Robotic assisted surgery reduces ergonomic risk during minimally invasive colorectal resection: the VOLCANO randomised controlled trial.

PURPOSE: Minimally invasive surgery benefits patients but poor operating ergonomics causes musculoskeletal injuries in surgeons. This randomised controlled trial aims to assess whether robotic-assisted surgery with the open-console Versius® system can reduce surgeons' ergonomic risks during major colorectal resections. METHODS: Prospectively registered at ClinicalTrials.gov (NCT05262296) in March 2022. Adult patients requiring a minimally invasive colorectal resection were potentially eligible. Photographs taken at 2-min intervals were analysed using the objective Rapid Entire Body Assessment (REBA) posture analysis scale to calculate intraoperative surgeon ergonomic risk. Secondary outcomes included team communication (Oxford NOTECHS II), surgeon cognitive strain (modified NASA-TLX scale), and clinical outcomes. RESULTS: Sixty patients were randomised in a 2:1 ratio (40 robot, 20 laparoscopic). Mean age was 65yrs and 34 (57%) were male. Body Mass Index did not differ between the 2 groups (overall mean 29.0 ± 5) and there were equal proportions of left and right-colonic resections. REBA was significantly lower in the robotic arm (median robot REBA score 3 vs lap REBA 5 [p < 0.001]), equating to an injury risk category drop from "medium" to "low risk". There were no significant differences in team communication, operative duration, or patient outcomes. Surgeon cognitive strain was lower in robotic cases (mean robot 32.4 ± 10.3 vs lap 45.6 ± 14.3 [p < 0.001]). CONCLUSIONS: This trial demonstrates that robotic surgery with an open-console system reduces ergonomic risk scores and cognitive strain during colorectal resections, with no apparent detriment to team communication. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons.

Implementation of robotic hernia surgery using the Versius® system.

This case series aims to demonstrate that hernia surgery is safe and feasible using the Versius® robotic system from CMR Surgical, and to describe the surgical techniques used. It is the first series published using this novel system. Forty-one consecutive hernia repair cases were completed using Versius®, including inguinal and ventral hernias. Data were collected prospectively on a number of pre-, peri-, and postoperative outcomes. Techniques are described for robotic transabdominal preperitoneal repair of inguinal hernia, and intraperitoneal onlay mesh repair of ventral hernia. Thirty-two inguinal and nine ventral hernia repairs were performed over a 12-month period. The population were 88% male with a mean body mass index of 27.4 ± 3.5. There were no conversions to open surgery. Median length of stay was 0 days. Six patients (15%) experienced urinary retention, and there were 2 further minor complications with no major complications, readmissions or reoperations. Use of the Versius® system for robotic hernia surgery is safe, with comparable results to existing robotic systems. Implementation is possible with minimal changes to established surgical techniques.

Initiation and feasibility of a multi-specialty minimally invasive surgical programme using a novel robotic system: A case series.

INTRODUCTION: There are a number of small case series examining new robotic surgical systems, but this is the first large case series assessing the feasibility of the Versius® system from CMR Surgical (1 Evolution Business Park, Cambridge, UK) in a multi-specialty setting. MATERIALS AND METHODS: All patients undergoing Versius®-assisted surgery in a previously robot-naïve centre were consented for collection of data on demographics, pre-, intra-, and postoperative outcomes. Data collection was performed prospectively from the start of the robotic surgical programme. RESULTS: 160 operations were performed over a 19-month period, including 68 colorectal, 60 gynaecology, and 32 general surgery cases. The conversion rate to open surgery was 4.4% for colorectal, and 0% for gynaecology and general surgery. Median length of stay was 6 days for colorectal, 1 day for gynaecology, and 0 days for general surgery. Other outcomes were comparable to existing literature for robotic assisted surgery. CONCLUSION: The Versius® system is safe and feasible for use in a multi-specialty minimally invasive surgery programme, including colorectal, general surgical & gynaecological cases, and operative volume can be safely and easily scaled up in a district general hospital setting without prior robotic surgical experience.

The Trendelenburg Position and Cognitive Decline: A Case-Control Interventional Study Involving Healthy Volunteers.

BACKGROUND: Postoperative cognitive decline (POCD) is defined as a new cognitive impairment arising after a surgical intervention. Aspects of cognitive function can be assessed using various validated cognitive function tests including the N-back task, the Stroop task, and the lexical decision-making task (LDT). There is some concern that prolonged Trendelenburg positioning during laparoscopic colorectal surgery may cause POCD. OBJECTIVE: The objective of this study was to assess the effect of time spent in the Trendelenburg position on cognitive function. METHODS: Volunteers were placed in the Trendelenburg position for 3 hours and, then, supine for 30 minutes. Validated cognitive function tests including 1-, 2-, and 3-back tasks, Stroop test, and LDT were performed at baseline and every 30 minutes after Trendelenburg positioning. Cognitive decline was defined per the International Study of Postoperative Cognitive Dysfunction trial: a decrease in accuracy from the volunteers' baseline or an increase in response time from the volunteers' baseline by >2 control group SDs. RESULTS: We recruited 15 healthy volunteers (8 males, 7 females) with an average age of 69 years (range 57-81) and average body mass index of 27.7 kg/m2 (range 20.9-33). Accuracy remained within 2 SDs at all time points. An increase in response time did occur, and of 15 participants, 3 (20%) showed cognitive decline in the Trendelenburg position after 30 minutes, 4 (27%) after 1 hour, 5 (33%) after 90 minutes, 4 (27%) after 120 and 150 minutes, and 6 (40%) after 180 minutes. On moving to a supine position, 33% (5/15) participants showed cognitive decline. CONCLUSIONS: The results of this study indicate that Trendelenburg positioning leads to cognitive decline. This may have implications for patients undergoing prolonged Trendelenburg positioning during laparoscopic colorectal surgery.

Evaluating the Variation of Intraocular Pressure With Positional Change During Colorectal Laparoscopic Surgery: Observational Study.

BACKGROUND: The incidence of perioperative visual loss following colorectal surgery in the US is quoted as 1.24 per 10,000. Raised intraocular pressure (IOP) during extreme Trendelenburg position leading to reduced optic nerve perfusion is thought to be a cause. OBJECTIVE: To assess the effect of the degree of Trendelenburg tilt and time spent in Trendelenburg on IOP during laparoscopic colorectal surgery. METHODS: Fifty patients undergoing laparoscopic colorectal surgery were recruited. A Tonopen XL applanation tonometer was used to take IOP measurements hourly during surgery, and each time the operating table was tilted. A correlation coefficient for the degree of Trendelenburg tilt and IOP was calculated for each patient. Group 1 included patients undergoing a right-sided colonic procedure, and Group 2 included all left-sided colonic operations. RESULTS: The mean age of Group 1 participants (n=25) was 69 years (SD 14), and Group 2 (n=25) was 63 years (SD 16; P>.05). The average length of surgery for Group 1 was 142 minutes (SD 48), and Group 2 was 268 minutes (SD 99; P≤.05). The mean maximum degree of Trendelenburg tilt in Group 1 was 10 (SD 7) and Group 2 was 19 (SD 6; P≤.05). The mean IOP increase was 9 mm Hg (SD 5) for Group 1 and 15 mm Hg (SD 5) in Group 2 (P≤.05). An overall correlation coefficient for the degree of Trendelenburg tilt and IOP change (n=48) was .78. CONCLUSIONS: There is a strong correlation between IOP elevation during laparoscopic colorectal surgery and the degree of Trendelenburg tilt. This may be significant for patients undergoing prolonged surgery and especially those with glaucoma.

Can the SENSIMED Triggerfish® lens data be used as an accurate measure of intraocular pressure?

PURPOSE: The SENSIMED Triggerfish® contact lens sensor (CLS) has an embedded micro-sensor that captures spontaneous circumferential changes at the corneoscleral junction and transmits them via an antenna to a device where these measurements are stored. During laparoscopic colorectal surgery, patients are placed in Trendelenburg position which has been shown to increase intraocular pressure (IOP). Laparoscopic colorectal surgery requires both pneumoperitoneum and Trendelenburg positioning; therefore, IOP can vary significantly. We aimed to assess whether circumferential changes in the corneoscleral area can be correlated to IOP changes measured using Tono-pen® XL applanation tonometer during laparoscopic colorectal surgery. METHOD: Patients undergoing laparoscopic colorectal resections were included. On the day of surgery, baseline IOP was taken and the SENSIMED Triggerfish® CLS was then set up in one eye of the patient. During surgery (whilst under general anaesthetic), IOP measurements were taken in the contralateral eye using a Tono-pen® XL applanation tonometer every hour and any time the table was moved to record the fluctuations of IOP during surgery and any association with position change. The timings of these readings were documented. RESULTS: Twenty patients were included in this study (six males, 14 females). Average age was 64.6 years (SD = 16.3). The fluctuation in IOP measured in the reference eye ranged between 6.3 and 46.7 mmHg. The mean correlation coefficient between CLS output measurements and these IOP measurements was r = 0.291 (95% CI). CONCLUSION: Our results showed a weak correlation between the SENSIMED Triggerfish® CLS data output and IOP measurements taken using the Tono-pen® XL applanation tonometer.

The Future of Emergency Surgery.

Introduction: Over the past three decades, there has been a recognised need for emergency surgery (ES). Studies of ES have demonstrated variation in patient outcomes depending on admission time or day. ES as a subspecialty is still under consideration in Europe despite being recognised as such in the US. This article reviews this need and addresses the issues required to develop ES as a separate surgical subspecialty in Europe. METHOD: A survey on ES was developed by the Educational Committee of the European Society for Trauma and Emergency Surgery (ESTES) and sent to all ESTES members with 102 responses received. Results: Of the responses, 93.1% had completed training. 75.3% of respondents report that ES should be a recognised subspecialty and 79% report that ES is capable of offering a rewarding career. 90% report that ES should have dedicated post-graduate training programme with 69.8% in agreement that dedicated emergency surgeons have improved outcomes following ES. CONCLUSION: Developing ES as a subspecialty in Europe would improve patient outcomes and facilitate resource allocation. This advancement is, however, still in its infancy and its evolution would require overhaul of our current European system, training methods and understanding of the role of emergency surgeons in ES.

Apps in Trauma and Emergency Surgery.

Background: As physicians, Mobile smartphones, laptops and tablets are now an integral part of our day to day activities including personal communications as well as our routine clinical practice. Methods: A digital survey was designed to explore the usage of mobile smartphones and the associated apps among surgeons in Trauma and Emergency departments. It was sent to 850 members of the European Society for Trauma and Emergency Surgery. Results: A total of 91 responses were received with 60.4% aged between 35 and 54 years. Only 24.1%of respondents found the available apps extremely useful in their practice, however 75.9% of participants agreed on not being able to identify a certain good application to rely on. CONCLUSION: Despite the widespread use of smartphones among doctors of different grades and specialties, there is a preference shown towards the use of instant messenger apps and the use of the camera for clinical photos. The usefulness of current available apps appears to be limited due to the absence of a regulating body to check the validity of data and peer review the contents of apps leaving a huge responsibility on the individual doctor using the app to rely on its results.

Evaluation of patient's understanding and recall of the consent process after open inguinal hernia repairs.

INTRODUCTION: Open inguinal Hernia repair is one of the most commonly performed operative procedure. Despite this, hernia repair can cause considerable morbidity and rarely mortality. Some of these complications such as chronic pain and testicular complications can be easily disregarded, thereby leading to medico-legal claims being made. As a result, the quality of consent process is crucial in increasing patient satisfaction after inguinal hernia repair. This is a prospective study exploring patient's recall of the consenting practice after elective open inguinal hernia repairs at our institute. METHODS: Patients who had an elective, Lichtenstein inguinal hernia repair between January to October 2009 were identified. Patients were contacted by telephone after 3 days and a questionnaire was completed. RESULTS: There were 86 patients included in our study. The male:female ratio was 70:16 whilst the average age was 63.2+/-19.2 years. 42 patients stated pain relief as the main indication for having the operation whilst 30 patients feared incarceration or strangulation as the main indication. Infection was the complication recalled most by patients in our study (31 patients), followed by bleeding (30 patients). Only 2 patients were aware of developing potential chronic pain and 10 patients realised the potential for testicular problems. 57 patients were aware of having a mesh inside their groin. There were 61 patients who were aware of laparoscopic approach as an alternative to open inguinal hernia repair. CONCLUSIONS: Recall of consent is very poor. As a result, repeating the information stated and providing additional resource may reinforce the consent process.