Aim Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency‐based training programme through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons. Method A Delphi questionnaire with a 72‐item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval. Results The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75–1). Conclusion This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.

Background Despite there being a considerable amount of published studies on robotic colorectal surgery (RCS) over the last few years, there is a lack of evidence regarding RCS training pathways. This study examines the short-term clinical outcomes of an international RCS training programme (the European Academy of Robotic Colorectal Surgery—EARCS). Methods Consecutive cases from 26 European colorectal units who conducted RCS between 2014 and 2018 were included in this study. The baseline characteristics and short-term outcomes of cases performed by EARCS delegates during training were analysed and compared with cases performed by EARCS graduates and proctors. Results Data from 1130 RCS procedures were collected and classified into three cohort groups (323 training, 626 graduates and 181 proctors). The training cases conversion rate was 2.2% and R1 resection rate was 1.5%. The three groups were similar in terms of baseline characteristics with the exception of malignant cases and rectal resections performed. With the exception of operative time, blood loss and hospital stay (training vs. graduate vs. proctor: operative time 302, 265, 255 min, p < 0.001; blood loss 50, 50, 30 ml, p < 0.001; hospital stay 7, 6, 6 days, p = 0.003), all remaining short-term outcomes (conversion, 30-day reoperation, 30-day readmission, 30-day mortality, clinical anastomotic leak, complications, R1 resection and lymph node yield) were comparable between the three groups. Conclusions Colorectal surgeons learning how to perform RCS under the EARCS-structured training pathway can safely achieve short-term clinical outcomes comparable to their trainers and overcome the learning process in a way that minimises patient harm.

This paper outlines how an understanding of the processes of building cognitive and sociopolitical legitimacy is relevant to the formation of a biorefi ning sector. First we describe a number of theoretical insights into challenges faced by emerging industries and how these can relate to the formation of a biorefi ning sector. Second, we present the conduct and results of an initial exploration of understanding, acceptance, and support for the biorefi nery concept among a sample of actors in the EU policy community. General conclusions of this study are then provided in these two areas. Addressing theory versus evidence from the fi eld, it is found that many phenomena predicted by theory indeed appear in the empirical results and seem immediately relevant to the formative biorefi ning industry. Analysis of the perceptions of members of the policy community toward biorefi nery-related environmental, social, policy, reputational and policy issues reveals that there are a number of areas where prompt action from the political and scientifi c communities could yield signifi cant benefi ts. We conclude that theories enfolding the concepts of cognitive and sociopolitical legitimacy are relevant to discussions of biofuels, bioproducts and biorefi ning. Importantly, proponents of the biorefi nery concept can draw upon a broad body of knowledge generated in both related and non-related industries, to support their work reducing barriers to the emergence of commercial biorefi neries.A key area in this regard will be improved communication of biorefi nery contributions to sustainable development.