Robotic TAPP was associated with a rapid reduction in operative time during our learning curve and afterwards the operative time to perform a robotic TAPP equals the operative time to perform a laparoscopic TAPP, both for unilateral and for bilateral groin hernia repairs. No complications related to the introduction of robotic-assisted laparoscopic groin hernia repair were observed.

Since laparoscopy was introduced, a long implementation process has been necessary to allow for standardization and improvement in surgical care, mastery of the technique, and the ability to obtain good perioperative results with safe oncologic outcomes.

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Introduction Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short‐term outcomes of TaTME, open, laparoscopic, and robotic TME internationally. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02–2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10–7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non‐transanal laparoscopic TME. However this association was lost in the mixed‐effects model controlling for patient and disease factors (OR 1.23, 0.77–1.97, P = 0.39 and OR 2.11, 0.79–5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55–4.77, P < 0.001) and male gender (OR 2.29, 1.52–3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%. Conclusion This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.

Introduction: B. virosa is a gram-negative rod who was first identified in rat faeces in 2009. Since then only six human infections have been described in literature. We report a clinical case of a subcutaneous infection mimicking necrotizing fasciitis due to B. virosa. Patient and methods: A 78-year-old man was referred to our hospital because of a wound infection with suspicion of necrotizing fasciitis. Treatment consisted of immediate surgical exploration with obtainment of intra-operative specimens for microbiologic examination, 15 days of negative pressure wound therapy (NPWT) and antibiotic treatment with piperacillin-tazobactam (12 days) plus vancomycin (9 days). Results: Surgical exploration did not show necrotising fasciitis but a subcutaneous infection mimicking necrotising fasciitis. The intra-operative specimens revealed the presence of Butyricimonas virosa and Finegoldia magna. Cultures taken during the NPWT replacements became negative and the patient was able to leave the hospital after 18 days. Conclusions: Considering there was no necrotizing infection present it may have been possible to safely close the wound sooner. However it is difficult to differentiate between an actual necrotizing fasciitis and a subcutaneous infection mimicking necrotizing fasciitis. Therefore further studies on effective assessment tools to diagnose necrotizing fasciitis could be helpful.

Background Laparoscopy has now been implemented as a standard of care for elective colonic resection around the world. During the adoption period, studies showed that conversion may be detrimental to patients, with poorer outcomes than both laparoscopic completed or planned open surgery. The primary aim of this study was to determine whether laparoscopic conversion was associated with a higher major complication rate than planned open surgery in contemporary, international practice. Methods Combined analysis of the European Society of Coloproctology 2017 and 2015 audits. Patients were included if they underwent elective resection of a colonic segment from the caecum to the rectosigmoid junction with primary anastomosis. The primary outcome measure was the 30‐day major complication rate, defined as Clavien‐Dindo grade III‐V. Results Of 3980 patients, 64% (2561/3980) underwent laparoscopic surgery and a laparoscopic conversion rate of 14% (359/2561). The major complication rate was highest after open surgery (laparoscopic 7.4%, converted 9.7%, open 11.6%, P < 0.001). After case mix adjustment in a multilevel model, only planned open (and not laparoscopic converted) surgery was associated with increased major complications in comparison to laparoscopic surgery (OR 1.64, 1.27–2.11, P < 0.001). Conclusions Appropriate laparoscopic conversion should not be considered a treatment failure in modern practice. Conversion does not appear to place patients at increased risk of complications vs planned open surgery, supporting broadening of selection criteria for attempted laparoscopy in elective colonic resection.

Introduction The mainstay of management for locally advanced rectal cancer is chemoradiotherapy followed by surgical resection. Following chemoradiotherapy, a complete response may be detected clinically and radiologically (cCR) prior to surgery or pathologically after surgery (pCR). We aim to report the overall complete pathological response (pCR) rate and the reliability of detecting a cCR by conventional pre‐operative imaging. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients treated by elective rectal resection were included. A pCR was defined as a ypT0 N0 EMVI negative primary tumour; a partial response represented any regression from baseline staging following chemoradiotherapy. The primary endpoint was the pCR rate. The secondary endpoint was agreement between post‐treatment MRI restaging (yMRI) and final pathological staging. Results Of 2572 patients undergoing rectal cancer surgery in 277 participating centres across 44 countries, 673 (26.2%) underwent chemoradiotherapy and surgery. The pCR rate was 10.3% (67/649), with a partial response in 35.9% (233/649) patients. Comparison of AJCC stage determined by post‐treatment yMRI with final pathology showed understaging in 13% (55/429) and overstaging in 34% (148/429). Agreement between yMRI and final pathology for T‐stage, N‐stage, or AJCC status were each graded as ‘fair’ only (n = 429, Kappa 0.25, 0.26 and 0.35 respectively). Conclusion The reported pCR rate of 10% highlights the potential for non‐operative management in selected cases. The limited strength of agreement between basic conventional post‐chemoradiotherapy imaging assessment techniques and pathology suggest alternative markers of response should be considered, in the context of controlled clinical trials.

Aim:The Enhanced Recovery After Surgery (ERAS®) Society guidelines aim to standardize perioperative care in colorectal surgery via 25 principles. We aimed to assess the variation in uptake of these principles across an international network of colorectal units.Method: An online survey was circulated amongst European Society of Coloproctology members in 2019-2020. For each ERAS principle, respondents were asked to score how frequently the principle was implemented in their hospital, from 1 ('rarely') to 4 ('always'). Respondents were also asked to recall whether practice had changed since 2017.Subgroup analyses based on hospital characteristics were conducted.Results: Of hospitals approached, 58% responded to the survey (195/335), with 296 individual responses (multiple responses were received from some hospitals). The majority were European (163/195, 83.6%). Overall, respondents indicated they 'most often' or 'always' adhered to most individual ERAS principles (18/25, 72%). Variability in the uptake of principles was reported, with universal uptake of some principles (e.g., prophylactic antibiotics; early mobilization) and inconsistency from 'rarely' to 'always' in others (e.g., no nasogastric intubation; no preoperative fasting and carbohydrate drinks). In alignment with 2018 ERAS guideline updates, adherence to principles for prehabilitation, managing anaemia and postoperative nutrition appears to have increased since 2017.Conclusions: Uptake of ERAS principles varied across hospitals, and not all 25 principles were equally adhered to. Whilst some principles exhibited a high level of acceptance, others had a wide variability in uptake indicative of controversy or barriers to uptake. Further research into specific principles is required to improve ERAS implementation.