title: Level of evidence in minimal access pediatric surgery.
abstract: BACKGROUND
  The use of minimal access techniques is rapidly expanding in pediatric surgery. Our aim was to answer two questions: (1) What is the current quality of evidence for minimal access pediatric surgery (MAPS)? and (2) Has the evidence for MAPS improved with respect to focus and methodology over a 12-year period (1995-2006)?
  
  
  METHODS
  A systematic review was performed. Data collected included: study characteristics, methods, and outcomes recorded. Approval by a research ethics board (REB) was recorded, where applicable, and articles were assessed for the reporting of learning curves and study limitations. Studies were divided into two eras according to publication date. Data were compared by using correlation, chi-squares, and univariate analyses.
  
  
  RESULTS
  Four hundred and ten studies met the inclusion criteria. Of those, 260 (63.4%) were published in the late era. Only 1.46% of studies were level 1, whereas level 4 evidence was predominant (71.46%). The two eras were comparable with regard to country of origin, single-institution studies, length of follow-up, and quality of outcomes reporting. More studies reported REB approval (P = 0.0001) and clearly documented limitation of study design (P = 0.03) in the late era.
  
  
  CONCLUSIONS
  There has been a significant increase in the number of articles dealing with MAPS. Recent studies were more likely to report limitations of study design and REB approval, but overall, there was no increase in level of evidence in the MAPS literature over the past 12 years. Although more research is being published, more attention needs to be paid to producing higher quality evidence.
authors.affiliation: Division of General Surgery, The Hospital for Sick Children, Toronto, Canada.
authors.forename: Neil
authors.initials: N
authors.lastname: Orzech
authors.forename: Mohammed
authors.initials: M
authors.lastname: Zamakhshary
authors.forename: Jacob C
authors.initials: JC
authors.lastname: Langer
mesh_terms: D002648:Child; D019317:Evidence-Based Medicine; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000592:standards*; D012107:Research Design