Evaluation of an established colorectal robotic programme at an NHS district general hospital: audit of outcomes and systematic review of published data.

INTRODUCTION: Robotic-assisted surgery (RAS) offers potential advantages over traditional surgical approaches. This study aimed to assess outcomes from a district general hospital (DGH) robotic colorectal programme against published data. MATERIALS AND METHODS: The robotic programme was established following simulator, dry/wet lab training, and proctoring. We performed a case series analysing technical, patient, and oncological outcomes extracted from a prospective database of colorectal RAS cases (2015-2022). A registered systematic review (PROSPERO CRD42022300773; PubMed, Web of Science, EMBASE) of single-centre colorectal series from established robotic centres (n>200 cases) was completed and compared to local data using descriptive summary statistics. Risk of bias assessment was performed using an adapted version of the Cochrane ROBINS-I tool. RESULTS: Two hundred thirty-two RAS cases were performed including 122 anterior resections, 56 APERs, 19 rectopexies, and 15 Hartmann's procedures. The median duration was 325 (IQR 265-400) min. Blood loss was < 100 ml in 97% of cases with 2 (0.9%) cases converted to open. Complications (Clavien-Dindo 3-5) occurred in 19 (8%) patients, with 3 (1.3%) deaths in < 30 days. Length of stay was 7 (IQR 5-11) days. In 169 rectal cancer cases, there were 9 (5.3%) cases with a positive circumferential or distal margin and lymph node yield of 17 (IQR 13-24). A systematic review of 1648 abstracts identified 13 studies from established robotic centres, totaling 4930 cases, with technical, patient, and oncological outcomes comparable to our own case series. CONCLUSIONS: Outcomes from our robotic colorectal programme at a UK DGH are comparable with the largest published case series from world-renowned centres. Training and proctoring together with rolling audit must accompany the expansion of robotic surgery to safeguard outcomes.

Cholecystocutaneous fistula: an unusual complication of a para-umbilical hernia repair.

This case describes a 94-year-old woman who presented 2 years postsutured para-umbilical hernia repair with a painful black lump protruding through her scar with blood stained discharge. This was initially thought to be either ischaemic bowel secondary to strangulated incisional hernia or a large organised haematoma. An urgent CT scan was performed following which the patient passed two large calculi and bile-stained fluid spontaneously through the wound, making the diagnosis somewhat clearer. The scan revealed an incisional hernia containing the gallbladder and two large calculi at the skin surface and an incidental large caecal cancer with surrounding lymphadenopathy. Frail health and the incidental finding of a colon cancer rendered invasive surgical management inappropriate. Therefore, she was managed conservatively with antibiotics. A catheter was inserted into the fistula tract to allow free drainage and alleviate pressure-related symptoms. The patient was discharged following a multidisciplinary team discussion.

An unusual case of chronic anal pain--a pin in the bum?

We report the case of a 70-year-old woman who had previously undergone anterior resection in 2001 for a diverticular stricture. Bleeding from pelvic veins intra-operatively necessitated the use of two thumbtacks to aid haemostasis. Over the next 7 years, she presented repeatedly with anal pain, bleeding and mucus discharge per rectum. Multiple lower gastrointestinal endoscopies failed to make a definitive diagnosis until a single thumbtack was found eroding through the rectal mucosa. This was removed and she has been subsequently asymptomatic. This condition was clearly difficult to diagnose and requires a high index of suspicion in those patients who have previously undergone pelvic surgery.