Journal of Surgical Innovation and Education

Volume 2(2); December 2025

How I Do It

High Lymph Node Dissection with Low Ligation: A Modified Technique for Left Colic Artery Preservation in Colorectal Cancer: Jesung Park, Beom Gyu Kim, Yong Gum Park, Byung Kwan Park; J Surg Innov Educ. 2025;2(2):27-30. Published online December 18, 2025; DOI: https://doi.org/10.69474/jsie.2025.00339

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Abstract PDF: The optimal level of inferior mesenteric artery (IMA) ligation in colorectal cancer remains controversial. High ligation allows complete D3 lymphadenectomy but sacrifices the left colic artery (LCA), raising concerns about anastomotic ischemia. This report presents a modified low ligation technique that achieves radical D3 dissection while preserving the LCA. The technique involves complete skeletonization of the IMA root with en bloc removal of surrounding lymphatic tissue while maintaining LCA continuity. Key procedural steps include: (1) medial-to-lateral mobilization, (2) exposure of the IMA origin, (3) para-IMA lymph node dissection along the vascular sheath, (4) preservation of the LCA and autonomic plexus, and (5) distal IMA division below the LCA bifurcation. Intraoperative images illustrate the dissected nodal field and preserved vasculature. This technique enables D3-level lymph node dissection comparable to high ligation, with clear visualization of the IMA root and preserved arterial supply. Thirty-five lymph nodes, including one metastatic node, were retrieved without compromising perfusion. This modified approach balances oncologic completeness with physiologic preservation and may serve as a practical model for achieving D3 lymphadenectomy with vascular preservation.

Indocyanine Green Fluorescence-Guided Enucleation via the Serosal Approach for Benign Subepithelial Tumors of the Gastroesophageal Junction: Ji-Hyeon Park, Sojung Kim, Ho Seok Seo, Kyo Young Song, Han Hong Lee; J Surg Innov Educ. 2025;2(2):31-34. Published online December 19, 2025; DOI: https://doi.org/10.69474/jsie.2025.00283

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Abstract PDF: Subepithelial tumors (SETs) located at the gastroesophageal (GE) junction remain technically challenging in minimally invasive surgery because the convergence of the esophageal sphincter, diaphragmatic hiatus, and gastric fundus creates a confined operative field. When a tumor is fully embedded within the muscular layer, its capsular margin is often indistinguishable from the serosal surface, making precise enucleation technically demanding. To address this limitation, we adopted a fluorescence-guided technique that enables accurate intraoperative localization of the tumor through indocyanine green (ICG) injection. After induction of anesthesia, approximately 0.1–0.2 mL (0.05–0.1 mg) of ICG diluted in normal saline is injected endoscopically into the submucosal plane at the tumor site for benign SETs. During surgery, near-infrared visualization provides a distinct fluorescent margin that guides safe serosal incision and enucleation while preserving the mucosa and the anatomy of the GE junction. This technique is particularly useful for benign, well-encapsulated lesions such as leiomyoma or ectopic pancreas, where clear dissection planes can be preserved. However, it should not be used for lesions with any suspicion of gastrointestinal stromal tumor or other malignant potential, because capsular or intratumoral injection may pose a theoretical risk of tumor cell dissemination. Careful peritumoral submucosal injection that avoids capsular disruption may be cautiously considered. In selected benign tumors, ICG-guided serosal enucleation provides clear localization, facilitates complete resection, and minimizes both functional and structural complications at the GE junction.

Laparoscopic Inguinal Hernia Repair in Female Pediatric Patients: Joong Kee Youn; J Surg Innov Educ. 2025;2(2):35-38. Published online December 19, 2025; DOI: https://doi.org/10.69474/jsie.2025.00325

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Abstract PDF: Laparoscopic inguinal hernia repair (LIHR) has become a widely adopted surgical approach for pediatric inguinal hernia because it offers superior visualization and enables simultaneous assessment of the contralateral side. An 8-month-old female infant presented with a spontaneously reducing bulge in the right inguinal region, most noticeable during diaper changes. Physical examination revealed an easily reducible inguinal mass that was palpably firm and spherical, raising strong suspicion for ovarian inclusion. A positive silk glove sign was also identified on the contralateral side. Under general anesthesia, a three-port laparoscopic technique was used, consisting of a 5-mm umbilical port and two 3-mm working ports. The peritoneum and gubernaculum were carefully dissected from surrounding structures using electrocautery before sac closure, a step performed to minimize the risk of recurrence. Both the symptomatic right hernia sac and the asymptomatic contralateral patent processus vaginalis, which was visually confirmed intraoperatively, were closed using an intracorporeal purse-string high ligation with absorbable sutures. Three-port LIHR with meticulous dissection of the peritoneum and gubernaculum represents an effective and definitive technique for pediatric inguinal hernia repair. This approach allows simultaneous bilateral repair and is associated with excellent postoperative recovery, supporting its continued use as a primary surgical method.

Dynamic Educational Manuscript

Carotid Endarterectomy with Plication: Seongeun Kim, Jun Gyo Gwon; J Surg Innov Educ. 2025;2(2):39-40. Published online December 16, 2025; DOI: https://doi.org/10.69474/jsie.2025.00290

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Short Communication

Robot-Assisted Surgery Training for Medical Students in Low-Resource Areas: A Study Protocol: Ifrah Khurram, Jaclyn Jakubowski, Jacob Minter, Pedro F. Escobar; J Surg Innov Educ. 2025;2(2):41-45. Published online December 15, 2025; DOI: https://doi.org/10.69474/jsie.2025.00094

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Abstract PDF: Robotic-assisted surgery (RAS), commonly associated with the da Vinci Surgical System (Intuitive Surgical, Inc.), has revolutionized minimally invasive surgery. As RAS systems are being increasingly adopted in teaching hospitals and used more frequently in procedures, there is a growing need for surgeons to be trained in this technology as early as the medical school years. In this article, we propose a potential low-resource, easily adoptable RAS pilot program that will be implemented at a medical school in Puerto Rico. A brief description of the program highlights faculty-led education, journal discussions, and simulation practice through hands-on modalities to establish early RAS proficiency in a feasible 2-week timeframe. By offering students early familiarity with robotic skills, this program may support specialty exploration and improve clinical preparedness. The goal of this pilot program proposal is not only to establish this protocol at a medical school in Puerto Rico but also to encourage other programs throughout the United States to consider adopting a similar training program in the hopes of making RAS training more ubiquitous in early medical training.

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