Re-pediatric laparoscopy: Facts and factitious claims.

Sir,

I have read Professor Raveenthiran's article titled “Pediatric Laparoscopy- Facts and factitious claims”, published recently[1] with keen interest. The drafting of this manuscript must have been an onerous task. The author deserves praise for this initiative. I concur with the author's conclusion that laparoscopy is not necessarily “minimally invasive” and “minimal access surgery” is a more accurate term to use.

However, it is important to minimize bias when reviewing evidence. The following methodological weaknesses in this work may have resulted in a bias.

Poorly focused search strategy. A more comprehensive use of search terms and searching of EMBASE and CENTRAL databases in addition to Medline would have been appropriate.[2] The author could have been more explicit in detailing the research question(s) and corresponding search strategies.[23] I wonder whether each of the subtopics deserved an independent search strategy, given the differences in the outcomes of interest.[2] For example, are we justified in excluding publications on robotic surgery, which is a subset of laparoscopy, when searching for evidence relating to family/ patient perspectives on operative scars or cosmesis? A more focused search [Table 1] helps in identifying at least two additional publications,[4,5] which specifically discuss the relevance of scars/ cosmesis to the families and the children.

Table 1

Search strategy focused at identifying studies which discuss importance of cosmesis and operative scars in children with reference to laparoscopic surgery (Medline 1950-2010)

Data extraction . It may have been worthwhile for the author to check the cross references or contact the experts to see if the analyzed data is truly representative of the current literature on the topic[2] and to have the abstracts screened by two independent reviewers instead of one.[3] This would minimize publication and selection bias.

Data synthesis . It is evident that results of studies comparing postoperative pain in laparoscopic and open procedures in children show significant qualitative differences. Appropriate data synthesis and reporting of pooled estimates would have been preferable.[3]

Failing these, the risk of introduction of an unintentional bias in the identification of relevant literature and its analysis remains high. As a result, one wonders if the author's conclusions are disproportionately stronger in comparison to the evidence provided by him.

Notwithstanding the shortcomings, this remains an important publication, which should serve to encourage studies aimed at generating high level of evidence in both, surgical outcomes and patient perspectives in pediatric minimal access surgery.