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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.

Emergency groin hernia repair is associated with increased mortality risk, but the actual risk is unknown. Therefore, this review aimed to investigate 30- and 90-day postoperative mortality in adult patients who had undergone emergency or elective groin hernia repair.This review was reported following PRISMA 2020 guidelines, and a protocol (CRD42021244412) was registered to PROSPERO. A systematic search was conducted in PubMed, EMBASE, and Cochrane CENTRAL in April 2021. Studies were included if they reported 30- or 90-day mortality following an emergency or elective groin hernia repair. Meta-analyses were conducted when possible, and subgroup analyses were made for bowel resection, sex, and hernia type. According to the study design, the risk of bias was assessed using either the Newcastle-Ottawa Scale or Cochrane Risk of Bias tool.Thirty-seven studies with 30,740 patients receiving emergency repair and 457,253 receiving elective repair were included. The 30-day mortality ranged from 0-11.8% to 0-1.7% following emergency and elective repair, respectively. The risk of 30-day mortality following emergency repair was estimated to be 26-fold higher than after elective repair (RR = 26.0, 95% CI 21.6-31.4, IThe overall mortality after emergency groin hernia repair is 26-fold higher than after elective repair, but the increased risk is attributable mostly to female and femoral hernias.PROSPERO protocol (CRD42021244412).

Emergency groin hernia is an understudied research field despite its severity requiring emergency surgery associated with high postoperative morbidity and mortality rates. Therefore, this study aimed to investigate the characteristics of patients, hernias, and surgical repairs, as well as complication rates following emergency groin hernia repair.Nationwide cohort study based on prospectively collected data obtained from the Danish Hernia Database and person-level linked to the Danish National Patient Registry. We included all adult patients undergoing an emergency groin hernia repair for inguinal- and/or femoral hernias registered in the Danish Hernia Database between January 1, 1998, and December 31, 2020. Primary outcomes were 30- and 90-day mortality, 30- and 90-day readmissions, and reoperations for recurrence. Outcomes were presented as crude numbers, odds ratios for mortality and readmission, and hazard ratios for reoperation.We included 9741 patients in the study. Within 30 days of surgery, 510 (6%) deaths and 1800 (23%) readmissions were recorded. During a median follow-up of 5 years, 537 (6%) reoperations for recurrence were performed. Multivariate analyses showed that mortality and readmission rates were influenced by increasing age, comorbidity, and bowel resection. Cumulative and adjusted reoperation rates were lower for mesh than non-mesh repairs. Moreover, mortality rates have improved over time, whereas readmission rates have increased over time.Complication and mortality rates after emergency groin hernia repair remain high. This study underlines the importance of a timely repair in incarcerated hernias to avoid contaminated surgical fields and the need for bowel resection.

Background and objective: We aimed to validate the diagnostic accuracy of appendicitis, its severity, its description, and the surgical approach, including open or laparoscopic appendectomy and diagnostic laparoscopy, in the Danish National Patient Registry (DNPR) against information from the electronic medical records. Methods: A random sample of 1046 patients of all ages and sexes recorded in the DNPR from the Capital Region of Denmark during 2010–2015 was investigated. Patients’ admission had to include a discharge code for appendicitis (K35−K379) according to the International Classification of Disease version 10 (ICD-10) alone or in combination with a surgical code for appendectomy or the surgical code for a diagnostic laparoscopy. We calculated the positive predictive values (PPVs) with 95% confidence intervals. Results: Data from a total of 1018 patients were available for data analysis. The ICD-10 codes for appendicitis resulted in a good PPV of >95% when combined with a surgical code. ICD-10 codes combined with the surgical codes could discriminate between uncomplicated and complicated appendicitis with some caution as the PPVs ranged from 68% to 93%. Only the surgical code for laparoscopic appendectomy yielded a good PPV (99%) for the actual surgical approach. The surgical code for a diagnostic laparoscopy alone did not cover a normal diagnostic laparoscopy. Conclusions: The diagnostic accuracy of appendicitis and appendectomy in routinely collected administrative health data is good for ICD-10 codes for appendicitis in combination with a surgical code and especially for laparoscopic appendectomy. Uncomplicated and complicated appendicitis can be distinguished with some caution.

Background Yersinia infection affects terminal ileum and lymph nodes and could therefore mimic the symptoms of appendicitis. We aimed to systematically characterise the suspected or confirmed abdominal diseases and/or surgeries associated with Yersinia infection. Materials and methods This systematic review and meta-analysis was reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol (CRD42016053252) was uploaded to PROSPERO. The searches were conducted in PubMed and EMBASE on October 2, 2020. Original reports on patients with abdominal surgical diseases were included. The primary outcome was to characterise suspected or confirmed abdominal surgical diseases and/or surgeries associated with Yersinia infection, while the secondary outcomes were the positive rate of Yersinia species for each disease and surgery, and to investigate the rate of Yersinia spp. in different geographic regions. We calculated the weighted mean prevalence of positive tests for Yersinia spp. for the different diseases and surgeries according to the detection method and for subgroups based on geographic region. Results From the search, 33 studies were included in the systematic review and 18 in the meta-analysis. Across geographic regions, the weighted mean prevalence for Yersinia spp. was 51% (95% CI 34%-69%) in mesenteric lymphadenitis, 65% (95% CI 45%-85%) in terminal ileitis, and 8% (95% CI 2%-15%) in normal appendices. Conclusions Around half of the patients with mesenteric lymphadenitis and terminal ileitis were serologically positive for infections with Yersinia spp. Yersinia infection may cause unnecessary surgery for suspected appendicitis due to symptoms from mesenteric lymphadenitis or terminal ileitis.

The number of scientific articles published each year is increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers' interpretation of results so that they are viewed more favorable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown.To determine the frequency and extent of spin in studies assessing robot-assisted groin hernia repair.This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE, and Cochrane Central.Of 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p 0.001) compared with those against or being neutral in their view of the procedure. Furthermore, being funded by or receiving grants from Intuitive Surgical were associated with a higher prevalence of spin (p 0.05) compared with those who were not.Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.

AIM Cochrane reviews are internationally recognized for their high quality, but to reduce the risk of transmitting misleading information, they must be kept up to date. The aim of this study was to quantify the number of reviews in the Cochrane Database of Systematic Reviews (CDSR) that have not been updated for more than five years and to characterize them. METHOD This study was reported closely adapted to the STROBE guidelines. Information about all reviews in the CDSR was extracted in August 2020. Based on a previous study, we defined inactive reviews as reviews with no update in "What's New" or no publication of a new version of the review within the last 5.5 years. The inactive reviews were quantified and characterized and results were visualized through tables and charts. RESULTS The study included 7931 reviews from the CDSR. The median age of all reviews in the CDSR was 5.3 years. Fifty-five percent were published for the first time between 1996 and February 2015 and 88% of these had been inactive for 5.5 years or more. Among these, 89% were first publication of the review that had never been updated afterward. CONCLUSION More than half of the Cochrane reviews in CDSR were first published before 2015 and only 12% of these were still active. In order to retain their validity, it would be preferable if Cochrane reviews were kept up to date by the authors either by an update in "What's New" or by publishing a new version of the review.

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.

Fast dissemination of research is important for improving treatments and thus benefitting patients, caregivers, and researchers. However, getting scientific papers published may take a long time. The editorial handling time can be delayed by several processes both before and after acceptance of the paper. The aim of this study was to systematically review the editorial handling time of biomedical peer-reviewed literature (i.e. time from submission to publication).The protocol for this systematic review was registered in PROSPERO (CRD42020196238). PubMed and EMBASE were searched systematically on 29 May 2020. We included publications on the timespan between submission and publication for accepted articles published in biomedical journals.Of the 4197 unique studies identified in the search, 69 were included in the systematic review. The mean timespan from submission to publication varied from 91 to 639 days, while the median timespan varied from 70 to 558 days. Submission to acceptance and acceptance to publication timespans showed similar disparity with means ranging from 50 to 276 and 11 to 362 days, respectively. Data were too statistically heterogeneous to perform meta-analyses.Editorial handling times of journals varied widely from a few months to almost two years, which delays the availability of new evidence. The editorial handling time did not differ between submission-to-acceptance-time and acceptance-to-publication-time. Examining differences in editorial processes between journals with long and short editorial handling times may help uncover, which processes are frequent causes of delay and thereby where to improve.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: MAIN OBJECTIVE: To assess the benefits and harms of mesh compared with non‐mesh in emergency groin hernia repair in adult patients with an inguinal or femoral hernia. SECONDARY OBJECTIVE: To assess whether the effects of mesh versus non‐mesh in emergency groin hernia repair differ according to the degree of contamination.

Ehlers-Danlos syndrome (EDS) constitutes a group of connective tissue diseases with variable organ dysfunction. We aimed to examine the comorbidity burden in patients with EDS. A nationwide population-based cohort study linking data from Danish registers from the year 2000���2014. The EDS cohort was identified using the International Classification of Diseases version 10 (ICD-10) EDS code. The control cohort was formed from the Danish general population by randomly matching the EDS cohort in a ratio of 1:25 by sex and date of birth. Hospital contacts were used to identify the most frequently occurring ICD-10 codes. We investigated the frequencies of the disease categories and unique ICD-10 codes and compared these between the cohorts. The EDS cohort included 1,319 patients and the control cohort 46,700 patients. All disease categories and ICD-10 codes were significantly more frequent within the EDS cohort, especially those related to common manifestations of EDS. Other comorbidities such as asthma, pneumonia, gastrointestinal functional disorders, and hernias were also significantly more common in the EDS cohort. The most common comorbidities in Danish patients with EDS were gastrointestinal functional disorders, hernias, asthma, pneumonia, and osteoporosis. The causality between these comorbidities and EDS should be investigated further.Implications for RehabilitationEhlers-Danlos syndrome constitutes a group of connective tissue diseases causing a variable range of organ dysfunction.The comorbidity burden for patients with Ehlers-Danlos syndrome was unexplored previously.This study showed that the most common comorbidities in Danish patients with Ehlers-Danlos syndrome are gastrointestinal functional disorders, hernias, asthma, pneumonia, and osteoporosis. Ehlers-Danlos syndrome constitutes a group of connective tissue diseases causing a variable range of organ dysfunction. The comorbidity burden for patients with Ehlers-Danlos syndrome was unexplored previously. This study showed that the most common comorbidities in Danish patients with Ehlers-Danlos syndrome are gastrointestinal functional disorders, hernias, asthma, pneumonia, and osteoporosis.

ImportanceSurgical training involves letting residents operate under supervision. Since hernia repair is a common procedure worldwide, it is a frequent part of the surgical curriculum.ObjectiveTo assess the risk of reoperation for recurrence after elective primary groin and ventral hernia repair performed by supervised residents compared with that by specialists.Design, Setting, and ParticipantsThis nationwide register-based cohort study included data from January 2016 to September 2021. Patients were followed up until reoperation, emigration, death, or the end of the study period. The study used data from the Danish Inguinal and Ventral Hernia Databases linked with data from the Danish Patient Safety Authority’s Online Register via surgeons’ unique authorization ID.The cohort included patients aged 18 years or older who underwent primary elective hernia repairs performed by supervised residents or specialists for inguinal, femoral, epigastric, or umbilical hernias. Hernia repairs were divided into the following 4 groups: Lichtenstein groin, laparoscopic transabdominal preperitoneal (TAPP) groin, open ventral, and laparoscopic ventral.ExposuresHernia repairs performed by supervised residents vs specialists.Main Outcomes and MeasuresReoperation for recurrence, analyzed separately for all 4 groups.ResultsA total of 868 specialists and residents who performed 31 683 primary groin and 7777 primary ventral hernia repairs were included in this study. The median age of patients who underwent hernia repair was 60 years (IQR, 48-70 years), and 33 424 patients (84.7%) were male. There was no significant difference in the adjusted risk of reoperation after Lichtenstein groin hernia repair (hazard ratio [HR], 1.26; 95% CI, 0.99-1.59), laparoscopic groin hernia repair (HR, 1.01; 95% CI, 0.73-1.40), open ventral hernia repair (HR, 0.89; 95% CI, 0.61-1.29), and laparoscopic ventral hernia repair (HR, 2.96; 95% CI, 0.99-8.84) performed by supervised residents compared with those by specialists. There was, however, a slightly increased unadjusted, cumulative reoperation rate after Lichtenstein repairs performed by supervised residents compared with those by specialists (4.8% vs 4.2%; P = .048).Conclusions and RelevanceThe findings of this study suggest that neither open nor laparoscopic repair of groin and ventral hernias performed by supervised residents appeared to be associated with a higher risk of reoperation for recurrence compared with the operations performed by specialists. This indicates that residents may safely perform elective hernia repair when supervised as part of their training curriculum.

A rapid review is a synthesis of available evidence in which some components of the review process are modified slightly to shorten the process. This will require tight control as well as day-to-day scientific mentoring. The typical rapid review has a focused research question covering a narrow and well-defined clinical problem. With a continuous focus on some elements in the planning and production phases, it is realistic to produce a rapid scoping or systematic review with or without meta-analysis within three months without compromising on scientific quality.

INTRODUCTION: A laparoscopic repair is recommended for emergency groin hernias. However, due to increasing sub-specialisation, the expertise in performing a laparoscopic hernia repair may not always be present. Therefore, this study aimed to assess the organisation of Danish hospitals' surgical acute teams in regard to emergency groin hernia care.METHODS: A nationwide questionnaire study was conducted for all Danish surgical departments performing emergency groin hernia repair and completed by the departments' administrative heads via REDCap.RESULTS: A total of 18 out of 19 departments completed the questionnaire. The overall response was positive towards providing emergency laparoscopic groin hernia repairs at all times. However, this was possible only in a minority of the departments outside daytime on weekdays, and regional differences were found. Surgical proficiency at the hospital and on-call from home varied, and only 24% of the departments could page surgeons (not on-call) to perform emergency laparoscopic groin hernia repair.CONCLUSIONS: A discrepancy was found between the wish of the surgical departments to provide laparoscopic emergency groin hernia repairs and the possibilities in today's surgical acute teams. Therefore, a reorganisation should be considered to ensure the availability of laparoscopic groin hernia repair for acute procedures.FUNDING: This study was funded by The Copenhagen Medical Society and Herlev and Gentofte Hospitals' research council. The funding providers had no role in designing, conducting or analysing the results.TRIAL REGISTRATION: not relevant.

INTRODUCTION We aimed to investigate how, changes in atmospheric pressure influence the human body. METHODS The study was an observational study, reported according to the STROBE-guideline (STrengthening the Reporting of OBservational studies in Epidemiology). Participants had their abdominal circumference measured on ground level, at the bottom of a pool, and during flight. This was used to investigate the relationship between atmospheric pressure and abdominal circumference. RESULTS We included 17 participants for the flight study and 12 participants for the pool study. Flying increased abdominal circumference from median 82 cm (range: 72-117 cm) at ground level to 86 cm (74-122 cm) in flight, p = 0.001. Submersion in water caused a decrease in abdominal circumference from median 82 cm (70-116 cm) at ground level to 79 cm (67-114 cm) under water, p = 0.003. Furthermore, flying resulted in a significant increase in self-reported flatulence and bloating from median 27 (0-69) to 50 (0-93), p = 0.02 (scale 0-100). Flying also caused an increase in abdominal pain from median 0 (0-68) to 3 (0-70), p = 0.02 (scale: 0-100). CONCLUSION Our findings confirm that changes to environment and thereby atmospheric pressure, influence abdominal circumference. This is likely due to expansion and compression of bowel gasses related to the ambient atmospheric pressure. Interestingly, our findings may help explain the physical appearance of mermaids. FUNDING none. TRIAL REGISTRATION none.

Aim This systematic review and meta-analysis aimed to investigate 30- and 90-day postoperative mortality in patients undergoing emergency or elective groin hernia repair. Material and Methods This review is reported after the PRISMA 2020 guidelines. A protocol (CRD42021244412) was registered to PROSPERO. Three databases (PubMed, EMBASE, and Cochrane CENTRAL) were searched in April 2021. The identified studies were screened for eligibility and included if they reported 30- and/or 90-day mortality following emergency or elective groin hernia repair. Meta-analyses were conducted when possible, and a subgroup analysis on patients undergoing bowel resection was made. Results We included 37 studies with a total of 30,740 patients receiving emergency repair and 457,253 receiving elective repair. Meta-analyses could not be conducted for the two repair settings separately due to heterogeneity. However, the 30-day mortality ranged from 0.0–1.7% following elective repair and 0.0–11.8% following emergency repair. The risk of 30-day mortality following emergency repair was estimated to be 26-fold higher than after elective repair. A subgroup meta-analysis on bowel resection in emergency repair estimated 30-day mortality to be 7.9%. Conclusions Emergency groin hernia remains a challenging and potentially fatal surgical emergency. This review emphasizes the importance of performing hernia repair in an elective setting to prevent a potential acute presentation with acute surgical intervention. Patients presenting with symptoms of emergency groin hernias should receive particular attention to minimize the high risk of mortality and morbidity following emergency repair.

Aim The number of articles published each year are increasing, resulting in greater competition to get work published. Spin is defined as specific reporting strategies used to distort the readers’ interpretation of results so that they are viewed more favourable. However, prevalence of spin in studies comparing robot-assisted groin hernia repair with traditional methods is unknown. The aim of the study was to determine the frequency and extent of misrepresentation of results, spin, in studies assessing robot-assisted groin hernia repair. Methods This systematic review was reported according to PRISMA guidelines, and a protocol was registered at PROSPERO before data extraction. Database search included PubMed, EMBASE and Cochrane Central. Results Of 35 included studies, spin was present in 57%. Within these, 95% had spin present in the abstract and 80% in the conclusion of the article. There was no association between study size and spin (p > 0.05). However, presence of spin in studies positively minded towards robot-assisted hernia repair was higher (p Conclusion Spin was found to be common in articles reporting on robot-assisted groin hernia repair, and presence of spin was higher in studies funded by or receiving grants from the robot company. This suggests that readers should be cautious when reading similar literature.

This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of antimicrobial treatment for uncomplicated/simple acute appendicitis for resolution of symptoms and complications. Antimicrobial treatment will only be compared with appendectomy.

We aimed to investigate the pharmacokinetics of fosfomycin and metronidazole after intraperitoneal administration of the combination of fosfomycin and metronidazole in patients undergoing laparoscopic appendectomy for uncomplicated appendicitis. We included eight otherwise healthy men undergoing laparoscopic appendectomy. The trial treatment was administered at the end of the surgical procedure and left in the abdominal cavity. Trial drugs consisted of 4 g fosfomycin and 1 g metronidazole in a total volume of 500.2 mL. Blood samples were collected prior to and ½, 1, 2, 4, 8, 12 and 24 h after administration. High-performance liquid chromatography-mass spectrometry was used for the measurement of plasma concentrations, and pharmacokinetic calculations were undertaken. Antimicrobial susceptibility testing was undertaken on isolates from intraoperatively collected specimens. The median maximal concentration for fosfomycin in plasma was 104.4 mg/L, median time point for the maximal concentration was 1.5 h, median half-life 3.0 h, and median area under the curve 608 mg*h/L. The median maximal concentration for metronidazole in plasma was 13.6 mg/L, median time point for the maximal concentration was 2.0 h, median half-life 7.3 h, and median area under the curve was 164 mg*h/L. All aerobic bacteria were susceptible to fosfomycin, and all anaerobes were susceptible to metronidazole. Plasma concentrations of fosfomycin and metronidazole were in line with concentrations reported from pharmacokinetic studies after intravenous administration and were within therapeutic ranges.

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.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.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%).Long-term mortality after laparoscopic cholecystectomy was 2%. The incidence of long-term intestinal obstruction after laparoscopic cholecystectomy was 1.3%.

Obturator hernias are rare and associated with high mortality. However, the optimal surgical approach remains unknown. We aimed to investigate the available evidence and examine the surgical details regarding obturator hernia defect closure as well as the recurrence rates of the different approaches. We reported this scoping review according to the PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analysis Extension for Scoping Reviews) and registered the protocol online. A comprehensive literature search in five different databases was conducted. The population was patients undergoing surgery for obturator hernia. Articles were included for data charting if the management of the hernia defect was reported. Data regarding surgical details, and hernia recurrence were extracted. A total of 1299 patients from 313 articles were included. In total, 937 patients underwent open obturator hernia repair, in which 992 hernias were repaired (including some bilateral obturator hernias). A total of 295 patients underwent laparoscopic repair for 341 obturator hernias, and for the remaining 67 patients, type of surgery was not reported. For open surgery, suture repair was the most common method of repair (n = 508, 51%) with a recurrence rate of 10%. For laparoscopic surgery, the most common repair of the defect was mesh repair (n = 299, 88%) with no reported recurrences. Open surgery with primary suture repair is the most common method of repair for obturator hernia but is associated with a recurrence rate of 10%. Laparoscopic mesh repair is becoming more common and have seemingly very low recurrence rates and may be a better method of repair.

Background Repairs of primary ventral hernias are common procedures but are associated with high recurrence rates. Therefore, it is important to investigate risk factors for recurrence to optimize current treatments. The aim of this study was to assess the impact of annual surgeon volume on the risk of reoperation for recurrence after primary ventral hernia repair. Study Design We conducted a nationwide register-based study with data from the Danish Ventral Hernia Database and the Danish Patient Safety Authority’s Online Register linked via surgeons’ authorization identification. We included patients 18 years and older, undergoing umbilical or epigastric hernia repair between 2011 and 2020. Annual surgeon volume was categorized into ≤ 9, 10 to 19, 20 to 29, and ≥ 30 cases. Patients were followed until reoperation, death, emigration, or end of the study period. Results We included 7,868 patients who underwent laparoscopic (n = 1,529 [19%]), open mesh (n = 4,138 [53%]), or open nonmesh (n = 2,201 [28%]) repair. There was an increased risk of reoperation after laparoscopic umbilical or epigastric hernia repair for surgeons with ≤ 9 (hazard ratio 6.57; p = 0.008), 10 to 19 (hazard ratio 6.58; p = 0.011), and 20 to 29 (hazard ratio 13.59; p = 0.001) compared with ≥ 30 cases/y. There were no differences in risk of reoperation after open mesh and open nonmesh repair in relation to annual surgeon volume. Conclusions There was a significantly higher risk of reoperation after laparoscopic primary ventral hernia repair performed by lower-volume surgeons compared with high-volume surgeons. Additional research investigating how sufficient surgical training and supervision are ensured is indicated to reduce risk of reoperation after primary ventral hernia repair.

Previous studies have shown a correlation between surgeons with high annual volume and better outcomes after various surgical procedures. However, the preexisting literature regarding groin hernia repair and annual surgeon volume is limited. The aim was to investigate how annual surgeon volume affected the reoperation rates for recurrence after primary groin hernia repair.This nationwide cohort study was based on data from the Danish Hernia Database and the Danish Patient Safety Authority's Online Register. Patients ≥ 18 years undergoing laparoscopic or Lichtenstein primary groin hernia repair between November 2011 and January 2020 were included. Annual surgeon volume was divided into five categories: ≤ 10, 11-25, 26-50, 51-100, and 100 cases/year.We included 25,262 groin hernia repairs performed in 23,088 patients. The risk of reoperation for recurrence after Lichtenstein repair was significantly higher for the volume categories of ≤ 10 (HR 4.02), 11-25 (HR 3.64), 26-50 (HR 3.93), or 51-100 (HR 4.30), compared with the 100 category. The risk of reoperation for recurrence after laparoscopic repair was significantly increased for the volume categories of ≤ 10 (HR 1.89), 11-25 (HR 2.08), 26-50 (HR 1.80), and 51-100 (HR 1.58) compared with the 100 category.The risk of reoperation for recurrence was significantly higher after Lichtenstein and laparoscopic repairs performed by surgeons with 100 cases/year compared with 100 cases/year. This indicates that higher surgeon volume minimizes the risk of reoperation for recurrence after groin hernia repair.

IntroductionMeta-analyses are considered the highest form of evidence and are, therefore, important for clinical guidance. Fast publication times are desirable as they ensure that up-to-date knowledge is available for the consumers. This study aimed to determine the time from registering the protocols for meta-analyses in PROSPERO until the results were publicly available either via ePub ahead of print or journal publication.MethodsThis observational database study was reported according to the RECORD guideline. The biomedical databases PubMed and EMBASE were searched on 11th March 2020 for published meta-analyses that were registered in PROSPERO. The meta-analyses were linked to their PROSPERO registrations via their 14-digit PROSPERO registration number in the abstract. Registration date, publication date, and characteristics of reviews were extracted from PubMed, EMBASE, and PROSPERO during March 2020.ResultsWe included 2475 published meta-analyses. The median publication time was 16 months, interquartile range 10–24 months. After publication, 26% had updated the review's status in PROSPERO to published. Fewer authors were associated with shorter publication times. No difference was seen in publication times between the ‘big five’ journals and other journals.ConclusionsOf all published meta-analyses with PROSPERO registrations, 75% were published within two years of the registration of their protocol. Few authors updated the status of their PROSPERO registrations after publishing, which may make identifying abandoned reviews difficult.

One-third of patients presenting with inguinal hernia are asymptomatic and the best treatment for these patients is unclear. The aim of this study was to assess the feasibility of applying a watchful waiting strategy for asymptomatic or minimally symptomatic inguinal hernia in men. PubMed, EMBASE, and Cochrane Library were searched from database inception to May 14, 2020. Included were all types of original data written in English, German, Danish, Swedish, or Norwegian involving ≥ 5 male patients aged ≥ 18 years old with asymptomatic or minimally symptomatic inguinal hernia and undergoing watchful waiting. This review was reported according to the PRISMA guideline. A total of nine studies were included; three randomized controlled trials, three prospective cohort studies, and three retrospective cohort studies. Data on a total of 858 unique patients following a watchful waiting strategy were included. Approximately one-third of patients crossed over from watchful waiting to surgery after 3 years increasing to more than two-thirds after 10 years. The most frequent reason for crossover was hernia-related pain (median 79%, range 48–91%). The rate of acute hernia-related operations was low (2–3%), and watchful waiting was not associated with increased mortality or postoperative complications. Levels of pain and discomfort after randomization were similar over time between patients undergoing elective repair or watchful waiting. Applying a watchful waiting strategy to men with asymptomatic or minimally symptomatic inguinal hernia was safe, but two-thirds of patients crossed over to surgical repair within 10 years mainly due to pain.

To determine the prevalence of gift and ghost authors in Cochrane reviews and to investigate possible predictors of gift authorship.An Internet-based survey was sent in April 2019 to 1,226 first authors of Cochrane reviews published between October 2016 and December 2018. Three reminders were sent. Responses were anonymized before data extraction.A total of 666 of 1,226 (54%) first authors completed the survey. The prevalence of gift authors was 41% and 2% reported ghost authorships. Of the first authors, 15% were not aware of the authorship criteria from the International Committee of Medical Journal Editors. In a multivariable analysis, factors associated with the existence of gift authorship were: first author was not aware of the International Committee of Medical Journal Editors authorship guidelines (odds ratio (OR) 2.08, 95% confidence interval (CI) 1.23-3.51, P = 0.006), increasing number of authors (P 0.001), and first author had offered an inappropriate authorship previously in their academic career (OR 1.96, 95% CI 1.23-3.13, P = 0.005).A substantial proportion of Cochrane reviews showed evidence of gift authorship, whereas ghost authorship was less prevalent. Thus, there is a need to increase awareness of this persistent issue in Cochrane reviews.

Background: We aimed to investigate the difference in the total length of hospital stay (LOS) after intraperitoneal vs. intravenous antibiotic treatment in patients with complicated appendicitis. Methods: We conducted a quasi-randomized prospective clinical trial. The intervention group received 4 g fosfomycin, 1 g metronidazole, and 50 μg recombinant human granulocyte-macrophage colony-stimulating factor intraperitoneally, which was left in the abdominal cavity, immediately after laparoscopic appendectomy. Postoperatively, this group received antibiotics orally. The control group received intravenous antibiotics both during surgery and postoperatively. We primarily evaluated total LOS within 30 days. Furthermore, we evaluated harms and adverse events, Gastrointestinal Quality of Life Index, postoperative complications, and convalescence. Participants were followed for 30 days postoperatively. Results: A total of 12 participants concluded the trial. The total LOS was significantly shorter in the intervention group (six participants, median 13 h; range 2–21 h) than in the control group (six participants, median 84 h; range 67–169 h), p = 0.017. Comparable harms and Gastrointestinal Quality of Life Index scores were found in the two groups. The time to return to normal activities was median 6 and 10 days for the intervention and the control group, respectively. There were no serious adverse events related to the trial nor any complications in the intervention group. In the control group, two patients developed intraabdominal abscesses. Conclusions: The intervention group had a significantly shorter total LOS. The study was not powered to assess differences in complications, but the results indicate that the intervention seems to be a safe regimen, which can be investigated further to treat patients with complicated appendicitis. Identifiers: EudraCT no. 2017-004753-16. ClinicalTrials: https://clinicaltrials.gov/ct2/show/NCT03435900?term=NCT03435900&draw=2&rank=1">draw=2&rank=1.

Previous studies have revealed the existence of illegitimate authorship, e.g. gift authors and ghostwriters, in Scandinavian journals as well as in international high-impact medical journals. In order to obtain transparent and accountable research it is important to eliminate inappropriate authorships, and in this review, we argue, this could be done by extending the knowledge of the authorship criteria and the different types of illegitimate authorship, especially through the education of both students and doctors.

BACKGROUND Scrubbing of the skin during Hammam, a Turkish spa treatment, removes cells from the ultraviolet radiation absorbing stratum corneum. AIM The aim of this study was to assess if skin is more susceptible to sunburn after a Hammam treatment. METHODS In this randomized controlled trial with a paired design, healthy adult participants with skin types 1-3 were randomized to receive Hammam treatment on one side of the back while the other side was used as control. Participants had 30 minutes of sun exposure on their backs. Erythema and pain were assessed before and 1, 4, 8, and 24 hours after sun exposure. Erythema was assessed by a visual scale and by using chromatography on high-resolution photos. Pain was assessed with the Visual Analogue Scale (VAS). The primary outcome was the difference in chromatography-assessed erythema from baseline to the 24-hour assessment, compared between the Hammam- and the control side. Secondary outcomes were differences in pain and visually assessed erythema. RESULTS Twelve participants were included with complete follow-up. Eight participants had type-3 skin and four had type-2 skin. There was no difference between the Hammam and the control side for any of the outcomes. Even though erythema assessed by chromatography was slightly higher for the Hammam side, the difference was insignificant. CONCLUSION Hammam treatment did not increase sunburn, measured by UV-induced skin erythema and pain, compared with untreated skin following 30 minutes of sun exposure.

Background and Aims: Appendectomy is a common surgical procedure, but no overview of the long-term consequences exists. Our aim was to systematically review the long-term complications of appendectomy for acute appendicitis. Materials and Methods: This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A protocol was registered on PROSPERO (CRD42017064662). The databases PubMed and EMBASE were searched for original reports on appendectomy with n ≥ 500 and follow-up >30 days. The surgical outcomes were ileus and incisional hernia; other outcomes were inflammatory bowel disease, cancer, fertility, and mortality. Results: We included 37 studies. The pooled estimate of the ileus prevalence was 1.0% over a follow-up period of 4.6 (range, 0.5–15) years. Regarding incisional hernia, we found a pooled estimate of 0.7% prevalence within a follow-up period of 6.5 (range, 1.9–10) years. Ulcerative colitis had a pooled estimate of 0.15% prevalence in the appendectomy group and 0.19% in controls. The opposite pattern was found regarding Crohn’s disease with a pooled estimate of 0.20% prevalence in the appendectomy group and 0.12% in controls. No clear pattern was found regarding most of the examined cancers in appendectomy groups compared with background populations. Pregnancy rates increased after appendicitis compared with controls in most studies. Mortality was low after appendectomy. Conclusion: Appendectomy had a low prevalence of long-term surgical complications. We did not find any significant other long-term complications, though the prevalence of Crohn’s disease was higher and the prevalence of ulcerative colitis was lower after appendectomy than in controls. Appendectomy did not impair fertility.

Background Treatment of secondary peritonitis includes surgery and antimicrobial agents. Antimicrobial agents are often administered intravenously, however, the alternative route intraperitoneal administration could be considered. Investigations must be conducted prior to clinical application. Therefore, we aimed to investigate the combination of fosfomycin, metronidazole, and recombinant human granulocyte-macrophage colony-stimulating factor with regard to its chemical properties and the solution’s stability. In addition, the antibacterial effect of the mixed drug solution was compared with the effect of the individual antibacterial agents. Methods The drugs were mixed to an aqueous solution. Basic chemical investigations of pH, precipitation, and calculated osmolarity of the drug combination were conducted. Fosfomycin and metronidazole’s chemical stability was investigated using High Pressure Liquid Chromatography-Mass Spectrometry. Microbiological investigations using the agar cup method were carried out to measure the antibacterial effect of fosfomycin and metronidazole. Results The aqueous solution of the combination of the three drugs had a pH of 7.46–7.62, which was stable during 24 h, was without precipitation, and had a calculated osmolarity of 293 mOsm/l. High Pressure Liquid Chromatography-Mass Spectrometry found stable concentrations of fosfomycin and metronidazole both alone and in combination during 24 h. The antibacterial effect of the drug combination solution was similar to the antibacterial effects of fosfomycin and metronidazole alone. Conclusion The drug combination had neutral and stable pH, was iso-osmotic, and had stable concentrations during 24 h of storage. The antibacterial effect of fosfomycin and metronidazole were not altered when the drugs were mixed.

Background Intraperitoneal drug administration applies treatment at the site of diseases with gynaecological, urological, or gastrointestinal origin. The objective of this systematic review was to investigate perioperative intraperitoneal administration of antibacterial agents to characterise the drugs used and their safety profile. Methods A protocol was registered at PROSPERO (CRD42016038956). A systematic review was conducted and reported according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A search was performed in PubMed and EMBASE on the 22nd of April 2016. The inclusion criteria were original articles involving at least 5 patients where antibacterial agents were administered intraperitoneally during or after abdominal surgery as prophylaxis or treatment of infection. Languages were limited to English, German, Danish, Norwegian, or Swedish articles. Results 79 studies were included which used a total of 12 different antibacterial classes. Aminoglycosides, 1st and 2nd generation cephalosporins, tetracyclines, and penicillins were most commonly administered intraperitoneally during or after surgery. The antibacterial agent was usually administered intraperitoneally as monotherapy. However, some studies administered combination regimens with heparin or with another antibacterial agent. The most frequent combination was aminoglycosides and lincosamides. In total, 43% of studies lacked information regarding adverse events. The most frequently reported adverse event was discomfort or pain during administration, especially with use of oxytetracycline. Conclusion At least 12 different classes of antibacterial agents have been administered intraperitoneally during or after surgery as prophylaxis or treatment of intraabdominal infections. Intraperitoneal administration seems safe although use of oxytetracycline may cause discomfort or pain.

Prolonging post-operative antibiotic treatment beyond 3 days does not seem to reduce the incidence of post-operative abscess formation or wound infection after surgery for complicated appendicitis. The route of administration seems to be based on an empirical basis. Using enteral antibiotics could reduce length of stay and reduce overall costs. We aimed to examine whether treatment with enteral antibiotics during the first three post-operative days is non-inferior to intravenous antibiotics regarding intra-abdominal abscess formation or wound infection after surgery for complicated appendicitis. A retrospective study of adult patients having surgery for complicated appendicitis within a period of 32 months in the Capital Region of Denmark. Primary outcome was the incidence of post-operative abscess formation, and secondary outcome was wound infections, both within 30 days of surgery. Route of antibiotic administration for the first three post-operative days was registered for all patients. A total of 1141 patients were included in the study. The overall risk of developing an intra-abdominal abscess was 6.7% (95% CI 5.2%; 8.1%), and the risk of wound infection was 1.2% (95% CI 0.6%; 1.8%). In a multivariate intention-to-treat analysis, patients treated post-operatively with enteral antibiotics had an odds ratio of 0.78 (95% CI 0.41; 1.45, p = 0.429) for developing an intra-abdominal abscess and an odds ratio of 0.86 (95% CI 0.17; 4.29, p = 0.851) for developing a wound infection compared to patients treated post-operatively with intravenous antibiotics. Treatment with enteral antibiotics was non-inferior compared to treatment with intravenous antibiotics during the first 3 days after surgery for complicated appendicitis.

Objectives The objective of the study is to examine the time from publication of the protocol for a Cochrane review to publication of the Cochrane review for the entire Cochrane Database of Systematic Reviews (CDSR). Study Design and Settings Cochrane reviews from the CDSR published between 1995 and 2019 were assessed. Characteristics of the reviews were extracted, and time from publication of protocol to publication of review was calculated. These times were grouped for relevant characteristics and visualized through charts and tables to illustrate trends. Results Of the total 8,201 reviews in the CDSR, 6,764 were included. The median publication time was 2 years (range 0 days to 21.7 years). Reviews that were published more than 5 years after the protocol made up 11% of all included reviews, whereas 19% of reviews were published within a year. The median publication time for the individual Cochrane Review Groups ranged from 15 to 39 months. Conclusion Half of Cochrane reviews were published later than Cochrane's aim of 2 years. Furthermore, the Cochrane Review Groups' median times from publication of protocol to publication of review varied widely.

Objective Recently, group authorships have become more common. Group authorship describes a situation where the name of a group of people is included in the byline of an article. Historically, however, group authorships have been associated with citation errors and difficulties identifying who could be regarded as an author. Cochrane is a collaboration that publishes high-quality systematic reviews and meta-analyses and transparency in authorship should be high. Group authorships in Cochrane have not previously been examined. This study aimed to describe group authorships in the Cochrane Database of Systematic Reviews (CDSR). Methods In total, 8396 reviews from the CDSR were screened for group authorships from inception to 31 December 2019. Data from group authorships were extracted and analyzed. Results A total of 41 reviews with group authorships were included. Almost half of group authorships (46%, 19/41) were published from 2015 to 2019. Median number of group members was 32 (range 6-91). Median publication time (protocol to review) of group authorships was 3.1 years. Of all group authorships, 39% met ICMJE's first authorship criterion, 41% met the second, and 12% met the third criterion. For only two studies all authors met the three authorship criteria. Conclusion A low prevalence of group authorships existed in Cochrane reviews. Reviews with group authorships took median three years to publish, and very few of group authorships in Cochrane complied with the ICMJE authorship criteria.

Objective To investigate authorship trends in Cochrane reviews from 1996 to 2018, and to examine if the authorship criteria from the International Committee of Medical Journal Editors (ICMJE) were met for Cochrane reviews with more than 15 authors based on the text in the section "Contributions of authors." Methods The median number of authors per review was calculated, and authorship trends within each editorial group were analyzed. The section "Contributions of authors" was assessed about the first and second authorship criteria from the ICMJE for reviews with more than 15 authors. Results A total of 7447 Cochrane reviews were studied based on data from the Cochrane Database of Systematic Reviews. The median number of authors per Cochrane review was 3 in 1996 (IQR 2.5-3, range 2-3), 4 in 2007 (IQR 3-5, range 1-13), and 5 in 2018 (IQR 4-7, range 2-22). Within each editorial group, the total number of authors either increased (26/55, 47%) or was unchanged (29/55, 53%). Based on the text in "Contributions of authors," 59% (16/27) of the reviews with more than 15 authors had authors that did not fulfil the ICMJE authorship criteria. However, the text in "Contributions of authors" was often difficult to interpret. Conclusions The number of authors per Cochrane review gradually increased from 1996 to 2018. The ICMJE authorship criteria were probably not met by all authors in more than half of the reviews with more than 15 authors.