Cutting edge blog
This section is designed to add value to the articles published in BJS and BJS Open.
If you wish to send a written (or even recorded) comment on one of the published articles, please send it to katie@bjsacademy.com.
If you wish to respond more immediately, please use social media directly by tagging @BJSurgery, @BjsOpen or @BJSAcademy
Assessing reinforced tension line sutures for hernia prevention: methodological considerations from the Rein4CeTo1 trial
Anshika Upasani
Correspondence to: Anshika Upasani (email: anshikaupasani11@gmail.com)
Department of General Surgery
All India Institute of Medical Sciences
Comment on: Management of bilioenteric anastomosis leakage after major liver resection
Christian Sturesson, Melroy D’Souza, Cecilia Strömberg, Ernesto Sparrelid, Stefan Gilg
Correspondence to: Christian Sturesson (email: christian.sturesson@ki.se)
Department of Clinical Science
Intervention and Technology
Surgery and the future of breast cancer care: breast cancer awareness month 2025
Matthew Lee PhD FRCS
Breast cancer is the most common cancer affecting women worldwide. It is likely that many people reading this know someone who has been affected by this condition. For many, surgery remains the cornerstone of curative treatment. Breast cancer surgery has advanced significantly since the first radical mastectomies of the late 19th century to today’s refined breast-conserving and reconstructive techniques.
Surgery remains a key component of treatment of breast cancer. For early-stage disease, removing the tumour can be enough to eradicate cancer completely. In more advanced cases, surgery is complemented by chemotherapy, radiotherapy, and hormone therapy.
The success of breast cancer surgery has not happened by chance. It reflects decades of rigorous research, often led by surgeons. Trials that once compared radical mastectomy with breast-conserving surgery laid the foundations for a global shift in practice. Randomised studies in axillary surgery demonstrated that less can be more, avoiding major complications such as lymphoedema without compromising oncological standards. The surgical research forces driving this rapid development have changed lives. They also act as an exemplar for other specialties.
Team design as innovation in perioperative care: the case of HPB anesthesiology
Julie Hallet, MD MSC, Naheed Jivraj, MD MSc
Change takes time – in all fields, including surgery. Yet, innovation is highly prized. The latest tools and technologies are celebrated and heavily invested in. But not all improvements require new technology.
For example, robotic pancreatic surgery is being adopted worldwide at a cost of millions in capital investment and ongoing expenses. Evidence shows it is mostly non-inferior to the standard of care.1–4 Another example is histotripsy for liver tumors, which has been rapidly purchased across multiple centers since FDA approval in 2023, spreading like mushrooms after the rain. Evidence is limited to technical feasibility, with no proof of superiority over standard care.5 Both technologies are used only in selected patients. By contrast, high-volume anesthesiology care for hepato-pancreato-biliary (HPB) surgery is associated with15% lower odds of 90-day major morbidity (OR 0.85, 95% CI 0.76–0.94), requires no capital investment, no recurring costs, and applies to all patients.
We are not debating or questioning the benefits of these technologies or the need to invest in new treatments. Rather, we would like to ask: if we are so willing to spend vast sums on new technology, why are we far less inclined to redesign how operative teams are organized?
Author response: Missing the split? Reconsidering the scope of biliary complications in the classification proposed at the BileducTx meeting
Hannah Esser, Iris de Jong, Floris M Roos, Robert J Porte, Stefan Schneeberger
Correspondence to: Stefan Schneeberger (e-mail: stefan.schneeberger@i-med.ac.at)
Department of Visceral
Transplant and Thoracic Surgery
Comment on: Ultra-low dose superparamagnetic iron oxide nanoparticle injection for sentinel lymph node detection in breast cancer: prospective cohort study
Lielong Yang, Yuzhou Zhu
Correspondence to: Yuzhou Zhu (e-mail: Zhuyuzhou@scu.edu.cn)
Colorectal Cancer Center
Department of General Surgery
Author response: Ultra-low dose superparamagnetic iron oxide nanoparticle injection for sentinel lymph node detection in breast cancer: prospective cohort study
Fredrik Wärnberg, Andreas Karakatsanis, Roger Olofsson Bagge
Correspondence to: Fredrik Wärnberg (e-mail: fredrik.warnberg@vgregion.se)
Department of Surgery
Sahlgrenska University Hospital
Reproductive outcomes after ileo-pouch anal anastomosis: clarifications and the importance of fertility counselling
Anders Mark-Christensen, Kirstine Kirkegaard, Mette Julsgaard
Correspondence to: Anders Mark-Christensen (e-mail: andersmark@dadlnet.dk)
Department of Surgery
Odense University Hospital
Birth rates and fertility are not the same
Eugenia Shmidt, Zoë S. Gottlieb, Marla C. Dubinsky
Correspondence to: Eugenia Shmidt (email: eshmidt@umn.edu)
Department of Medicine
University of Minnesota
Endoscopic mastectomy meta-analysis: commentary
Ayla Carroll, Carlos Robles, Hung-Wen Lai, Lidia Blay, Piotr Pluta, Gauthier Rathat, Guillermo Peralta, Rami Younan, Giada Pozzi, Daniel Martinez Campo, Robert Milligan, Glenn Vergauwen, Paolo Carcoforo, Antonio Toesca
Division of Breast Surgical Oncology
Candiolo Cancer Institute
Comment on: Oncological, surgical, and cosmetic outcomes of endoscopic versus conventional nipple-sparing mastectomy: a meta-analysis
Kefah Mokbel, MBBS, MS, FRCS
Correspondence to: Kefah Mokbel (email: kefahmokbel2@gmail.com)
The London Breast Institute
Princess Grace Hospital
Ergonomics in the operating room is a safety imperative
Julie Hallet, MD MSc, Fahad Alam, MD MEd
The operating room (OR) is often imagined as a highly choreographed space – every step deliberate, every movement precise, and every member essential. Yet, beneath this seamless surface lies a persistent under-addressed risk to those who make it all happen: the ever-growing ergonomic hazards faced by OR teams. Our group recently reported about live observations by ergonomic experts in the OR, in “Under Pressure: Live Observation of Ergonomic Challenges in the Operating Room” published in the BJS, to shine a spotlight on some of these challenges and adds to a growing call for change.1
We observed OR teams across multiple specialties and procedures to identify common ergonomic challenges to target for improvement in future educational interventions. The findings were both revealing and concerning: surgeons leaning awkwardly to see monitors, anesthesiologists contorted around ill-placed equipment, scrub nurses reaching and twisting repeatedly to manage instruments. These were not rare occurrences, they were routine. In a single two-hour procedure, 37 near-miss tripping incidents were recorded due to poor cord management. It is not just a matter of individual minor discomforts, but systemic risks that accumulate over time, leading to musculoskeletal injuries, burnout, and ultimately threats to patient safety and the sustainability of surgical care systems.
Historically, the conversation around ergonomics in surgery has been largely focused on surgeons. Whilst important, this lens is incomplete. Poor ergonomics affects everyone in the OR: nurses, anesthesiologists, technicians, and trainees. A scrub nurse standing for hours with no anti-fatigue mat is as vulnerable as the surgeon operating with prolonged neck flexion. An anesthesiologist forced into a hunched position for intubation is as likely to suffer long-term strain as any other member of the team. Moreover, poor ergonomics doesn’t just result in discomfort. It affects communication, reaction time, and decision-making, all which affect patient safety. Increasingly, we recognize that surgical safety is not only about checklists and technique; it is also about ensuring that the people delivering care are supported, protected, and able to perform at their best.
Strengthening the evidential basis of ward-round safety interventions
Wenbo Zhao, Yuquan Chen
Correspondence to: Yuquan Chen (email: yuquan.chen@monash.edu)
School of Public Health and Preventive Medicine
Faculty of Medicine
Author response: strengthening the evidential basis of ward-round safety interventions
Ellie C Treloar, Jesse D Ey, Matheesha Herath, Guy J Maddern
Correspondence to: Guy J. Maddern (email: guy.maddern@adelaide.edu.au)
Department of Surgery
The University of Adelaide
Science in a flash: pain, anxiety, stress and sleep disturbances among surgical patients
Jetske Marije Stoop, Markus Klimek, MD, PhD, DEAA, EDIC, FESAIC
How often do surgical patients experience pain, anxiety, stress, and sleep disturbance during their hospital stay? And how severe are these symptoms? In collaboration with numerous Dutch hospitals, we set out to answer these questions, using an uncommon and innovative, but for our goals perfectly fitting method: a flash mob study.
A flash mob study is a novel research design in which data is collected on a single day, simultaneously in multiple centres. It’s an efficient way to address clinically relevant questions on a large scale – in our case the point prevalence of surgical patient pain, anxiety, stress, and sleep disturbance. But this approach also requires meticulous planning: there’s only one shot to get it right.
The preparation for the project took a year. We started by developing the methodology and drafting the study protocol, followed by compiling all necessary documents for submission to the Medical Ethics Review Committee (MERC). While awaiting approval, we reached out to all hospitals across the Netherlands. Through secretaries and outpatient clinics, we found surgeons and residents in 29 Dutch hospitals who were eager to participate and helped forming a local research team and arranging institutional approval from the hospital board.
Comment on: Assessment of nodal staging and risk factors for nodal involvement in gallbladder cancer
Wissam Benhami, Dihia Makaci, Ahmed Fouad Bouras, Chafik Bouzid
Correspondence to: Dr. Wissam Benhami (email: wissambenhami@gmail.com)
Department of General Surgery
RAHMOUNI Djilali Public Hospital (Les Orangers)
Author response: Assessment of nodal staging and risk factors for nodal involvement in gallbladder cancer
Anita Balakrishnan, Petros Barmpounakis, Nikolaos Demiris, Bodil Andersson, Alejandro Brañes, Xavier de Aretxabala, Malin Sternby Eilard, Paul Gibbs, Simon J F Harper, Emmanuel L Huguet, Asif Jah, Vasilis Kosmoliaptsis, Javier Lendoire, Siong S Liau, Shishir Maithel, Jack L Martin, Colin Noel, Raaj K Praseedom, Alejandro Serrablo, Volkan Adsay, the OMEGA Study Investigators
Correspondence to: Anita Balakrishnan (email: ab2031@cam.ac.uk)
Department of Hepatopancreatobiliary Surgery
Cambridge University Hospitals NHS Foundation Trust
Arterial resections in pancreatic cancer: measure twice, cut once
Monish Karunakaran
Correspondence to: Monish Karunakaran (email: monish3682@gmail.com)
Department of Surgical Gastroenterology
Asian Institute of Gastroenterology
Comment on: Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas
Lauren Taylor, Chris Duff, David Mowatt, James Howard, Richard Whitehouse
Correspondence to: Lauren Taylor (email: lauren.taylor6@nhs.net)
Plastic Surgery Department
Wythenshawe Hospital
Author response: Intercontinental collaborative experience with abdominal, retroperitoneal and pelvic schwannomas
Samuel J Ford, James Hodson
Correspondence to: Samuel J Ford (email: samuel.ford@uhb.nhs.uk)
University Hospitals Birmingham
Edgbaston
Immunotherapy-enhanced tumour regression in rectal cancer: should surgery be omitted?
Wenlong Qiu, Xuan Zheng, Yunpeng Wu, Yong Yang, Qian Liu
Correspondence to: Qian Liu and Yong Yang
Qian Liu (e-mail: fcwpumch@163.com)
Department of Colorectal Surgery
Organ preservation for rectal cancer patients in the era of neoadjuvant immunotherapy
Kai Pang, Xinzhi Liu, Pengfei Zhao, Hongwei Yao, Yingchi Yang, Zhongtao Zhang
Correspondence to: Zhongtao Zhang (email: zhangzht@ccmu.edu.cn)
Department of General Surgery
Beijing Friendship Hospital
Comment on: Effect of transverse versus midline periumbilical incision on incisional hernia and short-term outcomes after laparoscopic colon cancer surgery: multicentre, open-label, randomized clinical trial
Jeremy Meyer, Jonathan Douissard, Marie Burgard
Correspondence to: Marie Burgard (email: marie.burgard@web.de)
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Missing the split? Reconsidering the scope of biliary complications in the classification proposed at the BileducTx meeting
Juri Fuchs, MD, Florent Guerin, MD, PhD, Geraldine Hery, MD, Virginie Fouquet, MD, Sophie Branchereau, MD, PhD
Department of General, Visceral, Pediatric and Transplantation Surgery
University of Heidelberg