Enhancing Safety in Gynecologic Surgery: Innovative Access and Lymphadenectomy Techniques to Reduce Complications
Round 1
Reviewer 1 Report
Comments and Suggestions for AuthorsDear Authors
Thanks for your valuable study.
1-please state the type of report as systematic review or meta-analysis.
2-It is better to choose keywords according to mesh words, you focus on laparoscopic innovation but you didn't mention the word " laparoscopy" in keywords.
3-please state registration information including the registration number of review.
4-It is better to Specify the publication year status in the method part.
5-Please specify the study selection by the flow diagram
6-It is better to discuss the limitations of the study.
7-The conclusion part is too long, It is better to summarize it.
Author Response
1. Please state the type of report as systematic review or meta-analysis.
1. Thank you for your comment regarding the classification of our manuscript. We would like to clarify that our submission is a narrative review, not a systematic review or meta-analysis. According to the “Instructions for Authors” provided by the journal (https://www.mdpi.com/journal/complications/instructions), the “Review” category accommodates both systematic and non-systematic reviews, the latter of which does not require adherence to the PRISMA guidelines.
Since our review does not employ a systematic methodology or meta-analytic approach, it does not meet the criteria for a systematic review or meta-analysis.
2. It is better to choose keywords according to mesh words, you focus on laparoscopic innovation but you didn't mention the word " laparoscopy" in keywords.
2. We have updated our keywords accordingly to better reflect our focus on laparoscopic innovation and to adhere to standard indexing practices. Specifically, we have added “Laparoscopy” as a keyword.
3. Please state registration information including the registration number of review.
3. As our submission is a narrative review rather than a systematic review, it is not subject to the registration requirements typically associated with systematic reviews. Consequently, we have not registered this review in a specific database (e.g., PROSPERO).
4. It is better to Specify the publication year status in the method part.
4. We have updated the manuscript to indicate that our comprehensive literature search was conducted in January 2025. This clarification is now included in the relevant paragraph detailing our review methodology.
5. Please specify the study selection by the flow diagram
5. As our manuscript is a narrative review, rather than a systematic review, we did not employ a fully systematic methodology with predefined inclusion and exclusion criteria or follow a formal screening process. Consequently, the construction of a PRISMA-style flow diagram is not applicable in this context.
Nevertheless, our search strategy did involve consulting major databases (e.g., PubMed, Scopus) and conducting a “snowball” search of relevant references. From this unstructured review, we ultimately selected 31 pertinent articles based on their relevance to the topic. We hope this clarifies our approach.
6. It is better to discuss the limitations of the study.
6. We have now included a section on the limitations of our review in the Discussion. This paragraph addresses the non-systematic nature of our methodology, potential selection bias, and the heterogeneity of the included studies.
7. The conclusion part is too long, It is better to summarize it.
7. Thank you for your guidance on summarizing the conclusion section. We have reduced the word count from 223 to 159 words, and we have condensed the conclusion into two concise paragraphs.
We appreciate your detailed revision process, which has significantly contributed to enhancing the overall quality of our manuscript.
Reviewer 2 Report
Comments and Suggestions for AuthorsThe whole article is well elaborated and sturctured. Literature was immergely studied in this topic.
I have only some minor comments:
The place of the table of key messages should be at the conclusion of the article as "take home message"
Authors do not write about the type and location of lymphadenectomy, as the indication of lymphadenetomy is more and more limited with an extreme focus on sentinel lymph node dissection. Which itself is a mean of reductiong complications.
Obesity remains the main reason of using high CO2 pressure and reduction of ventillation capacity. This context was not elucidated in the discussion.
Author Response
1. The place of the table of key messages should be at the conclusion of the article as "take home message"
1. We have now moved Table 1 (renamed as Table 2) to the end of the manuscript, placing it immediately before the conclusion. We believe this will improve clarity and highlight the key take-home messages for the reader.
2. Authors do not write about the type and location of lymphadenectomy, as the indication of lymphadenetomy is more and more limited with an extreme focus on sentinel lymph node dissection. Which itself is a mean of reductiong complications.
2. We have included the requested information regarding the types and location of lymphadenectomy, as well as the increasing focus on sentinel lymph node dissection, in Section 4.4 of our manuscript. These updates underscore how sentinel node techniques can reduce complications by minimizing the extent of nodal dissection. We appreciate your feedback and believe this revision adequately addresses your concerns.
3. Obesity remains the main reason of using high CO2 pressure and reduction of ventillation capacity. This context was not elucidated in the discussion.
3. We have incorporated the requested information regarding obesity, higher COâ‚‚ insufflation pressures, and associated ventilation considerations into Section 4.5.
We appreciate how your detailed feedback has substantially improved the overall quality of our manuscript.
Reviewer 3 Report
Comments and Suggestions for AuthorsThe article presents several original contributions and addresses critical gaps in the field of gynecologic surgery. Introduction of the Jain Point as an alternative laparoscopic entry site, particularly beneficial in patients with prior abdominal surgeries where umbilical adhesions may be present. Discussion of Palmer’s Point as an established yet underutilized technique to reduce vascular and bowel injuries during trocar insertion. Emphasis on the importance of individualized entry site selection based on patient anatomy and surgical history. The authors should consider several specific improvements in their methodology, as well as additional controls to strengthen the validity of their findings:
- While innovative techniques are discussed, direct comparisons with conventional approaches in controlled clinical settings would provide stronger evidence. The authors should include objective outcome measures such as complication rates, operative times, and recovery metrics.
- While the article acknowledges that individualized approaches improve safety, it lacks detailed subgroup analysis (stratifying patients by previous abdominal surgeries, or comorbidities). More specific recommendations based on patient risk factors would improve clinical applicability.
- The evidence would be stronger if data were collected from multiple institutions, reducing the impact of single-center practice patterns.
By implementing these methodological refinements and controls, the study’s findings would be more robust, generalizable, and clinically impactful.
Author Response
1. While innovative techniques are discussed, direct comparisons with conventional approaches in controlled clinical settings would provide stronger evidence. The authors should include objective outcome measures such as complication rates, operative times, and recovery metrics.
1. After conducting an extensive review of the literature, we found that the included studies vary greatly in design, patient population, and reported outcomes, which made it challenging to establish consistent, quantifiable objective outcome measures such as complication rates, operative times, and recovery metrics. Nevertheless, we endeavored to synthesize clear key findings that enable a comparative narrative across different laparoscopic techniques and intermediate steps. This approach allows us to present practical recommendations while acknowledging the limitations posed by heterogeneous data. We appreciate your suggestion and believe our current presentation effectively balances available evidence with clinical applicability.
2. While the article acknowledges that individualized approaches improve safety, it lacks detailed subgroup analysis (stratifying patients by previous abdominal surgeries, or comorbidities). More specific recommendations based on patient risk factors would improve clinical applicability.
2. We note that most studies reviewed do not sufficiently stratify patients by key risk factors, such as previous abdominal surgeries or comorbidities. As a result, we were unable to include the level of subgroup analysis recommended. However, we have addressed this gap by emphasizing the need for more detailed risk-based stratification in Section 4.3 of our manuscript. We believe this addition underscores the importance of individualized approaches and highlights areas for future research to enhance clinical applicability.
3. The evidence would be stronger if data were collected from multiple institutions, reducing the impact of single-center practice patterns.
3. We appreciate your suggestion. However, our current submission is a narrative, non-systematic review and did not encompass a multi-institutional scope. As a future step, we plan to conduct a systematic review involving a multidisciplinary team from different centers, which will allow for a broader data collection and a stronger evidence base.
