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The ideal ventral dissection plane follows the interface between the rectovaginal septum and the mesorectal fascia - unless the rectal tumour is located ventrally or the rectovaginal septum is not readily discernible. The surgical dissection planes for complete mobilization of the rectum/mesorectum are graphically highlighted and subsequently displayed from the dorsal, lateral to the ventral aspect, including pitfalls when deviating from the correct dissection plane. First, the mesorectal fascia, which envelopes the mesorectal tissue containing the superior rectal blood vessels and the major lymphatic drainage route of the rectum, is addressed. In men the rectoprostatic septum (Denonvilliers fascia) extends between the seminal vesicles/prostate and the anterior aspect of the mesorectal fascia. [Extracted from the article]

Background: Robotic-assisted surgery (RAS) offers improved visualisation and dexterity compared to laparoscopy. As a result, RAS is considered an attractive option for performing rectopexy, particularly in the confines of the lower pelvis. The aim of this study was to explore the benefits of RAS in rectopexy by analysing the views of a group of surgeons will have published on robotic rectopexy. Methods: A three-round Delphi process was performed. Combined qualitative, Likert scale and binary responses were utilised in rounds one and two with binary responses seeking overall consensus in round two and three. Particular areas that were studied included: clinical aspects of patient selection, technical aspects of using RAS to perform rectopexy, ergonomic factors, training, and consideration of the 'learning-curve'. Consensus was defined as agreement > 80% among participants. Potential experienced RAS rectopexy surgeons were identified using PubMed where authors of studies reporting outcomes from RAS rectopexy were searched and invited. Results: Twenty surgeons participated from the following countries: France, Germany, Ireland, Italy, Netherlands, Switzerland, UK, and USA. Participants had median operative experience of 75 (range 20–450) rectopexies (all techniques) and 11(range 0–300) robotic-rectopexies for all indications. All participants agreed that patient-reported functional outcomes and improved quality-of-life were the most important outcomes following rectopexy. Participants agreed the most significant benefits offered by RAS for rectopexy were improved precision due to better visualisation (80%), improved dexterity (90%) and improved overall accuracy e.g., for suture placement (90%). Ninety percent agreed that the superior ergonomics of RAS rectopexy improved their performance on several steps of the operation, in particular: mesh fixation (85%) and rectovaginal dissection (80%). Consensus on the learning curve for RAS abdominal rectopexy was not achieved: forty-five percent (n = 9) reported the learning curve as 11–20 cases and 55% (n = 11) as 21–30 cases. Conclusions: A panel of surgeons who had published on RAS view that it positively improves performance of rectopexy in terms of technical skills, improved dexterity and visualisation and ergonomics. [ABSTRACT FROM AUTHOR]

Background This study aimed to evaluate the use of binary metric-based (proficiency-based progression; PBP) performance assessments and global evaluative assessment of robotic skills (GEARS) of a robotic-assisted low anterior rectal resection (RA-LAR) procedure. Method A prospective study of video analysis of RA-LAR procedures was carried out using the PBP metrics with binary parameters previously developed, and GEARS. Recordings were collected from five novice surgeons (≤30 RA-LAR previously performed) and seven experienced surgeons (>30 RA-LAR previously performed). Two consultant colorectal surgeons were trained to be assessors in the use of PBP binary parameters to evaluate the procedure phases, surgical steps, errors, and critical errors in male and female patients and GEARS scores. Novice and experienced surgeons were categorized and assessed using PBP metrics and GEARS; mean scores obtained were compared for statistical purpose. Also, the inter-rater reliability (IRR) of these assessment tools was evaluated. Results Twenty unedited recordings of RA-LAR procedures were blindly assessed. Overall, using PBP metric-based assessment, a subgroup of experienced surgeons made more errors (20 versus 16, P  = 0.158) and critical errors (9.2 versus 7.8, P  = 0.417) than the novice group, although not significantly. However, during the critical phase of RA-LAR, experienced surgeons made significantly fewer errors than the novice group (95% CI of the difference, Lower = 0.104 – Upper = 5.155, df = 11.9, t = 2.23, p = 0.042), and a similar pattern was observed for critical errors. The PBP metric and GEARS assessment tools distinguished between the objectively assessed performance of experienced and novice colorectal surgeons performing RA-LAR (total error scores with PBP metrics, P  = 0.019–0.008; GEARS scores, P  = 0.029–0.025). GEARS demonstrated poor IRR (mean IRR 0.49) and weaker discrimination between groups (15–41 per cent difference). PBP binary metrics demonstrated good IRR (mean 0.94) and robust discrimination particularly for total error scores (58–64 per cent). Conclusions PBP binary metrics seem to be useful for metric-based training for surgeons learning RA-LAR procedures. [ABSTRACT FROM AUTHOR]

Abstract Background Accurate histopathological evaluation of resected lymph nodes (LN) is essential for the reliable staging of colorectal carcinomas (CRC). With conventional sectioning and staining techniques usually only parts of the LN are examined which might lead to incorrect tumor staging. A molecular method called OSNA (One Step Nucleic Acid Amplification) may be suitable to determine the metastatic status of the complete LN and therefore improve staging. Methods OSNA is based on a short homogenisation step and subsequent automated amplification of cytokeratin 19 (CK19) mRNA directly from the sample lysate, with result available in 30-40 minutes. In this study 184 frozen LN from 184 patients with CRC were investigated by both OSNA and histology (Haematoxylin & Eosin staining and CK19 immunohistochemistry), with half of the LN used for each method. Samples with discordant results were further analysed by RT-PCR for CK19 and carcinoembryonic antigen (CEA). Results The concordance rate between histology and OSNA was 95.7%. Three LN were histology+/OSNA- and 5 LN histology-/OSNA+. RT-PCR supported the OSNA result in 3 discordant cases, suggesting that metastases were exclusively located in either the tissue analysed by OSNA or the tissue used for histology. If these samples were excluded the concordance was 97.2%, the sensitivity 94.9%, and the specificity 97.9%. Three patients (3%) staged as UICC I or II by routine histopathology were upstaged as LN positive by OSNA. One of these patients developed distant metastases (DMS) during follow up. Conclusion OSNA is a new and reliable method for molecular staging of lymphatic metastases in CRC and enables the examination of whole LN. It can be applied as a rapid diagnostic tool to estimate tumour involvement in LN during the staging of CRC.

Aim: Sacral neuromodulation (SNM) is a widely adopted treatment for overactive bladder, non‐obstructive urinary retention and faecal incontinence. In the majority, it provides sustained clinical benefit. However, it is recognized that, even for these patients, stimulation parameters (such as amplitude, electrode configuration, frequency and pulse width) may vary at both initial device programming and at reprogramming, the latter often being required to optimize effectiveness. Although some recommendations exist for SNM programming, the scientific data to support them are understood by few clinicians. Methods: This is a narrative review of the literature covering some of the science behind stimulating a mixed peripheral nerve and available preclinical data in the field of SNM. It covers electrode configuration, amplitude, frequency, pulse width and cycling considerations. The review is targeted at clinicians with an interest in the field and does not seek to provide exhaustive detail on basic neuroscience. Results and conclusions: Knowledge of the science of neuromodulation provides some guiding principles for programming but these are broad. These principles are not refuted by preclinical data but specific parameters in clinical use are not strongly supported by animal data, even after the limitations of small and large animal models are considered. The review presents a shortlist of programming principles on a theoretical basis but acknowledges that current practice is as much derived from evolved experience as science. [ABSTRACT FROM AUTHOR]