Routine closed-suction drainage reduces seromas following totally extraperitoneal (TEP) inguinal hernia repair: A meta-analysis.

BACKGROUND: The value of prophylactic closed-suction drainage in totally extraperitoneal inguinal hernia repair (TEP) is still a matter of controversy. We conducted a meta-analysis of studies examining postoperative seroma rates in patients with or without routine placement of closed-suction drainage tubes. METHODS: A systematic literature search was conducted for trials comparing the outcome of TEP with or without routine drainage placement. Data regarding postoperative outcomes were extracted and compared by meta-analysis. The odds ratio and standardized mean differences with 95% confidence intervals were calculated. RESULTS: Four studies were identified, involving a total of 1626 cases (Drain: n = 1251, no Drain: n = 375). There was a statistically significant difference noted between the 2 groups regarding postoperative seroma formation favoring the Drain group (odds ratio = 0.12; 95% confidence intervals [0.05, 0.29]; P < .001; 4 studies; I2 = 72%). For the remaining secondary endpoints postoperative urinary retention, recurrence, mesh infection and in-hospital length of stay no statistically significant difference was noted between the 2 study groups. CONCLUSION: Current evidence suggests that patients who underwent TEP with routine closed-suction drain placement developed significantly fewer seromas without any additional morbidity or prolongation of in-hospital stay.

Pain management after tonsil surgery in children and adults-A national survey related to pain outcome measures from the Swedish Quality Register for tonsil surgery.

OBJECTIVE: The primary aim of this study was to describe the current practice regarding pain management in relation to tonsil surgery among Ear Nose and Throat (ENT) clinics in Sweden. The secondary aim was to determine the impact of the provider's regime of rescue analgesics on the pain related Patient Reported Outcome Measures (pain-PROMs) from the Swedish Quality Register for Tonsil Surgery (SQTS). MATERIALS & METHODS: A descriptive cross-sectional study originating from a validated web-based questionnaire. The survey enrolled one respondent from each ENT clinic (47/48 participated) nationally. Pain-PROMs from the SQTS, recorded from October 2019 to October 2022, were included (8163 tonsil surgeries). RESULTS: Paracetamol was used by all enrolled ENT clinics as preemptive analgesia. The addition of COX inhibitors was used in 40% of the clinics. Betamethasone was usually administered, to prevent pain and nausea (92%). All clinics gave postdischarge instructions on multimodal analgesia with COX inhibitors and paracetamol. Rescue analgesics were prescribed after tonsillectomy for 77% of adults, 62% of older children, 43% of young children and less often after tonsillotomy. The most frequently prescribed rescue analgesic was clonidine in children (55%) and oxycodone in adults (72%). A high proportion of patients reported contact with health care services due to postoperative pain (pain-PROMs/ SQTS). Tonsillectomy procedures were associated with the highest rates of contacts (children/adolescents 13-15%; adults 26%), while tonsillotomy were associated with lower rates, (5-7% of children/adolescents). There was no significant difference in the frequency of health care contacts due to pain regarding whether clinics routinely prescribed rescue analgesics or not after tonsillectomy. CONCLUSION: The Swedish analgesic regimen after tonsil surgery is good overall. Nevertheless, there is a need for increased awareness and knowledge to achieve optimal patient recovery. Pain-PROM data demonstrate the call for improvement in pain management after tonsil surgery.

Factors related to post-thoracotomy pain following robotic-assisted thoracic surgery.

BACKGROUND: Robotic-assisted thoracic surgery (RATS) is a minimally invasive procedure; however, some patients experience persistent postoperative pain. This study aimed to investigate factors related to postoperative pain following RATS. METHODS: The data of 145 patients with lung cancer, who underwent RATS with a four-port (one in the sixth intercostal space [ICS] and three in the eighth ICS) lobectomy or segmentectomy between May 2019 and December 2022, were retrospectively analyzed. Factors associated with analgesic use for at least 2 months following postoperative pain (PTP group) were analyzed. RESULTS: Patients who underwent preoperative pain control for any condition or chest wall resection were excluded. Among the 138 patients, 45 (32.6%) received analgesics for at least 2 months after surgery. Patient height and transverse length of the thorax correlated with PTP in the univariate analysis (non-PTP vs. PTP; height, 166 vs. 160 cm; p < .001; transverse length of the thorax, 270 vs. 260 mm, p = .016). In the multivariate analysis, height was correlated with PTP (p = .009; odds ratio, 0.907; 95% confidence interval, 0.843-0.976). Height correlated with the transverse length of the thorax (r = .407), anteroposterior length of the thorax (r = .294), and width of the eighth ICS in the middle axillary line (r = .210) using Pearson's correlation coefficients. When utilizing a 165-cm cutoff value for height to predict PTP using receiver operating characteristic curve analysis, the area under the curve was 0.69 (95% confidence interval, 0.601-0.779). CONCLUSION: Short stature is associated with a high risk of postoperative pain following RATS.

Transvaginal natural orifice transluminal endoscopic surgery for myomectomy: A more suitable surgical approach for enhanced recovery after surgery.

OBJECTIVE: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is widely recognized for its potential benefits, including reducing post-surgical pain and leaving no discernible scarring. However, the anatomical specificity of the vNOTES approach may elevate the risk of nearby organ damage, such as the rectum and bladder. Thus, this study aims to demonstrate the safety and relative merits of vNOTES over transumbilical laparoendoscopic single-site surgery (LESS). METHODS: The Longitudinal Vaginal Natural Orifice Transluminal Endoscopic Surgery Study (LovNOTESS), which was conducted in Chengdu, China. A total of 110 patients who underwent myomectomy in vNOTES or LESS from January 2021 to December 2022. This study prospectively collected and compared perioperative and follow-up data of the two groups. RESULTS: In the vNOTES group, patients had shorter postoperative anal exhaust time, lower pain medications use rate, shorter hospital stay but higher intraoperative conversion rate, and higher postoperative fever rate. vNOTES decreased the anal exhaust time by approximately 8.7 h (95 %CI: -16.182, -1.262, p = 0.007). Moreover, vNOTES reduces pain medication use risk by 73.1 % (OR: 0.269, 95 %CI: 0.172, 0.318, p = 0.016). CONCLUSION: Relative to LESS, vNOTES can make patients mitigate postoperative discomfort, accelerate the recovery of gastrointestinal function, curtail hospitalization duration, and enable a more rapid return to daily activities in myomectomy. However, vNOTES has a higher risk of surgical conversion and adjacent organ injury. Therefore, larger scale prospective studies are needed to prove its security and promote the widespread application of vNOTES in myomectomy.

Impact of superior hypogastric nerve block during uterine fibroid embolisation on pain scores, opioid requirements, and same-day discharge: a case-control study.

AIM: To assess the safety and efficacy of superior hypogastric nerve block (SHNB) in managing periprocedural pain associated with uterine fibroid embolisation (UFE) and in facilitating same-day discharge. MATERIALS AND METHODS: Prospectively enrolled case-control study with retrospective analysis comprising 119 eligible patients who underwent UFE for symptomatic fibroids was undertaken at a UK teaching hospital between January 2016 and September 2022. SHNB was administered to 62 participants in addition to systemic analgesia; 57 participants received systemic analgesia alone. SHNB was performed mid-UFE using 20 ml of 0.25% levobupivacaine. Pain scores were assessed using an 11-point (0-10) verbal numerical rating scale (NRS). The study received research and ethics committee approval. Statistical analysis was performed using the chi-square and independent t-test or Mann-Whitney U-test. A p-value of <0.05 defined significance. RESULTS: Participants who received SHNB experienced significantly less pain during the first 6 h post-procedure (averaged median pain score 2.6 versus 3.8, p=0.031). SHNB reduced the proportion of participants requiring post-procedural anti-emetics (45% versus 63%, p<0.05). For participants entered on the day-case pathway (SHNB = 34, no-SHNB = 16), those who received SHNB had a higher rate of successful same-day discharge (62% versus 31%, p=0.044). This SHNB group required significantly less opioids for periprocedural pain relief (median oral morphine equivalents; 44 mg versus 80 mg, p=0.020). No SHNB-related adverse events occurred. CONCLUSION: SHNB is safe and effective in reducing perioperative pain, opioid requirements, and anti-emetic use in patients undergoing UFE for symptomatic fibroids. SHNB, as an adjunct to analgesic optimisation, facilitates same-day discharge, which is often limited by severe post-embolisation pain.

Laparoscopic appendectomy with single port vs conventional access: systematic review and meta-analysis of randomized clinical trials.

BACKGROUND: Conventional three-access laparoscopic appendectomy (CLA) is currently the gold standard treatment, however, Single-Port Laparoscopic Appendectomy (SILA) has been proposed as an alternative. The aim of this systematic review/meta-analysis was to evaluate safety and efficacy of SILA compared with conventional approach. METHODS: Per PRISMA guidelines, we systematically reviewed randomised controlled trials (RCTs) comparing CLA vs SILA for acute appendicitis. The randomised Mantel-Haenszel method was used for the meta-analysis. Statistical data analysis was performed with the Review Manager software and the risk of bias was assessed with the Cochrane "Risk of Bias" assessment tool. RESULTS: Twenty-one studies (RCTs) were selected (2646 patients). The operative time was significantly longer in the SILA group (MD = 7,32), confirmed in both paediatric (MD = 9,80), (Q = 1,47) and adult subgroups (MD = 5,92), (Q = 55,85). Overall postoperative morbidity was higher in patients who underwent SILA, but the result was not statistically significant. In SILA group were assessed shorter hospital stays, fewer wound infections and higher conversion rate, but the results were not statistically significant. Meta-analysis was not performed about cosmetics of skin scars and postoperative pain because different scales were used in each study. CONCLUSIONS: This analysis show that SILA, although associated with fewer postoperative wound infection, has a significantly longer operative time. Furthermore, the risk of postoperative general complications is still present. Further studies will be required to analyse outcomes related to postoperative pain and the cosmetics of the surgical scar.

Comparison of modified tumescent and conventional laparoscopic transabdominal preperitoneal inguinal hernia repair: a retrospective clinical study.

OBJECTIVE: Laparoscopic transabdominal preperitoneal (TAPP) inguinal hernia repair poses certain challenges to less experienced surgeons. This study was performed to compare the clinical outcomes of modified tumescent laparoscopic TAPP (MT-TAPP) inguinal hernia repair versus conventional laparoscopic TAPP (CL-TAPP) inguinal hernia repair. METHODS: We retrospectively analyzed the perioperative data of patients with inguinal hernias who underwent either MT-TAPP repair (n = 57) or CL-TAPP repair (n = 54) at the General Surgery Department of Nanjing Yimin Hospital from November 2019 to June 2023. RESULTS: The durations of the total operation and the preperitoneal space dissection were shorter in the MT-TAPP than CL-TAPP group. The estimated blood loss volume was lower in the MT-TAPP than CL-TAPP group. The visual analogue scale scores recorded at the 12- and 24-hour postoperative time points showed significantly greater reductions in the MT-TAPP than CL-TAPP group. CONCLUSIONS: Using liquid injection and gauze dissection is both safe and practical. This technique results in a shortened total operation time, less time spent on preperitoneal space dissection, decreased estimated blood loss, and less severe postoperative pain.

Perioperative outcomes for single-port robotic versus single-incision laparoscopic surgery: a comparative analysis in colorectal cancer surgery.

BACKGROUND: Single-incision laparoscopic surgery (SILS) may offer improved cosmesis, reduced postoperative pain and faster recovery than conventional platforms, but widespread implementation was limited by technical demands. A single-port robotic platform was recently introduced, with components that further enhance SILS benefits without the technical challenges. No study to date has compared the two platforms to validate benefits. Our goal was to compare outcomes of SP robotics and SILS in colorectal cancer (CRC). METHODS: A prospective cancer registry was reviewed for CRC patients undergoing curative resection through a SILS or SP robotic approach from 2010 to 2022. Patient and cancer demographics, intraoperative, and postoperative outcomes were compared in a 1:1 propensity score-matched cohort, adjusting for baseline characteristics. The main outcome measures were complications, operative time, and oncologic quality measures. RESULTS: Matching resulted 50 SP robotic and 50 SILS patients. Cohorts were well matched in all demographics, but SP robotic rectal cancer cases were significantly closer to the anorectal ring than SILS (1.8 cm vs. 3.4 cm, p = 0.018). SP robotic and SILS platforms had similar operative times. Intraoperative conversions was comparable, but more SILS cases required additional ports to be placed (p = 0.040). The intraoperative complications rate, complete total mesorectal excision rates, and lymph node yield were not statistically significantly different. There were no positive margins in either group. Postoperatively, groups had analogous day of return of bowel function, comparable morbidity, and discharge destination. There was no mortality in either group. The length of stay was significantly shorter with SP robotics than SILS (mean 4.135 vs. 5.282 days, median 4 (2-8) vs. 5 (2-14) days; p = 0.045). CONCLUSIONS: Single-port robotics provided high quality oncologic surgery, adding the technical benefits of robotics to clinical and cosmetic benefits of single-port surgery. There were comparable operative time, complication rates, and oncologic outcomes in CRC cases, with shorter hospital stays with SP robotics. This early data is encouraging for expansion SP robotic technology.

Comparison of postoperative pain between transoral and conventional thyroidectomy: a propensity score-matched analysis.

BACKGROUND: The extent of postoperative pain following transoral thyroidectomy is not well-understood and remains a subject of debate. This study aims to analyze and compare postoperative pain levels between patients undergoing transoral and conventional transcervical thyroidectomy. METHODS: A prospective evaluation on postoperative pain was conducted in 310 patients undergoing conventional thyroidectomy and 194 undergoing transoral thyroidectomy. Pain levels were evaluated using the numerical rating scale (NRS, ranging from 0 to 10) through preoperative and postoperative questionnaires at specified time points: 1, 3, and 6 days, and 1 and 3 months following surgery. Propensity score-matched analysis was carried out based on six covariates: sex, age, body mass index, extent of thyroidectomy, tumor size, and central neck dissection. RESULTS: After propensity score matching based on the six covariates, 121 patient pairs were identified from each group. Within this matched cohort, postoperative pain scores significantly worsened 1 day after surgery but showed progressive recovery up to 3 months post-surgery in both groups. The transoral group exhibited higher postoperative pain scores than the conventional group from day 1 (4.43 ± 2.6 vs. 3.11 ± 2.5, p < 0.001) to day 6 (1.76 ± 1.9 vs. 1.13 ± 1.6, p = 0.016) post-surgery, with no significant difference noted at 1 month. Among transoral procedures, pain scores were significantly higher for the endoscopic approach compared to the robotic approach on days 1 (5.52 ± 2.3 vs. 4.29 ± 2.3, p = 0.028) and 3 (3.52 ± 2.5 vs. 2.64 ± 2.0, p = 0.047) post-surgery. CONCLUSIONS: Postoperative pain was significantly higher in transoral thyroidectomy compared to conventional thyroidectomy up to 6 days post-surgery. Within the transoral group, the robotic procedure resulted in lower pain levels than the endoscopic approach during the early postoperative period.

Laparoscopic vs. ultrasound-guided transversus abdominis plane (TAP) block in colorectal surgery: a systematic review and meta-analysis of randomized trials.

BACKGROUND: The transversus abdominis plane block (TAPB) is effective for postoperative pain management in patients undergoing colorectal surgery. However, evidence regarding the optimal delivery method, either laparoscopic (L-TAPB) or ultrasound-guided (U-TAPB) is lacking. Our study aimed to compare the effectiveness of these delivery methods. METHODS: We carried out a literature search of PubMed, Cochrane Library, Web of Science, and Google Scholar databases to include randomized studies comparing patients receiving either L-TAPB or U-TAPB during minimally invasive colorectal surgery. The primary endpoint was opioid consumption in the first 24 h after surgery. Risk of bias was assessed with the RoB-2 tool. Effect size was estimated for each study with 95% confidence interval and overall effect measure was estimated with a random effect model. RESULTS: The literature search revealed 294 articles, of which four randomized trials were eligible. A total of 359 patients were included, 176 received a L-TAPB and 183 received a U-TAPB. We established the non-inferiority of L-TAPB, as the absolute difference of - 2.6 morphine-mg (95%CI - 8.3 to 3.0) was below the pooled non-inferiority threshold of 8.1 morphine-mg (low certainty level). No difference in opioid consumption was noted at 2, 6, 12, and 48 h (low to very low certainty level). Postoperative pain, nausea and vomiting were similar between groups at different timepoints (low to very low certainty level). No TAPB-related complications were recorded. Finally, the length of hospital stay was similar between groups. CONCLUSION: For postoperative multimodal analgesia both L-TAPB and U-TAPB may result in little to no difference in outcome in patients undergoing colorectal surgery. Registration Prospero CRD42023421141.

Epididymectomy Is an Effective Treatment for Chronic Epididymal Pain.

INTRODUCTION: Chronic scrotal pain is difficult to manage, and epididymectomy is a treatment option for a subset of men with pain localized to the epididymis. We sought to evaluate the efficacy of epididymectomy at our institution. METHODS: Between 2000 and 2020, 225 men underwent epididymectomy at our institution for pain localized to the epididymis and not part of a greater constellation of pelvic pain or urinary symptoms. Our primary outcome measure was change in pain after epididymectomy, categorized as cured/improved or no change/worsened. Multivariable logistic regression compared the impact of pain duration, and surgical and psychiatric histories on postoperative pain. RESULTS: Patients in both outcome categories-cured/improved and no change/worsened-were similar in age and BMI. Overall, 162 patients (72%) reported cured/improved pain at the last documented follow-up visit. Median follow-up time was 12 (IQR 1-364) weeks. About half of the cohort (n = 117, 52%) had a prior vasectomy, and there was no difference in outcome based on vasectomy history on multivariate analysis (OR 0.625, P = .3). Men with pain duration > 1 year (OR 0.46, P = .03), diagnosed psychiatric conditions (OR 0.44, P = .04), or prior scrotal/inguinal/abdominal surgeries other than vasectomy (OR 0.47, P = .03) had decreased odds of pain relief after epididymectomy. CONCLUSIONS: This 20-year analysis is the largest review of postepididymectomy outcomes reported. Among carefully screened men, 72% had resolution or improvement of scrotal pain. Epididymectomy is most effective for men with < 1 year of focal epididymal pain, with no history of psychiatric conditions or scrotal/inguinal/abdominal surgery other than vasectomy.

Prediction of successful revision surgery for mesh-related complaints after inguinal hernia and pelvic organ prolapse repair.

PURPOSE: With this retrospective case series, we aim to identify predictors for reduction of pain after mesh revision surgery in patients operated for inguinal hernia or pelvic organ prolapse with a polypropylene implant. Identifying these predictors may aid surgeons to counsel patients and select appropriate candidates for mesh revision surgery. METHODS: Clinical records before and after mesh revision surgery from 221 patients with chronic postoperative inguinal pain (CPIP) and 59 patients with pain after pelvic organ prolapse (POP) surgery were collected at two experienced tertiary referral centers. Primary outcome was patient reported improvement of pain after revision surgery. A multivariable logistic regression model was used to specify predictors for pain reduction. RESULTS: The multivariable logistic regression was performed for each patient group separately. Patients with CPIP had higher chances of improvement of pain when time between mesh placement and mesh revision surgery was longer, with an OR of 1.19 per year. A turning point in chances of risks and benefits was demonstrated at 70 months, with improved outcomes for patients with revision surgery ≥ 70 months (OR 2.86). For POP patients, no statistically significant predictors for reduction of pain after (partial) removal surgery could be identified. CONCLUSION: A longer duration of at least 70 months between implantation of inguinal mesh and revision surgery seems to give a higher chance on improvement of pain. Caregivers should not avoid surgery based on a longer duration of symptoms when an association between symptoms and the location of the mesh is found.

Risk Factors of Acute Pain in Elderly Patients After Laparoscopic Radical Resection of Colorectal Cancer.

OBJECTIVE: To investigate the risk factors of acute pain after laparoscopic radical resection of colorectal cancer (CRC) in elderly patients. METHODS: Totally, 143 elderly patients (≥ 60 y old) who received laparoscopic radical resection of CRC in the People's Hospital of Xinjiang Uygur Autonomous Region from March 2021 to August 2022 were retrospectively analyzed. The patients were divided into 2 groups according to visual analog scale (VAS) scores 24 h after surgery: mild pain group (VAS score ≤ 3, n=108) and moderate to severe pain group (VAS score >3, n=35). The data of the patients, including sex, age, height, body mass, intraoperative blood loss, intraoperative urine volume, intraoperative opioid dosage, operation duration, preoperative Hospital Anxiety and Depression Scale (HADS) scores, preoperative Mini-Mental State Examination scores, VAS scores, postoperative nausea and vomiting scores were recorded. Multivariate logistic regression analysis was used to screen the risk factors of postoperative acute pain in elderly patients undergoing laparoscopic radical resection of CRC. RESULTS: The preoperative HADS score of the moderate to severe pain group was significantly increased compared with that of the mild pain group (10.8±2.4 vs. 6.2±1.9), as well as the operation duration (226.4±18.3 vs. 186.1±12.7), the intraoperative dosage of remifentanil (3.7±0.2 vs. 3.2±0.4), the preoperative VAS score [4(2, 7) vs. 2 (0, 4)] and postoperative VAS score [5 (4, 6) vs. 3 (2, 3)] ( P <0.05). Multivariate logistic regression analysis showed that high preoperative HADS score, long operation duration, and high preoperative VAS score ( P <0.05) were independent risk factors for acute pain after laparoscopic radical resection of CRC in elderly patients. CONCLUSION: Preoperative anxiety and depression, preoperative pain, and long operation duration are risk factors for acute pain in elderly patients after laparoscopic radical resection of CRC.

Incidence and risk factors of metachronous contralateral inguinal hernia development up to 25 years after unilateral inguinal hernia repair: a single-centre retrospective cohort study.

BACKGROUND: Patients undergoing unilateral inguinal hernia repair (IHR) are at risk of metachronous contralateral inguinal hernia (MCIH) development. We evaluated incidence and risk factors of MCIH development up to 25 years after unilateral IHR to determine possible indications for concomitant prophylactic surgery of the contralateral groin at the time of primary surgery. METHODS: Patients between 18 and 70 years of age undergoing elective unilateral IHR in the University Hospital of Leuven from 1995 to 1999 were studied retrospectively using the electronic health records and prospectively via phone calls. Study aims were MCIH incidence and risk factor determination. Kaplan-Meier curves were constructed and univariable and multivariable Cox regressions were performed. RESULTS: 758 patients were included (91% male, median age 53 years). Median follow-up time was 21.75 years. The incidence of operated MCIH after 5 years was 5.6%, after 15 years 16.1%, and after 25 years 24.7%. The incidence of both operated and non-operated MCIH after 5 years was 5.9%, after 15 years 16.7%, and after 25 years 29.0%. MCIH risk increased with older age and decreased in primary right-sided IHR and higher BMI at primary surgery. CONCLUSION: The overall incidence of MCIH after 25-year follow-up is 29.0%. Potential risk factors for the development of a MCIH are primary left-sided inguinal hernia repair, lower BMI, and older age. When considering prophylactic repair, we suggest a patient-specific approach taking into account these risk factors, the surgical approach and the risk factors for chronic postoperative inguinal pain.

Enhanced recovery after robotic ventral hernia repair: factors associated with overnight stay in hospital.

PURPOSE: Enhanced recovery after surgery (ERAS) protocols lead to reduced post-operative stay and improved outcomes after most types of abdominal surgery. Little is known about the optimal post-operative protocol after robotic ventral hernia repair (RVHR), including the potential limits of outpatient surgery. We report the results of an ERAS protocol after RVHR aiming to identify factors associated with overnight stay in hospital, as well as patient-reported pain levels in the immediate post-operative period. METHODS: This was a prospective cohort study of consecutive patients undergoing RVHR. Patients were included in a prospective database, registering patient characteristics, operative details, pain and fatigue during the first 3 post-operative days and pre- and 30-day post-operative hernia-related quality of life, using the EuraHS questionnaire. RESULTS: A total of 109 patients were included, of which 66 (61%) underwent incisional hernia repair. The most performed procedure was TARUP (robotic transabdominal retromuscular umbilical prosthetic hernia repair) (60.6%) followed by bilateral roboTAR (robotic transversus abdominis release) (19.3%). The mean horizontal fascial defect was 4.8 cm, and the mean duration of surgery was 141 min. In total, 78 (71.6%) patients were discharged on the day of surgery, and factors associated with overnight stay were increasing fascial defect area, longer duration of surgery, and transverse abdominis release. There was no association between post-operative pain and overnight hospital stay. The mean EuraHS score decreased significantly from 38.4 to 6.4 (P < 0.001). CONCLUSION: An ERAS protocol after RVHR was associated with a high rate of outpatient procedures with low patient-reported pain levels.

Evaluating mesh fixation techniques for ventral hernia repair: A systematic review and network meta-analysis of randomised control trials.

INTRODUCTION: There is uncertainty regarding the optimal mesh fixation techniques for laparoscopic ventral and incisional hernia repair. AIM: To perform a systematic review and network meta-analysis of randomised control trials (RCTs) to investigate the advantages and disadvantages associated with absorbable tacks, non-absorbable tacks, non-absorbable sutures, non-absorbable staples, absorbable synthetic glue, absorbable sutures and non-absorbable tacks, and non-absorbable sutures and non-absorbable tacks. METHODS: A systematic review was performed as per PRISMA-NMA guidelines. Odds ratios (ORs) and mean differences (MDs) were extracted to compare the efficacy of the surgical approaches. RESULTS: Nine RCTs were included with 707 patients. Short-term pain was significantly reduced in non-absorbable staples (MD; -1.56, confidence interval (CI); -2.93 to -0.19) and non-absorbable sutures (MD; -1.00, CI; -1.60 to -0.40) relative to absorbable tacks. Recurrence, length of stay, operative time, conversion to open surgery, seroma and haematoma formation were unaffected by mesh fixation technique. CONCLUSION: Short-term post-operative pain maybe reduced by the use of non-absorbable sutures and non-absorbable staples. There is clinical equipoise between each modality in relation to recurrence, length of stay, and operative time.

High-Intensity Progressive Rehabilitation Versus Routine Rehabilitation After Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: This study aimed to compare the effectiveness of high-intensity progressive rehabilitation training with routine training in the early treatment of patients undergoing total knee arthroplasty. METHODS: There were 78 patients who underwent total knee arthroplasty and were randomized into high-intensity progressive training and routine rehabilitation training groups (RRT). The primary outcome measures were the American Hospital for Special Surgery Knee Score (HSS), with secondary outcomes including patient satisfaction, visual analog pain score, first time of standing after surgery, 6-minute walk test, 36-Item Short Form Survey (SF-36), and length of hospital stay. The incidence of postoperative complications were recorded. RESULTS: The HSS scores were higher in the intervention group at 2 weeks, 3 months, and 12 months postoperatively (P < .001). The RRT group had higher visual analog pain scores than the intervention group at 24 hours, 3 days, and 2 weeks after surgery (P < .001). The intervention group had an earlier the first time of standing after surgery and a longer 6-minute walk test distance (P < .001, P = .028, P < .001, P < .001). Patient satisfaction was higher in the intervention group, with a higher quality of life rating at 3 months postoperatively (P < .001). However, 1 year after surgery, the 2 groups had no significant differences in mental component summaries. The length of hospital stay was shorter in the intervention group than in the RRT group. CONCLUSION: Compared to routine training, high-intensity progressive rehabilitation training is more effective. It reduces postoperative patient pain, accelerates recovery of joint function, increases patient satisfaction, improves quality of life, shortens hospital stays, and promotes rapid recovery.

Safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in pioneering hospitals in Japan: A nationwide retrospective cohort study.

INTRODUCTION: We aimed to evaluate the safety and short-term outcomes of robotic-assisted transabdominal preperitoneal repair for inguinal hernia in 12 pioneering hospitals in Japan. METHODS: Clinical data of patients who underwent robotic-assisted transabdominal preperitoneal repair between September 1, 2016, and December 31, 2021 were collected. Primary outcome measures were intra-operative adverse events and post-operative complications, whereas secondary outcomes were surgical outcomes, including chronic pain, recurrence, and learning curve. RESULTS: In total, 307 patients were included. One case of inferior epigastric arterial injury was reported; no cases of bowel or bladder injury were reported. Thirty-five seromas were observed, including four (1.3%) cases that required aspiration. The median operative time of a unilateral case was 108 minutes (interquartile range: 89.8-125.5), and post-operative pain was rated 1 (interquartile range: 0-2) on the numerical rating scale. In complicated cases, such as recurrent inguinal hernias and robotic-assisted radical prostatectomy-associated hernias, dissection and suture were safely achieved, and no complications were observed, except for non-symptomatic seroma. All patients underwent robotic procedures, and there was no chronic post-operative inguinal pain, although one case of hernia recurrence was reported. Regarding the learning curve, plateau performance was achieved after 7-10 cases in terms of operative time (P < .001). CONCLUSION: Robotic-assisted transabdominal preperitoneal repair can be safely introduced in Japan. Regardless of the involvement of many surgeons, the mastery of robotic techniques was achieved relatively quickly. The advantage of robotic technology such as wristed instruments may expand the application of minimally invasive hernia repair for complicated cases.

Intercostal nerve cryoablation reduces opioid utilization after thoracotomy in children with cancer.

BACKGROUND: Intercostal nerve cryoablation (INC) has shown promise as an adjunct method for analgesia in adults undergoing thoracotomy, but has yet to be widely used in children for this indication. We hypothesize that INC decreases opioid utilization in children undergoing thoracotomy for cancer operations. METHODS: A retrospective review was performed of children who underwent thoracotomy for cancer diagnosis at a freestanding children's hospital from 2018 to 2023. Patient characteristics, intraoperative data, and data on clinical course were collected. Patients were divided into those who underwent INC and those who underwent routine care for comparison. RESULTS: Twenty-six patients underwent 38 procedures at a median age of 16 years (range 5-21 years). INC was performed in 23 cases over a median of five intercostal levels (range 2-7). Total oral morphine equivalents during inpatient admission were significantly lower in INC patients (137.6 vs. 514.5 mg, p = .002). Routine care patients were more likely to be discharged with an opioid prescription (30.4% vs. 80.0%, p = .008). Length of stay was similar between patients with INC and routine care (4 vs. 5 days, p = .15). There were no differences in rates of reoperation or 30-day re-admission (emergency department or inpatient). CONCLUSTIONS: INC is a feasible and safe adjunct for children undergoing thoracotomy for cancer. INC is associated with reduced postoperative opioid utilization with respect to both inpatient use and outpatient prescriptions.