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Evidence for open groin hernia repair demonstrates less pain with bioglue mesh fixation compared with invasive methods. This study aimed to assess the short- and long-term effects of laparoscopic groin hernia repair with noninvasive and invasive mesh fixation. A systematic review of MEDLINE, CENTRAL, and OpenGrey was undertaken. Randomized trials assessing the outcome of laparoscopic groin hernia repair with invasive and noninvasive fixation methods were considered for data synthesis. Nine trials encompassing 1,454 patients subjected to laparoscopic hernia repair with mesh fixation using biologic or biosynthetic glue were identified. Short-term data were inadequate for data synthesis. Chronic pain was less frequently reported by patients subjected to repair with biologic glue fixation than with penetrating methods (odds ratio .46, 95% confidence interval .22 to .93). Duration of surgery, incidence of seroma/hematoma, morbidity, and recurrence were similar. Laparoscopic groin hernia repair with bioglue mesh fixation was associated with a reduced incidence of chronic pain compared with mechanical fixation, without increasing morbidity or recurrence. Longer term data on recurrence are necessary. •Bioglue has recently emerged as an alternative means of mesh fixation in open and laparoscopic groin hernia repair.•Synthesis of data suggests that this method reduces chronic postoperative pain, without increasing morbidity or recurrence.•Longer term data on recurrence are needed.

The rapid adoption of robotic surgical systems across Europe has led to a critical gap in training and credentialing for gastrointestinal (GI) surgeons. Currently, there is no existing standardised curriculum to guide robotic training, assessment and certification for GI trainees. This manuscript describes the protocol to achieve a pan-European consensus on the essential components of a comprehensive training programme for GI robotic surgery through a five-stage process. In Stage 1, a Steering Committee, consisting of international experts, trainees and educationalists, has been established to lead and coordinate the consensus development process. In Stage 2, a systematic review of existing multi-specialty robotic training curricula will be performed to inform the formulation of key position statements. In Stage 3, a comprehensive survey will be disseminated across Europe to capture the current state of robotic training and identify potential challenges and opportunities for improvement. In Stage 4, an international panel of GI surgeons, trainees, and robotic theatre staff will participate in a three-round Delphi process, seeking ≥ 70% agreement on crucial aspects of the training curriculum. Industry and patient representatives will be involved as external advisors throughout this process. In Stage 5, the robotic training curriculum for GI trainees will be finalised in a dedicated consensus meeting, culminating in the production of an Explanation and Elaboration (E&E) document. The study protocol has been registered on the Open Science Framework (https://osf.io/br87d/).

Background Laparoscopic techniques induced a tremendous revolution in surgery of the biliary tract, mainly due to improved results compared with the open approach and secondary because of their cosmetic advantage. A trend toward even more minimally invasive approaches has led to techniques of single-incision and natural orifice laparoscopic surgery. Because the evaluation of single-incision laparoscopic cholecystectomy (SILC) is rather fragmentary by single-institution small patient series, this article intends to examine the success and the risks of the technique, and attempts to determine its potential limitations. Methods A systematic review of the literature was performed to identify relevant articles. Studies enrolling at least ten patients who underwent SILC and reporting on analytical complication data were considered for inclusion. Results The literature search identified 29 studies, which included a total of 1,166 patients. Success and complication rates were 90.7% and 6.1%, respectively. Mean adjusted operative time was 70.2 min and mean adjusted hospital stay was 1.4 days. Analysis of outcome exhibited higher complication rates for studies with a mean patient age older than 45 years ( p  = 0.04), and higher operative time for studies with a mean body mass index >30 kg/m 2 (83.4 vs. 74.5 min) and female percentage lower than 70% (78.7 vs. 68.5 min). Acute cholecystitis as inclusion criterion was a factor for technical failure (success rate 59.9 vs. 93.0%, p  = 0.005) and resulted in an increase of operative time (78.1 vs. 70.6 min). Suture suspension of the gallbladder yielded significantly lower complication rates compared with instrument usage (3.3 vs. 13.3%, p  < 0.0001). Conclusions The clinical application of SILC exhibited satisfactory results. Cases of acute cholecystitis and older patients should be approached with caution, whereas improvement of the instrumentation is necessary.

Single-incision laparoscopic appendectomy has emerged as a less invasive alternative to conventional laparoscopic surgery. High-quality relevant evidence is limited. A systematic review of electronic information sources was undertaken, with the objective of identifying randomized trials that compared single-incision with conventional laparoscopic appendectomy. Outcome measures included 30-day morbidity, abdominal abscess, wound infection, open conversion, reoperation, operative time, length of hospital stay, and postoperative pain. Fixed-effects and random-effects models were used to calculate combined overall effect sizes of pooled data. Data are presented as odds ratios or weighted mean differences with 95% confidence intervals (CIs). Five randomized trials were identified, with a total of 746 patients. Thirty-day morbidity (9.6% vs 8.6%; odds ratio, 1.14; 95% CI, .69 to 1.89) and wound infection rates were similar between single-incision and conventional laparoscopy (4.0% vs 4.8%; odds ratio, .83; 95% CI, .41 to 1.68), whereas the duration of surgery was longer in the single-incision group (46.3 vs 40.7 minutes; weighted mean difference, 6.01; 95% CI, 2.26 to 9.76). Available data were not adequately robust to reach conclusions regarding the remaining outcome measures. Similar postoperative morbidity and wound infection rates for single-incision and conventional laparoscopic appendectomy are supported by the current literature, but single-incision surgery requires longer operative time.

Background This article reviews the feasibility of the laparoscopic treatment of Mirizzi syndrome and determines the associated risks and complications of this technique. Methods An electronic search of the literature between 1989 and 2008 was undertaken to identify relevant articles. Studies comprising at least four patients treated by laparoscopy and reporting on the preoperative diagnosis rate and analytical conversion and complication data were considered for inclusion. Results From 66 abstracts reviewed, 10 eligible studies were identified. Conversion, complication, and reoperation rates were 41%, 20%, and 6%, respectively. The risks for open conversion and procedure-related complications were similar for patients with type I and type II Mirizzi syndrome. However, patients of studies reporting a high preoperative diagnosis rate had a significantly lower risk for conversion ( p  < 0.05), procedure-related complications ( p  < 0.05), and reoperation ( p  < 0.05), when compared with studies with a low preoperative diagnosis rate. Conclusion Current evidence suggests that laparoscopic treatment of Mirizzi syndrome cannot be recommended as a standard procedure. Preoperative diagnosis of the syndrome seems an important predicting factor of technical success.

BackgroundAirSeal® is a valve-free insufflation system that enables a stable pneumoperitoneum with continuous smoke evacuation and CO2 recirculation during laparoscopic surgery. Comparative evidence on the use of AirSeal® and standard CO2 insufflator in laparoscopic general surgery procedures is scarce. The aim of this study was to compare surgical outcomes between AirSeal® and standard CO2 insufflators in patients undergoing the most frequently performed laparoscopic procedures.MethodsOne hundred and ninety-eight patients undergoing elective laparoscopic cholecystectomy, colorectal surgery and hernia repair were randomized to either AirSeal® (group A) or standard pressure CO2 insufflator (group S). The primary endpoints were operative time and level of postoperative shoulder tip pain (Visual Analog Scale). Secondary outcomes included Clavien–Dindo grade complications, surgical side effect and length of hospital stay.ResultsPatients were randomized to either group A (n = 101) or group S (n = 97) and were analyzed by intention-to-treat. There was no significant difference in mean operative time between the groups (median [IQR]; 71 min [56–94] in group A vs. 69 min [52–93] in group S; p = 0.434). Shoulder tip pain levels were significantly lower in group S (VAS 0 [0–3] in group S vs. 2 [0–4] in group A; p = 0.001). There was no significant difference in complications, surgical side effects (subcutaneous emphysema was not observed in any group) and length of hospital stay.ConclusionThis randomized controlled trial showed that using the AirSeal® system did not reduce operative time and was associated with a higher postoperative shoulder tip pain compared to standard CO2 insufflator for short elective surgeries.ClinicalTrials.gov (NCT01740011).

IntroductionSeveral risk factors for adverse events after endovascular aneurysm repair (EVAR) have been described, but there is no consensus on their comparative prognostic significance, use in risk stratification and application in determining postoperative surveillance.Methods and analysisA scoping review of the literature was conducted to identify risk factors for adverse events after EVAR. Main adverse events were considered post-EVAR abdominal aortic aneurysm rupture and reintervention. Risk factors were grouped into four domains: (1) preoperative anatomy, (2) aortic device, (3) procedure performance and (4) postoperative surveillance. The Delphi methodology will be used to steer a group of experts in the field towards consensus organised into three tiers. In tier 1, participants will be asked to independently rate risk factors for adverse events after EVAR. In tier 2, the panel will be asked to independently rate a range of combinations of risk factors across the four domains derived from tier 1. A risk-stratification tool will then be built, which will include algorithms that map responses to signalling questions onto a proposed risk judgement for each domain. Domain-level judgements will in turn provide the basis for an overall risk judgement for the individual patient. In tier 3, risk factor-informed surveillance strategies will be developed. Each tier will typically include three rounds and rating will be conducted using a 4-point Likert scale, with an option for free-text responses.Ethics and disseminationResearch Ethics Committee and Health Research Authority approval has been waived, since this is a professional staff study and no duty of care lies with the National Health Service to any of the participants. The results will be presented at regional, national and international meetings and will be submitted for publication in peer-reviewed journals. The risk stratification tool and surveillance algorithms will be made publicly available for clinical use and validation.

The aim of the present study was to comparatively evaluate the outcomes of laparoscopic transabdominal preperitoneal inguinal hernia repair and totally extraperitoneal repair. The electronic databases of Medline, EMBASE, and the Cochrane Central Register of Controlled Trials were searched, and a meta-analysis of randomized clinical trials was undertaken. Seven studies comprising 516 patients with 538 inguinal hernia defects were identified. A shorter recovery time (P = .02) was found for totally extraperitoneal repair in comparison with transabdominal preperitoneal inguinal hernia repair (weighted mean difference = −.29; 95% confidence interval [CI], −.71 to .07) although the length of hospitalization (P = .89) was similar in the 2 treatment arms (weighted mean difference = .01; 95% CI, −.13 to .15). Operative morbidity (P = .004) was higher for the preperitoneal approach (odds ratio = 2.15; 95% CI, 1.29 to 3.61). No differences were found with regard to the incidence of recurrence, long-term neuralgia, and operative time. Current evidence suggests similar operative results for endoscopic and laparoscopic inguinal hernia repair, with a trend toward higher morbidity for the preperitoneal approach. Randomized trials with a longer-term follow-up are needed in order to assess the effect of each approach on the prevention of recurrence.

IntroductionAppraisal of Guidelines for Research and Evaluation (AGREE II) is an instrument that informs development, reporting and assessment of clinical practice guidelines. Previous research has demonstrated the need for improvement in methodological and reporting quality of clinical practice guidelines specifically in surgery. We aimed to develop an AGREE II extension document for application in surgical guidelines.Methods and analysisWe have performed a structured literature review and assessment of guidelines in surgery using the AGREE II instrument. In exploratory analyses, we have identified factors associated with guideline quality. We have performed reliability and factor analyses to inform the development of an extension document. We will summarise this information and present it to a Delphi panel of stakeholders. We will perform iterative Delphi rounds and we will summarise the final results to develop the extension instrument in a dedicated consensus conference.Ethics and disseminationFunding bodies will not be involved in the development of the instrument. Research ethics committee and Health Research Authority approval was waived, since this is a professional staff study only and no duty of care lies with the National Health Service to any of the participants. Conflicts of interest, if any, will be addressed by reassigning functions or replacing participants with relevant conflicts. The results will be disseminated through publication in peer reviewed journals, the funders’ websites, social media and direct contact with guideline development organisations and peer-reviewed journals that publish guidelines.

•Research findings are not always transferred into clinical practice.•Appraisal of research evidence is the cornerstone of evidence-informed medicine.•The GRADE approach is the most widely used and accepted methodology to appraise evidence.•It sets several pillars for assessing the certainty of evidence from a study or a set of studies.•Web-based applications now facilitate rapid and objective appraisal of the certainty of evidence.