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Background: Laparoscopic (transabdominal preperitoneal (TAPP) and totally extraperitoneal (TEP)) and Lichtenstein procedures are the most commonly used approaches for primary unilateral inguinal hernia repair. However, only limited long-term data are available to compare the outcomes of these techniques, particularly from large cohorts. The aim of this study was to evaluate the long-term results of Lichtenstein and laparoscopic primary unilateral hernia repairs based on data from the Herniamed registry.

Methods: All patients registered in the Herniamed registry were included between 5 January 2009 and 4 October 2024. At the 5-year follow-up, a propensity score matched analysis was performed comparing Lichtenstein versus TEP, Lichtenstein versus TAPP, and TEP versus TAPP.

Results: In all, 109 130 patients with primary unilateral inguinal hernia and 5-year follow-up data were included in the study. Propensity score matching revealed 21 889, 27 439, and 29 475 matched pairs for comparisons of Lichtenstein versus TEP, Lichtenstein versus TAPP, and TEP versus TAPP, respectively. Lichtenstein repair had more general complications compared with TEP (1.2 versus 0.9%; P = 0.002), postoperative complications (3.4 versus 1.7%; P < 0.001), complication-related reoperations (1.0 versus 0.5%; P < 0.001), pain on exertion (6.7 versus 4.2%; P < 0.001), pain at rest (3.2 versus 2.3%; P < 0.001), pain requiring treatment (1.8 versus 1.3%; P < 0.001), and seroma (1.2 versus 0.9%; P < 0.001); discordant cases in matched-pair analyses. However, intraoperative complications were lower for Lichtenstein compared with TEP procedure (0.8% versus 1.0%; P = 0.038). Lichtenstein repair had more general complications compared with TAPP (1.2 versus 0.9%; P = 0.002), postoperative complications (3.5 versus 1.9%; P < 0.001), complication-related reoperations (1.0 versus 0.5%; P < 0.001), pain on exertion (6.3 versus 4.1%; P < 0.001), pain at rest (3.1 versus 2.2%; P < 0.001), and pain requiring treatment (1.8 versus 1.3%; P < 0.001).

Conclusion: In the evaluation of long-term results, laparoscopic techniques have advantages over the Lichtenstein procedure in primary unilateral inguinal hernia repair with regard to postoperative complications and chronic pain.

Background: Major lower extremity amputations are frequently performed for end-stage peripheral arterial disease and progressive diabetic foot complications. Wound complications after amputation affect up to one-third of limbs. The patient cohort undergoing amputation are typically high risk for poor wound healing, often with unmodifiable risk factors in an urgent clinical setting. Incisional negative pressure wound therapy (NPWT) has been shown to reduce wound complications in other high-risk populations. This randomized controlled trial investigates whether prophylactic NPWT reduces wound complications in patients after major amputation compared with standard dry dressings.

Methods: This protocol describes a prospective, multicentre, randomized controlled trial with an internal pilot recruiting patients undergoing major lower extremity amputation for any indication. Limbs will be randomized to receive either a single-use NPWT device on their closed surgical incision or a dry dressing. The primary clinical outcome is the rate of wound complications. Secondary outcomes include reoperation rates, length of hospital stay, cost-effectiveness of NPWT, and patient-reported quality of life. Follow-up will continue to 6 months after surgery. The initial pilot phase has a recruitment target of 96 limbs, whereas an estimated 728 patients will be required to power a definitive trial adequately.

Discussion: This trial aims to supplement the existing poor-quality data on this important aspect of care and equip healthcare professionals to make cost-effective decisions regarding postoperative wound management.

Background: The increasing detection of non-palpable breast lesions has made accurate preoperative localization essential to optimize breast-conserving surgery. Although multiple localization methods exist, there is still a lack of robust, large-scale, multicentre evaluations comparing different techniques.

Methods: The LOCALIZATION01 study compares real-world data from 13 breast units in Italy and Switzerland on the impact of localization techniques on breast-conserving surgery for non-palpable lesions between 2016 and 2024. Four localization techniques were compared: wire-guided (WGL), radio-guided (ROLL), magnetic seed (MSL), and carbon (CL). The main outcomes were margin status, calculated resection ratio, postoperative complications, and surgical time. Subgroup analyses were performed for body mass index, lesion morphology and histopathology.

Results: In total, 3241 patients were enrolled (ROLL 985, MSL 592, WGL 1079, and CL 585). ROLL achieved the highest rate of negative surgical margins, significantly outperforming MSL, WGL, and CL (97.5% versus 94.7% versus 94.5% versus 90.6%, respectively; P < 0.05). CL was associated with the highest postoperative complications rate (16.7%) versus ROLL (4.1%), MSL (4.5%), and WGL (2.1%) (P < 0.0001). The surgical time for MSL was significantly shorter when compared with WGL (46 versus 70 minutes (min); P < 0.0001) and CL (55 min; P < 0.0001). WGL had the most favourable calculated resection ratio (2.4), followed by MSL (2.6), ROLL (2.7), and CL (3.0). Multivariable analysis identified CL as an independent predictor of positive margins (odds ratio 1.82; P = 0.004), whereas ROLL was protective (odds ratio 0.45; P = 0.009).

Conclusion: ROLL and MSL outperformed WGL and CL across multiple endpoints. CL data revealed objective limitations that suggest caution in its use. A personalized approach considering lesion morphology, body mass index, and logistics is recommended.

Background: Tumour deposits are an important prognostic factor in colorectal cancer. In tumour node metastasis (TNM)8, the definition became stricter as TNM7's previous requirement for absence of lymphatic tissue was expanded to also include nerve and vascular tissue. TNM8 has been criticised for its limited prognostic value. This study aimed to compare prognostic differences for patients with colorectal cancer with tumour deposits staged with TNM7 and TNM8.

Methods: This national retrospective cohort study included patients with colorectal cancer who underwent surgical resection in 2011-2014 and 2017-2019. Exclusion criteria were metastatic stage IV disease, non-radical or non-curative surgery, unstated tumour deposit status, or early (≤ 30 days) mortality. Univariable, multivariable, and interaction term Cox regression analyses examined differences in overall survival and distant metastasis between TNM7 and TNM8 stagings. Multivariable models were adjusted for age, gender, American Society of Anesthesiologists score, number of positive lymph nodes, TNM stage, neoadjuvant, and adjuvant treatment.

Results: Of 19 413 patients operated on during 2011-2014 and 15 027 during 2017-2019, 23 966 were included. The TNM7 cohort had 1225 (9.5%) patients with tumour deposits, and the TNM8 cohort had 1407 (12.7%). There was an improved 5-year distant metastasis-free survival for patients with tumour deposits (hazard ratio 2.35 (95% confidence interval 2.14 to 2.58)) in the TNM8 cohort, but no benefit in overall survival, compared with patients in the TNM7 cohort. Interaction analysis revealed no prognostic difference associated with tumour deposit status between the two TNM editions.

Conclusion: Despite increased complexity, the revised definition of tumour deposits in TNM8 did not enhance prognostic ability compared with TNM7.

Background: Incisional hernia remains the most common complication of open abdominal surgery. The aim was to investigate whether a reinforced tension-line suture combined with standard 4 : 1 small-bite closure reduces the 3-year incidence of computed tomography-detected incisional hernia in open colorectal cancer surgery.

Methods: Patients aged > 18 years, scheduled for colorectal cancer resection through a midline incision between 2017 and 2021 at Skåne University Hospital Malmö and Kristianstad County Hospital, Sweden, were eligible for inclusion. Patients were randomized to fascial closure by reinforced tension-line suture combined with 4 : 1 small-bite closure with polypropylene sutures (RTL group) or 4 : 1 small-bite closure alone with polydioxanone sutures (PDS group), in a 1 : 1 ratio. Computed tomography interpreters were blinded to study groups. Univariate, bivariate, and multivariate logistic regression analyses were performed to investigate and adjust study groups for potential risk factors for incisional hernia.

Results: The study randomized 80 patients in each group. At 3 years, 101 remained for analysis: 43 in the RTL group and 58 in the PDS group. Incisional hernia was detected in 27 patients: 6 of 43 (14%) in the RTL and 21 of 58 (36%) in the PDS group, resulting in a significant risk difference of 22% (odds ratio 3.50, 95% confidence interval 1.27 to 9.66; P = 0.016). In multivariate analysis, the PDS group (odds ratio 3.40, 1.14 to 10.14; P = 0.028) and adjuvant chemotherapy (odds ratio 2.98, 1.10 to 8.08; P = 0.032) were significant risk factors for incisional hernia. No adverse events related to the closure techniques were found in either group.

Conclusion: Adding a reinforced tension-line suture significantly reduced the long-term incidence of incisional hernia compared with the 4 : 1 small-bite technique alone in patients undergoing open colorectal cancer surgery. These findings suggest that the reinforced tension-line suture is an efficient and easy way to prevent incisional hernia.

Background: Previous studies of minimally invasive liver surgery described results and experiences in high-volume centres and early adopters, but data on national levels are lacking. This study evaluated the implementation and outcomes of minimally invasive liver surgery in Sweden over a 15-year period, with a focus on colorectal liver metastases.

Methods: Data from patients undergoing liver surgery between 2009 and 2023 were obtained from the Swedish National Quality Registry for Liver, Gallbladder and Bile Duct Cancer, and evaluated in time intervals. Propensity score matching analysis was used to compare outcomes between open and minimally invasive liver surgery for colorectal liver metastases.

Results: A total of 9977 procedures were included in the study, of which 1490 (14.9%) were minimally invasive. Minimally invasive liver surgery was used increasingly over time, and had better short-term outcomes than open liver operations, including less blood loss (median 200 (interquartile range 50-400) versus 500 (250-1000) ml; P < 0.001), fewer major complications (127 (9.3%) versus 1697 (21.9%); P < 0.001), and a lower 30-day mortality rate (6 patients (0.4%) versus 107 (1.3%); P = 0.004). Use of robotically assisted liver surgery increased over time and it constituted 311 minimally invasive liver procedures (38.4%) in the late time period. Propensity score matching analysis for patients with colorectal liver metastases showed reduced blood loss with minimally invasive liver surgery (P < 0.001), a similar rate of radical resections, and similar overall survival.

Conclusion: The study demonstrated safe nationwide implementation of minimally invasive liver surgery. Use of the minimally invasive approach increased over time, including a rapid rise for robotically assisted procedures in the later period. Minimally invasive liver surgery maintained or improved favourable short-term outcomes without adverse effects on morbidity, mortality or long-term survival after surgery for colorectal liver metastases.

Background: Various studies have reported on the prognostic impact of ductal margin and radial margin status in resected perihilar cholangiocarcinoma (PCCA). No study has considered differences in the prognostic impact of individual resection margins. This study investigated the prognostic impact of individual planes on survival.

Methods: All patients undergoing surgery for PCCA at Amsterdam UMC and Karolinska University Hospital between January 2010 and May 2023 were included. Clinicopathological data were retrospectively retrieved. The primary outcomes were the prognostic significance of residual disease (< 1 mm to the nearest tumour growth) in individual dissection planes and resection margins for overall survival (OS) and disease-free survival (DFS), expressed as adjusted hazard ratios (aHRs).

Results: Of 199 patients, 81 (41%) underwent radical resection and 118 (59%) were reported to have microscopic residual disease. Only a positive proximal bile duct resection margin was significantly associated with shorter OS (adjusted median OS 24 versus 36 months; aHR 1.64; 95% confidence interval (c.i.) 1.05 to 2.56; P = 0.031) and DFS (aHR 2.01; 95% c.i. 1.30 to 3.10; P = 0.002). Other positive resection margins and dissection planes did not carry any prognostic information for OS (Pinteraction = 0.95) or DFS (Pinteraction = 0.56). Similar results were obtained in a 90-day landmark sensitivity analysis.

Conclusion: This study found that only tumour infiltration of the proximal bile duct resection margin was associated with worse prognosis, most likely reflecting the malignant behaviour of the disease rather than surgical failure. Larger prospective studies are needed to clarify the true prognostic impact of residual disease in individual resection planes to allocate patients to specific chemotherapeutic (neo)adjuvant treatments.