Journal of Surgical Innovation and Education

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

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.

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

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.

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

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

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.

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

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.

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