Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 4 appraisals
Hernia : the journal of hernias and abdominal wall surgery
Two-dimensional vs. three-dimensional laparoscopic transabdominal preperitoneal (TAPP) hernia repair: a systematic review and meta-analysis
BACKGROUND: Two-dimensional (2D) laparoscopy provides limited depth perception, which may limit performance during technically demanding operations. Three-dimensional (3D) systems offer stereoscopic vision, improving visualization. We compared 3D versus 2D systems in adults for operative time, visualization, and postoperative complications. METHODS: PubMed, Scopus, Web of Science, and Cochrane were searched through December 2025. We included randomized controlled trials and observational studies of patients undergoing TAPP repair, comparing 3D with 2D laparoscopy. Total operative time was the primary outcome; visualization and postoperative complications were secondary outcomes. Risk of bias was assessed using RoB 2 and the Newcastle-Ottawa Scale, and certainty of evidence using GRADE. RESULTS: Six studies met the inclusion criteria; five were included in the primary meta-analysis (n = 521 patients). Total operative time favored 3D (MD-18.48 min; 95% CI-29.27,-7.69; p = 0.0008), with substantial heterogeneity (I²=94%). Subgroup analysis also favored 3D in RCTs (MD-11.70; 95% CI-17.74,-5.66) and observational studies (MD-26.85; 95% CI-30.55,-23.15). Contrast favored 3D (MD 2.11; 95% CI 0.56, 3.67; p = 0.008), while sharpness was not statistically different (MD 1.49; 95% CI-0.25 to 3.24; p = 0.09). No difference in postoperative complications (MD 1.11; 95% CI 0.75, 1.65; p = 0.59). CONCLUSION: 3D laparoscopy has been proposed to improve visualization and shorten operative time; however this should be interpreted with caution due to very low certainty of evidence and variability in surgeon experience. REGISTRATION/FUNDING: PROSPERO CRD420251272842.
28 May 2026
Read appraisal →Hernia : the journal of hernias and abdominal wall surgery
Impact of the SUture BIte TEchnique on clinical outcomes after midline laparotomy closure: SUBITE-a systematic review and meta-analysis
BACKGROUND: The objective of this Systematic Review and Meta-Analysis (SR/MA) was to identify the best suture technique (short or large bites) for abdominal wall closure with respect to relevant outcome parameters such as incisional hernia (IH), surgical site infection (SSI) and linea alba (aponeurotic layer of the abdominal wall) dehiscence (LAD). METHODS: Registration was done in PROSPERO, a systematic literature search was performed in three data bases (PubMed, Embase and Cochrane). Randomised controlled (RCT) as well as non-randomised controlled trials (n-RCT) comparing the short (SB) versus large bite (LB) technique for abdominal wall closure after midline laparotomy were eligible for inclusion. Quality assessment was performed for RCTs (ROB) & n-RCTs (ROBINS-1, MINORS). The incidence of IH, SSI, LAD as well as the length of hospital stay (LOS) and time to close the linea alba (aponeurotic layer of the abdominal wall) were analysed as outcome parameters. Odds ratio with 95% confidence intervals were chosen to determine statistical significance. Heterogeneity was explored using the I2-statistics and funnel plots evaluated a possible publication bias. RESULTS: This SR/MA comprised in total 5886 patients (large bite group 3339 vs. 2547 short bite group) enrolled in 7 RCTs and 5 n-RCTs. The SB-technique was associated with a significant lower IH, SSI, FD rate and a shorter LOS compared to the LB-technique (IH: Odds Ratio OR = 0.47 (95% CI 0.38-0.58; p < 0.00001; I2 = 11%)); SSI: OR = 0.53 (95% CI 0.42-0.67; p < 0.00001; I2 = 0%); FD: OR = 0.60 (95% CI 0.38-0.93; p = 0.02; I2 = 0%); LOS: Mean difference in days MD = -1.04 (95% CI -1.70, -0.37; p = 0.002; I2 = 13%), respectively). Furthermore, pooled effect estimates derived from RCTs were comparable to n-RCTs. No statistical relevant publication bias was detected, and the confidence of resulting evidence was high according to the validated GRADE tool. CONCLUSION: This systematic review and meta-analysis demonstrate consistent reductions in incisional hernia and surgical site infection with the small bites technique for midline laparotomy closure. The direction of effect is stable across randomized and comparative studies and supported by available long-term data. The clinical relevance and consistency of these findings support preferential use of the small bites technique in routine practice. The present evidence provides a robust basis for consideration in future updates of EHS abdominal wall closure guidelines. REGISTRATION: PROSPERO, registration number: CRD420251033244, registration date: 16th April 2025.
20 May 2026
Read appraisal →Hernia : the journal of hernias and abdominal wall surgery
Complications after biosynthetic long-term absorbable mesh implantation for ventral hernia repair in clean and contaminated environments: a systematic review and meta-analysis
BACKGROUND: Ventral hernia repair (VHR) remains a common yet complex surgical procedure, with substantial recurrence and complication rates. Long-term absorbable biosynthetic meshes have been introduced to provide temporary reinforcement while potentially reducing mesh‑related morbidity. OBJECTIVE: This meta-analysis evaluates the safety and effectiveness of long-term absorbable biosynthetic meshes in VHR by synthesizing both comparative and descriptive studies. METHODS: Databases were searched up to October 2025 for studies on VHR with long-term absorbable biosynthetic mesh. Descriptive studies were pooled using random-effects models to determine event rates. Comparative studies were analyzed using odds-ratios (ORs). RESULTS: Thirty-five descriptive single-arm studies and seventeen comparative studies were included. Descriptive hernia recurrence rate was 11.6% (95%CI 9.3-14.3%), surgical site infection (SSI) 11.8% (95%CI 9.2-15.0%), surgical site occurrence (SSO) 21.9% (95%CI 15.9-29.5%), seroma 9.7% (95%CI 7.2-12.9%), and SSO/SSI requiring surgical-intervention (SSOPI) 9.7% (95%CI 7.6-12.3%). Mesh infection and explantation rates were 0.3% (95%CI 0.0-1.0%) and 0.5% (95%CI 0.0-1.6%) both also in single-arm studies. A significantly lower hazard of recurrence 0.47 (95%CI 0.24-0.93), and a non-significantly lower risk of SSI, SSO, mesh explantation, and SSOPI compared to biologic meshes was found in comparative studies. Absorbable meshes showed a non-significant difference in recurrence rate versus permanent synthetic mesh (OR 0.93, 95%CI 0.57-1.52) but significantly lower odds of mesh explantation (OR 0.46, 95%CI 0.27-0.79). CONCLUSIONS: Long-term absorbable biosynthetic meshes show low mesh infection and explantation rates in the available literature. Comparative analyses suggest lower recurrence versus biologic meshes and fewer explantations versus permanent synthetic meshes; however, these findings are based on heterogeneous, predominantly retrospective data with limited follow-up and should not be considered conclusive.
15 May 2026
Read appraisal →The Cochrane database of systematic reviews
Penetrating versus non-penetrating mesh fixation in laparoscopic groin hernia repair
RATIONALE: Groin hernia is a common condition, and the only curative treatment is an operation where laparoscopic groin hernia repair is the recommended choice. During laparoscopic repair, a mesh is placed in the groin, which many surgeons choose to fixate, but the best fixation method regarding chronic pain and recurrence has not been established. Theoretically, non-penetrating mesh fixation (glue or self-adhesive mesh) could result in a lower risk of chronic pain, while penetrating mesh fixation (tacks, staples, and sutures) could give a reduced risk of recurrence. OBJECTIVES: To assess the benefits and harms of penetrating versus non-penetrating mesh fixation in adults undergoing laparoscopic groin hernia repair. SEARCH METHODS: We searched CENTRAL, MEDLINE Ovid, Embase Ovid, ClinicalTrials.gov, and the WHO International Clinical Trial Registry Platform. Additionally, we performed reference checking, forward and backward citation searching, and contacted study authors to identify eligible studies. The latest search date was 14 November 2024. ELIGIBILITY CRITERIA: We included randomised controlled trials (RCTs) that compared non-penetrating (glue or self-adhesive mesh) with penetrating (tacks, staples, and sutures) mesh fixation in laparoscopic groin hernia repair in adults. OUTCOMES: The critical outcomes were chronic pain measured ≥ 6 months postoperatively and recurrence assessed ≥ 12 months postoperatively. Other important outcomes were acute pain, haematoma, mesh infection, serious vascular intraoperative events, operative time, and convalescence. RISK OF BIAS: We used the RoB 2 tool to assess the risk of bias for chronic pain (dichotomous and continuous), recurrence, acute pain (dichotomous and continuous), haematoma, mesh infection, serious vascular intraoperative events, operative time, and convalescence (both dichotomous and continuous). SYNTHESIS METHODS: We synthesised results for each outcome using meta-analysis where possible by applying a random-effects model, calculating the risk ratio (RR) using the Mantel-Haenszel method for dichotomous data and calculating the mean difference (MD) using the inverse-variance method for continuous data, along with 95% confidence intervals (CIs). Where this was not possible due to the nature of the data, we synthesised the results narratively. We used GRADE to assess the certainty of evidence for each outcome. INCLUDED STUDIES: We included 35 RCTs with 4329 participants. The studies randomised 2028 participants to non-penetrating mesh fixation and 2301 participants to penetrating mesh fixation, with a median sample size of 82 (range 30 to 600 participants). The mean or median age ranged from 37 to 66 years, and the majority (94%) were men. In general, the operated hernias were primary unilateral inguinal hernias. Most of the non-penetrating mesh fixation was fibrin sealant and cyanoacrylate glue, and most of the penetrating mesh fixation was permanent staples, permanent tacks, or absorbable tacks. SYNTHESIS OF RESULTS: RoB 2 assessment Regarding the overall risk of bias, most of the outcomes had some concerns or a high risk of bias. This was mostly due to missing information regarding the randomisation process, insufficient reporting of missing outcome data, or both. GRADE We assessed the certainty of evidence to be very low for most outcomes. This was mainly due to high or unclear risk of bias or due to imprecision because of few events, a wide confidence interval, or a small population. Critical outcomes Non-penetrating mesh fixation may result in little to no difference in the risk of chronic pain (RR 0.62, 95% CI 0.35 to 1.07; I² = 9%; 7 studies, 553 participants; very low-certainty evidence) and recurrence (RR 0.75, 95% CI 0.33 to 1.67; I² = 0%; 15 studies, 2165 participants; very low-certainty evidence), but the evidence is very uncertain. Non-penetrating mesh fixation may reduce the level of chronic pain (continuous), but the evidence is very uncertain (MD -0.34, 95% CI -0.56 to -0.11; I² = 98%; 7 studies, 639 participants; very low-certainty evidence). Important outcomes Non-penetrating mesh fixation may have little to no effect on the risk of acute pain (dichotomous) (RR 0.93, 95% CI 0.50 to 1.73; I² = 56%; 2 studies, 218 participants; very low-certainty evidence). Non-penetrating mesh fixation may reduce the level of acute pain (continuous) (MD -0.90, 95% CI -1.31 to -0.49; I² = 98%; 16 studies, 1611 participants; very low-certainty evidence), the risk of haematoma (RR 0.43, 95% CI 0.24 to 0.78; I² = 0%; 19 studies, 2560 participants; very low-certainty evidence), convalescence (RR 1.49, 95% CI 1.10 to 2.01; I² = 94%; 9 studies, 1116 participants; very low-certainty evidence), and the length of convalescence (MD -0.81, 95% CI -1.38 to -0.23; I² = 80%; 7 studies, 589 participants; very low-certainty evidence), but the evidence is very uncertain. Non-penetrating mesh fixation may have little to no effect on the risk of mesh infection (RR 0.34, 95% CI 0.01 to 8.23; I² not applicable; 5 studies, 1128 participants; very low-certainty evidence) and operative time (MD -0.26, 95% CI -3.11 to 2.59; I² = 94%; 20 studies, 1800 participants; very low-certainty evidence), but the evidence is very uncertain. Lastly, non-penetrating mesh fixation may result in little to no difference in serious vascular intraoperative events (RR 0.18, 95% CI 0.02 to 1.57; I² = 0%; 9 studies, 1289 participants; low-certainty evidence). AUTHORS' CONCLUSIONS: There may be little to no difference between non-penetrating and penetrating mesh fixation regarding the risk of chronic pain (dichotomous), recurrence, acute pain (dichotomous), mesh infections, and operative time, but the evidence is very uncertain. Non-penetrating mesh fixation may result in little to no difference in serious vascular intraoperative events. While the evidence is very uncertain, non-penetrating mesh fixation may slightly reduce the level of chronic pain (continuous), the level of acute pain (continuous), and the risk of haematoma, and shorten convalescence (dichotomous and continuous). Overall, this review demonstrated little to no difference in clinically important outcomes between penetrating and non-penetrating mesh fixation in laparoscopic groin hernia repair in adults, based on low- to very low-certainty evidence. FUNDING: This Cochrane review had no dedicated funding. REGISTRATION: Protocol available via DOI: 10.1002/14651858.CD016122.
11 Apr 2026
Read appraisal →