Clinical decision rules for appendicitis are not used by surgeons in training: A survey.

BACKGROUNDS: We aimed to investigate surgeons in training knowledge of clinical decision rules (CDR) for diagnosing appendicitis and their attitudes toward implementing them. METHODS: We included surgeons in training practicing in East Denmark who independently could decide to perform a diagnostic laparoscopy for suspected appendicitis. The survey was developed in Research Electronic Data Capture and face-validated before use. It consisted of three parts: (1) the characteristics of the surgeons, (2) their diagnostic approach, and (3) their knowledge and attitude toward introducing CDR in the clinic. Data were collected in January 2023. RESULTS: We achieved 83 (90%) responses, and 52% of surgeons in training believed that appendicitis was difficult to diagnose. Their diagnostic approach mostly included symptoms and physical examinations for abdominal pain, and C-reactive protein. A total of 48% knew of at least one clinical decision rule, and 72% had never used a clinical decision rule. Regarding the necessity of CDR in clinical practice, surgeons in training options were divided into thirds: not needed, neither needed nor not needed, and needed. Surgeons in training indicated that CDR needed to be validated and easily applied before they would implement them. CONCLUSION: Approximately 3/4 of surgeons in training had never utilized a clinical decision rule to diagnose appendicitis, and only half knew of their existence. The symptoms and findings incorporated in most CDR aligned with their diagnostic approach. They were conflicted if CDR needed to be implemented in clinical practice.

Anal incontinence in adults.

Anal incontinence affects more than 7% of the population, but it is likely to be underreported due to its sensitive nature. This review summarises the current knowledge of managing this condition. Initial diagnosis and evaluation of anal incontinence, as well as basic conservative treatment, can be managed in primary care. This may include patient education about the nature of the condition, as well as advice about appropriate diet, toilet routine, and lifestyle adjustments. Incontinence due to diarrhoea or constipation may be treated pharmacologically. If necessary, patients should be referred for specialised evaluation and treatment.

Robot-assisted groin hernia repair is primarily performed by specialized surgeons: a scoping review.

Surgical residents routinely participate in open and laparoscopic groin hernia repairs. The increasing popularity of robot-assisted groin hernia repair could lead to an educational loss for residents. We aimed to explore the involvement of surgical specialists and surgical residents, i.e., non-specialists, in robot-assisted groin hernia repair. The scoping review was reported according to PRISMA-ScR guideline. A protocol was uploaded at Open Science Framework, and a systematic search was conducted in four databases: PubMed, EMBASE, Cochrane CENTRAL, and Web of Science. Included studies had to report on robot-assisted groin hernia repairs. Data charting was conducted in duplicate. Of the 67 included studies, 85% of the studies described that the robot-assisted groin hernia repair was performed by a surgical specialist. The rest of the studies had no description of the primary operating surgeon. Only 13% of the included studies reported that a resident attended the robot-assisted groin hernia repair. Thus, robot-assisted groin hernia repair was mainly performed by surgical specialists, and robot-assisted groin hernia repair therefore seems to be underutilized to educate surgical residents.

A Critical Appraisal of the Chronic Pain Rate After Inguinal Hernia Repair.

Purpose: To critically appraise highly cited studies reporting on the rate of chronic pain after inguinal hernia repair. Methods: Google Scholar was searched on 23 May 2022. We only included publications with more than 10 citations per year since publication and more than 100 citations in total. Both reports of original data and systematic reviews were included. Risk of bias and quality of the included studies were assessed with either the Joanna Briggs Institute Checklist for Prevalence Studies or the AMSTAR 2 depending on study design. Results: Twenty studies were included and evaluated. The rate of chronic postoperative inguinal pain of any degree ranged from 10%-63%, and the rate of moderate-to-severe pain ranged from 1%-18%. All studies reported the rate of pain of any degree, and most studies reported the rate of moderate-to-severe pain influencing daily activities. Studies used different temporal definitions of chronic pain, but most studies defined it as pain persisting either three or six months postoperatively. Ten studies used unvalidated questionnaires or significantly modified versions of validated questionnaires. Eleven studies primarily included patients receiving open repair. Included studies had median 21 citations per year (range 10-39) and median 387 citations in total (range 127-788). Conclusion: The rates of chronic postoperative inguinal pain reported in the included highly cited studies are possibly inaccurate, excessive, and outdated. New prospective studies based on uniform definitions and standards of measurement are warranted to better assess a contemporary chronic pain rate after inguinal hernia repair.

Oral melatonin did not reduce anxiety before elective hernia repair: A randomised, double-blinded, placebo-controlled trial.

BACKGROUND: Preoperative anxiety is a common issue in surgery. Preoperative anxiety may lead to increased mortality, pain and dissatisfaction with surgery. Melatonin is a drug with only mild adverse effects and has previously been shown to reduce anxiety and pain in the perioperative setting. The aim of study was to investigate the anxiolytic effect of melatonin in the preoperative setting. METHODS: This study was a randomised, double-blinded, placebo-controlled clinical trial. Included patients were allocated in the ratio 1:1 to either the placebo group or the melatonin group. Patients received 10 mg melatonin or placebo the evening before surgery, 2 h before surgery, immediately after surgery and the evening after surgery. Preoperative anxiety was examined 1 h before surgery, using the State Trait Anxiety Inventory (STAI) questionnaire, along with a Visual Analogue Scale (VAS) of anxiety. Furthermore, participants filled out a sleep log each morning, where we examined sleep quality, comfort and drowsiness. RESULTS: Sixteen patients received placebo treatment and 17 patients received melatonin. Median state anxiety on the STAI scale at baseline was 27 (interquartile range [IQR] 22-34) for the melatonin group and 27 (IQR 23-31) for the placebo group. In the primary outcome of preoperative anxiety 1 h before surgery, the median state anxiety on the STAI scale was 27 (IQR 24-34) for the melatonin group and 28 (24-33) for the placebo group, p = .814. VAS anxiety was median 7 (0-28) for the melatonin group and median 7 (1-13) for the placebo group, p = .813. Furthermore, there were no statistically significant differences between the two groups in the secondary outcomes of sleep quality and consumption of analgesics. CONCLUSION: Melatonin did not reduce preoperative anxiety in patients undergoing hernia repair. Preoperative anxiety levels were low, which limits the generalisability of our findings.

Long-term mortality and intestinal obstruction after laparoscopic cholecystectomy: A systematic review and meta-analysis.

BACKGROUND: Long-term outcomes of cholecystectomy are largely unknown though it is a common procedure in general surgery. We aimed to investigate the long-term mortality rate and incidence of intestinal obstruction after laparoscopic cholecystectomy. MATERIALS AND METHODS: This systematic review and meta-analysis was reported according to the PRISMA 2020 and AMSTAR guidelines. A protocol was registered on PROSPERO (CRD42020178906). The databases PubMed, EMBASE, and Cochrane CENTRAL were last searched on February 9, 2022 for original studies on long-term complications with n > 40 and follow-up ≥ 6 months. Outcomes were long-term mortality and incidence of intestinal obstruction, and meta-analyses were conducted. Risk of bias was assessed with Newcastle-Ottawa Scale and Cochrane "Risk of bias"-tool according to study design. RESULTS: We included 41 studies that reported long-term follow-up on 1,000,534 patients. Of these, 38 studies reported on mortality (514,242 patients) that ranged from 0 to 32%. Meta-analysis estimated a long-term mortality rate of 2.0% (95% CI 1.7-2.3%) after laparoscopic cholecystectomy. Five studies including 486,292 patients reported on intestinal obstruction that ranged from 0 to 6%. Meta-analysis estimated a long-term rate of intestinal obstruction of 1.3% (95% CI 0.8-1.8%). CONCLUSION: Long-term mortality after laparoscopic cholecystectomy was 2%. The incidence of long-term intestinal obstruction after laparoscopic cholecystectomy was 1.3%.

Postoperative outcomes that matter to patients undergoing inguinal hernia repair: A qualitative study.

Background: The purpose was to explore which postoperative outcomes are important to patients operated for inguinal hernia to gain a better insight into the patient experience going through surgery. Methods: A qualitative study was performed using semistructured individual interviews. Participants were all male and had undergone inguinal hernia repair. Data were analyzed with directed content analysis. Results: Ten patients were interviewed. Identified domains were function, sensation, expectations, appearance, social aspects, and satisfaction with surgeon/staff. Preoperative functional limitations were the main motivation for seeking surgery, and postoperative functional improvement seemed to be the most important factor determining overall patient satisfaction. Conclusion: Patients consider a wide range of factors when assessing the outcome of their inguinal hernia repair. Our results suggest that the current practice of outcome assessment of inguinal hernia repair with focus on recurrence may be too narrow and may not adequately reflect the patients' experience. Summary: This qualitative study explored patients' perspectives on postoperative outcome after inguinal hernia repair, and the identified domains of importance were function, sensation, expectations, appearance, social aspects, and satisfaction with surgeon/staff. These results highlight that patients emphasize a wide range of elements when assessing the outcome of their inguinal hernia repair that are important to acknowledge, as current practice of outcome assessment of inguinal hernia repair may be too narrow.

Development of a core outcome set for groin hernia trials: a study protocol.

INTRODUCTION: Reporting of outcomes in groin hernia trials is inconsistent and poorly defined thereby limiting the production of high-quality meta-analyses. Outcome reporting can be standardised and improved through consensus-based development of a core outcome set, which is a minimum set of outcomes recommended to be reported in all effectiveness trials within a specific field of research. We aim to develop a core outcome set for effectiveness trials within clinical groin hernia research. METHODS: The study is divided into three phases. Phase 1 is an update of a systematic review on outcome reporting in groin hernia trials, which will identify relevant outcomes of groin hernia repair. In Phase 2, we will conduct multiple Delphi rounds to achieve consensus on which of the identified outcomes are most important. These Delphi rounds will involve important stakeholders in the field, i.e. patients, surgeons and researchers. In Phase 3, we will organise a consensus meeting to determine the final contents of the core outcome set. The meeting will involve the expert members of the study Steering Committee and invited key stakeholders. Data collection permissions and ethical approvals will be sought from the appropriate national and local authorities. CONCLUSION: Development of a core outcome set for groin hernia trials is necessary and feasible. FUNDING: none. TRIAL REGISTRATION: COMET Database (registration no.: 1331) https://www.comet-initiative.org/Studies/Details/1331.

Low long-term incidence of incisional hernia after cholecystectomy: A systematic review with meta-analysis.

BACKGROUND: Various surgical approaches are available for cholecystectomy, but their long-term outcomes, such as incidence of incisional hernia, are largely unknown. Our aim was to investigate the long-term incidence of incisional hernia after cholecystectomy for different surgical approaches. METHODS: This systematic review and meta-analysis was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42020178906). Three databases were searched for original studies on long-term complications of cholecystectomy with n > 40 and follow-up ≥6 months for incisional hernia. Risk of bias within the studies was assessed using the Newcastle-Ottawa Scale and the Cochrane "risk of bias" tool. Meta-analysis of the incidence of incisional hernia after 6 and 12 months was conducted when possible. RESULTS: We included 89 studies. Of these, 77 reported on multiport or single-incision laparoscopic cholecystectomy. Twelve studies reported on open cholecystectomy and 4 studies on robotic cholecystectomy. Weighted mean incidence proportion of incisional hernia after multi-port laparoscopic cholecystectomy was 0.3% (95% confidence interval 0-0.6) after 6 months and 0.2% after 12 months (95% confidence interval 0.1-0.3). Weighted mean incidence of incisional hernia 12 months postoperatively was 1.5% (95% confidence interval 0.4-2.6) after open cholecystectomy and 4.5% (95% confidence interval 0.4-8.6) after single-incision laparoscopic cholecystectomy. No meta-analysis could be conducted for robotic cholecystectomy, but incidences ranged from 0% to 16.7%. CONCLUSION: We found low 1-year incidences of incisional hernia after multiport laparoscopic and open cholecystectomy, whereas risks of incisional hernia were considerably higher after single-incision laparoscopic and robotic cholecystectomy.

Patient-Reported Outcome Measures for Patients Undergoing Inguinal Hernia Repair.

There are many ways to determine the success of an inguinal hernia operation. Traditional measures are hernia recurrence, neuralgia, mesh infection, or rather the absence of these complications. While these traditional measures obviously have their merits, alternative outcomes are emerging, and researchers and clinicians are gaining an increasing interest in patient-reported outcomes and patient reported outcome measures (PROMs). PROMs are patient questionnaires concerning quality of life, chronic pain, disability, or other subjects that are best assessed by the patients. PROMs come in two different forms: generic and condition specific. The generic PROMs concern general symptoms and issues, while the condition-specific PROMs target patients with a certain condition. Inguinal hernia-specific PROMs typically address issues like mesh-related symptoms, groin pain, sexual dysfunction, etc. Clinical measurement instruments such as PROMs should be carefully validated according to standardized guidelines to ensure their psychometric measurement properties. Unfortunately, this type of evidence is often lacking when it comes to inguinal hernia-specific PROMs. In this review, we explain why PROMs are useful for patients with inguinal hernia and why one should use inguinal hernia-specific PROMs as opposed to the generic ones. We address the importance of population-specific validation and explain what type of evidence is lacking. Last, we discuss the future prospects of using PROMs for patients with inguinal hernia.

Patient-reported outcome measures for inguinal hernia repair are insufficiently validated: a systematic review.

PURPOSE: To systematically assess the validity of patient-reported outcome measures (PROMs) for patients undergoing inguinal hernia repair. DATA SOURCES: A systematic review was performed according to the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) guideline for systematic reviews of PROMs. PubMed, EMBASE and PsycINFO were consulted. STUDY SELECTION: Only studies explicitly aimed at validation of PROMs specific for patients with inguinal hernia were included. DATA EXTRACTION: Data regarding measurement properties of PROMs were extracted from the included studies. Each study was critically assessed for methodological quality and each PROM was evaluated for sufficient measurement properties. RESULTS OF DATA SYNTHESIS: We included 15 studies, covering 11 different PROMs. The Carolinas Comfort Scale was the most frequently investigated PROM, being covered in five of the included publications. The included PROMs were evaluated according to nine different measurement properties, of which internal consistency and construct validity were the most frequently assessed. Evidence regarding content validity and structural validity was universally inadequate, according to the criteria for good measurement properties, as defined by the COSMIN. CONCLUSION: Based on the current evidence, it is not possible to formulate recommendations for application of PROMs for patients undergoing inguinal hernia repair. Further validation of the included PROMs is necessary especially regarding content validity and structural validity.