Journal of the European Society for Gynaecological Endoscopy


Efficiency based updating of evidence based surgical guidelines - Experiences from a multidisciplinary guideline upon Minimally Invasive Surgery

F.H.M.P. Tummers1, S.F.P.J. Coppus2, B.W. Lagerveld3, A. Demirkiran4, E.S. van Schrojenstein Lantman5, T.A. Brouwer6, W.A. Draaisma7, F.W. Jansen1,8

1 Department of Gynecology, Leiden University Medical Center, 2333 ZA Leiden, The Netherlands
2 Department of Gynecology, Maxima Medical Center, 5631 BM Veldhoven/Eindhoven, The Netherlands
3 Department of Urology, OLVG, 1091 AC Amsterdam, The Netherlands
4 Department of Surgery, Red Cross Hospital, 1942 LE Beverwijk, The Netherlands
5 Department of Medical Technology and Medical Physics, Albert Schweitzer Hospital, 3318 AT Dordrecht, The Netherlands
6 Department of Anesthesiology, Medical Center Leeuwarden, 8934 AD Leeuwarden, The Netherlands
7 Department of Surgery, Jeroen Bosch Hospital, 5223 GZ Den Bosch, The Netherlands
8 Department of BioMechanical Engineering, Delft University of Technology, 2628 CD Delft, The Netherlands.


Guideline development, Guideline updating process, Minimally Invasive Surgery, Surgical Guidelines, New techniques

Published online: Sep 24 2023


Background: Updating evidence-based clinical practice guidelines is an onerous process and there is a call for more efficient determination of key questions that need updating. Especially for surgical techniques it is unclear if new evidence will result in substantial changes after wide implementation and if continuous updating is always necessary.

Objectives: This study analyses the impact of updating a surgical guideline and proposes suggestions for optimising this process.

Materials and methods: The Dutch Minimally Invasive Surgery guideline was developed in 2011 and updated in 2021. For both versions a multidisciplinary guideline working group (GDG) was created, that determined key questions. Changes in conclusions and recommendations were analysed by the GDG and statements for expected change of recommendations in the future were made.

Results: 15 key questions were formed, of which 12 were updates of the previous guideline. For only 27% of the updated key questions, the conclusions changed. In ten years, the body grew only marginally for most key questions and quality of the evidence did not improve substantially for almost all key questions. However, in this first update of the MIC guideline, many recommendations did change due to a more robust interpretation of the conclusions by the GDG. Based on analysis of this updating process, the GDG expects that only four out of 15 recommendations may change in the future.

Conclusion: We propose an additional step at the end of guideline development and updating, where the necessity for updating in the future is determined for each key question by the GDG, using their valuable knowledge gained from developing or updating the guideline. For surgical guidelines, the authors suggest updating key issues if it includes a relatively newly introduced surgical- or adapted technique or a new patient group. Low quality or small body of evidence should not be a reason in itself for updating, as this mostly does not lead to new evidence-based conclusions. This new step is expected to result in a more efficient prioritising of key questions that need updating.

What’s new? By adding one additional step at the end of the updating process, the future updating process could become more efficient.