Korea’s rapid transition toward a super-aged society has markedly increased the demand for major abdominal surgery in older adults. Although minimally invasive surgery (MIS) provides perioperative advantages, including reduced surgical trauma, lower blood loss, and accelerated postoperative recovery, it also introduces pathophysiological challenges that require preoperative evaluation and risk stratification. This presidential lecture summarizes trends in geriatric surgery in Korea, highlights perioperative considerations for elderly patients undergoing MIS, and presents longitudinal outcomes from Severance Hospital. Surgical trends and perioperative outcomes were evaluated for major abdominal procedures, including gastrectomy, colectomy, major hepatectomy, and pancreatoduodenectomy (PD), in patients aged ≥70 years. Analyses demonstrated a progressive transition from open surgery toward minimally invasive approaches. Laparoscopic and robotic techniques have become the predominant approaches for gastrectomy and colectomy, including in octogenarians, while MIS adoption for complex procedures, such as major hepatectomy and PD, has also expanded substantially. Comparative analyses within this elderly cohort demonstrated that MIS was associated with superior perioperative outcomes compared with open surgery, including significantly reduced estimated blood loss, shorter hospitalization, and lower rates of clinically significant complications, such as postoperative pancreatic fistula, without compromising procedural safety. Advances in surgical technology and accumulated institutional expertise have established MIS as a feasible, standardized approach for major abdominal surgery in older adults. Integrating comprehensive preoperative assessment, particularly frailty screening, with the selective application of MIS may represent the optimal strategy for reducing operative risk and promoting postoperative functional recovery in geriatric surgical care.
Amyand’s hernia is the presence of the appendix within an inguinal hernia sac. A surgical rarity, this accounts for approximately 1% of all inguinal hernias, mostly in children, and presents a unique set of diagnostic and management challenges. This case report details a 61-year-old male presenting with suppurative appendicitis within a recurrent right inguinal hernia, managed through a hybrid approach involving a combination of open and laparoscopic surgical techniques. The purpose of this case report is to raise awareness among surgeons regarding the management of Amyand’s hernia with suppurative appendicitis and to recognize the need for further research pertaining to the use of biosynthetic meshes as an alternative to tension-free tissue-based repairs in such cases.
Mirizzi syndrome type IV, a rare and complex form of biliary obstruction, has traditionally required major open surgery. This case report describes a groundbreaking alternative: a 44-year-old woman successfully treated using a minimally invasive laparoscopic approach. The less invasive procedure resulted in rapid, complication-free recovery, with no evidence of biliary stricture at the 6-month follow-up. This outcome challenges conventional management and demonstrates that a minimally invasive approach can be both feasible and highly effective in carefully selected patients.
We describe a simple modification of the two-port laparoscopic technique for peritoneal dialysis (PD) catheter placement incorporating guideline-recommended trans-rectus insertion and dedicated exit-site design. A 5-mm trocar is inserted through a small trans-rectus incision using an open (Hasson) technique and subsequently serves as the final catheter insertion site. After placement of the first port, a second 5-mm port is safely inserted at the planned superficial cuff site under laparoscopic guidance and subsequently serves as the camera port for the remainder of the procedure. After laparoscopic inspection, the PD catheter is introduced along an oblique trans-rectus pathway to enhance catheter stability, and the superficial cuff is secured at the port site. The catheter is then directed through a subcutaneous tunnel and exteriorized through a small exit site. This modification provides a simple and reproducible option for PD catheter placement.
Routine ligation of the inferior mesenteric vein (IMV) during laparoscopic left hemicolectomy is widely practiced but may predispose patients to venous congestion, ischemia, and anastomotic complications, especially in patients with a long remnant sigmoid colon. IMV preservation remains underutilized due to technical difficulty and the absence of standardized guidance. This video article presents a structured, step-by-step technique for laparoscopic left hemicolectomy with D3 lymphadenectomy and IMV preservation in a 64-year-old male with distal transverse colon adenocarcinoma. Key elements include meticulous IMV skeletonization with selective tributary ligation, targeted left colic artery division, and extracorporeal functional end-to-end anastomosis. The patient recovered uneventfully and was discharged on postoperative day 3. A 6-month colonoscopy confirmed a well-healed anastomosis without congestion or stricture. IMV-preserving left hemicolectomy is safe, oncologically sound, and technically reproducible. Maintaining venous drainage may reduce anastomotic congestion and support optimal healing, offering meaningful value in selected patients.
Although minimally invasive surgery is a standard surgical approach because of its proven benefits to patient outcomes, it imposes increased cognitive demands on surgeons because of limited visualization, lack of tactile feedback, and constraints in instrument manipulation. These challenges have been partially mitigated by robot-assisted surgery, while recent advances in artificial intelligence (AI) have established intraoperative AI as a key technology enabling real-time support of surgical perception, decision-making, and instrument control. Here, we review the key AI technologies used during the intraoperative phase of endo-laparoscopic and robotic surgery, including anatomical and lesion recognition, instrument detection and tracking, surgical phase and workflow analysis, real-time tissue characterization, image-guided and augmented navigation, AI-assisted instrument control, and multimodal event detection. We also discuss key clinical integration challenges and future research directions focused on foundation and self-supervised learning paradigms, and human-AI collaborative system design.
Laparoscopic repeat hepatectomy (LRH) remains challenging when initial resection sites overlap with target areas. We report a safe surgical approach for LRH of the remnant right liver after prior posterior segment resection. An 83-year-old female with recurrent intrahepatic cholangiocarcinoma in segment 5, following segmentectomy 6, required right hepatectomy. Due to dense adhesions in the posterior segment making right lobe mobilization, including dissection around the inferior vena cava (IVC), difficult, we employed a medial-to-lateral approach for LRH. We initially performed parenchymal transection to expose the ventral side of the IVC, followed by a medial-to-lateral dissection around the IVC under a favorable operative field. Operative time was 469 minutes with 160 mL blood loss. The patient was discharged on postoperative day 17 without complications. In LRH after posterior segment resection, a medial-to-lateral approach using the parenchymal transection-first technique is effective for minimizing risks of collateral injury during right hepatectomy.
Repair of moderate-to-large-sized ventral incisional hernias often requires component separation to achieve tension-free posterior layer closure. Transversus abdominis muscle release (TAR), although effective, increases operative complexity and morbidity. We describe a tissue-preserving laparoscopic transabdominal retromuscular repair with hernia sac-assisted mesh coverage without TAR. Five patients with incisional ventral hernia underwent this procedure. The hernia sac was carefully dissected while maintaining continuity with the peritoneum and used to cover the retromuscular mesh. Primary fascial closure was achieved using barbed sutures, and a polypropylene mesh was placed in the retrorectus plane. There were no intraoperative complications. Seroma occurred in three patients and resolved with conservative management without aspiration. At a median follow-up of 10 months, no recurrence or chronic pain was observed. This technique may be a feasible tissue-preserving option to facilitate posterior layer closure without TAR in selected patients, with preliminary outcomes.
Radical cholecystectomy is the standard procedure for gallbladder (GB) cancer, offering the possibility of cure. Many surgeons have increasingly expanded surgical indications following the growing trend of robotic surgery in hepatobiliary and pancreatic surgery. This study presents our experience with several robotic single-port (SP) plus one-port radical cholecystectomies using the da Vinci system (Intuitive Surgical). Data from five patients who underwent robotic SP radical cholecystectomy for GB cancer between April 2024 and December 2024 were retrospectively reviewed. All patients presented with imaging findings suggestive of localized GB cancer (T2 or lower). The median operative time was 145 minutes (range, 121-153 minutes), and the median number of harvested lymph nodes was five (range, five to eight). The median hospital stay after surgery was 6 days (range, 6-7 days), with no major complications reported. Robotic SP radical cholecystectomy is a safe and feasible option for GB cancer.
This report is a novel laparoscopic technique for pediatric epigastric hernia repair using 3-mm instruments and intracorporeal barbed sutures. A series of three children aged 3 to 6 years presented with a visible or palpable midline bulge, with or without intermittent pain. All had solitary epigastric defects confirmed by ultrasound. Laparoscopic repair was performed via three left lateral abdominal 3-mm ports, avoiding visible central incisions. Preperitoneal fat was reduced or excised, and the fascial defect was closed with a running barbed suture without knots. All patients were discharged the same day without complications. Follow-up up to 2 years revealed no recurrences and excellent cosmetic outcomes, with nearly invisible scars and high parental satisfaction. This technique offers a safe, effective, and cosmetically superior alternative to traditional open repair, especially in small children with central abdominal wall defects.
This study evaluated the initial feasibility and safety of reduced-port robotic cholecystectomy using the Revo-i robotic system (meerecompany Inc.) in nine patients diagnosed with symptomatic gallstones and chronic cholecystitis. All surgeries were successfully completed without complications or conversion to conventional methods. Postoperative outcomes were excellent, with minimal pain immediately after surgery, significantly reduced by the next day. Most patients were discharged on postoperative day one. Cosmetic outcomes were outstanding, with barely noticeable scars at the umbilical and flank port sites. These findings demonstrate that Revo-i robotic cholecystectomy is technically feasible, safe, and patient-friendly, suggesting potential for broader application in hepatobiliary and pancreatic surgeries.
Minimally invasive surgery has become widely adopted in various types of surgery and is associated with faster postoperative recovery. Similar benefits may apply to pediatric patients, in whom enhanced recovery can facilitate timely initiation or resumption of systemic therapy which is an important component of multimodality treatment. We report the case of a 2-year-old child with neuroblastoma of the left adrenal gland who underwent robotic adrenalectomy. This case suggests that a robotic approach may be feasible in carefully selected pediatric patients and can be performed safely under appropriate expertise.
Purpose: This study aimed to compare perioperative and postoperative outcomes of single-port laparoscopic articulated instrument-assisted versus da Vinci SP-assisted totally extraperitoneal (TEP) inguinal hernia repair using a propensity score-matched multi-institutional cohort. Methods : Between April 2022 and July 2025, 221 patients underwent TEP unilateral inguinal hernia repair at four institutions. Among them, 33 patients underwent da Vinci SP-assisted repair (Intuitive Surgical) and 188 underwent single-port laparoscopy using the articulated instrument, ArtiSential (LivsMed). Propensity score matching was performed in a 1:1 ratio based on demographic and clinical variables, resulting in 30 matched patients in each group. Perioperative outcomes and postoperative complications were analyzed. Results : After matching, baseline characteristics were well balanced between the groups. Operative time was significantly longer in the da Vinci SP group than in the ArtiSential group (median [interquartile range], 82.0 [67.5-105.0] vs. 35.0 [28.5-47.5] minutes; p < 0.001). No open conversions occurred, and conversions to transabdominal preperitoneal repair were rare and comparable. Mesh size selection differed significantly, with smaller meshes more frequently used in the da Vinci SP group (p < 0.001). Postoperative outcomes, including length of hospital stay, overall complication rates, chronic pain, and recurrence, were similar between the groups. No major complications, readmissions, or reoperations were observed. Conclusion : Articulated instrument-assisted TEP inguinal hernia repair demonstrated a significantly shorter operative time than da Vinci SP-assisted repair, while perioperative safety and postoperative outcomes were comparable.
Purpose: Incidence of T1 colorectal cancer (CRC) has steadily increased. Although endoscopic resection is curative for many patients, lymph node metastasis (LNM) remains problematic, often prompting additional colectomy after endoscopic therapy. This study aimed to comparatively analyze major international guidelines for post-resection management of T1 CRC, summarize evidence supporting the key pathological risk factors for LNM, and examine the effect of divergent definitions and thresholds on variations in clinical decision-making. Methods : Within North America, Europe, and East Asia, current and comprehensive guidelines issued by internationally recognized professional societies for CRC management were included in the analysis. Each guideline was reviewed for its issuing organization, target population, scope, evidence methodology, consensus process, and update frequency. Our evaluation assessed how each guideline addressed individual pathological risk factors associated with LNM, specifically focusing on five key shared features. Results : Five pathological features were consistently recognized as increasing LNM risk: lymphovascular invasion, poor histological differentiation, deep submucosal invasion, tumor budding, and positive or indeterminate resection margins. Overall, although the guidelines shared the core pathological risk factors, their relative weights differed. Eastern guidelines were found to favor surgery based on a single adverse feature, whereas Western approaches prioritize cumulative risk and patient-specific factors. Conclusion : By highlighting areas of consensus and controversy, this comparative analysis underscores the limitations of binary risk stratification and the resulting burden of overtreatment; it also discusses emerging strategies to support more precise, individualized management of T1 CRC.
Purpose: Surgical resection of remnant gastric cancer (RGC) is technically challenging and difficult. Minimally invasive surgery (MIS) has been adopted for various procedures, but reports of MIS for RGC remain limited. Herein, we report the surgical techniques and short-term outcomes of MIS for RGC. Methods : We conducted a retrospective cohort study involving 61 consecutive RGC patients who underwent open or minimally invasive (laparoscopic or robotic) total gastrectomy for potentially curable RGC at our institution (January 1999-August 2025). A propensity score-matched cohort was used for an exploratory evaluation of the safety and efficacy of MIS for RGC, focusing on feasibility rather than superiority over open surgery. Results : Of these 61 patients, 53 underwent open surgery and eight underwent MIS gastrectomy for RGC. The median age was 70 years. The cohort comprised 53 men and eight women. The initial procedure was open surgery in 58 patients and MIS in three patients. Propensity score matching showed significantly reduced intraoperative blood loss in the MIS group compared with the open surgery group (39 mL vs. 576 mL, p < 0.05), and significantly longer operation time in the MIS group (352 minutes vs. 297 minutes, p < 0.05). Postoperative hospital stay was significantly shorter in the MIS group (12 days vs. 17 days, p < 0.05). The incidence of postoperative pancreatic fistula was lower in the MIS group, although not significantly different (0% vs. 16.7%). Conclusion : MIS, including robotic gastrectomy, is feasible and safe for RGC, with potential perioperative benefits requiring multicenter validation.
Purpose: Splenic flexure mobilization (SFM) is occasionally utilized during sigmoidectomy to facilitate a tension-free colorectal anastomosis. Present literature regarding its use, safety, and efficacy predominantly evaluates traditional laparoscopic vs. open techniques, thus not adequately representing the current minimally invasive surgical landscape. Methods : This retrospective cohort analysis evaluated SFM during sigmoidectomy for diverticular disease via traditional laparoscopic, single-incision laparoscopic, and robotic techniques at a United States academic institution from 2019 to 2022. Primary outcomes were the rate of SFM, independent predictors, and short-term outcomes. Results : A total of 117 patients underwent sigmoidectomy for diverticulitis by six colorectal surgeons, of whom 27 underwent SFM. SFM was associated with higher rates of complicated diverticulitis (85.2% vs. 46.7%, p < 0.001), including abscess (55.6% vs. 33.3%, p = 0.037) and fistulae (59.3% vs. 17.8%, p < 0.001). Presence of a fistula was an independent predictor of SFM by logistic regression (odds ratio [OR], 5.886; p < 0.001). Mobilization was associated with more concomitant surgical procedures (66.7% vs. 28.9%, p < 0.001). There was a significant association between SFM and conversion to open approach (14.8% vs. 3.3%, p = 0.049), longer length of stay (4.2 ± 2.8 days vs. 3.6 ± 4.3 days, p = 0.041), and increased operative time (241.7 ± 76.4 minutes vs. 199.2 ± 75.7 minutes). There was no difference in 30-day morbidity/mortality. Conclusion : Routine SFM can be considered in minimally invasive sigmoidectomy for complicated diverticulitis without significant impact on 30-day morbidity/mortality regardless of surgical approach and may be anticipated preoperatively, particularly when a fistula is present.
