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Objectives The Peritoneal Surface Oncology Group International (PSOGI) consensus subdivided pseudomyxoma peritonei (PMP) into four groups according to histopathological features. The aim of this paper is to report survival outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) from a national referral centre and to correlate the PSOGI classification with survival. Methods A retrospective study of a prospectively maintained database was performed. Consecutive patients treated with CRS + HIPEC for PMP of appendiceal origin were included (September-2013 to December-2021). Pathological features of the peritoneal disease were used to classify patients into the four groups proposed by PSOGI. Survival analysis was performed to evaluate the correlation of pathology on overall survival (OS) and disease-free survival (DFS). Results Overall, 104 patients were identified; 29.6 % were reclassified as acellular mucin (AM), 43.9 % as low-grade mucinous carcinoma peritonei (LGMCP), 22.4 % as high-grade MCP (HGMCP) and 4.1 % as HGMCP with signet ring cells (HGMCP-SRC). Median PCI and rate of optimal cytoreduction were 19 and 82.7 %, respectively. Median OS and DFS were not reached, 5-year OS and DFS were 88.6(SD 0.04) % and 61.6(SD 0.06) %, respectively. Log-Rank test revealed significant differences in terms of OS and DFS across the different histological subgroups (p Conclusions Survival outcomes after CRS + HIPEC for PMP are excellent. The PSOGI pathological classification correlates with OS and DFS, but differences were not significant at multivariate analysis when adjusted for other prognostic factors.

Introduction The advent of the COVID-19 pandemic led to recommendations aimed at minimizing the risk of gas leaks at laparoscopy. As this has continuing relevance including regarding operating room pollution, we empirically quantified carbon dioxide (CO2) leak jet velocity (important for particle propulsion) occurring with different instruments inserted into differing trocars repeated across a range of intra-abdominal pressures (IAPs) and modern insufflators in an experimental model. Method Laparoscopic gas plume leak velocity (metres/second) was computationally enumerated from schlieren optical flow videography on a porcine cadaveric laparoscopic model with IAPs of 4–5, 7–8, 12–15 and 24–25 mmHg (repeated with 5 different insufflators) during simulated operative use of laparoscopic clip appliers, scissors, energy device, camera and staplers as well as Veres needle (positive control) and trocar obturator (negative control) in fresh 5 mm and 12 mm ports. Results Close-fitting solid instruments (i.e. cameras and obturators) demonstrated slower gas leak velocities in both the 5 mm and 12 mm ports (p = 0.02 and less than 0.001) when compared to slimmer instruments, however, hollow instrument designs were seen to defy this pattern with the endoscopic linear stapler visibly inducing multiple rapid jests even when compared to similarly sized clip appliers (p = 0.03). However, on a per device basis the operating instrumentation displayed plume speeds which did not vary significantly when challenged with varying post size, IAP and a range of insufflators. Conclusion In general, surgeon's selection of instrument, port or pressure does not usefully mitigate trocar CO2 leak velocity. Instead better trocar design is needed, helped by a fuller understanding of trocar valve mechanics via computational fluid dynamics informed by relevant surgical modelling.

Despite increasing endorsement of near-infrared perfusion assessment using indocyanine green (ICG) during colorectal surgery, little work has yet been done regarding learning curve and interobserver variation most especially on surgical video reflective of real-world usage. Surgeons with established expertise in ICG usage were invited to participate in the study along with others without such experience including trainees. All participants completed an opinion questionnaire and interpreted video presentations of fluorescence angiograms in a variety of colorectal case scenarios. An interactive video platform (Mindstamp) enabled dynamic annotation. Statistical analysis of data was performed using Kruskal–Wallis and Mann–Whitney testing as well as Intraclass Correlation Coefficients and Fleiss Multi-rater Kappa Scoring. Forty participants (six experts) completed questionnaire data and provided judgement of 14 videos (nine showing proximal colonic transection site perfusion, four showing completed anastomoses and one an acutely strangulated bowel). 70% felt > 10 cases were needed for competency in use with the majority of experts advocating > 50 (p

A new concept in intraoperative decision support for tumour delineation is proposed showing that artificial intelligence provides categorising information and interpretation from the images captured during fluorescence-guided colorectal cancer operations. This is potentially applicable to all cancer subtypes and is pertinent to new fluorophore development.A new concept in intraoperative decision support for tumour delineation is proposed showing that artificial intelligence provides categorising information and interpretation from the images captured during fluorescence-guided colorectal cancer operations. This is potentially applicable to all cancer subtypes and is pertinent to new fluorophore development. A new concept in intraoperative decision support for tumour delineation is proposed showing that artificial intelligence provides categorising information and interpretation from the images captured during fluorescence-guided colorectal cancer operations. This is potentially applicable to all cancer subtypes and is pertinent to new fluorophore development. Shows promise

Advanced instrumentation whether robotic or non-robotic- hasn't itself made for better surgery as all critical measures of operative success depend still on intraoperative surgeon judgement and decision-making. Computer assisted surgery, or digital surgery, refers to the combination of technology with real-time data during an operation and is often assumed to need new hardware platforms to become a reality. However, methods to support personalised surgical endeavour exist now and can be deployed today within standard laparoscopic paradigms. Here we describe in detail the rationale for the deployment of such assistance for surgical step-advancement in our current practice evolution from traditional proximal colon cancer resection to complete mesocolic excision focussing on personalised 3d anatomical display, intraoperative, quantificative fluorescence assessment of intracorporeal anastomoses and postoperative digital feedback to enable reflection and identify areas of technical improvement.

Introduction: The risk of unknowingly disseminating leiomyosarcoma by morcellation in women undergoing laparoscopic hysterectomy has massively impacted gynaecological practice. Here, we present the results of an in vitro assessment of a novel protection system developed to mitigate this hazard. Methods: The Tissue Containment System for Manual Morcellation (Guardenia™, Advanced Surgical Concepts, Wicklow, Ireland) is an evolved wound protection/specimen extraction guarded bag system compatible with any 12mm trocar. Device use was assessed by device-naïve gynaecological and general surgeon volunteers (providing expert and inexpert morcellation cohorts, respectively) on a bench model consisting of biological tissue in a custom-built moulded rig with camera control after the operators were instructed in its use. Results: Twenty surgeons (10 gynaecologists/10 general surgeons, median duration of practice experience: 8 years, median annual number of laparoscopic operative procedures: 150 and 80, respectively) completed the user assessment. All subjects understood and correctly performed each step; i.e., (i) placement of the bag through the trocar, (ii) specimen bagging, (iii) incision extension (range 25-60 mm) after tethering the bag through the port, (iv) insertion of the device guard through the mouth of the bag after trocar removal, and (v) sufficient tissue morcellation within the bag to enable complete specimen removal (mean specimen weight 390g, range 201-1800g). There was 100% bag integrity by water-leak testing following use, despite scalpel contact with the guard in 14/20 cases (70%). Conclusion: Among first-time clinical users, this novel device enabled complete containment of morcellation debris and removal of a laparoscopic specimen, which would support further submission for regulatory approval.

Laparoscopic surgery has been undermined throughout the COVID-19 pandemic by concerns that it may generate an infectious risk to the operating team through aerosolization of peritoneal particles. There is anyway a need for increased awareness and understanding of the occupational hazard for surgical teams regarding unfiltered escape of pollutants generated by surgical smoke and other microbials. Here, the aerosol-generating nature of this access modality was confirmed through repeatable real-time methodology both qualitatively and quantitively to inform best practice and additional engineering solutions to optimize the operating room environment.Laparoscopic surgery has been undermined throughout the COVID-19 pandemic by concerns that it may generate an infectious risk to the operating team through aerosolization of peritoneal particles. There is anyway a need for increased awareness and understanding of the occupational hazard for surgical teams regarding unfiltered escape of pollutants generated by surgical smoke and other microbials. Here, the aerosol-generating nature of this access modality was confirmed through repeatable real-time methodology both qualitatively and quantitively to inform best practice and additional engineering solutions to optimize the operating room environment.

Cytoreductive Surgery (CRS) combined with hyperthermic intraperitoneal chemotherapy (HIPEC) is increasingly accepted as the optimal management of selected patients with peritoneal malignancy. There is limited published evidence on outcomes in older patients treated by this complex therapeutic strategy.A retrospective review of a prospective database of all patients who underwent CRS with HIPEC in a single institution over seven years. A comparative analysis of outcomes in patients under 65 undergoing CRS and HIPEC with patients ≥65 years was performed. The key endpoints were morbidity, mortality, reintervention rate and length of stay in the high dependency/intensive care (HDU/ICU) units.Overall, 245 patients underwent CRS and HIPEC during the study period, with 76/245 (31%) ≥65 years at the time of intervention. Tumour burden measured by the peritoneal carcinomatosis index (PCI) score was a median of 11 for both groups. Median length of hospital stay in the ≥65-year-old group was 14.5 days versus 13 days in the65-year-old group (∗p = 0.01). Patients aged ≥65-years spent a median of one more day in the critical care unit ∗(p = 0.001). Significant morbidity (Clavien-Dindo ≥ Grade IIIa) was higher in the ≥65-year than the65-year group (18.4% versus 11.2%). There were no perioperative deaths in the ≥65-year group.This study demonstrates higher perioperative major morbidity in ≥65-year group, but with low mortality in patients undergoing CRS/HIPEC for disseminated intraperitoneal malignancy. This increased morbidity does not translate into higher rates of re-interventions and highlights the importance of optimal patient selection.

Multimodal therapy incorporating cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) improve survival for selected patients with colorectal peritoneal metastases (CPMs). Many countries have centralised management of these patients, aiming to improve outcomes. There is ongoing debate on the need for and complications associated with HIPEC administration. We report indications and outcomes after CRS/HIPEC treated in a national centre in the modern era. A retrospective review of all CPM patients who underwent CRS and HIPEC since the initiation of an Irish national program in 2013. The primary endpoint was the overall survival associated with CRS/HIPEC. During the study period (April 2013–June 2020), 123 patients proceeded to planned CRS/HIPEC for CPM. Median age was 58 (IQR 47–67) and 55 patients (44.7%) were male. In 65 patients (52.8%), CPM was synchronous. In 7/123 (5.8%), disease was unresectable. The median peritoneal cancer index (PCI) was 10 (IQR 5–17). Overall, 104/123 (84.5%) underwent a complete cytoreduction (CC0/CC1). Thirteen out of 123 (10.5%) patients also had a synchronous liver resection. Forty out of 123 (32.5%) patients had adverse pathological features (poorly differentiated or signet ring cells). The median survival in patients after CC0, CC1 and CC2/3 resection was 50, 18 and 11 months respectively (*p =

Gas leaks occur frequently at laparoscopy and create jet-streams equivalent in velocity to human speaking. Focus on surgical smoke underestimates the issue and means any such guidance is incomplete.

Despite increasing endorsement of near-infrared perfusion assessment using indocyanine green (ICG) during colorectal surgery, little work has yet been done regarding learning curve and interobserver variation most especially on surgical video reflective of real-world usage.Surgeons with established expertise in ICG usage were invited to participate in the study along with others without such experience including trainees. All participants completed an opinion questionnaire and interpreted video presentations of fluorescence angiograms in a variety of colorectal case scenarios. An interactive video platform (Mindstamp) enabled dynamic annotation. Statistical analysis of data was performed using Kruskal-Wallis and Mann-Whitney testing as well as Intraclass Correlation Coefficients and Fleiss Multi-rater Kappa Scoring.Forty participants (six experts) completed questionnaire data and provided judgement of 14 videos (nine showing proximal colonic transection site perfusion, four showing completed anastomoses and one an acutely strangulated bowel). 70% felt 10 cases were needed for competency in use with the majority of experts advocating 50 (p 0.05). Overall agreement among experts was "good" for videos showing colonic transection perfusion (versus "moderate" among in-experts) with experts clustering more distally. In contrast, there was no interpretation concordance among experts or in-experts when judging ICG perfusion sufficiency on a yes/no basis.Significant experience is recommended before reliance on ICG perfusion angiograms. ICG fluorescence assessment is prone to variable interpretation and influenced by experience and, perhaps, knowledge of preassessment operative steps suggesting a role for objective flow analysis with artificial intelligence methods as the next phase of this technology.

The COVID‐19 pandemic has focused surgeons and healthcare systems on the aerosolization hazards of minimally invasive surgery and its devices. Energy and articulating laparoscopic and robotic instruments contain hollow spaces in their shafts and handles to allow cabling transmit electrical energy to the instrument tip and tissue. While much attention has been placed on the management of smoke that occurs during cautery by instrument activation, it may be less obvious that such instruments may act as chimney flues for intraperitoneal gas to flow unfiltered directly into the operating room environment. This gas will contain smoke but also simply the carbon dioxide (CO2) used to distend the abdominal cavity and any associated aerosolised cells and virions.

Minimally invasive surgical (MIS) procedures have been restricted during the COVID-19 pandemic, in part to reduce inpatient occupancy and minimize pressure on critical care and anaesthesia but also because of concern for the potential for transmission of infection via aerosols created by laparoscopy. Viral particles have now been identified in the blood, stool and peritoneal fluid of infected patients although the infectious potential of any such particles that may be carried via surgical gases is unclear.

Unanticipated behaviours of the Airseal Insufflation and Access System (Conmed, NY, USA), in the public domain since 2017, have been recently restated by the manufacturer in light of the COVID19 pandemic and widespread concerns regarding aerosolization hazards during surgery. The associated video illustrates this device’s tendency for intra‐abdominal gas effluvium to be continually blown into the operating room during use as well as the phenomenon of air entrainment (i.e. the tendency for room air to be sucked into the abdomen) during high pressure intraoperative suctioning. We used a combination of assessment technologies in a high‐fidelity simulation model (fresh porcine cadaver) as well as during clinical surgery to examine gas flow through the Airseal 12mm valve‐less trocar with the Airseal IFS carbon dioxide (CO2) insufflator in Airseal mode.

This clinical study confirms user acceptability of PAPR during surgery both at operating room team level as well as by groups of surgeons, anaesthesiologists and nursing level. While some care is needed in the use of this equipment, surgery can be performed safely with satisfactory user experience. Therefore PAPR is useable for surgery but scope exists for improvement.

Close contact between the patient and physician markedly affects local airflow and their spared airspace, and this can be moderated by mask wearing. Understanding this is particularly relevant in the COVID-19 pandemic and for those new to clinical practice, in particular medical students.

Microdamage and remodelling in an ovine model.