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Aim The involvement of pelvic sidewall (PSW) lymph nodes in rectal cancer is a marker of locally advanced disease and poor prognosis. Eastern countries generally advocate lateral lymph node dissection (LLND) over the Western approach of neoadjuvant chemoradiotherapy and more limited surgery. The aim of this study was to evaluate how these advanced cancers were treated in three UK Health Boards. Methodology This was a retrospective review of three colorectal multidisciplinary team meetings from 2008 to 2016. All patients with rectal cancer and suspicious PSW lymph nodes on pretreatment MRI were included. Results There were 153 (6.2%) patients who met the inclusion criteria from a total of 2461 diagnosed rectal cancers. There was significant variability between the three centres with surgical intervention ranging from 59.2% to 84.4%, P = 0.015. There were 81 patients who had neoadjuvant chemoradiotherapy prior to surgery; of these 67 (82.7%) still had positive PSW nodes on the restaging MRI, but only 13 (19.4%) had LLND. There was no difference in local recurrence (15.3% vs 11.8%, P = 0.66), 5-year overall survival (69.2% vs 80.1%, P = 0.16) or 5-year disease-free survival (69.2% vs 79.4%, P = 0.72) between patients having LLND and those receiving standard neoadjuvant treatment followed by total mesorectal excision surgery. Conclusions This study has demonstrated that rectal cancer patients with PSW positive nodal disease have advanced disease, mostly of the lower rectum, and receive a highly heterogeneous spectrum of therapies, even within a relatively small geographical area. Greater accuracy in our preoperative staging is needed to select those patients who will benefit from LLND surgery.

Introduction The NHS accounts for 5.4% of the UK’s total carbon foot print, with the perioperative environment being the most resource hungry aspect of the hospital. The aim of this systematic review was to assimilate the published studies concerning the sustainability of the perioperative environment, focusing on the impact of implemented interventions. Methods A systematic review was performed using Pubmed, OVIC, Embase, Cochrane database of systematic reviews and Medline. Original manuscripts describing interventions aimed at improving operating theatre environmental sustainability were included. Results 648 abstracts were screened with 33 manuscripts included. Studies were divided into broad themes; recycling and waste management, waste reduction, reuse, reprocessing or life cycle analysis, energy and resource reduction and anaesthetic gases. This review summarises the interventions identified and their resulting effects on theatre sustainability. Discussion This systematic review has identified simple, yet highly effective interventions across a variety of themes that can lead to improved environmental sustainability of surgical operating theatres. Combining these interventions will likely result in a synergistic improvement to the environmental impact of surgery.

Background The COVID‐19 global pandemic has resulted in a plethora of guidance and opinion from surgical societies. A controversial area concerns the safety of surgically created smoke and the perceived potential higher risk in laparoscopic surgery. Methods The limited published evidence was analysed in combination with expert opinion. A review was undertaken of the novel coronavirus with regards to its hazards within surgical smoke and the procedures that could mitigate the potential risks to healthcare staff. Results Using existing knowledge of surgical smoke, a theoretical risk of virus transmission exists. Best practice should consider the operating room set‐up, patient movement and operating theatre equipment when producing a COVID‐19 operating protocol. The choice of energy device can affect the smoke produced, and surgeons should manage the pneumoperitoneum meticulously during laparoscopic surgery. Devices to remove surgical smoke, including extractors, filters and non‐filter devices, are discussed in detail. Conclusion There is not enough evidence to quantify the risks of COVID‐19 transmission in surgical smoke. However, steps can be undertaken to manage the potential hazards. The advantages of minimally invasive surgery may not need to be sacrificed in the current crisis., The COVID‐19 pandemic is unprecedented and raises concerns regarding transmission of the virus within surgical smoke. This review summarizes the current evidence and provides advice for its management. Bad for your health?

Objective: The aim of this study was to determine the incidence of, and preoperative risk factors for, positive circumferential resection margin (CRM) after transanal total mesorectal excision (TaTME). Background: TaTME has the potential to further reduce the rate of positive CRM for patients with low rectal cancer, thereby improving oncological outcome. Methods: A prospective registry-based study including all cases recorded on the international TaTME registry between July 2014 and January 2018 was performed. Endpoints were the incidence of, and predictive factors for, positive CRM. Univariate and multivariate logistic regressions were performed, and factors for positive CRM were then assessed by formulating a predictive model. Results: In total, 2653 patients undergoing TaTME for rectal cancer were included. The incidence of positive CRM was 107 (4.0%). In multivariate logistic regression analysis, a positive CRM after TaTME was significantly associated with tumors located up to 1 cm from the anorectal junction, anterior tumors, cT4 tumors, extra-mural venous invasion (EMVI), and threatened or involved CRM on baseline MRI (odds ratios 2.09, 1.66, 1.93, 1.94, and 1.72, respectively). The predictive model showed adequate discrimination (area under the receiver-operating characteristic curve >0.70), and predicted a 28% risk of positive CRM if all risk factors were present. Conclusion: Five preoperative tumor-related characteristics had an adverse effect on CRM involvement after TaTME. The predicted risk of positive CRM after TaTME for a specific patient can be calculated preoperatively with the proposed model and may help guide patient selection for optimal treatment and enhance a tailored treatment approach to further optimize oncological outcomes.

Background The Welsh Institute for Minimal Access Therapy (WIMAT) colonoscopy suitcase is an ex vivo porcine simulator for polypectomy training. Objective To establish whether this model has construct and concurrent validity. Design Prospective, cross-sectional study. Setting Endoscopic training center. Participants Twenty novice (N), 20 intermediate (I), 20 advanced (Ad), and 20 expert (E) colonoscopists. Intervention A simulated polypectomy task aimed at removing 2 polyps; A (simple), B (complex). Main Outcome Measurements Two accredited colonoscopists, blinded to group allocation, scored performances according to Direct Observation of Polypectomy Skills (DOPyS) assessment parameters. Group performances were compared. Real-life DOPyS scores were correlated to simulator DOPyS results. Results Median overall DOPyS scores for novices were 1.00 (1.00-1.87) for A and 0.50 (0.00-1.00) for B (A vs B; P < .01). Intermediates scored 2.50 (2.00-2.88) for A and 2.00 (1.13-2.50) for B (A vs B; P = .03). The advanced group scored 3.00 (2.50-3.50) for A and 2.50 (2.00-3.00) for B (A vs B; P = .01). Experts scored 3.00 (3.00-3.88) for A and 3.00 (2.50-3.50) for B (A vs B; P = .47). Intergroup comparisons for A were, N vs I; P < .01, N vs Ad; P < .01, N vs E; P < .01, I vs Ad; P < .01, I vs E; P < .01, and Ad vs E; P = .46. Intergroup comparisons for B were, N vs I; P < .01, N vs Ad; P < .01, N vs E; P < .01, I vs Ad; P = .03, I vs E; P

Background The aim of this study was to establish if endoscopists can reliably self-assess their ability to perform simulated colonic polypectomy. Methods Novices, intermediates, advanced, and experts performed a video-recorded polypectomy task using the Welsh Institute for Minimal Access Therapy (WIMAT) colonoscopy suitcase simulator. This involved removal of a simple polyp (A) and a complex polyp (B). Participants self-assessed themselves using a Direct Observation of Polypectomy Skills (DOPyS) assessment form. Two blinded, independent, Joint Advisory Group on Gastrointestinal Endoscopy (JAG) accredited assessors graded each performance using the same DOPyS scoring. The Spearman coefficient was used to determine the correlation between self and assessors' scores. Results Eighty participants completed the task. There was a weak correlation between assessors' scores and self-assessment scores for all groups (novices: ρ = −.44, P = .85; intermediates: ρ = −.16, P = .51; advanced: ρ = .16, P = .50; and experts: ρ = .07, P = .76). There was a strong correlation between scores from assessor 1 and 2 for polyp A (ρ = .80, P ≤ .01) and polyp B (ρ = .80, P ≤ .01). Conclusions The correlation between self-assessment and assessors' scores is weak. Novices and intermediates underestimate performance, whereas advanced and experts overestimate performance. Regular feedback may improve accuracy.

ObjectivesIncisional hernias are common complications of midline abdominal closure. The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. There is evidence to suggest this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared Hughes repair with standard mass closure for the prevention of incisional hernia formation. This paper aims to test the feasibility of running a randomised controlled trial of a comparison of abdominal wall closure methods following midline incisional surgery for colorectal cancer, in preparation to a definitive randomised controlled trial.Design and settingA feasibility trial (with 1:1 randomisation) conducted perioperatively during colorectal cancer surgery.ParticipantsPatients undergoing midline incisional surgery for resection of colorectal cancer.InterventionsComparison of two suture techniques (Hughes repair or standard mass closure) for the closure of the midline abdominal wound following surgery for colorectal cancer.Primary and secondary outcomesA 30-patient feasibility trial assessed recruitment, randomisation, deliverability and early safety of the surgical techniques used.ResultsA total of 30 patients were randomised from 43 patients recruited and consented, over a 5-month period. 14 and 16 patients were randomised to arms A and B, respectively. There was one superficial surgical site infection (SSI) and two organ space SSIs reported in arm A, and two superficial SSIs and one complete wound dehiscence in arm B. There were no suspected unexpected serious adverse reactions reported in either arm. Independent data monitoring committee found no early safety concerns.ConclusionsThe feasibility trial found no early safety concerns and demonstrated that the trial was acceptable to patients. Progression to the pilot and main phases of the trial has now commenced following approval by the independent data monitoring committee.Trial registration numberISRCTN 25616490.

Background Incisional hernias are common complications of midline closure following abdominal surgery and cause significant morbidity, impaired quality of life and increased health care costs. The ‘Hughes Repair’ combines a standard mass closure with a series of horizontal and two vertical mattress sutures within a single suture. This theoretically distributes the load along the incision length as well as across it. There is evidence to suggest that this technique is as effective as mesh repair for the operative management of incisional hernias; however, no trials have compared the Hughes Repair with standard mass closure for the prevention of incisional hernia formation following a midline incision. Methods/design This is a 1:1 randomised controlled trial comparing two suture techniques for the closure of the midline abdominal wound following surgery for colorectal cancer. Full ethical approval has been gained (Wales REC 3, MREC 12/WA/0374). Eight hundred patients will be randomised from approximately 20 general surgical units within the United Kingdom. Patients undergoing open or laparoscopic (more than a 5-cm midline incision) surgery for colorectal cancer, elective or emergency, are eligible. Patients under the age of 18 years, those having mesh inserted or undergoing musculofascial flap closure of the perineal defect in abdominoperineal wound closure, and those unable to give informed consent will be excluded. Patients will be randomised intraoperatively to either the Hughes Repair or standard mass closure. The primary outcome measure is the incidence of incisional hernias at 1 year as assessed by standardised clinical examination. The secondary outcomes include quality of life patient-reported outcome measures, cost-utility analysis, incidence of complete abdominal wound dehiscence and C-POSSUM scores. The incidence of incisional hernia at 1 year, assessed by computerised tomography, will form a tertiary outcome. Discussion A feasibility phase has been completed. The results of the study will be used to inform current and future practice and potentially reduce the risk of incisional hernia formation following midline incisions. Trial registration Trial Registration Number: ISRCTN 25616490. Registered on 1 January 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1573-0) contains supplementary material, which is available to authorized users.