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Robot-assisted surgery (RAS) continues to grow globally. Despite this, in the UK and Ireland, it is estimated that over 70% of surgical trainees across all specialities have no access to robot-assisted surgical training (RAST). This study aimed to provide educational stakeholders guidance on a pre-procedural core robotic surgery curriculum (PPCRC) from the perspective of the end user; the surgical trainee. The study was conducted in four Phases: P1: a steering group was formed to review current literature and summarise the evidence, P2: Pan-Specialty Trainee Panel Virtual Classroom Discussion, P3: Accelerated Delphi Process and P4: Formulation of Recommendations. Forty-three surgeons in training representing all surgical specialties and training levels contributed to the three round Delphi process. Additions to the second- and third-round surveys were formulated based on the answers and comments from previous rounds. Consensus opinion was defined as ≥ 80% agreement. There was 100% response from all three rounds. The resulting formulated guidance showed good internal consistency, with a Cronbach alpha of > 0.8. There was 97.7% agreement that a standardised PPCRC would be advantageous to training and that, independent of speciality, there should be a common approach (95.5% agreement). Consensus was reached in multiple areas: 1. Experience and Exposure, 2. Access and context, 3. Curriculum Components, 4 Target Groups and Delivery, 5. Objective Metrics, Benchmarking and Assessment. Using the Delphi methodology, we achieved multispecialty consensus among trainees to develop and reach content validation for the requirements and components of a PPCRC. This guidance will benefit from further validation following implementation.

Over the past 50 years the capability of technology to improve surgical care has been realised and while surgical trainees and trainers strive to deliver care and train; the technological ‘solutions’ market continues to expand. However, there remains no coordinated process to assess these technologies. The FOS:TEST Report aimed to (1) define the current, unmet needs in surgical training, (2) assess the current evidence-base of technologies that may be beneficial to training and map these onto both the patient and trainee pathway and (3) make recommendations on the development, assessment, and adoption of novel surgical technologies. The FOS:TEST Commission was formed by the Association of Surgeons in Training (ASiT), The Royal College of Surgeons of England (RCS England) Robotics and Digital Surgery Group and representatives from all trainee specialty associations. Two national datasets provided by Health Education England were used to identify unmet surgical training needs through qualitative analysis against pre-defined coding frameworks. These unmet needs were prioritised at two virtual consensus hackathons and mapped to the patient and trainee pathway and the capabilities in practice (CiPs) framework. The commission received more than 120 evidence submissions from surgeons in training, consultant surgeons and training leaders. Following peer review, 32 were selected that covered a range of innovations. Contributors also highlighted several important key considerations, including the changing pedagogy of surgical training, the ethics and challenges of big data and machine learning, sustainability, and health economics. This summates to 7 Key Recommendations and 51 concluding statements. The FOS:TEST Commission was borne out of what is a pivotal point in the digital transformation of surgical training. Academic expertise and collaboration will be required to evaluate efficacy of any novel training solution. However, this must be coupled with pragmatic assessments of feasibility and cost to ensure that any intervention is scalable for national implementation. Currently, there is no replacement for hands-on operating. However, for future UK and ROI surgeons to stay relevant in a global market, our training methods must adapt. The Future of Surgery: Technology Enhanced Surgical Training Report provides a blueprint for how this can be achieved.

Aims In response to the COVID-19 pandemic and the cancellation of elective surgery, the Independent sector (IS) has been utilised to provide COVID-light sites. On average operative log book numbers have been reduced by 50% due to a reduction in operative exposure. The Four Educational Bodies continue to support training within the independent sector. This study aimed to qualitatively assess access and barriers to UK surgical training in the Independent Sector. Methods A snap-shot online survey was distributed to ASIT members of all training specialities and grades between 21/10/2020-11/11/2020 . Data measures included participant demographics, frequency of access, participation in training opportunities including outpatient clinic, theatre lists and endoscopy and any barriers encountered. A mixture of Likert scale and short answer questions were utilised. Results 249 complete responses representing all grades and specialities were included in the final analysis (34.29% CST and 56.3% HST). 35.7% of trainees reported access to the IS. 22.9% had access to at least one operating list whilst 70.3% had none. Access to outpatient clinics and endoscopy was negligible. 75% of trainees ‘strongly agreed’ that when access was achievable, it was beneficial to their training. Multiple barriers were identified including Human Resource requirements and local service provision. Conclusions Within the sample, access to the IS has been poor. There is wide variation in barriers to access across the 4 nations and IS providers. Trainees and Trainers should maximise training opportunities in the IS. Where barriers exist, they should be reported to local Training Programme Directors.

Aim The Postgraduate Virtual Learning Environment (PGVLE) is a digital platform developed by HEEWM in response to the COVID-19 pandemic to deliver a virtual teaching programme to surgical trainees. The programme is delivered through the BigBlueButton; an integrated virtual classroom. All teaching sessions are recorded and archived to allow trainees to review content at their convenience. We performed a contemporaneous study to review the effectiveness and quality of the platform in delivering teaching and suggest its future role in the surgical curriculum. Method Anonymised feedback was gathered of trainee’s perspective of the platform experience, the quality of teaching and the archived content. All trainees were General Surgery higher trainees (HST) (ST3-ST8). The data from sequential teaching days was analysed. Results Of 90 HST, on average 40 attended each monthly training day (consistent with pre-COVID attendance). 122 trainee responses were completed. 68% of respondents were between ST3-ST5. 91% rated the administration and delivery of the teaching sessions as excellent or very good. 16% of trainees watched the archived sessions after the teaching day of which 46% felt it met their educational expectations. Conclusions The PGVLE is an effective platform for the delivery of a virtual surgical teaching programme. It met with high levels of trainee satisfaction in the context of the pandemic. The archived content provides advantages to consolidation of learning. It is thought that the PGVLE platform will become a key feature of the surgical training programme in a hybrid learning model, related to relevant curricula, in the future.

AIM Delayed closure of ileostomy following an anterior resection for rectal cancer in the UK is common. The aims of this study were (i) to investigate the variation in patient pathways between hospitals, (ii) to identify the key learning points from units with the shortest time to closure and (iii) to develop guidance for a pathway to minimize delay in ileostomy closure. METHOD This was a mixed methods study. Thirty-eight colorectal units in the UK completed a short online survey. Nine colorectal units in Wales filled in an additional, expanded version of the survey. Semi-structured interviews were performed with clinicians from the six best performing units in terms of timely ileostomy closure. The optimal pathway suggested is based on the best evidence available and the Association of Coloproctology of Great Britain and Ireland guidelines. RESULTS Qualitative analysis revealed that 5% of units (n = 2) have a local target time for ileostomy closure. Of all units, 90% (n = 34) would consider implementing a pathway if guidelines were developed. In-depth interviews highlighted the importance of a multidisciplinary approach, a dedicated coordinator to facilitate timely booking, and consensus on whether closure should be performed before or after adjuvant chemotherapy. CONCLUSION There is a lack of national guidance in timing of contrast studies and ileostomy closure. Key aspects to consider are better information at consent regarding stoma closure timing, a dedicated person to track patients and the planning of contrast studies at discharge from initial surgery. With a dedicated approach closure of ileostomy within 10-12 weeks is feasible for most units.

Aim Cohort data suggest that anastomotic leak occurs after 8% of right colectomies causing significant morbidity and mortality. Patient selection, intra-operative factors, and technical variation all contribute to risk of leak. The EAGLE study will assess whether implementation of the European Society of Coloproctology (ESCP) Safe Anastomosis Intervention reduces anastomotic leak following right colectomy. Methods An international, multi-centre, cluster randomised trial will be undertaken with hospitals as clusters. Hospitals will be recruited in a number of distinct phases, with each phase following the same research plan, in which clusters are randomised to one of three, staggered (dog-leg) schedules for implementation of the Safe Anastomosis Intervention. Results Results from different phases will be meta-analysed. The intervention is a three-component behavioural change programme for surgeons, anaesthetists and operating room staff, supported by an online learning environment. All colorectal surgical units around the world will be eligible. Adults undergoing elective or emergency right colectomy or ileocaecal resection, by any approach and for any indication will be included. The primary outcome is 30-day anastomotic leak rate, defined as clinical or radiologically-detected leak or intra-abdominal or pelvic collection. Assuming hospitals provide data for an average of 10 patients per two month recruitment period, 333 clusters (4440 patients in total) will allow for detection of an absolute risk reduction of anastomotic leak from 8.1% to 5.6% (relative risk reduction 30%). This protocol adheres to Standard Protocol Items: Recommendations for Intervention Trials (SPIRIT). Discussion The protocol describes the methods for an evaluation of a hospital-level, education-based quality improvement intervention targeted to reduce the life-threatening surgical complication of anastomotic leak.

BACKGROUND Diverticular disease accounts for significant morbidity and mortality and may take the form of recurrent episodes of acute diverticulitis. The role of elective surgery is not clearly defined. OBJECTIVE This study aimed to define the rate of hospital admission for recurrent acute diverticulitis and risk factors associated with recurrence and surgery. DESIGN This is a retrospective population-based cohort study. SETTINGS National Health Service hospital admissions for acute diverticulitis in England between April 2006 and March 2011 were reviewed. PATIENTS Hospital Episode Statistics data identified adult patients with the first episode of acute diverticulitis (index admission), and then identified recurrent admissions and elective or emergency surgery for acute diverticulitis during a minimum follow-up period of 4 years. Exclusion criteria included previous diagnoses of acute diverticulitis, colorectal cancer, or GI bleeding, and prior colectomy or surgery or death during the index admission. INTERVENTIONS There were no interventions. MAIN OUTCOME MEASURES The primary outcomes measured were recurrent admissions for acute diverticulitis and patients requiring either elective or emergency surgery during the study period. RESULTS Some 65,162 patients were identified with the first episode of acute diverticulitis. The rate of hospital admission for recurrent acute diverticulitis was 11.2%. A logistic regression model examined factors associated with recurrent acute diverticulitis and surgery: patient age, female sex, smoking, obesity, comorbidity score >20, dyslipidemia, and complicated acute diverticulitis increased the risk of recurrent acute diverticulitis. There was an inverse relationship between patient age and recurrence. Similar factors were associated with elective and emergency surgery. LIMITATIONS The cases of acute diverticulitis required inpatient management and the use of Hospital Episode Statistics, relying on the accuracy of diagnostic coding. CONCLUSIONS This is the largest study assessing the rates of hospital admission for recurrent acute diverticulitis. Knowledge of the rate and risk factors for recurrent acute diverticulitis is required to aid discussion and decision making with patients regarding the need and timing of elective surgery. Some factors associated with recurrence are modifiable; therefore, weight reduction and smoking cessation can be championed. See Video Abstract at http://links.lww.com/DCR/A449.

Summary Background Closure of an abdominal stoma, a common elective operation, is associated with frequent complications; one of the commonest and impactful is incisional hernia formation. We aimed to investigate whether biological mesh (collagen tissue matrix) can safely reduce the incidence of incisional hernias at the stoma closure site. Methods In this randomised controlled trial (ROCSS) done in 37 hospitals across three European countries (35 UK, one Denmark, one Netherlands), patients aged 18 years or older undergoing elective ileostomy or colostomy closure were randomly assigned using a computer-based algorithm in a 1:1 ratio to either biological mesh reinforcement or closure with sutures alone (control). Training in the novel technique was standardised across hospitals. Patients and outcome assessors were masked to treatment allocation. The primary outcome measure was occurrence of clinically detectable hernia 2 years after randomisation (intention to treat). A sample size of 790 patients was required to identify a 40% reduction (25% to 15%), with 90% power (15% drop-out rate). This study is registered with ClinicalTrials.gov, NCT02238964. Findings Between Nov 28, 2012, and Nov 11, 2015, of 1286 screened patients, 790 were randomly assigned. 394 (50%) patients were randomly assigned to mesh closure and 396 (50%) to standard closure. In the mesh group, 373 (95%) of 394 patients successfully received mesh and in the control group, three patients received mesh. The clinically detectable hernia rate, the primary outcome, at 2 years was 12% (39 of 323) in the mesh group and 20% (64 of 327) in the control group (adjusted relative risk [RR] 0·62, 95% CI 0·43–0·90; p=0·012). In 455 patients for whom 1 year postoperative CT scans were available, there was a lower radiologically defined hernia rate in mesh versus control groups (20 [9%] of 229 vs 47 [21%] of 226, adjusted RR 0·42, 95% CI 0·26–0·69; p

Background. Although guidelines indicate when patients are eligible for antihypertensives and statins, little is known about whether general practitioners (GPs) follow this guidance. Objective. To determine the factors influencing GPs decisions to prescribe cardiovascular prevention drugs. Design of Study. Secondary analysis of data collected on patients whose cardiovascular risk factors were measured as part of a controlled study comparing nurse-led risk assessment (four practices) with GP-led risk assessment (two practices). Setting. Six general practices in the West Midlands, England. Patients. Five hundred patients: 297 assessed by the project nurse, 203 assessed by their GP. Measurements. Cardiovascular risk factor data and whether statins or antihypertensives were prescribed. Multivariable logistic regression models investigated the relationship between prescription of preventive treatments and cardiovascular risk factors. Results. Among patients assessed by their GP, statin prescribing was significantly associated only with a total cholesterol concentration ≥7 mmol/L and antihypertensive prescribing only with blood pressure ≥160/100 mm Hg. Patients prescribed an antihypertensive by their GP were five times more likely to be prescribed a statin. Among patients assessed by the project nurse, statin prescribing was significantly associated with age, sex, and all major cardiovascular risk factors. Antihypertensive prescribing was associated with blood pressures ≥140/90 mm Hg and with 10-year cardiovascular risk. Limitations. Generalizability is limited, as this is a small analysis in the context of a specific cardiovascular prevention program. Conclusions. GP prescribing of preventive treatments appears to be largely determined by elevation of a single risk factor. When patients were assessed by the project nurse, prescribing was much more consistent with established guidelines.

The primary aim of this retrospective study was to determine the medium-term survival of autologous osteochondral grafts (mosaicplasty) in the knee. The secondary aims were to evaluate any reason for failure, and to ascertain if age, gender, BMI, previous or associated knee surgery, site or size of the osteochondral graft had any influence on outcome. Fifty-five patients undergoing an autologous osteochondral graft procedure between 1999 and 2008 were evaluated, with a mean follow-up of 5.9 years (range 0.5 to 10.5). Loosening, graft degeneration or subsequent surgery in the form of arthroplasty, revision autologous osteochondral graft or any other osteochondral procedure, and an Oxford knee score above 49.7 (see text) were considered as failure. Kaplan-Meier analysis demonstrated an 87.5% survival at 8 years (95% CI 72% to 97%). The mean Oxford score at follow-up was 163% (95% CI 10.6% to 22.1%) at follow-up. Two of 6 failures occurred in patients with varus malalignment. Linear regression analysis demonstrated an improved outcome in Oxford knee score in younger patients. Gender, BMI, previous or associated knee surgery, site and size of the graft had no influence on outcome. The authors consider autologous osteochondral grafting as a reliable method of treatment in the medium-term for young patients with small contained articular cartilage lesions up to 4 cm2. Careful attention should be paid to the mechanical axis (varus) prior to grafting. Long-term studies are necessary.