Background and objectivesBenign anorectal diseases are prevalent in the general population. Currently, spinal anesthesia is mainly performed in the lateral and sitting positions and is rarely performed in the prone or jackknife positions. This study compared the effects of the prone, lateral, and sitting positions on sensory and motor blocks in patients undergoing anorectal surgery under spinal anesthesia.Materials and methodsIn this prospective comparative study, 75 ASA I and II class patients aged >18 years who underwent anorectal surgery were included, with 25 patients in each group. Spinal anesthesia was administered at the L3-L4 or L4-L5 intervertebral space using a No. 25 Quincke needle and 10 mg of 0.5% hyperbaric bupivacaine in the prone, lateral, or sitting position. Outcomes related to sensory and motor blocks and the anesthesia success rate were compared among the three groups.ResultsSensory block reached T10 in most patients in the prone (44%) and lateral (52%) groups, compared with L1 in the sitting group (56%; p = 0.004). Motor block depth (Bromage 3) was observed in 44% (prone), 48% (lateral), and 84% (sitting) of patients (p = 0.04). Sensory block onset was slower in the prone (2.92 ± 0.87 min) and lateral (2.72 ± 0.87 min) vs. sitting (1.94 ± 1.92 min; p = 0.001). Sensory block duration was longer in the prone (79.96 ± 14.42 min) and lateral (80.28 ± 16.55 min) vs. sitting (67.64 ± 15.99 min; p = 0.007). Motor block duration was shorter in the prone (75.64 ± 12.59 min) and lateral (74.12 ± 14.20 min) vs. sitting (87.30 ± 18.24 min; p = 0.005). Hemodynamic stability was better in the prone and lateral positions (p = 0.0001). First-attempt success was higher in the sitting group (76%) vs. prone (36%) and lateral (68%) positions (p = 0.009).ConclusionThe prone and lateral positions provide higher sensory block levels and better hemodynamic stability, whereas the sitting position is associated with faster sensory block onset, deeper motor block, and higher first-attempt success. The choice of position should be individualized according to surgical requirements and patient characteristics.

Narcolepsy presents unique perioperative challenges, particularly during postoperative recovery, while the prone position limits airway access. We present the case of a 32-year-old woman with untreated narcolepsy who underwent prone jackknife hemorrhoidectomy after declining neuraxial anesthesia. Following preoperative counseling and awake positioning, nonintubated intravenous anesthesia was maintained with remimazolam and propofol during spontaneous ventilation with high-flow nasal oxygen. A stop-and-supine airway rescue plan was prepared. She regained full orientation 13 min following anesthetic discontinuation and reported no worsening of daytime sleepiness or unintended sleep episodes during one-month follow-up. Airway rescue, emergence, and narcolepsy-related recovery were assessed as separate perioperative considerations.

Objective: To explore the feasibility and short-term outcomes of the jackknife position transanal-priority intersphincteric space (ISS) dissection combined with the modified Bacon procedure for special types of ultra-low rectal cancer. Methods: A retrospective observational study was performed. Clinical data of 7 patients with ultra-low rectal cancer who underwent transanal-first ISS dissection combined with modified Bacon technique for staged reconstruction at Zhongnan Hospital of Wuhan University between September 2024 and August 2025 were retrospectively analyzed. The patients were aged (58.3±11.2) years with a body mass index of (23.0±2.9) kg/m[2]. Based on preoperative pelvic MRI measurement, the median distance from the inferior tumor margin to the anal verge was 3.0 (2.4, 3.4) cm. Four patients received neoadjuvant chemoradiotherapy and achieved tumor regression. Among the 7 patients, preoperative imaging and digital rectal examination indicated anterior wall tumor involvement (partial or circumferential) in 6 cases, and tumor located at the right posterior wall in 1 case; one patient was complicated with drug-induced osteonecrosis of the femoral head and could not tolerate the conventional lithotomy position. Perioperative parameters and short-term oncological outcomes were analyzed. Results: All seven patients underwent successful laparoscopic surgery without conversion to open surgery or prophylactic stoma creation. The median operative time was 210 (180, 220) minutes, with intraoperative blood loss of 50 (50, 100) ml. Two perioperative complications occurred, both resolved conservatively. All cases achieved negative circumferential margins with a distal margin distance of 1.0 (0.5, 1.3) cm. Median follow-up was 18 (13, 19) months, with one case showing distant metastasis and no recurrence in the remaining patients. Overall, patients reported satisfactory anal function. Conclusion: The combination of the jackknife position transanal-priority ISS dissection and the modified Bacon procedure is a feasible and safe sphincter-preserving strategy for patients with ultra-low rectal cancer characterized by unfavorable tumor location, challenging anatomy, or high anastomotic risk. It serves as an effective supplementary option for managing such complex cases.

Objective: o investigate the feasibility, safety, and short-term efficacy of the presacral enucleation technique in combined pelvic organ resection for locally advanced or locally recurrent rectal cancer. Methods: A descriptive case series study was conducted. Based on the Chinese database of patients undergoing combined pelvic organ resection for rectal cancer, clinical data were collected from 34 patients admitted to the Department of Colorectal and Anal Surgery, the Second Affiliated Hospital of Naval Medical University between December 1, 2024 and June 30, 2025. All patients were diagnosed with locally advanced or locally recurrent rectal cancer without extrapelvic metastasis, or with only oligometastasis, and underwent combined pelvic organ resection combined with presacral enucleation or sacrectomy. Among the patients, there were 21 males (61.8%) and 13 females (38.2%); the median age was 52 (31-72) years. There were 4 cases (11.8%) of locally advanced rectal cancer and 30 cases (88.2%) of locally recurrent rectal cancer. The surgical procedure of presacral enucleation in our center was summarized as "taking the lateral sacral vessels as the central axis, performing flanking encirclement followed by basal control." The main observational indicators included: (1) Surgical parameters: surgical resection scope, operative time, intraoperative blood loss, and tissue reconstruction; (2) Postoperative recovery: intestinal function recovery time, drainage tube removal time, and empty pelvic cavity healing time; (3) Postoperative complications, which were graded according to the international Clavien-Dindo classification system. Results: All patients successfully completed combined pelvic organ resection with presacral enucleation. The median operative time was 639 (205-960) min, the median intraoperative blood loss was 1 700 (200-4 500) ml, and the median intraoperative blood transfusion volume was 1 400 (400-3 200) ml. R0 resection was achieved in 30 cases (88.2%), and R1 resection in 4 cases (11.8%). There were 3 cases (8.8%) of simple presacral enucleation, 1 case (2.9%) of presacral enucleation combined with coccygectomy, 16 cases (47.1%) of presacral enucleation combined with S4-5 resection and coccygectomy, 7 cases (20.6%) of presacral enucleation combined with S3-5 resection and coccygectomy, and 7 cases (20.6%) of presacral enucleation combined with S3-5 resection, coccygectomy, and S3 nerve root resection. Surgery was completed in the lithotomy position in 28 cases (82.4%), and in the combined lithotomy and prone jackknife position in 6 cases (17.6%). The median intestinal function recovery time was 3.8 (2.0-8.0) days, the median drainage tube removal time was 31.7 (19.0-48.0) days, and the median empty pelvic cavity healing time was 33.4 (24.0-63.0) days. There were 11 cases (32.4%) of grade I-II complications and 8 cases (23.5%) of grade IIIa-IV complications. The median follow-up duration was 8.5(6.0-13.0) months. No death occurred within 90 days after the operation. During the follow-up period, 2 patients (5.9%) died due to rapid progression of distant tumor metastasis. Conclusion: The presacral enucleation technique is safe and feasible in combined pelvic organ resection for locally advanced or locally recurrent rectal cancer.

Wing evolution enabled insects to pioneer aerial niches, a key innovation driving their remarkable radiation. However, interordinal relationships among early-diverging winged insects remain contentious, largely owing to the enigmatic phylogenetic position of Zoraptera, a species-poor and morphologically cryptic order. Since its discovery over a century ago, the 'Zoraptera problem' has persisted as a crucial issue in insect evolution, as alternative placements imply fundamentally different scenarios for polyneopteran diversification and trait evolution. Here, we sequenced and assembled two zorapteran genomes, integrating them with public data to compile a dataset of 89 polyneopteran species and 23 outgroups. Using 1367 universal single-copy orthologous genes, we evaluated phylogenetic signal under different evolutionary models and data treatments. Model testing revealed that the prevailing Haplocercata-first hypothesis (Zoraptera + Dermaptera as the earliest polyneopteran branch) collapses when among-site compositional heterogeneity is modelled to reduce systematic errors. Critically, under the optimal site-heterogeneous model, Zoraptera emerges as the earliest-diverging polyneopteran lineage, with Dermaptera + Plecoptera forming the sister clade Dermoplectopterida to all other Polyneoptera, a topology corroborated by multispecies coalescent and gene jackknifing analyses. Our findings highlight the necessity of multi-model approaches in insect phylogenomics, providing a robust framework for early winged insect diversification.

Presacral tumors are rare and heterogeneous neoplasms that develop in the space between the rectum and sacrum. Their low prevalence and diverse embryologic origins often complicate diagnosis and management. We present the case of a 43-year-old woman who was initially misdiagnosed with a pilonidal abscess, later identified as a benign presacral tumor. PATIENT DESCRIPTION A 43-year-old woman presented with a gradually enlarging mass in the pilonidal region over the course of several months. She was referred to our colorectal clinic with a presumptive diagnosis of a pilonidal abscess made by her primary care physician. The patient was otherwise healthy, with no complaints of pain, fever, chills, or unintentional weight loss. On physical examination, a non-tender mass was palpated over the coccygeal region. Notably, there were no midline pits or visible hair [Figure 1A]. Given the atypical presentation, a magnetic resonance imaging (MRI) was performed, which revealed a well-defined, large presacral bilobular thin-walled cystic mass, posterior to the rectum, without any post contrast ring-enhancement or intramural solid nodule [Figure 1B]. Due to the low anatomical position of the mass relative to the sacrum, a Kraske approach was selected for surgical excision. Under general anesthesia, the patient was placed in the prone jackknife position. A vertical midline incision was made 7 cm cephalad to the anal verge, over the coccyx. This position exposed a well-encapsulated, large presacral tumor [Figure 1C], which was excised en-bloc along with the tip of the coccyx [Figure 1D, Figure 1E]. The specimen was sent for pathological evaluation, which revealed a retrorectal epidermal cyst. The patient's postoperative course was uneventful, and she was discharged on postoperative day one. Informed consent was obtained from the patient.

Transanal minimally invasive surgery (TAMIS) is a widely used technique for treating rectal neoplasms, traditionally performed using a well-established laparoscopic platform. Recently, robotic TAMIS (R-TAMIS) has gained popularity due to potential advantages in ergonomics, visualization, and instrument dexterity. This study was designed to review the experience of a colorectal surgery group with both robotic and laparoscopic TAMIS (L-TAMIS) and to compare their short-term surgical outcomes. A retrospective chart review was conducted of the last 53 consecutive patients who underwent laparoscopic or robotic TAMIS for rectal neoplasms by four colorectal surgeons from October 2014 to September 2025. We collected data on patient demographics, surgical variables, pathological outcomes,  and 30-day complications. Demographic variables were similar between groups. A significantly larger median lesion size was observed in the R-TAMIS group (3.63 cm vs. 2.49 cm; p = 0.001). The average lesion distance from the anal verge was comparable, 8.08 cm (3–13 cm) for R-TAMIS and 7.52 cm (3–15 cm) for L-TAMIS. The mean operative time was 78 (±26.81) minutes for R-TAMIS and 71 (±25.49) minutes for L-TAMIS. No conversions or 30-day mortalities occurred in either group. After the introduction of R-TAMIS in 2022, operative times remained largely stable over time, with only a slight downward trend and no clear learning-curve effect. There was an approximately USD 757 increase in cost for R-TAMIS compared with L-TAMIS. R-TAMIS was associated with resection of larger lesions and demonstrated safety and feasibility, with low morbidity and no mortality. Once the robotic platform was adopted by our surgeons for TAMIS, the procedure was no longer performed laparoscopically. The prone jackknife position has been adequate for lesions in all locations when using the robotic platform. The retrospective design and small sample size were among the study’s limitations, and outcomes were only analyzed at 30 days. Future studies might better elucidate differences and determine surgeons’ preferences regarding both platforms.

Background: Traditional open surgical repairs, including flap techniques, are associated with high recurrence rates and significant morbidity. Robotic-assisted techniques have emerged as promising alternatives to conventional methods due to improved visualization, precision, and reduced postoperative complications. The robotic transanal minimally invasive surgery (R-TAMIS) technique offers a new route for rectovaginal fistula (RVF) repair, providing enhanced dexterity and access through the transanal approach. Methods: An R-TAMIS technique was employed for same-day repair of RVF using the da Vinci Xi® system. After bowel preparation and prophylactic antibiotics, the patient was positioned in prone Jackknife. The GelPOINT Path was used for transanal access, and robotic ports were placed. The fistula tract was identified and dissected circumferentially. The vaginal wall was closed with absorbable barbed sutures, reinforced with fibrin sealant and acellular dermal mesh. The rectal wall was then closed, and patency was confirmed via endoscopic inspection. Results: The procedure was well tolerated, and the patient was discharged the next day. Minimal postoperative pain was reported but didn't require analgesics. No major complications were observed in the immediate postoperative period. The robotic approach provided enhanced visualization and dexterity, facilitating precise dissection and suturing. The technique has already been successfully applied to benign RVFs and select rectourethral fistulas. Conclusion: Robotic-assisted transanal repair using the R-TAMIS technique is a feasible and effective minimally invasive option for selected patients with benign RVFs. With proper patient selection and dedicated surgical technique, this approach may reduce morbidity and improve outcomes compared to traditional open or laparoscopic methods.

Posterior retroperitoneoscopic surgeries for adrenal lesions are steadily gaining popularity over the transperitoneal approach because it allows easier surgical access and reduces the intraoperative and postoperative morbidity. Martin Walz et al. has been a pioneer in describing the modified prone jack-knife position which provides the surgeons a distinct advantage over the conventional prone jack-knife position. The technique has shown a distinct advantage in terms of reduced blood loss, lesser postoperative pain, and shorter length of hospital stay. However, this unconventional position makes some unconventional demands from the anesthetist in terms of the resources required, potential hemodynamic instability, and difficulty in ventilation. To the best of the author's knowledge, this case series is the first attempt at describing the anesthetic challenges faced during retroperitoneal laparoscopic adrenalectomy performed in this novel position. Through these five cases, we aim to provide insight into the intricacies of anesthetic management for this surgical approach with byzantine anesthetic implications.

Objective: To explore the feasibility, safety, and short-term efficacy of a total pelvic floor resection procedure as a component of combined resection of pelvic organs for locally advanced or locally recurrent rectal cancer. Methods: This was a descriptive case series. Relevant clinical data of patients with locally advanced or locally recurrent rectal cancer without extrapelvic metastasis or with only oligometastasis who had undergone combined pelvic organ resection with resection of the entire pelvic floor in the Department of Anorectal Surgery of the Second Affiliated Hospital of Naval Medical University from 1 January 2023 to 30 June 2024 were collected from a Chinese database of combined pelvic organ resection for rectal cancer. The study cohort comprised 143 patients, 74 of whom were male (51.7%) and 69 were female (48.3%); their ages averaged 54 (range: 31-75) years; 57 of the patients (39.9%) had locally advanced rectal cancer and 86 (60.1%) locally recurrent rectal cancer. In our institution, the pelvic floor is categorized into two anatomical layers: the levator ani/presacral anterior tissue, and the bone/ligament/pelvic floor soft tissue. The entire pelvic floor was resected en bloc after making incisions on both sides of the pelvic floor, followed by presacral sacral dissection, and abdominoperineal dissection of the anterior side of the pelvic floor. The main factors studied were related to the following: (1) surgical conditions, comprising the scope of surgical resection, operation time, intraoperative blood loss, tissue reconstruction; (2) postoperative recovery, comprising time to recovery of intestinal function, time to removal of drainage tubes, and time to healing of the empty pelvic cavity; and (3) postoperative complications, classified according to the international Clavien-Dindo classification. Results: Combined pelvic organ resection with entire pelvic floor resection was successfully completed in all patients. The operation time was 480 (390 to 1,020) minutes, intraoperative blood loss 800 (50 to 3,500) mL, and volume of blood transfused intraoperatively 1, 000 (400 to 7, 400). R0 resection was achieved in 116 cases (81.1%) and R1 resection in 27 (18.9%). The first layer of the pelvic floor wall (levator ani/sacral anterior tissue) was resected in 79 cases (55.2%) and the second layer of the pelvic floor wall (bone/ligament/pelvic floor soft tissue) in 64 (44.8%). The procedure was completed in the lithotomy position in 114 cases (79.7%) were and in the lithotomy + prone jackknife position in 29 (20.3%). The pelvic floor was reconstructed with mesh in 140 cases (97.7%) and with mesh plus pedicled omental flaps in 92 cases (64.3%). The urinary tract was reconstructed in 92 cases (64.3%). The time to recovery of intestinal function was 3.6 (2.0 to 7.0) days, to removal of drainage tubes 29.4 (24.0 to 54.0) days, and to healing of the empty pelvic cavity 36.2 (27.0 to 56.0) days. Twenty-three patients (16.1%) had Grade I - II complications and 36 (25.2%) Grade IIIa - IV complications. The median duration of follow-up was 15.5 (0.5 to 30.0) months. Six of the patients (4.2%) died, including two (1.4%) who died within 30 days after surgery. Conclusions: Pelvic floor en bloc resection has a high R0 resection rate and is a safe and feasible procedure for pelvic organ resection surgeries in patients with locally advanced or locally recurrent rectal cancer.

Simultaneous laparoscopic resection of colorectal cancer (CRC) and synchronous liver metastases (SLM) remains a surgical challenge, especially when lesions involve posterosuperior liver segments. We present a case of a 42-year-old male with a transverse colon adenocarcinoma with SLM in segments 7 and 4. A simultaneous laparoscopic procedure was performed: anatomical liver resections in a modified left jack-knife position followed by transverse colectomy in the supine position. In-flow and out-flow blood control was achieved using intracorporeal Pringle manoeuvre and right hepatic vein tourniquet. The patient initiated a chemotherapy regimen with capecitabine and oxaliplatin (CAPOX) postoperatively and remained recurrence-free at 8 months. This case demonstrates the feasibility and safety of simultaneous laparoscopic resection for CRC with limited SLM involving challenging hepatic segments.

Positional asphyxia refers to asphyxia resulting from an abnormal body posture that obstructs pulmonary ventilation. We report two cases in which individuals were unable to escape from positions that interfered with respiration, and cervical fractures were found upon autopsy. In the first case, a female in her 70s was found dead in a prone position on a bed following a traffic accident. Forensic autopsy findings suggested that she died from respiratory failure due to shallow breathing associated with pain from a rib fracture and prolonged prone positioning, possibly influenced by potential spinal cord injury associated with a cervical vertebral fracture. In the second case, a female in her 80s was found dead with her abdomen on a bed rail and her face down on the bed, a posture known as the jackknife position. Security camera footage showed that she was unable to escape from the position after the accidental fall, and after struggling in the same position for approximately 6 h, she became immobile, suggesting death by positional asphyxiation. Forensic autopsy revealed a fracture of the fifth cervical vertebra, raising the possibility of cervical spinal injury at the time of her fall. These cases indicate that cervical spinal fractures can be detected and associated with positional asphyxia deaths; however, their exact role in causing death remains uncertain. These findings highlight the importance of vigilant monitoring and timely medical intervention, particularly in older individuals, even when initial injuries appear minor.