A retrospective stratified study published in Surgical Endoscopy evaluated 226 patients undergoing laparoscopic common bile duct exploration (LCBDE) followed by primary duct closure for concomitant gallbladder and common bile duct stones. The investigators specifically examined whether the presence and severity of acute cholangitis influenced postoperative biliary and systemic outcomes.

Patients with mild or moderate acute cholangitis did not demonstrate a significant increase in biliary complications compared with patients without cholangitis. Rates of clinically relevant outcomes such as bile leakage, recurrent common bile duct stones, biliary stricture, and recurrent cholangitis remained comparable.

Importantly, selected patients with severe cholangitis who underwent adequate preoperative stabilization and intervention also did not demonstrate significantly higher biliary technical complication rates. However, severe cholangitis remained associated with greater systemic morbidity, longer total hospitalization, and increased treatment costs.

Surgical Relevance

The findings help refine selection for single-stage laparoscopic management of gallbladder and CBD stones. Primary duct closure avoids the morbidity associated with routine T-tube drainage but requires confidence in complete duct clearance, secure closure, adequate distal drainage, and appropriate patient selection.

The distinction between technical biliary risk and systemic disease severity is particularly important. A successfully explored and closed CBD does not eliminate the physiological consequences of severe sepsis.

Clinical Takeaway: Primary closure after LCBDE appears reasonable in appropriately selected patients with mild-to-moderate cholangitis. Severe cholangitis requires effective preoperative source control, physiological stabilization, careful selection, and heightened postoperative surveillance.

Source: PubMed – Primary Closure After LCBDE in Acute Cholangitis

DBE-ERCP Offers Minimally Invasive Treatment for Hepaticojejunostomy Strictures, but Recurrence Remains Substantial

A systematic review and meta-analysis in Surgical Endoscopy evaluated double-balloon enteroscopy-assisted ERCP (DBE-ERCP) for hepaticojejunostomy anastomotic strictures in patients with surgically altered gastrointestinal anatomy.

Across six studies involving 386 patients, pooled technical success was approximately 86%. Among technically successful procedures, pooled clinical success reached approximately 78%.

However, adverse events occurred in approximately 15%, while pooled stricture recurrence reached 36%. Thus, successful initial intervention does not necessarily represent definitive treatment.

Surgical Relevance

Hepaticojejunostomy strictures may develop following pancreaticoduodenectomy, complex biliary reconstruction, liver transplantation, or other Roux-en-Y biliary-enteric procedures. Conventional ERCP is often impossible because standard endoscopes cannot reach the biliary anastomosis.

DBE-ERCP can provide access for balloon dilation, stenting, stone extraction, and other therapeutic interventions while potentially avoiding percutaneous drainage or surgical revision.

The relatively high recurrence rate means treatment pathways should incorporate long-term biochemical surveillance, imaging, repeat endoscopic access planning, and multidisciplinary escalation strategies.

Clinical Takeaway: DBE-ERCP is an important minimally invasive option for hepaticojejunostomy strictures in altered anatomy, but successful treatment requires long-term follow-up because recurrent stenosis remains common.

Source: PubMed – DBE-ERCP for Hepaticojejunostomy Anastomotic Strictures

Mechanical Power Requires Careful Interpretation During Ventilation for Laparoscopic Bariatric Surgery

A secondary analysis of a randomized trial published in the Journal of Anesthesia examined the relationship between ventilator-derived mechanical power and postoperative pulmonary complications in 160 adults with obesity undergoing laparoscopic bariatric surgery.

Mechanical power attempts to quantify the energy transferred from a ventilator to the respiratory system over time. This is particularly relevant during bariatric laparoscopy because obesity, pneumoperitoneum, and operative positioning can substantially alter respiratory compliance and airway pressures.

The investigators found that dynamic mechanical power was not significantly associated with postoperative pulmonary complications. Total mechanical power demonstrated a more complex, non-linear inverted U-shaped relationship with pulmonary outcomes.

One explanation is that total mechanical power combines potentially harmful dynamic energy with energy generated through positive end-expiratory pressure (PEEP). Appropriate PEEP may help maintain alveolar recruitment rather than representing injurious ventilation.

Surgical Relevance

A single mechanical-power number should therefore not be interpreted in isolation. In bariatric MIS, perioperative teams should continue to consider the individual components of lung-protective ventilation, including:

• Tidal volume
• Driving pressure
• PEEP
• Recruitment strategy
• Respiratory-system compliance
• Pneumoperitoneum pressure
• Patient positioning
• Postoperative pulmonary-risk mitigation

Close communication between the surgeon and anesthesiologist remains particularly important because pneumoperitoneum pressure and positioning directly influence respiratory mechanics.

Clinical Takeaway: Mechanical power is an interesting physiological metric, but total mechanical power should not be used as a stand-alone marker of pulmonary risk during bariatric laparoscopy. Ventilation should remain individualized and component-based.

Source: PubMed – Mechanical Power During Laparoscopic Bariatric Surgery

Robotic Distal Pancreatectomy With Partial Splenectomy Offers a Middle Path for Selected Splenic-Hilar Tumors

An Annals of Surgical Oncology video case report describes robotic distal pancreatectomy combined with partial splenectomy for a pancreatic pseudopapillary neoplasm located close to the splenic hilum.

The tumor's anatomical relationship to the splenic vessels made a conventional Kimura spleen-preserving distal pancreatectomy, in which the splenic artery and vein are preserved, unsuitable.

Rather than performing total splenectomy, the surgeons divided the pancreas, controlled and ligated the relevant splenic vessels, and performed a partial splenectomy, preserving viable splenic tissue.

Intraoperative indocyanine green fluorescence imaging was then used to assess perfusion of the residual spleen. The preserved splenic remnant demonstrated satisfactory vascularity. The patient recovered uneventfully, and pathological margins were negative.

Surgical Relevance

Distal pancreatic tumors close to the splenic hilum can force a difficult choice between organ preservation and oncologically safe vascular dissection. This case illustrates a potential intermediate strategy between complete splenic-vessel preservation and total splenectomy.

Robotic articulation may facilitate precise hilar dissection and reconstruction, while ICG fluorescence provides immediate visual assessment of residual splenic perfusion.

However, this remains case-level evidence. Wider adoption requires evaluation of splenic infarction, abscess formation, delayed hemorrhage, remnant function, pancreatic fistula, and long-term outcomes.

Clinical Takeaway: Robotic distal pancreatectomy with partial splenectomy may provide a spleen-preserving option for selected pancreatic tail tumors when conventional vessel-preserving surgery is unsafe, with ICG fluorescence offering useful confirmation of remnant perfusion.

Source: PubMed – Robotic Distal Pancreatectomy With Partial Splenectomy

Point-of-Care Bioaerosol Sensing May Improve Operating-Room Smoke and Plume Safety

A clinical technology study published in ACS Sensors introduced SPOT, a portable microfluidic-plasmonic sensing platform designed to characterize surgical bioaerosols.

The system measures both proteinaceous aerosol burden and accessible ATP, potentially providing information about the biological content of surgical plume rather than relying solely on visible smoke concentration.

During thoracic surgical procedures, minimally invasive operations demonstrated a higher ATP-to-protein ratio than open procedures. This raises the possibility that lower visible aerosol mass does not necessarily indicate lower biologically active aerosol exposure.

The finding is exploratory and does not establish clinical infectivity or occupational disease risk. Nevertheless, it demonstrates how operating-room air quality may eventually be measured more objectively.

Surgical Relevance

Laparoscopic and robotic operations frequently use electrosurgery, ultrasonic energy, vessel-sealing systems and other energy devices capable of generating surgical plume. Pneumoperitoneum can contain and subsequently release aerosolized material through trocars, valves, instrument exchange, desufflation, or uncontrolled leakage.

Potential safety strategies include:

• Closed smoke evacuation
• Appropriate filtration
• Controlled pneumoperitoneum release
• Minimizing uncontrolled trocar leakage
• Correct energy-device use
• Adequate operating-room ventilation
• Objective environmental monitoring

Point-of-care sensing technologies could eventually help determine whether smoke-evacuation systems are functioning effectively and identify procedures associated with greater aerosol burden.

Clinical Takeaway: Surgical plume should be treated as an operating-room occupational safety issue. Portable sensing technologies may eventually enable objective monitoring, but clinical thresholds and outcome-based standards remain to be established.

Source: PubMed – Point-of-Care Sensing of Surgical Bioaerosols

Key Message

The 3 September 2026 evidence update demonstrates how minimally invasive surgery increasingly integrates technical refinement, physiology, organ preservation, advanced endoscopy, and operating-room safety. Primary closure after laparoscopic CBD exploration may be appropriate despite selected cholangitis; DBE-ERCP can rescue difficult biliary-enteric strictures; bariatric ventilation requires interpretation beyond a single mechanical-power value; robotic and fluorescence technologies may expand splenic preservation during pancreatic surgery; and objective bioaerosol monitoring may strengthen future surgical-smoke safety.

Modern minimally invasive surgery is not defined simply by completing an operation through small incisions—it requires the right patient, appropriate physiology, preservation of function, effective rescue pathways, and protection of both patients and the operating-room team.