Purpose Regional hospitals across Australia rely heavily on locum consultant surgeons to maintain emergency surgical services. However, the impact of continuity of locum engagement on elective surgical and endoscopic access remains poorly defined. This study evaluates whether recurrent locum consultant engagement is associated with improved elective and endoscopic service delivery compared with short-term locum placements. Methodology A retrospective service evaluation was conducted using a prospectively maintained consultant logbook documenting all operative and endoscopic activity between March and December 2025. Data were collected across regional hospitals in Queensland, New South Wales, Victoria and South Australia. A regional hospital supported by recurrent monthly locum engagement (“continuity site”) was compared with multiple hospitals covered by short-term locum placements. Outcomes included elective and emergency operative volume, endoscopy activity and procedural case mix. Results At the continuity site, recurrent locum engagement supported substantial elective throughput alongside sustained emergency cover, including 111 colonoscopies, 53 gastroscopies, 23 haemorrhoid banding procedures and a broad range of elective general surgical operations. Emergency surgical activity remained significant and included appendicectomy, emergency laparotomy, bowel resection and emergency endoscopy for gastrointestinal bleeding. In contrast, short-term locum placements were predominantly emergency-focused, with limited elective and endoscopic service provision and minimal opportunity for planned follow-up or elective conversion. Conclusion Continuity-based locum consultant models enhance elective surgical and endoscopic access in regional hospitals while maintaining emergency surgical capacity. Structured continuity of locum engagement represents a pragmatic workforce strategy to reduce surgical access inequity across regional Australia.

The Shetland Islands are the most northerly outpost of the United Kingdom. Shetland lies at 60 degrees North and is home to a population of 23,000 people on an archipelago of over 100 islands, 16 permanently inhabited. It is 110 miles north of the British mainland, 140 miles west of Norway, and 240 miles (by sea or air) north of Aberdeen Royal Infirmary, the closest tertiary hospital. The remoteness of Shetland and its substantial population necessitates the local presence of a capable surgical service. Four consultant general surgeons are currently in post with the expectation of working a 1 in 3 roster when “on island”, and they cover all surgical emergencies including some operative orthopaedics. There is a unique breadth and depth of skills required by the island surgeons, and the accrual of these has been greatly assisted by the Rural Surgical Fellowship. This fellowship is funded nationally by NHS Education for Scotland and provides up to 2 years of bespoke training, around or after completion of conventional general surgery training. It is ideally combined with a ‘proleptic’ appointment to one of Scotland’s 6 rural general hospitals and areas of focus will be tailored to the anticipated service needs. Elements can include Orthopaedics, Urology, Breast Surgery, Interventional Radiology and Obstetrics. Quality assurance is taken seriously. Surgeons participate in several weekly regional MDT discussions for cancer cases and orthopaedics. In recent years, appointed consultant surgeons have had regular humanitarian leave to work in low and middle-income countries. This has provided surgeons with experience of large numbers of complex major cases; otherwise hard to access while serving a small population. Shetland is an “unknown” to much of the UK let alone Australia, but their commitment and approach to providing a high quality locally led surgical service in a remote environment has many elements that could be adopted into the Australian system.

Background: Subcutaneous haematomas in elderly patients with dermatoporosis and comorbidities such as cardiovascular disease pose a high risk of skin necrosis, infection and morbidity. Conventional management using surgical debridement followed by non-operatively wound care or skin grafting is often prolonged, resource-intensive or associated with high morbidity. This study aims to evaluate the efficacy of the mesh protocol, a technique originally used for skin tears, as a novel, resource-efficient method for managing subcutaneous haematomas. Methods: A retrospective case series was conducted at Northern Beaches Hospital (November 2023–October 2024) including six elderly patients (mean age 92 years) with lower limb subcutaneous haematomas who underwent haematoma evacuation and mesh protocol application. The protocol involved meshing of excised viable skin and grafting it back onto the wound bed after evacuation of haematoma under local or general anaesthetic. Outcomes assessed included graft take at first review (days 5–7) and complications. Results: The time from injury to intervention ranged from 12 hours to 10 days. All six patients achieved 100% graft take with no incidence of graft failure, infection or need for further surgery. Procedures were predominantly performed at bedside under local anaesthetic and full healing was achieved in under three weeks in some cases. Conclusions: The mesh protocol is a safe, effective, and cost-efficient technique for subcutaneous haematoma management. Early haematoma evacuation with preservation and meshing of viable skin may minimise morbidity and accelerate healing, representing a valuable alternative to traditional approaches.

Purpose: This review aims to highlight key advances in the evolution of tracheostomy and tracheal intubation, and contextualise their impact on survival, ranging from ancient legends such as Alexander the Great to standardised modern critical care. Methodology: A literature review was conducted, summarising the historical development of airway management, with a focus on tracheostomy. Results: The origins of tracheostomy trace back to ancient civilisations, with the earliest depictions found in Greek and Roman texts around 2000 BC. Legend attributes one of the first life-saving tracheal incisions to Alexander the Great, who reportedly used his sword to open a soldier’s airway suffocating from an aspirated bone. In the thirteenth century, tracheostomy was formally condemned as a “semi-slaughter and a scandal of surgery.” During the Renaissance, progress continued when anatomist Andreas Vesalius demonstrated maintenance of animal ventilation through a reed passed into the trachea. Italian physician Antonio Brassavola reintroduced tracheostomy in humans in 1546 by performing the first documented successful tracheostomy. Further surgical accounts by French surgeon Nicholas Habicot in 1620 underscored its controversial use, including for a convicted thief who sought a pre-gallows tracheostomy. The 19th and 20th century ushered in significant technological progress in airway management with the development of laryngoscopy. Direct laryngoscopy was pioneered in 1895 by ENT surgeon Alfred Kirstein. Instrumentation improved in 1943 with the introduction of the Macintosh laryngoscope blade by Sir Robert Macintosh. The procedure’s profound, modern impact was exemplified by physicist Stephen Hawking, whose life was prolonged by decades following a tracheostomy necessitated by pneumonia in 1985. Conclusion: The extensive history of tracheostomy demonstrates the evolution of surgical techniques and reflects its trajectory from a last-resort emergency procedure to precise critical care.

The surgical management of gender incongruence has progressed from isolated and largely experimental interventions in the early 20th century to a well-established, multidisciplinary field that is associated with meaningful improvements in quality of life for transgender individuals. Some of the earliest documented gender-affirming procedures were performed in the 1920s and 1930s at Magnus Hirschfeld’s Institut für Sexualwissenschaft in Berlin, where early vaginoplasty techniques were developed. 95 years ago, Dora Richter was widely recognised as the first individual to undergo complete male-to-female genital reconstruction, including orchiectomy, penectomy and vaginoplasty (Richter 1892–1966). Substantial advances in masculinising reconstruction occurred in the mid-20th century. Sir Harold Gillies performed one of the earliest female-to-male phalloplasty procedures in the 1940s, using a staged reconstructive approach that laid important foundations for contemporary surgical techniques (Frey et al. 2017; Gillies 1882–1960). Since that time, phalloplasty has evolved considerably, with microsurgical free-flap reconstruction now regarded as standard practice in specialised, high-volume centres (Alba et al. 2024). Alongside developments in gender-affirming genital surgery, advances in transplant surgery have marked further milestones. In 2016, the first successful live birth following uterus transplantation in the United States expanded the scope of reproductive surgery (Cheng 2019). Concurrent progress in vascularised composite allotransplantation, including penile transplantation, has raised the possibility of future integration into gender-affirming reconstructive pathways (de Haseth 2023). Collectively, these milestones reflect significant advances in surgical technique, ethical governance and multidisciplinary care, underscoring the role of gender-affirming surgery in improving psychosocial wellbeing and health outcomes for transgender patients.