BACKGROUND:Laparoscopic intraperitoneal onlay mesh repair with defect closure (intraperitoneal onlay mesh repair with fascial defect [IPOM Plus]) is widely practiced for ventral hernia repair but remains associated with significant postoperative pain and intraperitoneal mesh-related complications. Transabdominal preperitoneal mesh repair with defect closure (vTAPP Plus) offers an anatomical, extraperitoneal alternative that may reduce postoperative pain along with reduced mesh-related complications. High-quality randomized evidence directly comparing these techniques is limited. METHODS:This prospective, single-center, randomized controlled trial was conducted at a tertiary care institute. Adults with small-to-medium primary ventral hernias (2-4 cm) were randomized to undergo laparoscopic IPOM Plus or vTAPP Plus repair. The primary outcome was mean postoperative pain score (Visual Analogue Scale [VAS]) within the first 24 hours. Secondary outcomes included serial pain scores up to 6 months, operative duration, length of hospital stay, postoperative complications, and recurrence. Statistical analysis was performed using appropriate statistical tests. RESULTS:In total, 68 patients were analyzed (IPOM Plus: n = 36; vTAPP Plus: n = 32). Baseline demographic and clinical variables were comparable between groups. vTAPP Plus demonstrated significantly lower postoperative pain at 6, 12, 24, and 48 hours, as well as at 14 and 30 days (P < .001). Differences diminished at 3 months and were not significant at 6 months. Operative time was marginally longer for vTAPP Plus, the hospital stay was significantly lower. Postoperative complication rates were comparable. No mesh infection or hernia recurrence was observed during follow-up. CONCLUSION:vTAPP Plus repair significantly reduces early and intermediate postoperative pain compared with IPOM Plus, without compromising safety or short-term efficacy. Thus, vTAPP Plus represents a better option for selected primary midline ventral hernias.
PURPOSE:Multiple techniques have been described for laparoscopic inguinal hernia repair in children. The purpose of this study was to describe our experience using cautery and Endoloops in pediatric female patients. METHODS:We conducted a retrospective review of pediatric female patients who underwent laparoscopic inguinal hernia repair using cautery and Endoloops at our center. This technique involves establishing laparoscopic access through the umbilicus, everting and cauterizing the hernia sac with a Maryland dissector, and placing two PDS Endoloops at the level of the internal ring. Outcomes included operative time and complications. RESULTS:We identified 50 female patients (mean age 5.6 years, range 2 months to 17 years) who underwent laparoscopic inguinal hernia repair using cautery and Endoloops from January 2015 to March 2024. The indication for surgery in most patients was a clinical hernia (n = 43/50). One of these was incarcerated and another was a recurrent hernia. Seven other patients underwent ligation of an incidental patent processus vaginalis during laparoscopic appendectomy (n = 4), laparoscopic ovarian detorsion (n = 2), or diagnostic laparoscopy for possible Meckel's diverticulum (n = 1). Median operative time was 30 minutes for unilateral inguinal hernias (n = 26/43) and 33 minutes for bilateral (n = 17/43). None experienced conversion to open procedure, surgical site infection, or recurrence. CONCLUSION:We conclude that laparoscopic inguinal hernia repair using cautery and Endoloops is safe and effective in pediatric female patients. This technique does not require specialized skills, training, or equipment. We have used this approach for primary repair of clinical hernia, incarcerated hernia, recurrent hernia, and incidental patent processus vaginalis.
BACKGROUND:Inguinal canal fat encountered during inguinal hernia repair is frequently described as a lipoma, although many lesions are continuous with preperitoneal fat (PPF) rather than true neoplasms. The lack of clear intraoperative criteria has led to controversy regarding routine excision versus conservative management. This study aimed to determine whether intraoperative differentiation between true lipomas and PPF can guide selective surgical management. METHODS:We retrospectively reviewed 2465 adult patients (aged ≥20 years) who underwent transabdominal preperitoneal (TAPP) repair between January 2019 and December 2023. Among them, 271 patients with fatty tissue in the inguinal canal were analyzed. Intraoperative fatty tissue was classified as either true lipoma or PPF based on encapsulation and continuity with the preperitoneal space. True lipomas were excised, and PPF was managed with reduction alone. RESULTS:The presence of inguinal canal fat was not associated with differences in the demographic or hernia-related clinical characteristics. Recurrence was rare in both groups (0.3% versus 0.4%), with no significant difference between the patients with and without fatty tissue. Operative time was longer in patients with fatty tissue (35.6 ± 8.2 versus 28.9 ± 5.8 minutes, P < .001). Within the fat group, lipoma excision required longer operative time (41.8 ± 9.5 versus 34.9 ± 7.8 minutes, P = .001) and was associated with a higher complication rate (10.0% versus 1.2%, P = .005) than was PPF reduction, while recurrence and metachronous contralateral inguinal hernia were rare in both subgroups. Other postoperative outcomes were comparable between the strategies. CONCLUSIONS:Most fatty protrusions encountered in the inguinal canal during TAPP repair were continuous with the PPF layer rather than discrete encapsulated lipomas. In appropriately selected cases, reduction of PPF without excision appeared feasible and safe, with favorable short- and long-term outcomes.
BACKGROUND:Neurologically impaired children frequently experience recurrent gastroesophageal reflux symptoms after laparoscopic Nissen fundoplication, even when the fundoplication remains anatomically intact. Esophagogastric dysfunction may contribute to these recurrences but is often underrecognized. AIM:To analyze the causes of recurrent gastroesophageal reflux symptoms in neurologically impaired children with an intact Nissen fundoplication attributable to esophagogastric dysfunction and to describe their management and outcomes. METHODS:We conducted a retrospective descriptive study of neurologically impaired children who underwent laparoscopic Nissen fundoplication between 2010 and 2025 and subsequently developed recurrent gastroesophageal reflux-related symptoms. All patients were evaluated with contrast upper gastrointestinal studies and upper gastrointestinal endoscopy; gastric emptying scintigraphy was performed when gastric atony was suspected. Demographic data, neurological diagnosis, Gross Motor Function Classification System level, nutritional status, symptoms, time to recurrence, imaging findings, treatment, and follow-up were recorded. RESULTS:A total of 124 children were included (96 with cerebral palsy, 18 with traumatic brain injury, and 10 with brain tumors). At 36-month follow-up, 82 patients achieved complete symptom remission. Forty-two children, all with cerebral palsy, developed recurrent symptoms between 10 and 48 months after surgery. Recurrence was due to paraesophageal hernia in 15 patients, all of whom underwent successful laparoscopic redo fundoplication. The remaining 27 children had an anatomically intact fundoplication: 10 presented bile reflux with duodenitis and improved with medical management, and 17 had gastric, pyloric, or duodenal dysfunction requiring laparoscopic pyloroplasty, esophagogastric disconnection, or gastrojejunostomy, with subsequent resolution of symptoms. CONCLUSIONS:In neurologically impaired children, esophagogastric dysfunction unrelated to wrap failure is a frequent and surgically treatable cause of recurrent symptoms after Nissen fundoplication.
BACKGROUND:Sleeve gastrectomy (SG) has become the most common bariatric procedure worldwide. Unfortunately, a significant number of patients require conversion to Roux-en-Y gastric bypass (RYGB) or single-anastomosis duodeno-ileal bypass (SADI) because of recurrent weight gain. This study aimed to determine the rates of complications and mortality associated with conversion from SG to RYGB (SG-RYGB) compared with conversion from SG to SADI (SG-SADI). METHODS:This retrospective analysis used data from the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program database from 2020 to 2022. Patients undergoing SG-RYGB or SG-SADI were included. Thirty-day operative outcomes, intraoperative and postoperative events, and mortality were analyzed. RESULTS:A total of 28,758 patients were included. Of these, 27,412 (95.3%) underwent SG-RYGB and 1346 (4.6%) underwent SG-SADI. The mean preoperative body mass index was 39.7 kg/m2 for SG-RYGB and 45.3 kg/m2 for SG-SADI (P < .001). SG-RYGB was associated with a higher frequency of intraoperative/postoperative complications within the first 30 days (5.9% versus 3.4%, P < .001), including transfusion (1.3% versus 0.4%, P = .004), readmission (7.3% versus 4.6%, P < .001), and emergency department visits (12.5% versus 8.5%, P < .001). Although SG-SADI was associated with a higher rate of anastomotic leak (0.4% versus 1.1%, P < .001), there was no difference in reoperation rates (2.8% versus 2.5%) or deaths (0.02% versus 0%). Overall, SG-SADI-S was associated with a lower risk of intraoperative/postoperative complications, with an adjusted odds ratio of 0.741 (95% confidence interval: 0.543-0.901, P = .041). CONCLUSIONS:Both revisional procedures are safe. Although SG-RYGB was associated with a higher frequency of intraoperative/postoperative complications within the first 30 days, SG-SADI had a higher rate of anastomotic leaks, with no difference in reoperation rates or deaths.
BACKGROUND:Periarterial divestment has emerged as an artery-preserving alternative to formal arterial resection for borderline resectable and locally advanced pancreatic cancer. However, the available evidence remains limited. This study aimed to evaluate the perioperative and oncologic outcomes of periarterial divestment in pancreatic cancer. METHODS:A systematic review was conducted using PubMed, Scopus, Web of Science, and the Cochrane Central Register to identify studies' data published up to March 2026. Continuous outcomes were pooled as means with 95% confidence intervals (CIs), and binary outcomes were pooled as proportions using random-effects models. Heterogeneity was assessed using the I2 statistic and the Cochrane Q test. Sensitivity analyses were performed using leave-one-out methods. All analyses were conducted in R version 4.4.2. RESULTS:Five retrospective observational studies comprising 474 patients were included, of whom 92.8% had locally advanced pancreatic cancer and 64.8% received neoadjuvant therapy. The pooled operative time was 333.0 minutes (95% CI: 232.6-433.4; I2 = 99%), estimated blood loss was 620.6 mL (95% CI: 292.4-948.7; I2 = 97%), and length of hospital stay was 12.4 days (95% CI: 9.1-15.6; I2 = 99%). The pooled incidence of intraabdominal infection, postoperative pancreatic fistula, postpancreatectomy hemorrhage, delayed gastric emptying, reoperation, major complications (Clavien-Dindo grade ≥ III), and 90-day mortality was 10.57%, 8.72%, 8.56%, 14.13%, 3.36%, 11.27%, and 4.18%, respectively. The pooled rates of venous resection, arterial resection, and R0 resection were 36.18%, 3.56%, and 43.33%, respectively. The pooled 1-year and 3-year disease-free survival rates were 50.42% and 17.77%, respectively, while the corresponding overall survival rates were 75.99% and 29.11%. CONCLUSION:Periarterial divestment has been applied in selected patients, with reported perioperative and oncologic outcomes across studies. However, the current evidence remains descriptive and does not allow comparative inference.
BACKGROUND:Intrathoracic wrap migration (IWM) is a relatively infrequent but clinically significant complication following laparoscopic fundoplication (LF). This meta-analysis aimed to synthesize the available evidence comparing the incidence of IWM after primary cruroplasty with or without mesh reinforcement. METHODS:A systematic search of PubMed, Embase, Scopus, Web of Science, and Cochrane Library was performed through February 2026. The primary outcome was the incidence of IWM following LF with mesh reinforcement versus simple suture repair. Secondary outcomes included operative time and postoperative dysphagia. The random-effects model was used to calculate the pooled odds ratios (OR) and mean difference (MD) with 95% confidence intervals (CI). RESULTS:Of 507 studies screened, 7 cohort studies comprising 1171 patients were included. The mesh group represented 43.5% of patients (n = 510). Overall, 43% were female (n = 504) with a mean age of 54.3 years. There was no significant difference in age or sex distribution between groups. Mesh reinforcement during LF was associated with a significantly lower risk of IWM (OR = 0.21; 95% CI = 0.10 to 0.42; I2 = 0%). Sensitivity analyses confirmed the robustness of the IWM findings across prospective studies and polypropylene mesh subgroups. There was no statistically significant difference in operative time (MD =+14.22 minutes; P = .05). Mesh reinforcement was associated with a higher risk of dysphagia at 3 months (OR = 2.22; 95% CI = 1.60 to 3.09; I2 = 0%), with no significant difference observed at 1-year follow-up. CONCLUSION:Mesh reinforcement during LF was associated with a significantly lower risk of IWM compared with simple suture repair, without significant differences in operative time and long-term dysphagia.
INTRODUCTION:Laparoscopic sleeve gastrectomy (LSG) is currently the most frequently performed bariatric surgery method worldwide. However, it includes the longest staple line (SL), remaining the major source of complications, with leak rates of 0.7% up to 5.7%. Because leaks occur just below the esophagogastric junction in up to 90% of cases, SL reinforcement is widely used, though its effect on failure locations remains insufficiently characterized. METHOD:This ex vivo study evaluated whether SL reinforcement affects mechanical resistance and leak localization. Sixty human LSG specimens (20/group) from routine resections were randomized to oversewing (Group 1), through-through suturing (Group 2), or no reinforcement (Group 3), using 3/0 polypropylene. Specimens were tested within 40 minutes by intraluminal insufflation via Veres needle and manometer while submerged; burst pressure and leak site were recorded. RESULTS:Baseline characteristics were comparable across groups (P > .05). Leaks occurred distally in 70% and proximally in 30% of specimens. Reinforcement affected leak topography (P = .011): Distal leaks predominated in Groups 1 (85%) and 2 (80%), while Group 3 concentrated proximally (55%). Burst pressure differed significantly (P = .001): Highest with oversewing (mean 116.84 ± 16.35; median 120 [110-130] mm Hg), intermediate with through-through sutures (78.52 ± 14.27; median 80 [65-90] mm Hg), and lowest without reinforcement (41.00 ± 9.26; median 40 [30-50] mm Hg). CONCLUSION:Oversewing provides the greatest pressure safety window and shifts failure from the high-risk proximal region to distal SL, suggesting reinforcement strategies should anticipate distalized leak patterns, while in vivo validation remains necessary.
Aim of the Study: Thoracoscopic repair of esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is an increasingly adopted approach. However, it is a complex minimally invasive technique that should be performed by experienced surgeons under optimal conditions. This study aims to determine whether delaying surgery to ensure these conditions is safe. Methods: We conducted a retrospective observational study (2017 to 2024) analyzing historical cohorts of 41 neonates with EA and distal TEF who underwent thoracoscopic repair. Fifteen (36.5%) were operated on the first day of life (Group A), while 26 (63.5%) underwent delayed surgery (Group B). Baseline characteristics, preoperative and intraoperative morbidity and mortality, and follow-up outcomes were analyzed. Results: There were no significant differences in sex, gestational age, birth weight, or associated anomalies, including anorectal malformation. Group B neonates underwent surgery at 2.38 ± 0.76 days of life. No preoperative respiratory infections or need for emergency surgery were reported, and there were no significant differences in atelectasis (6.6% versus 11%), respiratory distress (40% versus 34%), or intubation requirement (13% versus 19%). Intraoperatively, conversion rates (6.6% versus 7.6%) and desaturation events (20% versus 19%) were comparable. Postoperatively, no differences were found in intubation days (3.3 versus 3.37), infections (6.6% versus 11.5%), atelectasis (13.3% versus 19.2%), or follow-up complications ( P > .05). Conclusions: Delaying the repair of EA with distal TEF is safe, allowing thoracoscopic surgery to be performed by experienced surgeons under optimal conditions without increasing morbidity due to the wait.
INTRODUCTION:Superior mesenteric artery syndrome (SMAS) is an uncommon cause of abdominal pain, emesis, and weight loss in children. While there are many surgical options, we previously reported a small series of laparoscopic duodenal lowering (DL), which became our standard first approach. Here, we report our expanded experience on the surgical management of patients with SMAS. METHODS:We conducted a retrospective chart review of patients who underwent surgical management of SMAS between January 2008 and December 2023 at our institution. RESULTS:22 patients underwent surgical management for SMAS during this study period. The majority of patients were female (n = 19, 86%), and median age at time of surgery was 17 years (interquartile ranges: 16.0, 18.4). The median measured aorto-SMA angle was 16° (12, 20), with 3 patients having an aorto-SMA angle as narrow as 10°. Twenty patients underwent laparoscopic DL, and 2 patients underwent laparoscopic duodenojejunostomy, as they had previously undergone surgical procedures for SMAS at another institution (open duodenal de-rotation, open DL, and median arcuate ligament release). Of the 20 patients who underwent DL, 12 patients (60%) had resolution of their symptoms. Two of these patients had recurrence of symptoms within 6 months and underwent subsequent LDJ. Of the 8 patients without improvement after DL, 2 underwent subsequent LDJ with improvement of symptoms. The median follow-up for all patients was 51 days (33, 321). In both univariate and multivariate statistical analyses, having a diagnosis of Ehlers-Danlos syndrome was predictive of failure to achieve symptom resolution after DL (P = .004). No other clinical or demographic characteristics were found to be predictive of successful resolution of symptoms from surgery. CONCLUSIONS:Patients with SMAS are a complex population. The more conservative DL can be an efficacious first step when approaching surgical management of SMAS. Future investigation is warranted to characterize which patients are more likely to fail operative intervention or require repeat operations.
INTRODUCTION:Gastrojejunostomy tube (GJT) placement in pediatric patients may be indicated for a variety of reasons. Standard pathways exist for preoperative evaluation of patients prior to gastrostomy tube (GT) placement; however, the workup and referral patterns for patients needing GJT are not well described. METHODS:A single-center, retrospective cohort study of pediatric patients who underwent GJT placement between 2014 and 2024 was performed. Included were patients undergoing primary GJT (pGJT) placement and those undergoing staged GJT (sGJT) if the conversion from GT to GJT was within 1 year of index placement. sGJT was further grouped by planned and delayed cohorts, referring to the presence or absence of a plan for short-interval GJT exchange after GT placement. Preoperative workup methods and long-term enteral access outcomes were assessed. RESULTS:There were 90 patients who underwent GJT, including 30 pGJT, 29 planned sGJT, and 31 delayed sGJT. Most were referred by gastroenterology (45.6%), followed by intensivists (21.1%). Upper gastrointestinal fluoroscopic swallow study (60.0%), trial of transpyloric feeds (55.6%), and trial of proton pump inhibitors (41.1%) were frequently obtained preoperatively. The median time from GJT recommendation to surgery was 17.5 days. One year postoperatively, 92.2% of patients had ongoing GJT utilization, compared with 62.2% of patients at most recent follow-up (median: 4.08 years). CONCLUSION:Pediatric GJT placement referral patterns and preoperative workup are heterogeneous. About 40% of patients undergoing GJT placement will have alternative access at the median 4-year follow-up. Standardization of preoperative evaluation and workflow is warranted.
BACKGROUND:Obesity is a leading global health challenge associated with increased morbidity and mortality from cardiovascular disease, type 2 diabetes, hypertension (HTN), and other metabolic comorbidities. Bariatric surgery is currently the most effective long-term treatment for severe obesity. However, 20-30% of patients may experience weight regain or unsatisfactory metabolic outcomes after primary surgery, requiring revisional (redo) procedures. The Single Anastomosis Sleeve Ileal Bypass (SASI) is an innovative bariatric technique, recently proposed as a redo option due to its favorable balance of restrictive and malabsorptive mechanisms and technical simplicity. SASI is still considered "experimental" in major international guidelines, and data on its efficacy as revisional surgery are limited. METHODS:This retrospective study included 30 patients (mean age 50.8 ± 10.75 years) undergoing SASI after failed primary bariatric procedures (sleeve gastrectomy, gastric plication, Bariclip) between 2023 and 2024. Parameters analyzed included weight, body mass index (BMI), percentage of excess weight loss (%EWL), percentage of total weight loss (%TWL), remission of type 2 diabetes (T2DM), HTN, obstructive sleep apnea (OSA), gastroesophageal reflux disease (GERD), surgical complications, nutritional status. Follow-up was conducted at 1, 6, and 12 months postoperatively. RESULTS:Preoperatively, mean weight was 124 ± 29.1 kg and BMI 45.05 ± 5.4 kg/m2. At 1, 6, and 12 months after SASI, mean BMI was 42.85 ± 7.69, 37.6 ± 6.3, and 32.7 ± 3.83 kg/m2, respectively; mean weight was 113 ± 21.6, 99.25 ± 31.3, and 89.1 ± 18 kg. At 12 months, mean %EWL was 57.6 ± 19 and %TWL was 29.58 ± 8.16, exceeding standard benchmarks for bariatric success. Remission rates of T2DM, HTN, OSA and GERD all improved markedly, with nearly complete resolution of comorbidities at 12 months. No peri- or postoperative complications were observed. Considering the nutritional status at 12 months follow-up, no significant alterations were detected. In particular, we chose to analyze laboratory parameters such as serum albumin (3,7 ± 3), vitamin B12 (490 ± 250 pg/mL), folate (9 ± 6 ng/mL), iron (110 ± 32 ug/mL), ferritin (100 ± 35 ng/mL), and hemoglobin (12 ± 1,5). CONCLUSION:The SASI procedure demonstrated significant efficacy and safety as a revisional bariatric surgery, producing substantial weight loss, favorable metabolic improvement, and no surgical complications in this single-center cohort. These findings support the use of SASI as a valid option for redo bariatric procedures. Further prospective studies with larger cohorts and longer follow-up are needed to assess long-term results and nutritional outcomes.
Introduction: Primary tracheal tumors are rare pathologies that pose significant diagnostic and therapeutic challenges due to their low incidence, nonspecific symptoms, and technical complexity of surgical management. This study aimed to evaluate the clinical characteristics, surgical outcomes, and oncological results of patients treated for primary tracheal tumors at a single experienced center. Methods: A retrospective analysis was conducted of patients who underwent surgical treatment for primary tracheal tumors between October 2010 and October 2025. Patients treated for tracheal stenosis or managed with nonsurgical modalities alone were excluded. Demographic data, tumor characteristics, surgical approaches, perioperative outcomes, pathological findings, adjuvant treatments, and survival data were analyzed. Results: Nineteen patients (63.2% female, 36.8% male) with a mean age of 58.4 years were included. Surgical approach was individualized according to tumor localization and consisted of collar incision, collar incision combined with partial sternotomy, thoracotomy, or video-assisted thoracoscopic surgery. No difference was seen in the means of complication, survival, operation time, or length of hospital stay between continuous or interrupted sutures with PDS or polypropylene materials. Postoperative complications occurred in three patients (15.8%), including wound infection in two patients and anastomotic dehiscence complicated by pneumonia in one patient, which resulted in postoperative mortality. Malignant pathology was identified in 84.2% of patients, and selected cases with tumor-positive surgical margins received adjuvant radiotherapy. No tumor recurrence was observed, and 89.5% of patients were alive at the end of follow-up. Mean overall survival was 157.7 months. Conclusions: In the management of primary tracheal tumors, early diagnosis, appropriate patient selection, surgical treatment performed in experienced centers, and the use of a multimodal treatment approach when indicated constitute the key determinants of successful oncological and functional outcomes.
BACKGROUND:Laparoscopic repair is recommended for inguinal hernia because it is associated with reduced postoperative pain and faster recovery compared with open repair. However, the choice between transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP) techniques remains controversial. METHODS:A prospective randomized, clinical trial was conducted between November 2021 and June 2025. Adult male patients with unilateral uncomplicated inguinal hernias were included. Patients were randomized in a 1:1 ratio to undergo TAPP or TEP repair. The primary endpoint was 30-day postoperative complications graded according to the Clavien-Dindo classification. Secondary endpoints included chronic pain, functional recovery, and recurrence. RESULTS:A total of 144 patients were included and randomized, with 72 patients in each group. Briefly, 30-day postoperative complications were significantly more frequent after TAPP than TEP (19.4% versus 6.9%, P = .024). Most complications were minor (Grades I-II), and three Grade IIIa events required percutaneous aspiration. Chronic pain at 3 months was observed in 5.6% of patients after TAPP and 1.4% after TEP (P = .181). Time to return to normal activity did not differ significantly between groups. After a median follow-up of 26 months, the recurrence rate was 2.8% in both groups. CONCLUSION:TEP was associated with significantly lower short-term postoperative complications and shorter hospital stays, while long-term outcomes were comparable between techniques.
BACKGROUND:Artificial intelligence (AI) is rapidly transforming surgical practice, with applications spanning preoperative planning, intraoperative guidance, postoperative management, and surgical education. Despite accelerating research activity, the structure, thematic evolution, and funding landscape of AI research in general surgery remain incompletely characterized. This study aimed to systematically evaluate scientific production on AI in general surgery in the United States over the past 5 years using a bibliometric approach. METHODS:A bibliometric analysis was conducted following Preliminary Guideline for Reporting Bibliometric Reviews of the Biomedical Literature and Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines using Web of Science. English-language articles published between 2020 and 2025 with a U.S.-affiliated senior author and focused on AI use in general surgery were included. Publications were analyzed across five primary domains: authorship metrics, thematic endpoints, journal characteristics, country of origin, and funding patterns. Bibliometric indicators included H-index, citation counts, Article Influence Score (AIS), and Bradford's Law classification. Funding distribution across endpoints was evaluated using chi-square or Fisher's exact tests, with effect sizes estimated using Cramér's V and odds ratios. Temporal trends in endpoints and keywords were assessed using Poisson and negative binomial regression models. RESULTS:Fifty-nine studies met inclusion criteria, comprising 20 reviews and 39 original investigations. Scientific production increased consistently from one study in 2019 to 17 in 2023 and 16 in 2024, demonstrating sustained growth. Surgical workflow recognition (n = 19) and clinical decision support (n = 18) were the predominant research domains, representing 63% of the included literature. Temporal analysis demonstrated significant annual growth in reviews (Incidence rate ratios [IRR] 2.09, P = .002) and workflow-focused studies (IRR 1.37, P = .031). Keyword analysis revealed sustained prominence of AI and machine learning, with limited emergence of new thematic directions. Most studies reported no funding (57.6%). Although overall funding distribution did not significantly differ across application categories (P = .846), clinically actionable AI applications were significantly more likely to receive funding compared with other research areas (OR 4.0, 95% CI 1.22-13.13; P = .029). CONCLUSION:AI research in U.S. general surgery is growing but remains concentrated in workflow and decision-support domains. Funding favors clinically actionable applications, highlighting the need for broader, equity-focused AI development.
BACKGROUND:Mesh fixation strategy is a modifiable intraoperative factor that may influence postoperative recovery following totally extraperitoneal (TEP) inguinal hernia repair. Although self-fixating meshes were developed to avoid penetrating fixation and potentially reduce pain, their effect on multidimensional recovery trajectories remains unclear. METHODS:This retrospective cohort study included consecutive adults undergoing elective unilateral TEP repair at a tertiary referral center. Patients were grouped according to fixation strategy: self-fixating mesh or polypropylene mesh secured with absorbable tacks. The primary outcome was early quality of recovery measured using the Quality of Recovery-15 (QoR-15) questionnaire at postoperative week 1. Secondary outcomes included longitudinal QoR-15 and visual analog scale (VAS) pain scores at postoperative months 1 and 3, analgesic consumption, and time to functional recovery. Recovery trajectories were analyzed using linear mixed-effects models, with additional stratification by defect size (<20 mm versus ≥20 mm). RESULTS:A total of 134 patients were included (56 tack fixation, 78 self-fixating mesh). Early recovery at week 1 was comparable between groups. Mixed-effects modeling demonstrated significant improvement over time in both groups, without an independent association between fixation strategy and overall QoR-15 trajectory. However, in defects ≥20 mm, self-fixating mesh was associated with higher QoR-15 scores. Pain scores improved over time in both groups, with small but statistically significant differences favoring self-fixating mesh. CONCLUSIONS:In unilateral TEP repair, fixation strategy does not substantially influence overall early and short-term recovery. However, in larger defects (≥20 mm), self-fixating mesh may provide modest recovery advantages, suggesting a context-dependent rather than uniform effect.
OBJECTIVE:Endoscopic bariatric therapies, including intragastric balloons (IGBs) are effective minimally invasive options for obesity management, particularly for patients who are not candidates for bariatric surgery. This study aimed to compare the safety profiles, weight loss outcomes, and tolerability of three fluid-filled IGB systems used in routine clinical practice. METHODS:We conducted a retrospective cohort study of adults who underwent intragastric balloon placement at a single private bariatric center between January 2023 and January 2025. Data were derived from a prospectively maintained clinical database. Patients received one of three fluid-filled balloons: Allurion, Medsil, or Spatz3. Baseline demographic and anthropometric characteristics, weight loss outcomes, premature balloon removal, and readmission rates were assessed through completion of treatment. Comparative analyses across balloon types were performed using appropriate parametric and nonparametric statistical tests. RESULTS:A total of 113 patients were included (mean age 34.9 ± 9.3 years; 91.2% female). Mean baseline body mass index (BMI) was 40.0 ± 7.9 kg/m2. Balloon distribution was Allurion (n = 13), Medsil (n = 40), and Spatz3 (n = 60). Overall mean absolute weight loss was 14.0 ± 8.3 kg, corresponding to a mean BMI reduction of 5.0 ± 3.0 kg/m2. Mean percentage total body weight loss was highest in the Spatz3 group (13.1 ± 7.3%), followed by Medsil (12.0 ± 6.2%) and Allurion (9.8 ± 3.9%); however, differences were not statistically significant (P = .33). Premature balloon removal due to intolerance occurred in 10.6% of patients, with no significant differences between balloon types. No major complications were observed. CONCLUSION:All three fluid-filled intragastric balloons demonstrated meaningful weight loss with acceptable safety and tolerability profiles. While the Spatz3 balloon achieved numerically greater weight loss, outcomes were comparable across devices without major adverse events. These findings support the role of IGBs as effective endoscopic bariatric therapies within a comprehensive obesity management framework.
INTRODUCTION:YouTube has become a widely used tool for surgical education, offering open access to procedural videos for trainees and professionals alike. However, the reliability and pedagogical quality of these publicly available resources remain uncertain. In the context of minimally invasive inguinal hernia repair, we hypothesized that robotic (RT) surgery videos provide superior educational value compared with laparoscopic (LAP) ones. This study aimed to systematically evaluate and compare the quality of RT and LAP transabdominal preperitoneal (TAPP) inguinal hernia repair videos available on YouTube. METHODS:Based on a priori sample size calculation for moderate effect size (Cohen's d = 0.5), we determined that 63 videos per group would be required for adequate statistical power. On March 19, 2025, a structured search was performed on YouTube using the term "Transabdominal preperitoneal repair for inguinal hernia." This strategy generated an initial pool of 300 potentially eligible videos, which were screened sequentially until the predetermined sample size of 63 videos per group was achieved. Eligible content featured TAPP repairs via RT or LAP approach. Duplicates, non-inguinal TAPP procedures, videos consisting exclusively of animations, conference lectures, or irrelevant videos were excluded. The primary objective was to evaluate videos containing operative demonstrations of surgical procedures. After this selection, two blinded hernia surgeons independently assessed all videos using a newly developed 21-item qualitative evaluation tool and the validated LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) score, a tool for evaluating surgery videos submitted to presentations and publications. Group comparisons were conducted using Welch's t-test and Mann-Whitney U test. Effect size was reported using Cohen's d. Both assessment tools demonstrated adequate inter-rater agreement and internal consistency, supporting their reliability for evaluating educational video content. RESULTS:From 300 videos screened, 126 met inclusion criteria (63 RT, 63 LAP). RT videos scored significantly higher than LAP videos on the newly developed qualitative evaluation tool (mean score 0.54 vs. 0.44; P < .001; Cohen's d = -0.60), indicating a moderate effect size. Similarly, RT videos demonstrated higher LAP-VEGaS scores (7.46 vs. 6.34), although this difference did not reach statistical significance (P = .091). These findings suggest that RT videos present superior adherence to technical and educational standards, respectively. Both assessment tools demonstrated adequate inter-rater agreement and internal consistency, supporting their reliability for evaluating educational video content. CONCLUSION:YouTube contains a large repository of TAPP repair videos, but quality is inconsistent. The new qualitative tool demonstrated strong reliability and internal consistency, supporting its use for educational video assessment. RT videos showed greater adherence to technical and educational standards compared with LAP. RT videos may therefore offer more structured learning content, but general quality improvements remain necessary across both approaches.
INTRODUCTION:The current surgical approaches for treating congenital diaphragmatic hernia (CDH) are challenging. Thoracoscopic transcutaneous closure of CDH is described, of which a retrospective study was conducted to investigate the safety and effectiveness. MATERIALS AND METHODS:In thoracoscopic transcutaneous closure, a thoracoscope and operating forceps are placed through two intercostal ports to expose the defect, followed by stepwise thoracic pressure elevation to facilitate herniated organ reduction. A fascial closure device is introduced through a small skin incision to encircle the diaphragmatic rim in two semicircular passes, and the suture is then tightened extracorporeally to close the defect. RESULTS:Over a 8-year period, 33 TTC repairs were performed for CDH, including 31 Bochdalek and 2 Morgagni cases. Bochdalek repairs were completed in a mean operative time of 53.68 ± 45.81 minutes (range, 10-200 minutes), with a median age of 1 day and median weight of 3.25 kg. Among them, two patients experienced recurrence at 3 months and 7 months postoperatively. During hospitalization, four patients developed pneumothorax, and one patient developed chylothorax. The two Morgagni cases were repaired in 35 and 30 minutes at 5 and 6 months of age. Respiratory support was a median of 59 hours (range, 0-352 hours) in patients who required respiratory assistance, intensive care unit stay was a median of 15 days (range, 1-91 days) in patients admitted to the intensive care unit, and hospital stay was a median of 15 days (range, 2-91 days). All patients had uneventful wound healing without rib-development complications during follow-up. CONCLUSION:Thoracoscopic transcutaneous closure is a feasible and effective technique to treat CDH. While possessing the advantages of minimally invasive surgery, it shortens the operative time and learning curve.
Background: Single anastomosis duodeno-ileal bypass with sleeve gastrectomy (SG) (SADI-S) and distal one anastomosis transit bipartition (dOATB) represent two distal single-anastomosis metabolic procedures sharing similar anatomical configurations but differing fundamentally in their approach to duodenal transit. Both combine SG with an omega-loop anastomosis to the distal ileum approximately 250-300 cm from the ileocecal valve. However, SADI-S positions the anastomosis on the duodenal bulb, achieving complete duodenal exclusion, while dOATB performs a prepyloric antral anastomosis, preserving duodenal transit through a bipartition mechanism. This fundamental difference raises a critical question: Does complete duodenal exclusion matter for metabolic outcomes in distal intestinal procedures? Methods: We conducted a narrative review comparing anatomical, physiological, and clinical aspects of SADI-S and dOATB, emphasizing the role of duodenal exclusion in weight loss (WL), metabolic improvements, and nutritional consequences. We examined the hypotheses to provide a theoretical framework for understanding these procedures. Results: Both procedures demonstrate excellent WL, with total WL ranging from 35% to 45% and excess WL exceeding 80% at medium-term follow-up. Type 2 diabetes remission rates are remarkably high in both groups (85%-95%). SADI-S has a more extensive evidence base with longer follow-up and IFSO and ASMBS endorsement. Distal OATB, while demonstrating comparable metabolic efficacy, offers theoretical advantages in nutritional preservation through maintained duodenal transit and facilitated endoscopic access to the biliopancreatic system. The holoileum hypothesis suggests that adequate ileal stimulation through an elongated common channel may be more important than duodenal exclusion per se. Conclusions: Current evidence suggests that excellent metabolic outcomes can be achieved with distal single-anastomosis procedures regardless of duodenal exclusion status. The elongated common channel and ileal stimulation appear to be the critical determinants of metabolic success. Distal OATB may offer advantages in nutritional preservation and endoscopic accessibility while maintaining comparable metabolic efficacy. Prospective randomized trials directly comparing these procedures are warranted.
