Background: Successful implementation of enhanced recovery after surgery (ERAS) in kidney transplantation requires multidisciplinary consultation, education and attention to protocol. This study discusses the process implementation pathway of the ERAS protocol and its outcome. Methods: A standardized ERAS protocol was designed for the renal transplant recipient and from our renal database. The parameters of interest included length of stay, incidence of delayed graft function and readmission rate. Results: There was no difference in the demographics and the incidence of delayed graft function across both groups, although subgroup analysis suggested a significantly lower incidence of delayed graft function with kidneys donated after circulatory death in the cohort that were managed by the ERAS protocol. The median length of stay for patients on the ERAS protocol was 5 days (range 3-16 days). This was 2 days shorter than the median length of stay for patients not on the ERAS protocol (7 days; range 5-14, P < 0.001). This statistically significant difference in length of stay was consistent across all donor subgroups (living donor, donor after cardiac death and donation after brainstem death). Seventy-nine percent of the patients on the ERAS protocol were discharged on post-operative day 4. Conclusion: An ERAS protocol for renal transplant patients is feasible. Our data show that successful implementation of ERAS in kidney transplantation is possible and results in significant cost savings due to shorter length of stay.

Small bowel evisceration through the vagina is a rare surgical emergency that requires urgent surgical intervention because of the risk of developing acute small bowel ischemia. We present a case of a 91 year old female presenting with acute small bowel evisceration with majority of her small bowel visible outside the vagina. The bowel wall was edematous requiring emergent laparotomy and reduction of bowel with repair of the vaginal vault. The patient did not require bowel resection. Transvaginal small bowel evisceration is uncommonly described in the literature. Rare cases are reported in elderly, post-menopausal women who have undergone hysterectomy. Multiple approaches to surgical management including laparoscopic, open abdominal, transvaginal as well as combined approaches have been described. Perineal herniation must be kept in the differential in elderly post-hysterectomy patients with sudden onset of abdominal pain with urgent surgical intervention advised.

Meckel's Diverticulum is one of the most common congenital anomalies of the gastrointestinal tract. However, its presentation as a complicated Giant Meckel's Diverticulum in an adult is rare. We present a case of a perforated Giant Meckel’s mimicking ischemia of the right colon. This case report highlights the importance of having a high index of suspicion for this rare diagnosis.

BackgroundLaparoscopy has revolutionized the surgical field with the advent of minimally invasive techniques leading to smaller surgical wounds, enhanced recovery, early discharge from the hospital and early return to work. Since the initiation of three‐dimensional (3D) systems, studies have failed to prove significant advantages over traditional two‐dimensional systems which could be attributed to suboptimal image quality, poor illumination and high cost of earlier systems. Recent advances in stereoscopy have led to the introduction of high‐definition (HD) systems with improvement in image quality in both two‐dimensional and 3D systems. With HD and new 4K imaging system, the previous data are now obsolete.MethodsWe devised a cross‐over study using the Olympus 4K camera imaging system compared with the HD 3D systems using 40 novice surgeons with no prior surgical skills to perform standardized surgical tasks and the groups were crossed over to assess any difference in the learning curve with the imaging systems.ResultsThe data showed a statistically significant difference in errors performed with the 3D imaging system with reduction in errors for passing needle through a ring, knot tying, cutting circle and touching circles with a needle. The time taken to perform those tasks was comparable except in knot tying where there was significant reduction in the time taken to tie knots with a P‐value of <0.001 in both groups.ConclusionThe study showed no significant difference in the time to perform tasks. The precision of the tasks was significantly improved with the 3D systems.

Of the current published cases, six had a normal appendix and 10, including our own, had an inflamed, necrotic or perforated appendix and/or caecum. The incidence of appendicitis within an Amyand's hernia is reported as 0.1%. 1,8 Thus, we postulate that left-sided Amyand's hernia is far more likely to be associated with an acute inflammatory component compared with one in a right-sided hernia. The possible aetiology of left-sided Amyand's hernia include situs inversus, intestinal malrotation, a mobile caecum and a lengthy appendix reaching the left iliac fossa. 3,9 Previous studies have debated whether appendicitis is due to primary pathology or by hernia strangulation of blood supply with consequent necrosis, 7 the latter being the more likely aetiology in our patient. This rare case adds to the current sparse literature on acute leftsided Amyand's hernia and emphasizes the increased likelihood of acute appendicitis with left-sided rather than right-sided disease. It is a rare diagnosis worth considering in patients presenting acutely with large left-sided inguinoscrotal hernias. Informed consent has been obtained from the patient for publication of this manuscript.