Abstract Introduction Telemedicine uses communications technology for remote healthcare. Unreadiness includes difficulties with hearing, speaking, cognitive issues, vision problems, lack of internet-enabled devices, or no recent use of digital communication. Telehealth can enhance access and convenience, especially for rural patients, but faces challenges such as technology issues and impacts on patient-provider relationships, examination quality, care quality, and patient satisfaction. The COVID-19 pandemic has accelerated telemedicine adoption to protect medical personnel and patients, with significant promotion of video visits for home-based care. Objective This study aims to evaluate telemedicine unreadiness in an older, frail population at a geriatric clinic. Patients were contacted from February 1st to March 14th, 2021, during Ireland’s COVID-19 ‘third wave,’ with up to three contact attempts made. Method Statistical analysis was conducted using STATA 14. 84 patients attended the Geriatric clinic, with 33 excluded for various reasons, leaving 51 participants (67%) who completed the survey. The mean age was 81.7 years, with 49% female. Most referrals were for cognitive issues (59%), followed by BPSD (13%), weight loss (9%), and falls (7%). The median Clinical Frailty Score was 4, indicating moderate to severe frailty. Regarding mobility, 77% were independent, 21% used an aid, and 2% were immobile. Cognitive assessments revealed 25% had normal cognition, 18% had mild impairment, and 57% had dementia. Results Only 10% of patients were ideal for teleconsultations, while 90% faced significant barriers, such as environmental impairments (26), sensory impairments (2), and both (18). Additionally, 25% lacked computer, and only 10% used the internet regularly. Despite 59% having family assistance, overall, 82% had some form of environmental impairment. Sensory impairments were common, with 29% using hearing aids but 37% still experiencing issues. Visual impairments were better managed, with 76% wearing glasses. Conclusion Telemedicine adoption has accelerated due to COVID-19, but significant barriers for geriatric patients highlight the need for better support.

AIM:Deep infiltrating endometriosis (DIE) may involve the rectum or colon and is associated with pain, gastrointestinal dysfunction and reduced quality of life (QoL). While hormonal treatment may be effective, surgical intervention including colorectal resection can be required. Colorectal resection can result in functional changes and complications, which can also impair QoL. The aim of this study is to examine all available comparative pre- and postoperative data on QoL and symptom outcomes following colorectal resection for DIE. METHOD:An electronic database search was conducted for studies reporting pre- and postoperative QoL and symptom outcomes following colorectal resection for DIE. The study was registered with PROSPERO and followed PRISMA (Preferred Reporting Items in Systematic Reviews and Meta-analyses) guidelines. Data were combined using random-effects models. RESULTS:Fourteen studies including 1142 patients were included. Colorectal resection was associated with improved outcomes for all items in the SF-36 QoL questionnaire as well as symptom outcomes including dysmenorrhoea, chronic pelvic pain and deep dyspareunia. Importantly, the gastrointestinal QoL index was significantly improved (mean difference 24.50, 95% CI 15.93-33.08, p < 0.0001) as was dyschezia (mean difference -4.1, 95% CI -4.77 to -3.42, p < 0.0001). There was no change in low anterior resection syndrome scores (mean difference -5.28, 95% CI -11.65 to 1.10, p = 0.1046). CONCLUSION:This study demonstrates a significant postoperative improvement in patient-reported QoL, pain symptoms and gastrointestinal function following colorectal resection for endometriosis.

INTRODUCTION:This study aims to investigate the current evidence regarding long-term outcomes using laparoscopic peritoneal lavage (LPL) versus primary bowel resection (PR) in Hinchey III diverticulitis. METHODS:A systematic review was undertaken based upon articles published between January 1, 2000, and March 1, 2024. Databases Pubmed, Scopus, and Embase were used employing the key search terms "Diverticulitis" and "Peritoneal Lavage." Articles were selected according to the PRISMA guidelines and statistical analysis was undertaken. Cumulative analysis of diverticulitis recurrence and secondary outcomes of disease-related mortality, serious adverse events, stoma incidence, reoperation, and readmission rates were performed. RESULTS:An initial search identified 506 articles for review. A total of 294 patients were included for final analysis from 3 prospective randomized controlled trials. There was no significant difference in disease-related mortality or serious adverse events between LPL and PR. There was significantly decreased likelihood of having a stoma in the LPL group; however, there was also a significantly increased likelihood of having recurrent diverticulitis. There was heterogenicity across all trials. CONCLUSION:There is a paucity of level 1 evidence available regarding the long-term outcomes of Hinchey III diverticulitis managed with LPL. At 3-year follow-up, there is a significantly decreased likelihood of having a stoma, tempered by the fact that there is a significantly increased likelihood of having recurrent diverticulitis. Further homogenous high-quality randomized studies are required to clarify whether LPL shows long-term benefit over PR.

Background/Objectives: Colorectal liver metastases (CRLMs) occur in 25–30% of colorectal cancer (CRC) patients, significantly impacting survival. While major liver resection (MLR) was traditionally preferred for oncologic clearance, parenchymal-sparing surgery (PSS) has emerged as a less invasive alternative. This study compares perioperative and long-term outcomes of PSS versus MLR in CRLM patients. Methods: We conducted a retrospective cohort study at the Regional Oncology Institute, Iasi, Romania, analyzing patients who underwent hepatic resection for CRLM between August 2013 and June 2024. Patients were categorized into PSS (n = 58) and MLR (n = 28) groups. Outcomes assessed included perioperative parameters, postoperative morbidity, overall survival (OS), and disease-free survival (DFS). Results: PSS was associated with a shorter operative time (235.2 vs. 302.6 min, p = 0.003), lower morbidity (18.9% vs. 57.1%, p = 0.001), and fewer major complications (Clavien–Dindo ≥ III, p = 0.005). ICU stay was significantly longer in MLR patients (p = 0.04). After propensity score matching (PSM), PSS was found to have lower morbidity compared to MLR (p = 0.023) with similar major morbidity (p = 0.473) and LOS (p = 0.579). Overall survival (31 vs. 37.1 months, p = 0.884) and disease-free survival (25.2 vs. 22.2 months, p = 0.519) were comparable between the groups before and after propensity score matching PSM (40.9 vs. 21.2 months, p = 0.741 and 24.3 vs. 13.8 months, p = 0.653). Conclusions: PSS achieves comparable oncologic outcomes to MLR while reducing postoperative morbidity and ICU stay. These findings support PSS as the preferred approach for CRLM, reserving MLR for select cases requiring extensive resection.

Robotic ventral hernia repair is increasing worldwide. No guidelines currently exist regarding indications for this approach, or agreed operative steps. We aimed to develop expert consensus regarding indications for robotic approaches in patients with a primary ventral hernia, and define agreed procedural steps for each robotic technique. A systematic review was undertaken and used to generate statements relating to indications, peri-operative steps and dissection techniques in robotic ventral hernia surgery. Through a nominal group technique statements were revised and piloted. A panel of international robotic hernia surgeons was established. The experts performed three rounds of a Delphi survey responding to statements in each domain. Consensus was considered achieved for any statement reaching > 80

Background: Colorectal cancer (CRC) mainly affects older adults, yet elderly patients are underrepresented in outcomes research. Accurate risk stratification tools, such as the Charlson Comorbidity Index (CCI), are essential for guiding surgical decisions in this group. Methods: We conducted a retrospective review of patients aged 75 years or older who underwent colorectal cancer resection at a tertiary centre between January 2019 and September 2024. Clinical, pathological, and molecular data were analyzed. The primary outcome was a composite of major postoperative complications (Clavien–Dindo grade 3 or higher) or 30-day mortality, stratified by CCI (5 or higher vs. less than 5). Statistical tests included chi-square, Fisher’s exact, and Mann–Whitney U as appropriate. Results: The median age was 81 years (range 75–97), with 59.7% male. CCI ≥ 5 was observed in 24.6% (51/211). The primary composite outcome of major postoperative complications or 30-day mortality occurred in 15/51 (29.4%) patients with a CCI ≥ 5 compared to 19/160 (11.9%) with a CCI < 5 (p = 0.04). Major complications occurred in 18.5% (39/211) of cases, and the 30-day mortality rate was 3.3% (7/211). Laparoscopic resection was independently protective in multivariate analysis (adjusted OR 0.37, p = 0.048), while age ≥85 and emergency presentation were not statistically significant predictors. Conclusions: Colorectal resection in patients aged ≥75 is linked with acceptable morbidity and low short-term death rates. A CCI ≥ 5 significantly predicts adverse outcomes and should be included in preoperative assessments. Minimally invasive surgery seems advantageous and should be considered, when possible, to enhance results in this high-risk group.

INTRODUCTION:Mismatch repair deficiency (MMRd) is a tumour-agnostic biomarker predicting response to immune checkpoint inhibition (ICI). Microsatellite unstable (MSI-H) colorectal cancers (CRC) display poor response to 5-Fluorouracil-based chemotherapy. ICIs demonstrate benefit in stage IV disease, but data on neoadjuvant ICI remain limited. METHODS:Prospective case series evaluating early outcomes of downstaging PD-1 inhibition for locally unresectable ± oligometastatic MMRd colorectal adenocarcinomas. Primary endpoints are complete clinical response, conversion to curative resection or disease progression. Ethical approval was granted by the institution's ethical review board. RESULTS:From October 2022-September 2024, ten patients started downstaging ICI, including six right-sided, one left-sided and three rectal tumours. Median age was 59 (IQR 54-68). One patient had stage II, six stage III and three stage IV disease. All had threatened surgical margin necessitating downstaging. Three patients with rectal cancer also received radiotherapy, and two commenced systemic chemotherapy before switching to ICI. Five patients required a defunctioning stoma. Median follow-up was 21.5 months (IQR 16-26). Objective response rate (RECIST 1.1) was 9/10. Six of ten tumours were resected, with complete pathological response (pCR) in four. Three others underwent non-operative management, following a complete or near-complete clinical response (cCR/ncCR). Nine of ten patients are alive. Four patients had grade 2/3 toxicity, while four developed a clinically significant treatment-related stricture, with one perforation. CONCLUSION:We report promising downstaging and pCR/cCR rate of ICI for initially-unresectable MMRd CRC. ICI-first can permit curative resection, with risk of local complication from significant treatment response. Larger, multi-centre studies are needed to validate these findings.

Background: The rate of morbidity after liver surgery is estimated at 30% and can be even higher when considering higher-risk subgroups of patients. Frailty is believed to better predict surgical outcomes by showcasing the patient's ability to withstand major surgical stress and selecting frail ones. Methods: This is a single-centre, observational case-control study on patients diagnosed with liver malignancies who underwent liver resections between 2013 and 2024. The five-item modified Frailty Index (mFI-5) was used to split patients into frail and non-frail. The two groups were compared in terms of preoperative, operative and postoperative outcomes using a chi-squared and logistic regression model. Results: A total of 230 patients were included and split into two groups: non-frail, NF, n = 90, and frail patients, F, n = 140. Overall, F patients had a higher rate of morbidity (p = 0.04) but with similar mortality and length of stay. When considering only major liver resections, F patients had a higher probability of posthepatectomy liver failure (LR 6.793, p = 0.009), postoperative bleeding (LR 9.541, p = 0.002) and longer ICU stay (LR 8.666, p = 0.003), with similar rates of bile leak, surgical site infections, length of stay and mortality. Conclusions: Frailty seems to be a solid predictor of posthepatectomy liver failure in patients undergoing major liver resections and is associated with a longer ICU stay. However, mortality and surgical morbidity seem to be comparable between frail and non-frail patients.

AIM:Surgical site infection (SSI) and incisional hernia (IH) are common complications following midline laparotomy. The small-bites technique for closing a midline laparotomy has been suggested to improve SSI and IH rates compared with the classic mass closure. The aim of this work was to perform a systematic review, meta-analysis and fragility assessment of existing evidence comparing small-bites and conventional closure. METHOD:The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining small-bites versus conventional closure for midline laparotomy. The fragility index for randomized controlled trials (RCTs) was assessed and the number of outcomes required to render results insignificant using the Fisher exact test was calculated. RESULTS:Seven studies were included, with a total of 3807 patients. Small bites was performed in 1768 and large bites in 2039. Follow-up ranged from 12 to 52 months. On meta-analysis of all studies, small bites is associated with a lower risk of IH (p < 0.00001), SSI (p = 0.0002) and wound dehiscence (p = 0.02). On meta-analysis of RCTs there is a lower risk of IH (p = 0.01) but no difference in SSI (p = 0.06) or wound dehiscence (p = 0.73). Fragility is evident among RCTs reporting differences in IH rates. CONCLUSION:There is evidence to suggest that small-bites closure provides a decreased likelihood of IH over varying follow-up in RCTs but significant fragility exists among studies.

Abstract Background: Endometriosis is a chronic inflammatory condition that can infiltrate the rectum and colon in a significant proportion of those affected. Patients commonly seek information regarding their diagnosis and treatment on the internet. Information available, however, may be incomplete or not applicable to all cases. This study aims to evaluate the quality and content of internet information on colorectal endometriosis treatment. Methods: The search term ‘colorectal endometriosis’ was used to identify websites on popular search engines including Google, Yahoo, and Bing. Websites were classified into 4 subtypes: Academic Institutions, Private Medical Centres, Non-profit Organisations, and Commercial Websites. Two independent assessors evaluated the quality of the websites using the Journal of the American Medical Association (JAMA) benchmark criteria and the DISCERN scoring system. Results: Sixteen websites were identified. 25% from Academic Institutions, 25% from Private Medical Centres, 12.5% from Non-profit Organisations, and 37.5% were Commercial Websites. Mean(±SD) JAMA criteria and DISCERN scores for all websites were noted as 1.38±1.29 and 44.75±14.53 respectively. Most websites adequately discussed treatment options, mean(±SD) DISCERN score 3.69±1.40. Risks of surgeries were infrequently discussed, mean(±SD) DISCERN score 2.56±1.50. Only 50% of the websites discussed complications of colorectal surgery including anastomotic leak and stoma requirement. Conclusion: This study demonstrated variable levels of quality and reliability of internet content regarding colorectal endometriosis treatment and associated complications. These findings can be highlighted to patients using the internet to obtain information on colorectal endometriosis.

Background: Less than 10% of patients with stage IV endometriosis and bowel involvement will have evidence of endometriosis intra-luminally. Colonoscopy is however still used in almost all patients pre-operatively. The purpose of this study is to correlate operative complexity and endoscopic findings in patients undergoing surgery for stage IV endometriosis in Tallaght University Hospital. Methods: Patients undergoing combined colorectal/gynaecological surgery for stage IV endometriosis with sigmoid and rectal involvement diagnosed on magnetic resonance imaging (MRI) were recorded in a prospectively maintained database. All patients undergoing combined surgery from October 2022 to October 2023 were included. A chart and electronic records review assessed their pre-operative endoscopic findings. Results: During the study period, 22 patients underwent combined colorectal/gynaecological surgery. The mean age was 42.7 years. Among the 22 patients, 18 (82%) underwent extensive pelvic adhesiolysis with excision of rectal deposits, while 2 (9%) required pelvic adhesiolysis with excision of deposits and stoma formation. Another 2 patients (9%) required low anterior resection with loop ileostomy formation. Pre-operative endoscopic assessment was conducted in 16 out of 22 patients (73%). Of these, 12 had no findings on colonoscopy, 4 had rectosigmoid angulation preventing scope progression. In total, 2 out of 12 patients (17%) who did not require stoma or resection had impassable angulation during endoscopy. Additionally, 2 out of 4 (50%) patients who had stoma or resection had impassable angulation (P=0.18). Conclusions: The use of endoscopy as a pre-operative investigation in patients with stage IV endometriosis and rectal involvement remains unclear. Based on this study endoscopy could be performed on an individualised basis.

Robotic surgery has been utilized increasingly, including in colorectal surgery. Newer robotic platforms are coming onto the market, and more emphasis is being placed on the safety and adequate training of surgeons and theatre teams. Training in robotic colorectal surgery has not been standardized, and there are no agreed structured training and assessment methods. Some studies in minimally invasive surgery across specialities have shown that training curricula shortened the learning curve in minimally invasive surgery and, therefore, there is a greater need for guidance on training in robotic colorectal surgery based on up-to-date available evidence on the subject. The European Society of Coloproctology (ESCP) Guidelines Committee aimed to conduct a comprehensive literature review, assess currently available evidence and collate expert opinion on training in robotic colorectal surgery. Evidence was graded, and the recommendation was based on the GRADE (Grading of Recommendations Assessment, Development and Evaluation) methodology. When evidence is lacking expert opinion is considered, and the research gap is highlighted. The robotic guideline group addressed six topics with 15 research questions in the PICO format (patient/population, intervention, comparison and outcomes) and developed 11 recommendations. Most of the recommendations are based on a low or very low quality of evidence. Where the case benefits could be seen by indirect evidence or strong recommendations are unwarranted but made as good practice statements, they are made explicit by stating 'expert opinion only' without a GRADE level. The use of robotic surgery has steadily increased over the last years in both general surgery and colorectal surgery [1]. Approximately 1000 robotic-assisted procedures were performed worldwide in 2000; by 2018 this had increased to more than a million [2]. The advantages of robotic surgery were thought to be its suitability for confined spaces and complex operations such as rectal cancer surgery. The application and volume of practice continue to expand, and more robotic platforms are coming to the market [1, 3]. The projected global surgical robot market by 2025 is 275 billion USD. This is driven by innovation, growth in procedure volume and access to emerging markets [4]. It is crucial when introducing surgical techniques that patients should not come to harm, and surgical societies should have a leading role in appraising evidence and implementing surgical procedures [5, 6]. Evidence has suggested that training curricula shortened the learning curve in laparoscopic surgery and robotic surgery [7, 8]. However, there are variations in training components and assessments in different curricula [9]. It is therefore crucial to appraise the evidence on some key training components when implementing a structured training programme. This guideline is written and intended for surgeons, theatre teams, trainees, purchasers, local, regional and national policymakers, hospital leaderships, scientific societies, professional bodies for training and accreditation, and industry partners. The ESCP guidelines committee appointed project leads (ST, YM, DC) to curate this guideline. A steering group was formed with experts in robotic surgery, training and education, and guideline development with a common interest in improving training in robotic colorectal surgery. ESCP e-newsletters and social media announced a call for other working group members to participate in the guideline. The selection of final working group members was assessed based on the following set of criteria, and also keeping to the principle of equality, diversity and inclusion (EDI): 1. Appropriate and relevant clinical experience.2. A proven track record of scientific knowledge and research skills.3. International expertise and recognition or willingness to collaborate with diverse professionals and patients.4. Geographical distribution. The working group comprises colorectal surgeons, trainees, educators, expert robotic surgeons, surgical assist/allied health professionals familiar with robotic training, a patient representative and GRADE methodologist. A professor in systematic reviews and expert guideline methodologist helped with the methodological aspects of this guideline (Table 1). The group worked closely with the methodologist (JK) to devise a strategy to perform a single set of searches to address all statements and questions relating to training in robotic colorectal surgery. The searches were not limited by date, language or publication status. The group assessed the evidence with robust analysis using GRADE. The current guidance analysed all available data through GRADE so that the strengths and limitations are transparent, and the grade of recommendation is based on these analyses. This guideline development followed the ESCP guideline recommendations and the AGREE II tool [10]. This guideline focuses on the common training components, assessments and quality controls used in robotic colorectal training. Therefore it does not cover robotic surgery in other specialities nor other minimally invasive techniques in colorectal surgery. This guideline aims to address the PICO (Patient/Population/Problem, Intervention, Comparison, Outcome) questions detailed in the following subsections. What are the effects of robotic platform training (for learners) versus no robotic platform training on patient safety in robotic colorectal surgery? *What are the effects of procedural anatomy training (for learners) versus no procedural anatomy training on patient safety in colorectal robotic surgery training? *What are the effects of the modular approach on procedural training (for learners) versus not using the modular approach on the learning curve of colorectal robotic surgery training? Is eLearning more effective than traditional learning for health professional trainees in colorectal robotic surgery training? *Note: During the Working Group discussions, these two research questions were initially proposed but dropped: please see the Results section. What are the effects of having prior laparoscopic experience (for learners) versus no prior laparoscopic experience on the learning curve for robotic colorectal surgery? What are the effects of having prior experience of one robotic platform (for learners) versus no such prior experience on the learning curve for learning another robotic platform? What are the effects of simulation training (for learners) versus no simulation training on operative performance in colorectal robotic surgery? What are the effects of simulation training (for learners) versus no simulation training on patient outcomes in colorectal robotic surgery? What are the effects of using mentoring (for learners) versus no mentoring on clinical outcomes in training colorectal robotic surgery? What are the effects of telementoring versus onsite mentoring (for learners) on clinical outcomes in colorectal robotic surgery? What are the effects of the modular approach on procedural training in the operating room (for learners) versus not using the modular approach on the learning curve of colorectal robotic surgery training? What are the effects of attending a structured TTT course for robotic surgery (for trainer) versus not attending such a course on the operative performance (trainee) of colorectal robotic surgery training? What are the effects of nontechnical skills training (for learners) versus no nontechnical skills training on patient safety in colorectal robotic surgery? What are the effects of competency-, proficiency-based supervised training (for learners) versus noncompetency-, nonproficiency-based supervised training during colorectal robotic surgery training on operative performance? What are the effects of competency-, proficiency-based supervised training (for learners) versus noncompetency-, nonproficiency-based supervised training during colorectal robotic surgery training on patient clinical outcomes? What are the effects of credentialing (for the practitioner) versus no credentialing in colorectal robotic surgery on patient clinical outcomes? What are the effects of registering clinical outcome data (for the practitioner) versus no registering in colorectal robotic surgery on patient clinical outcomes? A list of outcome measurements was suggested by members of the working group relevant to the PICO questions. Some outcomes are more important in certain PICOs than others. As there are many PICO questions, these outcomes were grouped into the following categories. intraoperative postoperative◦ Clinical◦ Oncological◦ Functional◦ Quality of life operative skills surrogate markers◦ Time◦ Complication rates◦ Oncological outcomes health professionals' behaviour, skills or knowledge time to complete a task complications errors procedural steps completed validated scores◦ Global Assessment Score (GAS), Global Rating Scale (GRS)◦ Global Evaluative Assessment of Robotic Skills (GEARS)◦ objective performance metrics such as proficiency-based progression (PBP) metrics According to the GRADE recommendations [11], outcomes were ranked according to their relative importance into three groups by panel members: (1) critical for decision-making; (2) important, but not critical for decision-making; (3) of low importance. The number next to the outcomes is on an importance scale (e.g. 1 is least important and 9 is most important). Outcomes in the first two categories, i.e. (1) and (2), will be included in the evidence profile. Literature searches were conducted on 4 May 2022 to identify relevant references on training for robotic colorectal surgery. The search strategy was supported by an expert methodologist (JK) in systematic reviews and guidelines and his team. A single set of searches was devised which aimed to address all statements and questions raised in this topic area. The search strategies were developed specifically for each database and the keywords adapted according to the configuration of each database. Searches were not limited by date, language or publication status. A further up-to-date search was performed on 1 September 2023. Full details of all search strategies are presented in Appendix 0. References identified from the searches were downloaded into EndNote bibliographic management software for further assessment and handling. Two guideline authors (ST, KR) reviewed all the abstracts generated from the searches stored in the database and retrieved the full papers for the potential studies. The two guideline authors independently identified studies, resolving disagreements through discussion with the guideline group. References in the included studies were assessed for any suitable articles for inclusion and any additional studies identified by the working group. For each predefined review question, we included study(ies) with the best available evidence, and these include randomized controlled studies, comparative studies, case series, reviews and expert opinions. Guideline authors were not blind to authors' names, institutions or journals. For each included study, data extraction was based on predefined outcomes. If the data were available, we aimed to compare the differences in effect between the baseline and after treatment in the treatment group and the difference in baseline and after treatment in the control group. We intended to present the results using confidence interval (CI) with the use of Review Manager (RevMan) 5 (Version 5.4, Copenhagen, The Cochrane Collaboration). Individual study quality was assessed using the GRADE score. Additionally, the quality of the evidence for each question was evaluated with the use of the GRADE system, which assigns one of four levels of evidence: very low (⊕∘∘∘), low (⊕ ⊕ ∘∘), moderate (⊕ ⊕ ⊕∘) or high (⊕ ⊕ ⊕⊕). Within the GRADE system, randomized controlled trials (RCTs) were generally rated as high quality but may have been downgraded on the basis of specific design flaws. Observational studies were generally assigned a low quality but may have been upgraded based on the strength of the association demonstrated and the absence of bias. The outcomes of study assessment are presented using the GradePro Guideline Development Tool (https://gdt.gradepro.org/app/). In some instances where there was no evidence or a low level of evidence we upgraded the statement after discussion within the guideline group. When there was no clear evidence in the literature, yet practice or concept was established with consensus among clinicians, recommendations were made as 'Expert opinion only' and distinguished as 'Upgraded recommendation'. All statements and the initial supporting text were presented via a virtual working group meeting. The content and the strength of each statement and recommendation were further reviewed at a dedicated Guideline Session at the ESCP Annual Conference in Dublin in September 2022. All statements were then revised to meet the changes recommended. Following this meeting, a final working group virtual meeting was convened to finalize all statements. All statements and the supporting text were subsequently edited by ST, YM and KM before the paper was sent for final revision and approval by all the authors combined. The searches retrieved a total of 1831 records. After removing the duplicates, 1298 records remained and were screened by two guideline authors. Fifty-eight articles were included in this review (Figure 1). During the discussion among the working group, the question on procedural anatomy training was dropped as this question was best incorporated into eLearning. The modular approach of knowledge learning would be under eLearning/procedural training. However, we may have to reassess these research questions in the future guidance. In the end, the working group generated the following recommendation statements for these research questions. Question 1: What are the effects of robotic platform training (for learners) versus no robotic platform training on patient safety in robotic colorectal surgery? Robotic platform training is essential to patient safety and therefore should be used in a structured colorectal robotic training curriculum. [Expert opinion only] Very little evidence has addressed this question, as platform training has been accepted as a fundamental element and requirement of robotic surgery training from its inception. Few recent articles have focused on investigating it, including this literature summary. In 2015, Tsuda et al. published a literature review to summarize the clinical evidence of the safety and effectiveness of the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, CA) [12]. The authors summarized peer-reviewed publications up to 2014 and specifically supported individual platform training. It is considered best practice that all users undergo individual robotic platform training (basic technology training/basic device training/'buttonology') before performing live robotic surgery [13]. Furthermore, it is recommended that training should be completed on each different platform before use. This concept is translated from the aviation industry, where training is required on each aeroplane model before flying and is generally accepted. There is a paucity of research evidence on the benefits of specific device/console training in robotic surgery. This is gaining increasing importance with the clinical introduction of multiple robotic platforms. The transferability of skills from one platform to another should also be addressed, whether there are benefits of being trained in one platform previously and how it may impact the learning curve. Patient safety, in terms of complications, should be measured according to the type of platform training. Question 2: Is eLearning more effective than traditional learning for health professionals in colorectal robotic surgery training? eLearning could be used to deliver content in colorectal robotic surgery training. [Expert opinion only] One abstract described a dedicated website to promote surgical learning and training – the Advance in Surgery (AIS) Channel [14]. It was created to provide a learning experience for colorectal and robotic surgery. The teaching is self-administered without formal feedback. This website is online-based, delivered by experts and focuses on surgical techniques, anatomy, live surgery and debates. Two studies [15, 16] examined the educational value of videos of robotic right hemicolectomy posted on YouTube (San Bruno, CA, US). Uzunoglu and colleagues evaluated the educational value of the videos by three experienced oncological surgeons using a Likert scale. They classified these videos into good, moderate or poor according to how many predefined steps these videos contain. Sixty-eight videos were assessed, and the authors observed that the educational value of these videos was variable. Bal and colleagues conducted a similar study on a YouTube channel assessing robotic right hemicolectomy (with or without complete mesocolic excision). Various methods were used to evaluate the quality and educational value of these videos, including a modified LAP-VEGaS criterion [17, 18]. Seventy-two videos were assessed, and most were deemed to have insufficient educational value. Herrando et al. 2023 [19] published robotic colorectal procedural surgical techniques on the Colorectal Disease (the official Journal for the Association of Coloproctology of Great Britain & Ireland and ESCP) YouTube channel. The videos posted via this route have gone through the peer-reviewed process to enhance their educational value. There are widely available teaching materials for robotic surgery on the web, some are from individual surgeons and others are from organizations. There is no online quality assurance mechanism for materials, and the industry funds some of these teaching materials. It is crucial to have independent bodies provide objective assessments of the training materials to ensure there is no conflict of interest. These training materials should be developed with clear aims, objectives and assessment components for educational purposes and to assess learners' proficiency in the content. Studies should examine the effectiveness of this eLearning educational content, surgeons or trainees' acceptability and accessibility. Question 3: What are the effects of having prior laparoscopic experience (for learners) versus no prior laparoscopic experience on the learning curve for robotic colorectal surgery? Prior laparoscopic experience is not essential for training in robotic colorectal surgery. [Very low quality of evidence; conditional recommendation] Nine articles were considered relevant to this statement. Three of the nine articles had numerical data comparing the learning curve of trainees with prior laparoscopic colorectal experience with trainees with no such prior experience. Two studies [20, 21] had data on the learning curve of robotic colorectal surgery measured in terms of clinical outcomes. In this guideline, the clinical outcomes of these two studies have been pooled to facilitate comparison. Noh et al. (2020) was a retrospective observational study on 662 patients who underwent robotic low anterior resection for low rectal cancer [20]. They were stratified into five groups according to operating surgeons with varying laparoscopic experience (from a previous 403 laparoscopic cases to no cases) and their clinical outcomes were analysed. Sian et al. (2018) was an observational study on the clinical outcomes of the first 30 robotic colorectal procedures (including high anterior resection, low anterior resection, abdominoperineal resection, right hemicolectomy and abdominal suture rectopexy) performed by two surgeons, one who was a minimally invasive colorectal trained surgeon (T) and the other was a nonminimally invasive colorectal trained surgeon (nT) [21]. There were no statistical comparisons performed between the two comparators. Both studies have data on conversion rate and the results are summarized in Figure 2. There was no statistically significant difference in conversion between surgeons with prior laparoscopic experience and those without (p = 0.24). Both studies have data on postoperative complications and the results are summarized in Figure 3. There was no statistically significant difference in postoperative complications between surgeons with prior laparoscopic experience and those without (p = 0.33). However, it should be noted that while Sian et al. (2018) [21] had provided a description of postoperative complications included in their study, namely wound infection, pelvic collection, wound dehiscence and postoperative bleeding, Noh et al. (2020) [20] had not provided a breakdown of the postoperative complications observed. GRADE quality assessment for Noh et al. (2020) [20] and Sian et al. (2018) [21] on conversion and postoperative complications are summarized in Table 2. Both outcomes are graded very low in certainty due to risk of selection bias, confounding bias, inconsistency and imprecision. ⨁◯◯◯ Very low ⨁◯◯◯ Very low Noh et al. (2020) [20] provided the mean operating time while Sian et al. (2018) [21] provided the median operating time, therefore their results cannot be pooled together. In Noh et al, the average operating time for surgeons with previous laparoscopic experience was 303.09 min and that of the surgeon with no prior laparoscopic experience was 305.1 min. In Sian et al., the median operating times of T and nT were respectively 5 h and 5.5 h for high anterior resection, 7 and 5.5 h for low anterior resection and 8 and 4 h for abdominoperineal resection. The learning curve in terms of operating time was analysed in Noh et al. [20] using the cumulative sum technique. Surgeon A with the greatest experience of laparoscopic rectal surgery showed a learning curve period of 110 cases. Surgeons B and C, who had less laparoscopic experience, had learning curves of 39 and 114 cases, respectively, while surgeons D and E, with limited laparoscopic surgery experience, had learning curves of 55 and 23 cases, respectively. One potential confounding factor could be the different timing in initiating robotic surgery, with Surgeons A and C being early adopters. Surgeons B, D and E were later adopters and had a shorter learning curve. This might be because they had benefited from observing A's and C's experience and might have been offered more tips and training programmes before initiation. The results from the two studies could not be directly pooled. Noh et al. [20] reported 60 (9.6%) anastomosis-related complications among the surgeon group with prior laparoscopic experience and one (2.9%) in the surgeon group with no prior laparoscopic experience. This might not be due to the difference in complexity of cases in the two groups as there was no significant difference in the tumour locations. However, this could potentially be because of the discrepancy in the total number of cases performed in the two groups (n = 628 in prior laparoscopic experience group versus n = 34 in the no prior laparoscopic experience group). In Sian et al. [21], there were no anastomotic leaks in either group. Only one study [22] contained data on the learning curve measured in terms of robotic simulator performance. This was an observational study that compared the performance of a novice in laparoscopic surgery with that of an intermediate operator (≤100 laparoscopic cases) and expert operator (>100 laparoscopic cases). It concluded that there was no significant difference in the overall simulation score among the three groups in three of the four simulation tasks. The laparoscopic novice outperformed experts in one of the tasks (p = 0.004). Laparoscopic intermediates did not significantly differ from the other two groups in overall simulation score. There was no pattern or difference between groups in terms of parameters of specific simulator tasks. This study was not specific to colorectal procedures and assessed whether laparoscopic skills were transferable to robotics in general. It was hindered by a small sample size and differences in size between the experience groups (novice 41, intermediate 8, expert 11), limiting the generalizability of the findings. Furthermore, the study was observational with no randomization, blinding or allocation concealment. Another shortcoming of the study was that the intermediate and expert laparoscopic groups were potentially rather heterogeneous as they were defined by the previous number of laparoscopic procedures performed not considering the complexity of previously performed procedures. The current literature seems to suggest that prior laparoscopic experience may not have an effect on the learning curve of robotic colorectal surgery measured in terms of clinical outcomes. However, the literature on the topic specific to robotic colorectal surgery is scarce and of very low quality. Future research in the field is required to define prior experience and establish a learning curve by measuring performance for homogeneous case loads in comparative studies. Question 4: What are the effects of having prior experience of one robotic platform (for learners) versus no such prior experience on the learning curve for learning another robotic platform? No recommendation could be provided regarding the effects of having prior experience of one robotic platform versus no such prior experience on the learning curve for learning another robotic platform. Question 5: What are the effects of simulation training (for learners) versus no simulation training on operative performance in colorectal robotic surgery? Question 6: What are the effects of simulation training (for learners) versus no simulation training on patient outcomes in colorectal robotic surgery? Simulation should be used as part of the colorectal robotic training curriculum. [Very low level of evidence and expert opinion, upgraded by the guideline working group; strong recommendation] Although there is very little evidence on these topics, the guideline group felt that simulation should be offered as part of the robotic training curriculum based on the balance of benefits versus harm, as most robotic users have access to simulation and these include skill exercises and some procedural exercises. There is a scarcity of data on the effect of simulation training in colorectal robotic surgery with regard to operative performance and patient outcomes. Simulation training could potentially increase trainees' confidence and familiarity with the robotic platform. The most important reason to adopt effective simulation training is to ensure patient safety, in particular to avoid an increased rate of adverse clinical outcomes at the beginning of a surgeon's learning curve. Simulation training can potentially ensure that a trainee surgeon develops a certain level of competence in robotic skills and familiarity with the robotic platform in a safe environment before starting his or her first robotic case. Apart from simulation in basic surgical skills, a few simulation models designed specifically for robotic rectal dissection have been developed [23, 24]. A recent study has shown that although 63% of US residents indicated that they had participated in robotic cases, only 18% had experience using the robotic console and 60% received no prior education or training before their first robotic case [25]. Indeed, integrating surgical trainees into robotic procedures is challenging, especially in the initial phase of launching a new robotic service in a centre. One contributing factor is the lack of formal and mandatory robotic simulation curricula. Formal robotic platform training and simulation may allow increased trainee participation and skill acquisition in robotic procedures. This section explores the effect of simulation training on operative performance and patient outcomes in colorectal robotic surgery. Eight articles were considered relevant to this statement [23-30]. Three of the eight articles have data on operative performance and one of the eight articles has data on patient outcome. The three studies that had data on operative performance were Schlottman et al. (2019), Thomas et al. (2023) and Cho et al. (2013) [26-28]. The data from these studies cannot be synthesized as the specific operative performances they measured were different. We felt that the three studies were not suitable for quality assessment through GRADE because GRADE is an outcome-based assessment and the three studies did not have a common outcome measure. Specifically, Schlottman et al. [26] did not have an outcome measure of critical importance, Thomas et al. [27] is a conference abstract with limited data. The outcomes of Cho et al. [28] were specific to that study and did not conform to known outcome measures. Schlottman et al. [26] was an observational study comparing the confidence level of 20 senior surgical residents in using the robotic platform before and after simulation training with porcine tissue blocks to perform various operations including Heller myotomy, sleeve gastrectomy, colectomy and lobectomy. It showed a significant increase in confidence level in port placement (5.36 vs. 7.05, p = 0.007), docking (5.59 vs. 7.18, p = 0.01), suturing (5.05 vs. 7.50, p < 0.001), using an energy device (5.36 vs. 7.36, p < 0.001) and using staples (4.91 vs. 7.41, p < 0.001) after 3 days of simulation training. The highest increases in confidence level were seen in skills often less readily developed in theatre without prior practice, such as suturing and using energy devices or staples. The limitation is that the sample size was small and that the study was not limited to colorectal robotic procedures. Thomas et al. [27] is a conference abstract; 19 surgical residents practised during a training session using a live porcine model consist

BACKGROUND:Considered to reflect a patients' biological age, frailty is a new syndrome shown to predict surgical outcomes in elderly patients. In view of the increasing age at which patients are proposed oncological liver surgery and the morbidity associated with it, we attempted to perform a systematic review and meta-analysis to compare morbidity and mortality between frail and nonfrail patients after liver resections. METHODS:The study was registered with PROSPERO. A systematic search of PubMed and EMBASE databases was performed for all comparative studies examining surgical outcomes after liver resections between frail and nonfrail patients. RESULTS:Ten studies were included based on the selection criteria with a total of 71,102 patients, split into two groups: frail (n = 17,167) and the control group (n = 53,928). There were more elderly patients with a lower preoperative albumin level in the frail group (p = 0.02, p = 0.001). Frail patients showed higher rates of morbidity with more major complications and a higher incidence of postoperative liver failure (p < 0.001). Mortality (p < 0.001) and readmission rate (p = 0.021) also was higher in frail patients. CONCLUSIONS:Frailty seems to be a solid predictive risk factor of morbidity and mortality after liver surgery and should be considered a selection criterion for liver surgery in at-risk patients.

Transanal minimally invasive surgery (TAMIS) is a surgical alternative to proctectomy in the management of complex rectal polyps and early rectal cancers. In 2016, our institution introduced a TAMIS programme. The purpose of this study was to evaluate changes in practice and outcomes in our institution in the 3 years before and after the implementation of TAMIS. We conducted a retrospective analysis of a prospective database of patients who underwent proctectomy or TAMIS for the management of complex rectal polyps or early rectal cancers at our institution between 2013 and 2018. 96 patients were included in this study (41 proctectomy vs 55 TAMIS). A significant reduction was noted in the number of proctectomies performed in the 3 years after the implementation of TAMIS as compared to the 3 years before (13 vs 28) (P < 0.001); 43% of patients (n = 12) who underwent proctectomy in the period prior to implementation of TAMIS were American Society of Anaesthesiologists grade III, as compared to only 15% (n = 2) of patients during the period following TAMIS implementation (P = 0.02). TAMIS was associated with a significant reduction in length of inpatient stay (P < 0.001). Oncological outcomes were comparable between groups (log rank P = 0.83). Our findings support TAMIS as a safe and effective alternative to radical resection. The availability of TAMIS has resulted in a significant reduction in the number of comorbid patients undergoing proctectomy at our institution. Consequently, we have observed a significant reduction in postoperative complications over this time period.

Background: Postoperative ileus (POI) remains a common phenomenon following loop ileostomy closure. We aimed to determine whether preoperative physiological stimulation (PPS) of the efferent limb reduced the incidence of POI.