Introduction The percentage of people who are overweight or obese is increasing worldwide. Already today, almost three billion out of 8.2 billion people are overweight. Patients with overweight or obesity are at a higher risk of developing incisional hernias following abdominal procedures. Registry data on open ventral hernia repair reveal rates of 58.5% in the presence of obesity. There are very few studies on the outcome of incisional hernia repair in relation to BMI classes. Materials and methods In a retrospective study of data on incisional hernias in the Herniamed Registry, multivariable analysis of potential confounding factors on the outcome was carried out. The prime focus was on the association of BMI classes, as defined by WHO. Results Following patient selection, 42,081 patients were included in the analysis (normal weight: 22.9%; overweight: 38.5%, and obesity: 38.5%). No association was found between the outcome and the BMI classes with regard to the intraoperative complications, general complications or chronic pain requiring treatment. An unfavorable relationship was identified between higher BMI classes and the postoperative complications, complication-related reoperations and recurrences. A favorable relationship was seen between higher BMI classes and chronic pain at rest and on exertion. Conclusion Since higher BMI classes have a very negative association with the outcome in incisional hernia repair with regard to postoperative complications, complication-related reoperations and recurrence, preoperative weight loss seems to be an important measure to avoid complications and recurrences.

Intercontinental telesurgery is a surgery where surgeons operate on patients across continents using robots and telecommunication connections. Many parts of the world have limited access to safe and reliable surgery. This review is to understand the emerging technology and infrastructure in intercontinental telesurgery to bridge gaps in surgical care. This scoping review synthesized information from peer reviewed and gray literature published between 2001 and 2025. Databases like PubMed, Google Scholar, and Europe PMC were utilized. The review is organized thematically into schematic of intercontinental telesurgery, classification, technological enablers, real-world case studies, framework and guidelines, and legal and ethical issues. 262 records were identified through database searching and manual screening. After removing the duplicates, 250 remained; 39 met the inclusion criteria after screening and text review. The human intercontinental telesurgeries were safely completed with 150–300 ms latency, with no serious complications and outcomes comparable to local robotic surgery. Preclinical models confirmed long-distance viability via hybrid networks with stable latency. Technological catalysts included advanced robotic platforms and enhanced hepatic feedback. Constant obstacles were network instability, legal uncertainty, limited scalability, and surgeon fatigue. Intercontinental telesurgery has the potential to evolve the global surgical inequities, yet its sustainable adaptation needs more than just technological preparedness. Combined efforts in infrastructure development, equitable access, and ethical regulation are necessary. Future systems must ensure that this innovation serves all populations and not just those in high-resource environments by incorporating autonomy, digital twins, and a global legal framework.

Background Early endoscopic retrograde cholangiopancreatography (ERCP) with biliary drainage is recommended for acute cholangitis based on disease severity. However, the optimal timing of ERCP remains unclear. This study aimed to evaluate the impact of urgent ERCP (≤ 24 h) on clinical outcomes in patients with common bile duct (CBD) stone-related acute cholangitis. Methods A retrospective cohort study was conducted among patients who underwent ERCP for acute cholangitis due to CBD stones between 2008 and 2017. Patients were categorized according to ERCP timing: urgent (≤ 24 h) and non-urgent (> 24 h). Outcomes included in-hospital mortality, organ failure at 72 h, length of hospital stay, procedure-related complications, and 30-day readmission. Propensity score matching (PSM) was applied to balance baseline characteristics, including age, sex, comorbidities, Charlson comorbidity index, and cholangitis severity according to the Tokyo Guidelines 2018. Results Among 455 eligible patients, 191 matched pairs were analyzed. The mean age was 66 ± 16 years, and 50% were male. Among them, 21.5% had severe cholangitis, 40.4% moderate, and 38.1% mild disease. Following matching, patient characteristics of the two groups were balanced, except for a higher percentage of patients with moderate cholangitis in the non-urgent group. In-hospital mortality was significantly lower in the urgent ERCP group (0.5% vs 21%; adjusted OR 0.09; 95% CI: 0.01–0.73; p = 0.024). Median hospital stay was shorter (5 vs 8 days; p < 0.001), while stone clearance rates (approximately 75%), persistent organ failure, procedural complications, and readmission were comparable between groups. Subgroup analysis revealed a mortality benefit of urgent ERCP in moderate (p < 0.01) and severe (p = 0.024) cholangitis, but not in mild cases. Conclusions Urgent ERCP within 24 h significantly reduces in-hospital mortality and shortens hospitalization in patients with moderate to severe cholangitis due to CBD stones. These findings support early intervention as a key component of management in this population. Graphical Abstract

Background The impact of perioperative chemotherapy, including neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC), given for resectable colorectal liver metastasis (CLM) remains unclear. This study evaluates the optimal strategy for managing high-risk CLM. Methods The subjects of this retrospective study were patients who underwent liver resection for initially resectable CLM between 2006 and 2021. High-risk status was defined by four or more metastases, a tumor size ≥ 5 cm, or the presence of resectable extrahepatic disease. Among 363 eligible patients, 293 received NAC and 70 underwent upfront surgery. Propensity score matching (PSM) created balanced groups of 70 each. Results Among the patients who received NAC, seven did not undergo resection because they had disease progression. Intention-to-treat analysis revealed significantly longer median progression-free survival (PFS) (1.1 vs. 0.6 years, p < 0.001) and overall survival (OS) (5.2 vs. 4.3 years, p = 0.044) in the NAC group. Matched analysis confirmed superior PFS (1.2 vs. 0.6 years, p = 0.004) and a favorable OS trend (5.4 vs. 4.3 years, p = 0.164). Completion of the perioperative sequence of NAC, surgery, and AC was associated with the most favorable outcomes. Conclusion Achieving a sequential strategy of NAC, surgery, and AC may improve the long-term survival of patients with high-risk CLM, supporting its potential as a standard treatment strategy.

This study evaluated short-term outcomes and learning curves following the introduction of the Intuitive© da Vinci Xi robotic platform for elective colorectal cancer resections at West Hertfordshire Teaching Hospital NHS Trust (WHTH). A smooth transition was enabled by prior experience with the CMR Surgical© Versius platform, with outcomes benchmarked against national data. A prospective cohort study included consecutive patients undergoing elective colorectal resections between April 2024 and March 2025. Data included demographics, diagnosis, operative details, complications, length of stay (LOS), and oncological outcomes. Results were compared with historical laparoscopic data from the National Bowel Cancer Audit (NBOCA, 2019–2022) and Model Health System (MHS, 2024). Learning curves for operative time were assessed using cumulative sum (CUSUM) analysis across three procedures: right hemicolectomy (RH), anterior resection (AR), and abdominoperineal resection (APR).A total of 102 patients were included, with a median age of 69 years (IQR = 60–75), and 54.9% (n = 56) were male. All colonic resections (n = 72) achieved a lymph node yield ≥ 12, significantly higher than the 88.1% in NBOCA (p = 0.001). Among rectal resections (n = 30), 96.7% had negative margins versus 90.1% in NBOCA (p = 0.10). Conversion to open surgery was 3% (n = 3), the anastomotic leak rate was 1% (n = 1), and 4% (n = 4) required a return to theatre. MHS data showed that 13% of all colorectal patients at WHTH had a LOS ≥ 9 days, compared to 29% nationally (p = 0.0001), decreasing to 7.1% in the robotic cohort. CUSUM analysis showed stabilisation after ~ 12 right hemicolectomies and 20 low pelvic resections, with variability among surgeons. Surgeons with prior robotic experience achieved faster proficiency and generated time savings. The successful introduction of the da Vinci Xi platform at WHTH, supported by prior Versius experience, led to excellent oncological outcomes, shorter hospital stays, and low complication rates. These findings highlight the value of structured robotic implementation in advancing colorectal cancer care within the NHS.

Robotic-assisted surgery has transformed minimally invasive procedures by enhancing precision, dexterity, and visualization. However, it presents unique psychomotor and cognitive challenges that traditional surgical training often fails to address. Simulation-based platforms such as the da Vinci Skills Simulator (dVSS) and SimNow are widely implemented, yet a universally accepted standard for assessing robotic surgical proficiency remains elusive. Commonly used evaluation tools—GEARS, OSATS, and expert assessments—vary in standardization and applicability. To systematically review and quantitatively synthesize current evidence on simulation-based robotic surgical training in trainees, focusing on proficiency assessment tools, learning curve thresholds, and skill transfer from conventional surgical techniques. A systematic search of five databases (PubMed, Embase, Scopus, Web of Science, and Cochrane Library) was performed up to June 2025. Eligible studies included trainee populations assessed using validated robotic simulators or evaluation metrics. Data extraction followed PRISMA 2020 guidelines. Pooled effect sizes were calculated using a random-effects meta-analysis. Fourteen studies including 652 surgical trainees met the inclusion criteria. Simulation-based training significantly improved performance on GEARS (SMD 1.22, 95% CI 0.96–1.49) and OSATS (SMD 1.08, 95% CI 0.82–1.34). Task completion times (SMD –0.95) and error rates (SMD–1.03) also improved markedly. Learning curve analyses revealed performance plateaus between 15 and 35 sessions (median: 22). Subgroup analyses showed comparable efficacy between dVSS and SimNow simulators. Skill transfer from laparoscopic surgery showed a moderate effect (SMD ~ 0.40), while no significant benefit was observed from open surgical experience. The integration of expert-defined proficiency thresholds and real-time feedback accelerated skill acquisition and improved self-efficacy scores. Simulation-based training significantly enhances robotic surgical proficiency, especially when integrated with validated metrics and expert feedback. A competency-based framework incorporating performance analytics and learning curve insights is essential for effective training. Future research should prioritize AI-enhanced, personalized training platforms and long-term validation of simulator-acquired skills in clinical practice.

Background Use of Indocyanine green (ICG) dye and near infrared fluorescence has been recently described for visualizing the extrahepatic biliary anatomy during laparoscopic cholecystectomy (LC). The popular route for administration of ICG is intravenous (IV), 30–60 min before surgery. Direct injection of ICG into gall bladder (intracholecystic) (IC) is not commonly used. This study is designed to compare these two routes of ICG for visualization of extrahepatic biliary anatomy. Methods and procedure Forty patients undergoing elective LC were included and randomized into two groups of 20 patients each: IV-ICG and IC-ICG. In the IV-ICG group, ICG was administered in a dose of 0.01 mg/kg, 30–45 min before induction of anesthesia. In the IC-ICG group, ICG was injected directly into the gall bladder fundus using an 18-gauge needle. The two groups were compared with respect to the time of appearance of fluorescence in the biliary tree. A 5-point score was designed to compare the visualization of the biliary anatomy in the two groups. Results The mean visualization score in the IV-ICG group was 4.25 ± 1.17, while that in the IC-ICG group was 4.1 ± 1.18. The cystic duct could be delineated pre-dissection in 70% patients in IV-ICG and in 85% patients in IC-ICG, which changed to 85% and 95%, respectively, after dissection of Calot’s triangle. IV-ICG was found to be better at delineating the common hepatic duct (85%) compared to IC-ICG (45%), while CBD could be seen in 95% and 100% patients, respectively. Two patients in the IC-ICG group had minor leakage of bile from the puncture hole in the fundus. Conclusions This study found that the IC-ICG provides a faster visualization of extrahepatic biliary ducts during LC, with a better signal-to-background ratio compared to the IV-ICG. It can be utilized immediately without the need to wait for the dye to be excreted by the liver.

Background Parastomal hernia (PSH), a common ostomy complication, significantly impairs patient quality of life. Various prophylactic strategies, including surgical (mesh reinforcement) and non-surgical (abdominal wall strengthening exercises, AWSE) interventions, have been proposed, but their comparative effectiveness is unclear. This network meta-analysis primarily assessed PSH incidence. Methods Following PRISMA guidelines, we conducted a systematic review and network meta-analysis. Searches in PubMed, Embase and Web of Science identified randomised controlled trials (RCTs) and observational studies comparing prophylactic PSH prevention strategies. Data on PSH incidence were extracted. Network meta-analysis estimated odds ratios (ORs) and 95% confidence intervals (CIs). Effectiveness was determined by PSH incidence reduction, comparing all prophylactic interventions against a transrectal colostomy control group. Interventions were ranked using surface under the cumulative ranking curve probabilities. Results The analysis included 73 studies (30 RCTs, 44 observational; 7473 patients). Funnel mesh was the most effective intervention (OR 0.09, 95% CI 0.05–0.17), followed by Stapled Mesh stomA Reinforcement Technique (SMART) (OR 0.16, 95% CI 0.05–0.48) and AWSE (OR 0.18, 95% CI 0.08–0.39). Subgroup analyses confirmed consistency in findings across study designs but highlighted variability in ileal conduits due to limited data. Heterogeneity was moderate (τ2 = 0.21, I2 = 36.1%). Conclusions Funnel mesh could be the most effective measure for high-risk patients, while extraperitoneal colostomy (ES) and AWSE may be a practical and scalable alternative. Further high-quality RCTs are needed to validate these findings and refine clinical guidelines for PSH prevention.

Purpose Postoperative hemorrhagic complications in pancreatic surgery are classified according to the International Study Group for Pancreatic Surgery (ISGPS). However, following total pancreatectomy, the predominant bleeding causes associated with pancreatic fistula or insufficiency of the pancreatico-enteric anastomosis are eliminated. The objective of this study is to examine bleeding sources following total pancreatectomy, and propose a novel classification, termed Post-Total Pancreatectomy Hemorrhage (PTPH). Methods An overall of 195 patients was included and reviewed for baseline characteristics, comorbidities, intraoperative findings, perioperative coagulation profiles, and postoperative courses. Applicability of the ISGPS classification to PTPH was critically assessed with respect to the existing criteria: timely onset, location and cause, and severity. Subgroups were defined with regard to bleeding sources including erosion, surgical, gastrointestinal, and diffuse bleeding. Furthermore, we developed a severity index to enhance objectivity. Results Thirty-five of the patients experienced hemorrhagic complications. Timely onset and our severity index corresponded significantly with the bleeding source. Conclusion The ISGPS classification, although widely utilized in pancreatic surgery, does not fully account for the bleeding complications associated with total pancreatectomy. Our proposed classification for PTPH introduces a more granular and clinically relevant framework, with clearly delineated subgroups based on source, and an innovative severity index.

Background Laparoscopic splenectomy poses significant technical challenges due to variable splenic anatomy and patient-specific factors. A robust preoperative difficulty scoring system is essential to integrate critical predictors into a unified framework. This tool enables objective risk stratification, optimizes resource allocation, and enhances procedural safety through tailored surgical strategies. This study aimed to develop and validate a novel preoperative scoring system tailored to these challenges. Methods In this dual-center retrospective study, 181 patients undergoing laparoscopic splenectomy were divided into training (n = 118), validation 1 (n = 40), and validation 2 (n = 23) cohorts. Preoperative variables, including demographics, laboratory factors (INR, platelet count, et al.), and imaging indicators (CT-derived thickness, length, width, et al.), were analyzed. Multivariable regression identified predictors of surgical complexity (blood loss, operative time, conversion to open surgery). A difficulty score integrating regression coefficients and clinical feasibility was developed and validated using ROC curves, calibration plots, and decision curve analysis. Results Age, INR, splenic thickness, and cirrhosis-related hypersplenism emerged as independent predictors of surgical complexity (p < 0.05). The scoring system (range: 0–23) stratified patients into low- (0–7), intermediate- (8–15), and high-risk (16–23) tiers, demonstrating strong discrimination [training cohort AUC: 0.82 (95% CI 0.74–0.90); validation 1 cohort AUC: 0.80 (95% CI 0.66–0.94); validation 2 cohort AUC: 0.78 (95% CI 0.58–0.98)]. High-risk patients exhibited significantly greater blood loss, prolonged operative time, and higher conversion to open surgery rates. Calibration and decision curve analyses confirmed clinical utility, with net benefit surpassing “treat-all” strategies across risk thresholds. Conclusions This scoring system provides a validated tool for preoperative risk stratification in laparoscopic splenectomy, particularly for cirrhosis-predominant cohorts. By incorporating age, INR, splenic thickness, and pathogenesis, it attempts to account for regional epidemiological variations, potentially contributing to more tailored surgical planning in specific clinical contexts. Graphical abstract