Difficulty scoring systems overlook how a surgical team learns. We examined whether a structured team-based pathway (debriefing, risk stratification, protocolized decisions) was associated with a reduction in conversion in laparoscopic liver resection (LLR) without avoiding complex cases. This single-center retrospective cohort study analyzed 2,051 pure LLRs (2009–2018), grouped by IDEAL phases: early, exploration, and maturation. The pathway was introduced in 2015. Primary endpoint: unplanned conversion. The overall conversion rate was 7.2
While laparoscopic appendectomy is the standard of care for acute appendicitis, the clinical utility of prophylactic abdominal drainage in perforated acute appendicitis remains controversial. Previous observational studies often lacked granular perioperative covariate adjustment and control for institutional clustering effects. We aimed to determine the association between prophylactic drainage and intra-abdominal abscess (IAA) formation using a unified mixed-effects framework. The Drainage of Laparoscopic Appendectomy for Perforated Appendicitis (DLAP) study was a retrospective multicenter cohort study involving 21 institutions in Japan. Patients undergoing emergency laparoscopic appendectomy for perforated acute appendicitis between 2015 and 2023 were evaluated. Confounder adjustment across 16 baseline covariates was performed using Overlap Weighting (OW). Secondary sensitivity analyses utilized Inverse Probability of Treatment Weighting (IPTW) and 1:1 Propensity Score Matching (PSM). Institutional clustering was accounted for using generalized linear mixed-effects models (GLMM) with participating centers as random intercepts across the primary and sensitivity analyses. Predictive importance of variables for 30-day postoperative IAA was explored using a Random Forest classifier. Among 671 included patients, 452 (67.4
Robotic donor nephrectomy (RDN) offers a minimally invasive alternative to open and laparoscopic techniques for living kidney donation. As obesity rises among potential donors, data comparing RDN outcomes between non-obese and obese donors remain limited. This study evaluates the safety and feasibility of RDN in obese living kidney donors. A single-center retrospective analysis included 212 consecutive donors who underwent RDN between August 2020 and April 2025; after excluding one donor with incomplete covariate data, 211 (137 low BMI [< 30 kg/m2], 74 high BMI [≥ 30 kg/m2]) formed the analytic cohort. To account for baseline imbalance, the primary between-group comparison used propensity-score overlap weighting, with weighted differences and 95
To examine how Body Mass Index (BMI) impacts postoperative complications in robotic and 3D laparoscopic radical resection for colorectal cancer. A retrospective analysis was performed on 476 Individuals undergoing robotic and 3D laparoscopic colorectal cancer surgery at a single center. According to BMI, the patients were categorized into four groups: < 18.5 kg/m2, 18.5–23.9 kg/m2, 24–27.9 kg/m2, and ≥ 28 kg/m2. The intraoperative and postoperative complication rates among the groups were compared. In the low BMI group (< 24 kg/m2), no statistically significant difference has been seen in postoperative complication for both robotic and 3D laparoscopic groups. Starting from BMI ≥ 24 kg/m2, the robotic group showed significantly lower rates of anastomotic leakage, wound infection, intestinal obstruction, urinary retention, autonomic dysfunction, and unplanned reoperation in comparison with the 3D laparoscopic group (P < 0.05). Multivariate logistic regression was also performed, revealing that for every 1 kg/m2 increase in BMI, the 3D laparoscopic group's complication risk increased by approximately 33
Bariatric surgery remains the most effective treatment for obesity, yet nationwide bariatric-specific data evaluating early weight loss and comorbidity remission across contemporary procedures are limited. We aimed to compare 6-month outcomes after sleeve gastrectomy (SG), Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch (BPD-DS), and single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SADI-S). We analyzed adults aged 18–65 years who underwent primary laparoscopic or robotic SG, RYGB, BPD-DS, or SADI-S in the 2023 MBSAQIP database with available long-term follow-up PUF data. Six pairwise 1:1 propensity score-matched analyses were performed using 47 preoperative, intraoperative, and postoperative variables. Outcomes included 6-month weight loss and remission of diabetes, hypertension, hyperlipidemia, sleep apnea, and gastroesophageal reflux disease (GERD). A total of 116,195 patients were included: 80,614 SG, 33,148 RYGB, 1518 BPD-DS, and 915 SADI-S. Compared with SG, RYGB showed higher remission of diabetes (64.1
The optimal laparoscopic approach for bilateral inguinal hernia repair is unclear. The 2 primary methods are totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) approaches. We conducted a systematic review and meta-analysis to compare surgical outcomes of TEP and TAPP for bilateral inguinal hernia repair. PubMed, EMBASE, and CENTRAL databases were searched through April 15, 2025. Studies comparing TEP and TAPP in adults with bilateral inguinal hernias were included. Outcomes assessed included hernia recurrence, pain scores, length of hospital stay (LOS), operation time, return to activities of daily living, and complications. Odds ratios (ORs) and standardized mean differences (SMDs) were pooled using fixed or random effects models. Three randomized controlled trials (RCTs) and 4 retrospective studies with a total of 1164 patients were included in the analysis. Hernia recurrence was significantly lower with TAPP compared to TEP (pooled OR 0.27, 95
The optimal number of abdominal ports for minimally invasive McKeown esophagectomy remains debated. This study aimed to determine whether single-port laparoscopy combined with thoracoscopy yields superior perioperative outcomes compared to conventional multiport laparoscopy combined with thoracoscopy. Between October 2021 and December 2023, 147 patients were randomly assigned to single-port or multiport laparoscopic-assisted thoracoscopic surgery. Primary outcomes included operative time, intraoperative blood loss, postoperative pain, and lymph node yield; secondary outcomes comprised complications and recovery indicators. Total operative time was comparable between groups (P < . 05). The single-port group exhibited significantly lower total blood loss (60(15, 110) vs. 200(50, 250) mL, P < . 001) and shorter laparoscopic time (49 (39, 57) vs. 57 (45, 76) min, P = . 03). In patients with BMI > 25 kg/m2, these advantages were more pronounced (operative time: 54 ± 7 vs. 66 ± 12 min, P < . 01; blood loss: 11 ± 5 vs. 20 ± 7 mL, P < . 001). Pain scores were lower in the single-port group on postoperative day 3 (VAS 2. 45 ± 0. 42 vs. 2. 99 ± 0. 87, P < . 001). Lymph node yield was similar between groups. Complication rates and recovery indicators did not differ significantly. Compared with the multiport approach, single-port laparoscopy reduces blood loss, shortens operative time, and alleviates postoperative pain without compromising oncological efficacy or safety.
Exercise may have untapped potential as a tool to reduce the physical strain of operating and optimize surgeon career longevity. This study aims to systematically review the literature to identify peer-reviewed comparative studies of surgeon exercise as an intervention to improve surgical ergonomics. We conducted a systematic review of 4 literature databases through July 2026 following PRISMA guidelines. Studies of non-exercise interventions for surgical ergonomics were excluded as were studies not written in English. Meta-analysis could not be performed due to the heterogeneity of study outcomes. Data were extracted for a narrative summary of the literature. Evidence quality was assessed using JBI critical appraisal tools for individual studies and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach for the body of evidence. 185 citations were reviewed, and 6 studies (n=282 surgeons) met inclusion criteria: 1 multicenter randomized controlled trial, 4 pre-post studies, and 1 prospective interventional trial. All control groups were usual practice or pre-intervention. All studies favored the exercise intervention over control/pre-intervention. Exercise regimens targeted high-risk areas including back, neck, and shoulders, and most were designed in conjunction with physical therapists. 5 of the 6 studies combined exercise with another intervention such as education or a patient-positioning protocol. Reported outcomes varied widely and included musculoskeletal pain/disorders, muscle activity by EMG, and subjective improvement in physical performance. Most evidence was mostly moderate quality. Exercise-based interventions may improve surgeon ergonomics. Evidence is limited by small samples, heterogeneous outcomes, and lack of active control groups. Future trials are needed to identify the optimal exercise approach. PROSPERO 2025 Registration: CRD420251075237 ( https://www.crd.york.ac.uk/PROSPERO/view/CRD420251075237 )
We performed a systematic review meta-analysis to inform the development of a multi-society guideline on the management of diverticular disease. We identified randomized trials and cohort studies addressing five key questions for patients with symptomatic uncomplicated diverticular disease (SUDD), uncomplicated diverticulitis, and complicated diverticulitis. Our panel established outcomes and decision thresholds. Two reviewers performed screening by title and abstract and full-text, data extraction, and risk of bias appraisal. We applied a random-effects meta-analysis and appraised the certainty of the evidence per GRADE. We identified 27 studies from 5,449 articles. For KQ3, patients with recurrent symptomatic uncomplicated diverticulitis experienced an improvement in quality of life at 2 years [standardized mean difference of 0.53, 95
The AirSeal® insufflation system (ASIS) provides stable pneumoperitoneum during minimally invasive pancreaticoduodenectomy (MIPD), but its impact on postoperative venous thromboembolism (VTE) remains unclear. We retrospectively analyzed 142 consecutive patients who underwent MIPD between May 2021 and January 2026. Patients were divided into an ASIS group and a standard insufflation system (StIS) group. In both groups, pneumoperitoneum pressure was maintained at 10 mmHg. The primary outcome was VTE, including deep vein thrombosis (DVT) and pulmonary embolism (PE), occurring within 14 days after surgery. Among 142 patients, 48 underwent MIPD with ASIS and 94 with StIS. VTE occurred in 12 patients (8.5
The surgical strategy for hepatic alveolar echinococcosis (AE) differs from that for typical malignant tumors, as treatment is not solely determined by the feasibility of complete (R0) resection. While complete resection remains the preferred goal, cytoreductive surgery combined with albendazole therapy is considered in selected cases. The role of minimally invasive surgery (MIS) within this disease-control oriented strategy remains unclear. We retrospectively analyzed 126 patients who underwent liver resection for hepatic AE between January 2010 and March 2026: 87 underwent open surgery and 39 underwent MIS. Perioperative and disease-control outcomes were compared, with propensity score overlap weighting used to adjust for baseline differences. The MIS group had smaller lesions and less advanced disease. Operative time was similar, whereas blood loss, Clavien–Dindo grade ≥II morbidity, severe morbidity, and hospital stay were lower in the MIS group. After overlap weighting, MIS was not associated with an increased hazard of disease progression (hazard ratio 0.47, 95
Laparoscopic common bile duct exploration and primary suture (LBEPS) offers advantages such as minimal invasiveness, shorter operative time, and faster postoperative recovery in the treatment of common bile duct stones coexisting with cholecystolithiasis and has been widely adopted in clinical practice. However, its application in patients with concomitant acute cholangitis (AC), particularly those with severe cholangitis, remains controversial in terms of safety. A retrospective analysis was conducted on the clinical data of 226 patients with common bile duct stones who underwent LBEPS at our hospital between December 2018 and August 2025. Based on the presence and severity of concomitant AC, patients were divided into three groups: the non-AC group (n = 158), the mild/moderate AC group (n = 47), and the severe AC group (n = 21). Baseline characteristics, operative time, and the incidence of postoperative complications were compared among the three groups. Among the three groups, patients in the severe AC group were older and had lower serum protein and hemoglobin levels; the proportion of male patients increased with the severity of inflammation (P < 0.05). The mild/moderate AC group had a higher likelihood of concomitant acute pancreatitis, and operative time was significantly longer than that in the non-AC group (P < 0.05). No significant differences were observed among the three groups in biliary-specific complications such as postoperative bile leakage (3.8–4.8
This study aimed to characterize immune remodeling following laparoscopic splenectomy and azygoportal disconnection (LSD) in patients with cirrhotic portal hypertension. In this 1-year prospective study, a total of 49 patients with cirrhotic portal hypertension received LSD treatment. We analyzed the dynamic changes in immune function-related indices through serial assessments conducted preoperatively and at 1, 3, 6, and 12 months postoperatively (POM 1, 3, 6, 12), specifically focusing on CD4+ T cell, CD8+ T cell, and CD19+.CD20+ B cell. Postoperative immune function was remodeled: the relative count of CD4⁺ T cells decreased progressively from 59.13
Walled-off pancreatic necrosis (WOPN) is a serious sequela following acute pancreatitis with significant associated morbidity and mortality. These guidelines provide best practice recommendations for the management of this complication. A systematic review was conducted, including a literature search from 1/1/2020 to 1/24/2025, addressing four key questions regarding the management of WOPN in adults. The findings were subsequently presented to a multidisciplinary panel of surgeons, gastroenterologists, and interventional radiologists, including those from both the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the Americas Hepato-Pancreato-Biliary Association (AHPBA). The GRADE methodology was then used to develop evidence-based recommendations. All recommendations were based on very low certainty of evidence. A conditional recommendation was made for endoscopic management versus image-guided intervention. A conditional recommendation was made for image-guided intervention versus open surgery. A conditional recommendation was made for either minimally invasive surgery or image-guided intervention. A conditional recommendation was made for minimally invasive surgery versus endoscopic intervention. A conditional recommendation was made for either a pure endoscopic approach versus a step-up approach. These recommendations provide guidance for the approach to the management of WOPN according to the existing literature and expert input. The panel also highlighted evidence gaps to support future research for a stronger evidence base regarding the treatment of WOPN.
Technical errors during surgery are a major contributor to preventable adverse outcomes, driving demand for objective assessment tools. Laparoscopic cholecystectomy (LC) is a commonly performed procedure with a clearly defined set of procedure-related complications, making it an ideal candidate for targeted assessment. To evaluate manual, kinematic, and AI-based technical skills assessment tools for LC and compare validity evidence and methodological quality. A PRISMA 2020-compliant systematic review (PROSPERO CRD420251125937) searched MEDLINE, Embase, Web of Science, and Cochrane Library from inception to 12 August 2025. Studies evaluating objective LC skill assessment tools were included. Two reviewers independently performed screening. Data extraction and study appraisal were performed with independent verification by a second reviewer. Validity was assessed using Messick’s framework, methodological quality using MERSQI, and risk of bias using COSMIN for manual and kinematic studies and QUADAS-2 for AI studies. Results were synthesised narratively. Sixty studies were included (41 manual, 6 kinematic, 13 AI). Most were single centre and retrospective. Manual tools demonstrated the largest body of validity evidence across independent cohorts, though reliability was variable and outcome associations were lacking. Kinematic systems quantified motion but had limited validation. AI systems showed strong internal performance and early real-time use, particularly for critical view of safety detection, but lacked external validation and clinical impact evidence. Heterogeneity precluded meta-analysis and limited assessment of reporting bias and certainty. No tool demonstrated sufficient validity to represent a gold standard. Manual tools are most mature but lack scalability, while AI systems show promise but require robust validation and evidence of clinical impact.
Obesity is associated with increased intra-abdominal pressure and higher prevalence of paraesophageal hernias (PEHs), yet its impact on outcomes following PEH repair remains unclear. This study evaluated postoperative outcomes following isolated PEH repair in obese and non-obese patients and examined whether increasing obesity severity influences risk of adverse outcomes. A retrospective cohort study was conducted of patients undergoing elective isolated PEH repair at an academic health-system (2010–2023). Patients were stratified as obese (BMI ≥ 30) or non-obese (BMI < 30). The primary outcome was a composite adverse outcome (CAO) defined as postoperative GERD or dysphagia > 30 days, hernia recurrence, or reoperation. Multivariable logistic regression was used to identify factors associated with CAO. A sub-analysis stratified patients into non-obese, class I–II obesity (BMI 30– < 40), and class III obesity (BMI ≥ 40). A total of 530 patients met inclusion criteria, including 254 obese (47.9
Celiac axis stenosis (CAS) has been historically underappreciated in risk stratification for clinically relevant postoperative pancreatic fistula (CRPOPF). In this study, we aimed to investigate the role of CAS as an independent and clinically meaningful extrapancreatic predictor and assess its incremental value in established predictive models. Overall, 1214 consecutive pancreaticoduodenectomies were conducted between January 2021 and December 2023. Patients with available preoperative abdominal contrast-enhanced computed tomography images were identified for this outcome-based retrospective cohort study. The CAS rate was assessed retrospectively using sagittal reconstruction of arterial phases and classified into no (< 30
The European Association of Endoscopic Surgery (EAES) promotes surgical innovation, education, and quality assurance to optimize patient care. A core component of this work is the development of clinical practice guidelines. We outline the standard operating procedure for clinical practice guideline development within the EAES. We adhere to standards outlined by the Guidelines International Network (GIN), core Grading of Recommendations Assessment, Development and Evaluation (GRADE), and Appraisal of Guidelines for Research and Evaluation for guidelines of surgical interventions (AGREE-S). For all guidelines, the panel prioritizes outcomes and establishes decision thresholds for each PICO by converting utility values to absolute effect difference thresholds. Next, the systematic review group performs a comprehensive systematic review followed by a meta-analysis and/or network meta-analysis including rating of the certainty of evidence in line with core GRADE. An interdisciplinary panel of interest holders including patient partners then reviews this evidence using summary of findings tables and develops recommendations using the GRADE evidence-to-decision framework under the guidance of a guideline methodologist. EAES develops clinical practice guidelines according to the highest methodological standards to summarize evidence and provide health recommendations for a wide range of interest holders including clinicians, patients, researchers, and policymakers.
Minimally invasive adrenalectomy is associated with low postoperative morbidity, but early complications still occur and may be influenced by patient-related, endocrine, and operative factors. This study aimed to identify the factors associated with 30-day postoperative complications after minimally invasive adrenalectomy. This retrospective cohort study included adults undergoing minimally invasive adrenalectomy at a high-volume endocrine surgery referral centre between January 2012 and March 2026. The primary outcome was the occurrence of postoperative complications within 30 days after surgery. Univariable and multivariable logistic regression analyses were performed, with results expressed as odds ratios (ORs) with 95
Acute cholecystitis is the most common complication of gallstone disease. Although early cholecystectomy is recommended, surgery is frequently delayed in clinical practice. This study aimed to evaluate the association between preoperative length of stay and postoperative complications following cholecystectomy for acute cholecystitis. In addition, reasons for delayed surgery were assessed. This multicenter retrospective cohort study included consecutive patients undergoing laparoscopic cholecystectomy for acute cholecystitis between January 1, 2018, and December 31, 2022. Preoperative length of stay was defined as the time from admission to surgery. Postoperative complications were classified according to the Clavien–Dindo classification, and diagnosis and severity of acute cholecystitis were defined according to the Tokyo Guidelines. A total of 1,544 consecutive patients were included. After adjustment for age, body mass index, ASA classification, performance status, Tokyo Guidelines severity, symptom duration, and treating hospital, each additional preoperative hospital day was associated with higher odds of postoperative complications requiring pharmacological or surgical treatment (Clavien–Dindo ≥2) (OR 1.14, 95
