Ibrahim Moqbel

Objective: To compare the efficacy and safety of robotic ventral and incisional hernia repair techniques using network meta-analysis. Background: Robotic ventral hernia repair continues to evolve, but the comparative performance of individual robotic approaches remains uncertain. Methods: We conducted a systematic review and network meta-analysis of 14 studies, including 2 randomized trials and 12 retrospective cohorts, involving 9,348 adults undergoing ventral or incisional hernia repair. Techniques were classified by mesh plane and operative access. Frequently reported approaches were analyzed as separate nodes, whereas less commonly described but conceptually similar techniques were grouped into pooled preperitoneal and retromuscular nodes. Treatment effects were estimated using a R (netmeta); heterogeneity, transitivity were assessed, and certainty was rated with CINeMA. Results: rIPOM and rTAPP ranked highest for operative efficiency (SUCRA 94% and 96%, respectively), whereas rTAR ranked lowest. Compared with rIPOM, overall complications were lower with rTEP-RM (RR 0.23, 95% CI 0.07–0.74) and rTAPP (RR 0.55, 95% CI 0.30–0.99). rTEP-RM was also associated with lower seroma rates (RR 0.28, 95% CI 0.10–0.80) and shorter length of stay (MD − 5.33 days, 95% CI − 9.08 to − 1.58), although postoperative pain was higher. Surgical site infection was lower with rRS (RR 0.11, 95% CI 0.02–0.87) and rTAPP (RR 0.32, 95% CI 0.13–0.78). Pooled preperitoneal approaches were associated with lower short-term recurrence and 30-day readmission. Conclusions: Preperitoneal approaches, particularly rTEP-RM and rTAPP, were associated with more favorable early postoperative outcomes than rIPOM, although certainty of evidence was mostly low or very low.

Background: Patients undergoing bariatric surgery face an elevated risk of venous thromboembolism (VTE), primarily due to obesity-related hypercoagulability and changes in the pharmacokinetics of anticoagulants. The standard prophylactic dosing of enoxaparin may not be adequate for this group, leading to the consideration of higher or BMI-adjusted dosing regimens. Nevertheless, the comparative efficacy and safety of standard-dose versus higher-dose enoxaparin in the context of bariatric surgery remain unclear. Methods: A systematic review and meta-analysis were performed following the PRISMA 2020 guidelines. Searches were conducted in PubMed, Embase, Scopus, Web of Science, and the Cochrane Library from their inception through September 30, 2025. The review included randomized controlled trials and cohort studies comparing enoxaparin 40 mg with 60 mg for postoperative venous thromboembolism (VTE) prophylaxis in bariatric surgery. Studies utilizing fixed-dose or BMI-tiered dosing strategies were considered eligible. The primary outcome assessed was the achievement of prophylactic anti-factor Xa levels. Secondary outcomes comprised mean anti-factor Xa levels, sub- and supra-prophylactic anti-factor Xa levels, VTE occurrence, bleeding incidents, mortality rates, overall complications, operative duration, and transfusion requirements. Random-effects meta-analyses were conducted. Results: Ten studies encompassing 1,276 patients (727 receiving 40 mg and 549 receiving 60 mg) were included. Enoxaparin 40 mg was associated with significantly lower mean anti-factor Xa levels compared with 60 mg (MD − 0.08 IU/mL; 95% CI − 0.13 to − 0.03). Patients receiving 40 mg had higher rates of sub-prophylactic anti-Xa levels (RR 1.35; 95% CI 1.03–1.77), whereas 60 mg was associated with increased supra-prophylactic levels (RR 0.25; 95% CI 0.09–0.70). Overall achievement of target prophylactic anti-Xa levels did not differ between doses, although once-daily 40 mg dosing was associated with reduced target attainment compared with once-daily 60 mg. No significant differences were observed in VTE, deep vein thrombosis, pulmonary embolism, bleeding, mortality, overall complications, operative duration, or transfusion requirements. Conclusions: Although higher enoxaparin doses improved anti-factor Xa levels, this did not translate into reductions in venous thromboembolism, bleeding, or mortality, underscoring the disconnect between pharmacokinetic markers and clinical outcomes in bariatric surgery patients. Registration: PROSPERO CRDXXXXXXXXXXX.

Background and Aims: Bilateral Wilms tumor (BWT) presents a significant challenge in pediatric oncology, necessitating a delicate balance between achieving oncological control and preserving renal function. While nephron‐sparing surgery (NSS) has emerged as a promising alternative to radical nephrectomy, its overall safety and efficacy profile for BWT remains to be consolidated. This systematic review and meta‐analysis aimed to synthesize the available evidence to evaluate the pooled safety and efficacy outcomes of NSS in children with BWT. Methods: Following PRISMA guidelines, a systematic search was conducted across five databases (PubMed, Medline, Web of Science, SCOPUS, Cochrane Library). We included studies reporting on pediatric patients with BWT treated with NSS. A single‐arm meta‐analysis was performed using a random‐effects model to pool estimates for survival, recurrence, and renal function outcomes. Results: Thirteen studies comprising 749 patients were included. The pooled overall survival rate was 55.9% (95% CI: 38.2%–73.7%), relapse‐free survival was 51.4% (95% CI: 32.6%–70.3%), and event‐free survival was 38.0% (95% CI: 23.3%–52.7%). The recurrence rate was 14.9% (95% CI: 9.4%–20.5%). Critically, renal function was well‐preserved, with a mean glomerular filtration rate (GFR) of 92.0 mL/min/1.73 m². The need for dialysis (1.7%) and renal transplantation (4.3%) was low. Conclusion: NSS provides a viable surgical strategy for BWT, effectively preserving renal function without unduly compromising survival outcomes. The acceptable recurrence and low renal replacement therapy rates underscore its role in mitigating long‐term morbidity. Significant heterogeneity across studies highlights the need for standardized treatment protocols and prospective research to optimize patient selection and outcomes.

Perforated peptic ulcer (PPU) remains a life-threatening emergency. Laparoscopic repair is favored over open surgery, but intracorporeal suturing is demanding. Interrupted hand-tied sutures are traditional; knotless barbed sutures may simplify closure and shorten operative time. To evaluate the efficacy and safety of knotless barbed versus interrupted sutures in laparoscopic PPU repair. PubMed, Scopus, the Cochrane Library, Web of Science and Google Scholar were searched until 22 July 2025. Eligible comparative studies included adults undergoing laparoscopic gastroduodenal PPU repair using continuous knotless barbed sutures ± omental patch versus interrupted absorbable sutures ± omental patch. Outcomes were operative time, postoperative complications, leak, hospital stay, perforation size and wound complications. Random-effects models yielded mean differences (MDs) or risk ratios (RRs) with 95% confidence intervals (CIs) and heterogeneity (I²). Four retrospective cohorts (n = 575; 192 barbed, 383 interrupted) met criteria. Barbed sutures reduced operative time (MD -25.49 min; 95% CI -40.35 to -10.62; p = 0.0008; I² = 43%). No differences were observed for postoperative complications (RR 0.91; 95% CI 0.54-1.53; p = 0.72; I² = 2%), leak (RR 0.53; 95% CI 0.14-2.04; p = 0.35; I² = 0%), hospital stay (MD -0.73 days; 95% CI -2.85 to 1.39; p = 0.50; I² = 0%), perforation size (MD -0.06 cm; 95% CI -0.17 to 0.05; p = 0.26; I² = 0%) or wound complications (RR 0.99; 95% CI 0.28-3.47; p = 0.99; I² = 0%). In laparoscopic PPU repair, knotless barbed sutures improve operative efficiency without increasing adverse events. Given the small, retrospective evidence base and low certainty, randomized trials with standardized techniques are warranted. CRD420251119990. Not applicable.

Background: Laparoscopic cholecystectomy (LC) is the current gold standard for the management of acute cholecystitis, where ultrasonic dissection and electrocautery dissection are the two primary techniques used, however, it remains uncertain which approach is safer and more effective. Objectives: This systematic review and meta-analysis aimed to compare the clinical outcomes of ultrasonic dissection versus electrocautery dissection in LC for acute cholecystitis, particularly in operative time, hospital stay, blood loss, intraoperative and postoperative complications. Method: A systematic literature search was conducted in PubMed (MEDLINE), Scopus, Web of Science (WOS), EMBASE, and Cochrane CENTRAL up to January 7, 2025, following PRISMA guidelines. Eligible studies were randomized controlled trials (RCTs) comparing ultrasonic dissection and electrocautery dissection in LC for acute cholecystitis. Data extraction and risk-of-bias assessment were independently performed. Statistical analyses were conducted using Review Manager (RevMan 5.4), with heterogeneity assessed using I² statistics and a random-effects model where necessary. Results: A total of 28 RCTs, comprising 3383 patients (1720 in the ultrasonic dissection group and 1663 in the electrocautery group), were included. The meta-analysis demonstrated that ultrasonic dissection significantly reduced operative time (− 9.13 min, 95% CI − 9.65 to − 8.61, p < 0.0001, I² = 97%), hospital stay (− 0.95 days, 95% CI − 1.74 to − 0.17, p = 0.02, I² = 100%), and blood loss (− 27.60 ml, 95% CI − 38.48 to − 16.72, p < 0.00001, I² = 98%). Subgroup analysis reduced heterogeneity in some outcomes. Risk-of-bias assessment showed variability in study quality, with concerns in allocation concealment and performance bias in certain RCTs. Conclusion: Ultrasonic dissection demonstrated advantages over electrocautery dissection for laparoscopic cholecystectomy in patients with acute cholecystitis, including reduced operative time, lower blood loss, and shorter hospital stays. While some heterogeneity was observed among studies, ultrasonic dissection appears to be a safer and more efficient technique.

Background: Thoracic trauma significantly contributes to Iraq’s trauma mortality. While the Thoracic Trauma Severity Score (TTSS) and the Trauma and Injury Severity Score (TRISS) are validated internationally, their effectiveness in low-resource settings like Iraq remains unclear. This study aims to address this critical gap by evaluating and comparing the predictive performance of both tools in predicting clinical outcomes. The findings of this study will lay the groundwork for developing a more suitable chest trauma scoring model tailored to this unique setting and similar environments with limited resources. Methods: Prospective cohort study that will recruit 195 adult chest trauma patients (blunt/penetrating) from March to December 2025. Based on standardized protocols, TTSS and TRISS scores will be calculated within 6 hours of admission. Primary outcome: in-hospital mortality. Secondary outcomes: intensive care unit (ICU) admission, morbidity, early hospital discharge, and surgical intervention. Predictive accuracy will be compared using ROC-AUC analysis and sensitivity/specificity. Discussion: TTSS is likely to demonstrate greater specificity for thoracic outcomes than TRISS. Possible limitations include resource-related constraints that lead to inappropriate ICU allocation and prehospital delays affecting physiological measures. If validated, TTSS may streamline emergency room triage across Iraq-utilizing scarce critical care resources more effectively. Further studies should be done to validate findings across the various trauma centers in Iraq and develop hybrid scoring models.