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Transanal endoscopic microsurgery (TEM) allows the local excision of rectal tumors and achieves lower morbidity and mortality rates than total mesorectal excision. TEM can treat lesions up to 18 to 20 cm from the anal verge, obtaining good oncological results in T1 stage cancers and preserving sphincter function. TEM is technically demanding. Large lesions (>5 cm), those with high risk of perforation into the peritoneal cavity, those in the upper rectum or the rectosigmoid junction, and those in the anal canal are specially challenging. Primary suture after peritoneal perforation during TEM is safe and it does not necessarily require the creation of a protective stoma. We recommend closing the wall defect in all cases to avoid the risk of inadvertent perforation. It is important to identify these complex lesions promptly to transfer them to reference centers. This article summarizes complex procedures in TEM.

Background: Tissue ischemia is a key risk factor for anastomotic leakage (AL). Indocyanine green (ICG) is widely used in colorectal surgery to define the segments with the best vascularization. In an experimental model, we present a new system for quantifying ICG saturation, SERGREEN software.Methods: This was a controlled experimental study with eight pigs. In the initial control stage, ICG saturation was analyzed at the level of two anastomoses in the right and left colon. Control images of the two segments were taken after ICG administration. The images were processed with the SERGREEN program. Then, in the experimental ischemia stage, the inferior mesenteric artery was sectioned at the level of the anastomosis of the left colon. Fifteen minutes after the section, sequential images of the two anastomoses were taken every 30’ for the following 2 h.Results: At the control stage, the mean scores were 134.2 (95% CI: 116.3-152.2) for the right colon and 147 (95% CI: 134.7-159.3) for the left colon (p = 0.174). The right colon remained stable throughout the experiment. In the left colon, saturation fell by 47.9 points with respect to the preischemia value (p Conclusions: The SERGREEN program quantifies ICG saturation in normal and ischemic situations and detects differences between them. A reduction in ICG saturation of 32.6% or more was correlated with complete tissue ischemia.

Introduction Physicians, especially surgeons, are significatively affected by burnout. Duty-hour violation, as well as discrimination, abuse and sexual harassment may contribute to burnout. A study about this topic has been published in residents from United States, demonstrating a high incidence of burnout. Our objective is to know which is the situation in Spain and to compare it with United States. Methods Cross-sectional observational study carried out in January-February 2020, based on the responses to a validated survey administered to General Surgery residents in Spain. Results There are 931 General Surgery Residents. 739 have entered in the survey and 452 (61.2%) eventually responded to it. In any occasion during the training period, 55.1% reported discrimination based on their gender, 8.8% reported racial discrimination, 73.9% reported verbal/psychological abuse, 7.1% reported physical abuse and 16.4% reported sexual harassment. Attending surgeons are the most frequent source of sexual harassment and physical and verbal abuse, whereas patients are the most frequent cause of gender discrimination. Burnout symptoms were reported by 47.6% of residents and 4.6% reported suicidal thoughts. 98% of residents reported duty-hour violations and 47% of them do not have the day off after to be on call. Both of these issues are burnout predictive factors. Conclusions Mistreatment (discrimination, abuse and harassment) occurs among General Surgery residents during their training period in our country. Every kind of mistreatment is more frequent in Spain than in the United States, with the exception of racial discrimination. It is associated with exceeding weekly duty-hour. It is necessary to know these problems and to avoid them in order to improve work environment of General Surgery training period.

La toxina botulínica se ha aplicado en la reparación de defectos ventrales, pero la literatura sobre su aplicación en hernias inguinoescrotales es escasa. Presentamos el caso de un paciente con hernia inguinoescrotal gigante. Se realiza tomografía computada basal y otra a las 4 semanas de la administración de toxina botulínica en la musculatura oblicua y en el recto abdominal (reducción de grosor e incremento de longitud de la musculatura). Se repara la pared abdominal mediante la colocación de una malla tipo BioA intraperitoneal y otra tipo DynaMeshBotulinum toxin has been used in ventral defects repair, but literature on its application in inguinoscrotal hernias is scarce. Patient with giant inguinoscrotal hernia. A baseline CT scan is performed and it is repeated four weeks after botulinum toxin injection in oblique musculature and in the abdominal rectum (reduction in thickness and increase in muscle length is observed). The abdominal wall is repaired by placing an intraperitoneal BioA mesh and a retromuscular DynaMesh

La toxina botulinica se ha aplicado en la reparacion de defectos ventrales, pero la literatura sobre su aplicacion en hernias inguinoescrotales es escasa. Presentamos el caso de un paciente con hernia inguinoescrotal gigante. Se realiza tomografia computada basal y otra a las 4 semanas de la administracion de toxina botulinica en la musculatura oblicua y en el recto abdominal (reduccion de grosor e incremento de longitud de la musculatura). Se repara la pared abdominal mediante la colocacion de una malla tipo BioA intraperitoneal y otra tipo DynaMesh® retromuscular. La toxina puede tener un papel importante como adyuvante en la reparacion de hernias inguinoescrotales con perdida de domicilio. Botulinum toxin has been used in ventral defects repair, but literature on its application in inguinoscrotal hernias is scarce. Patient with giant inguinoscrotal hernia. A baseline CT scan is performed and it is repeated four weeks after botulinum toxin injection in oblique musculature and in the abdominal rectum (reduction in thickness and increase in muscle length is observed). The abdominal wall is repaired by placing an intraperitoneal BioA mesh and a retromuscular DynaMesh® mesh. The toxin can have an important role as an adjuvant in the reparation of inguinoscrotal hernias with loss of domain.

Forty-eight year old man with epigastric pain. CT scan shows a common hepatic artery aneurysm (HAA) of 4,6 cm in size with permeable portal vein. Angiography demonstrates that it affects from the beginning of the celiac trunk until hepatic arteries bifurcation, producing a proximal splenic artery stenosis. Proximal and distal embolization is done achieving a complete aneurysm occlusion. A stent is placed in celiac trunk in order to maintain splenic flow. Permeability of distal hepatic artery through choledochal arteries is observed in a month follow-up CT scan. HAA are infrequent but potentially lethal. Endovascular techniques should be considered of choice currently. HAA embolization has an elevated risk of hepatic ischemia.