Background: Video-assisted thoracoscopic surgery (VATS) has evolved from multiportal to uniportal approaches, theoretically offering reduced postoperative pain through single intercostal space access. However, inconsistent surgical definitions and mixed evidence have limited clinical guidance. Objectives: To systematically evaluate postoperative pain outcomes between true uniportal VATS (strictly defined by the 2019 European Society of Thoracic Surgeons criteria) and multiportal VATS for lung resections. Methods: We searched five databases during the period between January 2000 and January 2025 for comparative studies of uniportal vs. multiportal VATS reporting pain outcomes. True uniportal VATS requires a single intercostal incision (2.5–5 cm) with all instruments through one port. Meta-analyses were excluded to prevent data duplication. The primary outcome was 24-h pain intensity. A random-effects meta-analysis was performed to calculate standardized mean differences (SMD) with 95% confidence intervals (CI). Risk of bias was assessed using the revised Cochrane risk-of-bias tool (ROB 2) randomized controlled trials (RCTs) and the risk-of-bias in non-randomized studies of interventions (ROBINS-I) for observational studies. Results: Nineteen studies (6 RCTs, 13 observational) comprising 2,544 patients (1,156 uniportal, 1,388 multiportal) met the inclusion criteria. Uniportal VATS significantly reduced pain at 24 h (SMD −0.98, 95% CI −1.12 to −0.84, p < 0.0001), equating to a reduction of 2.5 points on a 10-point scale. Benefits persisted at 48 h (SMD −0.80) and 7 days (SMD −0.58). Opioid consumption decreased by 10.6 mg of morphine equivalents (95% CI −14.8 to −6.4). Heterogeneity was moderate (I ² = 63.6%). Studies using standardized analgesia protocols showed larger effects (SMD −1.05) with lower heterogeneity (I ² = 58.4%). Meta-regression identified a decrease in effect sizes over time (β = 0.05 per year, p = 0.024). Sensitivity analyses confirmed the robustness of the results, with all iterations maintaining statistical significance. Conclusions: True uniportal VATS provides clinically meaningful reductions in postoperative pain compared with multiportal approaches when applying strict anatomical criteria. Benefits are enhanced with standardized perioperative analgesia protocols. Implementation should consider local expertise and the observed heterogeneity in treatment effects. Registration: Not prospectively registered; PRISMA 2020 guidelines followed.

Background/Objectives: Effective pain management following thoracic surgery remains challenging yet crucial for optimal patient outcomes. This literature review compares the efficacy, safety, and clinical outcomes of different perioperative analgesia methods in thoracic surgery patients, focusing on paravertebral block (PVB), intercostal nerve block (ICNB), epidural analgesia (EPI), erector spinae plane block (ESPB), and patient-controlled analgesia (PCA). Methods: A systematic search was conducted across medical databases, yielding ten relevant randomized controlled trials and meta-analyses. Results: The evidence indicates that paravertebral block provides superior pain control with lower opioid requirements, fewer adverse events, and higher patient satisfaction compared to other methods. While epidural analgesia offers pain control comparable to PVB, it is associated with higher technical failure rates and side effects, including urinary retention, nausea/vomiting, and hypotension. ICNB and ESPB demonstrate efficacy superior to systemic analgesia but generally inferior to PVB in terms of pain scores and opioid consumption. Conclusions: This review highlights the need for individualized approaches to perioperative pain management in thoracic surgery, with paravertebral block emerging as a preferred option due to its favorable efficacy and safety profile.

Background: Optimal management of patients with severe hyperbilirubinemia (> 14.6 mg/dL) undergoing pancreaticoduodenectomy remains controversial. Methods: Single-center retrospective study of 665 pancreaticoduodenectomies (2007–2024). Patients were stratified: no preoperative biliary drainage (PBD) with high (> 14.6mg/dL, n = 83) or low (< 14.6mg/dL, n = 312) bilirubin; PBD for low bilirubin (n = 140); PBD for high bilirubin (n = 113). Primary outcomes: 90-day mortality, morbidity, and specific complications. Results: Ninety-day mortality was significantly higher in non-PBD patients with high bilirubin (13.3%) compared to other groups (2.9–5.7%, p = 0.001). Overall morbidity was also higher in this group (29.0% vs. 12.8–20.7%, p < 0.001). While PBD groups showed higher surgical site infections (21.2–26.4% vs. 9.6%, p = 0.001), non-PBD high-bilirubin patients demonstrated increased ARDS (6.0% vs. 0–1.4%, p = 0.016) and reoperation rates (18.1% vs. 9.3–11.5%, p = 0.029). Multivariate analysis identified preoperative bilirubin > 14.6mg/dL as an independent predictor of 90-day mortality. Conclusion: Preoperative bilirubin ≥ 14.6mg/dL independently predicts perioperative morbidity and mortality following pancreaticoduodenectomy. These findings support preoperative biliary drainage in patients with severe hyperbilirubinemia to optimize surgical outcomes, despite PBD-associated infectious complications.

Introduction: Artificial intelligence (AI) applications are increasingly integrated into hepato-pancreato-biliary (HPB) surgery training, yet their impact on educational outcomes and patient safety remains unclear. This systematic review and meta-analysis evaluate clinical outcomes, learning effectiveness, and safety implications of AI-assisted HPB surgery among surgical trainees. Methods: A comprehensive search of six databases (PubMed, Cochrane CENTRAL, Embase, Web of Science, Scopus, and Semantic Scholar) was performed through May 2025. Studies involving surgical trainees utilizing AI-based platforms with measurable clinical, educational, or safety outcomes were included. Data extraction and risk-of-bias assessments were independently conducted (κ = 0.86-0.91). Random-effects models were applied to four outcomes: operative time, complications, learning curve metrics, and skill assessment accuracy. Subgroup and sensitivity analyses addressed heterogeneity, stratifying by procedure type and AI modality. Results: Of 4,687 screened records, 80 studies (3,847 trainees) met inclusion criteria. Four separate meta-analyses revealed: (1) operative time reduction of 32.5 min (MD -32.5, 95% CI: -45.2 to -19.8; I2 = 65%; 15 studies, 1,234 procedures); (2) decreased complications (RR 0.72, 95% CI: 0.58-0.89; I2 = 42%; 18 studies, 2,156 patients); (3) accelerated learning with 2.3 fewer cases to proficiency (SMD -2.3, 95% CI: -2.8 to -1.8; I2 = 55%; 10 studies, 423 trainees); and (4) AI skill assessment accuracy of 85.4% (95% CI: 81.2%-89.6%; I2 = 78%; 12 studies, 847 assessments). Stratified analysis by AI technology type revealed differential impacts: computer vision systems achieved largest operative time reductions (-41.2 min, 95% CI: -54.3 to -28.1), augmented reality showed -38.7 min (95% CI: -49.8 to -27.6), while machine learning demonstrated -24.3 min (95% CI: -32.1 to -16.5); test for subgroup differences P = 0.02. Subgroup analysis showed greater benefits for complex procedures (pancreaticoduodenectomy: -48.3 min) versus simple procedures (cholecystectomy: -18.4 min, P = 0.003). Complications showed similar procedure-specific patterns, with pancreaticoduodenectomy achieving RR 0.65 versus cholecystectomy RR 0.78. Critical View of Safety achievement improved from 11% to 78% (RR 2.84, 95% CI: 2.12-3.81). Publication bias was not detected (Egger’s test P > 0.05 for all outcomes). Discussion: AI-assisted HPB surgical training improves operative efficiency, reduces complications, enhances learning curves, and enables accurate skill assessment. These findings support systematic AI integration with standardized protocols and multicenter validation.

Background: Incisional hernia remains a common complication following abdominal surgery with significant implications for patient quality of life and healthcare costs. This systematic review and meta-analysis aim to evaluate the relationship between various abdominal incision types and the development of hernias, while identifying key risk factors. Methods: A comprehensive literature search was conducted across multiple databases for studies published between January 2000 and January 2025. Studies reporting incisional hernia rates following abdominal surgery with clearly documented incision types and a minimum follow-up of 6 months were included. Data extraction included study characteristics, patient demographics, incision types, hernia rates, and associated risk factors. Random-effects meta-analysis was performed to calculate pooled hernia rates and odds ratios. Results: Forty studies comprising 183 496 patients were included. Midline incisions were associated with the highest hernia rates (12.8-35%, pooled rate 18.7%) compared to transverse incisions (4.8-10.2%, pooled rate 7.4%; OR 0.38, 95% CI 0.26-0.57). In colorectal surgery specifically, midline incisions carried an odds ratio of 11.7 (95% CI 3.3-42.0) for hernia formation compared to transverse approaches. Paramedian, oblique, and Pfannenstiel incisions demonstrated lower hernia rates (2.1-8.6%). Significant patient-related risk factors included obesity (OR 4.74, 95% CI 1.42-15.55), male gender (HR 2.2), COPD (HR 2.35, 95% CI 1.16-4.75), and wound infection (HR 3.66). Most hernias (54-80%) developed within the first year after surgery, though continued development was observed for up to 10 years. Conclusions: Transverse, paramedian, and Pfannenstiel incisions offer significant advantages over midline approaches for reducing incisional hernia risk. Patient-specific factors, particularly obesity and pulmonary comorbidities, substantially influence hernia development. A tailored approach to incision selection based on patient risk profile, coupled with meticulous technique and wound management, is recommended to minimize hernia occurrence.