Journal of Surgical Innovation and Education

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Most-read articles are from the articles published in 2023 during the last three month.

How I Do It

Laparoscopic Paraaortic Lymph Node Sampling in Gastric Cancer Patients with Suspected Paraaortic Lymph Node Metastasis: Ba Ool Seong, Ju No Yoo, Chang Seok Ko, Sa-Hong Min, Chung Sik Gong, In-Seob Lee, Moon-Won Yoo, Jeong Hwan Yook, Beom Su Kim; J Surg Innov Educ. 2024;1(2):34-38. Published online December 27, 2024; DOI: https://doi.org/10.69474/jsie.2024.00206

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Abstract PDF: D2 lymphadenectomy is the standard approach for lymph node dissection in curable gastric cancer. However, paraaortic lymph node (PALN) dissection in addition to D2 lymphadenectomy has not been shown to improve survival rates and is therefore not routinely performed. Nevertheless, PALN sampling may be indicated for diagnostic purposes because it can provide critical information for accurate staging and treatment planning. Laparoscopic PALN sampling, however, poses significant challenges due to limited accessibility and visibility in the paraaortic region. Moreover, the proximity of major blood vessels, such as the abdominal aorta and renal vein, is another difficult aspect of the procedure. In this context, we present two cases to demonstrate practical strategies for facilitating laparoscopic PALN sampling. The procedure can be effectively performed by first identifying the ligament of Treitz and then, when necessary, fixing the small bowel mesentery to the abdominal wall using a tagging suture so that there is adequate vision and enough working space. This enables careful and precise dissection of the target tissue without compromising the feasibility and safety of the operation.

Techniques of Creating an Arteriovenous Fistula for Hemodialysis Access: A Comprehensive Guide: Chang Sik Shin, Ji Il Kim; J Surg Innov Educ. 2024;1(2):49-52. Published online December 27, 2024; DOI: https://doi.org/10.69474/jsie.2024.00171

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Abstract PDF: Arteriovenous fistula (AVF) creation is crucial for patients with end-stage renal disease requiring long-term hemodialysis, due to its superior long-term patency and lower complication rates compared to arteriovenous grafts. This paper presents detailed techniques and a step-by-step tutorial for AVF creation—including radiocephalic, brachiocephalic, and brachiobasilic fistulas—offering valuable insights for both novice and experienced surgeons.

LuminoMark: An Alternative for Localization: Ee Jin Kim, Tae Kyung Yoo, Jisun Kim, Il Yong Chung, Beom Seok Ko, Hee Jeong Kim, Jong Won Lee, Byung Ho Son, Sae Byul Lee; J Surg Innov Educ. 2024;1(2):46-48. Published online December 13, 2024; DOI: https://doi.org/10.69474/jsie.2024.00178

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Abstract PDF: Breast cancer is the most common cancer among women in Korea. Given the increased preference for breast-conserving surgery (BCS), preoperative localization is crucial, especially for non-palpable lesions, to ensure clear resection margins. Traditional methods such as wire-guided localization have limitations, including patient discomfort and wire migration. Recently, LuminoMark, an indocyanine green–macroaggregated albumin–hyaluronic acid mixture, has emerged as a promising alternative with potential benefits over existing techniques. We present a case of a 67-year-old female with a non-palpable Breast Imaging-Reporting and Data System 5 breast lesion. Preoperative localization was performed using LuminoMark, with accurate placement verified by a Lumino-imager. The lesion was successfully excised, and the absence of residual fluorescence confirmed complete resection. LuminoMark provided effective lesion localization without skin pigmentation, reducing the risk of misdiagnosis during follow-up. The procedure demonstrated a short learning curve, similar to that of charcoal localization. However, the need for a costly near-infrared fluorescence detector and the lack of long-term follow-up data are current limitations. Despite minor drawbacks, LuminoMark offers advantages over traditional localization methods, including improved aesthetics and reduced complications. This case demonstrates its feasibility as a next-generation localization technique for BCS, emphasizing the importance of an accurate injection technique to ensure adequate dispersion and complete tumor resection. Further studies are warranted to validate its long-term efficacy.

Dynamic Educational Manuscript

Hepaticojejunostomy in Minimally Invasive Surgery: A Step-by-Step Guide: Younsoo Seo, Inhyuck Lee, Go-Won Choi, Yoon Soo Chae, Won-Gun Yun, Young Jae Cho, Hye-Sol Jung, Joon Seong Park, Jin-Young Jang, Wooil Kwon; J Surg Innov Educ. 2024;1(2):53-54. Published online December 12, 2024; DOI: https://doi.org/10.69474/jsie.2024.00192

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Abstract PDF: With rapid advances in minimally invasive surgery (MIS) techniques, such as laparoscopy and robotics, their application has expanded across various surgical fields, including pancreatobiliary surgery. Numerous studies have demonstrated the feasibility and potential benefits of MIS. Hepaticojejunostomy, a procedure creating a connection between the hepatic duct and the jejunum, is primarily used to bypass biliary obstructions or during operations that involve bile duct resection, such as pancreatoduodenectomy or choledochal cyst excision. Proficiency in minimally invasive hepaticojejunostomy techniques is essential for surgeons in this evolving field. This video presents a detailed, step-by-step guide to the principles and techniques of performing hepaticojejunostomy using both laparoscopic and robotic platforms.

How I Do It

Tips for Laparoscopic Feeding Jejunostomy Using a Barbed Suture: Sin Hye Park, Dong Jin Kim; J Surg Innov Educ. 2024;1(2):31-33. Published online December 9, 2024; DOI: https://doi.org/10.69474/jsie.2024.00108

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Abstract PDF: Feeding jejunostomy is crucial for patients with compromised oral intake, particularly after gastrointestinal surgery or esophagectomy. Traditional methods involve interrupted sutures to secure the feeding tube to the abdominal wall, but this can be cumbersome due to the need for knot tying. This paper presents the case of a 75-year-old male patient who underwent minimally invasive esophagectomy with feeding jejunostomy for esophageal cancer, and introduces the use of a knotless barbed suture, which is commonly employed in gastrointestinal operations. The laparoscopic procedure utilized four trocars for jejunostomy, employing a 3-0 silk purse string suture and a 14-Fr Foley catheter. The barbed suture was used to secure the catheter in place without knots, covering 360° around the catheter. This method aims to simplify laparoscopic feeding jejunostomy and improve clinical practice.

Indocyanine Green-Guided Precision in a Left Lateral Sectionectomy for Hepatocellular Carcinoma: Woohyung Lee, Kwang Pyo Hong, Mirang Lee, Minkyu Sung, Yejong Park, Ki Byung Song, Jae Hoon Lee, Dae Wook Hwang, Song Cheol Kim; J Surg Innov Educ. 2024;1(2):42-45. Published online December 3, 2024; DOI: https://doi.org/10.69474/jsie.2024.00087

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Abstract PDF: Parenchyma-sparing anatomical resection is recommended in patients with hepatocellular carcinoma due to the presence of underlying liver disease. More precise hepatectomy has been enabled by recent technical advancements, including negative staining with indocyanine green following ligation of the corresponding Glissonean pedicle, which offers intraoperative guidance by delineating the resection plane in real-time. Herein, we present a case of laparoscopic left lateral sectionectomy that used this staining technique.

Colorectal Endoscopic Submucosal Dissection Using the Double-Clips Traction Method: Dae Kyung Sohn; J Surg Innov Educ. 2024;1(2):39-41. Published online November 27, 2024; DOI: https://doi.org/10.69474/jsie.2024.00080

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Abstract PDF: Endoscopic submucosal dissection (ESD) is an advanced endoscopic technique used to remove large adenomas or early colorectal cancers. This paper presents a step-by-step introduction of the methodology for performing colorectal ESD using the double-clips traction method. The technique is designed to enhance visualization, shorten the procedure time, and improve the safety and efficacy of colorectal ESD, especially in challenging cases involving large or fibrotic lesions. By providing reliable traction, this method helps to maintain a stable and clear field of view throughout the procedure, which is critical for the success of the dissection.

Laparoscopic Right Hemicolectomy with an Inferior Approach: How I Do It: Young Il Kim, Hayoung Lee, Min Hyun Kim; J Surg Innov Educ. 2024;1(1):6-9. Published online June 28, 2024; DOI: https://doi.org/10.69474/jsie.2024.00038

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Abstract PDF: Since its introduction in the early 1990s, laparoscopic colorectal surgery has been extensively validated through randomized controlled trials, establishing its safety and efficacy from oncological and technical standpoints. Laparoscopic right hemicolectomy (LRHC) procedures exhibit variability in dissection extent and initiation sites. Complete mesocolic excision is essential in LRHC, involving precise dissection along embryologic planes and varying in lymph node dissection extent (D2 or D3). Other variations in LRHC include the use of the medial approach (or superior mesenteric vein [SMV]-first approach), where dissection starts along the SMV, the lateral approach (or inferior approach), starting with meso-ileal and retroperitoneal dissection, and the superior approach, initiated by separation of the omentum and transverse colon. This paper presents a case of LRHC for ascending colon cancer using an inferior approach. The procedure included trocar placement, followed by inferior, superior, and medial dissection phases, concluding with specimen extraction and extracorporeal anastomosis. With a standardized procedure, mastery of diverse approaches (inferior, medial, and superior) remains crucial, as the most appropriate method varies among cases.

Optimized Surgical Techniques in Laparoscopic Living-Donor Right Hemihepatectomy Using Indocyanine Green Fluorescence Images: YoungRok Choi, Suk Kyun Hong, Nam-Joon Yi, Kwang-Woong Lee, Kyung-Suk Suh; J Surg Innov Educ. 2024;1(1):14-17. Published online June 26, 2024; DOI: https://doi.org/10.69474/jsie.2024.00066

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Abstract PDF Supplementary Material: This paper outlines the surgical technique for laparoscopic living-donor right hemihepatectomy (LLDRH), a minimally invasive procedure that increases graft safety and reduces donor morbidity. The technique includes careful patient selection, precise port placement, meticulous liver mobilization, and careful parenchymal dissection, followed by secure graft extraction and effective hemostasis. LLDRH offers several advantages over open living-donor surgery, including lower costs, less postoperative pain, shorter hospital stays, and better cosmetic results. The use of advanced three-dimensional laparoscopic systems and indocyanine green fluorescence imaging has further increased the safety and effectiveness of this procedure. As laparoscopic technology continues to evolve, LLDRH is likely to become more widely adopted, offering a valuable option for liver transplantation programs. A video clip shows a 32-year-old woman with a body mass index of 25.7 kg/m2 who donated her right liver. Her remnant liver volume was 34%, and the estimated graft-to-recipient weight ratio was 1.2. The operation time was 240 minutes, with an estimated blood loss of 150 mL. She was discharged on the fifth postoperative day without any complications.

Dynamic Educational Manuscripts

Laparoscopic Conversion Surgery After Three Years of Palliative Chemotherapy for Unresectable Advanced Gastric Cancer: Ma. Jeanesse C. Bernardo, Mohd Firdaus Che Ani, Zhuang Chun, Abdullah Almayouf, Jee-sun Kim, Tae-Yong Kim, Seong-Ho Kong, Do-Joong Park, Han-Kwang Yang, Hyuk-Joon Lee; J Surg Innov Educ. 2024;1(1):26-27. Published online June 25, 2024; DOI: https://doi.org/10.69474/jsie.2024.00073

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Abstract PDF: Unresectable advanced gastric cancer remains a challenge in treatment, often requiring a multidisciplinary approach. Numerous studies have emphasized the role of palliative chemotherapy as the mainstay treatment for unresectable advanced gastric cancers. Some patients may still require conversion surgery to achieve survival gain and palliation. Several recent papers have shown the safety of laparoscopic gastrectomy after neoadjuvant chemotherapy for advanced gastric cancer. However, there is a difference between neoadjuvant chemotherapy and palliative chemotherapy in terms of the duration of chemotherapy (about 3 months vs. more than 6 months) and the initial state of advanced gastric cancer (resectable vs. unresectable and/or metastatic). To date, the safety and efficacy of laparoscopic gastrectomy after long-term palliative chemotherapy has been rarely reported. This video aims to share our experience in performing laparoscopic distal gastrectomy with D2 lymph node dissection after 3 years of palliative chemotherapy for an unresectable advanced gastric cancer.

Laparoscopic Pylorus Preserving Gastrectomy with Intra-Corporeal Gastro-Gastrostomy Guided by Intra-Operative Gastroscopy: Mohd Firdaus Che Ani, Zhuang Chun, Abdullah Almayouf, Jee-sun Kim, Seong-Ho Kong, Do-Joong Park, Han-Kwang Yang, Hyuk-Joon Lee; J Surg Innov Educ. 2024;1(1):28-29. Published online June 25, 2024; DOI: https://doi.org/10.69474/jsie.2024.00059

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Abstract PDF: Gastric cancer detection is advancing to a point where screening programs can detect gastric cancer at early stages. This allows surgical procedures to be less radical than before. Studies have proven that pylorus preserving gastrectomy is a safe procedure in early T1a and T1b gastric cancers where the tumour location is in the middle third of the stomach. However, due to the small tumour size, determining an appropriate resection margin can be challenging. A few techniques have been developed to overcome this difficulty, and at our centre, we perform intra-operative gastroscopy to synchronize with the laparoscopic view and precisely determine the tumour location for optimal gastric resections. This allows the gastrectomy to be performed safely and prevents inadequate resection leaving tumour cells behind. This video is aimed at sharing our experience in performing pylorus-preserving gastrectomy.

How I Do It

Single-Port Robotic Areolar Thyroidectomy: How I Do It: Myeong Ho Shin, Sun Min Lee, Hilal Ozer Hwang, Jin Wook Yi; J Surg Innov Educ. 2024;1(1):18-21. Published online June 25, 2024; DOI: https://doi.org/10.69474/jsie.2024.00052

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Abstract PDF Supplementary Material: With the recent development of the da Vinci Single Port (SP) robotic surgical system, new surgical methods applying the da Vinci SP in thyroid surgery are being reported. We first reported a method known as single-port robotic areolar (SPRA) thyroidectomy in 2023, and we performed more than 100 SPRA thyroidectomies in a year. SPRA is a more minimally invasive method than the existing bilateral axillary breast approach method, as the subcutaneous flap area is reduced by more than 50%. Herein, we present a step-by-step description of the method of SPRA thyroidectomy.

Techniques in Jejunojejunostomy, Gastrojejunostomy, and Esophagojejunostomy in Reduced-Port Gastrectomy: Sa-Hong Min; J Surg Innov Educ. 2024;1(1):3-5. Published online June 25, 2024; DOI: https://doi.org/10.69474/jsie.2024.00031

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Abstract PDF: Minimally invasive gastric cancer surgery aims to reduce morbidity and mortality while maintaining satisfactory oncological outcomes. Laparoscopic gastrectomy is a standard treatment, offering reduced pain, shorter hospital stays, and faster recovery. Reduced-port gastrectomy has gained popularity due to its requirement for limited assistants; however, it poses unique challenges. This paper shares the techniques used in three cases of jejunojejunostomy, gastrojejunostomy, and esophagojejunostomy during reduced-port gastrectomy. Reduced-port techniques were successfully implemented in all three cases. Key steps included proper port placement, the use of tagging sutures, and strategic stapler insertion and adjustment. The reduced-port approach demonstrated feasibility and effectiveness despite its inherent challenges. Reduced-port gastrectomy can be effectively performed with a careful technique and meticulous planning, despite the challenges of transitioning from conventional five-port techniques. Using fewer ports results in less pain, fewer complications, and shorter hospital stays without compromising oncologic outcomes. These techniques can be helpful for trainees and novice surgeons, though careful candidate selection is paramount.

How I Do It: The Very First Laparoscopic Cholecystectomy as a First-Year Resident, with a Step-by-Step Tutorial: Sujin Park, Hochang Chae, Hyeong Seok Kim, Hongbeom Kim, Sang Hyun Shin, In Woong Han, Jin Seok Heo, So Jeong Yoon; J Surg Innov Educ. 2024;1(1):10-13. Published online June 25, 2024; DOI: https://doi.org/10.69474/jsie.2024.00024

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Abstract PDF: Since its introduction in 1987, laparoscopic cholecystectomy (LC) has been widely performed by surgeons as a standard procedure for benign gallbladder diseases. Education and training by hepatobiliary experts are important in order to safely perform LC without critical complications. The present report discusses the first LC performed by a beginner surgeon who was trained with our institutional step-by-step tutorial. The step-by-step mentor-mentee tutorial had a total of four phases: video training, observation in the operating room, participation as an assistant, and finally performing LC independently. At every step, the mentor’s approval was required to move on to the next phase. After completing visual training and observation, the mentee participated in 10 consecutive LCs as an assistant or operator. Finally, LC for a 54-year-old female patient with gallbladder stones was independently performed by the mentee under the mentor’s supervision. The patient was discharged on the first postoperative day without complications. We report a case of LC successfully performed by a beginner surgeon with the aid of a newly established step-by-step tutorial. The tutorial is expected to be applied to numerous surgical trainees after further refinement regarding its safety and feasibility.

Laparoscopic Sleeve Gastrectomy: Ensuring Safety and Achieving an Aesthetic Gastric Tube Shape: Ba Ool Seong, Chang Seok Ko, Seul-Gi Oh, Seong-A Jeong, Jeoung Hwan Yook, Moon-Won Yoo, Beom Su Kim, In-Seob Lee, Chung Sik Gong, Sa-Hong Min; J Surg Innov Educ. 2024;1(1):22-25. Published online June 25, 2024; DOI: https://doi.org/10.69474/jsie.2024.00017

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Abstract PDF: Sleeve gastrectomy was first performed in Korea in the 2000s, and its frequency has gradually increased thereafter. It is now the most commonly performed procedure for bariatric surgery today. However, there are few detailed reports on this surgical method, and, in particular, no papers that include accompanying videos. Herein, we present the case of a 29-year-old male with a preoperative body mass index of 44 kg/m2, who also had hypertension and hyperlipidemia. A conventional laparoscopic sleeve gastrectomy was performed using a 5-port technique. The surgeon employed two methods to ensure a consistent and aesthetic gastric tube, as well as patient safety: the non-tension method and a Lembert suture on the staple line at the neo–greater curvature. By utilizing the aforementioned two tips effectively, even inexperienced surgeons can perform laparoscopic sleeve gastrectomy relatively safely and effectively.

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