Attitudes and access of Irish general surgery trainees to robotic surgical training.

Background: Although the use of robotic-assisted surgery is now mainstream for procedures such as robotic prostatectomy and hysterectomy, its role in general surgery is less well established. Access to training in robotics for general surgery trainees in the Republic of Ireland is variable. Further, there are no data on specific attitudes of Irish trainees toward the role of robotics. We aimed to establish attitudes of Irish general surgery trainees toward the perceived utility of robotic surgery as well as access and satisfaction with training. Methods: A survey was disseminated to trainees in the Republic of Ireland enrolled in a General Surgery training scheme via email and social media. Data collected included stage of training, intended subspecialty, interest in developing robotic skills, previous exposure to robotic surgery, satisfaction with current access to robotic training, and opinion on formally incorporating training in robotics into the general surgery curriculum. Results: The response rate was 53.8%. Of these, 83% reported interest in training in robotics and 66% anticipated using the technology regularly in consultant practice. Previous exposure to robotic-assisted surgery was significantly predictive of interest in developing the skillset (P = .014). More than 71% of trainees reported that they were not satisfied with access to robotic training. Of those satisfied with access, 40% felt there was a role for incorporating robotic training into the curriculum compared to 68% of those dissatisfied. Conclusion: Irish general surgery trainees perceive robotic-assisted surgery to be highly relevant to their future practice. There is an unmet need to provide additional training in the skillset.

Updated systematic review of the approach to pelvic exenteration for locally advanced primary rectal cancer.

OBJECTIVES: To review the evidence regarding surgical advances in the management of primary locally advanced rectal cancer. BACKGROUND: The management of rectal cancer has evolved significantly in recent decades, with improved (neo)adjuvant treatment strategies and enhanced perioperative protocols. Centralization of care for complex, advanced cases has enabled surgeons in these units to undertake more ambitious surgical procedures. METHODS: A Pubmed, Ovid, Embase and Cochrane database search was conducted according to the predetermined search strategy. The review protocol was prospectively registered with PROSPERO (CRD42021245582). RESULTS: 14 studies were identified which reported on the outcomes of 3,188 patients who underwent pelvic exenteration (PE) for primary rectal cancer. 50% of patients had neoadjuvant radiotherapy. 24.2% underwent flap reconstruction, 9.4% required a bony resection and 34 patients underwent a major vascular excision. 73.9% achieved R0 resection, with 33.1% experiencing a major complication. Median length of hospital stay ranged from 13 to 19 days. 1.6% of patients died within 30 days of their operation. Five-year overall survival (OS) rates ranged 29%-78%. LIMITATIONS: The studies included in our review were mostly single-centre observational studies published prior to the introduction of modern neoadjuvant treatment regimens. It was not possible to perform a meta-analysis on the basis that most were non-randomized, non-comparative studies. CONCLUSIONS: Pelvic exenteration offers patients with locally advanced rectal cancer the chance of long-term survival with acceptable levels of morbidity. Increased experience facilitates more radical procedures, with the introduction of new platforms and/or reconstructive options.

Obturator hernia of Richter type: a diagnostic dilemma.

An 85-year-old malnourished woman presented with symptoms of small bowel obstruction of uncertain aetiology. She had presented numerous times over the previous 2 years with symptoms of left groin and thigh pain, vomiting and abdominal distension. A CT of her abdomen and pelvis ultimately revealed a left-sided pelvic hernia, between the obturator internus and pectineal muscles. This was consistent with an obturator hernia. Diagnostic laparoscopy confirmed an obturator hernia of Richter type, incarcerated within the left obturator canal. Reduction revealed a hernia sac containing viable small bowel. A primary repair was performed using a double-layer suture technique to both close and plug the hernia defect. The patient rapidly recovered following hernia repair, with resolution of all previous long-standing symptoms. This case exemplifies the typical presentation of an obturator hernia and the diagnostic challenge it poses to clinicians.

Successful management of ultra short bowel syndrome in an elderly patient.

An 83-year-old woman presented emergently with a 1-week history of increasing abdominal pain and vomiting. Imaging confirmed an incarcerated incisional hernia containing viable small bowel. Laparotomy revealed profound ischaemic insult extending beyond the hernial contents, affecting virtually the entire small bowel, consistent with acute superior mesenteric artery thrombosis. The patient underwent resection of the entire small bowel except for 20 cm of the jejunum and 15 cm of the terminal ileum. Her duodenum and large bowel were unaffected. Despite her age, comorbidities and only 35 cm of the remnant small bowel, this patient made a remarkable recovery. She transitioned from total parenteral nutrition dependence in an acute hospital setting to being discharged into the community, relying on partial parenteral nutrition two times per week in a home setting.

Whirl Sign and Midgut Volvulus: An Unusual Cause of an Acute Abdomen in an Adult Patient.

We report the case of a 50-year-old lady who presented to the emergency department complaining of a two-day history of colicky right upper quadrant (RUQ) pain, which radiated through to her back, associated with nausea, anorexia, and two episodes of vomiting that day. She was found to be tender in the RUQ. Her blood tests were notable for an elevated white cell count. Initial impression was of acute cholecystitis. Ultrasound of her abdomen did not identify any features of acute cholecystitis; however, a large volume of free fluid was identified within the abdomen. CT of the abdomen/pelvis was obtained which identified dilated loops of small bowel, interloop ascites, and a whirl sign highly suggestive of midgut volvulus. During laparoscopy, the midgut volvulus was found to have resolved. No cause for the volvulus could be identified, and the patient was discharged home well on postoperative day two.