Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries.

A supralevator anorectal abscess may lead to a rare clinical complication, such as perineal necrotizing fasciitis. A 57-year-old man was admitted on an emergency basis with evidence of a deep anorectal abscess of 5-day duration. The clinical presentation involved an unbounded purulent destructive inflammation spreading onto the adjacent areas, with the development of a septic condition. Following a short preparation, a radical surgical debridement of a subfascial purulent necrotic phlegmon of the pelvic space was performed. Since the lower part of the abdomen, retroperitoneum and scrotum were involved, 4 additional subsequent necrectomies were performed at 48-hour intervals. The aggressive radical operative treatment and the combined intensive therapy were the main contributors to the favorable outcome of the disease.

Amyand hernia is a rare presentation in inguinal hernias (less than 1% of cases with inguinal hernias) which is evidenced when in herniated masses the presence of inflamed appendix is ​​ascertained or not. It was named after a French surgeon, Claudius Amyand (1660-1740), who performed the first successful appendectomy in 1735, where he found an acute appendicitis in a herniated mass. Most cases are diagnosed intraoperatively, as an accurate preoperative diagnosis rarely becomes evident. Management is individual depending on the stage of inflammation of the appendix, the presence of abdominal sepsis and concomitant factors. The decision should be based on factors such as the patient's age, the size and anatomopathological shape of the appendix, and in the case of an inflamed appendix, standard appendectomy and retinal herniorrhage should be the gold standard of treatment. Amyand hernia is usually misinterpreted as a common incarcerata hernia. Symptoms that mimic appendicitis may appear. Treatment consists of a combination of appendectomy and hernia repair. The inflammatory status of the appendix determines the type of hernia repair and the surgical technique. Occasional appendectomy in the case of a normal appendix is ​​not recommended. Amyand hernia is a rare type of inguinal hernia in which the appendix is located in the hernia sac. We present a case of a recurrent incarcerated Amyand’s hernia with complicated appendicitis. The 78 old polymorbide patient with right-sided incarcerated recurrent hernia was emergently operated on and appendectomy and non-mesh hernioplasty performed, on the 3rd postoperative day for a heart attack he was placed cardio stimulator with uneventful outcome. Fifteen months follow up did not show complications or complaints.

INTRODUCTION: Anorectal abscess (ARA) is frequently treated inappropriately with a simple incision and drainage. In 30-50% of the patients this leads to recurrent ARA, chronic rectal fistula and several hospital admissions. PATIENTS AND METHODS: For a ten years period, from 2007 till 2016, 547 patients with ARA were operated. Males were 419 and females 128, with a ratio of 3.3:1. Depending on localization, we divide four types of ARA: perianal-281 patients (51.4%), ischiorectal-176 patients (32.2%), intersphincteric-56 patients (10.2%), supralevator-34 patients (6.2%). RESULTS: Radical operative treatment of ARA depends of type and location of abscess, its relationship to the sphincter and the extent of the inflammatory process. In 204 patients (37.3%) was performed incision, revision and drainage. In perianal, lower types of intersphincteric ARA incision, revision, excision of the fistula and the crypt is performed. This kind of operation we carried out on 181 patients (33.1%). In all ischiorectal, high intersphincteric and supralevator ARA we made wide incision, digital revision, necrectomy, drainage and seton ligation for gradual and continuous section of the sphincter, performed on 162 patients (29.6%). CONCLUSIONS: Surgical tactics based on individual and differentiated approach of ARA treatment in specialized coloproctologic clinics assures effective and radical management, avoiding secondary abscess or chronic fistulization. Although still on debate, the primary or ligation fistulotomy should become a method of choice for the radical treatment of ARA, eliminating the possibility of recurrent inflammation or fistula-in-ano. Scr Sci Med 2017; 49(3): 45-48