搜索结果：Journal of abdominal wall surgery : JAWS

Abdominal wall hernia repair has progressed from suture-based open techniques to mesh-reinforced open repair, laparoscopic intraperitoneal onlay mesh (IPOM), endoscopic retromuscular approaches and most recently robot-assisted reconstructions 1 . Of course, this trajectory has provided important benefits (smaller incisions, faster recovery and best anatomical reconstructions and dissections) but it has also brought some drawbacks (rising procedure volumes, cost inflation, and treatment of hernias that might remain asymptomatic for years) 2,3 . That phenomenon (providing care whose potential benefit is eclipsed by its opportunity cost or risk) is labelled lowvalue care 4 . In abdominal wall surgery the line between value and overuse can sometimes be blurred and difficult to identify because most ventral, incisional and inguinal hernias are elective, their natural history variable, and the evidence base irregular.The purpose of this article is to make a reflection about the progressive evolution of abdominal wall surgery, the emergence of overuse as a major risk, the drivers behind low-value care and why shared decision making (SDM) (particularly the "option-talk" phase that weighs among other things the data efficacy and safety) may be one of the best antidote. A brief point of view is also made about the quality of the evidence surgeons rely on, including an explosion of publications and concerns that conventional peer review may be struggling which can hinder disruptive findings. Finally, it offers a focused reflection on robotic abdominal wall surgery, highlighting weak randomised data, divergent incentives between clinicians and industry and the argument for slowing the adoption curve.Early open herniorrhaphy required large incisions, prolonged convalescence and high recurrence rates 1 . Tension-free mesh repair reduced recurrence dramatically. Laparoscopic intraperitoneal mesh placement (IPOM) in the 1990s further lowered wound morbidity and hastened return to work. Over the last decade endoscopic retromuscular techniques such as eTEP and eTAR have recreated the biomechanical advantages of open sublay repair without a laparotomy 5 . Parallel progress in biomaterials has refined the balance between strength and foreign-body response 6 . Most recently, the robotic platform has extended wristed instrumentation and 3-D vision to hernia surgery allowing for improved minimally invasive approach for complex cases 7 . Artificial-intelligence image guidance and risk-prediction tools are now entering the field 8 .Globally over 20 million groin and over 700 000 ventral hernias are repaired each year 9 . Population studies show wide geographic variation in elective repair rates that cannot be explained by prevalence alone a classic signal of overuse 10 . In high income settings fee-for-service payment, defensive medicine, direct-to-consumer marketing, surgeons' learning-curve incentives and patients' expectations ("fix it now") all propel intervention 11 . In low and middle-income countries different mechanisms appear e.g., donor funding that prioritises volume rather than need, or import-driven dependence on premium meshes even where low-cost alternatives perform similarly 12,13 . The harm could be two-fold: individually, unnecessary repairs expose patients to mesh infection, chronic pain and loss of work without offsetting benefit; systemically, they divert theatre time and budgets from higher-value services.SDM reframes surgical consent from a one-way recommendation to an iterative conversation: choice talk (there is more than one path), option talk (weighing pros and cons), and decision talk (aligning with patient values). Randomised and observational studies in abdominal wall surgery show that decision aids reduce surgery rates without harming quality of life and increase preference-concordant care [14][15][16] . For us, option talk plays a key role in the SDM process and the option talk is only as good as the evidence on efficacy and safety that underpins it. Whether individual studies and/or systematic reviews are methodologically weak or skewed by publication bias the risk-benefit picture patients receive is distorted potentially fuelling overuse rather than curbing it.The volume of surgical literature grows around 5 % per year doubling every 14-17 years 17,18 . Peer-review pipelines and editorial standards have not scaled at the same pace prompting concern that "special-issue" models and article-processing-charge incentives could erode quality control 19,20 . Bibliometric studies show that while citations and team sizes soar the proportion of truly disruptive papers (those that redirect a field) has fallen sharply since the mid-1940s 20 . Critics argue that review burden, risk-averse funding and industry partnerships favour incremental work at the expense of bold ideas, leaving surgeons with an avalanche of low-signal data 21 . For abdominal wall surgery it could mean hundreds of small retrospective series and few adequately powered trials. Surgeons therefore rely on evidence that may be internally valid but externally fragile, again jeopardising option talk in SDM process.Robotic hernia repair (RHR) provides ergonomic suturing and easier retro-rectus dissection. Systematic reviews of observational studies suggested lower wound morbidity and shorter length of stay 22 . However, the first prospective randomised controlled trial comparing robotic with open retromuscular repair found no difference in composite surgical-site morbidity or two-year recurrence, although length of hospital stay was one day shorter with robotics 23 . A registry-based multicentre RCT (ROVHR) is under way but still recruiting 24 . Meta-analyses report similar outcomes but consistently higher direct theatre costs for RHR 25 . Device amortisation, longer set-up time, and disposable instrument pricing shift the cost-effectiveness threshold unfavourably when clinical benefit is marginal. Yet adoption curves remain steep, driven by marketing, institutional prestige, and surgeon training pathways aligned with robotic consoles. Surveys indicate that trainees perceive robotics as the default future despite uncertain evidence, could it be a sign of for technology-driven overuse? 26,27 . In addition, it may be that in today's abdominal wall surgery exercice the traditional dogma associated with individual practice (study, research, publication, and evidence-based acquisition of technical skills) may be challenged and replaced by other influences associated with opinion leaders, practice conformity, and reputational concerns 28 .The translation gap after surgical trials is often blamed on heterogeneity of technique and learning curves, but financial incentives also matter 29,30 . Manufacturers underwrite proctoring and conference symposia, whereas public funders bankroll the few head-tohead trials that might curb sales. Clinicians, under time pressure and mindful of competitive advantage may prioritise early adoption over equipoise. This divergence creates what some have called a "house divided": clinical equipoise versus commercial imperatives because clinical trials and health care delivery companies could be assisted by separate people, policies, institutions, and funding, leading to different motivations and aims 31,32 . Registries and audit networks offer a partial bridge, but without comprehensive cost data even robust outcome tracking cannot answer value questions 33 . Slow-medicine and surgery advocates 34,35 could argue that abdominal-wall surgery should take a lesson and insist on large, transparent, multi-stakeholder trials before population-level diffusion, in other words, modernizing the data infrastructure for clinical research avoiding postmarketing analysis 32 . Until then, SDM remains the ethical buffer allowing patients to choose or decline new technologies, devices or surgical techniques based on the current imperfect knowledge.The abdominal wall surgery exemplifies the surgical innovation of the XXI century with an unstoppable and fast evolution that seems to have immersed the surgeon interested in this pathology in a constant spiral of innovations and new concepts. However, knowledge (and the patient in the clinic) move at human speed. Low-value care emerges where that mismatch increases. Our opinión article could highlight four possible strategic responses. First, deepen the evidence base: pragmatic, registry-embedded RCTs should become the norm, with mandatory cost-utility endpoints. Publishers and funders must reward disruptive designs and negative trials alike. Second, slow premature diffusion: health systems can condition procurement of new devices or technological platforms on demonstrable incremental benefit not prestige. Third, operationalise SDM: decision aids, visual risk formats and "option talk" should be embedded in hernia pathways and audited like any other quality metric. Finally, realign incentives: bundled payments, appropriateness criteria and public reporting of longterm outcomes counteract volume-based drivers of overuse.The field is unlikely to revert to pre-mesh open repairs nor should it. But progress that outpaces reflection ceases to be progress. A deliberate pause (time to study, synthesise and decide with patients) may feel alien in an era of technological exuberance yet it is precisely the antidote to low-value care 20 . Abdominal wall surgery is not a race to implant the most advanced mesh with the newest technological platform it is a commitment to restore abdominal core function safely, effectively and only when truly necessary.

Background: Robotic-assisted surgery (RAS) for abdominal wall hernia repair is an established, minimally invasive technique that is in the early phase of adoption within the UK. We aimed to demonstrate the impact on patient outcomes and safety of hernia repair by adhering to the robotic abdominal wall surgery pathway developed by the European Hernia Society. Materials and Methods: Two experienced laparoscopic surgeons in the UK underwent four phases that involved preclinical and clinical phases. The surgeons performed RAS hernia surgery with a stepwise increase in complexity, from robotic transabdominal preperitoneal (rTAPP) inguinal hernia repair, robotic transabdominal retrorectus umbilical prosthesis (rTARUP)/extended totally extraperitoneal (eTEP) to robotic transversus abdominis release (rTAR). Results: In total, 144 patients underwent RAS for hernia repair. Of these, 97 underwent rTAPP inguinal hernia repair (23 bilateral cases). The median operative time was 56 min for unilateral and 101 min for bilateral repair. Four (3.3%) rTAPP patients experienced complications, with two recurrences at the 6-month follow-up. Forty-two patients underwent rTARUP/eTEP repair, with a median operative time of 167 min. Two (4.8%) of these patients experienced postoperative complications. No recurrences were observed at 6 months. Thirteen patients with incisional hernias underwent rTAR, with a median operative time of 426 min. No recurrences were observed in rTAR patients, followed for up to 12 months. Discussion: Implementation of the EHS training pathway for robotic abdominal wall surgery resulted in a low complication rate and satisfactory clinical outcomes and represents a robust mechanism for surgeons to safely adopt complex robotic abdominal wall surgery.

Purpose: Repairing complex abdominal wall hernias is challenging, often requiring component separation techniques (CST) for tension-free closure. Adjuvant therapies, such as botulinum toxin type A (BTA), preoperative progressive pneumoperitoneum (PPP), and intraoperative fascial traction (IFT), may reduce the need for CST by improving abdominal wall compliance and reduce the complexity of the hernia. There is limited knowledge about the effects of their combined use. Our aim is to evaluate the rate of CST in abdominal wall reconstruction for complex midline hernias after adjuvant therapies. Methods: A cross-sectional study was conducted on patients who underwent surgery for correction of midline complex abdominal hernias between June 2020 and June 2024. Patients submitted to BTA, PPP, or/and IFT were included. Exclusion criteria were non-midline hernias, non eletive surgeries and less than 3 months of follow-up. Results: Among the 44 patients studied, 61.4% underwent abdominal wall reconstruction without requiring CST. Traditional predictors like component separation index and rectus/defect ratio were not associated with a higher rate of CST after adjuvant therapies. 45.5% of patients underwent a combination of adjuvant techniques (BTA + PPP or BTA + IFT). The early and late complication rates were 20.5% and 9.1%. A recurrence rate of 4.5% was reported after a median follow-up of 13 months. Conclusion: This study suggests that adjuvant therapies may influence the surgical approach to abdominal wall reconstruction. The synchronous application of adjuvant therapies, both preoperatively and intraoperatively, could enhance their effect and contribute to the use of less disruptive techniques.

Background: Robotic-assisted abdominal wall surgery demands advanced technical proficiency. The advent of robotic platforms has driven the development of various training approaches, including simulation-based modules, animal models, and structured curricula. This systematic review critically assesses current training strategies and models, comparing their effectiveness in skill acquisition through validated assessment tools and evaluating their implementation from a cost-effectiveness perspective. Methods: A comprehensive search of the scientific literature was conducted across three major databases (PubMed, Embase, Cochrane, Google Scholar) up to April 2025. The study was registered in PROSPERO (CRD420251027155) and conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were selected based on inclusion of robotic training programs related to abdominal wall surgery. Results: Out of 3,038 records identified, 8 studies were included. The overall methodological quality was acceptable, with all studies showing moderate risk of bias. Training models varied and included virtual reality simulation (n = 4), inanimate models (n = 3), porcine models (n = 2), and intraoperative training (n = 4). Three studies described integrated, proficiency-based curricula. Skill acquisition was reported using validated tools such as GEARS, OSATS, or the Zwisch scale in only two studies. Reported costs ranged from €40 for silicone models to €600 for porcine models; one study demonstrated $1,207 in cost savings per case post-training. Conclusion: Current training models for robotic-assisted abdominal wall surgery are heterogeneous in design, assessment methods, and cost. While integrated curricula show promise, few studies employ validated tools to evaluate skill acquisition. Further high-quality research is needed to standardize training approaches and assess their cost-effectiveness.

Background: The incidence of incisional hernia following laparotomy varies between 2% and 30%. It is well-established that the need to control several risk factors prior to surgery exists (weight loss before surgery, diabetes control). Postoperative abdominal binder (AB) is often recommended by surgeons, yet evidence on this topic is lacking. The aim of this review was to present current evidence on the use of abdominal binders after abdominal surgery. Material and Methods: A comprehensive literature review between January and May 2024 was conducted using a range of search engines, including PubMed, Science Direct, EMBASE, Google Scholar, and Google. The following keywords were used: "abdominal binder," "abdominal support," "hernia," "girdle and hernia," "compression belt and hernia," and "abdominal support and hernia." Results: Sixteen articles were selected for further analysis (7 RCTs, 6 non-RCTs and 3 meta-analyses). None of the studies reported a reduction in the incidence of abdominal dehiscence or incisional hernia. Postoperative use of the AB has been shown to reduce postoperative discomfort and pain for a limited period of up to 48-72 h. There was no discernible difference in the incidence of surgical site complications. Conclusion: The current evidence indicates that the use of AB following abdominal surgery is safe, although no benefit has been established (except 48 h after surgery). AB may enhance comfort in select patients; however, further studies are necessary to justify their routine use, with a particular focus on the medical and economic implications.

Background The Da Vinci Single Port (SP) robotic platform has recently been approved for general surgery in the European Union. However, its application in abdominal wall hernia repair remains largely unexplored. This study focuses on the development of a novel suprapubic single-port extraperitoneal approach (SP 2 eTEP) for ventral hernia surgery. Method Following the IDEAL framework for introducing new surgical procedures, this study details the preclinical exploration and technical development of SP 2 eTEP using the Da Vinci SP system. The research included procedural development on human cadavers and skills training using a porcine model. Results Instrument reach and maneuverability were first evaluated using a silicone abdominal wall model. The model showed minimal reach loss between the 27 mm-SP metal cannula (29 cm straight, 27 cm articulated) and the collapsed SP small access port (28 cm straight, 26 cm articulated). Cadaveric sessions confirmed that the SP Access Port, placed suprapubically, allowed successful dissection in the preperitoneal, the retrorectus, and the subcutaneous planes. Additionally, bilateral component separation by transversus abdominis release was achieved using a bottom-up approach. The porcine model for inguinal hernia repair proved to be a suitable adjunct to simulator-based training for developing the necessary skills for subsequent clinical application. Conclusion This preclinical (pre-IDEAL stage) exploration and procedural development demonstrate the feasibility of SP 2 eTEP for ventral hernia repair with the Da Vinci SP platform. The findings support progression to clinical evaluation of this novel robotic approach for abdominal wall hernia repair.

Background: Botulinum toxin A (BTA) is increasingly used for preoperative conditioning in patients with large or complex abdominal wall hernias. Injection into the lateral abdominal muscles 4-6 weeks before surgery induces temporary muscular relaxation and facilitates primary fascial closure, even in extensive defects (EHS W3), potentially reducing the need for component separation. While surgical outcomes are well documented, data on patient-reported experiences during the preoperative period remain limited. This retrospective study evaluated patient-reported symptoms between BTA injection and surgery and analyzed surgical results in this cohort. Methods: Between 2018 and 2024, 50 patients with complex abdominal wall hernias received preoperative BTA treatment followed by surgical repair. Demographic and surgical data, as well as BTA-related complications, were analyzed descriptively. A retrospective questionnaire assessed subjective experiences from injection to surgery, focusing on pain, physical changes (e.g., abdominal contour, trunk stability), and functional impairments (e.g., breathing, urination, defecation). Results: . Thirty eight patients had W3 hernias according to EHS (≥10 cm), while BTA was also used in selected cases with smaller defects with complicating factors. No major BTA-related complications occurred; minor hematomas were observed. The mean interval between injection and surgery was 39 days. Primary fascial closure was achieved in all patients. Mesh reinforcement was used in all cases, most commonly in sublay position (n = 47). A transversus abdominis release was performed in 28 cases (52%), and anterior component separation in five. Twenty-two patients (44%) completed the questionnaire. Injection pain ranged from NRS 1-8, typically resolving within 1-3 days; three patients reported no pain. Eight noticed abdominal contour changes, and two reported altered trunk function. One patient experienced mild shortness of breath and another constipation; no urinary issues occurred. Conclusion: Preoperative BTA conditioning is a safe and effective adjunct for abdominal wall reconstruction in complex hernias. The treatment facilitates fascial closure, avoids major complications, and causes only minor, short-lived discomfort or functional limitations, maintaining overall quality of life in the preoperative phase.

Background: Botulinum toxin type A has become an increasingly used tool in the preoperative management of giant abdominal wall hernias. Its primary objective is to "downstage" the hernia by inducing temporary paralysis of the lateral abdominal wall muscles, thereby increasing their compliance and enabling safer fascial closure. While the muscular and anatomical benefits of this approach are well documented, the potential effects on pulmonary function remain poorly studied, despite the involvement of the targeted muscles in the process of breathing. Objective: This study aimed to evaluate the impact of botulinum toxin type A on respiratory system function, using spirometry to assess whether any observed changes reflect true improvement, mechanical compensation, or potential impairment. Methods: This prospective, observational study included 37 patients with large abdominal wall hernias and a Loss of Domain component. All patients received 300 units of botulinum toxin type A injected bilaterally into the external, internal oblique, and transversus abdominis muscles under ultrasound guidance. Spirometry was performed before the injection and again on the day of surgery. Evaluated parameters included forced vital capacity, forced expiratory volume in one second, the ratio of forced expiratory volume to forced vital capacity, peak expiratory flow, maximum mid-expiratory flow, maximal expiratory flow at 75, 50, and 25 percent of forced vital capacity, forced inspiratory vital capacity. Results were analyzed using paired statistical tests with a significance threshold of p < 0.05. Results: No statistically significant changes were observed in forced vital capacity or forced expiratory volume in one second. However, statistically significant increases were recorded in maximum mid-expiratory flow and maximal expiratory flow at 50 percent of lung volume. Peak expiratory flow showed a trend toward improvement but did not reach statistical significance. These changes appear to reflect altered expiratory dynamics due to increased diaphragmatic excursion, rather than improved ventilation. Forced inspiratory vital capacity decreased slightly. Only two patients reported subjective changes in breathing. Conclusion: Botulinum toxin type A does not impair core lung volumes but induces mechanical changes that may affect airflow velocity. Standard spirometry may not fully reflect these dynamics, and further investigation is warranted to better understand respiratory outcomes in this patient group.

Based on skeleton examination, cave-paintings and mummies the study of prehistoric medicine tells that the surgical experience dated with skull trepanning, male circumcision and warfare wound healing. In prehistoric tribes, medicine was a mixture of magic, herbal remedy, and superstitious beliefs practiced by witch doctors. The practice of surgery was first recorded in clay tablets discovered in ancient rests of Mesopotamia, translation of which has nowadays been published in Diagnoses in Assyrian and Babylonian Medicine. Some simple surgical procedures were performed like puncture and drainage, scraping and wound treatment. The liability of physicians who performed surgery was noted in a collection of legal decisions made by Hammurabi about the principles of relationship between doctors and patients. Other ancient cultures had also had surgical knowledge including India, China and countries in the Middle East. The part of ancient Indian ayurvedic system of medicine devoted to surgery Sushruta Samhita is a systematized experience of ancient surgical practice, recorded by Sushruta in 500 B.C.E. Ancient Indian surgeons were highly skilled and familiar with a lot of surgical procedures and had pioneered plastic surgery. In the ancient Egyptian Empire medicine and surgery developed mostly in temples: priests were also doctors or surgeons, well specialized and educated. The Edwin Smith Papyrus, the world?s oldest surviving surgical text, was written in the 17th century B.C.E., probably based on material from a thousand years earlier. This papyrus is actually a textbook on trauma surgery, and describes anatomical observation and examination, diagnosis, treatment, and prognosis of numerous injuries in detail. Excavated mummies reveal some of the surgical procedures performed in the ancient Egypt: excision of the tumors, puncture and drainage pus abscesses, dentistry, amputation and even skull trepanation, always followed by magic and spiritual procedures. Various types of instruments were innovated, in the beginning made of stone and bronze, later of iron. Under the Egyptian influence, surgery was developed in ancient Greece and in Roman Empire. Prosperity of surgery was mostly due to practice in treating numerous battlefield injuries. Records from the pre-Hippocrates period are poor, but after him, according to many writings, medicine and surgery became a science, medical schools were formed all over the Mediterranean, and surgeons were well-trained professionals. Ancient surgery closed a chapter when Roman Empire declined, standing-by up to the 18th century when restoration of the whole medicine began.

BACKGROUND: Robotic-assisted laparoscopy has become a widely and increasingly used modality of minimally invasive surgery in the treatment of endometrial cancer. Due to its technical advantages, robotic-assisted laparoscopic surgery offers benefits, such as a lower rate of conversions compared to conventional laparoscopy. Yet, data on long-term oncological outcomes after robotic-assisted laparoscopy is scarce and based on retrospective cohort studies only. OBJECTIVE: This study aimed to assess overall survival, progression-free survival, and long-term surgical complications in patients with endometrial cancer randomly assigned to robotic-assisted or conventional laparoscopy. STUDY DESIGN: This randomized controlled trial was conducted at the Department of Gynecology and Obstetrics of Tampere University Hospital, Finland. Between 2010 and 2013, 101 patients with low-grade endometrial cancer scheduled for minimally invasive surgery were randomized preoperatively 1:1 either to robotic-assisted or conventional laparoscopy. All patients underwent laparoscopic hysterectomy, bilateral salpingo-oophorectomy, and pelvic lymphadenectomy. A total of 97 patients (49 in the robotic-assisted laparoscopy group and 48 in the conventional laparoscopy group) were followed up for a minimum of 10 years. Survival was analyzed using Kaplan-Meier curves, log-rank test, and Cox proportional hazard models. Binary logistic regression analysis was used to analyze risk factors for trocar site hernia. RESULTS: In the multivariable regression analysis, overall survival was favorable in the robotic-assisted group (hazard ratio 0.39; 95% confidence interval [CI], 0.15-0.99, P=.047) compared to the conventional laparoscopy group. There was no difference in progression-free survival (log-rank test, P=.598). The 3-, 5-, and 10-year overall survival were 98.0% (95% CI, 94.0-100) vs 97.9% (93.8-100), 91.8% (84.2-99.4) vs 93.7% (86.8-100), and 75.5% (64.5-87.5) vs 85.4% (75.4-95.4) for the conventional laparoscopy and the robotic-assisted groups, respectively. Trocar site hernia developed more often for the robotic-assisted group compared to the conventional laparoscopy group 18.2% vs 4.1% (odds ratio 5.42, 95% CI, 1.11-26.59, P=.028). The incidence of lymphocele, lymphedema, or other long-term complications did not differ between the groups. CONCLUSION: The results of this randomized controlled trial suggest a minor overall survival benefit in endometrial cancer after robotic-assisted laparoscopy compared to conventional laparoscopy. Hence, the use of robotic-assisted technique in the treatment of endometrial cancer seems safe, though larger randomized controlled trials are needed to confirm any potential survival benefit. No alarming safety signals were detected in the robotic-assisted group since the rate of long-term complications differed only in the incidence of trocar site hernia.

Introduction: Botulinum Toxin A is increasingly used as a preoperative adjunct in the management of complex abdominal wall hernias, particularly in those with wider defects and/or loss of domain. While its anatomical and surgical benefits have been documented, patient-reported outcomes remain underexplored. Methods: An international, retrospective, observational study was conducted using a structured, anonymised survey available in five languages (German, English, Polish, French, Spanish). The survey included nine closed-ended and one open-ended question assessing pain perception, mobility, respiratory, gastrointestinal, and urinary function, and changes in abdominal contour. It was distributed by medical teams and through patient support forums between 2024 and 2025. Patients included had received BTA injections 4-6 weeks prior to elective hernia surgery. Results: Seventy patients from multiple European centres completed the survey. Pain during injection was minimal in 71.5% of cases, with 85.7% reporting complete resolution of pain within 1-3 days. Most respondents (74.3%) experienced no breathing difficulties and only mild symptoms in 18.6%. Mobility remained unchanged in 80%, while 15.7% noted slight deterioration. Changes in urinary and bowel function were uncommon and mostly transient. Over half of patients reported visible changes in abdominal shape. No severe complications were identified. Conclusion: This international patient survey suggests that BTA injections as preoperative preparation for complex hernias is well tolerated, with limited perceived side effects and functional disruption. These findings support its continued use and prompts further prospective data collection.

OBJECTIVE: To evaluate the safety and efficacy of Keyless Abdominal Rope-Lifting Surgery (KARS), for tubal sterilization procedures in comparison with the conventional CO2 laparoscopy. MATERIAL AND METHODS: During a one-year period, 71 women underwent tubal ligation surgery. Conventional laparoscopy (N = 38) and KARS (N = 33) were used for tubal sterilization. In KARS, an abdominal access pathway through a single intra-abdominal incision was used to place transabdominal sutures that elevated the abdominal wall, and the operations were performed through the intraumbilical entry without the use of trocars. In CO2 laparoscopy, following the creation of the CO2 pneumoperitoneum a 10 mm trocar and two 5 mm trocars were introduced into the abdominal cavity. Tubal sterilizations were performed following the creation of the abdominal access pathways in both groups. The groups were compared with each other. RESULTS: All operations could be performed by KARS without conversion to CO2 laparoscopy or laparotomy. The mean operative time of the two groups was not significantly different (P > 0.05). Intra- and postoperative findings including complications, bleeding, and hospital stay time did not differ between groups (P > 0.05). CONCLUSION: KARS for tubal sterilization seems safe and effective in terms of cosmesis, postoperative pain, and early hospital discharge.

Background: Mesh suture, or Duramesh™, has recently gained attention because of potential advantages over conventional techniques for abdominal wall closure. However, the evidence base for any advantage has not been assessed formally. Via systematic review we evaluated clinical outcomes for mesh suture and its precursor, mesh strip, in clinical trials of abdominal wall closure or ventral hernia repair. Methods: A systematic search of MEDLINE, CENTRAL, Embase, Cochrane, WHO International Clinical Trials Registry, and ClinicalTrials.gov was conducted to identify studies using mesh suture and/or mesh strip. Primary outcome was incisional hernia occurrence after primary closure or recurrence following ventral hernia repair, summarised with median percentage rates. Secondary outcomes included surgical site occurrences and reoperations. Risk of bias was assessed using adapted forms of ROBINS-I and Cochrane RoB2 tools. Results: Five single-arm case series and one interim report from a randomised controlled trial were eligible for inclusion, reporting 585 patients. Median follow-up was 11.9 months (range 2.7-35.3 months). Median incisional hernia occurrence was 3.4% (range 0%-50%). Median surgical site occurrence was 17.4% (range 0%-50%) and surgical site infection 5.4% (range 0%-19%). Overall, 6.0% patients (33 of 553) returned to theatre to manage complications. Overall risk of bias for included studies was critical. Conclusion: This systematic review highlights a need for high-quality randomised controlled trials with long-term follow-up to evaluate the clinical benefits of Duramesh™ for abdominal wall closure and ventral hernia repair. Better evidence is required to determine its safety and clinical efficacy.

Tubal ligation (TL) is an effective and common method of fertility control. In the year 2009, over 24,000 were performed in Canada alone. Migration of Filshie clips used during TL is estimated to occur in 25% of all patients; 0.1-0.6% of these patients subsequently experience symptoms or extrusion of the clip from anatomical sites such as the anus, vagina, urethra, or abdominal wall. Migrated clips may present as chronic groin sinus, perianal sepsis, or chronic abdominal pain. These symptoms can occur as early as 6 weeks or as late as 21 years after application. We present the case of a 49-year-old female with a 3.5-year history of intermittent dull nonradiating left upper quadrant (LUQ) pain lasting on average 2-3 days. There were no other associated symptoms, and the longest pain-free period was 4 days. Her past medical history includes COPD, GERD, IBS, and depression. Current medications are only remarkable for Symbicort. Pertinent past surgical history includes laparoscopic tubal ligation with Filshie clips in 1999, followed by a vaginal hysterectomy in 2013. Migrated tubal ligation clip was noted on an abdominal X-ray. The patient was then referred for surgical management. Subsequent CT scan confirmed a solitary clip present adjacent to the left lobe of the liver. No other abnormalities were reported. Patient underwent laparoscopy for removal of the clip, which was identified to be underneath the left lobe of the liver embedded in the gastrohepatic omentum. Please see the video link provided. Postoperative pathology report confirmed the presence of a Filshie clip. Patient reported complete resolution of her LUQ pain at a 5-week and 3.5-month follow-up. This case shows that although symptomatic clip migration is a rare phenomenon, it should be given special consideration in women with unexplained chronic abdominal pain and a history of TL. Additionally, removal of clip can provide resolution of symptoms.

One of the most performed procedures in the specialty of oral and maxillofacial surgery is removal of impacted teeth, especially third molars. Impaction is defined as failure of teeth to erupt into the dental arch within the expected time [1,2]. The reasons for tooth impaction include several factors subdivided into a local and general factors such as position and size of adjacent teeth, dense overlying bone, excessive soft tissue or a genetic abnormality including abnormal eruption path, dental arch length and space in which to erupt [1-3]. Clinically and radiographically, there are two types of impactions namely complete and partial. Complete impaction means that the tooth is covered by bone and mucosa and is prevented from erupting into a normal functional position; partial impaction means that the tooth is partially visible or in communication with oral cavity, but it has failed to erupt fully into a normal position [1]. The most common impacted teeeth are mandibular and maxillary third molars, followed by the maxillary canines and mandibular premolars. New data suggests that 72,2% of the world population has at least one impacted tooth (usually lower third molar) [3,4]. From the last 40 years, the incidence of impacted teeth has grown through different populations, due to living habits such as soft food diet and lower intensity of the use of the masticatory apparatus [3]. Only a few decades earlier, Inuits and Latin American Indians were described as populations with no impacted teeth [1]. Some authors suggest that race and gender have an influence on occurrence of impactions; thus, the impactions are more common in Caucasians than in Negroes; and females are more predisposed to this phenomenon than males. The age of the patients also play an important role in impacted teeth occurrence. Patients between 20 and 30 years of age are the most frequently affected with symptomatic impactions [4-7]. As age

BACKGROUND: The four approaches to hysterectomy for benign disease are abdominal hysterectomy (AH), vaginal hysterectomy (VH), laparoscopic hysterectomy (LH) and robotic-assisted hysterectomy (RH). OBJECTIVES: To assess the effectiveness and safety of different surgical approaches to hysterectomy for women with benign gynaecological conditions. SEARCH METHODS: We searched the following databases (from inception to 14 August 2014) using the Ovid platform: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; EMBASE; Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. We also searched relevant citation lists. We used both indexed and free-text terms. SELECTION CRITERIA: We included randomised controlled trials (RCTs) in which clinical outcomes were compared between one surgical approach to hysterectomy and another. DATA COLLECTION AND ANALYSIS: At least two review authors independently selected trials, assessed risk of bias and performed data extraction. Our primary outcomes were return to normal activities, satisfaction, quality of life, intraoperative visceral injury and major long-term complications (i.e. fistula, pelvi-abdominal pain, urinary dysfunction, bowel dysfunction, pelvic floor condition and sexual dysfunction). MAIN RESULTS: We included 47 studies with 5102 women. The evidence for most comparisons was of low or moderate quality. The main limitations were poor reporting and imprecision. Vaginal hysterectomy (VH) versus abdominal hysterectomy (AH) (nine RCTs, 762 women)Return to normal activities was shorter in the VH group (mean difference (MD) -9.5 days, 95% confidence interval (CI) -12.6 to -6.4, three RCTs, 176 women, I(2) = 75%, moderate quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. Laparoscopic hysterectomy (LH) versus AH (25 RCTs, 2983 women)Return to normal activities was shorter in the LH group (MD -13.6 days, 95% CI -15.4 to -11.8; six RCTs, 520 women, I(2) = 71%, low quality evidence), but there were more urinary tract injuries in the LH group (odds ratio (OR) 2.4, 95% CI 1.2 to 4.8, 13 RCTs, 2140 women, I(2) = 0%, low quality evidence). There was no evidence of a difference between the groups for the other primary outcomes. LH versus VH (16 RCTs, 1440 women)There was no evidence of a difference between the groups for any primary outcomes. Robotic-assisted hysterectomy (RH) versus LH (two RCTs, 152 women)There was no evidence of a difference between the groups for any primary outcomes. Neither of the studies reported satisfaction rates or quality of life.Overall, the number of adverse events was low in the included studies. AUTHORS' CONCLUSIONS: Among women undergoing hysterectomy for benign disease, VH appears to be superior to LH and AH, as it is associated with faster return to normal activities. When technically feasible, VH should be performed in preference to AH because of more rapid recovery and fewer febrile episodes postoperatively. Where VH is not possible, LH has some advantages over AH (including more rapid recovery and fewer febrile episodes and wound or abdominal wall infections), but these are offset by a longer operating time. No advantages of LH over VH could be found; LH had a longer operation time, and total laparoscopic hysterectomy (TLH) had more urinary tract injuries. Of the three subcategories of LH, there are more RCT data for laparoscopic-assisted vaginal hysterectomy and LH than for TLH. Single-port laparoscopic hysterectomy and RH should either be abandoned or further evaluated since there is a lack of evidence of any benefit over conventional LH. Overall, the evidence in this review has to be interpreted with caution as adverse event rates were low, resulting in low power for these comparisons. The surgical approach to hysterectomy should be discussed and decided in the light of the relative benefits and hazards. These benefits and hazards seem to be dependent on surgical expertise and this may influence the decision. In conclusion, when VH is not feasible, LH may avoid the need for AH, but LH is associated with more urinary tract injuries. There is no evidence that RH is of benefit in this population. Preferably, the surgical approach to hysterectomy should be decided by the woman in discussion with her surgeon.

BACKGROUND: Excessive tool-tissue interaction forces often result in tissue damage and intraoperative complications, while insufficient forces prevent the completion of the task. This review sought to explore the tool-tissue interaction forces exerted by instruments during surgery across different specialities, tissues, manoeuvres and experience levels. MATERIALS & METHODS: A PRISMA-guided systematic review was carried out using Embase, Medline and Web of Science databases. RESULTS: Of 462 articles screened, 45 studies discussing surgical tool-tissue forces were included. The studies were categorized into 9 different specialities with the mean of average forces lowest for ophthalmology (0.04N) and highest for orthopaedic surgery (210N). Nervous tissue required the least amount of force to manipulate (mean of average: 0.4N), whilst connective tissue (including bone) required the most (mean of average: 45.8). For manoeuvres, drilling recorded the highest forces (mean of average: 14N), whilst sharp dissection recorded the lowest (mean of average: 0.03N). When comparing differences in the mean of average forces between groups, novices exerted 22.7% more force than experts, and presence of a feedback mechanism (e.g. audio) reduced exerted forces by 47.9%. CONCLUSIONS: The measurement of tool-tissue forces is a novel but rapidly expanding field. The range of forces applied varies according to surgical speciality, tissue, manoeuvre, operator experience and feedback provided. Knowledge of the safe range of surgical forces will improve surgical safety whilst maintaining effectiveness. Measuring forces during surgery may provide an objective metric for training and assessment. Development of smart instruments, robotics and integrated feedback systems will facilitate this.

Purpose: Overlapped delta-shaped anastomosis is a newly developed intracorporeal procedure in totally laparoscopic surgery for colon cancer. We explored the safety and efficacy of three-dimensional (3D) totally laparoscopic surgery for colon cancer using overlapped anastomosis and compared its short-term outcomes with those of two-dimensional (2D) surgery. Materials and methods: From January 2016 to March 2018, 97 colon cancer patients were grouped into the 3D group (43 patients) and the 2D group (54 patients); they underwent totally laparoscopic surgery for colon cancer using overlapped anastomosis by 3D and 2D laparoscopy, respectively. Data regarding the clinical characteristics, surgical and pathological outcomes, postoperative recovery and complications were collected and compared. Results: These two groups were well balanced in terms of age, gender, body mass index, American Society of Anesthesiologists scores, previous abdominal operation history and preoperative chemotherapy ( P >0.05). The overall operation time, intraoperative blood loss and removal method of the specimen were similar between groups ( P >0.05), but the anastomosis time was significantly shorter in the 3D group than that in the 2D group ( P =0.004). There were no differences in terms of pathological outcomes, postoperative recovery and the postoperative complication rates between the groups ( P >0.05). Moreover, no mobility related to the anastomosis, such as anastomotic bleeding, stenosis or leakage, occurred in any patient. Conclusion: 3D totally laparoscopic surgery for colon cancer using overlapped delta-shaped anastomosis is safe and effective, with satisfactory short-term outcomes. In addition, it is less time-consuming than 2D surgery regarding the overlapped anastomosis procedure. Keywords: minimally invasive surgery, three-dimensional laparoscopy, intracorporeal anastomosis, colon neoplasms

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