No abstract

Colorectal surgery has been revolutionised towards minimally invasive surgery with the emergence of enhanced recovery protocol after surgery initiatives. However, laparoscopic colectomy has yet to be widely adopted, due mainly to the steep learning curve. We aim to review and discuss the methods of overcoming these learning curves by accelerating the competency level of the trainees without compromising patient safety. To provide this mini review, we assessed 70 articles in PubMed that were found through a search comprised the keywords laparoscopic colectomy, minimal invasive colectomy, learning curve and surgical education. We found England’s Laparoscopic Colorectal National Training Programme (LAPCO-NTP) England to be by far the most structured programme established for colorectal surgeons, which involves preclinical and clinical phases that end with an assessment. For budding colorectal trainees, learning may be accelerated by simulator-based training to achieve laparoscopic dexterity coupled with an in-theatre proctorship by field experts. Task-specific checklists and video recordings are essential adjuncts to gauge progress and performance. As competency is established, careful case selections with the proctor are essential to maintain motivation and ensure safe performances. A structured programme to establish competency is vital to help both the proctor and trainee gauge real-time progress and performance. However, training systems both inside and outside the operating theatre (OT) are equally useful to achieve the desired performance.

Treating problematic haemorrhoids has taken a long turmoil route. Its peak incidence is among 45 to 65 years of age group. Typically, problematic haemorrhoids present in multi-symptoms forms like a prolapsed lump, painless bleeding, discomfort, soiling, or itchiness. Many theories were postulated in the pathophysiology of symptomatic haemorrhoids. The sliding and engorged of anal cushion with hypervascularity is the most popular. This is an updated review of published English-language literature regarding the treatment of haemorrhoids. The treatment includes medical therapy, office procedures, and surgical operations. Merits and demerits of the different modalities of treatment of haemorrhoids are presented. The best treatment options are difficult to ascertain. It should be tailored to individualize treatment according to their presentation and severity. Up till recently, the excisional haemorrhoidectomies are considered the standard procedure for haemorrhoid treatment. These techniques produce significant post-operative pain to the patient, which hinders them from normal daily activity. Recent advancement in surgical intervention has focused on minimising severity of pain and enhances recovery.

Milligan-Morgan haemorrhoidectomy (MMH) is still regarded as the standard excisional haemorrhoid procedure. In our centre, prophylactic lateral internal sphincterotomy (LIS) has been routinely performed simultaneously with MMH due to increased incidence of concurrent chronic anal fissure (CAF). We aimed to review our practice, the safety and feasibility of routine MMH+ LIS among patients with or without CAF. A prospective observational study was conducted to examine the outcome of MMH + LIS in Kassala, Sudan, from 2015 to 2018. The short-term outcomes of patients undergoing MMH+LIS were compared between patients with or without CAF. There were 252 patients included in the study, with the median age of 33 (ranged 13-80), and 146 (57.94%) were male patients. Of these, 205 patients (81.3%) had third-degree prolapsed haemorrhoids, and 47 patients (18.7%) had fourthdegree prolapsed haemorrhoids, with 73 (29%) patients had a concurrent chronic anal fissure. There were no significant difference (p > 0.05) between the comparing groups with regard to the complications occurred, which were post-operative bleeding (n = 4, 1.6%), anal stenosis (n = 5, 1.98%), faecal incontinence (n = 2, 0.79%), chronic anal pain (n = 5, 1.98%), chronic anal discharge (n = 3, 1.19%), pruritus ani (n = 4, 1.58%) and obstructed defaecation symptoms (n = 4, 1.58%). The overall complication rates were 16/ 252 (6.3%). Patients without pre-existing CAF were significantly associated with increased post-operative pain (p < 0.0001) after LIS. Prophylactic LIS, along with MMH, is a safe strategy with reasonable desired short-term outcomes and low complication rates. Patients with pre-existing CAF gain better pain control having had concurrent LIS which ultimately justify the procedure.