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.

Understanding complaints made about surgical departments in a UK district general hospital.

BACKGROUND: Patient complaints are increasingly recognized to provide a valuable insight into patients' experience of healthcare. Being local and subjective, they can bring to light previously under-appreciated causes of patient dissatisfaction. The focus of surgical care is usually an intervention, and the nature of complaints made about surgical care may vary substantially from that in non-surgical specialties. This may have specific implications for quality improvement in surgical departments. OBJECTIVE: To investigate the causes of patient dissatisfaction in surgical care. METHODS: We retrospectively examined the content and frequency of patient complaints received by surgical departments at a UK district general hospital in the calendar year 2017. Second-hand reports of complaints, documented by the members of the hospital's complaints department, were collated from a prospectively maintained database and categorized by content. RESULTS: Three hundred and ninety-nine complaints were received over the study period. These related to the care of 327 different patients. One complaint was generated for every 111 patient encounters. Ninety-one per cent of the complaints were made by the patient, and 8.8% were made by a family member. Complaints cited communication with hospital staff in 25% of cases, out-of-hospital delays in 24%, clinical issues in 22%, hospital administration in 16% and in-hospital delays in 10%. Post-operative symptoms and complications accounted for only 2% of the complaints. Twenty-six per cent of the complaints resulted in the rescheduling of an operation or a clinic appointment. Seventeen per cent of the complaints prompted internal actions within the surgical department to investigate and learn from the incident. CONCLUSION: The profile of complaints made about surgical departments is similar to that of non-surgical departments in other studies. Clinical issues represented only the third largest cause of complaints. More complaints implicated patient-staff communication, and around half implicated management-related issues. Improving staff communication training, clinical standards and hospital administration continues to represent opportunities to enhance the patients' overall experience of surgical care.

The use of endoluminal techniques in the revision of primary bariatric surgery procedures: a systematic review.

BACKGROUND: Weight regain following primary bariatric surgery is attributed to anatomical, behavioural and hormonal factors. Dilation of the gastrojejunal anastomosis is a possible cause of weight regain after roux-en-Y gastric bypass (RYGB). However, surgical revision has significant risks with limited benefits. Endoluminal procedures have been suggested to manage weight regain post-surgery. This systematic review aims to assess efficacy of endoluminal procedures. METHODS: Studies where endoluminal procedures were performed following primary bariatric surgery were identified. Main outcome measures were mean weight loss pre- and post-procedure, excess weight loss, recurrence rates, success rates and post-procedure complications. RESULTS: Twenty-six studies were included in this review. Procedures identified were (i) endoluminal plication devices (ii) other techniques e.g. sclerotherapy, mucosal ablation, and Argon Plasma Coagulation (APC) and (iii) combination therapy involving sclerotherapy/mucosal ablation/APC and endoscopic OverStitch device. Endoluminal plication devices show greatest initial weight loss within 12 months post-procedure, but not sustained at 18 months. Only one study utilising sclerotherapy showed greater sustained weight loss with peak EWL (19.9%) at 18 months follow-up. Combination therapy showed the greatest sustained EWL (36.4%) at 18 months. Endoluminal plication devices were more successfully performed in 91.8% of patients and had lower recurrence rates (5.02%) compared to sclerotherapy and APC, with 46.8% success and 21.5% recurrence rates. Both procedures demonstrate no major complications and low rates of moderate complications. Only mild complications were noted for combination therapy. CONCLUSIONS: The paucity of good quality data limits our ability to demonstrate and support the long-term efficacy of endoluminal techniques in the management of weight regain following primary bariatric surgery. Future work is necessary to not only clarify the role of endoluminal plication devices, but also combination therapy in the management of weight regain following primary bariatric surgery.

Management of Staple Line Leaks Following Sleeve Gastrectomy-a Systematic Review.

BACKGROUND: A staple line leak following a sleeve gastrectomy is associated with significant morbidity and mortality. No uniform guideline or consensus exists with regard to the optimal treatment approach to managing a staple line leak. OBJECTIVES: The objective of this systematic review is to assess the efficacy and success rates of the different treatment strategies for staple line leak following sleeve gastrectomy. METHODS: A thorough search through four online electronic databases was conducted using predefined search criteria. Our primary outcome measure was to review the treatment options described in the management of the staple line leak following laparoscopic sleeve gastrectomy. Successful initial management was defined as the proportion of cases that were successfully treated using the first modality described, with no escalation to another treatment option. RESULTS: A total of 26 articles were included in this systematic review. Successful initial management of 62% was achieved in patients who underwent endoscopic management, 76% in those who underwent surgery and 82% in patients treated conservatively. A total of 7 patient deaths were noted, all of which were patients who underwent surgery as the initial management of their staple line leak. CONCLUSION: Prompt identification and adequate source control are crucial to successfully manage a staple line leak following sleeve gastrectomy. Treatment options are influenced by the clinical status of the patient. A stepwise treatment escalation approach is required to improve outcomes.

A systematic review of the aetiology and management of post cholecystectomy syndrome.

BACKGROUND: 10% of patients who undergo a cholecystectomy go on to develop post-cholecystectomy syndrome (PCS). The majority of these patients may suffer from extra-biliary or unrelated organic disorders that may have been present before cholecystectomy. The numerous aetiological causes of PCS result in a wide spectrum of management options, each with varying success in abating symptoms. This systematic review aims to provide a summary of the causative aetiologies of post cholecystectomy syndrome, their incidences and efficacy of available management options. METHODS: The Medline, Embase and Cochrane databases were searched for studies patients who developed PCS symptoms following laparoscopic cholecystectomy, published between 1990 and 2016. The aetiology, incidence and management options were extracted, with separate collation of randomised control trials and non-randomised studies that reported intervention. Outcomes included recurrent symptoms following intervention, unscheduled primary and secondary care attendances and complications. RESULTS: Twenty-one studies were included (15 case series, 2 cohort studies, 1 case control, 3 RCTs). Five studies described medical treatment (nifedipine, cisapride, opiates); seven studies described endoscopic or surgical intervention. Early presentation of PCS (<3 years post-cholecystectomy) was more likely to be gastric in origin, and later presentations were found to be more likely due to retained stones. Sphincter of Oddi dysfunction (SOD) accounted for a third of cases in an unselected population with PCS. CONCLUSIONS: Causes of post cholecystectomy syndrome are varied and many can be attributed to extra-biliary causes, which may be present prior to surgery. Early symptoms may warrant early upper gastrointestinal endoscopy. Delayed presentations are more likely to be associated with retained biliary stones. A large proportion of patients will have no cause identified. Treatment options for this latter group are limited.

Stem cells of the lower limb: their role and potential in management of critical limb ischemia.

Peripheral arterial occlusive disease (PAOD) contributes to decreased exercise tolerance, poor balance, impaired proprioception, muscle atrophy and weakness, with advanced cases resulting in critical limb ischemia (CLI) where the viability of the limb is threatened. Patients with a diagnosis of CLI have a poor life expectancy due to concomitant cardio and cerebrovascular diseases. The current treatment options to avoid major amputation by re-establishing a blood supply to the limb generally have poor outcomes. Human skeletal muscle contains both multipotent stem cells and progenitor cells and thus has a capacity for regeneration. Phase I and II studies involving transplantation of bone marrow-derived progenitor cells into CLI limbs show positive effects on wound healing and angiogenesis; the increase in quiescent satellite cell numbers observed in CLI muscle may also provide a sufficient in vivo source of resident stem cells. These indigenous cells have been shown to be capable of forming multiple mesodermal cell lineages aiding the repair and regeneration of chronically ischemic muscle. They may also serve as a repository for autologous transplantation. The behavior and responses of the stem cell population in CLI is poorly understood and this review tries to elucidate the potential of these cells and their future role in the management of CLI.

The evolution of minimally invasive bariatric surgery.

BACKGROUND: Obesity is a pandemic associated with significant morbidity and mortality. This historical article charts the progress of successful strategies that have been used to tackle weight loss from dietary modifications to the development of surgical interventions that have subsequently evolved. It also provides a précis of the reported outcome data following minimally invasive bariatric procedures. METHODS: A literature review was performed. All articles relevant to the progression of bariatric surgery and minimally invasive surgery were assessed, as were those articles that described the ultimate evolution, combination, and establishment of the two techniques. RESULTS: This article charts the progression of early weight loss strategies, from early dietary modifications and pharmacologic interventions to initial techniques in small bowel bypass procedures, banding techniques, and sleeve gastrectomies. It also describes the simultaneous developments of endoscopic interventions and laparoscopic procedures. CONCLUSIONS: A range of procedures are described, which differ in their success in terms of loss of excess weight and in their complication rates. Weight loss is greatest for biliopancreatic diversion followed by gastric bypass and sleeve gastrectomy and least for adjustable gastric banding. Bariatric surgery is an evolving field, which will continue to expand given current epidemiologic trends. Developments in instrumentation and surgical techniques, including single access and natural orifice approaches, may offer further benefit in terms of patient acceptability.

Mechanisms of reducing postoperative pain, nausea and vomiting: a systematic review of current techniques.

BACKGROUND: Multimodal recovery programmes decrease hospital stay. The objective of this systematic review was to assess how single-modality evidence-based care principles, regarding postoperative analgesia and postoperative nausea and vomiting (PONV) prophylaxis, combine to achieve this. METHODS: A systematic review of randomised controlled trials was performed. Relevant trials compared postoperative epidural analgesia/parenteral opioid analgesia/paracetamol/non-steroidal anti-inflammatory drugs (NSAIDs) and postoperative antiemetics. The effect on recovery was evaluated in terms of length of hospital stay, pain intensity, duration of gastrointestinal dysfunction and incidence of PONV. RESULTS: Twenty-three trials were included. Epidural anaesthesia failed to reduce length of stay or the incidence of PONV when compared to controls. Pain intensity and time to first bowel movement were reduced (p<0.05). Paracetamol did not reduce the incidence of PONV. NSAIDs reduced postoperative opioid consumption and the incidence of PONV (p<0.05). Dexamethasone and 5-HT3 antagonists reduced the incidence of PONV compared to controls. CONCLUSIONS: Epidural anaesthesia appears to not reduce length of hospital stay or incidence of PONV despite reducing pain intensity and ileus. NSAIDs are more effective than paracetamol in reducing postoperative opioid consumption and PONV, while dexamethasone and 5-HT3 antagonists are both effective in reducing PONV.

Paraoesophageal herniation: a review.

BACKGROUND: Paraoesophageal hiatus herniae repair can represent a formidable challenge. Afflicted patients tend to be elderly with multiple infirmities often with cardio-pulmonary dysfunction. They may present acutely with protracted vomiting and concurrent biochemical imbalances and it is a technically demanding procedure. There are several debated issues regarding operative technique. This paper will attempt to explain the nature of paraoesophageal hiatus herniae and reviews the recommended pre-operative investigations and operative strategies available. METHODS: A literature search was performed from Pubmed and suitable clinical papers were selected for review. When attempting to address whether meshes should be included routinely, electronic searches were performed in PubMed, Embase and the Cochrane library. A systematic search was done with the following medical subject heading (MeSH) terms: 'paraoesophageal hernia repair' AND 'mesh'. In PubMed and Embase the search was carried out with the limits 'humans', 'English language', 'all adult: 19+ years' and 'published between 1990 and 2010'. A manual cross-reference search of the bibliographies of included papers was carried out to identify additional potentially relevant studies. RESULTS: Firm conclusions are difficult to draw due to the diverse nature of both the disorder and the presentation however principals of management can be suggested. Similarly, there is no conclusive proof of the most effective operative technique and therefore the options are described. CONCLUSION: Due to the relative lack of cases encountered at smaller institutions, there is a good argument for centralisation of these cases into regional centres to allow research and facilitate improvements in care.

Statins inhibit neutrophil infiltration in skeletal muscle reperfusion injury.

BACKGROUND: Neutrophil infiltration is a major determinant of ischemia-reperfusion injury (IRI). Statins improve endothelial function by elevating nitric oxide synthase activity and inhibiting adhesion molecule expression and may, therefore, inhibit IRI-induced neutrophil extravasation. Although statins are protective against myocardial IRI and stroke, a role for statins in ameliorating skeletal muscle IRI has not yet been confirmed. This study, therefore, addressed the hypothesis that simvastatin would attenuate the severity of tissue damage during skeletal muscle IRI. METHODS: Rats were administered simvastatin for 6 d before 4 h hind limb ischemia and 24 h reperfusion. Neutrophil infiltration was assessed using myeloperoxidase (MPO) assays and tissue damage by quantitative immunohistochemical analysis of collagen IV. The effect of reducing nitric oxide levels on the severity of IRI was assessed by administering the NOS inhibitor, N-Imino-L-ornithine (L-NIO), before ischemia. RESULTS: Simvastatin significantly inhibited IRI-induced MPO activity but not collagen degradation in postischemic skeletal muscle. Inhibition of nitric oxide synthase by L-NIO markedly inhibited neutrophil infiltration and protected against IRI-induced collagen degradation. When both simvastatin and L-NIO were administered before IRI, the IRI-induced elevation in MPO activity was completely inhibited. However, paradoxically, simvastatin counteracted the protective effect of L-NIO against IRI-induced collagen IV degradation. CONCLUSIONS: The inhibition by simvastatin of IRI-induced neutrophil infiltration in skeletal muscle suggests that statins may be a useful therapy to attenuate the severity of IRI but their precise mechanisms of action remains to be determined. Nitric oxide also plays a cytotoxic, rather than protective, role in mediating IRI in this model.

A successful case of sural nerve cable grafting after a gunshot wound to the knees.

OBJECTIVE: To describe a successful case of sural nerve cable grafting to the leg following a gunshot injury. CLINICAL PRESENTATION AND INTERVENTION: A 28-year-old man was shot at close range, sustaining extensive damage to the left popliteal fossa. Initial exploratory operation revealed a pierced sciatic nerve proximal to its bifurcation into the tibial and common peroneal branches. The 60% division 3.5-cm common peroneal deficit and the complete transection of the tibial division were repaired using an ipsilateral sural cable nerve graft that was not reversed. Initial re-assessment in the clinic setting revealed a denervation atrophy of all 3 leg compartments and paraesthesia below the left knee sparing the sural nerve. After 3 months, the patient had a significant improvement in both power and sensation which was felt to be due to a resolution of a neuropraxic component to the nerve injury. Re-assessment at 9 months and later at 14 months revealed an almost full recovery, suggestive of the success of the nerve grafting procedure. CONCLUSION: This report shows that, given favourable conditions, a good result is possible following use of cable nerve grafting to treat nerve damage from gunshot.

Nitric oxide and skeletal muscle reperfusion injury: current controversies (research review).

Nitric oxide (NO) has been implicated in a large number of disease processes, including ischemia-reperfusion injury following the restoration of oxygenated blood to previously ischemic muscle, which is a recognized significant complication of vascular surgery. Altered metabolism of NO is implicated in the endothelial dysfunction that forms part of the pathophysiology of ischemia-reperfusion injury. However, NO can demonstrate either protective or cytotoxic effects during reperfusion injury. The use of transgenic mice, either NO synthase (NOS) gene knockout animals, or animals that over-express NOS isoforms, along with direct NO measurements and NO donor or inhibitor studies, have all demonstrated a role for NO in skeletal muscle reperfusion injury. There appears to be an initial stimulation of NO production in the first 20-min of ischemia, with a gradual decline through early reperfusion and a second higher peak of NO commencing in the later stages of reperfusion. The absolute levels of NO in the reperfused tissue and its regulation by the subtle interplay with superoxide and the subsequent production of the highly toxic peroxynitrite anion, are important factors in determining whether NO, in the context of ischemia-reperfusion injury, has damaging or protective effects in the body.