediatric and Transplantation Surgery
University of Heidelberg
Comment on: Optimizing ward rounds: systematic review and meta-analysis of interventions to enhance patient safety
Lingdan Chang, Hongjin Shi, Jinsong Zhang, Bing Hai
Correspondence to: Bing Hai (email: binghai999@163.com)
374
Dianmian Road
Author response: Optimizing ward rounds: systematic review and meta-analysis of interventions to enhance patient safety
Ellie C Treloar, Jesse D Ey, Matheesha Herath, Guy J Maddern
Correspondence to: Guy J. Maddern (e-mail: guy.maddern@adelaide.edu.au)
Department of Surgery
The University of Adelaide
A tribute to Paul Sugarbaker: the father of cytoreductive surgery
Aditi Bhatt MS, MCh, Brendan J. Moran MD, Marcello Deraco MD, Naoual Bakrin MD PhD, Joel Baumgartner MD, Vahan Kepenekian MD, PhD, Alvaro Arjona Sanchez MD, Vivek Sukumar MS, MCh, Kiran Turaga MD, MPH, Laurent Villeneuve MBE, PhD, Shigeki Kusamura MD, PhD, Olivier Glehen MD, PhD
Nearly thirty years ago Paul Sugarbaker first published the classification and description of the techniques of peritonectomy procedures and organ resections as part of cytoreductive surgery1. Since then, Paul Sugarbaker has published numerous manuscripts, books and book chapters and produced videos on peritonectomy procedures. Some of these have been improvisations of the previous descriptions while others have been descriptions of new peritonectomy procedures that he had devised2,3,4. The description of the hepatic bridge and the clearance of the peritoneum in the tunnel created by it, clearance of peritoneal disease in an inguinal hernia, clearance of the foramen of Winslow and peritonectomy of the sub-pyloric space are some of the techniques published subsequently5,6,7,8,9,10. The most recent addition to the list was peritonectomy of the colonic mesentery published in 202111.
Paul Sugarbaker started working on the treatment of peritoneal malignancies in the early eighties and coined the term cytoreductive surgery for a surgical procedure that involved resection of all macroscopic tumor, including electrosurgical removal of the peritoneal tumor deposits, combined with administration of intraperitoneal chemotherapy12,13. The body of publications by Sugarbaker on peritonectomy procedures is the most comprehensive resource on these procedures in the literature, both in terms of the included procedures and the technical descriptions of these procedures. In 2016, Grey’s anatomy, for the first time, included a chapter on the anatomy of the peritoneum by Paul Sugarbaker14. Paul Sugarbaker has set the bar for the quality of operative surgical images published in these manuscripts. Cytoreductive surgery addresses different regions of the peritoneal cavity, and organ systems, and can appear disjointed and unstructured, especially in the setting of extensive peritoneal disease. The intraoperative images in his manuscripts are pristine, demonstrating each anatomical structure with great clarity15. This attention to detail underlines the importance of meticulous surgical technique, and the pursuit of perfection, which to those who have trained and worked with him, are his well-known hallmarks.
Paul Sugarbaker has over the years laid great emphasis on minute technical aspects of cytoreductive surgery, such as the incision and exposure of the peritoneal cavity, meticulous excision of previous surgical scars, use of high voltage electrocautery and copious lavage of the peritoneal cavity16,17,17. One of his most famous aphorisms ‘It’s what the surgeon does not see that kills the patient’ is a manuscript focusing on meticulous surgical technique to reduce peritoneal dissemination from colorectal primary tumors19. In current times, this aphorism incorporates , and underlines, the importance of ‘complete’ cytoreductive surgery which requires meticulous exploration of the abdominal cavity and identification and resection of all sites of disease. However, the original aphorism refers to another important concept that he introduced whereby he described the technique of centripetal surgery which involved starting the dissection far away from the tumor, and employing local peritonectomy procedures to contain the colorectal primary tumor19. While most of his work was on peritoneal metastases of gastrointestinal origin, the principles and concepts introduced by him are applicable to all surgical approaches for peritoneal malignancies. Another very significant Sugarbaker concept is that the peritoneum helps prevent retroperitoneal dissemination of peritoneal malignancy and is thus “the first line of defense” again peritoneal metastases20.
Large-language models already match 80 percent of MDT decisions — here’s why surgeons should care
Dimitrios Chatziisaak, Pascal Burri, Moritz Sparn, Dieter Hahnloser, Thomas Steffen, Stephan Bischofberger
Tumour Boards (MDT) are swamped. Some UK centres now log more than 30 hours each month discussing colorectal cancer (CRC) cases. Yet large-language models (LLMs) such as ChatGPT could already shoulder a sizeable slice of that load.
We retrospectively audited 100 consecutive CRC cases discussed by our lower-GI MDT (September-December 2023)1 Raw patient data including surgical notes, preoperative work up, TNM staging, comorbidities and imaging summaries were uploaded to ChatGPT‑4 without prior medical interpretation. The model returned a single “best” plan for the pre‑ and (where applicable) post‑therapeutic settings (Figure 1). After that the concordance with the German S3 guideline was manually assessed by our team (Table 1)2. In the pretherapeutic discussions, complete concordance was observed in 72.5 per cent, with partial concordance in 10.2 per cent and discordance in 17.3 per cent. For post-therapeutic discussions, the concordance increased to 82.8 per cent; 11.8 per cent of decisions displayed partial concordance and 5.4 per cent demonstrated discordance. Key discordance drivers were age > 77 years (OR 1.08 per year) (Figure 2), ASA ≥ III, rectal cancer, N1 stage on the TNM Classification.
ChatGPT prompt.
Comment on: Negative pressure wound therapy for surgical wounds healing by secondary intention is not cost-effective
Yan Shao, Jinshan Liu
Correspondence to: Jinshan Liu (email: liujinshanqijiang@163.com)
Department of Gastrointestinal Surgery
Chongqing Hospital of Jiangsu Province Hospital
Author response: Negative pressure wound therapy for surgical wounds healing by secondary intention is not cost-effective
Ian Chetter, Catherine Arundel, Athanasios Gkekas, Pedro Saramago
Correspondence to: Catherine Arundel (email: catherine.arundel@york.ac.uk)
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The clinical impact of door openings in the operating room on surgical site infections
Hannah Groenen MD, Professor Marja A Boermeester MD, PhD
The impact of operating room door openings on surgical site infections (SSIs) has long been a topic of debate. Minimizing door openings – or implementing a strict zero door opening policy for certain surgical procedures - is a common recommendation in SSI prevention bundles and clinical guidelines. This recommendation is based on associations between door openings and surrogates of SSI, such as increased microbial air contamination or wound contamination. However, direct clinical evidence of an increase in SSI rates has been lacking.
Our systematic review and individual patient data meta-analysis (IPDMA) of eight observational studies including 4,412 procedures provides the first cumulative clinical data assessing the effect of the number of door openings in the operating room on SSIs across all surgical types1. Very low certainty of evidence suggested a marginal increase in SSI risk with each additional door opening per hour, patients at a higher baseline risk being more affected (Figure 1). Given the minimal observed effect on clinical outcomes and the very low certainty of the evidence, our results do not support enforcing a strict zero-door-opening policy solely for the purpose of SSI prevention.
We found it particularly relevant to examine the potential impact of door openings in clean surgeries and implant procedures, where strict zero-door-opening policies are often most rigorously enforced to minimize contamination risks. Although exogenous sources of contamination other than the patient’s own microflora are believed to play a role in infection after clean and long-duration surgery, this is primarily based on studies showing associations with surrogates such as colony forming units in wounds or operating rooms, rather than a direct effect on higher SSI rates2-4. In implant surgeries, the serious consequences of prosthetic infections, especially those linked to biofilm formation on implant surfaces, further support the rationale for stricter door-opening policies5. However, our findings suggest that the relationship between the number of door openings per hour and clinical SSI outcomes remains comparable across different wound contamination levels and implant statuses.
Author response: Concordance of ChatGPT artificial intelligence decision-making in colorectal cancer multidisciplinary meetings: retrospective study
Dimitrios Chatziisaak, Stephan Bischofberger
Correspondence to: Stephan Bischofberger (e-mail: stephan.bischofberger@kssg.ch)
Department of Surgery
Kantonsspital St. Gallen
Comment on: Concordance of ChatGPT artificial intelligence decision-making in colorectal cancer multidisciplinary meetings: retrospective study
Hinpetch Daungsupawong, Viroj Wiwanitkit
Corresponding author: Hinpetch Daungsupawong (email: hinpetchdaung@gmail.com)
Private Academic Consultant
Phonhong