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Background: The reported incidence of postoperative nausea and vomiting (PONV) after laparoscopic bariatric surgery is up to 60–80%. Hower, studies are limited, and larger studies are warranted. As PONV is usually evaluated in the post-anesthesia care unit (PACU), studying early PONV can be a valuable tool for exploring risk and associated factors for PONV.

Methods: Using prospectively collected data from the Swedish perioperative registry (SPOR) from 2016 to 2022, we explore the incidence and associated factors for early PONV after laparoscopic bariatric surgery. Laparoscopic gastric bypass and laparoscopic gastric sleeve procedures in adult patients (≥ 18 years) were included. The primary outcome was the incidence of PONV in the PACU. Secondary outcomes were factors associated with PONV, which were analyzed using a multivariate logistic regression model.

Results: In total, 14,098 procedures were identified in the registry during the study period, and 8426 unique patients from 32 hospitals in Sweden were included in the final study cohort. PONV in PACU was present in 36% (n = 3018) of patients. Factors associated with early PONV were female sex, age, moderate-severe pain, gastric sleeve procedures, duration in PACU, and hospital.

Conclusions: In this national register-based cohort study, one third of patients experienced early PONV in the PACU after laparoscopic bariatric surgery. Several risk factors were associated with increased occurrence of PONV, and there was variability among hospitals in the incidence of PONV.

Clinicaltrials.gov: NCT04433676

Purpose: The incidence of trocar site hernia (TSH) after bariatric surgery is unclear. This study aims to describe the cumulative incidence of ventral hernia surgery after laparoscopic bariatric surgery in total and by laparoscopic method (LRYGB; Roux-en-Y Gastric Bypass and LSG; Sleeve Gastrectomy).

Methods: This was a register based observational study on patients subjected to laparoscopic bariatric surgery (LRYGB or LSG) in Sweden 2009–2019. The Scandinavian Obesity Surgery Registry (SOReg) was linked to the Swedish National Patient Register (NPR) to obtain instances of ventral hernia surgery. Nearby codes were used as proxies for TSH surgery, since a specific procedure code for TSH surgery is lacking.

Results: In 64 124 patients, mean follow-up was 67 ± 36 months, LRYGB (n = 52 020) 74 ± 34 months and LSG (n = 12 104) 34 ± 22 months. Mean time between bariatric- and ventral hernia surgery was 36 ± 28 months (range 0–129). The five-year cumulative incidence of surgery for ventral hernia was 2.9% (CI 2.8–3.1). The probability of having hernia surgery was significantly higher for LRYGB compared to LSG (Breslow test, p < 0.001), still significant with differences in follow-up time accounted for (p < 0.001).

Conclusion: The incidence of surgery for ventral hernia after laparoscopic bariatric surgery is not negligible in this material covering over a decade of bariatric procedures. Ventral hernia surgery was more common after gastric bypass than after sleeve gastrectomy.

Introduction: As one of the most commonly performed surgeries in the world, safety during laparoscopic cholecystectomy (LC) is of utmost importance. Indocyanine green (ICG) has been used for different medical purposes including assessment of liver function since the 1950s. Its use during LC was first described in 2009 by Ishizawa. Since ICG is excreted in the bile, its fluorescent properties can be used to illuminate the bile ducts, and may reduce the risk for bile duct injury and other complications. Previous studies have compared ICG with conventional visualization showing shorter operation time and lower conversion rates during LC performed with traditional operation techniques. Results from LC performed with the Fundus First method (FF-LC) and ICG fluorescence has not been previously reported. The aim of this retrospective study was to compare LC with and without the aid of ICG fluorescence at a Swedish hospital routinely performing FF-LC.

Methods: Data from all patients operated with LC at Sundsvall General Hospital before and after the implementation of routine ICG between 2016 and 2023 were analyzed.

Results: The study included 2,009 patients; 1,455 operated with ICG (ICG-group) and 549 without (comparison group). FF-LC was used in 94.9% of all operations. The groups were comparable regarding gender, BMI, age, presence of acute cholecystitis and proportion urgent/elective surgery. ICG was found to be safe, with similar 30-day complication rates between study groups. A lower conversion rate was seen in the ICG-group (1.2% vs. 3.3%, p = 0.001) and there was a non-significant reduction in readmissions (p = 0.054). In univariate analysis, ICG was associated with prolonged operation time, but this was not supported in multivariate analysis. Time to cholangiography was prolonged in the ICG-group in both univariate and multivariate analyses.

Discussion: ICG fluorescence is an adjunct that could improve the operative safety. Implementation of routine ICG fluorescence at this Swedish hospital was found to be safe and efficient, suggesting improvement in safety during FF-LC. Further studies are needed to see if ICG increases safety in LC.

Background: Incisional hernia (IH) is common and recurrence rates remain high. Although the goal of treatment should be to improve quality of life, studies addressing this aspect are notably absent. We aimed to evaluate the long-term recurrence rate of open mesh repair of IH, investigate the burden of persisting discomfort, explore patient satisfaction, and identify risk factors for negative outcomes.

Methods: A single-center, retrospective study was conducted on all open mesh repairs of IH performed between January 2002 and October 2013. Clinical data were gathered from medical records and operative reports, while patient-reported outcome measures (PROMs) were obtained through telephone interviews. Risk factors for recurrence were assessed by survival analysis. PROMs were analyzed across patient subgroups by clinical and demographic variables.

Results: This study included 271 patients undergoing medical record review, with 136 patients completing the telephone interview. Recurrence rates at 2, 5, 10, and 15 years were 6%, 8%, 11%, and 12%, respectively. Risk factors for recurrence were obesity and an estimated mesh-defect overlap <7 cm. Bridged repair posed no increased risk. For PROMs, the median follow-up time was 13.6 years after which 78.7% of the patients reported no discomfort, and 89.0% were satisfied with their surgery. Patients <65 years and females experienced more long-term discomfort.

Conclusions: Recurrence rates were higher in obese patients and when the estimated mesh-defect overlap was <7 cm, but not in bridged repairs. Young patients and females are at increased risk for long-term discomfort. High satisfaction levels were reported.

Background: An alternative method to standard laparoscopic cholecystectomy (SLC) is the “fundus first” method (FFLC). Concerns have been raised that FFLC can lead to misinterpretation of important anatomical structures, thus causing complications of a more serious kind than SLC. Comparisons between the methods are complicated by the fact that FFLC is often used as a rescue procedure in complicated cases. To avoid confounding related to this we conducted a population-based study with comparisons on the surgeon level.

Method: In GallRiks, the Swedish registry for Gallbladder surgery, we stratified all cholecystectomies performed 2006–2020 in three groups: surgeries carried out by surgeons that uses FFLC in <20 % of the cases (N = 150,119), in 20–79 % of the cases (N = 10,212) and in 80 % or more of the cases (N = 3176). We compared the groups with logistic regression, adjusting for sex, age, surgical experience, year of surgery and history of acute cholecystitis. All surgical complications (bleeding, gallbladder perforation, visceral perforation, infection, and bile duct injury) were included as outcome. A separate analysis was done with regards to operation time.

Results: No difference in incidence of all surgical complications or bile duct injury were seen between groups. The rates of bleeding (OR 0.34 [0.14–0.86]) and gallbladder perforation (OR 0.61 [0.45–0.82]) were significantly lower in the “fundus first > 80% group” and the operative time was shorter (OR 0.76 [0.69–0.83]).

Conclusion: In this study including >160,000 cholecystectomies, both methods was found to be equally safe.

Key message: During laparoscopic cholecystectomy, the standard method of dissection and fundus first dissection are equally safe surgical techniques. Surgeons need to learn both methods to be able to use the one most appropriate for each individual case.

BACKGROUND: Laparoscopic cholecystectomy with ultrasonic dissection presents a compelling alternative to conventional electrocautery. The evidence for elective cholecystectomy supports the adoption of ultrasonic dissection, citing advantages such as reduced operating time, diminished bleeding, shorter hospital stays and decreased postoperative pain and nausea. However, the efficacy of this procedure in emergency surgery and patients diagnosed with acute cholecystitis remains uncertain. The aim of this study was to compare outcomes of electrocautery and ultrasonic dissection in patients with acute cholecystitis.

METHODS: A randomized, parallel, double-blinded, multicentre controlled trial was conducted across eight Swedish hospitals. Eligible participants were individuals aged ≥ 18 years with acute cholecystitis lasting ≤ 7 days. Laparoscopic cholecystectomy was performed in the emergency setting as soon as local circumstances permitted. Random allocation to electrocautery or ultrasonic dissection was performed in a 1:1 ratio. The primary endpoint was the total complication rate, analysed using an intention-to-treat approach. The primary outcome was analysed using logistic generalized estimated equations. Patients, postoperative caregivers, and follow-up personnel were blinded to group assignment.

RESULTS: From September 2019 to March 2023, 300 patients were enrolled and randomly assigned to electrocautery dissection (n = 148) and ultrasonic dissection (n = 152). No significant difference in complication rate was observed between the groups (risk difference [RD] 1.6%, 95% confidence interval [CI], - 7.2% to 10.4%, P = 0.720). No significant disparities in operating time, conversion rate, hospital stay or readmission rates between the groups were noted. Haemostatic agents were more frequently used in electrocautery dissection (RD 10.6%, 95% CI, 1.3% to 19.8%, P = 0.025).

CONCLUSIONS: Ultrasonic dissection and electrocautery dissection demonstrate comparable risks for complications in emergency surgery for patients with acute cholecystitis. Ultrasonic dissection is a viable alternative to electrocautery dissection or can be used as a complementary method in laparoscopic cholecystectomy for acute cholecystitis.

TRIAL REGISTRATION: The trial was registered prior to conducting the research on  http://clinical.trials.gov, NCT03014817.

BACKGROUND: Surgical safety and patient-related outcomes are important considerations when introducing new surgical techniques. Studies about the learning curves for different surgical procedures are sparse. The aim of this observational study was to evaluate the learning curve for ultrasonic fundus-first (FF) dissection in elective laparoscopic cholecystectomy (LC).

METHODS: The study was conducted at eight hospitals in Sweden between 2017 and 2019. The primary endpoint was dissection time, with secondary endpoints being intra- and postoperative complication rates and the surgeon's self-assessed performance level. Participating surgeons (n = 16) were residents or specialists who performed LC individually but who had no previous experience in ultrasonic FF dissection. Each surgeon performed fifteen procedures. Video recordings from five of the procedures were analysed by two external surgeons. Patient characteristics and data on complications were retrieved from the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks).

RESULTS: Dissection time decreased as experience increased (p = 0.001). Surgeons with limited experience showed more rapid progress. The overall complication rate was 14 (5.8%), including 3 (1.3%) potentially technique-related complications. Video assessment scores showed no correlation with the number of procedures performed. The self-assessed performance level was rated lower when the operation was more complicated (p < 0.001).

CONCLUSIONS: Our results show that dissection time decreased with increasing experience. Most surgeons identified both favourable and unfavourable aspects of the ultrasonic FF technique. The ultrasonic device is considered well suited for gallbladder surgery, but most participating surgeons preferred to dissect the gallbladder the traditional way, beginning in the triangle of Calot. Nevertheless, LC with ultrasonic FF dissection can be considered easy to learn with a low complication rate during the initial learning curve, for both residents and specialists.

Background: Laparoscopy is common in abdominal surgery. Trocar site hernia (TSH) is a most likely underestimated complication. Among risk factors, obesity, the use of larger trocars and the umbilical trocar site has been described. In a previous study, CT scan in the prone position was found to be a reliable method for the detection of TSH following gastric bypass (LRYGB). In the present study, our aim was to examine the incidence of TSH after gastric sleeve, and further to investigate the proportion of symptomatic trocar site hernias.

Methods: Seventy-nine patients subjected to laparoscopic gastric sleeve in 2011–2016 were examined using CT in the prone position upon a ring. Symptoms of TSH were assessed using a digital survey.

Results: The incidence of trocar site hernia was 17 out of 79 (21.5%), all at the umbilical trocar site. The mean follow-up time was 37 months. There was no significant correlation between patient symptoms and a TSH.

Conclusions: The incidence of TSH is high after laparoscopic gastric sleeve, a finding in line with several recent studies as well as with our first trial on trocar site hernia after LRYGB. Up to follow-up, none of the patients had been subjected to hernia repair. Although the consequence of a trocar site hernia can be serious, the proportion of symptomatic TSH needs to be more clarified.

Introduction: Surgical site infection (SSI) is one of the most common healthcare-associated infections (HAIs). However, there is a lack of data available about SSI in children worldwide, especially from low-income and middle-income countries. This study aimed to estimate the incidence of SSI in children and associations between SSI and morbidity across human development settings.

Methods: A multicentre, international, prospective, validated cohort study of children aged under 16 years undergoing clean-contaminated, contaminated or dirty gastrointestinal surgery. Any hospital in the world providing paediatric surgery was eligible to contribute data between January and July 2016. The primary outcome was the incidence of SSI by 30 days. Relationships between explanatory variables and SSI were examined using multilevel logistic regression. Countries were stratified into high development, middle development and low development groups using the United Nations Human Development Index (HDI).

Results: Of 1159 children across 181 hospitals in 51 countries, 523 (45·1%) children were from high HDI, 397 (34·2%) from middle HDI and 239 (20·6%) from low HDI countries. The 30-day SSI rate was 6.3% (33/523) in high HDI, 12·8% (51/397) in middle HDI and 24·7% (59/239) in low HDI countries. SSI was associated with higher incidence of 30-day mortality, intervention, organ-space infection and other HAIs, with the highest rates seen in low HDI countries. Median length of stay in patients who had an SSI was longer (7.0 days), compared with 3.0 days in patients who did not have an SSI. Use of laparoscopy was associated with significantly lower SSI rates, even after accounting for HDI.

Conclusion: The odds of SSI in children is nearly four times greater in low HDI compared with high HDI countries. Policies to reduce SSI should be prioritised as part of the wider global agenda.

Introduction: Laparoscopic cholecystectomy (LC) is a commonly performed surgical procedure with a low complication rate. It is performed either as an acute or as an elective procedure. Most elective LCs are performed on nonlethal diseases and this is why good quality is important. Our study compared the quality of LC in two surgical units in northern Sweden (Sundsvall and ostersund) which use different clinical structures (subspecialised vs. general surgery) and surgical techniques (ultrasound fundus first vs. conventional diathermy). The study aimed to investigate whether these differences affected the quality of outcomes after LC.

Materials and methods: This is a registry-based study which included 607 elective LCs from January 2014 to May 2016. There were 286 from Sundsvall and 321 from ostersund. Primary outcomes were operative time and the percentage of day surgeries. The secondary outcome was the presence of postoperative complications within the first 30 days in terms of bile duct injury, bleeding that necessitated reoperation, bile leakage and abscesses treated with drainage and mortality.

Results: The time length of surgery was shorter in Sundsvall (mean 48.3 min) compared to ostersund (mean 108.6 min, p < 0.001. The percentage of day care surgeries was 94% in Sundsvall and 23% in ostersund, p < 0.001. Six patients (2.1%) had a complication in Sundsvall compared to seven patients (2.2%) in ostersund, p = 1.00.

Conclusion: There is a significant difference between the two hospitals regarding operative time and the percentage of day surgeries. Complication rates in both units were equal and low.