Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 32 appraisals
Journal of robotic surgery
Perioperative outcomes and nodal station assessment after robotic-assisted versus video-assisted thoracoscopic segmentectomy for early-stage NSCLC: a systematic review and meta-analysis
The relative benefits of Robotic-assisted thoracoscopic segmentectomy (RATS) versus video-assisted thoracoscopic segmentectomy (VATS) for early-stage NSCLC remain uncertain. This meta-analysis compared perioperative outcomes, lymph node assessment, and postoperative safety between the two approaches. PubMed, Cochrane Library, Embase, and Web of Science were searched from inception to April 2026. Comparative studies of RATS versus VATS segmentectomy for early-stage NSCLC were included. Outcomes were pooled as weighted mean differences or odds ratios with 95% confidence intervals. Random-effects models were used for substantial heterogeneity (I² >50% or P < 0.05); otherwise, fixed-effects models were applied. Leave-one-out sensitivity plots are provided in the supplementary materials. Nine retrospective comparative studies involving 19,805 patients were included. Robotic-assisted segmentectomy was associated with a greater number of lymph node stations examined (WMD = 1.16, 95% CI: 0.51, 1.81, P < 0.001) and a shorter length of hospital stay (WMD = - 0.75, 95% CI: -1.36, - 0.15, P = 0.015). No significant differences were observed in operative time (WMD = 1.86, 95% CI: -8.80, 12.52, P = 0.732), duration of drainage (WMD = - 0.37, 95% CI: -0.79, 0.06, P = 0.090), overall complications (OR = 0.94, 95% CI: 0.67, 1.34, P = 0.745), air leak (OR = 1.02, 95% CI: 0.54, 1.91, P = 0.949), pneumonia (OR = 1.33, 95% CI: 0.89, 1.99, P = 0.170), or 30-day readmission (OR = 1.09, 95% CI: 0.94, 1.26, P = 0.257). Current retrospective evidence suggests that RATS may offer more examined lymph node stations and shorter hospital stay without increased morbidity, but these findings are limited by risk of bias and should not be interpreted as evidence of oncologic superiority.
22 July 2026
Read appraisal →Journal of robotic surgery
Robotic versus laparoscopic and open surgery for endometrial cancer: a systematic review of randomized trials and pooled analysis of conversion rates
To summarize randomized evidence assessing robotic surgery in relation to conventional laparoscopic and open abdominal approaches for endometrial cancer treatment, with particular attention to perioperative outcomes and conversion to open surgery. Randomized controlled trials evaluating robot-assisted surgical treatment of endometrial cancer were identified across major biomedical databases up to December 2025. Eligible studies compared the robotic approach against laparoscopic or open abdominal surgery. Quantitative pooling was undertaken only when outcome reporting was sufficiently consistent across studies. Eight randomized trials including 647 patients met the inclusion criteria. Overall, 322 patients underwent robotic surgery, 244 conventional laparoscopy, and 81 laparotomy. Most perioperative endpoints were reported heterogeneously, limiting formal pooling. Operative time varied across trials when robotics was compared with laparoscopy and was generally longer than laparotomy. Intraoperative blood loss and postoperative hospitalization did not show consistent differences between the two minimally invasive approaches. Compared with laparotomy, the robotic approach was linked to reduced postoperative stay. Conversion to laparotomy occurred less frequently after robotic surgery than after laparoscopy (0.7% vs. 8.4%; OR 0.17; p = .03). Complication reporting was inconsistent, although trials comparing robotics with laparotomy generally favored the robotic approach. Direct procedural costs were higher for robotics, whereas indirect costs favored robotics in the single study evaluating them. The robotic approach resulted in a lower need for open conversion compared with conventional laparoscopy. Other perioperative outcomes appeared broadly comparable between the two minimally invasive approaches, while comparisons with laparotomy suggested shorter hospital stay and fewer postoperative complications, although these findings should be interpreted cautiously because of the limited and heterogeneous randomized evidence.
21 July 2026
Read appraisal →Journal of robotic surgery
Transperitoneal versus retroperitoneal single-port robot-assisted partial nephrectomy: systematic review and meta-analysis of perioperative and functional outcomes
To systematically compare the safety and efficacy of the transperitoneal (TP) and retroperitoneal (RP) approaches in single-port robot-assisted partial nephrectomy (SP-RAPN). PubMed, Web of Science, and Embase were searched for comparative studies published before October 2025. The primary evaluated outcomes were grouped as Perioperative Outcomes (operative time, blood loss, ischemia time, positive surgical margin, postoperative eGFR, and hospital stay) and Surgical Safety (complication rate). Study inclusion and exclusion standards followed the PICOS guidelines. Four comparative studies with 384 patients (188 TP and 196 RP) were analyzed. Compared with the RP group, the TP group had higher intraoperative blood loss (WMD = 27.95 mL, 95% CI = 4.90-51.02, p = 0.018), longer hospital stay (WMD = 0.56 days, 95% CI = 0.34-0.78, p < 0.001), and higher absolute postoperative eGFR (WMD = 6.87, 95% CI = 2.65-11.10, p = 0.001). Operative time did not differ significantly in the main analysis (p = 0.356); an exploratory sensitivity analysis suggested a possible small difference (≈ 12 min) that requires confirmation. Warm ischemia time, positive surgical margin rate, and complication rate showed no significant differences between the two groups. Sensitivity analysis confirms the robustness of these findings, with overall low heterogeneity. Both transperitoneal and retroperitoneal SP RAPN are safe and feasible based on this limited evidence. Preliminary findings suggest the RP approach may offer advantages in blood loss, hospital stay, and renal preservation, but these results are hypothesis generating. Importantly, tumor location strongly influenced approach selection, and observed differences may be attributable to tumor location rather than the approach itself; causal inference is not possible from this observational data. Validation in larger, prospective, and preferably randomized studies is required.
21 July 2026
Read appraisal →ACS nano
Design and Applications of Magnetically Actuated Microrobots in Endovascular Embolization
Endovascular embolization is one of the core techniques in minimally invasive interventional medicine. It allows catheters to be accurately delivered to target blood vessels under image guidance for the implantation of embolic materials to achieve vascular occlusion. Although this technique has become increasingly mature, it still faces major challenges in precise delivery due to the limitations of embolic-agent properties and design concepts, restricting further improvement of the embolization therapeutic efficacy. Driven by continuous breakthroughs in materials science and control engineering, as well as the inevitable trend of medical development toward miniaturization, precision, and intelligence, microrobots show broad application prospects in precision disease treatment. They present advantages in accurate embolization and remote control in endovascular embolization, which can effectively improve embolization outcomes and reduce the risk of ectopic embolism. Taking the embolic microrobot system as the research focus, this paper systematically elaborates the design strategies, validation models, and practical applications of magnetically actuated embolic microrobots, comprehensively evaluates various imaging systems, and summarizes the supporting magnetic actuation technologies. It concludes the multimodule collaboration and adaptation framework of embolic microrobot systems. Finally, it analyzes the current limitations and potential translational challenges and presents a systematic prospect of its future development trends.
8 July 2026
Read appraisal →Nanoscale horizons
Multidimensional additive manufacturing micro/nanorobots: from elaborate design to smart cargo delivery
Micro/nanorobots have attracted much attention because of their potential to perform complex tasks with high precision under controlled actuation within the human body, such as targeted cargo delivery, lesion exploration, and minimally invasive surgery. Among the various emerging fabrication technologies, multidimensional additive manufacturing (MAM) technology can enable the design and fabrication of complex structures with multifunctional characteristics. Compared with traditional manufacturing methods, MAM significantly reduces production complexity and time while enhancing design flexibility and customization. This review provides a comprehensive overview of MAM technologies for constructing micro/nanorobots, along with their applications and associated challenges in the biomedical field. In addition, emerging MAM approaches, including 4D, 5D, and 6D printing assisted by physical intelligence, machine learning, and artificial intelligence show great potential for designing and fabricating more sophisticated and intelligent micro/nanorobots, thereby advancing their clinical translation in the near future.
8 July 2026
Read appraisal →Science advances
Toward autonomous robotic-assisted and microrobotic surgery
Autonomous robotic-assisted surgery (RAS) has emerged as a promising objective in biomedical technology, further enhanced by miniaturization toward microrobotic-assisted surgery (μ-RAS). This reduction in scale promises minimally invasive, partially or fully automated surgical procedures, with the potential to reduce patient recovery times, lower medical costs, and enable previously unavailable procedural options. This perspective highlights the specific advances in RAS that potentially map to the microscale (μ-RAS), organized across five surgical domains: endovascular, endoluminal, laparoscopic, ophthalmic, and orthopedic. We examine both clinical demands and technological advances in surgical robotics and identify the key innovations required for progress across these surgical fields. Our contribution is distinct in combining the perspectives of both surgical experts and bioengineering innovators, outlining a roadmap for the advancement and eventual integration of autonomous RAS and μ-RAS into mainstream surgical practice.
6 July 2026
Read appraisal →JMIR formative research
Effects of Virtual Reality on Postoperative Pain Management Following Minimally Invasive Gynecologic Surgery: Randomized Controlled Trial
BACKGROUND: Postoperative pain and anxiety remain common concerns after minimally invasive gynecologic surgery despite advances in surgical techniques and analgesic strategies. Virtual reality (VR) has been investigated as a potential nonpharmacological intervention for pain management; however, evidence in gynecologic postoperative settings is limited. OBJECTIVE: This study aims to evaluate the efficacy and safety of VR technology compared with standard postoperative analgesia for pain and anxiety management in patients undergoing minimally invasive gynecologic surgery. METHODS: This randomized controlled trial was conducted at Sun Yat-sen Memorial Hospital of Sun Yat-sen University in China. A total of 131 patients undergoing laparoscopy or combined hysteroscopy for benign gynecologic diseases were randomly assigned in a 1:1 ratio to either a VR group (n=68) or a control group (n=63). All patients received a standardized general anesthesia protocol intraoperatively. The control group received conventional analgesic therapy after surgery, and the VR group received a 20-minute VR intervention 6 hours postoperatively. The pain and anxiety levels were evaluated using a visual analog scale at 6 and 7 hours postoperatively. The primary outcome was the change in pain scores between 6 and 7 hours. Secondary outcomes included maximum pain score, anxiety score changes, length of hospital stay, hospitalization costs, and occurrence of adverse events. Analyses were performed according to the intention-to-treat principle. RESULTS: There was no statistically significant difference in the primary outcome between the VR and control groups (mean difference 0.169, 95% CI -0.271 to 0.608; P=.45). Similarly, no significant differences were observed in the maximum pain score (mean difference 0.839, 95% CI -0.101 to 1.779; P=.08), and no improvement was observed in the anxiety score (mean difference 0.042, 95% CI -0.365 to 0.449; P=.84). No significant differences were found in length of hospital stay, hospitalization costs, or incidence of adverse events, including dizziness, nausea, and vomiting (all P>.05). CONCLUSIONS: A single 20-minute VR intervention did not provide additional analgesic or anxiolytic benefit compared with standard postoperative care after minimally invasive gynecologic surgery. VR was well tolerated, and its role in postoperative recovery requires further investigation. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2400091244; https://tinyurl.com/4b92a9td.
5 July 2026
Read appraisal →Journal of robotic surgery
Emerging robotic platforms in gynecologic surgery: a systematic review.
Robotic innovation in gynecologic surgery has expanded beyond established multiport ecosystems toward single-port, modular multi-arm, transvaginal, AI-enabled, and teleoperated platforms. However, available evidence remains fragmented and unsuitable for quantitative synthesis. This systematic review evaluated emerging robotic platforms in gynecologic surgery, focusing on procedure types, outcomes, costs, and learning curves. The review was prospectively registered in PROSPERO (CRD420261360389). Eligible studies included clinical studies evaluating emerging robotic platforms in gynecologic surgery. PubMed, Scopus, and Web of Science were searched on 4 April 2026. After duplicate removal, 408 records were screened, 160 full texts assessed, and 92 studies included. Data extraction and risk of bias assessment were performed independently in duplicate. The 92 studies covered 13 platforms and were mainly retrospective single-center studies. Evidence was most extensive for da Vinci SP and HUGO RAS, with more limited but informative data for Senhance, Versius, hinotori, and KANGDUO. Evidence for other systems consisted mainly of first-in-human, pilot, or feasibility studies. Hysterectomy and sacrocolpopexy were the most frequently reported procedures. Overall, perioperative outcomes and short-term safety appeared favorable, despite limited follow-up and heterogeneous outcome definitions. Cost data were mainly available for Senhance and KANGDUO. Learning-curve evidence was strongest for da Vinci SP and HUGO RAS. Risk-of-bias was predominantly moderate. Emerging robotic platforms have demonstrated broad technical feasibility and generally acceptable short-term perioperative safety in selected gynecologic procedures, but current evidence is heterogeneous, observational, and methodologically limited. Rigorous prospective studies, standardized economic analyses, longer follow-up, and learning-curve evaluations are needed before comparative conclusions can be drawn.
23 June 2026
Read appraisal →Journal of robotic surgery
A focused systematic review and meta-analysis of robot-assisted inguinal lymphadenectomy versus open inguinal lymph node dissection in penile cancer
This focused systematic review and meta-analysis evaluated robot-assisted inguinal lymphadenectomy (RAIL) versus open inguinal lymph node dissection (OILND) in penile cancer, aiming to provide robot-specific comparative estimates rather than a broad minimally invasive synthesis. PubMed, EMBASE, Web of Science, and the Cochrane Library were searched through December 2025 for comparative studies. All meta-analyses were conducted using STATA 18, employing random-effects modeling. Binary outcomes were summarized using odds ratios (ORs), and continuous outcomes were presented as weighted mean differences (WMDs), with all estimates accompanied by 95% confidence intervals (CIs). Risk of bias in the included non-randomized comparative studies was assessed using the ROBINS-I tool. Four retrospective comparative studies involving 276 patients were included, and no randomized controlled trials were identified. A lower odds of total postoperative complications was observed with RAIL (OR = 0.52, 95% CI: 0.27, 0.97; P = 0.047), but this borderline finding should be interpreted cautiously given the small number of retrospective studies and potential residual confounding. Across individual studies, operative time generally tended to be longer with RAIL, whereas findings for estimated blood loss and drainage-related outcomes were inconsistent. Lymph node yield, skin-related complications, minor complications, and groins with positive nodes did not differ significantly between approaches. According to the GRADE assessment, the certainty of evidence was low for most pooled outcomes and very low for skin-related complications and lower-limb edema/lymphedema. RAIL may be associated with lower overall postoperative complications than open surgery, but the evidence remains low certainty and insufficient to establish a definitive morbidity-reduction benefit. In addition, several continuous perioperative variables showed extreme between-study heterogeneity and were not clinically interpretable as reliable pooled effects.
22 June 2026
Read appraisal →Journal of robotic surgery
Mapping the scientific landscape of robotic hernia repair: a bibliometric and topic modeling analysis of thematic transitions
Robotic hernia repair (RHR) has profoundly transformed modern surgery, yet it remains intensely debated. To understand this dynamic field, bibliometric analysis offers a powerful tool to evaluate its evolving research trends. Our study presents a comprehensive bibliometric and machine learning analysis of 1,503 publications from 2003 to 2025. The literature demonstrates a growth trend (R2 = 0.96), characterized by initial latency (2003-2015), steady adoption (2016-2020) and a recent exponential explosion (2020-2025) peaking at 262 publications in 2025. The United States is the leading contributing nation (n = 892), followed by Italy (n = 98), Germany (n = 71), and China (n = 68). Key contributors include Kudsi OY, Malcher F, and Muysoms F, with Surgical Endoscopy serving as the predominant publication venue (n = 203). Spatial and relational networks were mapped using VOSviewer and CiteSpace. Critically, Latent Dirichlet Allocation (LDA) topic modeling combined with principal component analysis (PCA) stratified the corpus into four major research domains comprising the anatomical spectrum, the balance between resource and risk management, hardware evolution and surgical education, and technical complexity coupled with high-level evidence. Longitudinal regression of thematic probabilities revealed a significant thematic transition in research emphasis from early hardware feasibility and technical exploration toward value-based evaluation. Current research priorities are increasingly focused on rigorous cost-effectiveness evaluation in high-risk populations together with the generation of high-quality randomized evidence. In conclusion, this multidimensional analysis illustrates how this field is increasingly guided by the interconnected domains of Evidence, Education and Economics, which align with established frameworks for sustainable surgical progress.
21 June 2026
Read appraisal →Journal of robotic surgery
Progress and perspectives in soft robotics for surgery and rehabilitation
Soft robotic systems have become a promising technology in the biomedical field due to their higher safety, dexterity and adaptability compared to traditional rigid robotic systems. This review focuses on recent advances in soft robotic systems applied to surgical assistance and rehabilitation. In surgery, soft grippers and flexible endoscopes show better adaptability, dexterity, and miniaturization, enabling safer and more precise manipulation of delicate tissues. In rehabilitation, wearable soft devices show great potential to help patients with neurological injuries to regain movement. Key innovations in actuation technology are examined, along with recent advances in multifunctional, self-healing, and environmentally responsive materials. Meanwhile, sensing systems are evolving from unimodal sensing to multimodal fusion, self-perception, and sense-drive integration, enabling robots to sense the body state and external environment with higher accuracy and realize closed-loop control. Finally, this paper points out that soft robots still face key challenges such as material durability, biosafety, and stability during clinical translation. In the future, the focus should be on the construction of systems with self-diagnosis, self-adaptive adjustment and closed-loop control, and promote the efficient landing and personalized application of soft robots from experimental research to real medical scenarios.
21 June 2026
Read appraisal →Journal of robotic surgery
Outcomes in laparoscopic versus robotic-assisted surgery for median arcuate ligament syndrome: a systematic review and meta-analysis
Median Arcuate Ligament Syndrome (MALS) is a rare condition caused by external compression of the coeliac artery by the median arcuate ligament (MAL), leading to postprandial abdominal pain, nausea, vomiting, and weight loss. This study aims to compare outcomes of robotic (RMALR) and laparoscopic (LMALR) MAL release. A systematic search of PubMed/MEDLINE, Scopus, and Embase databases was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to compare perioperative and postoperative outcomes of LMALR versus RMALR. Comparative studies including adult patients undergoing either approach were included. Outcomes assessed were conversion to open surgery, resolution of pain, length of admission, postoperative complications, symptom recurrence and time to recurrence. Five retrospective comparative studies comprising 158 patients were included. No differences were found between laparoscopic and robotic approaches in conversion to open, resolution of pain, postoperative complications, length of admission, or overall time to recurrence. However, RMALR showed a significantly longer time to symptom recurrence (9.04 months, 95% CI 4.18-13.89; p = 0.0003). Both LMALR and RMALR are safe and effective for MALS, with comparable perioperative and postoperative outcomes. The longer symptom-free interval after robotic surgery may reflect greater precision in dissection around the coeliac axis. However, further prospective studies with standardised follow-up are needed to validate these findings.
20 June 2026
Read appraisal →Techniques in coloproctology
Robotic versus laparoscopic TME for rectal cancer: meta-analysis of pathological quality indicators
BACKGROUND: Total mesorectal excision (TME) quality is a key determinant of oncological outcomes in rectal cancer. While robotic surgery offers technical advantages over laparoscopy in the confined pelvis, its superiority regarding pathological outcomes remains debated. We conducted a meta-analysis comparing robotic and laparoscopic TME focusing on quality indicators of TME and risk factors for incomplete TME. METHODS: A PROSPERO-registered systematic search of PubMed and EMBASE up to May 2025. Comparative studies reporting pathological outcomes of robotic versus laparoscopic TME were included. Primary endpoints were TME completeness, circumferential resection margin (CRM) positivity and distal resection margin (DRM) positivity. Secondary analysis included baseline characteristics (male gender, BMI, bulky tumours, distance to anal verge, neoadjuvant radiotherapy) and local recurrence rate. RESULTS: Fifty-six studies (27,648 patients; robotic 10,629, laparoscopic 17,019) were included. Robotic surgery was associated with significantly more complete TME specimens (OR 1.50, 95% CI 1.23-1.82, p < 0.001) and fewer positive DRMs (OR 0.68, 95% CI 0.48-0.97, p = 0.031). CRM positivity was comparable between groups (OR 0.93, 95% CI 0.77-1.12, p = 0.44). In random-effects analysis, there was a non-significant trend towards fewer local recurrences after robotic TME (OR 0.75, 95% CI 0.54-1.05, p = 0.09). Robotic cohorts more frequently included male patients, distal tumours and neoadjuvant chemoradiotherapy, suggesting preferential selection of technically challenging cases. CONCLUSIONS: Robotic TME is associated with higher specimen completeness and lower DRM positivity compared with laparoscopic TME, while CRM positivity and local recurrence rates appear broadly similar. These data support the use of robotics as a primary minimally invasive option for mid-low rectal cancer; however, as a result of low certainty of evidence, these findings should be interpreted cautiously. SYNOPSIS: This meta-analysis provides the most up-to-date synthesis of pathological outcomes comparing robotic and laparoscopic TME for rectal cancer, incorporating data from 56 studies including the recent REAL and COLRAR randomized trials. Unlike previous reviews, it exclusively analyses total mesorectal excision procedures, excluding partial or high anterior resections, thereby eliminating a major source of heterogeneity. The findings demonstrate that robotic TME is associated with higher specimen completeness and fewer positive distal margins, even in technically demanding mid- and low-rectal cancers, supporting the role of robotics as the preferred minimally invasive approach in mid-low, difficult tumours.
1 June 2026
Read appraisal →Journal of robotic surgery
Comparative efficacy and safety of open, laparoscopic, and robot-assisted radical cystectomy: a systematic review and network meta-analysis
The most appropriate surgical strategy for radical cystectomy in bladder cancer remains to be established. This study performed a network meta-analysis of randomized controlled trials to evaluate open, laparoscopic, and robot-assisted approaches. Outcomes were systematically classified into intraoperative metrics, postoperative recovery, perioperative safety, and oncological efficacy. A random effects model was employed, and treatment hierarchy was determined using the surface under the cumulative ranking curve. Eleven studies comprising 1270 patients met the inclusion criteria. Compared with open surgery, minimally invasive techniques were associated with reduced intraoperative blood loss and lower transfusion rates, although they required longer operative time. Among these, laparoscopic surgery was associated with a potentially greater likelihood of enhanced postoperative recovery and fewer complications, although these findings should be interpreted with caution given the sparse network and substantial heterogeneity in some outcomes. Robot-assisted procedures did not demonstrate consistent superiority over laparoscopy in perioperative measures. Oncological outcomes were similar across all modalities. Overall, minimally invasive approaches confer perioperative benefits and appear comparable to open surgery with respect to short-term surrogate oncological endpoints, although long-term outcomes remain to be determined.
31 May 2026
Read appraisal →Neurosurgical review
Modified tubular retractor for deep brain tumour resection: enhanced surgical outcomes in resource-constrained settings
Tubular retractors permit minimally invasive access to deep-seated intracranial tumours; however, limitations in visualisation and manoeuvrability reduce their suitability for lesions ≥ 3 cm, particularly in resource-limited centres. We evaluated a modified, low-cost tubular retractor incorporating enhanced visualisation and ergonomic features, comparing its performance with Leyla spatula-based retraction and traditional syringe-derived tubular systems. A prospective comparative cohort of 105 patients with deep brain tumours ≥ 3 cm was analysed. Patients underwent Leyla retraction (Group 1, n = 38), conventional tubular systems (Group 2, n = 32), or a modified tubular retractor (Group 3, n = 35). Outcomes included intraoperative visualisation, retractor stability, manoeuvrability, extent of resection, complications, and three-month Glasgow Outcome Scores. Owing to non-normal distribution, continuous variables were analysed using non-parametric tests and binary logistic regression. The modified tubular retractor demonstrated greater stability, broader visualisation, and enhanced instrument handling compared with conventional tubular systems. Gross total resection was achieved in 91.4% with the modified device, 78.9% with Leyla-based retraction, and 28.9% with traditional tubular systems. Logistic modelling identified retractor type (OR 2.59, p = 0.035), intraoperative visualisation (OR 2.01, p = 0.036), and histopathology (OR 1.41, p = 0.036) as independent predictors of residual tumour. The modified retractor group exhibited fewer complications, shorter ICU stays, and superior functional outcomes (GOS ≥ 4 in 91%). The modified tubular retractor demonstrated favourable operative handling and outcome trends for deep-seated tumours ≥ 3 cm, with improved visualisation, stability, and ergonomic access compared with conventional systems. However, limitations related to non-randomised design, learning-curve effects, advanced mapping, fluorescence integration, and supramaximal resection warrant cautious interpretation pending multicentre long-term validation.
29 May 2026
Read appraisal →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 →Journal of robotic surgery
AI-based automated bleeding monitoring in conventional and robot-assisted laparoscopic surgery: a systematic review
Artificial intelligence has emerged as a promising approach for improving the detection and management of intraoperative bleeding during conventional and robotic-assisted laparoscopic surgery, where delayed recognition of hemorrhage can lead to increased morbidity and procedural complexity. This review synthesizes current evidence on the use of artificial intelligence for intraoperative bleeding monitoring, with a particular focus on performance, feasibility, and clinical integration. A systematic review was conducted in accordance with PRISMA 2020 guidelines. Comprehensive searches of PubMed, Scopus, Web of Science, IEEE Xplore, Embase, and grey literature identified studies published between 2016 and 2025 that applied artificial intelligence to bleeding prediction, detection, localization, tracking, and quantitative blood-loss estimation during conventional and robotic-assisted laparoscopic surgery. Data relating to study design, model architectures, evaluation metrics, latency, and integration feasibility were extracted and summarized narratively. Across the included studies, artificial intelligence models demonstrated high detection accuracy in predominantly single-centre, retrospective, or simulation-based settings, with several approaches reporting promising real-time feasibility under controlled experimental conditions. Emerging work also explored bleeding source tracking, blood-loss estimation, and early integration into surgical workflows. However, most studies relied on small, single-center datasets and retrospective validation, limiting generalizability and clinical translation. Overall, artificial intelligence-based bleeding monitoring in conventional and robotic-assisted laparoscopic surgery shows increasing technical maturity and potential, though largely unvalidated in prospective clinical settings. Future research should prioritize large, multi-institutional datasets, prospective clinical evaluation, and optimized low-latency deployment within real surgical workflows to support safe and effective intraoperative use.
24 May 2026
Read appraisal →Journal of robotic surgery
A randomized controlled trial comparing robotic NOSES versus robotic TME for Mid-rectal cancer: short-term oncological and perioperative outcomes
This randomized study compared perioperative outcomes between robotic natural orifice specimen extraction surgery (R-NOSES) and robotic total mesorectal excision (R-TME) in participants with mid-rectal cancer. After exclusions, 71 participants in the R-TME cohort and 69 in the R-NOSES cohort were included in the final analysis, from an initial randomized cohort of 150 eligible participants (1:1 allocation). The two cohorts had comparable preoperative characteristics. Intraoperative and pathological outcomes, including blood loss, operative duration, and harvested lymph nodes, showed no notable differences. The rates of overall complication were comparable between the two groups (R-NOSES 13.0% vs. R-TME 15.5%, P = 0.679), and anastomotic leakage did not vary significantly. Conversely, the R-TME group experienced a higher rate of wound complications (5.6% vs. 0.0%, P = 0.045). Notably, the R-NOSES group demonstrated significant advantages in postoperative recovery, including shorter time to first flatus (48 vs. 53 h, P = 0.02), earlier resumption of a liquid diet (79 vs. 84 h, P = 0.041), and markedly reduced VAS pain ratings on postoperative days 1 and 3. In conclusion, for selected patients with middle rectal cancer, R-NOSES appears to be a safe and feasible alternative to R-TME, with similar short-term oncological outcomes. It may offer some benefits in terms of faster recovery, less postoperative pain, and fewer wound-related complications.Trial Registration: ClinicalTrials.gov Identifier NCT06454201.
22 May 2026
Read appraisal →Journal of robotic surgery
Intraoperative surgical needle loss in robotic-assisted and laparoscopic surgery: a systematic review and practical troubleshooting framework
Intraoperative loss of a surgical needle during minimally invasive surgery (MIS) is uncommon but clinically important. In robotic-assisted surgery (RAS), altered sensory conditions and evolving trocar designs may influence both needle-loss mechanisms and retrieval strategy. We systematically reviewed the literature and developed a practical troubleshooting framework. PubMed, Embase, CNKI, and Wanfang were searched from inception to January 2026 in accordance with PRISMA 2020. Studies reporting intraoperative needle loss during abdominal or pelvic MIS or RAS were included. Because of substantial heterogeneity, findings were synthesized narratively. Thirty-three studies were included, comprising 27 original studies and 6 narrative reviews. Quantitative outcome aggregation was restricted to clinical patient-level studies, yielding 37 extractable lost-needle events: 22 during RAS and 15 during conventional laparoscopy. Minimally invasive retrieval was successful in 35/37 cases, whereas incision extension or open conversion was required in 2/37. Recurrent practical risk scenarios included trocar-pathway entrapment, including the hypothesized "Trocar Trap," and possible risk amplification related to absent haptic feedback in RAS. Evidence supporting adjunctive localization tools, including fluoroscopy and magnetic assistance, remained limited and largely non-comparative. Needle loss in contemporary MIS and RAS should be regarded as a workflow-sensitive patient safety event supported mainly by low-level evidence. The most relevant contemporary implications concern robotic workflow, port-pathway inspection, disciplined handoff, and selective use of adjunctive retrieval tools within a stepwise troubleshooting framework. Registration: PROSPERO (CRD420261294460).
22 May 2026
Read appraisal →Journal of robotic surgery
Emerging robotic platforms in partial nephrectomy: a comparative systematic review and network meta-analysis
Robotic-assisted partial nephrectomy (RAPN) is the preferred minimally invasive nephron-sparing technique, with outcomes comparable to open and laparoscopic surgery. While most evidence derives from the da Vinci system, newer robotic platforms such as Hugo, Hinotori, KangDuo and MP1000 are emerging. This systematic review and network meta-analysis evaluated perioperative outcomes across available RAPN platforms. A systematic search of PubMed, Cochrane Library, CINAHL, and Scopus identified studies reporting RAPN outcomes across available robotic platforms. Eligible studies included randomized and observational cohorts. Risk of bias was assessed with ROBINS-I. Outcomes included in the analysis operative time (OT), estimated blood loss (EBL), and length of hospital stay (LOS). A frequentist NMA using the "netmeta" R package generated standardized mean differences (SMD) with 95% CIs, and P-scores ranked platform performance. The review was registered on PROSPERO (ID: CRD420251032233). This review was conducted in accordance with PRISMA guidelines. Thirteen studies (n = 2,450) were included. Under fixed-effects model, da Vinci SP (SMD - 0.63, 95% CI - 0.87 to - 0.40) and Xi (-0.52, 95% CI - 0.67 to - 0.38) revealed shorter operative times; however, under random-effects models these differences were not statically significant due to substantial heterogeneity. Heterogeneity (I² ≈ 84%) attenuated these effects. For ischemia time, Hugo RAS (-0.88, 95% CI - 1.45 to - 0.30) and Xi (-0.58, 95% CI - 0.73 to - 0.44) outperformed Si, though differences lost significance under random-effects (I² >90%). No significant differences were found for length of stay, blood loss, or R.E.N.A.L. nephrometry scores, although ranking differences were observed. Preoperative outcomes were revealed a comparable outcome using emerging robotic system with the established system. Favourable trends in operative and ischemia times were showed in some platforms; however, these differences were not vigorous under random-effects models and are limited by substantial heterogeneity. This raised the need for long-term, comparative follow-up studies, as the current evidence remains elementary.
22 May 2026
Read appraisal →Journal of robotic surgery
Perioperative and oncological outcomes of robotic versus laparoscopic low anterior resection in younger rectal cancer cohorts: a systematic review and meta-analysis with narrative functional assessment
Robotic low anterior resection (R-LAR) has been proposed to overcome technical limitations of laparoscopy in rectal surgery. However, previous meta-analyses have evaluated mixed-age populations, and no meta-analysis has specifically investigated younger patients (aged < 65 years) undergoing low anterior resection. This study aimed to compare operative, short-term postoperative, and oncological outcomes between robotic and laparoscopic low anterior resection in this cohort. A systematic review and meta-analysis were conducted according to PRISMA 2020 and the Cochrane Handbook, with prospective registration in Prospero. PubMed, Scopus, and the Cochrane Library were searched up to January 2026. Comparative studies evaluating R-LAR versus L-LAR in younger rectal cancer cohorts, defined as studies with mean patient age ≤ 65 years, were included. Random-effects models were used to calculate pooled mean differences (MD), odds ratios (OR), and hazard ratios (HR) with 95% confidence intervals (CI). Risk of bias was assessed using ROBINS-I and RoB2, and certainty of evidence using GRADE. A total of 16 studies were included. Compared with laparoscopy, R-LAR was associated with longer operative duration (MD 24.59 min, 95% CI 3.85-45.33, p = 0.02, I² = 96%), lower conversion to open surgery (OR 0.38, 95% CI 0.27-0.53, p < 0.0001, I² = 38%), lower overall complications (OR 0.84, 95% CI 0.73-0.97, p = 0.02, I² = 0%), lower 30-day mortality (OR 0.59, 95% CI 0.45-0.77, p = 0.006, I² = 0%), lower 30-day reoperation (OR 0.77, 95% CI 0.61-0.98, p = 0.04, I² = 0%), higher complete TME rates (OR 3.30, 95% CI 2.14-5.10, p = 0.003, I² = 0%) and shorter hospital stay (MD -0.82, 95% CI -1.50 to -0.13, p = 0.02, I²=97%). Estimated blood loss (p = 0.05) and major complications (p = 0.05) were borderline significant in favor of R-LAR. Anastomotic leakage (p = 0.17), postoperative ileus (p = 0.49), time to first flatus (p = 0.12), time to diet initiation (p = 0.10), CRM positivity (p = 0.56), lymph node yield (p = 0.09), local recurrence (p = 0.67), loop ileostomy (p = 0.56), disease-free survival (p = 0.53), and overall survival (p = 0.73) were comparable. The certainty of evidence ranged from very low to moderate. Functional outcomes were insufficient for pooling. Robotic low anterior resection in younger rectal cancer cohorts may improve several perioperative and technical outcomes without compromising oncological adequacy. Further high-quality studies are required to confirm these findings.
19 May 2026
Read appraisal →Journal of robotic surgery
Perioperative outcomes of transoral endoscopic vs. robotic thyroidectomy: a systematic review and meta-analysis
BACKGROUND: Transoral endoscopic thyroidectomy vestibular approach (TOETVA) and transoral robotic thyroidectomy (TORT) have emerged as scarless alternatives to conventional open thyroidectomy, offering excellent cosmetic outcomes. However, the comparative perioperative outcomes between these two minimally invasive techniques remain to be systematically evaluated. This meta-analysis aimed to compare the perioperative outcomes of TOETVA and TORT in patients undergoing thyroid surgery. METHODS: A systematic search was performed in PubMed, Embase, the Cochrane Library, and Web of Science from inception to March 1, 2026, for studies comparing TOETVA and TORT. The primary outcomes included recurrent laryngeal nerve injury, hypoparathyroidism, mental nerve injury, seroma, surgical site infection, and postoperative hemorrhage. The secondary outcome included operation time, length of hospital stay, number of lymph nodes dissected, and postoperative pain score. Pooled weighted mean differences (MD) or odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model. Study quality was assessed using the ROBINS-I tool. RESULTS: A total of 5 studies involving 1,080 patients were included (639 in the TOETVA group and 441 in the TORT group). Compared with TOETVA, TORT was associated with significantly longer operation time (MD = -56.74 min, 95% CI [-73.41, -40.07], p < 0.05) but shorter hospital stay (MD = 0.26 days, 95% CI [0.03, 0.49], p < 0.05). The incidence of transient recurrent laryngeal nerve injury was significantly higher in the TOETVA group than in the TORT group (OR = 3.56, 95% CI [1.14, 11.06], p = 0.03). There were no significant differences between the two groups in the number of lymph nodes dissected, the number of metastatic central compartment lymph nodes, the incidence of permanent recurrent laryngeal nerve injury, mental nerve injury, transient or permanent hypoparathyroidism, seroma, surgical site infection, or postoperative hemorrhage. CONCLUSION: Although TORT is associated with longer operative time, it demonstrates potential advantages in terms of length of hospital stay and neuroprotection.The two procedures are comparable in terms of radicality of lymph node dissection, postoperative pain, and low complication rates. TORT is a safe and effective minimally invasive surgical option with better neural protection, especially suitable for patients prioritizing cosmetic outcomes. Long-term oncological safety still needs to be verified in future multicenter studies with larger samples and longer follow-up durations.
18 May 2026
Read appraisal →Journal of robotic surgery
Comparative outcomes of da Vinci SP versus da Vinci Xi platforms in robotic cholecystectomy: a systematic review and meta-analysis
As robotic cholecystectomy adoption accelerates, the evidence comparing the perioperative outcomes of the Da Vinci Xi (DV-Xi) multiport platform to the Da Vinci Single-Port (DV-Sp) platform remains scarce. This meta-analysis provides the first systematic comparison of perioperative outcomes between these platforms. To compare perioperative safety and operative efficiency outcomes between the DV-Sp and the DV-Xi systems performing cholecystectomy. We thoroughly searched PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov from inception till December 22, 2025. The key outcomes of interest included mean operative time, console time, docking time, pain scores on the day of the operation, pain scores after 24 h, estimated blood loss, and length of hospital stay. We conducted random-effects meta-analysis and leave-one-out sensitivity analysis using RStudio v 4.5.2. The ROBINS-I was used for the risk of bias assessment. A GRADE assessment through GRADEpro was performed. Four observational studies comprising 833 patients (DV-Sp: n = 416; DV-Xi: n = 417) met the set inclusion criteria, and no RCTs were found. The DV-Sp showed significantly decreased mean operative time (MD = -2.41 min; 95% CI - 4.09 to - 0.73, p = 0.0049) and console time (MD = - 7.24; 95% CI - 9.77 to - 4.72, P < 0.0001) with no heterogeneity (I² = 0%). Two studies reported reduced pain scores in the DV-SP group. There was no significant difference found in the pooled estimates of post-operative pain scores, blood loss, docking time, and length of hospital stay between the two platforms. The DV-Sp demonstrated modest but consistent reductions in operative and console time with comparable safety to the DV-Xi system. Pain scores on the day of surgery and after 24 h of operation were reported low in the DV-SP group. While the magnitude of time differences is unlikely to impact individual patient outcomes, cumulative reductions across high-volume operating centers may translate into meaningful gains in operating room efficiency. However, substantial heterogeneity, particularly in pain-related outcomes and docking time, warrants cautious interpretation of these outcomes.
17 May 2026
Read appraisal →Techniques in coloproctology
Bridging the gap: a systematic literature review and meta-analysis on the management of rectal wall defect after transanal excision
BACKGROUND: Transanal resection techniques have gained considerable importance in the treatment of benign and malignant rectal neoplasms. However, there is no definitive consensus on whether the rectal defect should be closed or left open after excision. We sought to provide an updated pooled analysis of the management of rectal wall defect after transanal excision. METHODS: In accordance with PRISMA and Cochrane guidelines, this meta-analysis was performed using the PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Google Scholar databases to identify studies comparing perioperative outcomes after rectal defect closure versus leaving the defect open following full-thickness (FT) excision. Odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using Cochrane's Q test. Risk of bias and certainty of evidence were judged by ROBINS-I and GRADE, respectively. RESULTS: Six comparative studies meeting the inclusion criteria were included in the final analysis. Closing the rectal defect was associated with significantly reduced rectal bleeding (OR = 0.57, 95% CI: 0.35-0.94, p = 0.03; I2 = 26%) and re-admission rates (OR = 0.34, 95% CI: 0.16-0.76, p = 0.008; I2 = 0%) compared with the open group, while other outcomes were not significantly different. A prolonged operative time was noted when the rectal wall defect was sutured (SMD = 0.15, 95% CI: 0.03-0.28, p = 0.02; I2 = 44%). CONCLUSIONS: The present analysis revealed that both approaches are safe and technically feasible; however, closing the rectal wall defect after FT excision of rectal neoplasms was associated with lower bleeding and re-admission rates. Nevertheless, randomized studies with homogeneous protocols and consistent long-term outcome data are still needed to provide definitive answers.
17 May 2026
Read appraisal →Journal of robotic surgery
Robot-assisted versus laparoscopic distal pancreatectomy: an updated systematic review and meta-analysis including patient subgroups and meta-regression analyses
Robot-assisted distal pancreatectomy (RDP) was developed to overcome technical limitations of laparoscopic distal pancreatectomy (LDP), yet uncertainty persists regarding oncologic adequacy, learning-curve effects, and outcomes in high-risk subgroups. We synthesized current evidence to address these gaps. We systematically searched PubMed and EMBASE, in accordance with PRISMA guidelines, from inception to 2025 to identify comparative studies of RDP versus LDP. Using random-effects models, we calculated weighted mean differences (WMDs) for continuous outcomes and risk ratios (RRs) for dichotomous outcomes, and performed subgroup analyses, including pancreatic ductal adenocarcinoma (PDAC), along with meta-regression to explore heterogeneity sources. Sixty-four studies comprising 15,790 patients (5,723 RDP; 10,067 LDP; mean age 60.5 years; BMI 26.1 kg/m²) were included. RDP resulted in lower blood loss (WMD - 52.0 mL; p < 0.00001), fewer conversions (RR 0.49; p < 0.00001), and fewer unplanned splenectomies (RR 0.59; p < 0.0001). Operative time was longer (WMD + 24.06 min; p < 0.00001). Postoperative morbidity, POPF, PPH, infection, reintervention, and mortality were comparable. Length of stay was shorter with RDP (WMD - 0.57 days; p < 0.00001). Although lymph node yield appeared higher with LDP in the overall and PDAC cohorts, this difference was no longer significant in a sensitivity analysis, and R0 resection rates remained comparable. Costs were higher with RDP, with substantial heterogeneity. RDP and LDP demonstrate comparable safety and oncologic outcomes. RDP reduces blood loss, conversions, and splenectomy but increases operative time and cost. The operative time disadvantage likely reflects learning-curve. Selective use in high-risk and complex resections is supported; cost-effectiveness warrants further study.
15 May 2026
Read appraisal →Journal of robotic surgery
Robotic versus laparoscopic low anterior resection for rectal cancer: an updated systematic review and meta-analysis
Robotic surgery has increasingly been adopted for the treatment of rectal cancer. However, most previous meta-analyses included heterogeneous rectal procedures, limiting conclusions specific to low anterior resection. The present study aimed to provide an updated systematic review and meta-analysis comparing robotic versus laparoscopic low anterior resection for rectal cancer. This systematic review and meta-analysis was conducted according to PRISMA guidelines and recommendations from the Cochrane Handbook. PubMed, Scopus, and the Cochrane Library were systematically searched from inception to the most recent date. Comparative studies evaluating robotic low anterior resection (R-LAR) versus laparoscopic low anterior resection (L-LAR) for rectal cancer were included. Risk of bias was assessed using RoB 2 for randomized trials and ROBINS-I for non-randomized studies. Certainty of evidence was evaluated using the GRADE approach. Thirty-three studies including 82,149 patients were analyzed (R-LAR: 56,290; L-LAR: 25,859). R-LAR was associated with a significantly lower conversion rate (OR 0.45, 95% CI 0.40-0.51, p < 0.00001, I²=28%), lower 30-day reoperation rate (OR 0.86, 95% CI 0.77-0.96, p = 0.01, I²=0%), reduced 30-day mortality (OR 0.65, 95% CI 0.52-0.82, p = 0.002, I²=0%), and higher rate of complete total mesorectal excision (OR 2.71, 95% CI 1.38-5.33, p = 0.01, I²=72%). Operative time was significantly longer in the robotic group (MD + 30.58 min, 95% CI 13.71-47.45, p = 0.001, I²=97%). No significant differences were observed for estimated blood loss, overall complications, major complications, anastomotic leakage, postoperative ileus, recovery parameters, length of hospital stay, readmission, circumferential margin positivity, lymph node yield, local recurrence, diverting ileostomy formation, disease-free survival, or overall survival. Robotic LAR may reduce conversion, reoperation, and short-term mortality and may improve completeness of total mesorectal excision, although operative time is longer. These findings suggest potential technical advantages of R-LAR, but high-quality randomized trials are required to determine whether these translate into meaningful clinical benefit.PROSPERO: CRD420261326600.
15 May 2026
Read appraisal →Journal of robotic surgery
Robotic versus laparoscopic intracorporeal anastomosis learning curve: a systematic review
The learning curve for robotic colorectal surgery is increasingly characterised. However, the specific learning curve for intracorporeal anastomosis (IA) remains poorly defined. This review compares robotic and laparoscopic IA with respect to operative time, cases required for proficiency, complication rates, and conversion to extracorporeal anastomosis (EA). A systematic review was conducted in accordance with PRISMA guidelines. The protocol was registered on Open science framework ( https://doi.org/10.17605/OSF.IO/K4MYZ ). On March 18, 2025, OVID and PubMed were searched using the search terms; "laparoscopic," "robotic," "anastomosis," "learning," "education," and "training." Yielding a total of 273 results from PubMed (179) and OVID (94). After screening a total of thirteen studies were included. Thirteen studies met inclusion criteria, including eight comparative analyses and six directly comparing robotic and laparoscopic techniques. Four studies evaluated robotic learning curves without a comparator group, while one was a literature review incorporating institutional experience. Most studies were retrospective (n = 8), with two prospective clinical studies and two experimental simulation-based studies. Hybrid approaches (robotic mobilisation with laparoscopic EA) contributed to heterogeneity (Reitz et al. 2018, https://doi.org/10.1007/s00464-018-6074-7 ). Learning curve assessment was heterogeneous, with most studies using cumulative sum (CUSUM) or risk-adjusted CUSUM (RA-CUSUM) analyses based on operative time or technical performance metrics. Proficiency in robotic IA was reported after approximately 11-29 cases in some series and around 20 cases in others, although larger studies of robotic colorectal surgery demonstrated broader ranges of up to 100 cases. Robotic right hemicolectomy with IA demonstrated a shorter learning curve and reduced anastomosis time compared with laparoscopic IA. Complication rates, conversion rates, and oncological outcomes were comparable between approaches (Gachabayov et al. 2019, Surg Technol Int, 34:163-168). Robotic intracorporeal anastomosis, particularly in right hemicolectomy, appears to have a shorter and less technically demanding learning curve compared with laparoscopic techniques, without compromising safety or oncological outcomes. These findings support a potential role for robotic platforms in facilitating adoption of intracorporeal anastomosis. However, current evidence is limited by retrospective design, small cohorts, and inconsistent definitions of proficiency (Gachabayov et al. 2019, Surg Technol Int, 34:163-168; Van Eetvelde et al. 2022, https://doi.org/10.1007/s11701-022-01514-6 ).
14 May 2026
Read appraisal →World journal of urology
Quantifying ergonomic challenges for urologists operating flexible ureteroscopes through artificial intelligence-based posture estimation
PURPOSE: The ergonomic challenges faced by surgeons during flexible ureteroscopy have yet to be thoroughly evaluated using objective methods. However, robot-assisted ureteroscopy has emerged as a promising treatment for urinary stones. The present study quantitatively assesses operative posture during transurethral ureteroscopy via an artificial intelligence-based posture estimation framework, and identifies kinematic differences associated with surgical expertise. METHODS: Expert and novice urologists performed standardized flexible ureteroscopic tasks in a simulated transurethral ureteroscopy environment using kidney phantoms containing artificial stones. Upper-body movements were continuously video-recorded and joint coordinates of the shoulders, elbows, and wrists were extracted using an artificial intelligence-based pose estimation system. Kinematic parameters were quantitatively analyzed and compared between groups. RESULTS: Experts completed observation of the entire renal pelvis significantly faster than novices (median 58 vs. 102 s, p < 0.001). Accumulated travel distance was markedly less in experts for the left shoulder (125 vs. 300 cm, p < 0.001), right elbow (324 vs. 1035 cm, p = 0.028), left elbow (349 vs. 772 cm, p = 0.019), and left wrist (729 vs. 3798 cm, p < 0.001). Experts had smaller movement areas at the left shoulder (6.29 vs. 40.5 cm2, p < 0.001) and right elbow (17.3 vs. 281 cm2, p = 0.040), and reduced movement ranges across multiple joints. Their angle fluctuation ranges were also narrower for the right shoulder (32.0 vs. 76.3°, p = 0.028) and left elbow (70.4 vs. 122.4°, p < 0.001). CONCLUSIONS: The artificial intelligence-based posture analysis objectively demonstrated ergonomic advantages associated with surgical expertise during flexible ureteroscopy and revealed persistent ergonomic risks to the wrist and elbow.
11 May 2026
Read appraisal →BMJ open
Indocyanine green fluorescence for intraoperative detection of liver tumours in minimally invasive surgery: protocol for the LIVERGREEN phase IV multicentre clinical trial
INTRODUCTION: Liver tumours are a leading cause of global morbidity and mortality. Current diagnostic tools, including computed tomography (CT), magnetic resonance imaging (MRI) and intraoperative ultrasound (IOUS), have limitations in detecting liver neoplasms. Indocyanine green (ICG) has emerged as a promising tool for improving liver tumour detection. This study aims to assess the impact of preoperative ICG on intraoperative tumour detection in minimally invasive surgery and develop a machine-learning algorithm to enhance tumour detection using ICG fluorescence. METHODS AND ANALYSIS: This prospective, multicentre, phase IV clinical trial adheres to Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines. Patients with liver tumours eligible for minimally invasive surgery and a preoperative imaging test will be included. ICG will be administered intravenously 24 hours before surgery. Intraoperative procedures will include IOUS, ICG mapping and photographic documentation. Patients will be followed for 90 days to assess tumour progression, morbidity and mortality. The photographic analysis will enable the development of an artificial intelligence algorithm using machine learning and neural networks to identify lesions based on ICG fluorescence. The estimated sample size is 173 patients and the trial is predicted to accrue in 3 years. ETHICS AND DISSEMINATION: The trial will be conducted in accordance with the Declaration of Helsinki and the Spanish Agency of Medicines and Medical Devices (AEMPS) guidelines. Approved by the local institutional Ethics Committee and the AEMPS, the results will be shared with the scientific community through publications and conferences. EUDRACT NUMBER: 2023-5 08 316-27-00. TRIAL REGISTRATION NUMBER: NCT06398028. PROTOCOL VERSION: V.12, 18 March 2025.
18 Apr 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 →Scientific reports
Effects of different inflatable heater temperature settings on early postoperative recovery after hysteroscopic surgery: a randomized clinical trial
To investigate the effect of perioperative temperature settings of an inflatable warming device on postoperative recovery quality in patients undergoing hysteroscopic myomectomy, this randomized controlled trial enrolled 258 patients receiving laryngeal mask general anesthesia at Xuzhou Central Hospital, China, between March 2022 and August 2024. Patients were allocated to perioperative temperature management with an inflatable warming device set to 38 °C (Group L, n = 129) or 43 °C (Group H, n = 129). A total of 211 patients were included in the final analysis after accounting for exclusions. At 24 h postoperatively, the QoR-40 score was significantly higher in Group H compared to Group L (P < 0.05). At baseline (T0), no significant differences in core body temperature, mean arterial pressure (MAP), or heart rate (HR) were observed between groups (P > 0.05). From T1 to T6, Group H exhibited higher and more stable core body temperature, MAP, and HR compared to Group L (P < 0.05). There were no statistically significant differences in QoR-40 scores at 48 h (P > 0.05) or in the incidence of postoperative restlessness, chills, and infection between the two groups. Compared to 38 °C, the perioperative application of a 43 °C inflatable warming device improved early postoperative recovery quality at 24 h in hysteroscopic myomectomy patients without increasing complication risks.
10 Apr 2026
Read appraisal →Archives of gynecology and obstetrics
Vaginal natural orifice transluminal endoscopic surgery versus laparoscopy for ovarian cystectomy: a prospective, open-label, randomized, non-inferiority pilot trial
PURPOSE: Vaginal natural orifice transluminal endoscopic surgery (vNOTES) is an innovative minimally invasive procedure. The study aimed to evaluate whether vNOTES achieves non-inferior results compared to conventional laparoscopy in patients undergoing ovarian cystectomy. METHODS: Participants with benign ovarian tumors were randomly assigned (1:1) to undergo laparoscopy or vNOTES. Randomization was stratified based on the size of the ovarian tumor. Patients and surgeons were aware of the allocated procedures. The primary outcome was the proportion of patients successfully treated by the allocated procedure (non-inferiority hypothesis, margin of 15%). The secondary outcomes included operative time, estimated blood loss, time for specimen retrieval, postoperative pain score, use of analgesics, time to first flatus, and perioperative complications. RESULTS: Sixty-four patients were randomly assigned to laparoscopy (n = 32) and vNOTES (n = 32) and were included in the intention-to-treat analysis. The success rates were 100% and 96.9%, respectively. Non-inferiority of vNOTES was demonstrated, as the lower limit of the one-sided 95% confidence interval for the stratified risk difference was -12.7%, which lies above the pre-specified non-inferiority margin of -15%. The vNOTES group exhibited lower pain scores, with a median difference of -1 (95% CI -1 - -1, p < 0.001). CONCLUSION: vNOTES demonstrates non-inferiority to laparoscopy for ovarian cystectomy in selected patients, with notable advantages in cosmetic outcomes and reduced postoperative pain. CLINICAL TRIAL IDENTIFICATION NUMBER: ChiCTR2300070890.
4 Apr 2026
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