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Surgical site infections are a common source of post-operative morbidity and contribute significantly to healthcare costs. Patients undergoing emergency laparotomy and/or bowel surgery are particularly at risk. Prophylactic negative pressure wound therapy (NPWT) has been shown to reduce wound infection. However, to date, there has been a lack of consensus around its use for closed laparotomy wounds. We conducted a systematic review of randomised controlled trials comparing the use of prophylactic negative pressure wound therapy with standard dressings for closed laparotomy incisions. The primary outcome was incidence of incisional surgical site infection (SSI) at 30 days post-operatively. Secondary outcomes included superficial and deep SSI, skin dehiscence, fascial dehiscence and length of stay. A total of 2182 publications were identified, of which, following review of titles, abstracts and full texts, five studies met the criteria for inclusion. Across these studies, 467 patients were randomised to NPWT and 464 to standard dressings. Overall SSI rate was 18.6% (n = 87/467) versus 23.9% (n = 111/464) in the NPWT and standard dressing groups, respectively (Odds ratio 0.71, 95% CI 0.52-0.99, p = 0.04*). Deep SSI incidence was the same in both groups (2.6%). Both skin dehiscence and fascial dehiscence were slightly higher in the standard dressing group ((4.2%, n = 11/ 263 versus 3.1% (n = 8/261) and (0.9% (n = 3/324) versus 0.6% (n = 2/323)), respectively. This study observed that NPWT reduces the overall SSI for closed laparotomy wounds. It supports data recommending the use of prophylactic NPWT dressings, especially in high-risk patients in both emergency and elective circumstances.

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Symmetrical peripheral gangrene (SPG) is a rare complication of septicaemia and disseminated intravascular coagulation (DIC) characterised by distal ischaemia in two or more extremities without large vessel obstruction. SPG has high mortality and morbidity rates, though consensus guidelines for management have yet to be produced. We herein present the case of a 28-year-old woman with meningococcal septicaemia complicated with extensive bilateral upper and lower limb SPG. We discuss the various management options of SPG. While reported cases are scarce in the literature, early recognition of sepsis and prompt withdrawal of vasoconstrictors in an intensive care setting, combined with timely heparinisation, appear to be the most common management strategy thus far.

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The RETAINER Collaborative Group reports the impact of COVID-19 on international elective inguinal hernia practice.

INTRODUCTION: Phyllodes tumours represent 0.3–1% of breast tumours, typically presenting in women aged 35–55 years. They are classified into benign, borderline and malignant grades and exhibit a spectrum of features. There is significant debate surrounding the optimal management of phyllodes tumour, particularly regarding appropriate margins. METHODS: This is a retrospective review of a prospectively maintained database of patients who underwent surgical management for phyllodes tumours in a single tertiary referral centre from 2007–2017. Patient demographics, tumour characteristics, surgical treatment and follow-up data were analysed. Tumour margins were classified as positive (0 mm), close (≤2 mm) and clear (>2 mm). RESULTS: A total of 57 patients underwent surgical excision of a phyllodes tumour. The Mean age was 37.7 years (range: ages 14–91) with mean follow-up of 38.5 months (range: 0.5–133 months). There were 44 (77%) benign, 4 (7%) borderline and 9 (16%) malignant phyllodes cases. 54 patients had breast conserving surgery (BCS) and 3 underwent mastectomy. 30 (53%) patients underwent re-excision of margins. The final margin status was clear in 32 (56%), close in 13 (23%) and positive in 12 (21%). During follow-up, 4 patients were diagnosed with local recurrence (2 malignant, 1 borderline and 1 benign pathology on recurrence samples). CONCLUSION: There are no clear guidelines for the surgical management and follow-up of phyllodes tumours. This study suggests that patients with malignant phyllodes and positive margins are more likely to develop local recurrence. There is a need for large prospective studies to guide the development of future guidelines.