Grand challenges in colorectal and proctological surgery

Abstract

"You must do the thing you think you cannot do." -Eleanor Roosevelt.Colorectal surgery (CRS) and proctology represent a branch of general surgery that is becoming increasingly important and relevant. In recent decades, there have been so many innovations that have given coloproctological surgery an identity of its own. In recent years, innovations in major CRS have been revolutionizing healthcare and improving patient outcomes ranging from early diagnosis to the most modern treatment options.One of the most significant breakthroughs in CRS has been the widespread adoption of minimally invasive techniques.Laparoscopic surgery is now extremely widespread and practiced in CRS and the latter has completely revolutionized the field of major abdominal surgery by offering patients a less invasive approach that allows shorter hospital stays, reduced pain, and quicker recoveries. On the other hand, clinical research in the surgical field is moving in the direction of ever better instruments and technologies for the operating room. Recently, the single-incision laparoscopy technique has also been proposed in major colorectal surgery with total colectomy. This technique is often referred to as single-port laparoscopy or SILS (Single-Incision Laparoscopic Surgery) and represents a cuttingedge advancement in minimally invasive surgery. (1) Another recently introduced new technology that allows an even less invasive approach to surgery with even fewer abdominal accesses is the Natural Orifice Transluminal Endoscopic Surgery (NOTES). Utilizing natural body openings such as the anus, vagina, and stomach for entry into the surgical area, it has been advocated as a method that leaves no visible scars. This technique allows access to various structures, including the distal rectum, which is challenging to approach using traditional laparoscopic methods. However, this approach has been associated with an increased risk of perioperative infection due to potential contamination and inadequate closure of access sites and the limited spatial orientation and the current skill level and instruments further compound the difficulty in learning and mastering this approach. Therefore, although several ideas have been proposed to secure the stapler anvil in NOTES, they have yet to gain widespread acceptance among surgeons. (2) What until recently was not feasible and suitable for major surgery, today, through surgical technological innovations is instead possible. Similarly, transanal total mesorectal excision (TaTME) offers the surgeon the possibility of combining a meticulous dissection of the mesorectal plane with a minimally invasive approach, ensuring a higher likelihood of complete tumour removal and reducing the risk of local recurrence. The Short-Stump and High-Anastomosis Pull-Through Procedure (SHiP) is an innovative approach recently introduced for treating rectal cancer. Unlike traditional methods, SHiP eliminates the need for creating a diverting ostomy, leading to a significant enhancement in patients' post-operative quality of life. Nonetheless, there is a possibility of functional post-operative changes, such as the occurrence of Low Anterior Rectal Resection Syndrome (LARS), anstomotic leak for ischemia of the rectal stump, anatostotic stenosis, and patient's discomfort from 7 to 14 days between the two operations. According to Bianco et al., with some technical modification, they made possible to avoid some of the drawbacks of the procedure. However, it needs further investigations. (5,6) Robotic platforms for major abdominal surgery have recently been introduced into surgical technology. Their use to date is on an upward trend due to the continuous improvement in precision, manual dexterity and ergonomics, as well as the possibility of integrating the machine with other technologies. Despite this, some trials have shown that the robotic platform is not superior to the use of the laparoscopic technique in rectal surgery. However, robotic p