Background: ERAS protocols are perioperative interventions aimed at reducing postoperative complications, length of hospital stay (LOS) and early return to normal activities. This has improved outcome in many surgical specialties, including breast surgery. We present the surgical outcome of breast cancer (BC) patients treated over a 12-month period following the principle of ERAS protocols and highlight the underpinning evidence. Methods: A retrospective analysis of all BC patients diagnosed and had breast cancer surgery over 12 months. Data collected included patient's demographics, type of surgery, LOS, other perioperative care and significant postoperative complications. Excluded were patients with bilateral cancer surgeries, diagnostic excision, margin clearance or breast reconstruction. Results: There were 621 BC diagnosed including 5 male and 12 bilateral female BC. The ages ranged from 25 to 93 years. Excluding bilateral BC, 351 patients (70.2 %) had breast conserving surgery (BCS) while 149 (29.8%) patients had mastectomy as index cancer surgery. Sixteen (4.5%) of the women who initially underwent BCS subsequently had a completion mastectomy. The overall rate of successful BCS was 335/500 (67%). 441 (85.5%) of patients were discharged same or next day. 12 (7.2%) cases of postoperative haematoma, 6 cases of wound infection and a case of seroma requiring surgical/radiological drainage recorded. Conclusion: ERAS protocol in BC surgery is associated with decreased LOS and low complication rate. Delayed discharges are mostly due to adverse social factors and medical comorbidity rather than post-operative surgical complications.

The diagnosis of an inguinal hernia, be it complicated or uncomplicated, is often simple and straight forward. Rarely, this simple presentation may be the external manifestation of a distant pathology, which is in communication with the inguinal canal through its anatomic relationship. We report a case of ruptured abdominal aortic aneurysm (AAA) that presented as a strangulated left inguinal hernia. To the best of our knowledge, this is the first reported case where the patient was stable on initial presentation, both clinically and biochemically. The only clue for our patient that pointed towards a potential aneurysm was the presence of intra-operative blood in the spermatic cord. We conclude that any patient presenting with symptoms suggestive of a hernia, particularly on the left side, should have a thorough assessment to rule out AAA.

Background: Ultrasound-guided, vacuum-assisted excision [UGVAE] of fibroadenomas is an emerging minimally invasive procedure. UGVAE is being increasingly employed by breast radiologists and surgeons. It has been approved for this use since 2006 by the National Institute for Health and Clinical Excellence in the UK. The aim of this systematic review is to evaluate the efficacy and safety of this procedure based on the up to date available evidence. Methods: A comprehensive literature search of the Cochrane library, Medline, Embase, PubMed, Google scholar, Trip-database, Internet, and the reference lists of relevant articles was performed. We searched for literature with sizeable cases of therapeutic vacuum-assisted excision of fibroadenomas. All prospective studies with more than 20 study participants were screened. The study quality was assessed using the Grading of Recommendations Assessment, Development, and Evaluation [GRADE] approach. All were in English. Results: Of the four case series that fulfilled the inclusion criteria there were 516 patients in which 520 procedures were performed. Overall complete excision rate was 89.4%. In two of the studies, this was 100% when the lesions were less than 1.5 cm but reduced to 61% when between 1.5 and 2 cm. Most common significant complication was bleeding with 2 cases of pneumothorax. None of the studies can be regarded as high quality going by GRADE approach. Conclusion: Within the limit of the current published case series, UGVAE appears to be an effective and safe procedure for excision of small fibroadenomas of less than 15 mm in size. A well designed case control study or randomized controlled trials with a sufficient sample size is needed to further 96assess its safety, effectiveness and more importantly, patients' satisfaction especially in larger sized fibroadenomas.

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