A multicenter Japanese phase II JCOG1809 trial provides prospective evidence regarding laparoscopic or robotic total gastrectomy with spleen-preserving splenic hilar (No. 10) lymph-node dissection for carefully selected patients with locally advanced proximal gastric cancer involving the greater curvature.
The study excluded patients with type 4 gastric cancer, large type 3 tumors, and clinically obvious No. 10 nodal metastasis, thereby focusing on patients in whom a minimally invasive spleen-preserving oncological approach was considered technically appropriate.
A total of 85 patients were enrolled and 81 underwent resection by qualified surgeons. Histopathological examination demonstrated No. 10 lymph-node metastasis in 12.5%, confirming the potential oncological relevance of splenic hilar nodal clearance in this population.
Median operative time was relatively long at 379 minutes, reflecting the complexity of minimally invasive total gastrectomy with splenic hilar dissection. Nevertheless, median blood loss was only 30 mL. Grade III or higher morbidity occurred in 9.9% of patients.
Importantly, the trial's primary safety endpoint—grade III or higher pancreatic fistula and/or intra-abdominal abscess—occurred in only 1.2%, significantly below the prespecified safety threshold. No treatment-related mortality was reported.
Surgical Relevance
Splenic hilar dissection is technically demanding because of the close relationship between lymphatic tissue, splenic vessels, pancreatic tail and splenic parenchyma. Historically, oncological clearance in this region could involve splenectomy, with its associated morbidity.
The study demonstrates that experienced and credentialed minimally invasive surgeons can perform spleen-preserving No. 10 dissection with acceptable short-term safety in carefully selected patients.
The results should not be generalized indiscriminately to bulky disease, type 4 cancer, large type 3 tumors, or clinically evident No. 10 nodal disease.
Clinical Takeaway: Minimally invasive spleen-preserving No. 10 lymphadenectomy appears feasible and safe in selected proximal gastric cancers when performed by appropriately qualified surgeons within a standardized oncological pathway.
Source: PubMed – JCOG1809 Phase II Trial
Gallbladder Cancer Study Warns Against Inadequate Laparoscopic Lymphadenectomy
A three-institution retrospective study compared laparoscopic and open radical resection for T2/T3 gallbladder cancer, with particular emphasis on whether the operation actually met predefined oncological standards.
Protocol-adherent radical surgery required an appropriate hepatic resection—either gallbladder-bed wedge resection or segment IVb/V bisegmentectomy—combined with retrieval of at least four lymph nodes.
Among 203 patients, protocol-adherent surgery was achieved in only 18.4% of laparoscopic cases compared with 59.8% of open operations. The most frequent deficiency in the laparoscopic group was inadequate lymph-node retrieval.
After propensity-score matching, five-year overall survival was not significantly different between laparoscopic and open surgery. Importantly, among patients who actually underwent protocol-adherent oncological resection, survival was similar between approaches. Nodal stage and elevated CA 19-9 independently predicted poorer prognosis.
Surgical Relevance
The study provides a fundamental oncological message: the quality of cancer surgery is more important than the access route.
A technically elegant minimally invasive procedure is inadequate if it compromises hepatic margins or regional lymphadenectomy. Laparoscopic radical cholecystectomy should therefore be undertaken only when the surgeon can reproduce the oncological principles of open surgery.
Clinical Takeaway: In gallbladder cancer, oncological completeness must take priority over maintaining minimally invasive access. If adequate liver resection and lymphadenectomy cannot be achieved laparoscopically, early conversion or referral is preferable to an inadequate cancer operation.
Source: PubMed – Laparoscopic Versus Open Radical Gallbladder Cancer Surgery
Intraperitoneal Lidocaine Reduces Pain and Opioid Consumption After Laparoscopic Cholecystectomy
A systematic review and meta-analysis of eight randomized controlled trials involving 532 patients evaluated intraperitoneal lidocaine for analgesia following laparoscopic cholecystectomy.
Compared with saline controls, intraperitoneal lidocaine reduced early postoperative pain, pain at 24 hours, shoulder-tip pain, and overall opioid consumption.
No significant improvement was demonstrated in postoperative nausea and vomiting or length of hospitalization.
When intraperitoneal lidocaine was compared directly with intravenous lidocaine, early analgesic effectiveness was broadly similar. However, intravenous administration demonstrated better sustained pain control and prolonged the interval before the first request for rescue analgesia.
Surgical Relevance
Post-laparoscopic pain is multifactorial, arising from port-site trauma, peritoneal irritation, diaphragmatic stretching and residual pneumoperitoneum. Intraperitoneal local anesthetic therefore represents one component of a broader multimodal strategy.
For ambulatory laparoscopic cholecystectomy, a low-cost analgesic adjunct that reduces both abdominal and shoulder-tip pain could facilitate mobilization, patient comfort and opioid-sparing recovery.
Clinical Takeaway: Intraperitoneal lidocaine is a useful adjunct to multimodal analgesia following laparoscopic cholecystectomy but should complement—not replace—appropriate systemic analgesia, port-site infiltration, residual CO₂ evacuation and ERAS-based recovery protocols.
Source: PubMed – Intraperitoneal Lidocaine After Laparoscopic Cholecystectomy
Circular-Stapled Cervical Anastomosis May Improve Early Recovery After Minimally Invasive McKeown Esophagectomy
A Western single-center study evaluated the transition from hand-sewn to circular-stapled cervical esophagogastric anastomosis following minimally invasive three-stage McKeown esophagectomy.
In 36 matched patient pairs, the circular-stapled group demonstrated numerically lower rates of anastomotic leak (8.3% versus 19.4%) and stricture (16.7% versus 30.6%), although neither difference reached statistical significance.
High tumor location was independently associated with an increased risk of anastomotic leakage.
Patients undergoing circular-stapled reconstruction resumed oral intake earlier and experienced a shorter hospital stay, while overall complication rates and complication severity remained comparable.
Surgical Relevance
Cervical esophagogastric anastomosis remains one of the most consequential technical components of minimally invasive esophagectomy. Anastomotic leak can substantially increase morbidity, hospitalization and subsequent stricture formation.
The findings do not establish the superiority of circular stapling but support the potential benefits of a standardized and reproducible reconstruction technique, particularly when institutions are developing or refining an MIE pathway.
Clinical Takeaway: Standardization of cervical anastomosis may improve recovery after minimally invasive McKeown esophagectomy, but larger studies are required to establish whether circular stapling meaningfully reduces leak or stricture rates.
Source: PubMed – Cervical Anastomosis After Minimally Invasive McKeown Esophagectomy
Endoscopic Anti-Reflux Mucosectomy Emerges as a Possible Bridge for Refractory GERD After Sleeve Gastrectomy
A two-patient clinical report describes endoscopic anti-reflux mucosectomy (ARMS) for persistent gastroesophageal reflux disease following laparoscopic sleeve gastrectomy.
Both patients developed troublesome GERD after sleeve surgery. Revisional Roux-en-Y gastric bypass was considered in one case but was avoided because of previous abdominal surgery and patient preference.
Following endoscopic anti-reflux mucosectomy, both patients demonstrated symptomatic and endoscopic improvement. One patient reportedly maintained remission at two years.
Surgical Relevance
GERD after sleeve gastrectomy remains an important long-term bariatric problem. Management may range from medical therapy and endoscopic assessment to hiatal reconstruction or conversion to Roux-en-Y gastric bypass, depending on anatomy and symptom severity.
ARMS attempts to create scar-mediated narrowing around the gastroesophageal junction through controlled mucosal resection. It may eventually provide an intermediate option for highly selected patients who remain symptomatic despite medical therapy but are poor candidates for, or wish to avoid, revisional surgery.
However, evidence from two cases is clearly insufficient to establish effectiveness, durability or safety.
Clinical Takeaway: Endoscopic anti-reflux mucosectomy is an interesting potential bridge between medical treatment and revisional bariatric surgery, but it remains investigational and should not currently replace established evaluation and treatment pathways for post-sleeve GERD.
Source: PubMed – Anti-Reflux Mucosectomy After Sleeve Gastrectomy
Robotic Hiatal Hernia Repair Shows Lower Recurrence but Longer Operative Time in Retrospective Comparison
A retrospective study from Hamad Medical Corporation compared robotic and laparoscopic hiatal hernia repair in 126 patients treated between 2019 and 2025.
Robotic repair required longer operative time but was associated with shorter hospitalization, fewer postoperative complications and lower reported recurrence—9.8% versus 27.4% following laparoscopic repair.
Thirty-day readmission and reoperation were uncommon, and no 30-day mortality was reported.
Multivariable analysis identified higher ASA score, smoking and longer operative duration as factors associated with recurrence. Nissen fundoplication and Phasix mesh reinforcement were associated with lower recurrence odds in this cohort.
Surgical Relevance
Hiatal hernia recurrence depends on numerous factors beyond operative platform, including hernia size, crural tissue quality, esophageal mobilization, tension at closure, fundoplication technique, mesh use, obesity, smoking and follow-up duration.
The apparent robotic advantage therefore requires cautious interpretation because retrospective platform comparisons are vulnerable to patient selection, surgeon experience and institutional technique.
Clinical Takeaway: Robotic hiatal hernia repair may offer favorable outcomes in experienced centers, but current retrospective evidence does not justify automatic platform preference. Quality of mediastinal dissection, crural reconstruction and appropriate anti-reflux strategy remain more important than the platform itself.
Source: PubMed – Robotic Versus Laparoscopic Hiatal Hernia Repair
Shoulder-Support Exoskeletons Reduce Muscle Activity During Simulated Laparoscopic Surgery
An ergonomics study evaluated two commercially available shoulder-support exoskeletons during representative simulated laparoscopic postures in 27 participants.
Both devices reduced shoulder-muscle activity compared with performing the same tasks without exoskeletal support.
The soft Hapo system consistently reduced anterior deltoid activity across all tested shoulder positions and reduced medial deltoid activity in most configurations. The more rigid Paexo device appeared particularly beneficial at higher degrees of shoulder elevation.
Usability scores were acceptable, supporting further evaluation during real operative procedures.
Surgical Relevance
Laparoscopic surgery exposes surgeons to prolonged static shoulder elevation, instrument torque, repetitive upper-extremity movements, fixed monitor-dependent posture and cumulative musculoskeletal strain.
Exoskeletons represent a novel approach to surgeon ergonomics, but simulated muscle-activity reduction does not automatically translate into clinical usability. Future operating-room studies need to evaluate sterility, freedom of fine movement, interference with gowns and equipment, fatigue, comfort during prolonged cases and interaction with the surgical team.
Clinical Takeaway: Shoulder-support exoskeletons may reduce muscular workload during laparoscopy and could eventually contribute to surgeon occupational health, but live operating-room validation is required before routine adoption.
Source: PubMed – Shoulder-Support Exoskeletons During Simulated Laparoscopy
Key Message
The 25 August 2026 evidence update demonstrates that progress in minimally invasive surgery increasingly depends on quality rather than access alone. Spleen-preserving hilar dissection can extend oncological laparoscopy when expertise and patient selection are controlled; inadequate lymphadenectomy can negate the value of a laparoscopic cancer operation; multimodal analgesia can improve recovery after cholecystectomy; standardized reconstruction may refine esophagectomy outcomes; endoscopic therapy may expand options after bariatric surgery; robotic foregut surgery requires objective outcome auditing; and surgeon ergonomics is emerging as an important component of sustainable surgical practice.
The best minimally invasive operation is not simply the one performed through the smallest access—it is the operation that preserves oncological principles, minimizes physiological and technical harm, accelerates recovery, and protects both the patient and the surgeon.
