Since the early 1980s, efforts to standardize ergonomic practices in laparoscopic surgeries have aimed to improve procedural efficiency and reduce complications, but clinical validation remains limited. In metabolic and bariatric surgeries (MBS), innovations in trocar site placements, driven by the popularity of laparoscopic sleeve gastrectomy (LSG), have advanced surgical techniques. However, practices often vary based on individual surgeon preferences rather than standardized evidence-based criteria. This study introduces the Port Site Placement and Outcomes for Surgical Obesity and Metabolic Surgeries (PSPOSO) checklist, aiming to standardize port placements and improve reporting consistency. A systematic review and meta-analysis of LSG studies were conducted following PRISMA guidelines. Data were extracted from 34 studies involving 7173 cases. Key variables included port configurations, manipulation angles, and outcomes such as operative time and excess weight loss percentage (EWL%). Innovative methods were used to estimate manipulation and azimuth angles from available intraoperative images. Statistical analyses and meta-regression were performed to identify associations between port configurations and surgical outcomes. Findings revealed substantial variability in port placements, with no significant effect of manipulation angles or port numbers on operative time or EWL% at 6, 12, and 24 months (p-values > 0.05). High residual heterogeneity suggests that factors beyond manipulation angles and port counts contribute to outcome variability. The PSPOSO checklist provides a framework for standardizing port placement and ergonomic parameters in MBS, enhancing reproducibility and safety. Future studies should validate the checklist across diverse clinical settings to refine surgical approaches and improve patient outcomes. PROSPERO: CRD42024598674.

Background: Roux-en-Y gastric bypass (RYGB) is a widely performed metabolic and bariatric surgery (MBS) procedure with proven efficacy. However, significant variability exists in its technical execution. This study aimed to evaluate global practice patterns among surgeons affiliated with the International Federation for the Surgery and Other Therapies for Obesity (IFSO), identifying key variations and factors influencing intraoperative decision-making. Methods: A cross-sectional survey was distributed between January and November 2025 to active IFSO members performing RYGB. The survey explored techniques related to the gastric pouch configuration, intestinal limb lengths, gastrojejunostomy, ring augmentation, and adjunct use. Responses from 245 surgeons across 47 countries were analyzed using descriptive statistics, subgroup comparisons, and multivariable logistic regression. Results: Technical variability was widespread. Only 53.5% routinely measured gastric pouch length; 67.3% described their pouches as “short” or “small,” with variable anatomical endpoints. Bougie sizes ranged from 28 to 46 Fr, with 36 Fr being most common (41.2%). Only 21.6% of respondents reported routinely measuring total bowel length. Ring-augmentation was used by 20.4%, with significant regional and experiential variation. Linear stapling was preferred for gastrojejunostomy (81.2%), but stoma size and suture materials varied. Routine closure of both Petersen’s space and the jejunojejunal mesenteric defect was common (69%) yet non-uniform. High-volume surgeons had shorter hospital stays and longer follow-up, but technical patterns were similar. Conclusion: Global RYGB practice exhibits heterogeneity in several key operative steps. Improved reporting of intraoperative technical variables may help clarify which differences are most relevant to perioperative, long-term, and registry-based outcomes, and may support future consensus-building in areas where standardization is clinically justified.