A systematic review and meta-analysis of the use of methylene blue to improve the lymph node harvest in rectal cancer surgery.

BACKGROUND: Methylene blue staining of the resected specimen has been described as an alternative to the conventional palpation and visual inspection method to improve lymph node harvest. This meta-analysis evaluates the usefulness of this technique in surgery for rectal cancer, particularly after neoadjuvant therapy. METHODS: Randomized controlled trials (RCTs) comparing lymph node harvest in methylene blue-stained rectal specimens to those of unstained specimens were identified from the Medline, Embase, and Cochrane databases. Non-randomized studies and those with only colonic resections were excluded. The quality of RCTs was assessed using Cochrane's risk of bias tool. A weighted mean difference (WMD) was calculated for overall harvest, harvest after neoadjuvant therapy, and metastatic nodal yield. In contrast, the risk difference (RD) was calculated to compare yields of less than 12 lymph nodes between the stained and unstained specimens. RESULTS: Study selection comprised seven RCTs with 343 patients in the unstained group and 337 in the stained group. Overall lymph node harvest and harvest after neoadjuvant therapy were significantly higher in stained specimens with a WMD of 13.4 and 10.6 and a 95% confidence interval (CI) of 9.5-17.2 and 4.8-16.3, respectively. Harvest of metastatic lymph nodes was significantly higher in the stained group (WMD 1.0, 95% CI 0.6-1.4). The yield of less than 12 lymph nodes was significantly higher in the unstained group with RD of 0.292 and 95% CI of 0.182-0.403. CONCLUSION: Despite a small number of patients, this meta-analysis confirms improved lymph node harvest in surgical specimens stained with methylene blue compared with unstained specimens.

Robotic colorectal surgery in elderly patients: A single-centre experience.

INTRODUCTION: The purpose of this study was to evaluate outcomes in elderly patients (age ≥ 65 years) undergoing robotic colorectal surgery (RCRS) in comparison with non-elderly patients. MATERIALS AND METHODS: Data was collected on elderly and non-elderly patients who underwent RCRS from a prospectively maintained database. RESULTS: A total of 89 elderly and 73 non-elderly patients were identified. No statistically significant differences in postoperative complication, reoperation, wound infection, anastomotic leak or mortality were observed. The median length of stay was 1 day longer in elderly patients (p = 0.007). Subgroup analysis of octogenarians demonstrated outcomes that compared favourably with younger patients. CONCLUSION: RCRS in elderly patients is safe and effective, with outcomes that do not differ significantly with younger patients. Older age should not be considered to be a specific exclusion criteria for RCRS. To our knowledge, this study represents the largest in the literature to examine outcomes specifically in elderly patients undergoing RCRS.

Necrotising fasciitis in the COVID-19 era: A consequence of caution - A case series.

Necrotising fasciitis (NF) is a severe soft tissue infection that is associated with a high risk of morbidity and mortality. During the coronavirus disease 19 (COVID-19) pandemic, the population has been actively discouraged from presenting to emergency medical services unless absolutely necessary. While this was an important step in allowing for preservation of limited resources in a time of crisis, it may have resulted in immeasurable 'secondary victims' of the pandemic as patients with time-critical conditions delay hospital presentation. In this case series, we describe three patients that noted symptoms of soft tissue infection, but delayed seeking healthcare advice due to concerns regarding COVID-19 exposure. All three progressed to NF, requiring highly morbid wide surgical debridement and prolonged hospital admission, with a high risk of potential mortality. The findings of this series demonstrate the importance of consistently delivering appropriate and timely healthcare interventions to patients with non-COVID-19-related conditions. While efforts must be made to ensure preservation of valuable healthcare resources in a global pandemic, patients must also be empowered to seek timely care for non-COVID-19-related conditions even in this time of crisis.

The impact of body mass index on outcomes in robotic colorectal surgery: a single-centre experience.

Obesity is an independent risk factor for postoperative morbidity and mortality in laparoscopic colorectal surgery (LCRS). The technological advantages of robotic colorectal surgery (RCRS) may allow surgeons to overcome the limitations of LCRS in obese patients, but it is largely unknown if this translates to superior outcomes. The aim of this study was to compare perioperative, postoperative and short-term oncological outcomes in obese (BMI ≥ 30.0 kg/m2) and non-obese (BMI < 30 kg/m2) patients undergoing RCRS in a university teaching hospital. Demographic, perioperative and postoperative data along with short-term oncological outcomes of obese and non-obese patients that underwent RCRS for both benign and malignant colorectal disease were identified from a prospectively maintained database. A total of 107 patients (34 obese, 73 non-obese) underwent RCRS over a 4-year period. No statistically significant differences in the incidence of complications, 30-day reoperation, 30-day mortality, conversion to open surgery, anastomotic leak or length of inpatient stay were demonstrated. Obese patients had a significantly higher rate of surgical site infection (SSI) (p < 0.0001). Short-term oncological outcomes in both groups were favourable. There was no statistically significant difference in median duration of surgery between the two cohorts. The results demonstrate that obese patients undergoing RCRS in this institution experience similar outcomes to non-obese patients. These results suggest that RCRS is safe and feasible in obese patients and may be superior to LCRS in this cohort, where the literature suggests a higher complication rate compared to non-obese patients. The inherent advantages of robotic surgical platforms, such as improved visualisation, dexterity and ergonomics likely contribute to the improved outcomes in this challenging patient population.

Robotic versus laparoscopic right hemicolectomy: a case-matched study.

The current gold standard surgical treatment for right colonic malignancy is the laparoscopic right hemicolectomy (LRH). However, laparoscopic surgery has limitations which can be overcome by robotic surgery. The benefits of robotics for rectal cancer are widely accepted but its use for right hemicolectomy remains controversial. The aim of this study was to compare outcomes in patients undergoing robotic right hemicolectomy (RRH) and LRH in a university teaching hospital. Demographic, perioperative and postoperative data along with early oncological outcomes of patients who underwent RRH and LRH with extracorporeal anastomosis (ECA) were identified from a prospectively maintained database. A total of 70 patients (35 RRH, 35 LRH) were identified over a 4-year period. No statistically significant differences in estimated blood loss, conversion to open surgery, postoperative complications, anastomotic leak, 30-day reoperation, 30-day mortality, surgical site infection or lengths of stay were demonstrated. Surgical specimen quality in both groups was favourable. The mean duration of surgery was longer in RRH (p < < 0.00001). A statistically significant proportion of RRH patients had a higher BMI and ASA grade. The results demonstrate that RRH is safe and feasible when compared to LRH, with no statistical difference in postoperative morbidity, mortality and early oncological outcomes. A difference was noted in operating time, however was influenced by training residents in docking the robot and a technically challenging cohort of patients. Operative time has shortened with further experience. Incorporating an intracorporeal anastomosis technique in RRH offers the potential to improve outcomes compared to LRH.

The first robotic transanal minimally invasive surgery in Ireland: a case-based review.

Transanal minimally invasive surgery (TAMIS) has gained worldwide acceptance as a means of local excision of early rectal cancers and benign rectal lesions. However, it is technically challenging due to the limitations of rigid laparoscopic instruments in the narrow rectal lumen. Robotic platforms offer improved ergonomics that are valuable in operative fields with limited space. Robotic TAMIS represents an exciting new development that may be more versatile than traditional TAMIS. In this review, we describe the first case of robotic TAMIS performed in our country and a review of current literature on the technique.

A meta-analysis of low Hartmann's procedure versus abdominoperineal resection for non-restorative treatment of rectal cancer.

BACKGROUND: Non-restorative surgery for rectal cancer is indicated in patients with comorbidities, advanced disease and poor continence. The aim of this meta-analysis was to compare the postoperative morbidity of Hartmann's procedure (HP) with that of extrasphincteric and intersphincteric abdominoperineal resection (APR) in the treatment of rectal cancer. METHODS: The Medline, Embase and Cochrane databases were searched for publications comparing postoperative morbidity of HP and APR. The incidence of overall surgical complications, pelvic-perineal complications and pelvic abscess was analysed as primary endpoints. Readmissions requiring reintervention and postoperative mortality were also compared. RESULTS: A cumulative analysis showed a significantly higher rate of overall complications (odds ratio (OR) 0.553, 95% confidence interval (CI) 0.320 to 0.953 and P value 0.033) and pelvic-perineal complications (OR 0.464, 95% CI 0.250 to 0.861 and P value 0.015) after APR. The incidence of isolated pelvic abscess formation was significantly higher after HP (OR 2.523, 95% CI 1.383 to 4.602 and P value 0.003). A subgroup analysis of intersphincteric APR compared with HP did not show any significant difference in the incidence of overall complications, pelvic-perineal complications or pelvic abscess formation (P values of 0.452, 0.258 and 0.100, respectively). There was no significant difference in readmissions, reinterventions and mortality after HP and APR (P 0.992, 0.198 and 0.151). CONCLUSION: An extrasphincteric APR is associated with higher overall and pelvic-perineal complications and may be reserved for tumours invading the anal sphincter complex. In the absence of sphincter involvement, both HP and intersphincteric APR are better alternatives with comparable morbidity.

Communication, collaboration and contagion: "Virtualisation" of anatomy during COVID-19.

COVID-19 has generated a global need for technologies that enable communication, collaboration, education and scientific discourse whilst maintaining physical distance. University closures due to COVID-19 and physical distancing measures disrupt academic activities that previously occurred face-to-face. Restrictions placed on universities due to COVID-19 have precluded most conventional forms of education, assessment, research and scientific discourse. Anatomists now require valid, robust and easy-to-use communication tools to facilitate remote teaching, learning and research. Recent advances in communication, video conferencing and digital technologies may facilitate continuity of teaching and research activities. Examples include highly-interactive video conferencing technology, collaborative tools, social media and networking platforms. In this narrative review, we examine the utility of these technologies in supporting effective communication and professional activities of anatomists during COVID-19 and after.

A review of clinical and oncological outcomes following the introduction of the first robotic colorectal surgery programme to a university teaching hospital in Ireland using a dual console training platform.

Robotic-assisted surgery is evolving, with improving clinical and cancer outcomes. The aim of this study was to present the clinical and cancer outcomes of patients undergoing robotic-assisted colorectal surgery (RAS-CR) at University Hospital Limerick (UHL) since its introduction to the 100th case, using the daVinci Xi dual-console surgical system. The RAS-CR programme at UHL commenced in June 2016 and the 100th case was performed in July 2019. All patient-related data were recorded prospectively during the perioperative period by the RAS-CR team. Statistical analysis was performed using SPSS, version 22. One hundred patients were operated on, comprising of 47 males and 53 females. The median age was 65 years (IQR 13.0; range 25-84) with 69% of cases performed for cancer [N = 39 rectal cancer, N = 30 colon cancer], 20% for benign disease and 11% for dysplasia. Median length of stay for cancer operations was 6.5 days for colon cancer cases (5.0 days when cases with complications were excluded) and 7.0 days for rectal cancer cases. Median operative time was 255 mins (IQR 130 min; all cases), median docking time was 33 mins (IQR 20 mins) and median intra-operative blood loss was 80 ml (IQR 70 ml). Thirty-one patients developed a post-operative complication (5% anastomotic leak; 13% SSI). In cancer cases, median nodal harvest was 14 nodes (IQR10) and an R0 resection was achieved in 98.6% (n = 68) of cancer cases. Three patients (4.3%) developed metastatic disease at a median interval of 16.5 months. Clinical and operative outcomes remained stable over time from case 1 to 100. Structured introduction of a RAS-CR programme with appropriate governance and continuous audit results in favourable clinical and cancer outcomes and provides an excellent training opportunity for surgical residents.

The Mesentery, Systemic Inflammation, and Crohn's Disease.

Initially thought to be a structure that only provided support to the abdominal contents, the mesentery has now gained special attention in the scientific community. The new approach of studying the mesentery as an individual organ has highlighted its importance in the development of local and systemic inflammatory diseases and its potential role in Crohn's disease. Its topographical relationship with the intestine in the setting of active inflammation and "creeping fat" is possibly one of the most important arguments for including the mesentery as an important factor in the pathogenesis of Crohn's disease. In this review, we discuss the importance of the mesentery from the anatomical and embryological standpoints. We also will summarize data on mesenteric inflammation in patients with Crohn's disease. The significance of the mesentery in systemic inflammatory syndromes will be discussed, and we provide an overview of primary inflammatory disorders of the mesentery. Finally, we discuss surgical approaches for patients requiring resection for Crohn's disease that incorporate mesenteric factors, pointing out recent data suggesting that these have the potential for improving outcomes and reducing disease recurrence.10.1093/ibd/izy201_video1izy201.video15794169491001.

Anatomy of the mesentery: Historical development and recent advances.

Recent appraisals of mesenteric anatomy clarify its structure and show a continuous and helical-shaped organ. This new model signifies a departure from the conventional model which described multiple, separate "mesenteries". Renaissance anatomists depicted the mesentery as a continuous structure. Events that led to replacement of a continuous with a fragmented model span several centuries. In effect, the scientific and clinical community has come full circle and back to the Renaissance model. Here we review the historical development of our understanding of the mesentery. We discuss how the fragmented model replaced the continuous model. Additionally, we examine factors that contributed to recent advances in mesenteric anatomy as these present new opportunities for systematic investigation.

Anatomy of the mesentery: Current understanding and mechanisms of attachment.

An understanding of the anatomy of the mesentery is necessary to undertake any appraisal of the literature on its development. The mesentery is the collection of tissues that maintain all abdominal digestive organs in position and connection with the rest of the body. Therefore, it is also necessary to detail the exact mechanisms that maintain the mesentery in position. We explore these mechanisms, including the supportive functions of structures such as Toldt's fascia, the peritoneal reflection, and vascular connections, in this article.

Development of mesenteric tissues.

Mesothelial, neurovascular, lymphatic, adipose and mesenchymal tissues make up the mesentery. These tissues are pathobiologically important for numerous reasons. Collectively, they form a continuous, discrete and substantive organ. Additionally, they maintain abdominal digestive organs in position and in continuity with other systems. Furthermore, as they occupy a central position, they mediate transmission of signals between the abdominal digestive system and the remainder of the body. Despite this physiologic centrality, mesenteric tissue development has received little investigatory focus. However, recent advances in our understanding of anatomy demonstrate continuity between all mesenteric tissues, thereby linking previously unrelated studies. In this review, we examine the development of mesenteric tissue in normality and in the setting of congenital abnormalities.

Development of a Novel Technique to Dissect the Mesentery That Preserves Mesenteric Continuity and Enables Characterization of the ex vivo Mesentery.

Introduction: The conventional model of abdominal anatomy described multiple mesenteries. Dissection techniques were based on this. Recent studies demonstrate the mesentery is continuous from duodenojejunal flexure to anorectal junction. Given this, it is important to update dissection techniques related to the mesentery in the cadaveric setting. Materials and Methods: A technique of mesenteric dissection was developed and tested in a cohort of 20 adult human cadavers (12 male and 8 female). As the technique enabled excision of the mesentery as a single unit, it was possible to characterize the anatomy of the ex vivo mesentery. Results: The technique developed enabled dissection of an intact and continuous mesentery in all cadavers examined. Examination of the ex vivo mesentery demonstrated that a mesoduodenum was present in all cases. The mesentery was continuous from the mesoduodenum to the mesorectum and ended at the level of the anorectal junction. Conclusions: A technique was developed that reproducibly enabled dissection of an intact and continuous mesentery from the duodenum to the anorectal junction. A mesoduodenum was consistently observed and noted to be in continuity with the remainder of the mesentery.

Festschrift for Patrick Ronan (PR) O'Connell (also known as ROCON): reconciling surgery and science.

Ronan O Connell's clinical activities were fundamentally based on accurate data. His scientific outputs were based on similarly high quality data. Anybody who trained with him and in particular those who trained with him on more than occasion base their clinical and scientific activities on a similar approach. His many clinical, scientific and political achievements and accolades will be detailed in the articles in this Festschrift. There is an advancement that is important to me personally and that I would like to attribute to his influence. Exceptional and highly reproducible technique underpinned his surgery and explained the outcomes his patients experienced. Recent clarification of the anatomical basis of these techniques (the mesenteric basis) provides a unifying platform across which to reconcile human abdominal anatomy and surgery.

Prophylactic Negative Pressure Dressing Use in Closed Laparotomy Wounds Following Abdominal Operations: A Randomized, Controlled, Open-label Trial: The P.I.C.O. Trial.

OBJECTIVE: A randomized controlled trial was undertaken to investigate the effect of prophylactic negative pressure dressings on postoperative surgical site infection (SSI) rates in closed laparotomy wounds. SUMMARY OF BACKGROUND DATA: Laparotomy wounds are associated with high rates of SSI. The effect of prophylactic negative pressure dressing of closed incisional wounds on SSI rate is unknown. METHODS: A randomized, controlled, open-label trial was conducted (clinicaltrials.gov registration number NCT02780453). Fifty patients undergoing open abdominal surgery were included, with 25 patients randomized to the negative pressure dressing group and 25 to the standard dressing group. The primary endpoint was SSI incidence at 30 days postoperatively. Secondary endpoints included SSI incidence at 4 days, length of stay, cosmetic outcome, and patient satisfaction. Statistical analysis was performed on a per-protocol basis using SPSS version 23.0. RESULTS: The incidence of SSI at 30 days postoperatively was significantly reduced in the treatment group compared with the control group [8.3% vs 32.0%, P = 0.043 (1-sided), P = 0.074 (2-sided)]. There was no difference in SSIs at 4 days postoperatively [4.1% vs 8.0%, P = 0.516 (1-sided), P = 1.0 (2-sided)]. Analysis of predictors of wound infection identified standard wound dressings as the only significant predictor of SSI development. Length of stay was significantly reduced in the negative pressure dressing group [6.1 vs 14.7 days, P = 0.019 (2-sided)]. Cosmetic outcome and patient satisfaction did not show any difference between the 2 groups. CONCLUSIONS: Prophylactic use of negative pressure dressings for closed laparotomy wounds significantly reduces the incidence of SSI at 30 days postoperatively.