BJS, 2024, znad361

https://doi.org/10.1093/bjs/znad361
Cutting Edge Review

Topical haemostatic agents in surgery

Kilian G. M. Brown1,2,3,4 and Michael J. Solomon1,2,3,4,*
1
Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, NSW, Australia
2
Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, NSW, Australia
3
Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital, Sydney, NSW, Australia
4
Faculty of Medicine and Health, Central Clinical School, The University of Sydney, Sydney, NSW, Australia

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*Correspondence to: Michael J. Solomon, Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, PO Box M157, Missenden Road, Sydney, NSW
2050, Australia (e-mail: [email protected])

Introduction with a sponge. This group of agents are bio-dissolvable and may
cause surgical drain fluid to appear discoloured (for example,
Intraoperative haemostasis is generally achieved by
brown) and congealed, and thus has the potential to create
electrosurgical coagulation, suture ligation or suture repair of
diagnostic confusion and raise concern for gastrointestinal
blood vessels. Use of topical haemostatic agents may assist
perforation or deep surgical site infection. The appearance of
haemostasis in certain circumstances. This includes situations
matrix agents on postoperative cross-sectional imaging varies
where suturing or electrocautery are likely to be ineffective
depending on the agent, time from surgery and co-existing
(such as raw surface bleeding from the cut edge of bone, solid
pathology, but may resemble a fluid collection with or without
organs or other soft tissue structures) or potentially hazardous
gas and can be mistaken for a haematoma or abscess. Their use,
(where the bleeding is from or near structures at risk of
therefore, should always be documented in operative reports7.
inadvertent damage from sutures or thermal spread). This
article provides an overview of the types and mechanisms of
action of available topical haemostatic agents, and describes
Oxidized regenerated cellulose
their potential applications in the pelvis as illustrative examples. Oxidized regenerated cellulose (ORC) provides a scaffold around
which a clot can form and is produced by regenerating the
cellulose of decomposed plants as continuous fibres. Examples
Bone wax and putty of commercially available ORC-based products are Surgicel
These natural or synthetic agents can be applied to the transected Nu-Knit® (a fabric-like mesh) and Surgicel Fibrillar® (which
surfaces of bone in order to directly tamponade bleeding from the resembles cotton wool). These agents can be trimmed or
medulla of the bone, and are commonly used in neurosurgical, moulded to various shapes and sizes to match the contours of
orthopaedic or cardiac procedures (after sternotomy). Bone wax the bleeding surface and to fit through ports during minimally
is a sterile mix of natural beeswax, paraffin and isopropyl invasive surgery. Rather than being moistened, ORC-based
palmitate (softener) and is moulded into the cut edge of bone in products are applied dry and manually compressed with a digit
order to directly occlude medullary vessels (Fig. 1). It is relatively or surgical pack to achieve haemostasis. ORC agents are useful
cheap and readily available and, because it is soft and to address bleeding from dissected retroperitoneal or pelvic
malleable, can be used for irregular bone defects. However, it surfaces, the parenchyma of partially resected or lacerated solid
has been associated with granuloma formation and surgical site organs, or suture holes of vascular anastomoses or repairs.
infection because it is non-absorbable and elicits a foreign body ORC causes a reduction in pH in the surrounding milieu, which
reaction1,2. Ostene (Baxter International, Inc., Deerfield, Illinois, leads to lysis of erythrocytes (explaining the brown discolouration
USA) is a synthetic putty that can be used as an alternative to that results from contact with blood) and may have an
wax for bone surface bleeding. It is resorbed within 24–48 h of antimicrobial effect8,9. Absorption takes between 2 and 6
application3,4 and animal studies suggest it has less effect on weeks10,11. Disadvantages of ORC are the inhibition of some
bone healing compared to bone wax5,6. biological agents (such as thrombin) due to the acidic environment
created and therefore combination use with other agents is
limited. The lower pH may also elicit a local inflammatory
Absorbable matrix agents response and delay tissue healing, and form a nidus for infection9.
These agents are biologically inactive and provide a scaffold
around which a thrombus can form from platelets and Gelatin matrix
components of the endogenous coagulation pathways. They are Gelatin is a hydrocolloid made from porcine collagen that
generally available in simple packaging and do not require any provides a moist scaffold that absorbs blood, concentrates
special storage or preparation. They are applied directly to the endogenous coagulation factors and facilitates platelet
area requiring haemostasis, which is then gently compressed aggregation. In commercially available agents the gelatin is

Received: October 10, 2023. Accepted: October 15, 2023

© The Author(s) 2023. Published by Oxford University Press on behalf of BJS Society Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial License (https://creativecommons.org/
licenses/by-nc/4.0/), which permits non-commercial re-use, distribution, and reproduction in any medium, provided the original work is properly cited. For
commercial re-use, please contact [email protected]
2 | BJS, 2024, Vol. 111, No. 1

whipped and baked to make a sponge or powder11. Gelatin powder Microporous polysaccharide spheres
is commonly mixed with normal saline or topical thrombin (which Microporous polysaccharide spheres (MPS) are derived from plant
is possible due to its neutral pH) to form a foamy paste solution starch and manufactured in powder form, which, on application,
that can be applied to bleeding surfaces or delivered through a absorbs water from surrounding tissues and forms an adhesive
syringe, and can be used as an alternative to bone wax for gel. The starch provides a scaffold for fibrin formation and the
control of bleeding from transected bone12. Gelatin sponges are absorption of water concentrates platelets and endogenous
applied to the bleeding surface with direct pressure for several coagulation factors11. A sucker and sponge is first used to dry
minutes and are available in various sizes and shapes, including the bleeding surface as much as possible before generous
a hollow cylinder designed for use in the anal canal (Spongostan application of the powder to the surface using a manual bellows
Anal) (Fig. 2). They can absorb approximately 40 times their applicator. The area is then packed for direct pressure
weight and substantially increase their volume, causing local tamponade. Arista™ AH and PerClot are examples of MPS-based
tissue compression which contributes to haemostasis by products and long tip applicators are available for use in
tamponade. This does, however, also have the potential to cause minimally invasive surgery (Table 1). The advantages of MPS
complications related to compression of adjacent structures,

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products are that they are rapidly absorbed (starting within
particularly when used in proximity to neurovascular 48 h) and biologically inert. Potential adverse effects include
structures9. Gelatin is absorbed at 4–6 weeks13. hyperglycaemia and embolism if administered intravascularly14.

Microfibrillar collagen
Similar to other matrix agents, bovine collagen (derived from
bovine dermis) provides a scaffold for thrombus formation.
When platelets come into contact with collagen fibrils (of which
there is a large surface area) they are activated and
subsequently aggregate and degranulate. Powder and sponge
forms of microfibrillar collagen are available, which are applied
directly to the bleeding surface and are absorbed in
approximately 8 weeks11,14. They are typically most useful for
bleeding over large surface areas, such as dissected
retroperitoneal or pelvic surfaces. These agents tend to stick to
wet surfaces including surgical gloves and instruments, and
therefore can be difficult to handle. Additionally, they cannot be
used with blood salvage systems because the fibres may pass
through the system filters and cause embolism9. Because the
mechanism of action is platelet activation/aggregation,
microfibrillar collagen agents are less effective in patients with
thrombocytopaenia, but still effective in heparinized patients15.

Biologically active thrombin-based products

Fig. 1 Bone wax applied topically to the amputated sacral stump to These agents enhance the endogenous process of haemostasis
achieve haemostasis following total pelvic exenteration with en-bloc by application of concentrated thrombin, which may be
high sacrectomy bovine-derived, human or recombinant. Endogenous thrombin

a b

Fig. 2 a Use of gelatin sponges (Spongostan Anal) to pack the lateral pelvis to address diffuse bleeding following lateral pelvic exenteration. b Sponges
can be tied together with Surgicel NuKnit to form large packs to fill large cavities
 Brown and Solomon | 3

Table 1 Commercially available topical haemostatic agents

Category Agent Trade Names Mechanism of action and Uses Potential adverse effects

Wax and Bone wax Bone Wax (Ethicon) • Direct occlusion of blood vessels • Infection
putty within medullary bone • Allergic reaction
• Haemostasis at cut edge of bone • Local tissue reaction
• Non resorbable • Impaired osteogenesis

Synthetic putty Ostene • Similar to bone wax, but is • Infection (lower than bone
HEMASORBPLUS resorbable and does not impair wax)
osteogenesis • Allergic reaction
• Local tissue reaction

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Matrix Oxidized regenerated Surgicel (Ethicon) • Provides cellulose scaffold for clot • Foreign body reaction
agents cellulose Fibrillar initiation and formation • Infection
Nu-Knit • Easy to handle • Delayed wound healing
SNoW • Applied dry followed by manual • Local inflammation due to
Powder pressure lower pH
WoundClot • Reabsorption time varies, typically • Risk of spinal cord
(CoreScientific 2–6 weeks compression if used in or
Creations) • Cannot be used in combination with near spinal canal
BloodSTOP biological agents
(LifeScience Plus

Gelatin matrix Gelfoam (Baxter) • Provides moist scaffold which • Infection

Surgifoam, absorbs blood and concentrates • Compression of adjacent
Spongostan (Ethicon) coagulation factors neurovascular structures
• Swells substantially causing local • Embolization if
compression and tamponade intravascular application
• Moistened before application
(sponges) or mixed with thrombin to
form paste (powder)
• Can be combined with active agents
due to neutral pH
• Reabsorption time 4–6 weeks

Microporous Arista AH (Bard) • Absorbs water and concentrates • Embolization if

polysaccharide spheres PerClot (Cryolife Inc.) coagulation factors, provides intravascular application
scaffold for fibrin formation • Hyperglycaemia
• Applied via bellows applicator
• Dry field as much as possible before
application
• Rapidly absorbed, starting within
48 h

Microfibrillar collagen Avitene (Bard) • Large surface area of collagen fibrils • Contraindicated with
Helistat, helitene causes platelet activation/ blood salvage systems due
(Integra) aggregation to risk of embolism
INSTAT MCH • Typically useful for large surface • Allergic reaction
(Ethicon) area bleeding • Infection
• Sticks to surgical gloves and wet • Foreign body reaction
instruments
• Less effective in thrombocytopaenic
patients
• Reabsorption time ∼8 weeks

Biological Topical thrombin (bovine, THROMBIN-JMI (Pfizer) • Converts fibrinogen to fibrin, • Immune-mediated
agents human or EVITHROM (Ethicon) activates clotting factors and coagulopathy
recombinant) GELFOAM PLUS promotes platelet aggregation • Viral or prion disease
(Baxter) • Applied in liquid form by syringe or transmission
RECOTHROM aerosolized applicator • Allergic reaction
(Mallinckrodt • Stored as freeze-dried powder which
Pharmaceuticals) is reconstituted by mixing with
normal saline, or as a frozen
solution

(continued)
4 | BJS, 2024, Vol. 111, No. 1

Table 1 (continued)

Category Agent Trade Names Mechanism of action and Uses Potential adverse effects

Thrombin and gelatin FLOSEAL (Baxter) • Combines haemostatic actions of • As for topical thrombin
matrix SURGIFLO (Ethicon) thrombin with tamponade effect and gelatin matrix agents
from swelling of the gelatin
• Thrombin concentrate is
reconstituted before it is mixed with
the gelatin matrix, takes several
minutes
• Mixing produces foam-like agent
that expands when applied to the
bleeding surface
• Reabsorption time 6–8 weeks

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Thrombin and fibrinogen TISSEEL (Baxter) • Mixing allows thrombin to converts • Viral or prion disease
(fibrin sealants) EVICEL (Ethicon) fibrinogen to fibrin, forming clot transmission
EVARREST patch • Two-chamber syringe containing • Allergic reaction
(Ethicon) frozen thrombin and fibrinogen • Immune-mediated
Tachosil patch separately, require thawing coagulopathy
(Baxter) • Suitable for diffuse venous bleeding
including raw surface of transected
solid organ, and for vascular
anastomoses
• Rapid reabsorption time, 14 days

Autologous fibrinogen, Vitagel (Stryker) • Action of thrombin forms fibrin clot • Calculus formation if used
platelets, bovine around collagen matrix from within renal collecting
thrombin and collagen autologous fibrinogen, stabilized by system
(platelet sealants) platelets
• Requires centrifugation of patient
blood at time of surgery

Synthetic Polyethylene glycol (PEG) Coseal (Baxter) • PEG polymer-based sealants • Compression of adjacent
and other DuraSeal (Integra) • Coseal used for suture hole bleeding structures
sealants Progel (Bard) after vascular anastomosis • Allergic reaction
• DuraSeal and Profel indicated for • Cerebrospinal fluid leak
dural repair during neurosurgery • Infection
and sealing lung parenchyma and • Delayed wound healing
pleura, skin wound/graft
approximation

Albumin-based BioGlue (CyroLife) • Albumin and glutaldehyde agent • Allergic reaction

that seals tissue by denaturing • Wound infection
albumin, independent of clotting • Embolism
process • Anastomotic
• Similar uses as for polyethylene pseudoaneurysm
glycol (including large vascular • Local tissue fibrosis
anastomoses), as well as partially
resected or injury solid organs
(kidney, spleen)

Cyanoacrylates Omnex (Ethicon) • Uses are primarily skin wound/graft • Embolism

Dermabond (Ethicon) approximation (Dermabond) and • Local tissue inflammation
sealing vascular anastomoses
(Omnex)

is an enzyme that is activated by the intrinsic and extrinsic powder form and then reconstituted by mixing it with normal
pathways of the coagulation cascade and converts fibrinogen to saline before application, or as a frozen solution which requires
fibrin. Concentrated thrombin augments clot formation by at least 10 min to thaw at 37°C16. Bovine thrombin-based
converting fibrinogen to fibrin, activating clotting factors (V, VIII, products can elicit a profound immune response and have been
XI) and by facilitating platelet aggregation11. Commercially associated with the development of antibodies toward thrombin
available agents are applied as a liquid, via a sprayer for and other clotting factors17 as well as severe coagulopathy18,
application to a broad area, or syringe for application to a with randomized data demonstrating that recombinant human
specific area. They may also be used to coat a surgical pack or thrombin is comparatively less immunogenic and therefore
gelatin sponge. The thrombin can be stored in a freeze-dried favoured19. Human thrombin, which is derived from pooled
 Brown and Solomon | 5

human plasma, carries the potential (albeit rare) risk of viral or These products can be stored at room temperature and do not
prion disease transmission20. require mixing prior to application (Table 1).

Thrombin-gelatin combinations Platelet gel

Concentrated thrombin can be combined with a gelatin-based Vitagel is a variant of the fibrin sealants and is a combination
matrix (for its ability to swell and create tamponade) with the product containing microfibrillar collagen (MFC) and bovine
aim of producing a more stable fibrin clot. These ‘flowable’ thrombin as well as fibrinogen and platelets from the patient’s
agents, marketed as FLOSEAL (Baxter) and SURGIFLO (Ethicon), own plasma. The product is formulated as a dual-chamber
require the thrombin concentrate to first be reconstituted before syringe, where one chamber contains thrombin and MFC and
it is mixed with the gelatin matrix in the application syringe, a the other chamber is filled with the patient’s own plasma (blood
process which takes several minutes. The result is a foam-like is taken and centrifuged at the time of surgery). This system is
mixture that expands up to 20 per cent within 10 min of expensive and preparation is time-consuming given the
application to the bleeding surface21. Contact with blood is requirement for patient plasma9.
required in order to provide a source of fibrinogen for clot

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formation. After mixing, if use is delayed, it can be stored for Synthetic and other tissue sealants
3–8 hours. Synthetic tissue sealants include cyanoacrylate (Dermabond),
These combined agents may be more effective for controlling polyethylene glycol hydrogel and albumin-based agents
arterial bleeding than fibrin sealants (see below) because of the (Table 1)11. Although some can be used to seal vascular
swelling and tamponade effect of the gelatin matrix in addition anastomoses, they are most commonly used for their sealant
to the haemostatic effect of the thrombin9. Reabsorption occurs properties (for example, approximation of skin wounds, sealing
in approximately 6–8 weeks16. FLOSEAL has been shown to be dura in neurosurgery) rather than haemostasis and therefore
associated with improved rates of haemostasis compared to will not be reviewed in detail.
alternative topical agents or no topical agents in vascular,
thoracic and cardiac surgery22–24.
Autologous and other haemostatic adjuncts
Fibrin sealants Epiploic appendages and rectus muscle can be harvested and
Fibrin sealants are combined agents containing thrombin and used as autologous topical adjuncts to haemostasis, particularly
fibrinogen, most commonly human derived. Commercially for control of presacral pelvic bleeding (Fig. 3). These may be
available products (for example, TISSEEL, EVICEL) are secured using high-power electrocautery to ‘weld’ the
formulated as a two-chamber syringe containing separate autologous tissue to the site of bleeding28,29, sutures30 or pins
frozen thrombin and fibrinogen solutions, which require (Fig. 3). Argon beam coagulation produces a spray of argon gas
thawing in a warm water bath (for a minimum of 5 min) prior to and electrical current jet which causes rapid, shallow surface
use. The solutions are mixed in a common channel as they are coagulation of the target tissue31 and can be useful for control
injected, either through the blunt nose of the syringe or via an of difficult, diffuse surface bleeding (such as bleeding from
attachable aerosolizer (for which there are laparoscopic retroperitoneal varices during liver transplantation).
extensions for use in minimally invasive surgery). When mixed, In addition to traditional packing, tamponade using mechanical
the thrombin catalyses the conversion of fibrinogen to fibrin, compression can be achieved with inflatable balloon devices.
rapidly forming a stable clot on the bleeding surface. Some The choice of device depends on the location and size of the
products also contain human factor XIII (which stabilixes the bleeding—for example, tissue expanders or Sengstaken-Blakemore
clot) and aprotinin (which inhibits fibrinolysis)13. Alcohol- or tubes can be used in the pelvis32, while a Foley catheter may
iodine-based solutions must be washed from the area of be useful for bleeding from smaller or inaccessible cavities such
application prior to use, as they may degrade the thrombin and as in penetrating chest or neck trauma33. A sausage-shaped
fibrinogen and reduce efficacy of the product9. intrahepatic tamponade balloon can be constructed by rupturing
Fibrin sealants are useful for controlling minor but ongoing the small (usually 10 ml) balloon of a Foley catheter, and securing
diffuse venous bleeding from a broad surface (such as the the finger of a large glove to the catheter with sutures, which can
retroperitoneum or pelvis), from the raw surface of a transected then be inflated with water or saline using the main drainage
solid organ (for example, during partial nephrectomy or for minor channel of the catheter to tamponade the tract of a penetrating
splenic capsular tears)25,26 or to achieve haemostasis at vascular liver injury34.
anastomoses. In a randomized trial that compared the use of a
fibrin sealant and conventional haemostatic agents in patients
undergoing cardiac surgery, fibrin sealant was associated with
Applications in the pelvis
rapid haemostasis (within 5 min) in 93 per cent of patients No topical agent is a substitute for good surgical technique
compared to 12 per cent in those treated with conventional involving careful haemostasis. These products should be used
topical agents27. These products can also be used to secure mesh as adjuncts to electrocautery, suture ligation, clips and surgical
during hernia repair, as an alternative to tacks or sutures. packing. Although uncommon, potential serious adverse effects
The advantages of sealants are that they are rapidly reabsorbed and complications relating to the use of haemostatic agents
(approximately 14 days), do not elicit a significant immune, have been reported, and therefore they should be used sparingly
inflammatory or foreign body response, or cause tissue fibrosis and only when necessary. Adverse events have been previously
(although all are possible)11. The main disadvantage is the described11 and those that are more common are summarized
requirement to store the products frozen and the time taken to in Table 1. The following description of the use of haemostatic
thaw them. To overcome this issue, fibrin sealant patches have agents and techniques is based on the authors’ experience at a
been developed, which combine thrombin and fibrinogen with high-volume pelvic exenteration unit, where typical blood loss
ORC (EVARREST patch) or equine collagen (TachoSil patch). in the pelvis is 1–2 l and can be >5 l35.
6 | BJS, 2024, Vol. 111, No. 1

a b

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Fig. 3 a Harvesting rectus abdominus muscle at the site of planned ostomy trephine for use as a muscle pledget to control sacral bleeding, b secured
with a paediatric spiked fixation staple (11 × 15 mm, Smith & Nephew/Richards)

The choice of topical haemostatic agent and how it is used when suturing and electrocautery are ineffective or potentially
depends on the location and nature of bleeding. Generally, hazardous. Choice of agent and how it is used (including in
inactive matrix agents are most useful for diffuse, minor venous combination with another agent or technique) depends on the
oozing, whereas biologically active agents may be more useful for nature and location of the bleeding, with consideration given to
brisk bleeding or in coagulopathic patients. For generalized minor patient or disease factors that may preclude use of a particular
oozing from raw surfaces in the pelvis, using high-powered agent (for example, due to a history of hypersensitivity reactions).
electrocautery (80 Watts) by ‘arcing’ the tip of the diathermy can
be effective. If the use of electrocautery is not safe due to the
proximity of neurovascular structures (for example, in a Author contributions
dissected pelvic sidewall after lateral lymph node dissection), Kilian Brown (Conceptualization, Writing—original draft) and
gently packing the area with gelatin sponges is useful (Fig. 2). Michael Solomon (Conceptualization, Supervision, Writing—
When major bleeding is encountered in the pelvis, it is most review & editing).
commonly from the presacral venous plexus, or from branches
and tributaries of the internal iliac axis in the pelvic sidewall.
Temporary control by direct compression using digital pressure, a Funding
small sponge on a long forceps, or by traditional packing is the The authors have no funding to declare.
first course of action. Communication with the nursing and
anaesthetic team about anticipated blood loss is critical.
Dissection around the point of bleeding is helpful to optimize Disclosure
exposure where possible and direct suture ligation of vessels is The authors declare no conflict of interest.
always preferred, but may not be feasible for presacral bleeding.
Use of thumbtacks to control presacral bleeding is commonly
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 European Colorectal Congress
3 – 6 December 2023, St.Gallen, Switzerland

A gaze in the crystal ball: Where is the role of virtual

OVERVIEW reality and artificial Intelligence in colorectal surgery
Sun, 3 Dec 2023 Müller Beat, Basel, CH

MASTERCLASS MALIGNANT COLORECTAL DISEASE

PROCTOLOGY DAY
Cytoreductive Surgery
ROBOTIC COURSE
and Intraperitoneal Chemotherapy – facts and hopes
DAVOSCOURSE@ECC Michel Adamina, Winterthur, CH

SCIENTIFIC PROGRAMME Metastatic Colorectal Cancer – surgical approaches and limits

Jürgen Weitz, Dresden, DE
Mon, 4 Dec – Wed, 6 Dec 2023
Extended lymph node dissection
DIVERTICULAR DISEASE for rectal cancer, is it still under debate?
Miranda Kusters, Amsterdam, NL
Gut microbiome and surgery
Phil Quirke, Leeds, UK Organ preservation functional outcome in rectal
cancer treatment – in line with patient’s needs?
Diet in diverticular disease (Robot – laparoscopic – open surgery?)
Pamela Buchwald, Lund, SE Hans de Wilt, Nijmegen, NL

Decision making in the management of acute ROBOTICS

complicated Diverticulitis beyond the guidelines
Seraina Faes, Zurich, CH Advances in Robotic Surgery and what we learnt so far
Parvaiz Amjad, Portsmouth, UK
Diverticular Abscess –
Always drainage or who benefits from Surgery? Challenging the market:
Johannes Schultz, Oslo, NO Robotic (assistant) Devices and how to choose wisely
(Da Vinci – Hugo Ras – Distalmotion ua)
Perforated Diverticulitis: Khan Jim, London, UK
Damage Control, Hartmann‘s Procedure,
Primary Anastomosis, Diverting Loop TAMIS - Robotic Transanal Surgery, does it make it easier?
Reinhold Kafka-Ritsch, Innsbruck, AT Knol Joep, Genk, BE

When to avoid protective stoma Live Surgery – Contonal Hospital of St.Gallen

in colorectal surgery Walter Brunner, St.Gallen, CH;
Antonino Spinelli, Milano, IT Salvadore Conde Morals, Sevilla, ES;
Friedrich Herbst, Vienna, AUT;
ENDOMETRIOSIS Amjad Parvaiz, Portsmouth, UK

Endometriosis – Video Session

what is the role of the abdominal surgeon
Tuynman Juriaan, Amsterdam, NL Lars Pahlmann Lecture
Markus Büchler, Lisboa, PRT
Challenges in Surgery of Endometriosis –
always interdisciplinary? Honorary Lecture
Peter Oppelt, Linz, AT; Andreas Shamiyeh, Linz, AT Bill Heald, Lisboa, PRT

Information & Registration www.colorectalsurgery.eu