
==== Front
Int J Surg
Int J Surg
JS9
International Journal of Surgery (London, England)
1743-9191
1743-9159
Lippincott Williams & Wilkins Hagerstown, MD

38781046
IJS-D-24-01158
10.1097/JS9.0000000000001634
00044
3
Reviews
Perioperative outcomes and safety of valveless insufflation system in minimally invasive urological surgery: a systematic review and meta-analysis
Lu Youyi MD lyy_561@163.com
a
Zou Qingsong MD azou_qingsong@126.com

Jiang Bo MD b*jiangboqdy@126.com

Li Qi MM c*719981127@qq.com

a Department of Urology, The Affiliated Yantai Yuhuangding Hospital of Qingdao University, Yantai
b Department of Urology, Qingdao Municipal Hospital, Qingdao University, Qingdao
c Department of Endocrinology, Yantai Municipal Government Hospital, Yantai, Shandong, People’s Republic of China
* Corresponding author. Address: Department of Endocrinology, Yantai Municipal Government Hospital, NO. 16 West Yuhuangding Road, Yantai 264000, Shandong, People’s Republic of China. Tel.: +18 61 595 66 69. E-mail: 719981127@qq.com (Q. Li); Department of Urology, Qingdao Municipal Hospital, Qingdao University, NO. 1 Jiaozhou Road, Qingdao 266000, Shandong, People’s Republic of China. Tel.: +183 639 382 96. E-mail: jiangboqdy@126.com (B. Jiang).
9 2024
23 5 2024
110 9 57635770
27 3 2024
6 5 2024
Copyright © 2024 The Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal. http://creativecommons.org/licenses/by-nc-nd/4.0/

Background:

With the rapid development of laparoscopic and robot-assisted surgery, many technological innovations and improvements have emerged to optimize minimally invasive surgery and ensure minimal patient risk. Although AirSeal has been widely reported in the field of urology, its perioperative outcomes and safety in minimally invasive urological surgery remain unclear because of inconsistent levels of evidence.

Objectives:

The authors performed this meta-analysis to evaluate the perioperative outcomes and safety of the valveless insufflation system (VIS) in minimally invasive urological surgery compared with the conventional insufflation system (CIS).

Methods:

The authors comprehensively searched PubMed, Web of Science, Cochrane Library, and Embase databases to identify eligible studies published up to January 2024. Review Manager software (version 5.3.0) was used for the statistical analysis. Eligible studies were randomized controlled trials (RCTs) or non-RCTs of minimally invasive urological surgery with VIS vs CIS. The study outcomes included perioperative outcomes and safety. The authors excluded publication types, including letters, reviews, case reports, and animal and pediatric studies.

Results:

The authors finally identified five RCTs and eight non-RCTs in this meta-analysis. The meta- analysis indicated that the operative time was comparable between the groups (P=0.57, I 2=91%). However, a VIS may increase blood loss (P=0.0004, I 2=45%) and shorten hospital stays (P<0.00001, I 2=90%). Due to the high heterogeneity of the results, the authors carefully evaluated all included studies and discovered that the studies by Bucur and Ferroni may be the sources of heterogeneity. When these two studies were excluded, heterogeneity was significantly reduced, and the operative time for VIS was significantly shorter than that for CIS (P=0.0002). Adjusted blood loss showed no difference between the VIS and CIS groups (P=0.10). In terms of safety, the pooled results revealed that the incidence of Clavien–Dindo III–IV complications in the VIS group was significantly lower than that in the CIS group (P=0.02, I 2=0%). Moreover, VIS significantly reduced general pain (P=0.02, I 2=15%) and shoulder pain (P=0.001, I 2=0%) 12–24 h postoperatively. No significant differences were observed in total complications (P=0.06, I 2=0%), blood transfusion (P=0.14, I 2=0%), and subcutaneous emphysema (P=0.96, I 2=63%) between the two groups.

Conclusions:

Our meta-analysis revealed additional perioperative advantages of the VIS in minimally invasive urological surgery. Moreover, VIS is superior to CIS owing to less severe complication rates, general pain, and shoulder pain.

Keywords:

AirSeal
meta-analysis
postoperative pain
urological surgery
valveless insufflation system
OPEN-ACCESSTRUE
SDCT
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pmcIntroduction

Highlights

Many technological innovations and improvements have emerged to optimize minimally invasive surgery and assure minimal patient risk.

The perioperative outcomes and safety of AirSeal, a novel insufflator with valveless insufflation system, are still unclear because of inconsistent levels of evidence, especially in the field of minimally invasive urological surgery.

Through comparison with convention insufflation system, we found AirSeal may offer more perioperative advantages, less severe complications, and lower incidence of general pain and shoulder pain.

Recently, laparoscopic and robot-assisted surgery has provided a minimally invasive technical option for the surgical field. Minimally invasive surgery (MIS) has rapidly developed in the field of urology due to its advantages of minimal trauma and fewer postoperative complications. For MIS, the safe establishment of an artificial pneumoperitoneum is crucial, as it separates the abdominal wall from the organs for better surgical field exposure and larger surgical space.

An insufflator is a specialized device for establishing and maintaining pneumoperitoneum. A conventional insufflation system (CIS) adopts a standard one-way valve trocar. However, a one-way valve trocar may lead to unstable pneumoperitoneum, elevated intraperitoneal CO2 levels, and surgical smoke obstruction1, which potentially reduces surgical efficiency and increases the risk of perioperative complications. With the rapid development of MIS, many technological innovations and improvements have emerged to optimize MIS and minimize patient risk.

AirSeal (CONMED, Utica), a novel insufflator with a valveless insufflation system (VIS) and a barrier-free surgical trocar on the access port, has been introduced to the market2. This valveless trocar system uses a three-lumen tube on top of the access port to form the circulating gas injection mode. This technical modification has been proven to achieve laparoscopic and robotic surgery under low abdominal pressure, improve cardiopulmonary parameters, and maintain a stable pneumoperitoneum with no air leakage valve during the entire surgical process3–6.

The stable pneumoperitoneum provided by AirSeal system can prevent the collapse of the abdominal cavity, help to evacuate surgical smoke, and improve operative field exposure5, which seems to further reduce operative time, blood loss, and postoperative complications. Although AirSeal has been widely reported in the field of urology, its perioperative outcomes and safety in minimally invasive urological surgery remain unclear. Some studies showed shorter operative time and fewer complications in favor of VIS compared with CIS7,8, while other studies indicated conflicting results2,9. Therefore, to explore the potential benefits of VIS, we conducted a meta-analysis to compare the perioperative outcomes and safety of VIS and CIS in terms of minimally invasive urological surgery.

Materials and methods

Search strategy

This study was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA, Supplemental Digital Content 1, http://links.lww.com/JS9/C642, Supplemental Digital Content 2, http://links.lww.com/JS9/C643)10 and Assessing the Methodological Quality of Systematic Reviews (AMSTAR, Supplemental Digital Content 3, http://links.lww.com/JS9/C644) Guidelines11.

This research was registered by the authors on PROSPERO. Two authors independently searched PubMed, Web of Science, Cochrane Library, and Embase to identify eligible studies published up to January 2024 using the search terms ‘(AirSeal OR valveless trocar OR valve-less trocar) AND (insufflation OR pneumoperitoneum)’. The references of the relevant articles to identify additional studies were also manually searched.

Inclusion criteria

We included studies with a population of adults with minimally urological surgery. The included studies met the following criteria: (a) comparison VIS with CIS for minimally urological surgery. (b) The study outcomes included perioperative outcomes and safety. (c) Full text and analyzable data were available. (d) The study design was a randomized controlled trial (RCT) or non-RCT. When the same study was featured in different texts or years, we included the most comprehensive study. We excluded publication types, including letters, reviews, case reports, and animal and pediatric studies.

Two authors carefully read all the identified literature separately and conducted a detailed screening based on the title/abstract. If there was any controversy or uncertainty, they discussed and determined the results through consultation with a third author.

Data extraction and quality assessment

Two authors independently collected the relevant data. In cases of disagreement, they discussed with other reviewers to reach a consensus. Variables were pooled for analysis only when evaluated in more than two studies.

The quality of the included RCTs was assessed using the Cochrane Risk of Bias Assessment Tool. Each item was evaluated based on high, low, or unclear risk of bias12. The methodological quality of the included non-RCT studies was evaluated using the Methodological Index for Non-randomized Studies (MINORS) score13.

Statistical analysis

Review Manager software (version 5.3.0) was used for the statistical analysis. Continuous outcomes were assessed using the mean difference (MD) with 95% CIs, and dichotomous outcomes were assessed using the odds ratio (OR) with 95% CI. We used a fixed-effect model in homogeneous studies (P-value of χ 2 test ≥0.05, I 2<50%). When there was significant heterogeneity between studies (P-value of χ 2 test <0.05, I 2≥50%), a random-effect model was adopted for data analysis. P<0.05 was considered statistically significant.

Results

Characteristics of the included studies

We finally identified five RCTs9,14–17 and eight non-RCTs2,8,18–23 in this meta-analysis. The flow diagram of the study selection process is displayed in Figure 1. Among the included studies, three involved laparoscopic renal surgery14,18,21 and 10 employed robotic urologic surgery (mainly kidney, bladder, and prostate)2,8,9,15–17,19,20,22,23. Table 1 displays the main characteristics of the included studies, including the first author, publication year, country, study design, surgical procedure, intervention methods, and number of patients.

Figure 1 Flow diagram of the study selection.

Table 1 Main characteristics of the included studies.

Study	Country	Design	Surgery	Intervention	Number of patients	
Randomized controlled trials	
 Bucur14 (2016)	USA	RCT	Laparoscopic renal surgery	VIS 12 mmHg CIS 12 mmHg	28 28	
 Covotta15 (2017)	Italy	RCT	RARC	VIS 12 mmHg CIS 12 mmHg	28 28	
 Feng16 (2021)	USA	RCT	RAPN	VIS 12 mmHg VIS 15 mmHg CIS 15 mmHg	31 31 31	
 Desroches17 (2021)	USA Swedish	RCT	RAPN	VIS 12 mmHg VIS 15 mmHg CIS 15 mmHg	66 69 66	
 Abaza9 (2021)	USA	RCT	Robotic Prostatectomy	VIS 6 mmHg CIS 6 mmHg	50 50	
Non-randomized studies	
 Herati18 (2011)	USA	Prospective	Laparoscopic renal surgery	VIS 12 mmHg CIS 11 mmHg	26 25	
 Horstmann2 (2013)	Switzerland	Prospective	Robotic radical prostatectomy	VIS 12 mmHg CIS 12 mmHg	19 17	
 George19 (2015)	USA	Retrospective	Robotic prostatectomy	VIS 10 mmHg CIS 12 mmHg	257 385	
 Annino20 (2017)	Italy	Prospective	RAPN	VIS 12 mmHg CIS 12 mmHg	67 55	
 Ferroni22 (2019)	Ireland	Retrospective	Robotic prostatectomy	VIS 6 mmHg CIS 15 mmHg	300 300	
 Shahait8 (2019)	USA	Prospective	Robotic radical prostatectomy	VIS 12 mmHg CIS 15 mmHg	100 100	
 Forte21 (2023)	Italy	Retrospective	Laparoscopic partial nephrectomy	VIS 12 mmHg CIS 12 mmHg	14 13	
 Ayoub23 (2023)	USA	Retrospective	Robotic radical prostatectomy	VIS 8/12 mmHg CIS 12 mmHg	125 201	
CIS, conventional insufflation system; RAPN, robotic-assisted partial nephrectomy; RARC, robot-assisted radical cystectomy; RCT, randomized controlled trial; VIS, valveless insufflation system.

The comparison of basic clinical characteristics between the two treatment groups is displayed in Table 2. Age (MD −0.01, 95% CI: −0.59–0.57, P=0.98), sex (OR 0.99, 95% CI: 0.72–1.35, P=0.94), smoker (OR 1.25, 95% CI: 0.71–2.19, P=0.43), prostate specific antigen (PSA) (MD 0.23, 95% CI: −0.64–1.10, P=0.61), and margins (OR 0.97, 95% CI: 0.77–1.23, P=0.81) were comparable. However, the BMI was significantly higher in the VIS group (MD 0.55, 95% CI: 0.18–0.93, P=0.004).

Table 2 Clinical characteristics.

Variable	N	I 2 (%)	95% CI	P	
Age (years)	12	0%	MD −0.01 (−0.59–0.57)	0.98	
BMI (kg/m2)	12	0%	MD 0.55 (0.18–0.93)	0.004	
Sex	9	0%	OR 0.99 (0.72–1.35)	0.94	
Smoker (n)	4	0%	OR 1.25 (0.71–2.19)	0.43	
PSA (ng/ml)	4	0%	MD 0.23 (−0.64–1.10)	0.61	
Margins	4	24%	OR 0.97 (0.77–1.23)	0.81	
DBP, diastolic blood pressure; MD, Mean difference; OR, odds ratio; SBP, systolic blood pressure.

Qualitative assessment of individual studies

Among the five included RCTs, the quality assessment is illustrated in Figure 2. The quality assessment of the non-RCTs is presented in Table 3. The MINORS scores with 12 evaluation indicators ranged from 15 to 20.

Figure 2 Risk of bias assessment.

Table 3 Quality assessment of Non-RCT studies using MINORS.

Study	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11	Q12	Score	
Herati18 (2011)	2	1	2	2	0	0	2	0	2	2	2	2	17	
Horstmann2 (2013)	1	1	2	2	0	0	2	0	1	2	2	2	15	
George19 (2015)	2	1	2	2	0	0	2	0	2	2	2	2	17	
Annino20 (2017)	2	1	2	2	0	0	2	1	2	2	2	2	18	
Ferroni22 (2019)	2	2	2	1	0	2	2	1	2	1	2	2	19	
Shahait8 (2019)	2	1	2	1	0	2	2	0	1	2	1	2	16	
Forte21 (2023)	2	1	2	2	2	0	2	0	2	2	2	2	19	
Ayoub23 (2023)	2	2	2	2	0	2	2	0	2	2	2	2	20	
Q1, clearly stated aim; Q2, inclusion of consecutive patients; Q3, prospective data collection; Q4, endpoints appropriate to the study aim; Q5, unbiased evaluation of study endpoints; Q6, follow-up period appropriate to the aim of the study; Q7, loss to follow-up <5%; Q8, prospective calculation of study size; Q9, an adequate control group; Q10, contemporary groups; Q11, baseline equivalence of groups; Q12, adequate statistical analysis.

Perioperative outcomes

Operative time and blood loss

Eight studies, comprising two RCTs and six non-RCTs involving 1967 patients, provided data on operative time and blood loss. Among them, 883 patients were in the VIS group, and 1084 were in the CIS group. A random-effect model revealed no significant difference in operative time between the two groups (MD −4.01, 95% CI: −17.75 to 9.73, P=0.57, I 2=91%) (Fig. 3). However, regarding the estimated blood loss, a fixed-effects model indicated an MD of 0.16 with a 95% CI of 0.07–0.25 (P=0.0004, I 2=45%; Fig. 4). The results indicated a significant increase in blood loss in the VIS group.

Figure 3 Forest plots comparing valveless insufflation system (VIS) with conventional insufflation system (CIS) for operative time (min). df, degree of freedom; IV, inverse variance.

Figure 4 Forest plots comparing valveless insufflation system (VIS) with conventional insufflation system (CIS) for blood loss (ml). df, degree of freedom; IV, inverse variance.

Hospital stays

Six articles (four RCTs and two non-RCTs) were included in the pooled analysis of hospital stays. A random-effect model revealed that patients in the VIS group had shorter hospital stays than those in the CIS group (MD −0.29, 95% CI: −0.41 to 0.17, P<0.00001, I 2=90%; Fig. 5).

Figure 5 Forest plots comparing valveless insufflation system (VIS) with conventional insufflation system (CIS) for hospital stay (days). df, degree of freedom; IV, inverse variance.

Safety

We compared the incidence of postoperative complications between the two surgical techniques (Table 4).

Table 4 Pooled outcomes of complications.

Variable	N	I 2 (%)	95% CI	P	
Overall complications	6	0%	OR 0.69 (0.46–1.02)	0.06	
Clavien–Dindo I–II	4	42%	OR 0.88 (0.54–1.44)	0.61	
Clavien–Dindo III–IV	4	0%	OR 0.40 (0.19–0.85)	0.02	
General pain	
 <12 h	5	0%	MD −0.38 (−0.92–0.16)	0.17	
 12–24 h	3	15%	MD −0.79 (−1.46, −0.12)	0.02	
 Time of discharge	3	0%	MD −0.33 (−0.88–0.23)	0.25	
Shoulder pain	
 <12 h	5	53%	MD −0.44 (−0.91–0.03)	0.07	
 12–24 h	3	0%	MD −0.79 (−1.27, −0.32)	0.001	
 Time of discharge	3	0%	MD −0.15 (−0.45–0.15)	0.31	
Morphine equivalents	3	0%	MD 0.06 (−0.24–0.35)	0.70	
Blood transfusion	5	0%	OR 0.48 (0.18–1.28)	0.14	
Subcutaneous emphysema	6	63%	OR 1.03 (0.34–3.10)	0.96	
MD, Mean difference; OR, odds ratio.

Total complications

Six studies involving 1875 patients (836 patients in the VIS group and 1039 patients in the CIS group) provided data on total complications. Data were available from one RCT and five non-RCTs. Fixed-effect model analysis revealed no significant difference in total complications between the two groups (OR 0.69, 95% CI: 0.46–1.02; P=0.06; I 2=0%).

Four of the six studies also conducted a subgroup analysis for surgical complications based on the Clavien–Dindo grading system. The pooled result showed no significant difference in the incidence of Clavien–Dindo I–II complications (OR 0.88, 95% CI: 0.54–1.44; P=0.61; I 2=42%), while the incidence of Clavien–Dindo III–IV complications in the VIS group was significantly lower than that in the CIS group (OR 0.40, 95% CI: 0.19–0.85; P=0.02; I 2=0%).

General pain, shoulder pain, and morphine equivalents

Two articles provided data on the incidence of general pain, shoulder pain, and morphine equivalents. Regarding general and shoulder pain, there was no significant difference at postoperative 0–12 h and at the time of discharge. However, VIS significantly reduced general pain (MD −0.79, 95% CI: −1.46 to −0.12; P=0.02; I 2=15%) and shoulder pain (MD −0.79, 95% CI: −1.27 to −0.32; P=0.001; I 2=0%) at 12–24 h postoperatively.

In terms of morphine equivalents throughout the entire hospital stay, a fixed-effect model analysis revealed no significant difference between the two groups (OR 0.06, 95% CI: −0.24–0.35; P=0.70; I 2=0%).

Blood transfusion

Five non-RCT studies involving 1168 patients (489 patients in the VIS group and 679 patients in the CIS group) provided data on blood transfusion. The pooled results showed no significant difference in the incidence of blood transfusion between the two groups (OR 0.48, 95% CI: 0.18–1.28; P=0.14; I 2=0%).

Subcutaneous emphysema (SCE)

Regarding the SCE, 499 patients were included in the event analysis. The pooled results revealed no significant difference between the two groups (OR 1.03, 95% CI: 0.34–3.10; P=0.96; I 2=63%).

Discussion

To date, the available studies on AirSeal have primarily focused on general surgery, gynecology, and urology. Balayssac et al.24 conducted a systematic review based on relevant articles in these three fields to explore the clinical impact of AirSeal during laparoscopic surgery. They found that the total number of complications, postoperative room, and total length of stay were similar between the groups. However, the operative time, postoperative pain, and morphine consumption showed inconsistent results without statistical analysis. Another meta-analysis by Claroni et al.7 compared the impact of VIS and CIS on postoperative pain and operative time, particularly for MIS. Their meta-analysis only included three studies, and the findings indicated a significant reduction in shoulder pain with the use of VIS at 24 h. However, no significant difference was observed between the two groups in terms of operation time. Notably, only one of the three included studies regarded laparoscopic renal surgery, whereas the other two studies focused on laparoscopic gynecological surgery.

Our study is distinctive in that it focused on minimally invasive urological surgery. Razdan et al.25 published a systematic review on the application of AirSeal in robotic urological surgery. They reported the benefits of AirSeal on cardiopulmonary parameters. However, its effects on operative time, duration of hospital stay, and safety remain unclear. In our meta-analysis, we aimed to evaluate the perioperative outcomes and safety of VIS compared to CIS in minimally invasive urological surgery.

AirSeal provides significant advantages in the stability of pneumoperitoneum and fewer trocar operations, and previous studies19,23 have reported that AirSeal can significantly shorten the operative time. Inconsistent results were shown in our analysis, and no significant difference was observed between the two groups in terms of operative time. However, due to the high heterogeneity of the results, we evaluated each included study thoroughly and established that the studies by Bucur et al.14 and Ferroni and Abaza22 may be the sources of heterogeneity. In a study by Bucur et al.14, the VIS group tended to have larger tumors and more complicated procedures, which may have led to an increase in operative time. In a study by Ferroni and Abaza22, the VIS group used 6 mmHg low insufflation pressure, which may weaken the tamponade effect on venous bleeding, resulting in more intraoperative blood loss and poor visualization of the surgical field, thereby increasing the operative time. When Bucur et al.14 and Ferroni and Abaza22 were excluded, the heterogeneity was reduced significantly, and the result showed a shorter operative time in the VIS group (P=0.0002; Supplement Figure 1, Supplemental Digital Content 4, http://links.lww.com/JS9/C645).

Moreover, our results revealed an increase in blood loss in the VIS group but no increase in transfusion requirement compared to the CIS group. When we also excluded the articles by Bucur et al.14 and Ferroni and Abaza22, the pooled result of blood loss showed no difference between VIS and CIS (P=0.10; Supplement Figure 2, Supplemental Digital Content 4, http://links.lww.com/JS9/C645), consistent with the result of transfusion requirement. Moreover, no statistically significant difference was observed in overall complications, Clavien–Dindo I–II complications, and SCE between the two groups. However, the incidence of Clavien–Dindo III–IV complications in the VIS group was significantly lower than that in the CIS group, which also explains the shorter hospital stay in the VIS group.

Shoulder pain is distinct from laparoscopic surgery and has a multifactorial and clinically relevant effect26. The main cause of postoperative pain is overstretching of the diaphragmatic ligaments during CO2 insufflation. We evaluated postoperative pain (general pain, shoulder pain, and morphine equivalents) and observed that Bucur et al.14 and Feng et al.16 specifically made pain assessments by the visual analog scale at different follow-up visits. The pooled results revealed that general and shoulder pain were significantly lower at 12–24 h postoperatively in the VIS group, comparable to the conclusion of Claroni et al.7. No difference in postoperative pain within 12 h was observed, which may be associated with certain factors, including anesthesia and potential bladder spasms induced by urethral catheters22. Moreover, an additional evaluation parameter, morphine equivalent did not differ significantly between the two groups, which is inconsistent with the pain score outcome and may be due to the small sample size and lack of segmental evaluations at the corresponding time points. Postoperative pain is multifactorial. We believe that lower postoperative pain is associated with AirSeal-mediated abdominal insufflation, stable pneumoperitoneum, and sustained evacuation of smoke.

This meta-analysis had several limitations. First, the number of included studies, particularly high-quality RCTs, was limited. Consequently, we were unable to conduct a potential publication bias or meta-regression analysis. Moreover, several outcomes should be interpreted with caution because of the high heterogeneity. Second, patients in the VIS group had a significantly higher BMI than those in the CIS group, which may increase the difficulty of surgery and increase morphine equivalent, resulting in longer operative time and higher postoperative risk. Third, since CIS can significantly shorten the duration of hospital stay and reduce postoperative pain and serious complications, the economic burden on patients can be greatly reduced, which may surpass the expense associated with this technology. However, this is true for single-payer systems. Currently, the published literature does not report the economic cost of AirSeal. As an important part of new technology assessment, the cost effect is essential.

In conclusion, our meta-analysis revealed more perioperative advantages of a VIS in minimally invasive urological surgery. Moreover, VIS is significantly superior to CIS because of its lower incidence of general pain, shoulder pain, and severe complications. Our meta-analysis also provides recommendations for future studies. More well-designed and larger RCTs are expected to provide sufficient data and increase the robustness of our findings. In the future, we should concentrate on AirSeal cost concerns.

Ethical approval

This is a meta-analysis. All analyses were based on previous published studies, thus ethical approval and patient consent are not required.

Consent

Not applicable.

Sources of funding

This research did not receive any grant from funding agencies in the public, commercial, or not-for-profit sectors.

Author contribution

Q.L. and B.J.: project development and revised the manuscript; Y.L., Q.Z., and Q.L.: screened and collected studies; Y.L., Q.Z., Q.L., and B.J.: extracted and analyzed the data; Y.L. and Q.L.: draft the manuscript.

Conflicts of interest disclosure

The authors declare no conflicts of interest.

Research registration unique identifying number (UIN)

Name of the registry: International prospective register of systematic reviews (PROSPERO).

Unique identifying number of registration ID: CRD42024506298.

Hyperlink to our specific registration (must be publicly accessible and will be checked): https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024506298.

Guarantor

Youyi Lu, Qingsong Zou, Qi Li, and Bo Jiang.

Data availability statement

All data used and/or analyzed in the current study are available on request from the corresponding author.

Provenance and peer review

Not commissioned, externally peer-reviewed.

Supplementary Material

Acknowledgements

The authors thank Home for Researchers editorial team (www.home-for-researchers.com) for language editing service.

Youyi Lu contributed to this work as first author.

Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article.

Supplemental Digital Content is available for this article. Direct URL citations are provided in the HTML and PDF versions of this article on the journal’s website, www.lww.com/international-journal-of-surgery.

Published online 23 May 2024
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