Long-term outcomes of sentinel lymph node navigation surgery for early-stage cervical cancer.

BACKGROUND: Sentinel lymph node navigation surgery, which identifies the sentinel lymph node in early cervical cancers and omits systemic pelvic lymphadenectomy in cases where no lymph node metastasis is present, has recently gained attention. However, there are few reports on lymph node recurrence and the long-term outcomes of cervical cancer surgery performed using sentinel lymph node navigation surgery. In this study, we aimed to evaluate the long-term outcomes of sentinel node navigation surgery for early-stage cervical cancer. METHODS: One hundred thirty-eight patients with cervical cancer were enrolled. Sentinel lymph nodes were identified by injecting 99 m Technetium-labeled phytate and indocyanine green into the uterine cervix. Surgery and survival outcomes were also analyzed. RESULTS: The median age and body mass index of the patients were 40 years (20-78) and 21.7 kg/m2 (16.5-50.4), respectively. Open surgery, laparoscopic surgery, and robotic surgery were performed in 77 (56%), 53 (38%), and 8 (6%) patients, respectively. The overall and bilateral detection rates of the sentinel lymph node were 100% and 94%, respectively. Only one case (0.7%) exhibited lower extremity lymphedema, and pelvic lymphocele was observed in three cases (2.2%). Four cases (3%) experienced recurrence over a median follow-up of 57.5 months (range, 2-115 months), with five-year recurrence-free and overall survival rates of 97% and 97.3%, respectively. CONCLUSIONS: Our results demonstrate that sentinel node navigation surgery may be safe and effective for early-stage cervical cancer.

Clinical outcomes of sentinel node navigation surgery in patients with preoperatively estimated stage IA endometrial cancer and evaluation of validity for continuing sentinel node navigation surgery based on dispersion of recurrence probability.

BACKGROUND: To evaluate the feasibility of the use and continuation of sentinel lymph node navigation surgery (SNNS) as an alternative to pelvic lymph node dissection (PLND) for patients with preoperatively estimated stage IA endometrial cancer. METHODS: This retrospective study selected the electronic medical records of all patients who had received CT scans and MRI imaging before surgery from April 1, 2009 to March 31, 2021. Sentinel lymph nodes (SLNs) were detected by administrating 99mTc-phytate and/or indocyanine green into the cervix, and the clinical outcomes of the patients who underwent SNNS or PLND were evaluated. Furthermore, in case of nodal recurrence, a new procedure to determine whether the facility should continue with SNNS or not was developed that compares the maximum likelihood hypothesis and an alternative one based on recurrence rates. RESULTS: Among 137 patients, SLN biopsies with ultrastaging were performed on 91 patients. The SLN detection rate was 95.6%. Over a 59-month median observation period, no statistically significant differences were shown in overall survival, disease-specific survival and disease-free survival between the SNNS and PLND groups when introducing the propensity score method (p-values: 0.06, 0.153, and 0.625, respectively). Our procedure demonstrated that, in our department without recurrence up to the 65th attempt, it was possible to continue SNNS if a recurrence occurs at the 66th attempt. CONCLUSION: This study suggests the validity of SNNS as an alternative to PLND. Even in the absence of evidence from randomized controlled trials, we can confirm the validity of continuing SNNS using our procedure.

A clinical assessment of three-dimensional-printed liver model navigation for thrice or more repeated hepatectomy based on a conversation analysis.

PURPOSES: We performed a conversation analysis of the speech conducted among the surgical team during three-dimensional (3D)-printed liver model navigation for thrice or more repeated hepatectomy (TMRH). METHODS: Seventeen patients underwent 3D-printed liver navigation surgery for TMRH. After transcription of the utterances recorded during surgery, the transcribed utterances were coded by the utterer, utterance object, utterance content, sensor, and surgical process during conversation. We then analyzed the utterances and clarified the association between the surgical process and conversation through the intraoperative reference of the 3D-printed liver. RESULTS: In total, 130 conversations including 1648 segments were recorded. Utterance coding showed that the operator/assistant, 3D-printed liver/real liver, fact check (F)/plan check (Pc), visual check/tactile check, and confirmation of planned resection or preservation target (T)/confirmation of planned or ongoing resection line (L) accounted for 791/857, 885/763, 1148/500, 1208/440, and 1304/344 segments, respectively. The utterance's proportions of assistants, F, F of T on 3D-printed liver, F of T on real liver, and Pc of L on 3D-printed liver were significantly higher during non-expert surgeries than during expert surgeries. Confirming the surgical process with both 3D-printed liver and real liver and performing planning using a 3D-printed liver facilitates the safe implementation of TMRH, regardless of the surgeon's experience. CONCLUSIONS: The present study, using a unique conversation analysis, provided the first evidence for the clinical value of 3D-printed liver for TMRH for anatomical guidance of non-expert surgeons.

No differences in long-term clinical outcomes and survival rate of navigation-assisted versus conventional primary mobile-bearing total knee arthroplasty: A minimum 10-year follow-up.

PURPOSE: This study aimed to compare long-term clinical and radiographic outcomes and survival rates between navigation-assisted (NAV) total knee arthroplasty (TKA) and conventional (CON) TKA using a mobile-bearing insert. METHODS: From May 2008 to December 2009, 45 and 63 mobile-bearing TKA patients were enroled in the CON- and NAV-TKA groups with 146.8 months follow-up, respectively. Clinical outcomes (Western Ontario and McMaster University Osteoarthritis Index and Knee Society Scores), radiographic outcomes (hip-knee-ankle [HKA], lateral distal femoral, medial proximal tibial, γ, and δ angles), and survivorship were compared between both groups. RESULTS: The number of HKA angle outliers (more than 3 degrees or less than -3 degree) was significantly lower in the NAV-TKA group (24.4% vs. 9.5%, p = 0.036) than in the CON-TKA group. However, long-term clinical outcomes were similar between both groups. The cumulative survival rate (best-case scenario) was 98.3% in the CON-TKA group and 97.5% in the NAV-TKA group, with no significant difference between the groups (p = 0.883). CONCLUSION: Long-term clinical outcomes and survival rates were similar between the two groups despite fewer outliers of postoperative lower-limb alignment in the NAV-TKA group. Excellent survival rates were observed in both groups using mobile-bearing inserts. LEVEL OF EVIDENCE: Level IV, case series.

Augmented Reality in Spine Surgery: A Case Study of Atlantoaxial Instrumentation in Os Odontoideum.

Despite advancement in surgical innovation, C1-C2 fixation remains challenging due to risks of screw malposition and vertebral artery (VA) injuries. Traditional image-based navigation, while useful, often demands that surgeons frequently shift their attention to external monitors, potentially causing distractions. In this article, we introduce a microscope-based augmented reality (AR) navigation system that projects both anatomical information and real-time navigation images directly onto the surgical field. In the present case report, we discuss a 37-year-old female who suffered from os odontoideum with C1-C2 subluxation. Employing AR-assisted navigation, the patient underwent the successful posterior instrumentation of C1-C2. The integrated AR system offers direct visualization, potentially minimizing surgical distractions. In our opinion, as AR technology advances, its adoption in surgical practices and education is anticipated to expand.

Development of real-time navigation system for laparoscopic hepatectomy using magnetic micro sensor.

BACKGROUND: We report a new real-time navigation system for laparoscopic hepatectomy (LH), which resembles a car navigation system. MATERIAL AND METHODS: Virtual three-dimensional liver and body images were reconstructed using the "New-VES" system, which worked as roadmap during surgery. Several points of the patient's body were registered in virtual images using a magnetic position sensor (MPS). A magnetic transmitter, corresponding to an artificial satellite, was placed about 40 cm above the patient's body. Another MPS, corresponding to a GPS antenna, was fixed on the handling part of the laparoscope. Fiducial registration error (FRE, an error between real and virtual lengths) was utilized to evaluate the accuracy of this system. RESULTS: Twenty-one patients underwent LH with this system. Mean FRE of the initial five patients was 17.7 mm. Mean FRE of eight patients in whom MDCT was taken using radiological markers for registration of body parts as first improvement, was reduced to 10.2 mm (p = .014). As second improvement, a new MPS as an intraoperative body position sensor was fixed on the right-sided chest wall for automatic correction of postural gap. The preoperative and postoperative mean FREs of 8 patients with both improvements were 11.1 mm and 10.1 mm (p = .250). CONCLUSIONS: Our system may provide a promising option that virtually guides LH.

An intraoperative artificial intelligence system identifying anatomical landmarks for laparoscopic cholecystectomy: a prospective clinical feasibility trial (J-SUMMIT-C-01).

BACKGROUND: We have implemented Smart Endoscopic Surgery (SES), a surgical system that uses artificial intelligence (AI) to detect the anatomical landmarks that expert surgeons base on to perform certain surgical maneuvers. No report has verified the use of AI-based support systems for surgery in clinical practice, and no evaluation method has been established. To evaluate the detection performance of SES, we have developed and established a new evaluation method by conducting a clinical feasibility trial. METHODS: A single-center prospective clinical feasibility trial was conducted on 10 cases of LC performed at Oita University hospital. Subsequently, an external evaluation committee (EEC) evaluated the AI detection accuracy for each landmark using five-grade rubric evaluation and DICE coefficient. We defined LM-CBD as the expert surgeon's "judge" of the cystic bile duct in endoscopic images. RESULTS: The average detection accuracy on the rubric by the EEC was 4.2 ± 0.8 for the LM-CBD. The DICE coefficient between the AI detection area of the LM-CBD and the EEC members' evaluation was similar to the mean value of the DICE coefficient between the EEC members. The DICE coefficient was high score for the case that was highly evaluated by the EEC on a five-grade scale. CONCLUSION: This is the first feasible clinical trial of an AI system designed for intraoperative use and to evaluate the AI system using an EEC. In the future, this concept of evaluation for the AI system would contribute to the development of new AI navigation systems for surgery.

Lymphatic flow mapping during colon cancer surgery using indocyanine green fluorescence imaging.

With the development of surgical technology, indocyanine green (ICG) fluorescence navigation systems may be useful in various areas of colorectal surgery, including tumor location confirmation, bowel perfusion, ureter identification, and lymph node mapping. This review provides an overview of the current status of ICG-based navigation surgery in colorectal surgery, emphasizing its role in lymphatic flow mapping. This state-of-the-art approach will allow for appropriate oncological surgeries in the field of colorectal cancer and improve the patient's prognosis.

What's New with Endoscopic Treatments for Early Gastric Cancer in the "Post-ESD Era"?

BACKGROUND: Endoscopic treatments for gastric cancers have still been progressing even after the great success of endoscopic submucosal dissection (ESD). SUMMARY: In further advancements of ESD, safe and less-invasive procedures are challenged by managing postoperative bleeding, one of the major adverse events in ESD. Covering the mucosal defect after removal of lesions appears reasonable and effective for preventing delayed bleeding from the post-ESD ulcers. Shielding with biodegradable sheets is attempted on clinical trials, which show equivocal results. Although suturing of the mucosal rims is technically challenging, pilot studies demonstrate favorable outcomes for avoiding post-ESD bleeding even in cases at high risk. In cases after noncurative resection of ESD, the selection of patients who truly require additional gastrectomy with lymph node dissection is important to provide necessary surgery. Risk stratification of lymph node metastases and surgery has been developed, which offers tailor-made management to each patient considering the risks and benefits. In surgery, function-preserving gastrectomy to minimize the resection area in both lymphadenectomy and the primary site is clinically introduced. The sentinel node navigation surgery is promising to realize the minimally invasive gastrectomy, and it should strongly fit ESD as well as laparoscopic endoscopic cooperative surgery or endoscopic full-thickness resection, although nonexposure approaches are desirable. Key Message: Development for less-invasive managements on gastric cancer will be continued in step with the advancement of endoscopic treatments.

Real-time detection of the recurrent laryngeal nerve in thoracoscopic esophagectomy using artificial intelligence.

BACKGROUND: Artificial intelligence (AI) has been largely investigated in the field of surgery, particularly in quality assurance. However, AI-guided navigation during surgery has not yet been put into practice because a sufficient level of performance has not been reached. We aimed to develop deep learning-based AI image processing software to identify the location of the recurrent laryngeal nerve during thoracoscopic esophagectomy and determine whether the incidence of recurrent laryngeal nerve paralysis is reduced using this software. METHODS: More than 3000 images extracted from 20 thoracoscopic esophagectomy videos and 40 images extracted from 8 thoracoscopic esophagectomy videos were annotated for identification of the recurrent laryngeal nerve. The Dice coefficient was used to assess the detection performance of the model and that of surgeons (specialized esophageal surgeons and certified general gastrointestinal surgeons). The performance was compared using a test set. RESULTS: The average Dice coefficient of the AI model was 0.58. This was not significantly different from the Dice coefficient of the group of specialized esophageal surgeons (P = 0.26); however, it was significantly higher than that of the group of certified general gastrointestinal surgeons (P = 0.019). CONCLUSIONS: Our software's performance in identification of the recurrent laryngeal nerve was superior to that of general surgeons and almost reached that of specialized surgeons. Our software provides real-time identification and will be useful for thoracoscopic esophagectomy after further developments.

Real-time vascular anatomical image navigation for laparoscopic surgery: experimental study.

BACKGROUND: Recognition of the inferior mesenteric artery (IMA) during colorectal cancer surgery is crucial to avoid intraoperative hemorrhage and define the appropriate lymph node dissection line. This retrospective feasibility study aimed to develop an IMA anatomical recognition model for laparoscopic colorectal resection using deep learning, and to evaluate its recognition accuracy and real-time performance. METHODS: A complete multi-institutional surgical video database, LapSig300 was used for this study. Intraoperative videos of 60 patients who underwent laparoscopic sigmoid colon resection or high anterior resection were randomly extracted from the database and included. Deep learning-based semantic segmentation accuracy and real-time performance of the developed IMA recognition model were evaluated using Dice similarity coefficient (DSC) and frames per second (FPS), respectively. RESULTS: In a fivefold cross-validation conducted using 1200 annotated images for the IMA semantic segmentation task, the mean DSC value was 0.798 (± 0.0161 SD) and the maximum DSC was 0.816. The proposed deep learning model operated at a speed of over 12 FPS. CONCLUSION: To the best of our knowledge, this is the first study to evaluate the feasibility of real-time vascular anatomical navigation during laparoscopic colorectal surgery using a deep learning-based semantic segmentation approach. This experimental study was conducted to confirm the feasibility of our model; therefore, its safety and usefulness were not verified in clinical practice. However, the proposed deep learning model demonstrated a relatively high accuracy in recognizing IMA in intraoperative images. The proposed approach has potential application in image navigation systems for unfixed soft tissues and organs during various laparoscopic surgeries.

Sentinel node navigation surgery in cervical cancer: a systematic review and metaanalysis.

Sentinel node navigation surgery (SNNS) is used in clinical practice for the treatment of cervical cancer. This study aimed to elucidate the appropriate sentinel lymph node (SLN) mapping method and assess the safety and benefits of SNNS. We searched the PubMed, Ichushi, and Cochrane Library databases for randomized controlled trials (RCT) and studies on SLN in cervical cancer from January 2012 to December 2020. Two authors independently assessed study quality and extracted data. We quantitatively analyzed the detection rate, sensitivity/specificity, and complications and reviewed information, including the survival data of SLN biopsy (SLNB) without pelvic lymphadenectomy (PLND). The detection rate of SLN mapping in the unilateral pelvis was median 95.7% and 100% and in the bilateral pelvis was median 80.4% and 90% for technetium-99 m (Tc) with/without blue dye (Tc w/wo BD) and indocyanine green (ICG) alone, respectively. The sensitivity and specificity of each tracer were high; the area under the curve of each tracer was 0.988 (Tc w/wo BD), 0.931 (BD w/wo Tc), 0.966 (ICG), and 0.977 (carbon nanoparticle). Morbidities including lymphedema, neurological symptoms and blood loss were associated with PLND. One RCT and five studies all showed SNNS without systematic PLND does not impair recurrence or survival in early-stage cervical cancer with a tumor size ≤ 2-4 cm. Both Tc w/wo BD and ICG are appropriate SLN tracers. SNNS can reduce the morbidities associated with PLND without affecting disease progression in early-stage cervical cancer.

Right top pulmonary vein is a venous anomaly of which surgeons should be aware in subcarinal dissection for thoracoscopic esophagectomy: a case report and literature review.

BACKGROUND: A right top pulmonary vein (RTPV) that crosses behind the right main or intermediate bronchus is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage or ligation of this abnormal vessel can lead to massive intraoperative bleeding and serious complications, such as congestion of the posterior segment of the right upper lobe and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical thoracoscopic esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which thoracic surgeons should be aware. CASE PRESENTATION: A 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV. CONCLUSION: In our review of the relevant literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter was 7.0 mm at the maximum and 2.2 ± 0.72 mm at the minimum, with the right superior pulmonary vein being a relatively common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of thoracoscopic esophagectomy, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side. This is also true in the case of RTPV, which should be noted to avoid injury. In cases involving an RTPV larger than 4.5 mm, ligation should be avoided, and preoperative recognition of the exact run of this abnormal vessel using three-dimensional imaging can be very useful.

Total laparoscopic resection by medial-retroperitoneal approach using virtual navigation: two case reports of primary retroperitoneal schwannoma.

BACKGROUND: We report two rare cases of retroperitoneal schwannoma completely resected by a laparoscopic medial-retroperitoneal approach aided by virtual navigation. Three-dimensional images have been used in liver and lung surgery, but there are few prior reports on retroperitoneal surgery. CASE PRESENTATION: These two case reports are of a 60-year-old man and a 40-year-old man with asymptomatic retroperitoneal schwannoma. In both cases, the tumors were located in the right renal hilum and were close to the duodenum, right ureter, and inferior vena cava. Simulation using three-dimensional images was performed before surgery, and a medial-retroperitoneal approach was performed to secure a wide surgical field. During the operation, we confirmed the location of the main feeder and the relationship between the tumor and organs with those shown on the three-dimensional images and performed total laparoscopic resection. CONCLUSION: The medial-retroperitoneal approach provides operative safety. Preoperative simulation and intraoperative navigation with three-dimensional images, which can be freely rotated and interactively visualized from any angle, are useful methods to enhance the surgeon's understanding of a patient's specific anatomy and are especially effective when resecting a retroperitoneal tumor that is located in an anatomically deep and complex location.

Posterolateral Floating Technique for the Thoracic Ossification of the Posterior Longitudinal Ligament with Navigation: A Technical Note.

We describe a floating technique via a posterolateral approach with intraoperative O-arm navigation to facilitate decompression of the spinal cord in thoracic myelopathy due to severe ossification of the posterior longitudinal ligament (OPLL). A 62-year-old man with myelopathy due to thoracic OPLL had left-leg muscle weakness, urinary disturbance, and spastic gait. Bilateral leg pain and gait disturbance had persisted for 2 years. He was successfully treated by the posterolateral OPLL floating procedure and posterior pedicle fixation under O-arm navigation. At a 2-year follow-up, manual muscle testing results and sensory function of the left leg had recovered fully. His cervical Japanese Orthopedic Association score had improved from 5/12 to 11/12. The novel intraoperative O-arm navigation-guided posterolateral floating procedure for thoracic OPLL is effective for achieving precise decompression and strong fixation with a posterior approach only and can provide an excellent result for severe thoracic OPLL without the risk of adverse events from intraoperative radiation.

C-arm Free O-arm Navigated Posterior Atlantoaxial Fixation in Down Syndrome: A Technical Note.

The surgical treatment of pediatric atlantoaxial subluxation (AAS) in Down syndrome (DS) remains technically challenging due to radiation exposure and complications such as vertebral artery injury and nonunion. The established treatment is fixation with a C1 lateral mass screw and C2 pedicle screw (modified Goel technique). However, this technique requires fluoroscopy for C1 screw insertion. To avoid exposing the operating team to radiation we present here a new C-arm free O-arm navigated surgical procedure for pediatric AAS in DS. A 5-year-old male DS patient had neck pain and unsteady gait. Radiograms showed AAS with an atlantodental interval of 10 mm, and irreducible subluxation on extension. CT scan showed Os odontoideum and AAS. MRI demonstrated spinal cord compression between the C1 posterior arch and odontoid process. We performed a C-arm free O-arm navigated modified Goel procedure with postoperative halo-vest immobilization. At oneyear follow-up, good neurological recovery and solid bone fusion were observed. The patient had no complications such as epidural hematoma, infection, or nerve or vessel injury. This novel procedure is a useful and safe technique that protects surgeons and staff from radiation risk.

Preliminary study for developing a navigation system for gastric cancer surgery using artificial intelligence.

PURPOSE: We are attempting to develop a navigation system for safe and effective peripancreatic lymphadenectomy in gastric cancer surgery. As a preliminary study, we examined whether or not the peripancreatic dissection line could be learned by a machine learning model (MLM). METHODS: Among the 41 patients with gastric cancer who underwent radical gastrectomy between April 2019 and January 2020, we selected 6 in whom the pancreatic contour was relatively easy to trace. The pancreatic contour was annotated by a trainer surgeon in 1242 images captured from the video recordings. The MLM was trained using the annotated images from five of the six patients. The pancreatic contour was then segmented by the trained MLM using images from the remaining patient. The same procedure was repeated for all six combinations. RESULTS: The median maximum intersection over union of each image was 0.708, which was higher than the threshold (0.5). However, the pancreatic contour was misidentified in parts where fatty tissue or thin vessels overlaid the pancreas in some cases. CONCLUSION: The contour of the pancreas could be traced relatively well using the trained MLM. Further investigations and training of the system are needed to develop a practical navigation system.

Comparison of Survival Rate and Outcomes Between Conventional and Navigation-Assisted Primary Total Knee Arthroplasty in Severe Varus Knees: A Minimum 10-Year Follow-Up.

BACKGROUND: This study aimed to compare the long-term clinical and radiographic outcomes and survival rates between navigation-assisted (NAV) total knee arthroplasty (TKA) and conventional (CON) TKA in patients with preoperative severe varus deformity. METHODS: From January 2005 to December 2011, 152 TKAs and 62 TKAs with preoperative hip-knee-ankle (HKA) angles more than 15° were enrolled in the CON-TKA and NAV-TKA group with 135.7 months follow-up. Clinical outcomes (Western Ontario and McMaster University Osteoarthritis Index and Knee Society Scores), radiographic outcomes (HKA, α, ß, γ, and δ angles), and survivorship were compared between the groups. RESULTS: The mean value of radiographic outcomes was not statistically different; however, outliers of the HKA angle were significantly higher in the CON-TKA group (18.4% versus 8.1%, P = .04). However, long-term clinical outcomes were similar between both groups. The cumulative survival rate was 96.1% in the CON-TKA group and 96.8% in the NAV-TKA group, with no difference between the groups (P = .962). CONCLUSION: NAV-TKA showed fewer outliers in the HKA angle for severe preoperative varus deformity compared with CON-TKA. The long-term clinical outcomes and survival rates were similar between the 2 techniques. A survival rate of more than 96% was observed in both groups. STUDY DESIGN: Level III, retrospective comparative study.

Thoracoscopic surgery for congenital lung cysts: an attempt to limit pulmonary resection in cases of lesions involving multiple lobes.

PURPOSE: Although we generally perform thoracoscopic lobectomy for congenital lung cysts (CLCs), we recently began performing thoracoscopic-limited pulmonary resection (segmentectomy or small partial lung resection) on relatively small lesions and on lesions involving multiple lobes. Our study aimed to determine the therapeutic outcomes of thoracoscopic CLC surgery. METHODS: We retrospectively reviewed patients aged ≤ 18 years who underwent their first CLC surgery at our facility between 2013 and 2020. RESULTS: A comparison between patients < 4 months old and those ≥ 4 months old showed no significant difference in operating time or incidence of complications. Blood loss volume (mL/kg) was significantly greater in patients < 4 months old and in patients who had undergone semi-urgent or urgent surgery. Operating time and postoperative complications were not increased in semi-urgent or urgent surgeries. There was no significant difference in operating time, blood loss volume, or postoperative complications between patients with a preoperative history of pneumonia and patients with no such history. CONCLUSION: In most patients, thoracoscopic surgery for CLC was safely performed. Limited pulmonary resection is considered difficult to perform thoracoscopically in children, but can be safely performed using new devices and navigation methods. LEVEL OF EVIDENCE: III.

Current Status and Trends of Minimally Invasive Gastrectomy in Korea.

Since its introduction in the early 1990s, laparoscopic gastrectomy has been widely accepted for the treatment of gastric cancer worldwide. In the last decade, the Korean Laparoendoscopic Gastrointestinal Surgery Study group performed important clinical trials and exerted various efforts to enhance the quality of scientific knowledge and surgical techniques in the field of gastric cancer surgery. Laparoscopic gastrectomy has shifted to a new era in Korea due to recent advances and innovations in technology. Here, we discuss the recent updates of laparoscopic gastrectomy-namely, reduced-port, single-incision, robotic, image-guided, and oncometabolic surgery.