Ann R Coll Surg Engl 2008; 90: 22-24 22Tw enty years before Louis Pasteur developed the germ theory, Ignaz Semmelweis in Vienna established the practice of washing hands in a chloride solution to prevent puerperal fever. 1 Joseph Lister, who is widely credited for introducing asepsis into surgery, subsequently started sterilising bandages and surgical instruments with steam and used carbolic acid to clean wounds with great success. Today, surgical hand disinfection remains an important part of modern surgical practice.Traditionally, surgical hand disinfection (scrubbing) comprises washing with antimicrobial soap containing water, detergent and an antiseptic agent such as chlorhexidine, iodine, alcohol or a quaternary ammonium compound. The minimum recommended time to ensure disinfection varies between 2-6 min depending on the product used. Alternative alcohol-based hand rub disinfectants can provide superior disinfection 2 when compared to traditional techniques, thus saving a significant amount of water at a time when this resource is in high demand.The objectives of this study were to: (i) quantify water usage of operating theatre staff during surgical hand disinfection and thereby estimate potential water savings in using alternative means of hand disinfection; and (ii) investigate the cost involved in adopting a new hand disinfection technique in our hospital. Materials and MethodsThe number of operations and operating lists over a 1-year period, including the number of scrubbed staff members involved in every procedure, was determined from a prospectively collected theatre database. In order to determine the amount of water and disinfectants used during a scrubbing episode, we undertook a small observational study of 30 scrub episodes in our operating department, collecting data on the time period that taps were running and the number of squirts of soap or alcohol rub used by theatre staff. The volumes of the two traditional antimicrobial soaps used, chlorhexidine gluconate solution 20% (Hibiscrub™, Regent Medical Ltd, Irlam, UK) and Povidone-iodine 7.5% in aqueous solution (Videne ® , Adams Healthcare, Leeds, UK), was measured by then dispensing the soaps into a 50-ml syringe from their standard dispensers. The amount of alcohol rub (Sterillium ® , Bode Chemie, Hamburg, Germany) used to disinfect hands was measured from standard dispensers, again by using a 50-ml syringe. In addition, the There is a growing trend to use alcohol-based hand disinfectants in clinical practice. In addition to their antibacterial efficacy, these disinfectants offer an alternative to traditional surgical hand disinfection agents that can save water in the operating theatre.

BackgroundEndoscopic procedures performed via trans-anal access is a rapidly expanding field of cancer surgery.1 Because of space constraints necessitating a single surgeon, teaching these techniques is mostly simulation based. Animal large bowel can be used for teaching basic Transanal Endoscopic Microsurgery (TEMS) but as is does not accurately portray human anatomy it is not ideal for the more complex TransAnal Minimally Invasive Surgery (TAMIS). Human cadavers are difficult to obtain and very costly and require dedicated structure and equipment. We were asked to build a rectal model including perirectal tissue that was cost effective, haptically realistic, dissectible and suitable for simulation training for TAMIS.MethodologyWe constructed a rectal model out of four layers of 5 cm stockinette (appropriately dyed) impregnated with ADAMgel (Aqueous Dietary fibre Antifreeze Mix gel). This was moulded around a plastic drainage pipe, the first two layers representing the mucosal and serosal layer of the large bowel. This was surrounded by ADAMgel meso rectal tissue analogues of appropriate dimension, colour and consistency in anatomical correct positions and then encased in the remaining layers of stockinette representing appropriate fascial layers. Cost were <£5 per specimen. The model was then evaluated by the UK colorectal surgeon with the most experience in teaching TAMIS, and by a group of European surgeons during a TAMIS conference for anatomical and haptic realism and utility as simulation phantom.ResultsFeedback were universally positive. The model offered anatomical (dissection and identification of planes) and haptic high-fidelity. The model was easily adaptable to a commercially available training box and allowed the use of an insufflator.ConclusionThis rectal model seems suitable for TAMIS simulation training. Arterial analogues can be inserted in the model for Transanal Haemorrhoidal Dearterialization (THD) teaching as well.ReferenceTransanal minimally invasive surgery: a giant leap forward. Atallah S, Albert M, Larach S. Surg Endosc. 2010;24(9):2200–5

BackgroundPorcine intestine is the mainstay of small bowel (SB) surgical simulation.1 These tissues of healthy young animals, although excellent for basic skills, cannot provide high fidelity for more complex surgical simulation involving pathological SB. In addition there is potential infection control and ethical/cultural issues. We explored creating a SB phantom would solve these problems.MethodologySB substitute was created by a double layer processed collagen sausage casing joined by a thin layer of dilute coloured gelatine/ADAMgel (Aqueous Dietary fibre Antifreeze Mix gel) mix. This was filled with fluid spill absorption granules soaked in coloured fluid representing SB content. This was intertwined with and wrapped in a thin film of water rich ADAMgel, and left outside to cure for 48 h.ResultsThe ADAMgel film dehydrated causing it to toughen and become more adherent to SB. This created an excellent model of SB adhesion. Adhesiolysis performed on the specimen felt realistic. The extent and tensile strength of adhesions could be varied emulating anatomical pathology. The SB analogue could be incised, sutured, resected and anastomosed using same equipment and techniques as with human SB. It was not as robust as healthy pig gut, and thus more like SB encountered with adhesions. The SB model can be made more friable by using a single collagen skin, or more robust by adding tubinette between the two layers. A mesentery can be attached to the SB by folding over a collagen sheet and inserting a film of ADAMgel between the two layers. Both diathermy and harmonic scalpel can be used on all components.ConclusionIt is possible to create a SB phantom for surgical simulation that emulates pathology and variety. The cost is the same as pig intestine per metre (<£1), but can be stored on the shelf and prepared in shorter lengths.ReferenceBijoy M, Thomas M, Dandolu V, Caputo P, Milner R, Hernandez E. Resident education in principles and technique of bowel surgery using an ex-vivo porcine model. Obstet Gynecol Int. 2010;852647