Surgical Theatre Research Articles

Audit of oral neoplasms in children and young adults in Nigeria

BackgroundOrofacial neoplasms in children and young adults may differ significantly from those observed in adults. Our aim was to describe the epidemiological characteristics of histologically diagnosed orofacial neoplasms among children and young adults in Nigeria.MethodsThis was a multicenter cross-sectional study across geopolitical zones in Nigeria. Annual reports of clinical information and surgical biopsies submitted at the Oral Pathology Laboratory, clinic day registries, surgical day case registries and operative theatre registries were retrieved from January 2008 to March 2024. The relevant demographic data were obtained for each patient. The study subjects were categorized by age into children, adolescents and young adults. Tissue involvement was classified as soft tissue involvement, bony involvement or both soft tissue and bony involvement. The site and behaviour of the lesions were subdivided according to the ICD-10 codes. Statistical analysis was performed via the R programming language.ResultsA total of 1889 cases were observed during the period under review, with a mean age of 15 years. Cases were more common in females (52%) and in young adults (47%). Most cases were benign neoplasms (85%), and bony affectation (54%) was slightly predominant. Odontogenic tumours (38%) and fibro-osseous lesions (20%) were the most common category of lesions observed, whereas salivary gland tumours (2.2%) and neoplasms of epithelial origin (2.5%) were the least common. Neoplasms in children involved mostly soft tissues, whereas those in adolescents and young adults had a preference for bone (p < 0.001). In all age groups, benign lesions were mostly observed in the mouth and pharynx. For malignant lesions, in children, the bones of the skull and face were mostly involved, whereas in adolescents, the mandible was the predominant site (p < 0.001). In children, mesenchymal neoplasms were the most prevalent category of lesions, whereas in both adolescents and young adults, odontogenic tumours were more common. The proportion of malignant neoplasms in males was significantly greater than that in females (p < 0.001).ConclusionThis study revealed that although most biopsied orofacial lesions were more often benign, the proportion of malignant neoplasms in this population was greater than that previously reported.

Kinematic analysis of engagement and bending capabilities of a point-of-care, incremental skeletal fixation plate bending system

The current standard of care for skeletal reconstruction surgery is to join skeletal disunions with fixation plates and these plates are most commonly fit to bones through manual bending. The bending procedure is often performed in the surgical operating theatre with specialized pliers or, if available, lengthy pre-operative bending to fit a 3D printed skeletal model prepared on computer as part of a virtual surgical plan. Manual bending of fixation plates by eye or to a model can take considerable time. Repetitive bending at a single location can result in work hardening that increases the subsequent risk of fatigue failure. However, incremental forming systems may provide a solution to automatically bend fixation plates accurately, rapidly, and as little at any one location as possible. This paper is an investigation of the kinematics and manipulability of two versions of an incremental fixture plate bending system for Point of Care Manufacturing (POCM) of craniomaxillofacial (CMF) skeletal fixation hardware. The Automatic Plate Bender (APB) v1 is a minimal POCM system that is designed for simple straight plates with a constant incremental pitch. The APB v2 is a more complex POCM that is designed to accommodate a larger variety of standard plates. Kinematic and manipulability analysis demonstrate the engagement and bend classes that each system can accomplish, and identifies a critical singularity in the APB v2 mechanism. The paper concludes with two case studies in which a path planning algorithm uses a manipulability analysis to avoid singularities during incremental bending.

Autologous micrografting improves regeneration of tissue-engineered urinary conduits in vivo

Urogenital reconstructive malformation surgery is sometimes hampered by lack of tissue for the repair. We have previously shown that autologous micrografting allows for single-staged scaffold cellularization after surgical implantation. Here, a collagen-based scaffold reinforced with biodegradable mesh and a stent was implanted as a bladder conduit in ten full-grown female minipigs. We aimed to assess short-term regenerative outcomes, safety, and feasibility of implanting tubular urinary micrografted scaffolds versus acellular controls. Five scaffolds were embedded with autologous urothelial micrografts harvested perioperatively. After six weeks, all animals were assessed by cystoscopy, CT-urography, and microanatomical assessment of the urinary conduits. The procedure proved technically feasible within the confines of a regular surgical theater, with duration-times comparable to corresponding conventional procedures. No animals experienced postoperative complications, and all implanted conduits were patent at follow-up. Improved tissue regeneration was observed in the micrografted conduits compared with the acellular controls, including increased luminal epithelialization, increased cell proliferation, decreased cell apoptosis, and increased conduit vascularization. We concluded that single-staged on-site construction and implantation of tissue engineered urinary conduits proved feasible and safe, with improved regenerative potentials in micrografted conduits. This study presents a new approach to urinary conduits, and merits further investigations for advancement towards clinical translation.

Observations from the first 100 cases of intraoperative MRI – experiences, trends and short-term outcomes

BackgroundWe sought to analyze, in well-defined clinical setting, the first 100 patients treated at the intraoperative MRI (iMRI) hybrid surgical theatre at our facility in a population-based setting to evaluate which pathologies are best approached with iMRI assisted surgeries, as this is not yet clearly defined.MethodsPatients undergoing surgery in the 3T iMRI hybrid surgical theatre at our neurosurgical department between December 2017 to May 2021 were included after informed consent. Demographic, clinical, surgical, histological, radiological and outcome parameters, as well as variables related to iMRI, were retrospectively collected and analyzed. Patients were subdivided into adult and pediatric cohorts.ResultsVarious neurosurgical procedures were performed; resection of tumors and epileptic foci, endoscopic skull base procedures including pituitary lesions, deep brain stimulation (DBS) and laser interstitial thermal therapy (LITT). In total, 41 patients were pediatric. An iMRI scan was carried out in 96% of cases and led to continuation of surgery in 50% of cases, mainly due to visualized remaining pathological tissue (95.2%). Median time to iMRI from intubation was 280 min and median total duration of surgery was 445 min. The majority of patients experienced no postoperative complications (70%), 13 patients suffered permanent postoperative deficits, predominantly visual.ConclusionHerein, we demonstrate the first 100 patients undergoing neurosurgery aided by iMRI at our facility since introduction. Indications for surgery differed between pediatric and adult patients. The iMRI was utilized for tumor surgeries, particularly adult low-grade gliomas and pediatric tumors, as well as for epilepsy surgery and DBS. In this heterogenous population, iMRI led to continuation of surgery in 50%. To establish the benefit in maximizing the extent of resection in these brain pathologies future studies are recommended.Clinical trial numberNot applicable.

SP1.9 - Management of cutaneous abscesses and infected sebaceous cysts using inhaled methoxyflurane Penthrox®: a 12 month prospective observational study

Abstract Aims Incision and drainage of abscesses contribute a significant burden upon emergency general surgical theatres. The purpose of this study was to look at the safety and effectiveness of incision and drainage using inhaled methoxyflurane (Penthrox®) to reduce reliance upon surgical theatres and provide an effective alternative to local anaesthetic. Methods After a successful pilot of 20 patients, adults with ‘simple’ abscesses were enrolled over a 12-month period and given inhaled methoxyflurane for ward-based incision and drainage. Pilonidal and perianal abscesses, patients with ASA ≥3 and abscesses greater than 5cm in size were excluded. Length of admission and outcomes at 1 week, 1 month and 3 months post procedure were compared to previously audited data on simple abscess drainage in theatre to determine safety, efficacy and cost-savings. Results 130 patients had an abscess drained using Penthrox® inhaled analgesia. 93.8% (122/130) had successful drainage with a mean admission time of 99 minutes. Eight patients reattended for further treatment (3&amp;lt;3 months, 3&amp;lt;1 month and 2&amp;lt;1 week); two patients required antibiotics and five required further drainage. Patients taken to theatre spent on average 34.5 hours in hospital compared to 1.65 hours for those performed using Penthrox®. A patient feedback tool captured very positive comments with no negative experiences recorded. Conclusion Penthrox® is a safe, effective analgesic for the incision and drainage of simple abscesses and patient experience is overwhelmingly positive. In addition, it significantly reduces the burden on emergency theatres and the hospital bed-base with an estimated minimum saving of £1704 per patient.

FP8.3 - Reducing Waste with Remanufactured Harmonic Devices

Abstract The NHS produces an estimated 590,000 tonnes of waste per annum and disposable harmonic scalpels are costly both financially and environmentally. The average cost of a new harmonic device nationally is £460. Remanufactured harmonic devices are not only recommended by the Intercollegiate Green Theatre Checklist and NHS England but also the Department of Health Med Tech Strategy. North Bristol NHS Trust has engaged with the initiative from Vanguard to reduce clinical waste as well as utilise remanufactured harmonic devices. Initially the project began in January 2023 with collecting used devices only, but this was followed by the rollout and use of remanufactured devices within colorectal surgery in May 2023. The initiative has resulted in a reduction of clinical waste produced as well as a significant cost saving. 56 devices used so far in colorectal surgery have saved £12,880 and the estimated CO2 saving is 97 kilograms. There have been no incidents regarding the use of remanufactured devices or concerns raised. The project’s success has resulted in recent expansion into gynaecological surgery where the first remanufactured devices are in use. Based on previous harmonic device usage within NBT of 618 per annum, projected savings of using remanufactured devices are likely to reach £71,070 and half a tonne of CO2 in the next year. This represents a significant financial and environmental initiative to continue the drive to reduce disposable waste within surgical theatres.

WP5.3 - Rejuvenating the golden patient protocol in a tertiary centre general surgical emergency theatre

Abstract Aims Poor patient flow and complex sub-specialty decision making discussions lengthened time to operation of lower priority operations e.g. appendicectomy/abscesses. By prioritising start times and registrar patient selection for low complexity cases/day case discharge, we rejuvenated the golden patient protocol (GPP) and assessed the implementation and impact of a novel GPP in a tertiary centre emergency list on surgical wait times and overall theatre flow. Methods The GPP was agreed between surgical/anaesthetic night registrars and theatre staff which took into consideration the urgency of the surgery, fitness of patient and anaesthetic/technical difficulties. Eligible patients were identified prior to 08:00 and scheduled as the first case of the day to be huddled and sent for by 08:30. Two cycles were conducted, one month before and after GPP introduction, using the trust theatre management system (TMIS). Results Time series analysis was conducted for patient sent-for, anaesthetic room entry, and procedure start times during both cycles. Results indicated a median decrease of 11-minutes in patient sent-for time (Cycle 1: 08:56, Cycle 2: 08:45) and a 12-minute reduction in median procedure start time (Cycle 1: 09:42, Cycle 2: 09:30). The proportion of low complexity cases performed first-on-list also increased by 22.5% (Cycle 1: 35.5%, Cycle 2: 58.0%). Conclusions This analysis demonstrates a positive change by starting theatre faster with lower complexity cases, developing surgical registrar independence, improving time to treatment without complex discussions delaying first send.

Performance of an Autonomous Sanitary Sterilisation Ultraviolet Machine (ASSUM) on terminal disinfection of surgical theaters and rooms of an intensive-intermediate care unit

Ultraviolet- C (UV-C) light is effective for reducing environmental bioburden in hospitals, and the use of robots to deliver it may be advantageous. To evaluate the feasibility and clinical efficacy of an autonomous programmable UV-C robot in surgical and intensive care unit (ICU) rooms of a tertiary hospital. During ten consecutive months, the device was used in six theatres where cardiac, colorectal and orthopaedic surgeries were performed, and in the rooms previously occupied by patients subjected to contact precautions of a 14-bed ICU. Surgical site infection (SSI) rates of procedures performed in the UV-cleaned theatres were compared with those of the previous year. Incidence in clinical samples of ICU-acquired multiple-drug resistant (MDR) microorganisms was compared with that of the same period of the previous year. An UV-C exposure study done by semi-quantitative dosimeters and a survey of the bioburden on surfaces were carried out. SSI rates in the pre- and post-intervention periods were 8.67% (80/922) and 7.5% (61/813), respectively (p=0.37). Incidence of target microorganisms in clinical samples remained unchanged (38.4 vs. 39.4 per 10,000 patient-days, p=0.94). All the dosimeters exposed to ≤1 meter received ≥500 mJ/cm2. The bacterial load on surfaces decreased after the intervention, particularly in ICU rooms (from 4.57±7.4 CFU to 0.27±0.8 CFU, p<0.0001). Deployment of an UV-C robot in surgical and ICU rooms is feasible, ensures adequate delivery of germicidal UV-C light and reduces the environmental bacterial burden. Rates of surgical site infections or acquisition of MDR in clinical samples of critically-ill patients remained unchanged.

578 Optimising Emergency Theatre Efficiency with the Use of a Pre-Anaesthetic Holding Bay, a Quality Improvement Project

Abstract Aim An efficient emergency theatre depends on the coordination of multiple surgical specialties, anaesthetists, and theatre staff. The serial nature of an operating list leads to downtime between cases. We sought to reduce delays between emergency cases by implementing a pre-anaesthetic holding bay. Method Anonymised data was collected from a prospectively maintained mandatory database of theatre activity. Exclusion criteria were non-surgical procedures, first case, out-of-hours procedures, and critical care admissions. Suitability was determined from a period pre-implementation and a pre-defined trial period to ensure safe rollout. Pre-, trial, and post-implementation were compared. Results 349 emergency procedures were performed in three months post-implementation. After exclusion criteria 110 were suitable for pre-anaesthetic holding bay use, and in 35 (31.8%) it was utilised. Most cases were general surgery (61%), vascular surgery (15%), and gynaecology (12%). Holding bay use decreased time without a patient in the anaesthetic room from 50 to 5 minutes (p&amp;lt;.001) and the time between procedures from 86 to 43 minutes (p&amp;lt;.001). There was no difference in anaesthetic time between the groups (36 vs 38 minutes, p=.40). Over the three months 40 more in-hours cases were completed in 48 days with no difference in procedures across the periods. Conclusions Pre-anaesthetic holding bay use reduced theatre downtime by 90%, allowing more procedures to be performed in-hours. All specialties engaged with the holding bay but to varying extent, and ensuring investment from surgeons, anaesthetists, and theatre staff is essential. This intervention, implemented with no extra resources, has increased efficiency and improved safety in the emergency theatre list.

728 Laparoscopic Fundoplication as a Day Case Procedure - Patient Comprehension for a Successful Model

Abstract Aim The British Association of Day Surgery states that elective laparoscopic Nissen’s fundoplication procedures should be performed as a day case in 40% of patients. The purpose of the study was to design a model for laparoscopic fundoplication to increase the numbers done as a day case procedure. Method This was a retrospective study of all patients who underwent laparoscopic fundoplication from 2014 - 2019. We introduced patient information leaflets and awareness amongst the patients regarding the procedure following our initial audit in 2014. Further intervention in terms of the surgical team and theatre staff awareness to reach our goal by distributing surgery-oriented pamphlets and information. We re-audited to see if there were any improvements in 2016 and 2019 when compared to our previous cohort. A total of 104 patients were audited through the years. Results In 2019, 34.4 % patients regardless of hiatus hernia size were discharged on the same day; 48.2 % patients were discharged on the next day; 24.1% patients had a large hiatus hernia or gastric volvulus; 40.9% patients excluding large and complicated hiatus hernia were discharged on the same day; 75.8 % patients had intraoperative local anaesthetic inject at the operative field. Conclusions The main two factors which contributed to improvement of our results were Intraoperative injection of local anaesthetic medications to operative field and Patient information pamphlets. Also, when a patient is made aware of the procedure being a day case in advance, they are more prepared to return home the same day following the procedure.

Implementing an Internal Audit: Evaluating Hand Scrub Compliance in a Tertiary Care Hospital.

Background Aseptic protocol adherence and sterilization are the most important factors in a patient's satisfactory recovery after surgery. The standard hand scrubbing procedure helps control infection and keeps the surgical site clean by adhering to aseptic principles. Methods Thirty-six young residents and house officers participated in this prospective audit after ethical clearance was obtained. The World Health Organization (WHO) standard criteria were adhered to both before and after the intervention. Participants were observed in the surgical operation theatre (OT) without prior notice to ensure hand hygiene compliance before surgical procedures. The intervention included a video presentation as well as a live demonstration. Results Only 64.41% (n=23) of residents and house officers followed the recommended standard hand hygiene procedures before the intervention. This percentage rose to 93.92% (n=33) following the intervention, suggesting a noteworthy improvement. Conclusion Significant changes in the acceptance rates for the essential requirements of hand hygiene were observed after the evaluation in the second cycle. Adhering to WHO guidelines for procedures will help reduce the risk of infections and promote awareness of asepsis in practice.

SURG-03. VIRTUAL REALITY ASSISTANCE IN THE MANAGEMENT OF PEDIATRIC BRAIN TUMORS

Abstract BACKGROUND Virtual reality (VR) solutions are emerging as a useful adjunct to the armamentarium of the neurosurgeon. Surprisingly, little data is available in the literature regarding its utility in pediatric neurosurgical oncology. We hereby report our preliminary Institutional experience on the application of VR to surgical rehearsal in a series of pediatric brain tumors. METHODS Virtual models were obtained by the Surgical Planner (Surgical Theatre, Inc) in a series of 50 consecutive brain tumor cases treated at Bambino Gesù Children’s Hospital. Utility of VR was scored based on operators’ perception. Explored items included: planning, execution, resection, sparing of eloquent tissue, and overall surgical management. Scoring was performed using a customized Likert scale. RESULTS We prospectively collected 100 consecutive questionnaires from surgeons participating to brain tumor resection procedures. In a multivariate analysis VR was found to be significantly more beneficial in specific surgical settings. Leading surgeons (LS) judged VR significantly more useful in supratentorial tumors, in children younger than 10 years, and in planned partial resections. Assistant surgeons (AS) found VR more useful in supratentorial lesions, particularly in deep seated tumors. Both LS and AS perceived VR to be less useful for in embryonal tumors and epilepsy-associated gliomas (LEAT). CONCLUSIONS Our data suggest that VR technology is useful in the surgical management of children with brain tumors. There might be specific clinical scenarios in which the advantage of VR availability might have a significant clinical impact in planning and performing surgical resection.

Minimally Invasive Approaches in Reoperations after Conventional Craniotomies : Case Series.

Reoperations are part of neurosurgical practice. In these cases, an already formed craniotomy seems the most logical and appropriate. However, reoperations via large approaches can be quite traumatic for the patient. Then minimally invasive approaches, being less traumatic, can be a good alternative. We describe 7 consecutive patients who underwent reoperations using minimally invasive approaches in the areas of conventional craniotomies. Surgical Theater® visualization platform was used for preoperative planning. The study evaluated the size of surgical approach, surgical efficacy, and the presence of complications. The size of a minimally invasive craniotomy was significantly smaller than that of a conventional approach. The preoperative goals were achieved in all described cases. There were no complications in the early postoperative period. Although the anatomy of the operated brain region in reoperations is altered, keyhole approaches can be successfully used with the support of preoperative planning and intraoperative neuronavigation. Given that the goals of reoperations may differ from those of the primary surgery, and a large approach is more traumatic for the patient, minimally invasive craniotomy can be considered as a good alternative. The successful use of minimally invasive approaches in areas of conventional craniotomies reinforces the philosophy of keyhole neurosurgery. In cases where goals can be achieved using small approaches, it makes no sense to use large conventional ones. Minimally invasive approaches can be successfully used during reoperations in patients after conventional craniotomies.

A Quantitative Analysis of Intraoperative Distractions and When They Occur During General Surgical Operations.

Introduction Distractions in operating theatres prevent team members from concentrating on the complex tasks required for a successful operation. This can be a potential hazard to care for, and previously, correlations have been made between increased theatre distractions and adverse events. However, it remains unclear how frequently such events occur during routine care in theatres. The present study aims to quantify distractions and analyse any differences between staff groups, operative stages, and modes of operation. Methods A single-centre prospective study was conducted to assess disruptions in general surgical theatres. Events were recorded using a previously described categorization system on a proforma by a single researcher. The source and severity of distraction were recorded, as well as the mode of operation (elective/emergency), stage of operation, and staff team (scrubbed/floor). Results A total of 4,219 minutes of surgery were observed over four weeks, and 1,095 distraction events were recorded. Of the 14 elective and nine emergency procedures recorded, there was a mean of 54.8 distractions per procedure and a frequency of one distraction every three minutes and 51 seconds (15.6 hr-1). Irrelevant communication relating to the patient's case was the most common source, accounting for 24.7% of all distractions. The most frequently disrupted stage of the procedure for scrubbed staff was during anastomosis/resection for both elective and emergency procedures, with 16.9 and 32.6 distractions occurring per hour, respectively. Scrubbed staff were significantly more susceptible to distraction in emergency procedures than the floor staff. Discussion Our study reflects previous assessments with irrelevant communications and emergency procedures yielding the highest prevalence of distraction. This investigation provides novel information about the different stages of general surgery and the frequency of distractions that occur.

Improving Environmental Sustainability of Operating Theatres: A Systematic Review of Staff Attitudes, Barriers, and Enablers.

To understand views of staff in relation to attitudes, enablers, and barriers to implementation of environmentally sustainable surgery in operating theatres. This will ultimately help in the goal of successfully implementing more sustainable theatres. Global healthcare sectors are responsible for 4.4% of greenhouse gas emissions. Surgical operating theatres are resource intensive areas and improvements will be important to meet Net-Zero carbon emissions within healthcare. Three databases were searched (Web of Science, Ovid and PubMed), last check January 2024. We included original manuscripts evaluating staff views regarding sustainable operating theatres. The Mixed Methods Appraisal Tool was used for quality appraisal and data analysed using thematic synthesis. 2933 articles were screened and 14 fulfilled inclusion criteria, using qualitative (1), quantitative (2), and mixed methods (11). Studies were undertaken in a variety of clinical (Department of Anaesthesia, Surgery, Otolaryngology, Obstetrics & Gynaecology and Ophthalmology) and geographical settings (Australia, Canada, France, Germany, New Zealand, USA, UK & Ireland,). Across studies there was a lack of evidence exploring enablers to implementation, but barriers mainly related to the following themes: education and awareness, leadership, resistance to change, facilities and equipment, time, and incentive. This systematic review identified attitudes and barriers perceived by clinicians towards improving environmental sustainability within operating theatres, which may inform future strategy towards sustainable surgery. Most studies used a survey-design, whereas use of interviews may provide deeper insights. Future work should be extended to wider stakeholders influencing operating theatres. Additionally, implementation studies should be carried out to examine whether barriers do change in practice. This systematic review identified attitudes and barriers perceived by clinicians towards improving environmental sustainability within operating theatres, which may inform future strategy towards sustainable surgery. Most studies used a survey-design, whereas use of interviews may provide deeper insights. Future work should be extended to wider stakeholders influencing operating theatres. Additionally, implementation studies should be carried out to examine whether barriers do change in practice.

Transurethral water vapour thermal therapy for benign prostatic hyperplasia under local anaesthesia alone: initial experience in Chinese patients.

This study evaluated the perioperative and early postoperative outcomes of transurethral water vapour thermal therapy (WVTT) under local anaesthesia alone for benign prostatic enlargement in Chinese patients. This retrospective review of transurethral WVTT for benign prostatic enlargement focused on 50 Chinese patients who exhibited clinical indications (acute retention of urine or symptomatic lower urinary tract symptoms due to benign prostatic enlargement) for surgical treatment between June 2020 and December 2021 in Hong Kong. Exclusion criteria included active urinary tract problems and urological malignancies. Follow-up was conducted at 3 months postoperatively. The median patient age was 71.5 years. The mean preoperative prostatic volume was 56.7 mL. The mean operation time was 25.1 minutes. All procedures were performed under local anaesthesia alone. The mean pain scores for transrectal ultrasound probe insertion, transperineal local anaesthesia injection, and transurethral WVTT were 2, 5, and 4, respectively. Forty-nine patients (98%) were discharged on the same day with a urethral catheter. Forty-eight patients (96%) successfully completed a trial without catheter within 3 weeks postoperatively. Five patients (10%) had unplanned hospital admission within 30 days postoperatively due to surgical complications (Clavien-Dindo grade 1). Transurethral WVTT, an advanced surgical treatment for benign prostatic enlargement, is a safe procedure that relieves lower urinary tract symptoms with minimal hospital stay. It can be performed in an office-based setting under local anaesthesia, maximising utilisation of the surgical theatre.

Extended Reality Head-Mounted Displays Are Likely to Pose a Significant Risk in Medical Settings While Current Classification Remains as Non-Critical.

Extended reality (XR) devices, including virtual and augmented reality head-mounted displays (HMDs), are increasingly utilised within healthcare to provide clinical interventions and education. Currently, XR devices are utilised to assist in reducing pain and improving psychological outcomes for immunocompromised patients in intensive care units, palliative care environments and surgical theatres. However, there is a paucity of research on the risks of infection from such devices in healthcare settings. Identify existing literature providing insights into the infection control risk XR HMDs pose within healthcare facilities and the efficacy of current infection control and cleaning procedures. Three databases (PubMed, Embase and CINAHL) in addition to Google Scholar were systematically searched. A total of seven studies were identified for this review. Microorganisms, including pathogenic bacteria (e.g., Staphylococcus aureus and Pseudomonas aeruginosa), were found to be present on XR HMDs. Published cleaning and infection control protocols designed to disinfect XR HMDs and protect users were heterogeneous in nature. Current cleaning protocols displayed varying levels of efficacy with microbial load affected by multiple factors, including time in use, number of users and XR HMD design features. In healthcare settings, fitting XR HMDs harbouring microorganisms near biological and mucosal entry points presents an infection control risk. An urgent revision of the Spaulding classification is required to ensure flexibility that allows for these devices to be reclassified from 'Non-critical' to 'Semi-Critical' depending on the healthcare setting and patient population (surgery, immunocompromised, burns, etc.). This review identified evidence supporting the presence of microorganisms on XR HMDs. Due to the potential for HMDs to contact mucosal entry points, devices must be re-considered within the Spaulding classification as 'Semi-critical'. The existence of microbial contaminated XR HMDs in high-risk medical settings such as operating wards, intensive care units, emergency departments, labour and delivery wards and clinical areas with immunosuppressed patients requires urgent attention. Public health authorities have a duty of care to develop revised guidelines or new recommendations to ensure efficient sanitation of such devices.

Evaluation of Patient's Safety Measures in ICU and Surgical Theatre in Hospitals in Menoufia Governorate, Egypt

Evaluation of Patient's Safety Measures in ICU and Surgical Theatre in Hospitals in Menoufia Governorate, Egypt

P230: The challenges of implementing early surgery for terminal ileal Crohn’s disease – a qualitative study of the clinician perspective

Abstract Background Recent evidence suggests that “early” bowel resection may offer more stable remission in terminal ileal (TI) Crohn’s disease compared to medical therapy. Surgery is still often considered late in the treatment pathway. The aims of this study were to understand how clinicians make decisions about treatment for TI Crohn's and to explore their views on the role of surgery. Methods Semi-structured interviews with clinicians across the UK, with an interest in inflammatory bowel disease (IBD), were undertaken using videoconferencing (February to November 2022). Inductive thematic analysis was performed and 10% of the data were double-coded. Data saturation was confirmed before stopping recruitment. Results Participants included 9 consultant surgeons, 7 consultant gastroenterologists and 7 specialist nurses (n=23) from secondary care and tertiary referral centres. Five key themes were identified: approach to management and decision-making, opinions on medical therapy, opinions on surgery, approach to information-giving, and patients’ preferences from a clinician perspective. Symptoms, disease phenotype, patient choice and the influence of the IBD multidisciplinary team were frequently discussed factors that guide management. Trial of multiple drugs before offering surgery was commonly described. A lack of IBD surgeons and long waiting lists for surgical clinics and theatre were cited as barriers to timely surgery. Patients' fear of surgery was thought to be driven by the risk of a stoma. Conclusion This study highlights key barriers to early surgery for TI disease. Early discussion of surgery may allow patients to make an informed choice. Organisational barriers should be considered when designing local services.

Cubital tunnel release with Wide Awake Local Anaesthesia No Tourniquet (WALANT) technique in an outpatient setting is safe and effective.

Ulnar nerve release is often performed under general anaesthesia. Wide Awake Local Anaesthesia No Tourniquet (WALANT) is a new anaesthetic method increasingly used by hand surgeons in an outpatient setting. It has advantages such as the possibility to shift surgical interventions out of the regular surgical theatre settings into an outpatient clinical setting, no risk of complications or side effects resulting from regional and general anesthesia and decreased costs. The use of WALANT has not been investigated extensively in elbow surgery. This study aims to evaluate clinical outcomes after ulnar nerve release under WALANT 27 patients with ulnar nerve release for cubital tunnel syndrome were included. The primary outcome was the presence of (remaining) symptoms after ulnar nerve release. Data was extracted from medical records. 13 out of 27 patients had (mild) remaining symptoms after ulnar nerve release, and 1 complication (superficial wound infection) was seen. Ulnar nerve release under WALANT is safe and effective in patients with primary ulnar nerve entrapment that have failed conservative therapy.