Acute Abdominal Surgery Research Articles

Therapeutic interventions using the peritoneal and coelomic cavity in dogs, cats, and exotic pets.

To provide a video tutorial describing intraperitoneal (IP) and intracoelomic (IC) therapeutics (IP/IC fluid therapy, euthanasia, direct peritoneal resuscitation). Dogs, cats, and exotic pets. Peritoneal and coelomic centesis allows for delivery of fluids or to perform euthanasia. The peritoneal and coelomic membranes contain a vast network of capillaries and lymphatics that allow absorption of fluids and blood products. Needles are inserted aseptically IP or IC at species-specific locations to avoid iatrogenic damage. In mammals, the needle is inserted in a periumbilical location at a 1- to 2-cm radius from the umbilicus, while the needle is inserted into the ventral inguinal fossa in chelonians and lateroventrally in lizards and snakes. Direct peritoneal resuscitation is a human technique in which a dextrose/electrolyte solution infused IP reduces ischemia-reperfusion injury, edema, and tissue necrosis to improve mortality in patients with diseases like shock and sepsis or who require acute abdominal surgery. Isotonic crystalloids are given IP/IC at 10- to 20-mL/kg doses (smaller volumes in reptiles) and blood products at standard calculated doses. Sodium pentobarbital without phenytoin (3 mL/4.5 kg) is used for IP/IC euthanasia. Being aware of multiple routes for fluid and blood product administration allows treatment in animals for which intravenous or intraosseous catheterization is undesirable or impossible. While intravenous or intraosseous routes are always preferred, especially for resuscitation, familiarity with locations for IP/IC fluid and euthanasia is useful. Techniques like direct peritoneal resuscitation are not currently used in animals but might be translated to veterinary cases in the future.

Effects of oral probiotics on inflammation and intestinal function in adult patients after appendectomy: Randomized controlled trial.

Appendectomy is an acute abdominal surgery that is often accompanied by severe abdominal inflammation. Oral probiotics are one of the postoperative treatments for rapid rehabilitation. However, there is a lack of prospective studies on this topic after appendectomy. To investigate whether the postoperative probiotics can modulate the inflammatory response and restore intestinal function in patients following appendectomy. This was a prospective, randomized trial. A total of 60 emergency patients were randomly divided into a control group (n = 30) and a probiotic group (n = 30). Patients in the control group started to drink some water the first day after surgery, and those in the probiotic group were given water supplemented with Bacillus licheniformis capsules for 5 consecutive days postsurgery. The indices of inflammation and postoperative conditions were recorded, and the data were analyzed with RStudio 4.3.2 software. A total of 60 participants were included. Compared with those in the control group, the C-reactive protein (CRP), interleukin 6 and procalcitonin (PCT) levels were significantly lower in the probiotic group at 2 d after surgery (P = 2.224e-05, P = 0.037, and P = 0.002, respectively, all P < 0.05). This trend persisted at day 5 post-surgery, with CRP and PCT levels remaining significantly lower in the probiotic group (P = 0.001 and P = 0.043, both P < 0.05). Furthermore, probiotics resulted in a shorter time to first flatus and a greater percentage of gram-negative bacilli in the feces (P = 0.035, P = 0.028, both P < 0.05). Postoperative oral administration of probiotics may modulate the gut microbiota, benefit the recovery of the early inflammatory response, and subsequently enhance recovery after appendectomy.

Peripheral perfusion index stratifies risk in patients with intraoperative anemia: A multicentre cohort study

Study objectiveEvidence for red blood cell (RBC) transfusion thresholds in the intraoperative setting is limited, and current perioperative recommendations may not correspond with individual intraoperative physiological demands. Hemodynamics relevant for the decision to transfuse may include peripheral perfusion index (PPI). The objective of this prospective study was to assess the associations of PPI and hemoglobin levels with the risk of postoperative morbidity and mortality. DesignMulticenter cohort study. SettingBispebjerg and Hvidovre University Hospitals, Copenhagen, Denmark. PatientsWe included 741 patients who underwent acute high risk abdominal surgery or hip fracture surgery. InterventionsNo interventions were carried out. MeasurementsPrincipal values collected included measurements of peripheral perfusion index and hemoglobin values. MethodsThe study was conducted using prospectively obtained data on adults who underwent emergency high-risk surgery. Subjects were categorized into high vs. low subgroups stratified by pre-defined PPI levels (PPI: > 1.5 vs. < 1.5) and Hb levels (Hb: > 9.7 g/dL vs. < 9.7 g/dL). The study assessed mortality and severe postoperative complications within 90 days. Main resultsWe included 741 patients. 90-day mortality was 21% (n = 154), frequency of severe postoperative complications was 31% (n = 231).Patients with both low PPI and low Hb had the highest adjusted odds ratio for both 90-day severe postoperative complications (2.95, [1.62–5.45]) and 90-day mortality (3.13, [1.45–7.11]).A comparison of patients with low PPI and low Hb to those with high PPI and low Hb detected significantly higher 90-day mortality risk in the low PPI and low Hb group (OR 8.6, [1.57–162.10]). ConclusionHigh PPI in acute surgical patients who also presents with anemia was associated with a significantly better outcome when compared with patients with both low PPI and anemia. PPI should therefore be further investigated as a potential parameter to guide intraoperative RBC transfusion therapy.

Economic Analysis of AbClo, a Novel Abdominal Fascia Closure Device, for Patients With an Open Abdomen Following Trauma or Acute Abdominal Surgery.

Open Abdomen (OA) cases represent a significant surgical and resource challenge. AbClo is a novel non-invasive abdominal fascial closure device that engages lateral components of the abdominal wall muscles to support gradual approximation of the fascia and reduce the fascial gap. The study objective was to assess the economic implications of AbClo compared to negative pressure wound therapy (NPWT) alone on OA management. We conducted a cost-minimization analysis using a decision tree comparing the use of the AbClo device to NPWT alone among patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure. The time horizon was limited to the length of the inpatient hospital stay, and costs were considered from the perspective of the US Medicare payer. Clinical effectiveness data for AbClo was obtained from a randomized clinical trial. Cost data was obtained from the published literature. Probabilistic and deterministic sensitivity analyses were performed. The primary outcome was incremental cost. The mean cumulative costs per patient were $76582 for those treated with NPWT alone and $70,582 for those in the group treated with the AbClo device. Compared to NPWT alone, AbClo was associated with lower incremental costs of -$6012 (95% CI -$19449 to +$1996). The probability that AbClo was cost-savings compared to NPWT alone was 94%. The use of AbClo is an economically attractive strategy for management of OA in in patients with midline laparotomy for trauma or acute abdominal surgery who were ineligible for primary fascial closure.

Feasibility and safety of laparoscopy in acute non-traumatic emergency abdominal surgery: A prospective study

Introduction: The use of laparoscopy in emergency abdominal surgery is considered high-risk due to its elevated morbidity, requiring expertise in laparoscopic surgery. Objective: Assessing the feasibility, reproducibility, and safety of laparoscopy in non-traumatic acute abdominal surgery. Methods: Descriptive, prospective and evaluative study, conducted between February 2018 and October 2021. We have included in this study: acute appendicitis and its complications, lithiasis acute cholecystitis (LAC), peritonitis by perforation of peptic ulcer, adhesive acute intestinal obstruction, adnexal torsion, extra-uterine pregnancies, and non-specific acute abdominal pain. Results: We operated on 337 patients laparoscopically, with an average of 02 surgeries per medical shift. In 62.6%, surgeries were performed outside of regular working hours. We encountered temporary, material, and human difficulties in 10.8% of the cases. Average age of the patients is 38 years ±15 years. F/H sex ratio =1.29. Diagnostic accuracy of laparoscopy was 100 %. Intraoperative laparoscopic scanning corrected the preoperative diagnosis in 15.73% of cases. Average operative time was 52.09 min ± 24.14 min. One conversion recorded (0.3%). Rate of postoperative complications was 6.2%. These complications are classified at grade I according to the Clavien-Dindo classification in 85.71%. Only one patient (0.3%) required a second operation. Average length of overall hospitalization was 1.5 days. Conclusion: Our results suggest that emergency laparoscopy is feasible, safe, and reproducible. So it can claim to replace laparotomy in the management of acute, non-traumatic abdominal emergencies.

The effects of troponin screening among patients undergoing acute high-risk abdominal surgery: A retrospective cohort study.

Acute high-risk abdominal (AHA) surgery is associated with a high short-term mortality rate. This might be partly attributed to myocardial injury after non-cardiac surgery (MINS) defined by elevated postoperative troponin levels. The myocardial injury is often asymptomatic; thus, troponin screening seems to be the best diagnostic method. We aimed to assess whether implementing troponin screening with subsequent individualised interventions as standard care is associated with reduced mortality after AHA surgery. We also explored the treatment implications in the screening period. A retrospective cohort of 558 patients undergoing surgery from February 2018 to March 2021 was included. The patients undergoing surgery before March 2019 served as the historical control group, while the screening group consisted of patients undergoing surgery from March 1, 2019. Troponin I was to be measured 6-12 h postoperatively and in the morning of the succeeding 4 days. Patients with myocardial injury were assessed, and treatment was individualised after multiple disciplinary consultations. The primary outcome was the unadjusted 30-day mortality rates. Inverse probability treatment weighting was used to adjust for selection bias. We included 558 patients: 382 in the screening group and 176 in the historical control group. In the screening group, 15 patients (3.9%) died before the first blood sampling, and in 31 patients (8.1%), troponin screening was omitted, leaving only 336 patients screened. Myocardial injury was diagnosed in 81 patients (24.1%) of the 336 patients. Of these, 59 (72.8%) had a cardiac consultation. No interventions or alterations in relation to myocardial injury were done in 67 patients (82.7%). The 30-day mortality was 13.8% (95% CI 8.7%-18.9%) in the control group and 11.1% (95% CI 8.0%-14.3%) in the screening group. The absolute risk difference was -2.7% (95% CI -8.7%-3.3%; p = .38), which was unchanged after adjustment. The difference remained unchanged after 90 days and 1 year. The implementation of postoperative troponin screening was not associated with reduced mortality after AHA surgery. Research on the prevention and treatment of MINS is warranted before the implementation of standard troponin screening.

Enhanced Th17 responses in the appendix of children with complex compared to simple appendicitis are associated with microbial dysbiosis.

Appendicitis is one of the most common causes of acute abdominal surgery in children. The clinical course of appendicitis ranges from simple to complex appendicitis. The mechanisms underlying the heterogeneity of appendicitis in children remain largely unclear. Dysregulated T cell responses play an important role in several inflammatory diseases of the intestine, but the extend of T cell dysregulation in appendicitis in children is less well known. To characterize appendiceal T cells in simple and complex appendicitis we performed in-depth immunophenotyping of appendiceal-derived T cells by flow cytometry and correlated this to appendiceal-derived microbiota analyses of the same patient. Appendix samples of twenty children with appendicitis (n = 8 simple, n = 12 complex) were collected. T cells in complex appendicitis displayed an increased differentiated phenotype compared to simple appendicitis, including a loss of both CD27 and CD28 by CD4+ T cells and to a lesser extent by CD8+ T cells. Frequencies of phenotypic tissue-resident memory CD69+CD4+ T cells and CD69+CD8+ T cells were decreased in children with complex compared to simple appendicitis, indicating disruption of local tissue-resident immune responses. In line with the increased differentiated phenotype, cytokine production of in particular IL-17A by CD4+ T cells was increased in children with complex compared to simple appendicitis. Furthermore, frequencies of IL-17A+ CD4+ T cells correlated with a dysregulation of the appendiceal microbiota in children with complex appendicitis. In conclusion, disruption of local T cell responses, and enhanced pro-inflammatory Th17 responses correlating to changes in the appendiceal microbiota were observed in children with complex compared to simple appendicitis. Further studies are needed to decipher the role of a dysregulated network of microbiota and Th17 cells in the development of complex appendicitis in children.

One-year mortality rates after standardized management for emergency laparotomy: results from the Swedish SMASH study.

Patients who require an emergency laparotomy suffer from high mortality and morbidity rates. Studies have shown that the standardization of perioperative management reduces complications in the short term. The aim of the present study was to report long-term mortality rates for the SMASH (Standardized perioperative Management of patients operated with acute Abdominal Surgery in a High-risk and emergency setting) study, as well as short- and long-term outcomes for different age groups within the SMASH study. A prospective intervention study was introduced in 2018, with the aim of investigating the introduction of a standardized protocol for emergency laparotomy. For 42 months, intervention patients were managed according to the protocol and outcomes were then compared with those of historical controls. A total of 1344 unique patients were included (681 in the intervention group and 663 in the control group). The 90-day mortality rate was 14.1 per cent in the intervention group and 20.8 per cent in the control group (P = 0.002) and the 1-year mortality rate in adjusted analyses was 19.7 and 27.8 per cent respectively (P =< 0.001). An age-related subgroup analysis showed that the oldest patients (76 years and older, 260 in the intervention group and 240 in the control group) had a 1-year mortality rate of 29.6 and 43.8 per cent respectively (P = 0.004) and a mean duration of hospital stay of 9.9 and 11.6 days respectively (P = 0.027). Among older adults (61-75 years), the mean duration of hospital stay was 11.7 days in the intervention group compared with 15.1 days in the control group (P = 0.009) and the mean duration of ICU care was reduced to 4.49 days compared with 7.29 days (P = 0.046). The standardized protocol associated with an emergency laparotomy appears to be beneficial, even in the long term. For elderly patients, it appears to reduce mortality rates and the durations of hospital stay and ICU care.

Comparison of Stump Closure Methods in Laparoscopic Appendectomy: Hem-o-Lok Clip and Laparoscopic Titanium Clip.

Appendectomy for acute appendicitis is the most common acute abdominal surgery. Open and laparoscopic appendectomy surgeries are performed with different techniques. Laparoscopic appendectomy has become a widespread method due to its advantages. The aim of this study is to compare the complications, surgery time, hospitalization length, and cost-effectiveness of titanium clips and hem-o-lok clips for stump closure in laparoscopic appendectomy. This study included 187 patients who were operated on laparoscopically for acute appendicitis at our hospital between April 2019 and June 2022. The patients' follow-up for 30 days after surgery was evaluated. The data of 179 patients in whom titanium and hem-o-lok clips were inserted during an appendectomy were included in the study. Between April 2019 and June 2022, 179 patients were included in the study retrospectively. When the correlation between complications and surgical methods was analyzed, 98.8% of the hem-o-lok clip group and 99% of the titanium clip group had no complications. No statistically significant difference was observed between complications and surgery type (P > .05). In the hem-o-lok and titanium clip groups, the operative time was 52.4 minutes and 53.1 minutes, and the hospitalization times were 1.7 days and 1.8 days, respectively. It is concluded that the use of titanium clips that completely close the root of the appendix is as safe, accessible, feasible, practical, and effective as the hem-o-lok clip method. It was observed to be used safely as an alternative to other appendix root closure methods.

Frequency and risk factors of atrial fibrillation after acute abdominal surgery: A prospective cohort study.

Scarce data exist on the true incidence of postoperative atrial fibrillation (POAF) after acute abdominal surgery and associated outcomes. The current study aimed to identify the frequencies of clinically recognized POAF and associated complications, along with their risk factors. This study was a prospective, single-center cohort study of unselected adult patients referred for acute abdominal surgery during a 3-month period. Through careful review, demographics, comorbidity, and surgical characteristics were prospectively drawn from medical charts. The primary outcome was clinically recognized POAF occurring in-hospital. Logistic regression was used to determine the risk factors of POAF and associated complications. A subgroup was enrolled in a feasibility study of peri- and postoperative continuous cardiac rhythm monitoring. In total, 450 patients were enrolled. Clinically recognized in-hospital POAF was observed in 22 patients (4.9%). All cases were observed in patients aged ≥60 years, corresponding to 22 of 164 patients (13.4%). Multiple risk factors were observed, such as age, prior atrial fibrillation, heart failure, hypertension, diabetes mellitus, chronic renal disease, and major (vs. minor) surgery. POAF was associated with severe in-hospital complications (POAF group 45.5% vs. non-POAF group 8.6%, p < .001) and in-hospital mortality (POAF group 13.6% vs. non-POAF group 3.0%, p = .043). In total, 295 patients were monitored by continuous cardiac rhythm monitoring for 12,148 h, yielding five patients with asymptomatic AF. In conclusion, this prospective study of POAF in patients undergoing acute abdominal surgery showed that one in 20 patients developed clinically recognized in-hospital POAF. Multiple risk factors of POAF were identified. POAF was associated with severe complications up to 30 days after surgery.

Clinical and Therapeutic Issues Associated with Acute Abdominal Surgery Performed during the COVID - 19 Epidemic

Clinical and Therapeutic Issues Associated with Acute Abdominal Surgery Performed during the COVID - 19 Epidemic

Acute Perforated Appendicitis: A Case Report

Appendicitis is an inflammation that occurs in appendix vermicularis, a tubular organ located at the base of the large intestine located in the lower right abdomen, which acute inflammation of the appendix. Appendicitis is the most common case of acute abdominal surgery. Appendicitis can hit all age groups, although it is not common in children before school age. can causes dangerous complications if surgery is not performed immediately. The patient's history of the course of the disease and physical examination are the most important things in diagnosing appendicitis. All cases of appendicitis require the removal of the inflamed appendix, both with laparotomy and with laparoscopy. If treatment is not taken, the mortality rate will be high, mainly caused by peritonitis and shock. Here we present a case of acute perforated appendicitis in a 29-year-old male patient.

Early intensive mobilization after acute high-risk abdominal surgery: a nonrandomized prospective feasibility trial.

Mobilization after emergency abdominal surgery is considered essential to facilitate rehabilitation and reduce postoperative complications. The aim of this study was to evaluate the feasibility of early intensive mobilization after acute high-risk abdominal (AHA) surgery. We conducted a nonrandomized, prospective feasibility trial of consecutive patients after AHA surgery at a university hospital in Denmark. The participants followed a predefined, interdisciplinary protocol for early intensive mobilization during the first 7 postoperative days (PODs) of their hospital admission. We evaluated feasibility in accordance with the percentage of patients who mobilized within 24 hours after surgery, mobilized at least 4 times per day and achieved daily goals of time out of bed and walking distance. We included 48 patients with a mean age of 61 (standard deviation 17) years (48% female). Within 24 hours after surgery, 92% of the patients were mobilized and 82% or more were mobilized at least 4 times per day over the first 7 PODs. On PODs 1-3, 70%-89% of the participants achieved the daily goals of mobilization; participants still in hospital after POD 3 were less able to achieve the daily goals. Patient reported that the primary factors limiting their level of mobilization were fatigue, pain and dizziness. Participants not mobilized independently on POD 3 (28%) had significantly (p ≤ 0.04) fewer hours out of bed (4 v. 8 h), were less able to achieve the goals of time out of bed (45% v. 95%) and walking distance (62% v. 94%) and had longer hospital stays (14 v. 6 d) than participants mobilized independently on POD 3. The early intensive mobilization protocol seems feasible for most patients after AHA surgery. For nonindependent patients, however, alternative mobilization strategies and goals should be investigated.

Standardized perioperative management in acute abdominal surgery: Swedish SMASH controlled study.

Acute high-risk abdominal surgery is common, as are the attendant risks of organ failure, need for intensive care, mortality, or long hospital stay. This study assessed the implementation of standardized management. A prospective study of all adults undergoing emergency laparotomy over an interval of 42 months (2018-2021) was undertaken; outcomes were compared with those of a retrospective control group. A new standardized clinical protocol was activated for all patients including: prompt bedside physical assessment by the surgeon and anaesthetist, interprofessional communication regarding location of resuscitation, elimination of unnecessary factors that might delay surgery, improved operating theatre competence, regular epidural, enhanced recovery care, and frequent early warning scores. The primary endpoint was 30-day mortality. Secondary endpoints were duration of hospital stay, need for intensive care, and surgical complications. A total of 1344 patients were included, 663 in the control group and 681 in the intervention group. The use of antibiotics increased (81.4 versus 94.7 per cent), and the time from the decision to operate to the start of surgery was reduced (3.80 versus 3.22 h) with use of the new protocol. Fewer anastomoses were performed (22.5 versus 16.8 per cent). The 30-day mortality rate was 14.5 per cent in the historical control group and 10.7 per cent in the intervention group (P = 0.045). The mean duration of hospital (11.9 versus 10.2 days; P = 0.007) and ICU (5.40 versus 3.12 days; P = 0.007) stays was also reduced. The rate of serious surgical complications (grade IIIb-V) was lower (37.6 versus 27.3 per cent; P = <0.001). Standardized management protocols improved outcomes after emergency laparotomy.

How can we achieve better results with acute abdominal surgery?

How can we achieve better results with acute abdominal surgery?

Small Bowel Gist in a Patient with Neurofibromatosis Type 1: Revealed by Acute Abdominal Surgery: A Case Report

We decided to report a case of gastrointestinal stromal tumor of the small intestine in a patient with neurofibromatosis type 1 because of the increase of its incidence as shown in the literature, also, by its revelation; its occurrence in a picture of acute peritonitis due to the rupture of the tumor. These tumors, commonly called by their English acronym GIST (Gastro-Intestinal Stromal Tumors), found in people with neurofibromatosis type 1 generally occur in the small intestine and are often multiple.

The Role of Insulin-Like Growth Factor 1 in Delirium: A Systematic Review and Meta-Analysis

Background: The relationship between delirium and low levels of insulin-like growth factor 1 (IGF-1) is contradictory and uncertain. We hypothesised that low levels of IGF-1 are a predisposing factor for delirium in medical and abdominal surgical cohorts, in contrast to other surgical cohorts. Aims: Systematic review and meta-analysis investigating the association between peripheral levels of IGF-1 and delirium in medical and surgical patients to explore if there are distinct patterns of associations by using subgroup meta-analysis. Methods: PubMed, Scopus, CINAHL, Cochrane, and Embase databases were searched. Inclusion criteria were prospective studies in medical and surgical populations and available data. The following were collected: the setting (surgical/medical), the type (orthopaedic surgery, abdominal, cardiovascular, or medical), the number of participants, mean age, the number of delirious patients, scale/criteria for delirium, IGF-1 levels, and MMSE. Results: Thirteen studies were included and analysed. Low levels of IGF-1 are significantly associated with delirium in abdominal surgical samples and medical samples but not in the other surgical samples. Age, cognition, and the setting (medical vs. surgical) do not have any significant effect on the differences in IGF-1 levels between those with and without delirium. Discussion: Delirium in acute medical and abdominal surgery is triggered by low IGF-1 which may reflect chronic conditions like frailty/cachexia/sarcopenia, while in other surgeries perhaps from an inflammatory process. Conclusions: Low peripheral levels of IGF-1 are a predisposing factor for delirium only in acute medical and abdominal surgery. More studies are needed to confirm and to explore further this finding.

Perioperative changes in fluid distribution and haemodynamics in acute high-risk abdominal surgery

BackgroundUnderstanding the pathophysiology of fluid distribution in acute high-risk abdominal (AHA) surgery is essential in optimizing fluid management. There is currently no data on the time course and haemodynamic implications of fluid distribution in the perioperative period and the differences between the surgical pathologies.MethodsSeventy-three patients undergoing surgery for intestinal obstruction, perforated viscus, and anastomotic leakage within a well-defined perioperative regime, including intraoperative goal-directed therapy, were included in this prospective, observational study. From 0 to 120 h, we measured body fluid volumes and hydration status by bioimpedance spectroscopy (BIA), fluid balance (input vs. output), preload dependency defined as a > 10% increase in stroke volume after preoperative fluid challenge, and post-operatively evaluated by passive leg raise.ResultsWe observed a progressive increase in fluid balance and extracellular volume throughout the study, irrespective of surgical diagnosis. BIA measured variables indicated post-operative overhydration in 36% of the patients, increasing to 50% on the 5th post-operative day, coinciding with a progressive increase of preload dependency, from 12% immediately post-operatively to 58% on the 5th post-operative day and irrespective of surgical diagnosis. Patients with overhydration were less haemodynamically stable than those with normo- or dehydration.ConclusionDespite increased fluid balance and extracellular volumes, preload dependency increased progressively during the post-operative period. Our observations indicate a post-operative physiological incoherence between changes in the extracellular volume compartment and inadequate physiological preload control in patients undergoing AHA surgery. Considering the increasing overhydration during the observational period, our findings show that an indiscriminate correction of preload dependency with intravenous fluid bolus could lead to overhydration.Trial registration clinicaltrials.gov. (NCT03997721), Registered 23 May 2019, first participant enrolled 01 June 2019.

Laparoscopic Cholecystectomy after Acute Biliary Pancreatitis in a Patient with Situs Inversus Totalis.

Situs inversus totalis (SIT) is a rare disorder defined as symmetrical transposition of thoracic and abdominal organs. Laparoscopic cholecystectomy (LC) is a routine surgical operation and gold standard for symptomatic gallstones. LC can be challenging in SIT due to patient positioning on the operating table and the surgeon's operating position, especially for right-handed surgeons. In this case, we share our experience of a 60-year male with a history of SIT presenting with acute epigastric pain. Serum amylase and lipase were increased and imaging studies showed multiple millimetric calculi in gallbladder. The patient was diagnosed as having acute biliary pancreatitis and admitted to the surgery ward. Intravenous fluids and symptomatic treatment were given. The patient recovered and a delayed LC was planned. During the operation, trocar sites were mirror images of routine LC and the operation was completed without complications. Diagnosis of acute abdominal pain and abdominal surgery in SIT patients can be demanding. Various transformations in standard LC are possible and SIT is not a contraindication for LC Key Words: Laparoscopy, Cholecystectomy, Situs inversus totalis, Pancreatitis, Gallbladder.

Validation of Two Activity Monitors in Slow and Fast Walking Hospitalized Patients.

To evaluate interventions to promote physical activity, valid outcome measures are important. This study evaluated the validity and reliability of the ActivPAL3™ and the SENS motion® activity monitors with regard to the number of steps taken, walking, and sedentary behavior in hospitalized patients (n = 36) (older medical patients (+65 years) (n = 12), older patients (+65) with acute hip fracture (n = 12), and patients (+18) who underwent acute high-risk abdominal surgery (n = 12)). Both monitors showed good (≥60%) percentage agreement with direct observation for standing and no. of steps (all gait speeds) and high agreement (≥80%) for lying. For walking, ActivPAL3™ showed moderate percentage agreement, whereas SENS motion® reached high percentage agreement. The relative reliability was moderate for sedentary behavior for both monitors. The ActivPAL3™ showed poor (walking) to moderate (steps) reliability for walking and steps, whereas SENS motion® showed moderate reliability for both activities. For slow walkers, the relative reliability was moderate for SENS motion® and poor for ActivPAL3™. This trial is registered with the ClinicalTrials.gov identifier NCT04120740.