This is the first randomised controlled trial to assess the operating ergonomics of open console robotic surgery for inguinal hernia surgery. Intraoperative ergonomic risk was assessed using the Rapid Entire Body Assessment (REBA) scale, with photographs taken at 1-min intervals. Secondary outcomes included team nontechnical skills (NTS) assessment, surgeon cognitive strain, and patient clinical outcomes. Patients were stratified on unilateral/bilateral hernias. Sixty patients were randomised, 1 was withdrawn (39 robot:20 lap). Robotic REBA scores were significantly lower than laparoscopic (median robot 3.0 vs lap 5.0 [p ​< ​0.001]). Robotic operations were longer (mean 64.9 ​± ​21.1 ​min vs 31.7 ​± ​10.3 ​min [p ​< ​0.001]). More robotic patients had resumed normal activities at 14-days (15(39 ​%) vs 1(5 ​%) [p ​= ​0.006]). Team NTS (Oxford NOTECHS II) and surgeon cognitive strain (modified NASA-TLX) were unaffected by modality, and all other patient outcomes were equal. This trial demonstrates that robotic surgery reduces ergonomic risk during inguinal hernia surgery, with no detriment to cognitive strain or team functioning. This may therefore be a safe & feasible solution to the increasing problem of work-related musculoskeletal injuries in surgeons.

This pre-post trial investigates whether ergonomic education using the STEPS model (Screen, Table, Equipment, Posture, Stance) can improve laparoscopic surgeons' ergonomic risk. Intraoperative photographs taken at 1-min intervals were used to calculate risk through the objective Rapid Entire Body Assessment (REBA) scale. Surgeons were reobserved immediately after an educational video, then again 4-6 weeks later. Cognitive strain (modified NASA-TLX), subjective outcomes, and knowledge retention were also assessed. Ten surgeons were recruited from colorectal, general, and gynaecology. There was no difference in REBA between baseline (REBA ​= ​5.0) and early reobservation (REBA ​= ​4.5) [0 ​= ​0.058], but between baseline and late reobservation (REBA ​= ​4.5) there was a significant reduction [p ​= ​0.028]. The overall scores for each day remained in the "medium risk" category. Knowledge retention was good (90 ​% correct answers). All found the education worthwhile and subsequently made changes to their practice. Ergonomic education is desired and deemed very important by surgeons, and reduces both their ergonomic risk and subjective experience of pain, but laparoscopic surgery remains ergonomically "medium risk" overall. Further solutions must be found to reduce risk.

Abstract Aim This study assesses preoperative perceptions and postoperative satisfaction amongst patients undergoing robotic-assisted colorectal surgery, in order to optimise preoperative information provision and improve patient experience. Method A structured quantitative and qualitative questionnaire was designed, to include questions on preoperative perceptions and prior knowledge about robotic surgery, and postoperative experiential feedback. All patients who had robotic colorectal resection at the host institution were included and had previously consented to potential inclusion in future research. Patients were contacted postoperatively. Quantitative outcomes were assessed using descriptive statistics and qualitative analysis was conducted using a thematic approach. Results Of 151 eligible participants, 108 provided complete responses. All underwent colorectal resection between November 2019 and August 2022.The mean±SD age of respondents was 63.1±15.2 years and 55% (n=59) were male. Prior knowledge varied; 73% (n=79) knew nothing about robotic surgery and 9% (n=10) reported apprehension, although others were intrigued (16%) or excited (14%). Four percent (n=4) of patients thought the robot was autonomous. After clinic review 81% (n=88) felt well informed about the robotic aspect. Positive feelings towards robotics were based on a perception of new technology as “better” and trust in surgeons’ advice. Post-surgery feedback was positive; 71% (n=77) were extremely satisfied and only 14% (n=15) had a neutral or negative experience. Ninety-three percent (n=100) would recommend robotic surgery to others. Conclusions Improved patient information leaflets may alleviate preoperative concerns about robotic surgery, but generally this innovation is well received by patients and may indicate that patients actively seek out this modality in future.

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. 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. Sixty patients were randomised in a 2:1 ratio (40 robot, 20 laparoscopic). Mean age was 65yrs and 34 (57

Introduction Colorectal cancer (CRC) is a major cause of cancer related mortality. Iron deficiency anaemia (IDA) contributes to this mortality, it is common in CRC and is often treated with oral iron. However, excess of luminal iron promotes pathogenic bacteria and a pro-inflammatory microenvironment associated with increased risk of cancer progression. Tumour Associated Macrophages are innate immune cells that, upon activation with Toll Like Receptor (TLR2) ligands, store iron and acquire tumoricidal properties. We previously demonstrated that intravenous iron (IV) is compartmentalised within macrophage-like cells associated with the stromal tissue away from the tumour cells. Whereas oral iron was expressed within cells localised to the tumour tissues. Our aim is to determine the effect of oral versus IV iron on the number, localisation and activation of tissue macrophages from CRC patients with IDA. Methods Normal and tumour tissues were obtained from patients enrolled in the IVICA trial (REC 11/EM/0237). Patients with CRC and IDA were randomised to receive oral ferrous sulphate (n=20) or IV ferric carboxymaltose (n=20). Macrophages were identified as CD68 positive and the expression of TLR2 and TLR4 determined using immunofluorescence microscopy. Results The number of macrophages was significantly higher on tumour tissues compared with normal tissues (mean ± SD, 68.8 ± 34.5 vs 39.6 ± 28.1), (p<0.02). Macrophage expression was also significantly higher on tumour tissues obtained from patients who received IV iron compared with oral iron (103 ± 42.3 vs 68.8 ± 34.5) respectively, (p<0.02). In CRC tissues macrophages were localised as clusters in the stromal tissue. There were no significant differences in the number of macrophages in normal tissue between the treatment groups. In normal tissue, macrophages were distributed evenly in the lamina propria. TLR2 expression was significantly higher on macrophages from tumour tissues compared with normal tissues (89 ± 35 vs 52.8 ± 16), (p<0.007). Moreover, TLR2 expression was significantly higher on macrophages from tumour tissues obtained from patients who received IV iron compared with oral iron (73.7 ± 30 vs 40.8 ± 15), (p<0.03). There were no significant differences in TLR4 expression between tissue types or treatment groups. Conclusions Data demonstrated, in vivo, that IV iron treatment may increase the recruitment of macrophages to tumour tissues and increase TLR2 expression in CRC patients. TLR2 upregulation, stimulates macrophages to sequester iron and produce proinflammatory mediators that may be beneficial in regulating tumour progression. Further studies are ongoing to confirm the phenotype and function of macrophages in the tumour microenvironment of patients with CRC and IDA.

BACKGROUND:Anaemia is highly prevalent in people with advanced, palliative cancer yet sufficiently effective and safe treatments are lacking. Oral iron is poorly tolerated, and blood transfusion offers only transient benefits. Intravenous iron has shown promise as an effective treatment for anaemia but its use for people with advanced, palliative cancer lacks evidence. AIMS:To assess feasibility of the trial design according to screening, recruitment, and attrition rates. To evaluate the efficacy of intravenous iron to treat anaemia in people with solid tumours, receiving palliative care. DESIGN:A multicentre, randomised, double blind, placebo-controlled trial of intravenous iron (ferric derisomaltose, Monofer®). Outcomes included trial feasibility, change in blood indices, and change in quality of life via three validated questionnaires (EQ5D5L, QLQC30, and the FACIT-F) over 8 weeks. (ISRCTN; 13370767). SETTING/PARTICIPANTS:People with anaemia and advanced solid tumours who were fatigued with a performance status ⩽2 receiving support from a specialist palliative care service. RESULTS:34 participants were randomised over 16 months (17 iron, 17 placebo). Among those eligible 47% of people agreed to participate and total study attrition was 26%. Blinding was successful in all participants. There were no serious adverse reactions. Results indicated that intravenous iron may be efficacious at improving participant haemoglobin, iron stores and select fatigue specific quality of life measures compared to placebo. CONCLUSION:The trial was feasible according to recruitment and attrition rates. Intravenous iron increased haemoglobin and may improve fatigue specific quality of life measures compared to placebo. A definitive trial is required for confirmation.

INTRODUCTION:As laparoscopic surgery is used more widely across the globe and within multiple surgical specialties the potential impact on surgeons is yet to be fully quantified. Maintenance of uncomfortable body positions may lead to work-related musculoskeletal disorders (WMSD) in surgeons, with potential knock-on effects. METHODS:An international open online survey of multispecialty laparoscopic surgeons was carried out, designed and reported in accordance with the CHERRIES checklist for internet e-survey research. There was no paid advertising and no incentives offered. RESULTS:A total of 259 surgeons from 9 specialties and 32 countries answered the survey, with 90% reporting pain attributable to performing laparoscopic surgery. All training grades were represented. Longer average operative duration and a greater number of years in practice were both associated with a significantly higher prevalence of pain. Surgeons with a pre-existing injury were significantly more likely to report pain than those without. Twenty per cent of surgeons would consider early retirement owing to pain. CONCLUSIONS:The impact on surgeons of performing laparoscopic surgery is significant, even given the limitations of an open survey. Innovations such as robotic surgery and improved ergonomic education may reduce the incidence of WMSD in surgeons, to mitigate both the personal effects on surgeons and the wider effect on the future surgical workforce.

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.

As robotic assisted colorectal surgery increases in prevalence new systems are entering the market, each of which requires technique modifications. In this technical note we describe technical insights and tips gained from our extensive experience of 150 colorectal resections using the Versius® system from CMR Surgical. The triad of optimal bedside unit placement, port placement, and arm configuration is described for right hemicolectomy and anterior resection.

We would like to thank Mr McSorley et al for their insightful letter regarding our recent study investigating the long term outcomes of colorectal cancer patients who have received preoperative intravenous (IV) iron for their anaemia (1).

This study investigates whether a straight‐to‐test (STT) colorectal cancer pathway improves attainment of the National Health Service (NHS) England 28‐day Faster Diagnosis Standard and the effect of the pathway on reducing face‐to‐face outpatient clinic appointments. Patient satisfaction and the safety of a novel general practitioner (GP) led patient triage system regarding suitability for colonoscopy are also evaluated.

Oral iron promotes intestinal tumourigenesis in animal models. In humans, expression of iron transport proteins are altered in colorectal cancer. This study examined whether the route of iron therapy alters iron transport and tumour growth. Colorectal adenocarcinoma patients with pre-operative iron deficiency anaemia received oral ferrous sulphate (n = 15), or intravenous ferric carboxymaltose (n = 15). Paired (normal and tumour tissues) samples were compared for expression of iron loading, iron transporters, proliferation, apoptosis and Wnt signalling using immunohistochemistry and RT-PCR. Iron loading was increased in tumour and distributed to the stroma in intravenous treatment and to the epithelium in oral treatment. Protein and mRNA expression of proliferation and iron transporters were increased in tumours compared to normal tissues but there were no significant differences between the treatment groups. However, intravenous iron treatment reduced ferritin mRNA levels in tumours and replenished body iron stores. Iron distribution to non-epithelial cells in intravenous iron suggests that iron is less bioavailable to tumour cells. Therefore, intravenous iron may be a better option in the treatment of colorectal cancer patients with iron deficiency anaemia due to its efficiency in replenishing iron levels while its effect on proliferation and iron metabolism is similar to that of oral iron treatment.

This study investigates whether a straight-to-test (STT) colorectal cancer pathway improves attainment of the National Health Service (NHS) England 28-day Faster Diagnosis Standard and the effect of the pathway on reducing face-to-face outpatient clinic appointments. Patient satisfaction and the safety of a novel general practitioner (GP) led patient triage system regarding suitability for colonoscopy are also evaluated. This is an observational study of all patients managed via an STT colorectal cancer pathway between 1 September 2019 and 19 March 2020. Comparison is made with all patients referred on the suspected colorectal cancer pathway prior to implementation of the STT pathway from 1 January 2019 to 30 July 2019. Patient satisfaction with the STT pathway was assessed with a telephone-based questionnaire. Attainment of the 28-day diagnosis target for all suspected colorectal cancer referrals improved following the establishment of the STT pathway (88% vs. 82%, P  < 0.0001). From a potential total of 548 outpatient colorectal clinic appointments for patients on the STT pathway, 504 (92%) were avoided. In those eligible for the STT pathway, GP assessment of patients suitable for colonoscopy agreed with that of the colorectal department in 93% of cases. Of the 50 patients who undertook the satisfaction survey, 86% were satisfied or very satisfied with the pathway. No patient suffered adverse events as a result of their STT investigations. An STT pathway for suspected colorectal cancer referrals with novel GP-led patient triage safely streamlines patients through the suspected colorectal cancer diagnostic pathway and significantly reduces requirement for face-to-face outpatient clinic attendance. This is achieved with high patient satisfaction.

Introduction Concerns relating to coronavirus disease 2019 (COVID-19) and general anesthesia (GA) prompted our department to consider that open appendicectomy under spinal anesthesia (SA) avoids aerosolization from intubation and laparoscopy. While common in developing nations, it is unusual in the United Kingdom. We present the first United Kingdom case series and discuss its potential role during and after this pandemic. Methods We prospectively studied patients with appendicitis at a British district general hospital who were unsuitable for conservative management and consequently underwent open appendicectomy under SA. We also reviewed patient satisfaction after 30 days. This ran for 5 weeks from March 25th, 2020 until the surgical department reverted to the laparoscopic appendicectomy as the standard of care. Main outcomes were 30-day complication rates and patient satisfaction. Results None of the included seven patients were COVID positive. The majority (four-sevenths) had complicated appendicitis. There were no major adverse (Clavien-Dindo grade III to V) postoperative events. Two patients suffered minor postoperative complications. Two experienced intraoperative pain. Mean operative time was 44minutes. Median length of stay and return to activity was 1 and 14 days, respectively. Although four stated preference in hindsight for GA, the majority (five-sevenths) were satisfied with the operative experience under SA. Discussion Although contraindications, risk of pain, and specific complications may be limiting, our series demonstrates open appendicectomy under SA to be safe and feasible in the United Kingdom. The technique could be a valuable contingency for COVID-suspected cases and patients with high-risk respiratory disease.

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 (R) system from CMR Surgical (1 Evolution Business Park, Cambridge, UK) in a multi-specialty setting. Materials and methods: All patients undergoing Versius (R)-assisted surgery in a previously robot-naive 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 (R) 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.

The number of abdominal procedures performed via a robotic-assisted approach is increasing as potential advantages of the modality are recognised. We report the first in human case series of major colorectal resection performed using a new system, Versius®, and assess the feasibility of its use. The initial cases performed using Versius® at a single centre in the UK were included in the study. Anonymised data were prospectively collected including patient demographics, operative details and postoperative outcomes. Twenty-three operations were performed, including left (n = 14) and right (n = 9)-sided colonic resections. Rectal mobilisation was performed in 13. Fifty-seven percent of the patients were male, with a malignant indication for surgery in 70% of cases. Overall mean age was 59.1 ± 15.3 (range 23–89) years. Overall mean body mass index was 28.9 ± 5.2 with a mean of 31.3 ± 4.5 for left-sided resections. The median console operating time was 166 min (range 75–320 min). All malignant cases had negative resection margins and the mean lymph node yield was 18 (SD 9.4). Only one operation (4%) was converted from robotic to open approach. Postoperative length of stay was a median of 5 days (range 3–34 days) and there were no readmissions within 30 days. These results compare favourably with the literature on existing robotic systems and also conventional laparoscopic surgery; hence, we believe that this series indicates the Versius® system is feasible for use in major colorectal resection. These early results from a robot-naïve centre show exciting promise for an expanding robotic market and highlight the need for further evaluation.

As a topical domain, robotic surgery is a fast moving area of both research and innovation, but there seems to be a dearth of information about training and curricula. Looking at training and future practice for robotic surgery, the authors examine the current situation but also consider potential future directions in terms of mandatory curricula (for multiple specialties) and assessment of competence. The article also covers some general areas of implementation and learning curves for new technologies. An international consensus on robotic surgical training is required to guarantee regulated uptake of this expanding area of innovation.

Aim Preoperative iron is frequently used for the correction of anaemia in colorectal cancer surgery. However, enteral iron intake may promote tumour growth and progression which could influence cancer recurrence and patient survival. We explore the long-term outcomes of patients receiving either oral or intravenous iron replacement therapy as part of a previous randomized controlled trial. Methods The IVICA trial randomized anaemic colorectal cancer patients to receive either oral (OI, control) or intravenous (IVI, treatment) iron prior to their elective operation. Follow-up analysis of all patients recruited to this multicentre trial who underwent surgical resection with curative intent was performed. Kaplan-Meier survival estimates and Cox proportional hazard models were used to compare groups. A pooled group multivariable analysis comparing patients who achieved resolution of anaemia preoperatively to those who did not was also undertaken. Results In all, 110 of the 116 patients previously enrolled were eligible for analysis (OIn = 56, IVIn = 54). Median overall follow-up duration was 61 months (interquartile range 46-67). No significant difference in 5-year overall survival (hazard ratio (HR) 1.22, 95% CI 0.65-2.28,P = 0.522) or disease-free survival (HR 1.08, 95% CI 0.61-1.92,P = 0.79) was observed between OI and IVI. A pooled analysis of treatment groups found that preoperative resolution of anaemia led to improved 5-year overall survival on multivariable analysis (HR 3.38, 95% CI 1.07-11.56,P = 0.044). Conclusion We recommend IVI for the preoperative correction of anaemia. Route of iron therapy did not significantly influence survival. Preoperative anaemia correction may lead to an overall survival advantage following elective colorectal cancer surgery.

Background: Oral iron promotes intestinal tumourigenesis in animal models. In humans, expression of iron transport proteins are altered in colorectal cancer. This study examines whether the route of iron therapy alters iron transport and tumour growth. Methods: Colorectal adenocarcinoma patients with pre-operative iron deficiency anaemia received oral ferrous sulphate (n=15), or intravenous ferric carboxymaltose (n=15). Paired (normal and tumour tissues) samples were compared for expression of iron loading, iron transporters, proliferation, apoptosis, Wnt signalling pathway and microsatellite instability using immunohistochemistry and RT-PCR. Results: Iron loading was increased in tumour and distributed to the stroma in intravenous treatment and to the epithelium in oral treatment. The protein and mRNA expression of iron transporters were increased in tumours compared to normal tissues but there were no significant differences between the treatment groups. However, intravenous iron treatment reduced ferritin mRNA levels in tumours (p<0.001) and successfully replenished body iron stores without increasing tumour growth, DNA damage markers, proliferation or apoptosis compared with oral iron treatment. Conclusion: Iron distribution to non-epithelial cells in intravenous iron treatment suggests that iron is less bioavailable to tumour cells. Therefore, intravenous iron supplementation could be a safer option in the treatment of colorectal cancer patients with iron deficiency anaemia due to the differential compartmentalisation of iron within the intestinal mucosa and its efficiency in replenishing body iron levels without increasing the risk of tumour growth.Trial registration: The study was registered with the Medicines and Healthcare Regulatory Agency, clinical trials.gov (NCT01927328) and EudraCT (2013-000209-22).