Increased level of fluorescence intensity of breast cancer and normal mammary gland tissue a Haematoxylin and eosin-stained sections of normal and cancer tissue. The area outlined in green indicates the breast cancer. b Top images are fluorescence intensity images of γ-glutamyl hydroxymethyl rhodamine green (gGlu-HMRG) (green) at each time point overlaid on white light images. The fluorescence increase (FI) was obtained by subtracting the baseline fluorescence from the fluorescence at each time point. FIs are represented by the pseudocolour scale on the right side of the image.

Guest blog: a novel fluorescence technique for detecting breast cancer

Author: Hiroki Ueo, Department of Surgery and Sciences, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; Ueo Breast Cancer Hospital, Oita, Japan

Breast cancer is the most common cancer in women, and its incidence continues to increase worldwide. From the patient’s perspective, breast conserving surgery (BCS) with radiation achieves a balance between a satisfactory cosmetic result and a low recurrence rate. Although it has been established as a routine surgery, surgeons need to be careful about positive surgical margins. Remnant cancer cells in the preserved tissue increase the risk of recurrence. Therefore, a positive margin on postoperative pathology warrants additional surgery. In these cases, the additional treatment harbours unexpected outcomes, including physical, mental, cosmetic, and economic burden on the patients. 

To avoid the additional operation, pathological evaluation using an intraoperative frozen section is conducted. It is the most reliable method to prevent misdiagnosis and to achieve clear surgical margins. However, this conventional method is time consuming and costly. Moreover, it is dependent on the skill and experience of the pathologists and personnel, and it requires space for preparation of the frozen sections. Therefore, only a limited number of samples are examined to save time and resources. An alternative, rapid, and reliable technique to detect cancer in surgical margins enables simultaneous testing, leading to a reduced false negative rate of local recurrence incidence. In addition, pathologists can focus on the definitive diagnosis using permanent paraffin sections because it is difficult to make a diagnosis based on intraoperative frozen sections without pathological architecture. Pathologists only need to make an intraoperative diagnosis when the specimen cannot be evaluated via the fluorescence procedure. Thus, it is important to enhance the rapid fluorescent detection of breast cancer during surgery. To address these diagnostic issues, Prof. Urano invented chemical reagents (gamma-glutamyl hydroxymethyl rhodamine green [gGlu-HMRG]) that quickly fluoresce by reacting with an enzyme (gamma-glutamyl transferase [GGT]), overexpressed in cancerous tissues. It exhibits strong fluorescence a few minutes after reacting with GGT in vitro. A gGlu-HMRG solution is applied to the surgical margins to recognize cancer cells as green fluorescence intraoperatively. A previous study in 2015 documented the ability of this reagent to mark cancerous tissues in surgical breast tissues. Furthermore, this reagent did not interfere with the pathological examination, while the frozen section analysis tissues were difficult to reuse as formalin-fixed and paraffin-embedded permanent pathological specimens. 

The clinical utility of this technique was examined. The results were published in the British Journal of Surgery. Since the initial report in 2015, a more feasible and reproducible sample preparation protocol has been developed. Then, a dedicated apparatus, including a built-in camera, software program, and multiple sample wells, was developed. This system automatically measured and analyzed the increase in fluorescence of multiple samples simultaneously. Then, the increase in fluorescence of gGlu-HMRG, applied to breast tissues, was measured in four different institutes. The sample tissues were examined by four pathologists independently. These pathologists diagnosed the samples without knowing the background information of the patients. The clinical utility of the current fluorescent procedure was evaluated by comparing the fluorescence data and the pathological diagnosis. 

A clear threshold to distinguish between cancerous and non-cancerous tissues was not determined due to the heterogeneity of breast cancer tissues. Instead, the negative threshold to achieve a false negative rate <2% and the positive threshold to achieve a false positive rate <2% were established. Samples in which the increase in fluorescence was below the negative threshold value were considered cancer-free margins with a false negative rate <2%. The false negative samples in our study were tissues containing non-invasive cancer. This suggested that the samples below the negative threshold can be considered free of invasive cancer. Samples in which the increase in fluorescence was above the positive threshold value were considered cancerous tissue with a false positive rate <2%.

The disease prevalence determines the performance of a diagnostic tool. The percentage of positive and negative test results among those with or without the disease are the positive and negative predictive values, respectively. These positive and negative predictive values depended on the prevalence. Therefore, to estimate the performance of this technique, the prevalence and margin positive rate in this case should be considered. The margin positive rate was expectedly lower than that of our clinical study. In our protocol, three pieces of tissue were sampled: the central portion, where the breast cancer is located; its periphery, which contains non-invasive cancer; and the distal portion, which ideally contains normal mammary tissue. Cancer was detected in 46% of the samples. Based on the actual margin assessment, the prevalence was lower than that of our study. Assuming a prevalence <30%, the negative predictive value, the ratio of true negative samples among fluorescent negative samples, was larger than 98%. This indicated that this method was useful for detecting negative margins. 

According to this multicenter study, the fluorescent diagnosis was applicable to any breast cancer subtype, regardless of its pathological findings and subtype. Moreover, the similar accuracy among several institutes confirmed that the fluorescent diagnosis was applicable to any institute, following the protocol. Compared to the intraoperative frozen section analysis, the fluorescent diagnosis was a more rapid and accessible method with a low cost. It was not dependent on the skills of pathologists, and it did not require a large amount of space.           

In conclusion, this method can facilitate the rapid assessment of negative surgical margins during BCS while reducing the testing time, cost of diagnosis, and tasks of the pathologists and staff. 

Roux en Y gastric bypass

Guest blog: Bariatric Surgery – the safe solution to the metabolic pandemic

Authors: A G N Robertson (Twitter: @robertson_a), T Wiggins (@TomWiggins23), F P Robertson, L Huppler (@LucyLucyHuppler), B Doleman, E M Harrison (@ewenharrison), M Hollyman (@misshollyman), R Welbourn

Obesity is the preventable and reversible disease of our lifetime. It is a worldwide health, economic and environmental problem in need of urgent and essential attention, and it has become clear that the world needs more than the traditional recommendations to survive this metabolic pandemic.  The traditional advice has been acknowledged for centuries and even more so since the worldwide prevalence of obesity nearly tripled between 1975 and 20161. These lifestyle recommendations include physical exercise, less high calorific food content, balanced meals, optimising portion size, intermittent fasting and so on; we all know them. However, the human race is still falling short of tackling the major public health concern that this disease threatens to be. 

Bariatric or weight loss surgery is a surgical sub-speciality which has been evolving since the first procedures of this type in the mid 20th century. Its development has led to the most effective method to achieve long-term weight loss, as well as the additional health benefits weight loss offers as a by-product. However, accessibility to this specialist treatment is limited with only 1% of eligible patients going on to receive bariatric surgery.2Reasons for this limited access are multifactorial, however a considerable factor is thought to be concerns regarding the perceived risks of weight-loss surgery from patients across all populations. We should therefore aim to give our patients the most up to date worldwide risk of mortality of these potentially life-saving procedures. 

This month in the BJS, we’ve published the largest meta-analysis asking this question to date – and the findings are pivotal at providing a unanimous international statistic on this discussion. We’ve looked at perioperative mortality rates (inpatient, 30 day and 90 day mortality) of a range of bariatric procedures to include laparoscopic adjustable gastric band (LAGB), sleeve gastrectomy (SG), Laparoscopic Roux-en-Y gastric bypass (LRYGB), one-anastomosis gastric bypass (OAGB), biliopancreatic diversion/duodenal switch (BPD-DS) and other malabsorptive procedures. We’ve included 58 studies in our meta-analysis which has given us information on roughly 3.6 million patients over a 6-year period from worldwide practice. Multiple sources for data were used including administrative datasets, bariatric surgery registries, large scale case series as well as randomised controlled trials (RCTs). 

The paper looks at mortality within each subgroup of operation. There are interesting findings within this showing significant differences in perioperative mortality between procedures (P<0.001) with biliopancreatic diversion/duodenal switch or other malabsorptive procedures having the highest perioperative mortality rates (0.41%) and laparoscopic adjustable gastric band (LAGB) followed by sleeve gastrectomy (SG) being the procedures with the lowest perioperative mortality rates (0.03% and 0.05% respectively). This naturally reflects the trend towards these latter procedures being offered more commonly in international practice. Although this paper looks closely at perioperative mortality it is noteworthy to mention that it doesn’t look at long term morbidity following these procedures or their potential complication rates. 

Without a doubt, our most noteworthy finding has been the discovery that overall perioperative mortality following bariatric surgery is likely much lower than previously thought, with our pooled perioperative mortality rate at 0.08% (95% CI 0.06%-0.10%). It perhaps makes this statistic even more relatable when this is compared to other procedures we consider as ‘low-risk’ in our daily surgical practice. For example, laparoscopic cholecystectomy or fundoplication have comparable perioperative mortality rates reported at 0.1%. This new statistic is also lower than previously quoted in the literature from smaller scale studies. The mortality rate calculated in this meta-analysis puts bariatric surgery as a whole at lower risk of mortality as knee arthroplasty (0.3%)3. With this in mind, we hope that there can be a culture shift from avoidance of bariatric surgery due to risk, to giving patients the correct information to confidently weigh up the true risks and benefits of these procedures when indicated. 

How should these findings shape the future of bariatric surgery in Europe and beyond? Certainly in the UK, the acceptability of bariatric surgery as a viable treatment option for obesity is limited. It is surprising how often we see patients who are eligible for bariatric surgery and who have met the criteria for some time yet to be offered this as a treatment option. There is a distinct barrier to accessing bariatric surgery for the wider population, perhaps due to taboo surrounding broaching the issue of weight in the primary care setting, and although many general practitioners do this very well, there remain limiting factors. Another stand-out factor includes lack of funding or commissioning within the public health service for referral for weight loss specialist services. Therefore, with the addition of this new internationally applicable statistic, our hope is that the most effective treatment option for sustained weight loss can now be available for all that require it. Bariatric surgery is safe. 

  2. Welbourn R, le Roux CW, Owen-Smith A, Wordsworth S, Blazeby JM. Why the NHS should do more bariatric surgery; how much should we do? Bmj. 2016;353:i1472.
  3. Aminian A, Brethauer SA, Kirwan JP, Kashyap SR, Burguera B, Schauer PR. How safe is metabolic/diabetes surgery? Diabetes, Obes Metab. 2015; 17(2):198-201.

Image source: Eslam ibrahim66 2021 Creative Commons

Visual abstract for COVIDHAREM appendicitis study

Guest blog: Antibiotics – not operations – to treat adult appendicitis?

By Hannah Javanmard-Emamghissi (@hannahjavanmard), NELA Research Fellow and RCSEng Research fellow on behalf of the COVID:HAREM Collaborative 

Keyhole surgery (laparoscopic appendicectomy) has been the mainstay of adult appendicitis treatment in Europe and the United States for the last several decades. In spite of this numerous trials have been ongoing exploring if there is a role for non-operative management of appendicitis with antibiotics. The APPAC and CODA trials both demonstrated that antibiotics were effective at treating simple appendicitis that was not perforated, gangrenous or associated with an abscess in the majority of patients.(1,2) However, it remained an underutilised treatment strategy. 

This all changed during February and March of 2020, when the Sars-COV-2 virus (COVID-29) swept across much of the globe. Healthcare providers were forced to make contingency plans for hospitals that faced being overwhelmed by patients infected with COVID-19. Much of the anaesthetic workforce had been redeployed to intensive cares and there was uncertainty of the safety of general anaesthesia for patients with peri-operative COVID-19 and of the safety of the theatre teams exposed to virus aerosols during laparoscopy.(3,4) Non-operative management strategies were implemented recommended by surgical professional bodies across many surgical disciplines as a way of mitigating for these uncertainties.(5)

Our collaborative’s report, just published in BJS, represents the first time non-operative management of appendicitis has been implemented on a wide scale in the United Kingdom. We collected data on patients over the age of 18 presenting during the first wave of the COVID-19 pandemic presented with signs and symptoms suggestive of acute appendicitis, whether they were managed operatively and non-operatively. These patients were followed up for 90 days for length of hospital stay, complications, representation to hospital and appendicitis recurrence. Patients managed non-operatively were matched with similar patients managed operatively using propensity score matching, and their outcomes were compared.

Patients from 97 hospitals across the United Kingdom and Republic of Ireland were included in our study. Three thousand four hundred and twenty patients were included, of which 41% had initially been treated with antibiotics. When they were matched using propensity score matching with similar patients who had non-operative management, the group treated with antibiotics spent less time in hospital and had fewer complications than those who had an operative management. Non-operative management was successful in 80% of the patients managed in this way, with 20% going on to have an appendicectomy in the 90 days after their first attendance. 

We also teamed up with a health economics team from the London School of Tropical Medicine to calculate the costs associated with each treatment method. We found that, even when accounting for the 20% of patients that had surgery within the 3 months of being treated with antibiotics, non-operative management was associated with a cost reduction of €1034 per patient compared to operative management. 

This study proves that antibiotics are an effective management strategy for appendicitis and can be utilised on a large scale beyond trials for the first time ever. Patients may be keen to avoid surgery for a number of reasons and going forward surgeons should incorporate a discussion about the risks, benefits and uncertainties of non-operative management into conversations they have with patients about appendicitis management options. Our results have shown how reducing the number of operations we do for appendicitis can have benefits for the patient in terms of complications and days in the hospital away from work and home, but it may have wider benefits to the hospital and world. Not only is non-operative management cheaper for the hospital, but reducing the number of appendicectomies performed can free up theatre time so the most urgent surgical emergencies have less delay accessing theatre. All operations are associated with a significant amount of carbon emissions and single use plastic waste, but despite our best efforts to reduce the harm that surgery can cause to the environment the most effective strategy remains reducing the amount of unnecessary surgery performed.(6)

That is not to say that the study of non-operative management of appendicitis is over, there is still debate about the long-term efficacy of antibiotic management and concern that some cancers of the appendix may be missed by not removing the appendix at the first presentation, as well as questions about how acceptable patients find non-operative management. Our collaborative hopes to answer these questions and more in a one year follow up study and ongoing patient and public involvement work. 

Conflicts of Interest 

None to declare 


No funding was received for this blog article 


1.        Salminen P, Tuominen R, Paajanen H, Rautio T, Nordström P, Aarnio M, et al. Five-year follow-up of antibiotic therapy for uncomplicated acute appendicitis in the APPAC randomized clinical trial. JAMA. 2018 Sep 25;320(12):1259–1265. 

2.        CODA Collaborative, Flum DR, Davidson GH, Monsell SE, Shapiro NL, Odom SR, et al. A Randomized Trial Comparing Antibiotics with Appendectomy for Appendicitis. N Engl J Med. 2020 Nov 12;383(20):1907-1919.

3.        Nepogodiev D, Bhangu A, Glasbey JC, Li E, Omar OM, Simoes JF, et al. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet [Internet]. 2020 Jul 4 [cited 2020 Nov 5];396(10243):27–38. Available from:

4.        SH E. Should we continue using laparoscopy amid the COVID-19 pandemic? Br J Surg [Internet]. 2020 Jul 1 [cited 2021 Sep 5];107(8):e240–1. Available from:

5.        Hettiaratchy S, Deakin D. Guidance for surgeons working during the COVID-19 pandemic from the Surgical Royal Colleges of the United Kingdom and Ireland. Intercollegaite Royal Colleges of Surgery. London; 2020. 

6.        MacNeill AJ, Lillywhite R, Brown CJ. The impact of surgery on global climate: a carbon footprinting study of operating theatres in three health systems. Lancet Planetary Health [Internet]. 2017 Dec 1 [cited 2021 Sep 5];1(9):e381–8. Available from:

External aspect of the operative field: DaVinci™ robotic system docked to the patient

Guest blog: What advantage does robot-assisted and transanal TME have over laparoscopy?

Authors: Jeroen C. Hol, Colin Sietses


Correspondence to: “Comparison of laparoscopic versus robot-assisted versus TaTME surgery for rectal cancer: a retrospective propensity score matched cohort study of short-term outcomes

Image source: Robinson Poffo et. al. Robotic surgery in Cardiology: a safe and effective procedure. under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The emergence of minimally invasive surgery has led to the development of three new surgical techniques for oncological rectal resections: laparoscopic, robot-assisted and transanal TME (TaTME). When we compared the three techniques executed in expert centres, we expected to find an advantage for one of the three techniques in terms of reduced complication rates. But contrary to our expectations, no difference was seen. There was one striking difference however, when comparing these techniques, though it might be something different than you might have thought. We shine a light on all three techniques to explain their advantages. 

Laparoscopy: minimally invasive surgery

In the 1980’s, Heald introduced the total mesorectal excision (TME) principle, which comprises excision of the rectum and its surrounding fatty envelop with preservation of the autonomic nerves [1]. TME has become the golden standard for surgical resection for rectal cancer and helped dropping local recurrence rates drastically. The past decades laparoscopy has been introduced and gradually replaced open surgery. Laparoscopy offers short term benefits of minimally invasive surgery, such as faster recovery and reduced complication rates [2, 3]. It offers similar long-term outcome as open surgery [4]. But laparoscopy is technically demanding because it is difficult to work with rigid instruments in the narrow and confined area of the pelvis. Therefore, conversion rates to open surgery of more than 10% were seen [5]. Conversion is linked to increased morbidity and worse oncological outcome [6]. In order to overcome those technical limitations of laparoscopic TME, new techniques have been introduced; robot-assisted TME and TaTME. 

Robot-assisted TME: the same, but different

Robot-assisted TME comprises the same approach as laparoscopy, but with the use of a surgical robot. The surgical robot provides a stable platform with supreme vision and supreme instrument handling. Surgeons thought this technique might improve results in terms of reduced complication rates and reduced conversion rates. However, the largest randomized trial so far comparing robot-assisted and laparoscopic TME failed to show any difference in these outcomes [7]. This might have been the result of a methodological flaw, because the robotic surgeons in that trial were not as experienced as their laparoscopic colleagues [8]. In our study, we tried to eliminate this by only selecting experienced centres that were beyond their learning curve. However, we did not see reduced complication rates or reduced conversion rates after robot-assisted TME compared to laparoscopy.

Transanal TME: a different approach

TaTME comprises a different approach to address the most difficult part of the dissection. In TaTME the most distal and difficult part of the rectum is dissected from below using a transanal insufflator port. However, this is a technically demanding technique and has a long learning curve [9]. Some initial series showed high loco regional recurrence rates, which even led to a halt of TaTME in Norway [10, 11]. The potential learning curve effect is now part of an ongoing debate about the oncological safety of this technique. Most initial results however looked promising and showed consistently good quality specimen and lower conversion rates [12, 13]. In our study, conversion rates, number of complete specimen and morbidity rates did not differ from the other laparoscopy and robot-assisted TME. 

Technological advantage 

The results of our study showed similar and acceptable short-term results for all three techniques in expert centres. The most striking difference was that in centres with robot-assisted or TaTME, more primary anastomoses were made. The technological advantage of the two new techniques could have contributed to higher restorative rates. Both robot-assisted and TaTME provide better access and visibility to the distal rectum, enabling surgeons to complete the TME dissection safely and create an anastomosis. Robot-assisted TME could overcome technical limitations of laparoscopy in the narrow pelvis thanks to the use of 3D vision, lack of tremor, and superior instrument handling, thereby facilitating safe creation of an anastomosis [7, 14]. TaTME does not need multiple staple firing to transect the distal rectum and without requiring conversion to open surgery [13]. In fact, TaTME does not need cross-stapling at all, preventing the creation of dog-ears which are prone to ischemia [15]. 

Patient’s perspective

In conclusion, the technological advantage of robot-assisted TME and TaTME manifests itself in higher restorative rates. Each technique seems to be equally beneficial in terms of oncological outcomes and morbidity. However, anastomosis creation, quality of life and functional outcome are becoming of great importance to patients. It seems to be that an increasing proportion of patients is now in pursue of an anastomosis. The overall anastomosis rate of more than 84% for robot-assisted and TaTME in our study was higher than the anastomosis rate of 50% in a previous national study [16]. A note of caution should be added, as an anastomosis might not be always better in terms of functional outcome and quality of life. Patients with a low anastomosis are at risk of developing severe low anterior resection syndrome (LARS) symptoms. Severe LARS symptoms can have a detrimental effect on quality of life [17].  Further research should be undertaken to investigate whether a higher anastomosis rate is beneficial in terms of quality of life and functional outcome and whether this higher anastomosis rate actually leads to increased patient satisfaction. 


1.         Heald, R.J., E.M. Husband, and R.D. Ryall, The mesorectum in rectal cancer surgery–the clue to pelvic recurrence? Br J Surg, 1982. 69(10): p. 613-6.

2.         Stevenson, A.R., et al., Effect of Laparoscopic-Assisted Resection vs Open Resection on Pathological Outcomes in Rectal Cancer: The ALaCaRT Randomized Clinical Trial. JAMA, 2015. 314(13): p. 1356-63.

3.         van der Pas, M.H., et al., Laparoscopic versus open surgery for rectal cancer (COLOR II): short-term outcomes of a randomised, phase 3 trial. Lancet Oncol, 2013. 14(3): p. 210-8.

4.         Bonjer, H.J., et al., A Randomized Trial of Laparoscopic versus Open Surgery for Rectal Cancer. N Engl J Med, 2015. 373(2): p. 194.

5.         Chen, K., et al., Laparoscopic versus open surgery for rectal cancer: A meta-analysis of classic randomized controlled trials and high-quality Nonrandomized Studies in the last 5 years. Int J Surg, 2017. 39: p. 1-10.

6.         Allaix, M.E., et al., Conversion of laparoscopic colorectal resection for cancer: What is the impact on short-term outcomes and survival? World J Gastroenterol, 2016. 22(37): p. 8304-8313.

7.         Jayne, D., et al., Effect of Robotic-Assisted vs Conventional Laparoscopic Surgery on Risk of Conversion to Open Laparotomy Among Patients Undergoing Resection for Rectal Cancer: The ROLARR Randomized Clinical Trial. JAMA, 2017. 318(16): p. 1569-1580.

8.         Corrigan, N., et al., Exploring and adjusting for potential learning effects in ROLARR: a randomised controlled trial comparing robotic-assisted vs. standard laparoscopic surgery for rectal cancer resection. Trials, 2018. 19(1): p. 339.

9.         Koedam, T.W.A., et al., Transanal total mesorectal excision for rectal cancer: evaluation of the learning curve.Tech Coloproctol, 2018. 22(4): p. 279-287.

10.       Larsen, S.G., et al., Norwegian moratorium on transanal total mesorectal excision. Br J Surg, 2019. 106(9): p. 1120-1121.

11.       van Oostendorp, S.E., et al., Locoregional recurrences after transanal total mesorectal excision of rectal cancer during implementation. Br J Surg, 2020.

12.       Detering, R., et al., Three-Year Nationwide Experience with Transanal Total Mesorectal Excision for Rectal Cancer in the Netherlands: A Propensity Score-Matched Comparison with Conventional Laparoscopic Total Mesorectal Excision. J Am Coll Surg, 2019. 228(3): p. 235-244 e1.

13.       Grass, J.K., et al., Systematic review analysis of robotic and transanal approaches in TME surgery- A systematic review of the current literature in regard to challenges in rectal cancer surgery. Eur J Surg Oncol, 2019. 45(4): p. 498-509.

14.       Kim, M.J., et al., Robot-assisted Versus Laparoscopic Surgery for Rectal Cancer: A Phase II Open Label Prospective Randomized Controlled Trial. Ann Surg, 2018. 267(2): p. 243-251.

15.       Penna, M., et al., Four anastomotic techniques following transanal total mesorectal excision (TaTME). Tech Coloproctol, 2016. 20(3): p. 185-91.

16.       Borstlap, W.A.A., et al., Anastomotic Leakage and Chronic Presacral Sinus Formation After Low Anterior Resection: Results From a Large Cross-sectional Study. Ann Surg, 2017. 266(5): p. 870-877.

17.       Emmertsen, K.J. and S. Laurberg, Low anterior resection syndrome score: development and validation of a symptom-based scoring system for bowel dysfunction after low anterior resection for rectal cancer. Ann Surg, 2012. 255(5): p. 922-8.

Schematic of process for classifier design

Guest blog: 21st century surgery is digital

Ronan Cahill, Digital Surgery Unit, Mater Misericordiae University Hospital, Dublin, Ireland and UCD Centre for Precision Surgery, Dublin, Ireland.

Niall Hardy, UCD Centre for Precision Surgery, Dublin, Ireland.

Pol MacAonghusa, IBM Research, Dublin, Ireland.

Twitter @matersurgery Email:

Cancerous tissue behaves differently from non-cancerous tissue. Every academic oncology paper ever written tells us this. The appearances of any cancer primary (or indeed secondary lesion) result from biological and molecular processes that are the hallmarks of malignancy including dysregulated cell function and composition, host-cancer stromal and inflammatory response and angiogenesis. However, we surgeons haven’t really yet been able to exploit this knowledge during surgery in a way that helps us make a better operation. Instead, our learning and research about oncological cellular processes has predominantly advanced through basic science geared more towards perioperative prognostication and/or adjuvant therapy stratification. Wouldn’t it be great if realisation of cancer microprocesses could usefully inform decision-making intraoperatively?

We’ve just published an initial report in the BJS showing this very thing – that it is indeed possible to ‘see’ cancer by its behaviour in real-time intraoperatively. We’ve used Artificial Intelligence (AI) methods in combination with near-infrared fluorescence laparoendoscopy to judge and classify neoplastic tissue nature through the observation of differential dye diffusion through the region of interest in comparison with that happening in normal tissue being viewed alongside it. Through our understanding of biophysics (flow parameters and light/dye interaction properties), a lot of information can be drawn out over short periods of times via advanced computer vision methodology. With surgical video recording in the region of 30 frames per second, big data generates over the time frame of a few minutes.  While the gross signal shifts are discernible even without AI, smart machine learning capabilities certainly mean their interrogation becomes really usable in the provision of classification data within moments. What’s more, while we’ve focused initially on colorectal cancer, the processes we are exploiting seem common across other solid cancers and using other camera-based imaging systems. By combining with the considerable amount of knowledge we already have accrued regarding tissue biology, chemistry, physics as relate and indeed surgery, our AI methods are giving explainable and more importantly interpretable recommendations with confidence using a smaller dataset than that demanded by deep learning methodologies.

This though is just an early exemplar of what’s becoming possible through ‘Digital Surgery’, a concept that seems far more likely to transform contemporary surgical practice than our current general surgery “robotic” systems, hulking electromechanical tools entirely dependent on the user – a rather 20th century concept! Indeed, there is sophisticated technology everywhere in today’s operating theatres – surgeons sure don’t lack technical capability. Yet often despite vaulting costs, advance of real, value-based outcomes has been disappointingly marginal in comparison over the last two decades. The key bit for evolved surgery is instead going to be assisting surgeons to make the best decision possible for each individual patient by providing useful, discerning information regarding the surgery happening right now, and somehow plugging this case circumstances directly into the broad knowledge bank of expertise we have accrued as a profession (and not just be dependent on any single surgeon’s own experience).

To do this we need to realise the importance of visualisation in surgical procedures versus manual dexterity.  All surgery is performed through the visual interpretation of tissue appearances and proceeds via the perception-action cycle (‘sense, predict, act, adjust’). This is most evident during minimally invasive operations where a camera is used to display internal images on a screen but applies of course to open procedures as well. As all intraoperative decisions are made by the surgeon, the entire purpose of surgical imaging has been to present the best (‘most visually appealing’) picture to the surgeon for this purpose. Experiential surgical training is for the purpose of developing the ‘surgical eye’, that is learning how to make qualitative intraoperative judgments reliably to a reasonable standard. We haven’t however gotten the most out of the computer attached to the camera beyond image processing where we have concerned ourselves with display resolutions and widths. 

Imagine instead if some useful added interpretations of images could be made without adding extra cognitive burden to the surgeon, perhaps with straightforward on-screen prompts to better personalise decisions? This would be particularly exciting if these data were not otherwise easily realisable by human cognition alone and could be immediately and directly relevant to the person undergoing the operation. Every operation is in effect a unique undertaking, informed by probabilities accruing through individual and collected prior experience for sure but a new thing in and of itself for which the outcome at the time of its performance is unknown. How this individual patient differs from others and most especially how might an adverse outcome be avoided is a crucial thing to flag before any irreversible surgical step that commits an inevitable future. 

Right now, we are in a golden age of imaging. This is intricately linked to advances in computer processing and sharing power along with AI methods. This means we can harvest great additional information from the natural world around us across the spectrum of enormous (radio waves spanning the universe) to tiny (high resolution atomic imaging) distances and apply methods to help crystalise what this means to the observer. While a lot of AI is being directed at the easier and safer areas of standard patient cohort datasets, increasingly it’s possible to apply computer intelligence to the data rich surgical video feeds being generated routinely during operations to present insights to the surgeon. While early first steps at the moment relate to rather bread and butter applications such as instrument or lesion recognition and tracking as well as digital subtraction of smoke or anonymization protocols to prevent inadvertent capture of operating rooms teams when the camera is outside the patient, soon the capability to parse, segment and foretell likely best next operative steps will be possible at scale.

At present, the biggest limitation is that surgery lacks large warehoused archives of annotated imagery because operative video is a more complex dataset to scrutinise than the narrower image datasets available in specialities such as radiology, pathology and ophthalmology. Thanks to advances in computing, this is changing. Surgical video aggregation to enable building of representative cohorts is increasingly possible and, by combining with metadata and surgical insights, its full value can begin to be realised. GDPR frameworks provide structure and surgeons are increasingly understanding of the value of collaborating in research, education and practice development. However, while certain siloed sites focused around specific industry projects are already manifesting, the key area for greatest general advance lies within the surgical community combining broadly to construct appropriately developed and secured, curated video banks of procedures that can then be made accessible to entities from regulators and standard bodies, academia and indeed corporations capable of advancing surgery. This gives by far the greatest chance of the best of surgical traditions carrying through the 21st century while our weak spots are fortified for better surgery in the public interest.

Further reading: 
Artificial intelligence indocyanine green (ICG) perfusion for colorectal cancer intra-operative tissue classification.
 Cahill RA, O’Shea DF, Khan MF, Khokhar HA, Epperlein JP, Mac Aonghusa PG, Nair R, Zhuk SM.Br J Surg. 2021 Jan 27;108(1):5-9. PMID: 33640921 

The age of surgical operative video big data – My bicycle or our park? Cahill RA, MacAonghusa P, Mortensen N. The Surgeon 2021 Epub ahead of press

Ways of seeing – it’s all in the image. Cahill RA. Colorectal Dis. 2018 Jun;20(6):467-468. PMID: 29864253

tangled threads

Appendicitis (really).

tangled wicker mooring ropes in ship

Sometimes you read a collection of paper and see common threads. Here are some from BJS Open.

Nihil sub sole novum

The phrase ‘nothing new under the sun’ is often a cry of despair borne from monotony. Is this true for appendicitis? From reading this article from 1893, there are certainly principles that remain constant. There has been a recent flurry of papers on appendicitis published in BJS Open. As I’ve been reading them as they hit early access, I thought it might be interesting to have a look at them and see where they fit in the wider context of the literature and practice. 

We enter 2021 with the non-operative management of acute uncomplicated appendicitis being broadly accepted as a viable option. This has likely been increased by the (ongoing) COVID pandemic, with its subsequent impact on surgical resource and workforce availability.

First of all, appendicitis remains relevant. The paediatric surgery research priority setting exercise had two questions on appendicitis; one on the antibiotic only approach in uncomplicated appendicitis, and one on the use of drains post-operatively.

Telling the difference

And then we turn our attention to discriminating between complicated and uncomplicated appendicitis. What is the best modality? As a profession, we are keen not to over irradiate our patients with excessive CT scans. Naturally, we look to ultrasound and MRI scans. Unfortunately, a systematic review of diagnostic accuracy in all three modalities found limitations in both US and MRI, and a high negative predictive value when CT is used. So that is settled then, CT to reassure us that the patient has uncomplicated appendicitis and can be managed non-operatively.

Caution was raised by a study from Helsinki, Finland. This looked at 837 patients diagnosed with uncomplicated appendicitis on CT scan, and found that at surgery, 22% had perforated. The data is from 2014/2015, which isn’t *that* long ago, although it feels higher than I expected. So perhaps we need a better test to pick out complicated appendicitis?

Blood tests

Enter Kiss et al, who looked at genetic expression in peripheral blood mononuclear cells. This study found upregulation of genes associated with T & B cell interaction in those patients who had phlegmonous appendicitis, and upregulation of markers of antibacterial activity (e.g. monocytes and neutrophils). Perhaps this is interesting and personalised blood test to explore for the future. Point of care testing anyone? On the point of novel tests, an Irish group looked at the role of circulating fibrocytes in the diagnosis of appendicitis. This is a class of cells that is increased in states of inflammation. Sensitivity and specificity were in the high 60s, but in a modest sample that might be expected. Something to investigate further in a larger sample for sure. 

And finally, the role of blood tests in the immunosuppressed, specifically the HIV+ve patient. We classically use blood tests such as leucocyte count or C-reactive protein to aid diagnosis. This study from South Africa showed that, perhaps counterintuitively, CRP levels tended to be higher in HIV+ve patients with appendicitis than HIV-ve patients with appendicitis. Leucocyte levels were lower in the HIV+ve group. Useful to know this data exists as many of the risk models used are not calibrated for this population.


To wrap this up, I want to point out the opening gambit from the paper by Kiss et al:

‘Surgeons know how to treat appendicitis: either surgically with appendicectomy and supporting measures like abscess drainage, or conservatively without operation’

Whilst we may retain the technical principles of surgery, there is work to do. This seems to be around:

  • Improving the diagnosis of appendicitis, hopefully avoiding radiation in the process.
  • Accurate estimation of risk of perforation in patients with a diagnosis of appendicitis

Publications arising in the last six months in BJS Open alone suggest that we have a way to go to truly ‘know‘ how to treat appendicitis.


Patients should receive COVID-19 vaccine before surgery to reduce risk of postoperative death – study

The CovidSurg collaborative have published a new paper in BJS showing that global prioritisation of pre-operative vaccination for elective patients could prevent an additional 58,687 COVID-19-related deaths in one year. Watch the video abstract above or read the paper for free.

BJS Connect hashtag image

A summary of the #BJSConnect tweetchat on pregnancy and parenthood for surgeons

An interview with past BJS Editorial Assistant Claire Donohoe on the paper she co-authored entitled “Pregnancy, parenthood and second-generation bias: women in surgery

Thank you for joining us @ClaireDonohoe6. Here is the first question. Can you summarise in one sentence the take-home message from the paper?

Second-generation bias results in perceptions that surgeons fit a certain stereotype & pregnancy is highly disruptive to the prevailing culture …so… until we change the culture we can’t make pregnancy more ”acceptable”.

Current policy can be seen to amplify female difference and may even be viewed as “benevolent sexism”.

Changing the culture may make working as a surgeon more enjoyable and sustainable for all surgeons, not just parents.

Thank you @ClaireDonohoe6! Now for Question 2: What is second generation bias?

This is bias that is often unintended and unconscious, whereby people who don’t meet the stereotypical norms of the profession, fail to thrive in the environment despite “mitigating” strategies.

For example, mothers may not achieve leadership roles and this is attributed to their parenting roles. The “solution”? Women should be encouraged to accept policies aiming to mitigate work-family conflicts BUT this may actually impede their advancement.

To an extent we all play the role that is expected of us – we act a certain way because that is how it “should” be – e.g. “my male colleagues take 3 weeks annual leave so I should take 3 weeks leave post-partum” so as not be disruptive.

You mentioned that there is a difference in perception between male and female surgeons. Can you explain this a little more?

Studies show that other professionals & patients have different perceptions of communication and personalities of male & female surgeons. “Warm” males are seen as competent, but “warm” females are not. In reality gender shouldn’t influence perception of competence (but it does).

What are some of the challenges facing surgeons who are parents?

What is a normal life event is seen as disruptive because of the work culture of surgery. Combining family life with attentive patient care means that the traits maintaining the status quo: perfectionism, compulsion, denigration of vulnerability & martyrdom are questioned. Also my personal privilege protects me from lots of the issues facing others of lower income, less secure employment and other biases.

Thank you. And finally: What do you think the solutions might be?

Policy to support diverse lives outside of work will be required, at a minimum, to enable culture change.

@RCSI_Irl have PROGRESS fellowships for senior female trainees AND have done a lot of work on underlying issues (see here). Thanks to work from @dmcsurg and others.

Research tells us that focusing on “equipping women” has not lead to increased leadership participation for women – culture needs to change (see @sinead_lydon‘s systematic review).

IMHO, the bare minimum should be: reasonable limits on working during the third trimester, adequate parental leave, on-site childcare, support and mentorship.

For example… from a consultant surgeon job advert: “There is… access to a Childcare Co-ordinator to help staff with their childcare arrangements”.

We should aim for diversity – families exist in multiple forms, females are not the default primary caregiver. Many men would prefer accommodations to allow them participate more fully in family life. Some people choose not to become parents AND also have commitments

The Anatomy Lesson of Dr. Nicolaes Tulp by Rembrandt

Guest post: Why should you care about the history of surgery?

Dr. Tyler Rouse is an anatomical pathologist at the Huron Perth Healthcare Alliance in Stratford, Canada, and an adjunct professor in the Department of Pathology at the Schulich School of Medicine and Dentistry, Western University. He is the creator and host of the history of surgery podcast ‘Legends of Surgery’.

Why should you care about the history of surgery?

To begin with, it is unquestionably fascinating and fun. The history of surgery is filled with heroes and villains, triumphs and tragedies, progress and setbacks, but continuously moves towards the easing of suffering and the protection and prolonging of life. Yet there is something deeper and more meaningful that can be gained from the study of history. It grounds us, gives us a richer understanding of the world in which we live, and tells us how we arrived at this point in history, and provides a sense of identity and belonging in the world. 

The knowledge we now possess finds its origins in the writings of Hippocrates and Galen and the classical world of ancient Greece and Rome, which is reflected in the Latin and Greek roots of the words of the ‘lingua franca’ of medicine that we use every day. This was preserved and advanced during the Dark Ages by the physicians and surgeons of the Islamic Golden Age, and then “rediscovered” in the Renaissance, until the scientific revolution of the Age of Enlightenment shook us from the bonds of classical dogma and led to an explosion of medical and surgical knowledge through experimentation. The Industrial Age created added significant technological advances, arguably the most important of which was the ability to inhibit pain and avoid infection, allowing surgeons to delve ever deeper into the mysteries of the human body. This opened the window to the contributions from surgeons from across the globe that have brought us to this moment in time. This accumulated knowledge has been passed down from master to apprentice, teacher to learner, staff to student, in an unbroken chain that directly links us with the surgeons of the past.

Their influence is all around us when we step into the operating theatre, from hand washing (Semmelweiss), to the asepsis of the operative field (Lister), to the wearing of surgical gloves (Halsted) to the countless eponymously named instruments, procedures, and anatomical structures, that are part of every operating theatre around the world. Just about every part of an operation links us to the past, and to the people that came before us who discovered this hard-won knowledge. 

File:Use of the Lister carbolic spray, Antiseptic surgery, 1882. Wellcome M0003436.jpg
Use of the Lister carbolic spray. Credit: Antiseptic surgery : its principles, practice, history and results / by W. Watson Cheyne. Public Domain Mark. From Wellcome Images.

Studying these individual surgeons can both inspire us, and serve as a warning by demonstrating how good intentions can lead us astray. In addition to their contributions to surgical practice, many surgeons were basic scientists, Nobel Prize winners, public health advocates, artists, musicians, writers, and influential public figures that captured the imagination of society, both with their innovative breakthroughs and sometimes, their larger than life personalities. The English surgeon Percival Potts discovered the link between chimney sweeping and scrotal cancer in 1775, considered the first identification of an environmental carcinogen. American neurosurgeon Harvey Cushing won a Pulitzer Prize for his biography on Sir William Osler. South African surgeon Christiaan Barnard, who performed the world’s first successful heart transplant, was also an outspoken opponent of apartheid. And there are countless other examples.

Harvey Williams Cushing. Photograph by W.(?)W.B.
Harvey Williams Cushing. Credit: Harvey Williams Cushing. Photograph by W.(?)W.B. Credit: Wellcome CollectionAttribution 4.0 International (CC BY 4.0)

Surgeons have also experimented on the unwilling; for example, J. Marion Sims (of Sims retractor fame) did much of his ground-breaking work on obstetrical fistulas on African-American enslaved women in the mid-1800s. A number of surgeons were associated with the Nazi party, including Nobel Prize winner and French surgeon-scientist Alexis Carrel and the pioneering German thoracic surgeon Ferdinand Sauerbruch. And surgeons have taken part in the eugenics movement and forced sterilization, among other failings. Studying these examples shows us how surgery is not practiced in isolation, but rather affects and is effected by the world, society, and history. Surgeons have the potential to accomplish great things, but are also human, with all the flaws that come with it, and are not immune to the ills that plague society at large. It is important to recognize the bad with the good, and to ensure that history does not repeat itself.

Finally, one of the greatest challenges in medicine and surgery today is the epidemic of burnout, the causes of which are multifactorial, but includes a loss of finding meaning and purpose in work, and a feeling of disconnection. I believe that knowledge of our shared history, and studying those that came before us, can give a sense of identity and meaning to the practice of surgery. In an era of increasingly burdensome administrative tasks, it is easy to feel a sense of detachment and futility. But by studying the history of surgery, a greater sense of being rooted in community and purpose can be nurtured, and inspiration can be found to further the development of surgery towards better treatments and innovations, and to advocate for the patients that, too, have been a part of this shared history. 

Senior surgeon training junior surgeon in laparoscopy

Guest post: The Great Danes? Surgical training on a 37-hour week

By Mr Henry G Smith MBBS MRCS PhD, specialist registrar at The Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen

The number of hours in training that it takes for a surgical trainee to achieve both clinical and technical competence is a seemingly endless topic of debate. The significant global
variation in a surgical trainee’s average hourly week begs the question as to why such variation exists and to what extent all training programmes are created equal (1). Given the increasing recognition of burnout amongst medical professionals, and its association with excessive workloads, it is reasonable to think a shorter working week may benefit the surgical trainee’s wellbeing (2). However, any potential benefits much be weighed against the risk of reducing training opportunities and clinical exposure. Having personal experience of both British, with its nominal 48-hour working week, and Danish general surgical training, where surgeons work a 37-hour week, it is clear that whilst these countries have very similar healthcare systems, they differ markedly in their approach to training. Whilst neither training programme is without its limitations, their differences highlight potential ways in which the efficiency of surgical training may be improved.

The most striking difference between the British and Danish programmes is the absence of the ‘firm’ structure in Denmark. Trainees belong to the department rather than to subspeciality specific teams. The same is true of acutely admitted patients, who whilst broadly divided into those with upper and lower gastrointestinal conditions are not ‘owned’ by the consultant who was on call at the time of admission. As a consequence, there are no ward rounds, post-take or otherwise. Instead, the acute and elective inpatients are divided more or less equally between consultants and trainees alike, with a typical ratio of 2-3 patients to be seen by a single doctor each day. The lack of a rigid structure dictated by a team-based ward round leads to much greater flexibility in all other aspects of the working day. These days are thematic, with trainees having 4 major functions: elective operations, endoscopy, outpatient clinics and on-calls. When a trainee is not assigned to one of these functions, they have zero hours to be used as they see fit.

The flexibility of the Danish system brings two major advantages. The first is that the structure leaves the trainee with the feeling that the majority of time spent at work is spent training. That feeling is emphasised by the organisation of the operating days in particular.

Whilst the trainee spends undoubtedly fewer days in an elective theatre than in the British system, these days are almost exclusively spent attending training lists. Attended by a single trainee and a consultant, comprising repeated exposure to the same operation and booked on the presumption that the trainee will be the primary surgeon, these lists maximise training opportunities. The same is more or less true in endoscopy, where the trainee has their own full day list, with a supervisor on hand if needed. The second advantage is that the planning of absence from work for annual leave, courses or conferences is far less complicated. The minimum number of trainees required at work is determined at a departmental level, avoiding the need to organise cross cover between firms. As such, denied requests to attend conferences are very much the exception rather than the rule and it is almost unheard of that a trainee would be unable to take all of their allocated leave during a rotation.

These structural differences are accompanied by an in-house culture that not only prioritises training but is also ferocious in its defence of working conditions. There is a greater expectation for trainees to be actively involved, at least in part, in the majority of operations, and independent operating is encouraged at a much earlier stage. Senior house officers are expected to be capable of independently performing common acute operations, such as appendicectomies, and whilst consultants are often present for laparotomies, their presence is not compulsory. ‘Service provision’ is rarely mentioned, perhaps a reflection of a healthcare system that is better resourced to match the demands of its population. With regard to the working environment, trainees hold a structured monthly meeting for both positive and negative feedback on issues ranging from training opportunities and supervision to the frequency of on-call duties and conditions of the on-call rooms. The vocal complaints in a recent meeting of the comfiness of the on-call beds are not only a far cry from trying to catch some rest on an old sofa in a British hospital mess but also give an insight into how seriously the Danes take their working conditions.

However, not all the differences are positive. The greater flexibility in the Danish system
places greater demands on the discipline of its trainees. Although there are still dedicated
rotations in trauma and tertiary centres, the lack of other subspecialty specific rotations
means that the trainee must take more responsibility for ensuring that they meet the specific requirements of the training programme. Whilst focused trainees may turn this to their advantage, allowing them to focus on their preferred subspecialty at an earlier stage of training, those who are as of yet undecided may be at risk of drifting in a less structured system. In a similar vein, for a trainee raised in the British system, the absence of the firm structure is accompanied by a sense of a lack of belonging, at least at the beginning of a new placement, although this is somewhat lessened by the daily morning conferences, attended by the whole department. A further concern is the consequences a more flexible system has on the quality and continuity of care. It is not uncommon for acutely admitted patients to be seen by a different doctor each day, a situation commonly thought to increase the risk of delays in discharge or investigations. However, this does not appear to have an adverse effect on patient outcomes, with a 30-day mortality following high-risk laparotomies of approximately 20% in Denmark, mirroring the reports from the National Emergency Laparotomy Audit (NELA) in Britain (3-5). Finally, one must remember that achieving competence as a surgeon is not only about developing technical skills. As the old saying goes “good surgeons know how to operate, better surgeons know when to operate, and the best surgeons know when not to operate”. Although the Danes may have a more efficient approach to the technical aspects of training, it is undeniable that the clinical exposure of British trainees is far greater. The cumulative clinical experience of following both elective and acute patients from admission to discharge is difficult to replicate and whilst any differences in decision-making seem to have disappeared by the end of training, these skills appear to develop more rapidly in the British systems. Disruptions to the continuity of care present another barrier for clinical exposure in the Danish system, with the following up of the patients seen on-call or in the operating theatre left to the trainee’s own initiative.

The hourly week occupies much of the debate on surgical training and, in doing so,
prioritises quantity over quality of training. With a focus on maximising the efficacy of
training opportunities, the Danish surgical training system demonstrates how surgeons can be effectively trained on a shorter working week. Whilst this system has its own limitations, the organisation of a trainee’s operative commitments in particular provides an example for other systems to follow. Surgical training faces major challenges ahead, with a global pandemic that has not only limited training opportunities but also taken an inevitable toll on workforce morale (6). Furthermore, the backlog of operations cancelled since the beginning of the pandemic is likely to place a huge emphasis on efficiency in operating theatres, which may have further negative effects on training opportunities (7-8). However, the return of some degree of normality will also offer the opportunity to reconsider the structure of training and perhaps in doing so, the best aspects of these respective training systems could be combined, shifting the focus away from the number of hours spent at work to the amount of time spent training.


  1. Jackson GP, Tarpley J. How long does it take to train a surgeon? British Medical
    Journal. 2009, 5;339:b4260.
  2. Galaiya R, Kinross J, Arulampalam T. Factors associated with burnout syndromes in
    surgeons: a systematic review. Annals of the Royal College of Surgeons of England.
    2020, 102(6):401-407.
  3. Cihoric M, Tengberg LT, Foss NB, et al. Functional performance and 30-day post-
    operative mortality after emergency laparotomy – a retrospective, multicenter,
    observational cohort study of 1084 patients. Perioperative Medicine. 2020, 9(13).
  4. Peacock O , Bassett M G, Kuryba A, et al., National Emergency Laparotomy Audit (NELA) Project Team. Thirty-day mortality in patients undergoing laparotomy for small bowel obstruction. Br J Sur. 2018 Jul;105(8):1006-1013. doi: 10.1002/bjs.10812. Epub 2018 Mar 30
  5. Boyd-Carson H, Doleman B, Herrod P J J, et al., on behalf of the NELA Collaboration, Association between surgeon special interest and mortality after emergency laparotomy, British Journal of Surgery, Volume 106, Issue 7, June 2019, Pages 940–948,
  6. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020;107(11):1440-1449. doi:10.1002/bjs.11746
  7. Rai O, Fernandes R. COVID-19 and the reintroduction of surgical training. British Journal of Surgery, Volume 108, Issue 1, January 2021, Page e6,
  8. Hennessy O, Fowler A L, Hennessy C, et al. Covid 19 and Surgical training: Carpe Diem. British Journal of Surgery, Volume 107, Issue 12, November 2020, Page e591,