A PubMed-indexed review from the Journal of Southern Medical University examines how neoadjuvant and perioperative immunotherapy are changing the surgical pathway for locally advanced gastric cancer. The implications extend beyond achieving pathological complete response; increasingly, the key question is how the biological response to systemic therapy should influence the extent and nature of subsequent surgery.

Traditionally, operative planning for locally advanced gastric cancer has relied heavily on pretreatment anatomical staging, with oncologically appropriate gastrectomy and D2 lymphadenectomy forming the surgical foundation. Immunotherapy introduces greater complexity because responses may be heterogeneous. The primary gastric tumor and regional lymph nodes may not necessarily demonstrate equivalent treatment responses.

The review emphasizes increasingly sophisticated biomarker-based patient stratification, including microsatellite instability (MSI) status, PD-L1 expression, and refined HER2 classification. Such biological information may become progressively important when predicting response and determining the optimal sequence of systemic and surgical treatment.

Response Assessment Is Moving Beyond CT

Conventional CT-based restaging may not adequately characterize biological treatment response following immunotherapy. Future assessment is likely to combine multiple modalities, potentially including:

• Endoscopic reassessment and targeted biopsy
• Pathological regression assessment
• Functional and metabolic imaging
• Circulating tumor DNA or other liquid-biopsy biomarkers
• Molecular tumor profiling
• AI-assisted integration of imaging, endoscopic and pathological information

A particularly important surgical issue is discordance between primary-tumor response and lymph-node response. This complicates decisions regarding the appropriate extent of gastric resection and lymphadenectomy following neoadjuvant treatment.

Surgical Relevance

For laparoscopic and robotic gastric surgeons, advanced technical capability in minimally invasive D2 gastrectomy remains essential, but it increasingly represents only one component of modern gastric cancer management. Surgical planning after immunotherapy should incorporate pretreatment stage, treatment response, tumor biology, nodal status and multidisciplinary oncological assessment.

The future direction may gradually move from maximum anatomical radicality toward biologically informed and function-preserving surgery in rigorously selected responders. Such de-escalation, however, requires prospective oncological validation before routine adoption.

Clinical Takeaway: Neoadjuvant immunotherapy may eventually change not only when gastric cancer is operated upon, but also how much surgery is necessary. Until stronger prospective evidence becomes available, response-adapted surgery should remain oncologically disciplined and multidisciplinary.

Source: PubMed – Neoadjuvant Immunotherapy and Gastric Cancer Surgery

Device-Related Pressure Injury Is Common During Prolonged Operations

A prospective single-center study involving 367 adults undergoing elective procedures lasting at least three hours examined device-related intraoperative pressure injuries. Approximately 30% of patients developed a device-associated pressure injury, although almost all were classified as stage 1.

Several factors were associated with increased risk, including age above 48 years, BMI ≥25 kg/m², pre-existing skin abnormalities, repositioning after induction, operative duration ≥250 minutes, blood loss ≥150 mL, and exposure to 13 or more intraoperative medical devices.

Although the study was not restricted to minimally invasive surgery, its findings have direct implications for prolonged robotic, bariatric, colorectal, gynecologic, urological, HPB and advanced laparoscopic procedures.

Why Minimally Invasive Surgery Is Particularly Relevant

Complex minimally invasive procedures may require patients to remain immobilized for several hours in steep Trendelenburg, reverse Trendelenburg, lithotomy, lateral or modified positions. Pressure may originate not only from the operating table but also from stirrups, shoulder supports, straps, padding edges, monitoring devices, tubing, cables and other equipment.

Robotic surgery introduces additional considerations because the patient may become relatively difficult to access after docking. Prevention therefore needs to begin before robotic docking or establishment of the final operative position.

Surgical Relevance

Positioning should be regarded as an active component of surgical safety rather than a task completed before incision. For prolonged cases, teams should consider systematic assessment of:

• Pressure points and padding
• Head, neck and upper-extremity alignment
• Stirrups and lower-limb pressure
• Shoulder and brachial plexus protection
• Monitoring leads, cables and tubing beneath the patient
• Sequential compression devices
• Robotic arm and instrument clearance
• Skin condition before and after prolonged positioning

Clinical Takeaway: In prolonged minimally invasive and robotic operations, every device touching the patient should be considered a potential pressure point. Positioning and device-contact checks should form part of the surgical safety workflow, particularly before docking and during lengthy procedures.

Source: PubMed – Device-Related Intraoperative Pressure Injury Study

Hepatic Ischemia-Reperfusion Injury Links Mitochondrial Dysfunction, Lipid Metabolism and Ferroptosis

A review in Biochemical and Biophysical Research Communications provides an updated mechanistic perspective on hepatic ischemia-reperfusion injury (HIRI), describing it as an interconnected metabolic process involving mitochondrial dysfunction, altered lipid metabolism, oxidative injury and ferroptosis.

During hepatic ischemia, reduced oxygen availability and ATP production may suppress normal fatty-acid oxidation and promote intracellular lipid accumulation. When blood flow is restored, reperfusion can generate a rapid increase in mitochondrial reactive oxygen species, calcium disturbance and abnormalities in mitochondrial quality-control mechanisms.

These changes can promote membrane lipid peroxidation and cellular injury.

Ferroptosis Emerges as an Important Pathway

The review highlights ferroptosis, an iron-dependent form of regulated cell death characterized by excessive lipid peroxidation, as a potentially important contributor to hepatic ischemia-reperfusion injury.

Several molecular pathways are implicated, including iron metabolism, GPX4-dependent lipid peroxide detoxification, and antioxidant signaling involving pathways such as Nrf2/SLC7A11/HO-1.

Rather than functioning independently, mitochondrial dysfunction, lipid remodeling, oxidative stress and ferroptotic signaling appear to interact dynamically during ischemia and reperfusion.

Importantly, much of this evidence remains derived from experimental models. These pathways therefore represent promising biological targets rather than established perioperative treatments.

Surgical Relevance

For laparoscopic and robotic hepatobiliary surgeons, ischemia-reperfusion biology is directly relevant whenever temporary inflow control is employed during liver transection. It may influence future thinking around:

Pringle maneuver duration and intermittency, hepatic inflow-control strategy, parenchymal preservation, ischemic preconditioning, liver transplantation, major minimally invasive hepatectomy, and pharmacological or metabolic organ-protection strategies.

The biological response to inflow occlusion may ultimately prove as important as the technical duration of vascular clamping.

Clinical Takeaway: Hepatic ischemia-reperfusion injury should be understood as a complex metabolic and mitochondrial process rather than simply a consequence of temporary blood-flow interruption. Ferroptosis and mitochondrial-lipid interactions represent promising future therapeutic targets, but clinical translation remains investigational.

Source: PubMed – Hepatic Ischemia-Reperfusion Injury, Mitochondria and Ferroptosis

Key Message

The 20 August 2026 evidence update demonstrates how minimally invasive surgery is increasingly shaped by factors extending beyond operative technique. Tumor biology may influence the future extent of gastric cancer surgery; prolonged positioning and device contact represent preventable sources of perioperative injury; and molecular understanding of hepatic ischemia-reperfusion may eventually improve organ protection during complex liver surgery.

For the modern laparoscopic and robotic surgeon, technical excellence must therefore be integrated with precision oncology, structured patient-safety systems, perioperative physiology, and translational science.

The future of minimally invasive surgery is not simply smaller access—it is more precise biology, safer perioperative care, and increasingly individualized surgery.