Robotic transanal minimally invasive surgery (r-TAMIS): perioperative and short-term outcomes for local excision of rectal cancers.

BACKGROUND: Transanal minimally invasive surgery (TAMIS) is an advanced technique for excision of early rectal cancers. Robotic TAMIS (r-TAMIS) has been introduced as technical improvement and potential alternative to total mesorectal excision (TME) in early rectal cancers and in frail patients. This study reports the perioperative and short-term oncological outcomes of r-TAMIS for local excision of early-stage rectal cancers. METHODS: Retrospective analysis of a prospectively collected r-TAMIS database (July 2021-July 2023). Demographics, clinicopathological features, short-term outcomes, recurrences, and survival were investigated. RESULTS: Twenty patients were included. Median age and body mass index were 69.5 (62.0-77.7) years and 31.0 (21.0-36.5) kg/m2. Male sex was prevalent (n = 12, 60.0%). ASA III accounted for 66.7%. Median distance from anal verge was 7.5 (5.0-11.7) cm. Median operation time was 90.0 (60.0-112.5) minutes. Blood loss was minimal. There were no conversions. Median postoperative stay was 2.0 (1.0-3.0) days. Minor and major complication rates were 25.0% and 0%, respectively. Seventeen (85.0%) patients had an adenocarcinoma whilst three patients had an adenoma. R0 rate was 90.0%. Most tumours were pT1 (55.0%), followed by pT2 (25.0%). One patient (5.0%) had a pT3 tumour. Specimen and tumour maximal median diameter were 51.0 (41.0-62.0) mm and 21.5 (17.2-42.0) mm, respectively. Median specimen area was 193.1 (134.3-323.3) cm2. Median follow-up was 15.5 (10.0-24.0) months. One patient developed local recurrence (5.0%). CONCLUSIONS: r-TAMIS, with strict postoperative surveillance, is a safe and feasible approach for local excision of early rectal cancer and may have a role in surgically unfit and elderly patients who refuse or cannot undergo TME surgery. Future prospective multicentre large-scale studies are needed to report the long-term oncological outcomes.

Robotic Lateral Pelvic Lymph Node Dissection in Rectal Cancer: A Feasibility Study from a European Centre.

INTRODUCTION: The role of robotic lateral pelvic lymph node dissection (LPLND) for lateral pelvic nodal disease (LPND) in rectal cancer has yet to be investigated in the Western hemisphere. This study aims to investigate the safety and feasibility of robotic LPLND by utilising a well-established totally robotic TME protocol. METHODS: We conducted a retrospective study on 17 consecutive patients who underwent robotic LPLND for LPND ± TME for rectal cancer between 2015 and 2021. A single docking totally robotic approach from the left hip with full splenic mobilisation was performed using the X/Xi da Vinci platform. All patients underwent a tri-compartmental robotic en bloc excision of LPND with preservation of the obturator nerve and pelvic nerve plexus, leaving a well-skeletonised internal iliac vessel and its branches. RESULTS: The median operative time was 280 min, which was 40 min longer than our standard robotic TME. The median BMI was 26, and there were no conversions. The median inpatient stay was 7 days with no Clavien-Dindo > 3 complications. One patient (6%) developed local recurrence and metastatic disease within 5 months. The proportion of histologically confirmed LPND was 41%, of which 94% were well to moderately differentiated adenocarcinoma. Median pre-operative lateral pelvic node size was significantly higher in positive nodes (14 mm vs. 8 mm (p = 0.01)). All patients had clear resection margins on histology. DISCUSSION: Robotic LPLND is safe and feasible with good peri-operative and short-term outcomes, with the ergonomic advantages of a robotic TME docking protocol readily transferrable in LPLND.

Surgical trainee experience and opinion of robotic surgery in surgical training and vision for the future: a snapshot study of pan-specialty surgical trainees.

BACKGROUND:  Robotic surgery is well established across multiple surgical specialities in the United Kingdom (UK) and Republic of Ireland (ROI). We aimed to elucidate current surgical trainee experience of and attitudes to robotic surgery in a surgical training programme across the UK and ROI to determine the future role of robotic surgery in international surgical training programmes. Methods: A pan-specialty trainee cross-sectional study was performed on behalf of the Association of Surgeons in Training (ASiT) using mixed-methodology. Round 1: a digital questionnaire was disseminated to all ASiT members. Round 2: 'live-polling' was performed prior to and following the Robotic Surgery plenary session convened at the ASiT 2020 International Conference (Birmingham). Data analysis was performed using a combination of quantitative and qualitative methods. RESULTS:  Three hundred and four responses were analysed (n = 244 digital questionnaire, n = 60 live-polling). Overall, 73.8% (n = 180) of trainees would value greater access to robotic surgery training. 73.4% (n = 179) believed that robotic surgery was important for the future of their desired specialty and 77.2% (n = 156) believed it should be incorporated into formal surgical training. Qualitative analysis identified that trainees believe that robotic training should have a formal role in surgical training. Perceived disadvantages of robotic surgery experience in surgical training included expense and the current impact of consultant robotic learning curves on training. CONCLUSION:  Current surgical trainees desire greater access to robotic surgery in surgical training. Robotic surgery is developing an increasing role in current surgical practice and it is important that it is introduced in a timely, evidence-based fashion to surgical trainees at an appropriate stage of training.

Day case laparoscopic cholecystectomy at Kilimanjaro Christian Medical Centre, Tanzania.

INTRODUCTION: The Lancet Commission on Global Surgery has promoted the case for safe, affordable surgical care in low- and middle-income countries (LMICs). In 2017, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania introduced a day case laparoscopic cholecystectomy (DCLC) service, the first of its kind in Sub-Saharan Africa (SSA). We aimed to evaluate this novel service in terms of safety, feasibility and acceptability by patients and staff. METHODS: This study used mixed methods and was split into two stages. In stage 1, we reviewed records of all laparoscopic cholecystectomies (LCs) comparing day cases and admissions. These patients were followed up with a telephone questionnaire to investigate complication rates and receive service feedback. Stage 2 consisted of semi-structured interviews with staff exploring the challenges KCMC faced in implementing DCLC. RESULTS: 147 laparoscopic cholecystectomies were completed: 109 were planned for DCLC, 82 (75.2%) of which were successful, whilst 27 (24.8%) patients were admitted. No variables significantly predicted unplanned admission, the commonest causes for which were pain and nausea. In the DCLC group there was 1 readmission. 62 patients answered the follow up questionnaire, 60 (97%) of which were satisfied with the service. Stage 2 interviews suggested staff to be motivated for DCLC but revealed poor organisation of the day case pathway. CONCLUSION: High rates of DCLC combined with low rates of complications and readmission suggests DCLC is feasible at KCMC. However, staff interviews alluded to administrative problems preventing KCMC from reaching its full DCLC potential. A dedicated day case surgery unit would address most of these problems.

The role of pectoral nerve blocks in a day-case mastectomy service: A prospective cohort study.

BACKGROUND: It is now recognised that the majority of breast surgery can be safely undertaken as day case procedures. We aimed to evaluate the effect of pectoral nerve (Pecs2) blocks on recovery parameters and day case rates in patients undergoing mastectomy for breast cancer. METHODS: A prospective cohort study was performed in a single NHS Foundation trust between 1st April 2014 and 31st December 2016. Visual analogue scale (VAS) pain scores (0-10) at 4 and 8 h, episodes of post-operative nausea ±â€¯vomiting (PONV), opioid use and day case outcome were compared between Pecs2 and no Pecs2 groups. RESULTS: 22 patients underwent general anaesthesia (GA) + Pecs2 block and 30 GA ± local anaesthetic infiltration.Mean pain scores were significantly lower in the Pecs2 (2.5) vs no Pecs2 (4.6) group at 4 h (p = 0.0132) and 8 h, Pecs2 (1.9) vs no Pecs2 (3.6) (p = 0.0038).Episodes of PONV requiring additional anti-emetic were lower and statistically significant in the Pecs2 group (2/22, 9%) than the no Pecs2 group (14/30, 46%), (p = 0.005).Additional opioid use was significantly lower in the Pecs2 group (4/22, 18%) than in the no Pecs2 group (14/30, 46%) (p = 0.0423).18 patients in the Pecs2 group were discharged the same day in contrast to just 3 patients in the no Pecs2 group. This was highly statistically significant (p = 0.0001). CONCLUSIONS: Pecs2 blocks can significantly reduce post-operative pain, nausea and vomiting in patients undergoing mastectomy. Their use can enable units to achieve high day-case mastectomy rates.

Surgical trainees' experience of pregnancy, maternity and paternity leave: a cross-sectional study.

BACKGROUND: Internationally, supporting surgical trainees during pregnancy, maternity and paternity leave is essential for trainee well-being and for retention of high-calibre surgeons, regardless of their parental status. This study sought to determine the current experience of surgical trainees regarding pregnancy, maternity and paternity leave. METHODS: A cross-sectional anonymised electronic voluntary survey of all surgical trainees working in the UK and Ireland was distributed via the Association of Surgeons in Training and the British Orthopaedic Trainees' Association. RESULTS: There were 876 complete responses, of whom 61.4% (n=555) were female. 46.5% (258/555) had been pregnant during surgical training. The majority (51.9%, n=134/258) stopped night on-call shifts by 30 weeks' gestation. The most common reason for this was concerns related to tiredness and maternal health. 41% did not have rest facilities available on night shifts. 27.1% (n=70/258) of trainees did not feel supported by their department during pregnancy, and 17.1% (n=50/258) found the process of arranging maternity leave difficult or very difficult. 61% (n=118/193) of trainees felt they had returned to their normal level of working within 6 months of returning to work after maternity leave, while a significant minority took longer. 25% (n=33/135) of trainees found arranging paternity leave difficult or very difficult, and the most common source of information regarding paternity leave was other trainees. CONCLUSION: Over a quarter of surgical trainees felt unsupported by their department during pregnancy, while a quarter of male trainees experience difficulty in arranging paternity leave. Efforts must be made to ensure support is available in pregnancy and maternity/paternity leave.

Multiple Aneurysms and a Transplanted Kidney in Behçet Disease.

Arterial manifestation of Behçet disease represents a challenging clinical scenario with a potential for fatal complications. This case depicts the surgical management of a 4.5-cm infrarenal aortic aneurysm and a 6-cm left renal artery aneurysm in a patient with known Behçet disease. The presence of a contralateral living donor kidney transplant added to the complexity of the case. Open surgical repair was performed on both aneurysms with the use of axillofemoral bypass to protect the transplanted kidney. This case highlights the challenges of treating an aortic aneurysm in a patient with Behçet disease and a kidney transplant.