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Colorectal surgery has benefited from advances in precision medicine such as total mesorectal resection, and recently, mesocolon resection, fluorescent perfusion imaging, and fluorescent node mapping. However, these advances fail to address the variable quality of mesocolon dissection and the directed extent of vascular dissection (including high ligation) or pre-resection anastomotic perfusion mapping, thereby impacting anastomotic leaks. We propose a new paradigm of precision image-directed colorectal surgery involving 3D preoperative resection modeling and intraoperative fluoroscopic and fluorescence vascular imaging which better defines optimal dissection planes and vascular vs. anatomy-based resection lines according to our hypothesis. Six pigs had preoperative CT with vascular 3D reconstruction allowing for the preoperative planning of vascular-based dissection. Laparoscopic surgery was performed in a hybrid operating room (OR). Superselective arterial catheterization was performed in branches of the superior mesenteric artery (SMA) or the inferior mesenteric artery (IMA). Intraoperative boluses of 0.1 mg/kg or a continuous infusion of indocyanine green (ICG) (0.01 mg/mL) were administered to guide fluorescent-based sigmoid and ileocecal resections. Fluorescence was assessed using proprietary software at several regions of interest (ROI) in the right and left colon. The approach was feasible and safe. Selective catheterization took an average of 43 min. Both bolus and continuous perfusion clearly marked pre-identified vessels (arteries/veins) and the target colon segment, facilitating precise resections based on the visible vascular anatomy. Quantitative software analysis indicated the optimal resection margin for each ROI. Intra-arterial fluorescent mapping allows visualization of major vascular structures and segmental colonic perfusion. This may help to prevent any inadvertent injury to major vascular structures and to precisely determine perfusion-based resection planes and margins. This could enable tailoring of the amount of colon resected, ensure good anastomotic perfusion, and improve oncological outcomes.

Background COVID-19 pandemic presented an unexpected challenge for the surgical community in general and Minimally Invasive Surgery (MIS) specialists in particular. This document aims to summarize recent evidence and experts’ opinion and formulate recommendations to guide the surgical community on how to best organize the recovery plan for surgical activity across different sub-specialities after the COVID-19 pandemic. Methods Recommendations were developed through a Delphi process for establishment of expert consensus. Domain topics were formulated and subsequently subdivided into questions pertinent to different surgical specialities following the COVID-19 crisis. Sixty-five experts from 24 countries, representing the entire EAES board, were invited. Fifty clinicians and six engineers accepted the invitation and drafted statements based on specific key questions. Anonymous voting on the statements was performed until consensus was achieved, defined by at least 70% agreement. Results A total of 92 consensus statements were formulated with regard to safe resumption of surgery across eight domains, addressing general surgery, upper GI, lower GI, bariatrics, endocrine, HPB, abdominal wall and technology/research. The statements addressed elective and emergency services across all subspecialties with specific attention to the role of MIS during the recovery plan. Eighty-four of the statements were approved during the first round of Delphi voting (91.3%) and another 8 during the following round after substantial modification, resulting in a 100% consensus. Conclusion The recommendations formulated by the EAES board establish a framework for resumption of surgery following COVID-19 pandemic with particular focus on the role of MIS across surgical specialities. The statements have the potential for wide application in the clinical setting, education activities and research work across different healthcare systems.

Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investigated the feasibility and outcome of performing localized sigmoidectomy in its entirety via NOTES.A survival study of five male minipigs (mean weight, 30 kg) was conducted. After anesthesia, a gastrotomy was created by a per os double-channel endoscope, and full peritoneoscopy was performed. A Berci needle then was inserted transparietally to allow maintenance and monitoring of the pneumoperitoneum. Using a transanal probe to facilitate intestinal retraction, the mesentery was dissected with instruments worked through the channels of the transgastric endoscope. The anvil of a circular stapler then was passed per anum into the colon above the point of intended transection. A penetrating transrectal trocar was placed to allow entry of a linear stapler into the peritoneum through a colotomy, and the sigmoid was cross-stapled proximally. The strut of the anvil then was snugged into a colotomy made at this staple line. The specimen was delivered via the anus by a "pull-through" technique. The distal sigmoidal margin was cross-stapled extracorporeally, ensuring that the colotomy was included within the specimen. Retrograde passage of the circular stapler head per anus allowed colocolonic reanastomosis by its mating with the anvil already in situ. The gastrotomy was closed with a previously validated prosthesis. Postoperatively, all the animals were recovered and monitored for well-being during convalescence. Endoscopy (gastroscopy and sigmoidoscopy), laparoscopy, and laparotomy were performed on postoperative day 14 as follow-up measures.Each operation was satisfactorily completed. The mean operative time was 76 min (range, 44-95 min). All the animals prospered postoperatively. Follow-up examination showed full healing of all anastomoses and gastrotomy sites. There was no evidence of luminal stricturing, peritonitis, or intraabdominal sepsis in any animal.Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format.

Following an extensive literature search and a consensus conference with subject matter experts the following conclusions can be drawn: 1. Robotic surgery is still at its infancy, and there is a great potential in sophisticated electromechanical systems to perform complex surgical tasks when these systems evolve. 2. To date, in the vast majority of clinical settings, there is little or no advantage in using robotic systems in general surgery in terms of clinical outcome. Dedicated parameters should be addressed, and high quality research should focus on quality of care instead of routine parameters, where a clear advantage is not to be expected. 3. Preliminary data demonstrates that robotic system have a clinical benefit in performing complex procedures in confined spaces, especially in those that are located in unfavorable anatomical locations. 4. There is a severe lack of high quality data on robotic surgery, and there is a great need for rigorously controlled, unbiased clinical trials. These trials should be urged to address the cost-effectiveness issues as well. 5. Specific areas of research should include complex hepatobiliary surgery, surgery for gastric and esophageal cancer, revisional surgery in bariatric and upper GI surgery, surgery for large adrenal masses, and rectal surgery. All these fields show some potential for a true benefit of using current robotic systems. 6. Robotic surgery requires a specific set of skills, and needs to be trained using a dedicated, structured training program that addresses the specific knowledge, safety issues and skills essential to perform this type of surgery safely and with good outcomes. It is the responsibility of the corresponding professional organizations, not the industry, to define the training and credentialing of robotic basic skills and specific procedures. 7. Due to the special economic environment in which robotic surgery is currently employed special care should be taken in the decision making process when deciding on the purchase, use and training of robotic systems in general surgery. 8. Professional organizations in the sub-specialties of general surgery should review these statements and issue detailed, specialty-specific guidelines on the use of specific robotic surgery procedures in addition to outlining the advanced robotic surgery training required to safely perform such procedures.

Several techniques are described in the literature about laparoscopic treatment of the right colon. Among them, laparoscopic-assisted colectomy (LAC) with creation of an extracorporeal ileocolonic anastomosis remains the favourite approach in most centers. So far, total laparoscopic colectomy (TLC) with intracorporeal anastomosis is not widely performed, because it requires adequate skills and competence in the use of mechanical linear staplers and laparoscopic manual sutures. The purpose of this study was to determine prospectively if TLC offers some advantages in short-term outcomes over LAC. A prospective comparative study was designed for 80 consecutive patients who were alternatively treated with TLC and LAC for right colon neoplasms. The following data were collected: operative time, intra- and postoperative complication rate, time to bowel movement, hospitalization time, length of minilaparotomy, number of harvested lymph nodes, and specimen length. Operative time in TLC resulted significantly longer than in LAC (230 vs. 203 min), complication rate was similar in both groups, with no case of anastomotic dehiscence, two anastomotic bleedings in TLC vs. three in LAC and one case of postoperative ileus for each group. One case of death occurred in LAC patient developing a postoperative severe cardiopulmonary syndrome. Time to first flatus was in favour of TLC (2.2 vs. 2.6 days), whereas hospitalization was comparable. As regards to the oncological parameters of radicality, the specimen length was superior in TLC group, but the number of lymph nodes excised was equivalent. The length of the minilaparotomy was clearly shorter in TLC group (5.5 vs. 7.2 cm). No evidence of relevant differences in terms of functional and safety outcomes between the two laparoscopic procedures. TLC determines less abdominal manipulation and shorter incision length, but clear advantages must be still demonstrated. Larger series are necessary to test the superiority of totally laparoscopic procedures for right colectomy.

The idea of reinforcing staple lines by using a material with the purpose of diminishing suture morbidity is not new. Over the last decades many strategies have been adopted, in both gastrointestinal and thoracic surgery. The first bolsters used for staple lines were nonabsorbable (e.g., expanded polytetrafluoroethylene, ePTFE), semi-absorbable (bovine pericardial and collagen strips), and bioabsorbable materials (L-lactic acid-co-epsilon-caprolactone) [1, 2]. The problem has always been to find the optimal material that yields the greatest advantages in terms of reduced incidence of leakage, stricture, and bleeding of the staple line. Gore Seamguard is a bioabsorbable membrane of polyester braided suture, a random-fiber web of a copolymer glycolide (PGA) and trimethylene carbonate (TMC) microporous structure. The advent of Seamguard in reinforcement of linear sutures yielded good results, reducing the rate of clinical leaks and anastomotic bleeding, and offering satisfactory anastomoses [3–5]. The application of Seamguard to circular staplers ensued and yielded the same good results [6]. Further applications in the strategy of reinforcement of linear sutures have been use of Seamguard for lung resections [7], appendectomy [8], bariatric surgery [9], and gastric surgery [10, 11]. In our experience we have observed some advantages after adopting Seamguard biomaterial as staple-line reinforcement when using linear staplers, in particular in laparoscopic surgery of stomach and distal pancreas. On the whole, since June 2000 we have performed 79 laparoscopic gastrectomies for various pathologies: 6 for benign ulcer, 5 for nodular histiocytic (NH) lymphoma, 2 for gastrointestinal stromal tumor (GIST), and 66 for gastric cancer. We registered three duodenal leaks at the beginning of laparoscopic experience (one following gastrectomy for benign ulcer and two for adenocarcinoma) when we used to merely transect the duodenum by a 45-mm linear cutting stapler without enclosing or reinforcing the staple line (20 cases). From 2002 on, after transecting the duodenum laparoscopically with linear stapler, we enclosed the staple line by separated extracorporeal stitches (9 cases), while after 2003 the staple line was routinely protected with Seamguard (50 cases), since which no leaks have been registered [10, 11]. Certainly, a comparison between enclosing suture versus reinforcement of the staple line would have been of great interest, but the leak rate was nil in both groups, hence such a comparison was nonsense. The reason why we prefer BSG bolster now is only because it is less time consuming than tying extracorporeal slipknots on the duodenal stump. On the other hand, reinforcement by BSG bolster is certainly more expensive. Recently, some interesting studies confirmed the effectiveness of Seamguard in reducing the rate of leak after distal pancreatectomy, in both open surgery [12, 13] and laparoscopy [14, 15]. In our experience we registered a statistically relevant difference with Fisher’s exact test between the leak rate (within 30 days) after pancreatic transection by linear staple plus buttress and by BSG reinforcement [15]. This noticeable outcome in our series has confirmed the statistically significant results obtained in open surgery by others [12, 13]. The polyglycolic acid–trimethylene carbonate BSG (Bioabsorbable Seamguard , WL Gore & Associates, Flagstaff, AZ, USA), is a material absorbable within 6 months. In our series one patient experienced a late pancreatic leak 42 days after surgery, probably due to initial absorption of BSG material that disclosed the presence of an underlying leak. R. Pugliese (&) D. Maggioni F. Sansonna G. C. Ferrari S. Di Lernia A. Forgione C. Magistro Divisione di Chirurgia Generale e Videolaparoscopica, Ospedale di Niguarda Ca’ Granda, Piazza Ospedale 3, 20162 Milano, Italy e-mail: chirurgiaurgenza@ospedaleniguarda.it