Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 5 appraisals
Hernia : the journal of hernias and abdominal wall surgery
Open versus laparoscopic repair in pediatric incarcerated inguinal hernia: a systematic review and meta-analysis
PURPOSE: The optimal surgical approach for pediatric incarcerated inguinal hernia remains controversial. This study aimed to systematically compare the clinical outcomes of laparoscopic repair (LH) and open repair (OH) in children with incarcerated inguinal hernia through a systematic review and meta-analysis. METHODS: A comprehensive literature search was conducted in PubMed, Embase, Web of Science, and the Cochrane Library from database inception to March 2026. Comparative studies evaluating LH versus OH in pediatric incarcerated inguinal hernia were included. Primary outcomes included operative time, intraoperative blood loss, and length of hospital stay. Secondary outcomes included intraoperative injury, wound infection, testicular atrophy, and recurrence. Pooled mean differences (MD) and odds ratios (OR) with 95% confidence intervals (CI) were calculated using Review Manager 5.4. RESULTS: Nine studies involving 584 pediatric patients were included in the meta-analysis. Compared with OH, LH was associated with significantly shorter operative time and reduced intraoperative blood loss. The length of hospital stay was also significantly shorter in the LH group. In addition, LH showed a significantly lower risk of intraoperative injury and recurrence. No statistically significant differences were observed between the two groups in terms of wound infection or testicular atrophy. CONCLUSIONS: Laparoscopic repair appears to be a safe and effective alternative to open repair for pediatric incarcerated inguinal hernia. Further high-quality prospective studies are warranted to confirm these findings.
14 May 2026
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Chronic pain after Shouldice versus Lichtenstein inguinal hernia repair: a systematic review and meta-analysis
PURPOSE: The Lichtenstein (mesh) and Shouldice (non-mesh) techniques are the main options for open inguinal hernia repair. This systematic review and meta-analysis compared the prevalence of chronic postoperative pain between them. METHODS: A systematic search was conducted in Medline, Embase and Cochrane databases for studies comparing the prevalence of chronic pain after Shouldice and Lichtenstein techniques in adult patients undergoing inguinal hernia repair. Meta-analysis was performed using RevMan and the effect model was determined based on heterogeneity, assessed by the I² statistic. Subgroup analyses were conducted by mean follow-up duration and study design. RESULTS: Ten studies with 4,122 patients (59.8% Lichtenstein) were included. Shouldice repair was associated with a 34% relative risk reduction in chronic postoperative pain compared to Lichtenstein (RR 0.66; 95%CI 0.56-0.78; p < 0.00001; I² = 5%). Conversely, the Shouldice technique demonstrated a higher risk of long-term hernia recurrence (RR 2.54; 95%CI 1.15-5.63; p = 0.02). There were no statistically significant differences between the two techniques regarding early postoperative complications (RR 1.01; 95%CI 0.85-1.19; p = 0.95) or mean operative time (MD 5.96 min; 95%CI -0.79 to 12.71; p = 0.08). CONCLUSION: Although the Lichtenstein repair is more widely practiced, the Shouldice technique yields significantly lower rates of chronic postoperative pain, albeit with a higher risk of long-term recurrence. This trade-off highlights Shouldice as a potential alternative in selected patients.
14 May 2026
Read appraisal →Hernia : the journal of hernias and abdominal wall surgery
Can preoperative optimization improve abdominal wall surgery outcomes? a qualitative systematic review.
BACKGROUND: Ventral hernia repair (VHR) is commonly performed in patients with multiple modifiable risk factors. Preoperative rehabilitation programs aim to optimize these risk factors and improve surgical outcomes; however, their implementation and effectiveness remain variable. This systematic review evaluates current evidence on the role of preoperative optimization in patients undergoing VHR. MATERIALS AND METHODS: Cochrane Central, Embase, and PubMed were searched for studies comparing preoperative interventions versus standard care in patients undergoing VHR. The primary outcome was characterization of rehabilitation strategies. Secondary outcomes included surgical utilization, emergent repair, readmission, surgical site infection (SSI), surgical site occurrence (SSO), recurrence, reoperation, and mortality. RESULTS: Six studies were included, comprising a total of 3,556 patients, of whom 1,805 (50.7%) underwent preoperative optimization. Preoperative optimization interventions were highly heterogeneous and primarily consisted of multidisciplinary programs focused on exercise, weight loss, and lifestyle modification. Control groups varied widely, precluding formal meta-analysis. Studies requiring predefined optimization targets reported unsuccessful rehabilitation rates of 5.1%-45%. Emergent repair occurred in 6.8% of intervention patients in one study. SSI rates seemed lower and ranged from 4.2% to 11.8% in intervention groups versus 11.0%-16.7% in controls, SSO and reoperation rates were generally lower in optimization groups. CONCLUSION: Structured preoperative optimization pathways may be associated with improved short-term outcomes in select patients undergoing VHR. However, the current literature is heterogeneous, and standardized protocols and prospective studies are needed to better define optimal implementation strategies and long-term effectiveness.
11 May 2026
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Report cards and outcome measurements to improve the safety of surgical care (North America): an updated systematic review from Making Healthcare Safer IV
OBJECTIVES: In the USA, an estimated 40-50 million operations are performed annually, with high rates of adverse events. Since the 1980s, report cards have been used for outcome measures and to improve safety of surgical care. As part of Making Healthcare Safer IV-an initiative aimed at publishing evidence-based reviews as they are completed to help healthcare leaders, researchers and policymakers act more quickly on evidence-supported practices-we performed an updated review on the certainty of evidence on patient safety practices related to the use of surgical report cards and outcome measurements. DESIGN: Systematic review using the Grade of Recommendations Assessment, Development and Evaluation (GRADE) approach. DATA SOURCES: PubMed, Web of Science, Scopus and the Cochrane Library were searched from November 2011 to May 2023. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We included primary research studies (randomised control trials or observational studies with a comparison group, including pre-post studies) or observational studies that investigated a surgical report card in adult or paediatric surgical patients at the hospital or surgeon level in inpatient or outpatient settings. Excluded studies included: narrative reviews, scoping reviews, editorials, commentaries, abstracts, studies that measured only patient knowledge or levels of engagement or studies using local surgical dashboard data. DATA EXTRACTION AND SYNTHESIS: Screening and eligibility were done in duplicate, while data extraction was done by one reviewer and checked by a second reviewer. Specific items in the Risk Of Bias In Non-randomised Studies - of Interventions tool and a modification of the National Institutes of Health Tool were used to assess for bias in studies. Two reviewers assessed each study for risk of bias. A modified version of the GRADE framework was used to assess the certainty of evidence. RESULTS: We identified 19 studies that met the inclusion criteria: 13 primary research studies and 6 descriptive studies of surgical collaboratives. Of the primary studies, nine used a pre-post or longitudinal study design and four used a regression discontinuity or concurrent controlled design. Seven of the studies were about the American College of Surgeons National Surgical Quality Improvement Project. Five studies were from single institutions and the remainder included nine to greater than 700 hospitals. Pre-post studies of report cards that prompted quality improvement (QI) programmes all reported improvements in outcomes, longitudinal studies reported benefits in some but not all outcomes and one in four controlled before-and-after studies reported a statistically significant mortality benefit. All studies, except for one, were at moderate or high risk of bias. Six collaboratives were identified with preliminary data. CONCLUSIONS: Based on the above evidence, the theoretical rationale and parallel evidence in other settings, we judged that it was moderate certainty that report cards and outcomes measurements can improve surgical outcomes. However, given the evidence from studies where report cards were actively linked to institutional QI initiatives, we recommend that outcome data must be paired with actionable QI efforts to meaningfully improve patient outcomes.
19 Apr 2026
Read appraisal →Hernia : the journal of hernias and abdominal wall surgery
The impact of socioeconomic status in hernia treatment: a qualitative systematic review.
INTRODUCTION: Hernias are among the most common surgical conditions worldwide. However, access to optimal treatment remains disproportionately distributed. Socioeconomic disparities play a critical role in determining whether patients receive timely surgical intervention, access to minimally invasive techniques, or suffer from postoperative complications due to delayed or suboptimal care. This study aims to evaluate the impact of socioeconomic disparities on the treatment of ventral hernia repair. METHODS: This systematic review was conducted following PRISMA guidelines. A comprehensive search was conducted using MEDLINE/Pubmed, EMBASE, Web of Science, Cochrane Library, and LILACS, from inception until March 2026 without any filter applied. A search strategy was created using the MeSH terms. Our inclusion criteria comprise studies related to socioeconomic disparities in ventral hernia repair within the United States. Due to heterogeneity in study designs, socioeconomic variables, and outcome definitions, a meta-analysis was not feasible, and findings were synthesized using a narrative synthesis. A qualitative assessment of included studies was made using the Cochrane Risk of Bias tool, ROBINS-I. RESULTS: A total of 28 studies were included, encompassing 2,096,513 patients with ventral hernia. Most were retrospective cohorts, with sample sizes ranging from a few hundred to over 665,000 patients. Across studies, patients with government funded insurance (Medicaid or Medicare) generally experienced higher rates of complications, readmissions, and recurrences compared to commercial insured patients, although the magnitude of association varied. Odds ratios demonstrated increased risks of wound complications, readmission, and recurrence among government funded insured and uninsured patients, while commercial insured and higher-income patients were more likely to undergo advanced surgical approaches and had shorter hospital length of stay. Some studies also highlighted socioeconomic and racial disparities, with vulnerable populations and minority groups showing disproportionately higher complication rates and different patterns of insurance coverage. CONCLUSION: This systematic study demonstrates significant racial and socioeconomic disparities in ventral hernia repair. Government funded insurance holders or lower incomers, faced higher complication rates, more emergent presentations, and worse outcomes, including increased mortality and readmissions. Moreover, they usually have less access to minimally invasive and robotic techniques. These inequities highlight systemic barriers in healthcare access.
18 Apr 2026
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