Aim: We aimed to evaluate the knowledge, attitude, and practices in the application of AI in the emergency setting among international acute care and emergency surgeons. Methods: An online questionnaire composed of 30 multiple choice and open-ended questions was sent to the members of the World Society of Emergency Surgery between 29th May and 28th August 2021. The questionnaire was developed by a panel of 11 international experts and approved by the WSES steering committee. Results: 200 participants answered the survey, 32 were females (16%). 172 (86%) surgeons thought that AI will improve acute care surgery. Fifty surgeons (25%) were trained, robotic surgeons and can perform it. Only 19 (9.5%) were currently performing it. 126 (63%) surgeons do not have a robotic system in their institution, and for those who have it, it was mainly used for elective surgery. Only 100 surgeons (50%) were able to define different AI terminology. Participants thought that AI is useful to support training and education (61.5%), perioperative decision making (59.5%), and surgical vision (53%) in emergency surgery. There was no statistically significant difference between males and females in ability, interest in training or expectations of AI (p values 0.91, 0.82, and 0.28, respectively, Mann–Whitney U test). Ability was significantly correlated with interest and expectations (p < 0.0001 Pearson rank correlation, rho 0.42 and 0.47, respectively) but not with experience (p = 0.9, rho − 0.01). Conclusions: The implementation of artificial intelligence in the emergency and trauma setting is still in an early phase. The support of emergency and trauma surgeons is essential for the progress of AI in their setting which can be augmented by proper research and training programs in this area.

Background: Minimally invasive surgery (MIS) for adrenal glands is becoming increasingly developed worldwide and robotic surgery has advanced significantly. Although there are still concerns about the generalization of outcomes and the cost burden, the robotic platform shows several advantages in overcoming some laparoscopic shortcomings. Materials and Methods: A systematic review and meta-analysis were conducted using the PubMed, MEDLINE and Cochrane library databases of published articles comparing RA and LA up to January 2024. The evaluated endpoints were technical and post-operative outcomes. Dichotomous data were calculated using the odds ratio (OR), while continuous data were analyzed usingmean difference (MD) with a 95% confidence interval (95% CI). A random-effects model (REM) was applied. Results: By the inclusion of 28 studies, the meta-analysis revealed no statistically significant difference in the rates of intraoperative RBC transfusion, 30-day mortality, intraoperative and overall postoperative complications, re-admission, R1 resection margin and operating time in the RA group compared with the LA. However, the overall cost of hospitalization was significantly higher in the RA group than in the LA group, [MD USD 4101.32, (95% CI 3894.85, 4307.79) p < 0.00001]. With respect to the mean intraoperative blood loss, conversion to open surgery rate, time to first flatus and length of hospital stay, the RA group showed slightly statistically significant lower rates than the laparoscopic approach. Conclusions: To our knowledge, this is the largest and most recent meta-analysis that makes these comparisons. RA can be considered safe, feasible and comparable to LA in terms of the intraoperative and post-operative outcomes. In the near future, RA could represent a promising complementary approachto LA for benign and small malignant adrenal masses, particularly in high-volume referral centers specializing in robotic surgery. However, further studies are needed to confirm these findings.

Background: In the past 20 years, the fast spread of new surgical technologies has reached an important peak with the advent of the robotic surgery. Many studies have been run about a cosmetic desire to avoid neck scars after thyroid surgery and this has led to the development of remote access robotic thyroidectomy (RT). Among the various RT approaches, unilateral transaxillary access is one of the most widely used, reporting excellent results in terms of feasibility and patient's compliance. The mini-invasive technique demonstrated many potential shortcoming overcomes with the robotic approach. At our institution a team of 3 skilled endocrine surgeons with experience in laparoscopic and robotic procedures performed RT. Our aim is to report our 8-year single-centre robot-assisted thyroidectomy experience, by applying a gasless unilateral transaxillary approach with the so-called hybrid technique, and to demonstrate its safety and feasibility. Methods: In the period between September 2010 and June 2018 at our institution, a total of 472 patients underwent thyroid and parathyroid transaxillary surgery. The hybrid technique was applied for all the robotic procedures. A total of 412 procedures were performed with the use of external “Modena Retractor” (CEATEC ^® Medizintechnik) and with 3 surgeons. According to international guidelines, our indications for robotic surgery were benign lesions with a diameter <5 cm, Graves' disease, well-differentiated thyroid cancers, and parathyroid adenomas. Results: In this series, a total of 449 cases were registered. General data of patients were analyzed: gender, age, body mass index, tumor size, preoperative fine-needle aspiration examination, definitive histological examination, operative time, and postoperative complications. Conclusions: This study confirms the application of robotic approach in thyroid surgery as a feasible technique in terms of safety and complications risk. The hybrid technique, together with a dedicated surgical team, can lead to obtaining the same outcomes of traditional anterior cervicotomic surgery, adding a scarless thyroidectomy.

Objective: To gain insight into the global practice of robot-assisted minimally invasive gastrectomy (RAMIG) and evaluate perioperative outcomes using an international registry. Background: The techniques and perioperative outcomes of RAMIG for gastric cancer vary substantially in the literature. Methods: Prospectively registered RAMIG cases for gastric cancer (≥10 per center) were extracted from 25 centers in Europe, Asia, and South-America. Techniques for resection, reconstruction, anastomosis, and lymphadenectomy were analyzed and related to perioperative surgical and oncological outcomes. Complications were uniformly defined by the Gastrectomy Complications Consensus Group. Results: Between 2020 and 2023, 759 patients underwent total (n=272), distal (n=465), or proximal (n=22) gastrectomy (RAMIG). After total gastrectomy with Roux-en-Y-reconstruction, anastomotic leakage rates were 8% with hand-sewn (n=9/111) and 6% with linear stapled anastomoses (n=6/100). After distal gastrectomy with Roux-en-Y (67%) or Billroth-II-reconstruction (31%), anastomotic leakage rates were 3% with linear stapled (n=11/433) and 0% with hand-sewn anastomoses (n=0/26). Extent of lymphadenectomy consisted of D1+ (28%), D2 (59%), or D2+ (12%). Median nodal harvest yielded 31 nodes (interquartile range: 21–47) after total and 34 nodes (interquartile range: 24–47) after distal gastrectomy. R0 resection rates were 93% after total and 96% distal gastrectomy. The hospital stay was 9 days after total and distal gastrectomy, and was median 3 days shorter without perianastomotic drains versus routine drain placement. Postoperative 30-day mortality was 1%. Conclusions: This large multicenter study provided a worldwide overview of current RAMIG techniques and their respective perioperative outcomes. These outcomes demonstrated high surgical quality, set a quality standard for RAMIG, and can be considered an international reference for surgical standardization.

Background: The incidence of the highly morbid and potentially lethal gangrenous cholecystitis was reportedly increased during the COVID-19 pandemic. The aim of the ChoCO-W study was to compare the clinical findings and outcomes of acute cholecystitis in patients who had COVID-19 disease with those who did not. Methods: Data were prospectively collected over 6 months (October 1, 2020, to April 30, 2021) with 1-month follow-up. In October 2020, Delta variant of SARS CoV-2 was isolated for the first time. Demographic and clinical data were analyzed and reported according to the STROBE guidelines. Baseline characteristics and clinical outcomes of patients who had COVID-19 were compared with those who did not. Results: A total of 2893 patients, from 42 countries, 218 centers, involved, with a median age of 61.3 (SD: 17.39) years were prospectively enrolled in this study; 1481 (51%) patients were males. One hundred and eighty (6.9%) patients were COVID-19 positive, while 2412 (93.1%) were negative. Concomitant preexisting diseases including cardiovascular diseases (p < 0.0001), diabetes (p < 0.0001), and severe chronic obstructive airway disease (p = 0.005) were significantly more frequent in the COVID-19 group. Markers of sepsis severity including ARDS (p < 0.0001), PIPAS score (p < 0.0001), WSES sepsis score (p < 0.0001), qSOFA (p < 0.0001), and Tokyo classification of severity of acute cholecystitis (p < 0.0001) were significantly higher in the COVID-19 group. The COVID-19 group had significantly higher postoperative complications (32.2% compared with 11.7%, p < 0.0001), longer mean hospital stay (13.21 compared with 6.51 days, p < 0.0001), and mortality rate (13.4% compared with 1.7%, p < 0.0001). The incidence of gangrenous cholecystitis was doubled in the COVID-19 group (40.7% compared with 22.3%). The mean wall thickness of the gallbladder was significantly higher in the COVID-19 group [6.32 (SD: 2.44) mm compared with 5.4 (SD: 3.45) mm; p < 0.0001]. Conclusions: The incidence of gangrenous cholecystitis is higher in COVID patients compared with non-COVID patients admitted to the emergency department with acute cholecystitis. Gangrenous cholecystitis in COVID patients is associated with high-grade Clavien-Dindo postoperative complications, longer hospital stay and higher mortality rate. The open cholecystectomy rate is higher in COVID compared with non -COVID patients. It is recommended to delay the surgical treatment in COVID patients, when it is possible, to decrease morbidity and mortality rates. COVID-19 infection and gangrenous cholecystistis are not absolute contraindications to perform laparoscopic cholecystectomy, in a case by case evaluation, in expert hands. Graphical