Background Following several landmark trials, laparoscopic rectal resection has reached standard clinical practice. Current literature is undecided on the advantages of robotic rectal resection and little is known on its learning curve. This study aimed to compare the outcomes of the first 100 robotic rectal resections to the laparoscopic approach in a teaching hospital experienced in laparoscopic colorectal surgery. Methods A retrospective analysis was conducted of a prospective cohort of all consecutive rectal resections between January 2012 and September 2019 at a single center. All laparoscopic cases were compared to the robotic approach. Outcomes included operative time, morbidity, anastomotic leakage, and hospital stay. Results Out of the 326 consecutive resections, 100 were performed robotically and 220 laparoscopically, the remaining 6 open cases were excluded. Median operative time was lower for robotic cases (147 (121–167) versus 162 (120–218) minutes P = 0.024). Overall morbidity was lower in robotic cases (25% versus 50%, P < 0.001), while major morbidity was similar. Anastomotic leakage was observed in 11% (8/70) of robotic and 15% (18/120) of laparoscopic anastomoses, despite more anastomoses in the robotic group (70%, 70/100 versus 55%, 120/220, P = 0.001). Median length of stay was 4 (4–7) days after a robotic and 6 (5–9) days after a laparoscopic procedure. Discussion Implementation of a robotic rectal resection program in an experienced laparoscopic surgery center was associated with reduced operative time, length of stay, and fewer complications despite a learning curve.

Background: Surgical site infections (SSI) are seen in up to 5% of patients after appendectomy for acute appendicitis. SSI are associated with prolonged hospital stay and increased costs. The aim of this multicenter study was to identify factors associated with SSI after appendectomy for acute appendicitis. Methods: Patients who underwent appendectomy for acute appendicitis between June 2014 and January 2015 in 6 teaching hospitals in the southwest of the Netherlands were included. Patient, diagnostic, intra-operative and disease-related factors were collected from the patients' charts. Primary outcome was surgical site infection. Multivariable logistic regression was performed to identify independent risk factors for SSI. Results: Some 637 patients were included. Forty-two patients developed a SSI. In univariable analysis body temperature >38°C, CRP>65 and complex appendicitis were associated with SSI. After multivariable logistic regression with stepwise backwards elimination, complex appendicitis was significantly associated with SSI (OR 4.09; 95% CI 2.04-8.20). Appendiceal stump closure with a stapler device was inversely correlated with SSI (OR 0.40; 95% CI 0.24-0.97) Conclusions: Complex appendicitis is a risk factor for SSI and warrants close monitoring postoperatively. The use of a stapler device for appendiceal stump closure is associated with a reduced risk of SSI.

This experimental study suggested that XCM Biologic was superior in terms of incorporation, macroscopic mesh infection, and histological parameters such as collagen deposition and neovascularization. There must be sufficient overlap of mesh during placement, as XCM Biologic showed a high rate of shrinkage. Surgical relevance The use of synthetic mesh to repair a potentially contaminated incisional hernia is not supported unequivocally, and may lead to a higher failure rate. A biological mesh might be considered as an alternative. There are few long-term studies, as these meshes are expensive and rarely used. This study evaluated the use of biological mesh in a contaminated environment, and investigated whether there is an ideal mesh. A new non-cross-linked biological mesh (XCM Biologic ) was evaluated in this experiment. The new non-cross-linked biological mesh XCM Biologic performed best and may be useful in patients with a potentially contaminated incisional hernia.

Background . In laparoscopic incisional hernia repair, direct contact between the prosthesis and abdominal viscera is inevitable and may lead to adhesions. Despite the large variety of mesh prosthesis, little is known about their in vivo behavior. Biological meshes are considered to have many advantages, but due to their price they are rarely used. A rat model was used to assess biological and conventional synthetic meshes on their in vivo characteristics. Design . One-hundred twenty male Wistar rats were randomized into five groups of 24 rats. A mesh was implanted intraperitoneally and fixated with nonresorbable sutures. The following five meshes were implanted: Parietene (polypropylene), Permacol (cross-linked porcine acellular dermal matrix), Strattice (non-cross-linked porcine acellular dermal matrix), XCM Biologic (non-cross-linked porcine acellular dermal matrix), and Omyra Mesh (condensed polytetrafluoroethylene). The rats were sacrificed after 30, 90, or 180 days. Incorporation, shrinkage, adhesions, abscess formation, and histology were assessed for all meshes. Results . All animals thrived postoperatively. After 180 days, Permacol, Parietene, and Omyra Mesh had a significantly better incorporation than Strattice ( P = .001, P = .019, and P = .037 respectively). After 180 days, Strattice had significantly fewer adhesions on the surface of the mesh than Parietene ( P < .001), Omyra Mesh ( P = .011), and Permacol ( P = .027). After 30 days, Permacol had significantly stronger adhesions than Strattice ( P = .030). However, this difference was not significant anymore after 180 days. After 180 days, there was significantly less shrinkage in Permacol than in Strattice ( P = .001) and Omyra Mesh ( P = .050). Conclusion . Based on incorporation, adhesions, mesh shrinkage, and histologic parameters, Strattice performed best in this experimental rat model.

Aim: Numerous quality improvement initiatives for rectal cancer surgery have focused on textbook outcome parameters. In these studies, resection rate and patients who did not undergo surgery are not included, but these parameters might help to evaluate the surgical care for rectal cancer. The aim of this study is to assess the variation of non-metastatic rectal cancer resection rates among hospitals and its effect on patient outcomes. Methods: All patients diagnosed with non-metastatic rectal cancer between 2013 and 2018 were selected from the Netherlands Cancer Registry. Hospitals were categorized in quartiles according to resection rates. A multivariable logistic analysis was performed to determine variation in resection rate between these quartiles using a logistic regression analysis to correct for confounders. The association between resection rates and survival was analyzed using Kaplan-Meier method and Cox-regression analysis. Results: A total of 22,530 patients were included in the analysis. Resection rates varied from 68 to 89% between hospitals. After multivariable analysis, resection rate remained significantly different among the quartiles when correcting for several factors (odds ratio (95%Confidence-interval) 1.71 (1.56e1.88), 2.42 (2.19e2.67), and 4.04 (3.61e4.53) for increasing resection rate quartiles, in reference to the lowest quartile). A higher resection rate was associated with better overall survival, in multivariable analysis this survival benefit could no longer be identified. Conclusion:There is a substantial variation in resection rates for rectal cancer among hospitals in the Netherlands with an impact on overall survival. This may be a relevant issue when analyzing the overall quality of rectal cancer care.

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Background and Objectives: Magnetic resonance imaging of the pelvis has a limited accuracy to detect positive lymph nodes but does dictate neoadjuvant treatment in rectal cancer. This study aimed to investigate preoperative lymph node understaging and its effects on postoperative local recurrence rate. Methods: Patients were selected from a retrospective cross-sectional snapshot study. Patients with emergency surgery, cM1 disease, or unknown cN-or (y)pN category were excluded. Clinical and pathologic N-categories were compared and the impact on local recurrence was determined by multivariable analysis. Results: Out of 1548 included patients, 233 had preoperatively underestimated lymph node staging based on (y)pN category. Out of the 695 patients staged cN0, 168 (24%) had positive lymph nodes at pathology, and out of the 594 patients staged cN1, 65 (11%) were (y)pN2. Overall 3-year local recurrence rate was 5%. Clinical N-category was not associated with local recurrence when corrected for pT-category, neoadjuvant therapy, and resection margin, neither in patients with (y)pN1 (hazard ratio [HR]: 1.67 (95% confidence interval [CI]: 0.68-4.12) P = .263) nor (y)pN2-category (HR: 1.91 95% CI: [0.75-4.84], P = .175). Conclusion: Preoperative understaging of nodal status in rectal cancer is not uncommon. No significant effect on local recurrence or overall survival rates were found in the present study.

Aim An increasing number of centers have implemented a robotic surgical program for rectal cancer. Several randomized controls trials have shown similar oncological and postoperative outcomes compared to standard laparoscopic resections. While introducing a robot rectal resection program seems safe, there are no data regarding implementation on a nationwide scale. Since 2018 robot resections are separately registered in the mandatory Dutch Colorectal Audit. The present study aims to evaluate the trend in the implementation of robotic resections (RR) for rectal cancer relative to laparoscopic rectal resections (LRR) in the Netherlands between 2018 and 2020 and to compare the differences in outcomes between the operative approaches. Methods Patients with rectal cancer who underwent surgical resection between 2018 and 2020 were selected from the Dutch Colorectal Audit. The data included patient characteristics, disease characteristics, surgical procedure details, postoperative outcomes. The outcomes included any complication within 90 days after surgery; data were categorized according to surgical approach. Results Between 2018 and 2020, 6330 patients were included in the analyses. 1146 patients underwent a RR (18%), 3312 patients a LRR (51%), 526 (8%) an open rectal resection, 641 a TaTME (10%), and 705 had a local resection (11%). The proportion of males and distal tumors was higher in the RR compared to the LRR. Over time, the proportion of robotic procedures increased from 15% (95% confidence intervals (CI) 13–16%) in 2018 to 22% (95% CI 20–24%) in 2020. Conversion rate was lower in the robotic group [4% (95% CI 3–5%) versus 7% (95% CI 6–8%)]. Anastomotic leakage rate was similar with 16%. Defunctioning ileostomies were more common in the RR group [42% (95% CI 38–46%) versus 29% (95% CI 26–31%)]. Conclusion Rectal resections are increasingly being performed through a robot-assisted approach in the Netherlands. The proportion of males and low rectal cancers was higher in RR compared to LRR. Overall outcomes were comparable, while conversion rate was lower in RR, the proportion of defunctioning ileostomies was higher compared to LRR.