OpenUCT :: Browsing by Department "Department of Surgery"

Browsing by Department "Department of Surgery"

Now showing 1 - 20 of 165

Open Access
A 40-50kDa Glycoprotein Associated with Mucus is Identified as α-1-Acid Glycoprotein in Carcinoma of the Stomach
(2012) Chirwa, Nthato; Govender, Dhirendra; Ndimba, Bongani; Lotz, Zoe; Tyler, Marilyn; Panieri, Eugenio; KAHN, DELAWIR; Mall, Anwar S
Background and Aim: Secreted gastric mucins are large O-glycosylated proteins of crude mucus gels which are aberrantly expressed in malignancy. An albumin associated 55-65kDa glycoprotein was previously shown in mucus gels in gastric cancer. The aim of this study was to investigate its expression and identification in human gastric tissue. Methods: Mucins were purified from crude mucus scrapings of 16 partial and 11 total resections and a rabbit polyclonal antibody was raised to the 55-65kDa glycoprotein. The location and expression of the glycoprotein was examined in normal gastric mucosa (n=20), intestinal metaplasia (n=18) and gastric cancer (n=27) tissue by immunohistochemistry. Mucins were analyzed by isoelectric focusing (IEF) on 2-D polyacrylamide gels. Identification of the 40-50kDa glycoprotein was by MALDI-TOF MS technique. Plasma levels were examined by Western blotting. Results: Extensive SDS-PAGE analysis gave a PAS positive glycoprotein in the 40-50kDa range, in patients with gastric cancer but not normals. It was expressed in parietal and columnar cells of normal gastric tissue and intestinal metaplasia respectively, and in 22 of 27 gastric cancer specimens. In 2-D PAGE stained with Coomassie Blue there were 3 spots positively identified as alpha-1-acid glycoprotein (AGP) by MALDI-TOF MS technique. PAS staining revealed a single bright spot in the same position but could not be identified. Preliminary measurements showed slightly higher levels of AGP in plasma of patients with gastric carcinoma. Conclusion: AGP levels are increased in gastric tissue and in the plasma of those with carcinoma of the stomach.
Open Access
A contribution to the etio-pathogenesis of chronic middle ear effusions
(1969) Kuschke, Erich Reinier Hermann
Open Access
A descriptive study of patients presenting with a chief complaint of seizures to the prehospital emergency care practitioner of the Western Cape
(2019) Bester, Beatrix Hendrina; Saunders, Collen; Allgaier, Rachel
Background Seizures are considered one of the most common time-sensitive and potentially life-threatening medical emergencies presenting to emergency centres and attended to by prehospital emergency care practitioners. These require a rapid response, prompt identification and appropriate management. There is a paucity of information describing the demographics and prehospital management of patients presenting with seizures in South Africa. Objectives The aim of this study was to describe the demographics and prehospital management of patients presenting with a chief complaint of seizures and/or convulsions to prehospital emergency care practitioners within the Western Cape Government Emergency Medical Services. Methods This retrospective study included all Western Cape Government Emergency Medical Services calls indicating a chief complaint of seizures and/or convulsions between August 2017 and July 2018. Descriptive statistics were performed to describe basic demographics in this population. A sample of emergency calls originating within the City of Cape Town was selected for a clinical chart review to describe on-scene clinical presentation and vitals, response times, and prehospital treatment provided. Results A total of 24 746 seizure and/or convulsion cases were recorded during the study period. The highest frequency of patients was in the 21 - 40 year age group (31%), and 57% of patients were male. The subsample (n=3 075) yielded 1 571 cases with completed electronic patient care records. The mean dispatch and response times were 20 (±36) and 14 (±10) minutes respectively with a mean on-scene time of 25 (±13) minutes. No on-scene vital signs were recorded in 11.3% of patients. Recorded on-scene vitals indicated that 36% of patients presented with a tachycardia, 14% had an oxygen saturation of < 95%. Airway manoeuvres were performed in 30% of cases, and 50% of patients presenting with a SpO2 < 95% received supplemental oxygen. The benzodiazepine Diazepam was the most common medication administered, and 83% of medications were administer through the intravenous route. Conclusions Seizures are a recognised time-sensitive emergency, however in this sample of patients we observed a longer than expected dispatch time. Although the importance of recording baseline vital signs is recognised, there was a large proportion of undocumented vital signs 35 within the sample. Despite consensus recommendations that intramuscular midazolam are the preferred medication and route, IV diazepam was the most frequently administered. Seizures are an under-recognised burden on Emergency Medical Services within the Western Cape. This study provides an initial description of the epidemiology within this population, allowing for optimization of recognition and management in these patients.
Restricted
A modified exercise for combined reduction mammoplasty and breast conservation therapy in the treatment of breast cancer
(2007) Hudson, Donald A
Wide local excision combined with postoperative radiotherapy is a useful technique for patients with breast cancer. For patients with macromastia whose tumor is situated in the lower pole of the breast, a breast reduction (keyholeinverted T pattern ) can be used to achieve wide local excision. However, for patients whose tumor is not in the inferior portion of the breast, and in whom this cancer also is situated close to the skin (requiring excision of skin with a 1-cm margin for oncologic safety), the traditional keyhole pattern cannot be used. A modification of the keyhole patterninverted T is described. The pedicle used depends on the site of the tumor. Although the breast scars are in different positions, a similar breast shape as well as symmetry still can be achieved. This is a useful technique for a select subgroup of patients. The outcomes for three patients are presented.
Open Access
A new approach to hormone dependence in human breast cancer
(1973) Flax, Herschel
Open Access
A retrospective audit of the outcomes of the Fellow Of College Of Surgeons (FCS) (General Surgery) Final Examinations
(2018) Kahn, Miriam; Kahn, Delawir; Navsaria, Pradeep H; Klopper, Juan
Background and aim: An audit of the Fellowship of the College of Surgeons FCS (SA) Final Examination results has not been previously performed. The purpose of this study was to review and determine any predictors of outcome. Methods: The results of the FCS (SA) Final Examinations from October 2005, to and including, October 2014, were retrieved from the College of Medicine of South Africa database. The current format of the examinations consists of: two written essay question papers, an OSCE, two clinical cases and two vivas. These were retrospectively reviewed and analyzed. Predictors of failure or success were determined. Analysis was performed using IPython for scientific computing. Assumptions for the normal distribution of numerical values were made based on the Kolmogorov-Smirnov test and quantile-quantile plots. Normally distributed variables were analyzed by parametric tests. In all other cases nonparametric tests were employed. An alpha value of 0.05 was chosen to indicate statistical significance, using a confidence level of 95%. Results: During the 10-year study period, 472 candidates attempted the examinations. A total of 388 (82,2%) candidates were successful in the written component of the examination and were subsequently invited to participate in the oral/clinical component of the examinations. 9 Overall, 296 (62,7%) of candidates passed and 176 (37,3%) failed. A total of 19 candidates achieved less than 50% for both papers, yet still managed an average of more than 45%. A total of 15 (79%) of these candidates went on to fail the examination. There were 51 candidates who were invited to the oral examinations despite an average of less than 50% in the two papers, and 34 (67%) failed the overall examination. Similarly, 126 candidates were invited having failed one of the two papers of which 81 (64.3%) ultimately failed. A total of 49 candidates failed the OSCE, 82% of these candidates failed overall. There was strong correlation between paper one and paper two (r = 0.56, p-value < 0.01), oral one and oral two (r = 0.41, p-value < 0.01) and case one and case two (r = 0.38, p-value < 0.01). Similar correlations were seen between the averages of the papers versus the orals (r = 0.52, p-value < 0.01), the papers versus the cases (r = 0.5, p-value < 0.01) and the papers versus the OSCE (r = 0.54, p-vale < 0.01). Conclusion: The written papers are the main determinant of invitation to the second part of the examination. Candidates with marginal scores in the written component had an overall failure rate of 67%. Failing one paper and passing the other, resulted in an overall failure rate 64,3%. Failing the OSCE resulted in an overall 82% failure rate. With the high failure rate of candidates with marginal scores and with the inter-examination variability of the papers, it might be prudent to revisit both the process of invitation selection and the decision to continue with the long-form for the written component.
Open Access
A retrospective study of the prehospital burden of trauma managed by the Western Cape Government emergency medical service
(2019) Abdullah, Mohammed Naseef; Saunders, Colleen; McCaul, Michael; Nyasulu, Peter
Introduction: Trauma is one of the leading causes of premature death and disability in South Africa. There is a paucity of data describing the prehospital trauma burden in sub-Saharan Africa. The aim of this study was to describe the epidemiology and common trauma emergencies managed by the Western Cape Government emergency medical service (WCG EMS) in South Africa. Methods: The WCG EMS call centre registry was retrospectively analysed for all trauma patients managed between 01 July 2017 to 30 June 2018. A descriptive analysis of the data was performed using standard procedures for all variables. To date, this was the first analysis of this dataset or any prehospital trauma burden managed in the Western Cape of South Africa. Results: The WCG EMS managed 492 303 cases during the study period. Of these cases, 168 980 (34.3%) or 25.9 per 1000 population were trauma related. However, only 91 196 met the inclusion criteria for the study. The majority of patients (66.4%) were males and between the socio-economically active ages of 21-40 years old (54.0%). Assaults were the most common cause of trauma emergencies, accounting for 50.2% of the EMS case load managed. The patient acuity was categorised as being urgent for 47.5% of the cases, and 74.9% of the prehospital trauma burden was transported to a secondary level health care facility for definitive care. Conclusion: This is the first report of the prehospital trauma burden managed in the Western Cape of South Africa. The Western Cape suffers a unique trauma burden that differs from what is described by the WHO or any other LMIC. It also provides the foundation for further research towards understanding the emergency care needs in South Africa and to support Afrocentric health care solutions to decrease this public health crisis.
Open Access
A01 The Esophagus - Embryology
(2014-09-12) Klopper, Juan
This video is the first in a series of surgical study videos focusing on managing acute care surgical conditions. This particular video focuses on the embryology of the oesophagus. This resource is useful for junior medical students who are developing their anatomical knowledge.
Open Access
Adult pedestrian traffic trauma in Cape Town with special reference to the role of alcohol
(1997) Peden, Margaret Mary; Van der Spuy, Johan
This research is a prospective, descriptive survey of adult pedestrian injuries in Cape Town. It profiles 'at risk' pedestrians and describes their injuries, injury severity and outcome. The role which alcohol plays in these collisions is threaded through the thesis. Since no study of this nature has been done in South Africa, it provides baseline data on the epidemiology, alcohol-relatedness, clinical presentation and prevention of adult pedestrian collisions in the metropole. Data were collected prospectively on all injured pedestrians who presented consecutively, within six hours of being injured, to the Trauma Unit of Groote Schuur Hospital over a nine week period in 1993. Data were also gathered retrospectively from the state mortuary on all pedestrians who died before reaching hospital during the same time period. A total of 227 patients were included in the study. Data gathered included demographics, physiological response to injury, anatomical nature and severity of injuries as well as progress and outcome. Injuries were assessed and scored using the Abbreviated Injury Score (1990 revision) and the New Injury Severity Score. Alcohol consumption was assessed using four measures, viz. self-evaluation, clinical assessment, breath alcohol analysis and blood alcohol concentration (SAC). Data were analysed using SAS version 6. The study recorded a very high incidence of alcohol intoxication among injured pedestrians in Cape Town. This is highly suggestive of a causal link. One hundred and forty-one patients (62.1%) were found to have positive BACs; more than 40% had BACs in excess of 0.20 g/100ml. SAC positive pedestrians were found to have more severe injuries, to require longer hospitalisation periods and to need more complex management. They consequently cost more to treat than their sober counterparts. The comparison between the four methods of alcohol assessment revealed that self-evaluation and clinical assessment were poor screening tools. Breath alcohol analysis, using a Lion Alcolmeter S-D2, had a high degree of accuracy when compared to the SAC, which remains the 'gold standard'. It is therefore recommended that all traffic trauma patients be subjected to breath analysis. The study also generated recommendations for the prevention of pedestrian collisions. These address pre-crash, crash and post-crash factors. Control of drunken driving and walking, as well as road safety education, particularly to pedestrians, are key issues. However, there remains a need for improved road engineering and better monitoring of the roadworthiness of vehicles. This thesis highlights the severity of alcohol-related pedestrian injuries and the importance of preventative strategies.
Open Access
An analysis of the descriptors of acute myocardial infarction used by South Africans when calling for an ambulance from a National Emergency Call Centre
(2019) Buma, Chloe Ashton; Saunders, Collen; Stassen, Willem
Introduction Acute Myocardial Infarction (AMI) is a time sensitive emergency. In resource limited settings such as South Africa, prompt identification and management of these patients in the pre-hospital setting may minimise the negative consequences of an overburdened emergency medical and hospital service. Expedited care thus, in part, relies on the dispatch of appropriate pre-hospital medical providers by emergency medical dispatchers. Identification of these patients in the call centre is challenging due to a highly diverse South African society, with multiple languages, cultures, and levels of education. The aim of this study was therefore, to describe the terms used by members of the South African public when calling for an ambulance for patients suffering an AMI. Methodology In this qualitative study, we performed content analysis to identify keywords and phrases that callers used to describe patients who were experiencing an AMI. Using the patient report form number of randomly selected paramedic- diagnosed AMI cases, original voice recordings between the caller and call centre operators at the time of the emergency were extracted and transcribed verbatim. Descriptors of AMI were identified, coded and categorised using content analysis, and quantified. Results Of the 50 randomly selected calls analysed, 5 were not conducted in English. The descriptors (meaning units) used by callers were and found to fall into three categories; Pain: Thorax, No pain: Thorax and Ill- health. The code that occurred most often was no pain, heart related (n=16; 23.2%), followed by the code describing pain in the chest (n=15; 21.7%). Conclusion South African callers use a consistent set of descriptors when requesting an ambulance for a patient experiencing an AMI. The most common of these are non- pain descriptors related to the heart (“heart attack”). These descriptors may ultimately be used in developing validated algorithms to assist dispatch decisions. In this way, we hope to expedite the correct level of care to these time- critical patients and prevent the dispatching of resource limited advanced life support paramedics to inappropriate cases.
Open Access
Analysis of practical Surgical experience and Case Reports, part.III
(1977) Berkowitz, L
Metadata only
Anatomy of the oesophagus for medical students and young doctors
(2013) Klopper, Juan
In this second video in the series of the management of acute conditions in surgery for medical students and young doctors we take a look at the anatomy of the oesophagus. Anatomy of the oesophagus for senior medical students preparing for their clinical exams and young doctors facing patients with acute conditions of the oesophagus.
Metadata only
Anatomy of the oesophagus for senior medical students preparing for their clinical exams and young doctors facing patients with acute conditions of the oesophagus
(2013) Klopper, Juan
Lecture series in acute care surgery. Managing acute care surgical conditions.
Open Access
Attitudes to adverse drug reactions and their reporting among medical practitioners
(1987) Robins, A H; Weir, M; Biersteker, E M
The adverse drug reaction (ADR) reporting rate within the medical profession is exceptionally low, and doctors' approaches and attitudes to ADRs were explored through personal structured interviews. The total sample comprised 104 doctors in private practice, divided into three groups: 59 general practitioners, 26 medical specialists and 19 surgical specialists. Certain differences emerged between the groups. The surgical group observed far fewer ADRs than the other groups and not a single member had ever reported an ADR. A significantly larger number of medical specialists considered it necessary to report an ADR to an outside agency, while general practitioners tended to believe that only newly released medicines required ADR reporting. However, few doctors of any specialty regarded ADR reporting as part of the action they would take in their handling of ADRs in practice. The commonest explanation advanced for the marked underreporting of ADRs was that unusual or serious reactions were very infrequent and the common or trivial ones did not warrant reporting. Apathy and indifference were rated as the next most pertinent influence in non-compliance, while such factors as fear of personal consequences (e.g. criticism, medicolegal action) and uncertainty about what to report were deemed to be relatively unimportant.
Open Access
Audit of abdominal vena cava injuries in an urban truama centre
(2013) Hampton, Mark Ian; Navsaria, Pradeep H
The aim of this thesis is to present the surgical management of injuries to the abdominal vena cava (AVC) and to identify clinical and physiological factors and management strategies that affect outcome.
Open Access
An audit of provincial gastroenterology services in the Western Cape
(Health and Medical Publishing Group, 2008) Goldberg, P A; Watermeyer, G; Van Wyk, M E C
Background: While disorders such as gastro-oesophageal reflux disease, gastrointestinal (GI) cancers and inflammatory bowel disease are prevalent among all racial groups in the Western Cape, there is little knowledge of local GI service provision. The state of equipment, facilities and staffing is largely unrecorded and to date unknown. The aim of this study was to audit the availability of GI facilities in the provincial sector, which provides care for the majority of people in the Western Cape. Method: All hospitals in the Western Cape providing endoscopy were evaluated by means of a hands-on audit, to identify available organisational infrastructure. Data including staffing, details and utilisation of existing equipment, maintenance and disinfection techniques and delays in service provision were collected. Results: Over a period of 12 months, 17 Western Cape hospitals were visited : 3 tertiary, 5 regional and 9 district-level institutions. There are currently 89 GI endoscopes in state service, with an average age of 6.1 years (range 1 - 23 years). While most institutions utilise video endoscopy, in many instances equipment is near the end of its economic life. A total of 26 434 endoscopic procedures were performed over a 12-month period. Overall at least 60% of all adult endoscopy was undertaken at tertiary institutions. The mean delay from consultation until gastroscopy or colonoscopy was 9.25 weeks (range 0.5 - 28 weeks) and 8 weeks (range 1 - 20 weeks), respectively. Only 1 tertiary and 1 regional hospital employed fully trained, registered nurses, and the majority of institutions did not conform to internationally accepted standards for the maintenance and disinfection of endoscopic equipment. Conclusion: While endoscopy equipment is widely distributed throughout the province, it is evident from this study that services in the Western Cape fall short of international standards, with delays in endoscopic provision, lack of adequate equipment, inadequate scope maintenance and disinfection and a shortage of trained staff. As such, much of the population reliant on state facilities has poor access to GI health care. These deficiencies need to be addressed.
Open Access
An audit of the workload of an acute surgery unit in a tertiary academic hospital before and after the closure of a referring community hospital
(2015) Moodie, Quintin Keith; Klopper, Juan; Kahn, Delawir
Aim: An audit of the workload of an Acute Care Surgery Unit in a Tertiary Academic Hospital and an assessment of the impact on this Unit by the closure of a busy Community Hospital. Background: The primary mission of the Acute Care Surgery service is to provide timely surgical assessment, operative and/or non-operative management of the acutely ill non-trauma surgical patient. Both locally and internationally, fewer surgeons are perusing general practice, opting instead for subspecialty training, with no or only minimal time spent in emergency surgical care. This is demonstrated for example by evidence that some colorectal surgeons refer diseases of the appendix to the general surgeon, reflecting the narrow point of care that is being practiced in certain fields of surgery. In many cases acute care surgery has been described as a multidisciplinary approach involving Emergency and Trauma Surgery, and Critical Care Medicine.(1-3) In South Africa the rules and regulation by the Health Professions Council stipulates the requirement of training and qualifying as a General Surgeon, before pursuing Fellowship training in a field of subspeciality. As treatment paradigms shift and surgical emergency disease management evolves, we need properly trained surgeons that are willing to pursue the optimal emergency care (surgical or non-operative) for specific conditions in patients presenting with these acute surgical emergencies.(2,4) Groote Schuur Hospital (GSH) is privileged in its provision of an Acute Care Surgical Unit (ACSU) that functions in a tertiary environment and is affiliated with the University of Cape Town (UCT), the leading ranked University on the African Continent. The ACSU in GSH has 28 dedicated beds, and functions as a secondary and tertiary level General Surgery Unit excluding all acute trauma care. Provision is also made for the management of primary level surgical diseases. A neighboring surgical referral hospital, GF Jooste Hospital (GFJH), has 90 dedicated surgery beds. It is a Community Hospital, which caters for primary and secondary level diseases. Acute care is also given to tertiary level trauma and emergency surgical diseases. The unit at GFJH will be closing to allow for a reconstruction of the building, and thus the patient population will require access to alternate facilities whilst awaiting the reopening. A subset of these patient will have to be accommodated at GSH.
Open Access
The biochemical analysis of mucus and mucins in respiratory diseases with a focus on tuberculosis
(2016) Mofokeng, Henrietta Refiloe; Mall, Anwar Suleman
Respiratory diseases are a major cause of death in South Africa, with TB being one of the major respiratory illnesses. The respiratory tract is lined by a layer of mucus which protects the airways and lungs against injury by foreign agents. The main constituents of this layer of mucus are mucins. MUC5AC and MUC5B are the predominant respiratory tract mucins. However, little is known of the association between respiratory mucins and TB. This study aimed at describing the types and role of respiratory mucins in TB. Fifty six sputum samples, 17 tracheal aspirates and 95 bronchoalveolar lavages (BALs) were collected in 6M guanidinium hydrochloride and inhibitors. The airway mucus was divided into TB and non-TB groups. Mucins were reduced and alkylated with DTT and iodoacetamide and purified by density gradient ultracentrifugation in caesium chloride. Identification of MUC5AC, MUC5B, MUC2 and MUC7 were determined by western blotting and confirmed by immunohistochemistry. Western blot data proved the dominance of MUC5AC and MUC5B mucins in airway mucus. In comparison to the non-TB group, a higher secretion of MUC5AC than MUC5B in patients with TB was observed. MUC5AC also showed distinct behavioural characteristics in its fractionation in a caesium gradient compared to MUC5B. The presence of MUC5AC and MUC5B in different fractions suggests varying glycosylation of the mucin. Varying populations of MUC5B were observed in sputa with 3 new glycoforms shown in TB. A small group of TB patients had MUC7 in the sputa (and not in the lavage) and there were varying amounts of MUC2 in some TB samples and non-TB mucus. At tissue level, MUC5B was found to be the main secreted gel-forming mucin. MUC5B and MUC7 were found to play a role in the protection again infection by Mycobacterium tuberculosis in tuberculous granulomas. Using proteomics it was demonstrated that respiratory mucus protein expression differs in, tracheal aspirates, BALs and sputa. Although inter-individual variations were observed in all samples, similar proteins were expressed in relation to the functioning of the lung. O-glycan analysis showed that the majority of the O-glycans detected were sialylated and that core 3 and 4 O-glycan structures diminished in the presence of HIV.
Open Access
Biochemical and immunohistochemical charterisation of mucins in 8 cases of colonic disease - a pilot study
(Health and Medical Publishing Group, 2007) Chirwa, N; Govender, D; Kahn, D; Mall, A; Tyler, M; Kavin, B; Goldberg, P; Krige, J E J; Lotz, Z; Hunter, A
Objectives: To characterise mucins in cancer of the colon and compare these with controls using stringent biochemical measures to avoid endogenous proteolysis. Design: Crude mucus scrapings were collected from 12 specimens obtained by colectomy. Specimens from 3 traumatic colectomies and 1 sigmoid volvulus were used as controls, and compared with 6 specimens from colons resected for adenocarcinoma and 2 irradiated colons. Subjects: The median age of the 4 female patients was 76 years (range 49 - 82 years), and of the 8 male patients 46.5 years (range 16 - 74 years). Results and conclusions: The crude mucus scrapings in the 9 specimens ranged in weight from 353 mg to 7 697 mg (median 4 928 mg). The median of purified mucin in the 9 specimens was 0.72 µg/mg wet weight of scraped material. Eight samples gave non-extractable pellet material, and were treated with DTT to reduce disulphide bonds for further analysis. One of these 8 pellets was resistant to reduction and had to be digested with papain before analysis. Only 5 of these pellets had mucin. Gel filtration and SDS-PAGE (sodium dodecyl sulphate polyacrylamide gel electrophoresis) analysis revealed different populations of mucin based on size and extent of degradation. Western blotting and immunohistochemical analysis confirmed the presence of MUC2 in all samples, MUC5AC in 2 and MUC5B in 5 diseased specimens. Immunohistochemical analysis showed that there was no MUC1 in the normal specimens, MUC1 apoprotein MUC1 core) in 2 cancer specimens and MUC1 in 1 cancer specimen. Histochemical analysis showed that normal tissue expressed neutral and acidic mucins and diseased specimens predominantly expressed acidic mucins. The electrophoretic behaviour of MUC2 in sigmoid volvulus was different from that in cancer of the colon.
Open Access
Cervical lymph node biopsy - watch the nerves!
(2006) Numanoglu, A; Rode, H
Experience with the delayed diagnosis and severe consequences of accessory nerve injury following cervical gland lymph node biopsy prompted us to survey the practice of South African paediatric surgeons and to ascertain the incidence of accessory nerve injury. Cervical lymph gland biopsies are often performed for diagnostic and therapeutic purposes and although spinal accessory nerve (SAN) injury seldom occurs, it remains a significant injury. The operation is relatively minor and cervical glands are commonly biopsied/removed in South Africa by junior doctors, registrars and general practitioners. The operation is often performed as a day case under suboptimal circumstances, despite the fact that it is common knowledge that posterior triangle nodular biopsy carries the risk of iatrogenic damage to the accessory nerve.