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Anastomotic complications occur after 5% to 20% of operations for rectosigmoid colon cancer. The intestinal perfusion status at the anastomotic site is an important modifiable risk factor, and surgeons should carefully evaluate and optimize the perfusion at the intended site of anastomosis. Indocyanine green (ICG) angiography is a simple noninvasive perfusion assessment modality. The use of ICG angiography is rapidly spreading in the field of colorectal surgery. However, there is debate on its contribution to reducing anastomotic complications. In this review, we discuss the clinical utility and the standardization of ICG angiography. ICG angiography can unequivocally reveal unfavorable perfusion zones and provide quantitative parameters to predict the risk of hypoperfusion-related anastomotic complications. Many studies have demonstrated the clinical utility of ICG angiography for reducing anastomotic complications. Recently, two multicenter randomized clinical trials reported that ICG angiography did not significantly reduce the incidence of anastomotic leakage. Most previous studies have been small-scale single-center studies, and there is no standardized ICG angiography protocol to date. Additionally, ICG angiography evaluations have mostly relied on surgeons’ subjective judgment. For these reasons, it is necessary to establish a standardized ICG angiography protocol and develop a quantitative analysis protocol for the objective assessment. In conclusion, ICG angiography could be useful for detecting poorly perfused colorectal segments to prevent anastomotic leakage after colorectal surgery. An optimized and standardized ICG angiography protocol should be established to improve the reliability of perfusion assessments. In the future, artificial intelligence-based quantitative analyses could be used to easily assess colonic perfusion status.

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Although obstructive colon cancer can often be treated with first-stage resection with primary anastomosis, the results of the oncological outcome of using stenting as a bridge of surgery in the literature are still controversial. Stent insertion for obstructed cancer provides an opportunity for bowel preparation and makes preoperative work-up and clinical staging possible. However, although stenting is becoming a more frequent treatment modality, studies with a significant number of patients acting as a bridge between surgery are still lacking. In this issue of Journal of Minimally Invasive Surgery, the study by Kim et al. highlights the efficacy of stent insertion as the initial treatment and analyzed the prognostic factors in symptomatic obstructive colon cancer. The study demonstrated that emergent surgery, vascular invasion, and omitting adjuvant chemotherapy were independent poor prognostic factors in long-term oncologic outcomes suggested that stent insertion should be considered an initial treatment for symptomatic obstructive colon cancer.

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Gallstone disease is the most common global indication for abdominal surgery. Especially acute cholecystitis in the elderly is frequently encountered due to an increasingly elderly population. Although cholecystectomy is the gold standard treatment for acute cholecystitis, the surgical management in the elderly presents specific challenges due to associated comorbidities, the severity of their presenting disease, and a greater likelihood of suffering postoperative complications and prolonged hospital stay. Further effort to provide firm evidence to clarify the safety and feasibility of cholecystectomy for acute cholecystitis in extremely elderly patients such as octogenarians and even nonagenarians.

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Purpose: The prognostic factors in obstructive colon cancer have not been clearly identified. We aimed to identify the prognostic factor to establish optimal treatment strategy in obstructive colon cancer.
Methods: Patients who underwent surgery for primary colon cancer in stages II and III with symptomatic obstruction from 2004 to 2010 in six hospitals were retrospectively collected. Clinicopathological and surgical outcomes were compared between stent insertion and emergent surgery group. Multiple regression analysis and survival curve analysis were used to identify the prognostic factors in symptomatic obstructive colon cancer.
Results: Among 210 patients, 168 patients (80.0%) underwent stent insertion followed by surgery and 42 patients (20.0%) underwent emergent surgery. Laparoscopic approach (55.4% vs. 23.8%, p < 0.001) and adequate lymph node (LN) harvest (≥12) (93.5% vs. 69.0%, p < 0.001) were significantly higher in stent insertion group. In multiple regression analysis, emergent surgery (hazard ratio [HR], 2.153; 95% confidence interval [CI], 1.031–4.495), vascular invasion (HR, 6.257; 95% CI, 2.784–14.061), and omitting adjuvant chemotherapy (HR, 3.107; 95% CI, 1.394–6.925) were independent poor prognostic factors in 5-year overall survival, and N stage (N1: HR, 3.095; 95% CI, 1.316–7.284; N2: HR, 4.156; 95% CI, 1.671–10.333) was the only poor prognostic factor in 5-year disease-free survival.
Conclusion: In symptomatic obstructive colon cancer, emergent surgery, N stage, vascular invasion, and omission of adjuvant chemotherapy were independent poor prognostic factors. Stent insertion is suggested as the initial treatment for symptomatic obstructive colon cancer, and adjuvant chemotherapy is recommended, especially when vascular invasion or LN metastasis is confirmed.

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Purpose: Cholecystectomy is the gold standard treatment for gallbladder disease. As life expectancy increases, awareness of cholecystitis treatment in the elderly changes. The safety and feasibility of cholecystectomy in octogenarians have been proven in many studies. Surgical treatment for cholecystitis should be considered in octogenarians and even nonagenarians. In this study, we aimed to assess the outcomes of cholecystectomy in octogenarians and nonagenarians with acute cholecystitis.
Methods: A total of 393 patients aged 80 to 89 years (352 octogenarians) and 90 to 99 years (41 nonagenarians) diagnosed with acute cholecystitis underwent cholecystectomy between March 2012 and June 2020. All patients were classified according to the Tokyo guidelines. The evaluated parameters included demographic data, surgical outcomes, American Society of Anesthesiologists physical status classification, and Tokyo guidelines.
Results: All 393 patients were analyzed and divided into two groups according to age; octogenarians (83.57 ± 2.64 years) and nonagenarians (92.98 ± 3.15 years). The survival rate was 97.7% for octogenarians and 97.6% for nonagenarians. Laparoscopic surgery was performed more in both groups (96.8% in octogenarians and 92.7% in nonagenarians) than open surgery (3.2% in octogenarians and 7.3% in nonagenarians). The operation time of the nonagenarian group (74.63 ± 30.83 minutes) was shorter than the octogenarian group (75.85 ± 34.63 minutes). The incidences of postoperative complications in the octogenarian and nonagenarian groups were as follows: pneumonia, 5.7% and 7.3%; bleeding, 1.7% and 2.4%; gastrointestinal symptoms, 6.0% and 2.4%; and bile leakage, 0.6% and 2.4%, respectively.
Conclusion: Cholecystectomy is a safe and efficient procedure for the treatment of acute cholecystitis in both octogenarians and nonagenarians.

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Purpose: Single-incision cholecystectomy is a surgical method that offers comparable results to conventional laparoscopic cholecystectomy. However, a high risk of postoperative incisional hernia is an issue in single-incision cholecystectomy. This study evaluated the risk factors and incidences of incisional hernia after single-incision cholecystectomy and the advantage issue of using barbed suture material during wound closures.
Methods: A total of 1,111 patients underwent laparoscopic or robotic single-incision cholecystectomy between March 2014 and February 2020 at our institution at CHA Bundang Medical Center. During this period, there were 693 patients who underwent wound closure with monofilament suture material (Monosyn 2-0; B. Braun) and the other 418 patients used barbed suture material (Stratafix 2-0; Ethicon).
Results: The two patient groups were comparable in age, body mass index, and diagnosis. The total incidence of incisional hernia after single-incision cholecystectomy was 0.5% (five cases). All patients who developed incisional hernia were in the monofilament suture material group (0.7% vs. 0%, p = 0.021). The influence of predictive and possible risk factors on incisional hernia rate was analyzed. Among these factors, only old age was an independent predictive risk factor of incisional hernia.
Conclusion: Our study showed a low incidence of incisional hernia, all of which occurred in the monofilament suture material group. If technically appropriate, single-incision cholecystectomy does not appear to present a high incidence of hernia. Barbed suture material can be safely applied in wound closure showing comparable incisional hernia incidence to monofilament suture material.

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Purpose: Single-port laparoscopic surgery is anticipated to become the future of minimally invasive surgery. We have devised an alternative approach for laparoscopic cholecystectomy by inserting a single port at the umbilicus and using the abdominal wall-lifting method, without establishing pneumoperitoneum.
Methods: Retrospective analysis of 130 patients undergoing laparoscopic cholecystectomy was done to compare the conventional laparoscopic cholecystectomy (CLC) (n = 69) and the novel single-port laparoscopic cholecystectomy (SLC) using the abdominal wall-lifting method (n = 61). The surgical procedures were as follows. A 2- to 3-cm transumbilical incision was made, and a wound retractor was inserted into the abdomen without difficulty. Abdominal distension was obtained using a fan-shaped retractor without the use of carbon dioxide insufflations. A 5-mm flexible scope and modified curved graspers and dissectors were used to give the feeling of triangulation during dissection.
Results: The SLC group consisted of 25 males and 36 females with a mean age of 58.1 ± 7.2 years and a mean body mass index of 23.1 ± 3.2 kg/m². The two groups were comparable for mean age, sex, disease, American Society of Anesthesiologists physical status classification, and comorbidity. Likewise, the duration of operation, postoperative hospital stays, complications, the number of use of analgesics, and conversion rate to open technique were not significantly different in the two groups.
Conclusion: The impaired view in single-port laparoscopic surgery can be improved by using articulating instruments that can be rotated out of the field of view. This novel gasless method is cost-effective and produces minimal postoperative discomfort with no additional scars.

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Purpose: Drain insertion after proctectomy is common in clinical practice, although the effectiveness of drains has been questioned. However, drains are commonly displaced after surgery. We hypothesized that drain displacement is associated with clinical outcomes and aimed to assess differences in clinical outcomes, such as overall morbidity, including anastomotic leakage (AL), reintervention rates, length of hospital stay, and mortality rates, between patients who experienced displaced drains and those who did not.
Methods: Rectal cancer patients who underwent proctectomy at a single institution between January 2015 and December 2020 were retrospectively reviewed. Clinical characteristics were compared between patients who experienced displaced drains and those who did not. The primary endpoint was the occurrence of reintervention in patients with AL. The secondary endpoints were overall morbidity rates, AL rates, length of hospital stay, and mortality within 30 days.
Results: Among 248 patients who underwent proctectomy, 93 (37.5%) experienced displaced drains. A higher proportion of patients who experienced displaced drains required reintervention due to AL than those who did not experience displaced drains (odds ratio, 3.61; 95% confidential interval, 1.20–10.93; p = 0.016). However, no significant difference was found in the overall morbidity rate, mortality, and length of hospital stay between the groups.
Conclusion: Drain displacement does not worsen outcomes such as overall morbidity rate, mortality, and length of hospital stay after proctectomy but is associated with an increase in the need for reintervention in patients with AL.

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Hydatid disease is a zoonosis caused by a parasite, Echinococcus granulosus, characterized by a cystic lesion in the liver, lung, or (rarely) in other parts of the body. Typical radiological findings make the diagnosis easy and help the surgeons to plan the management of hydatid disease. We report a case of giant hepatic hydatid cyst in a 12-year-old boy who presented with epigastric swelling and pain for 6 months. Contrast-enhanced abdominal computed tomography findings were highly suggestive of a giant hydatid cyst in the left lateral segment of the liver. Laparoscopic partial pericystectomy was done. The patient was discharged on the fifth postoperative day. The patient took oral albendazole preoperatively and postoperatively. Laparoscopic management of hepatic hydatid cysts is safe and effective. Laparoscopic approach is recommended with good technique and controlled suction of cyst content. Surgery combined with oral antihelminthics is the mainstay of treatment for hepatic hydatidosis.

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Laparoscopic pancreatoduodenectomy (LPD) in pancreatic cancer is primarily criticized for its technical and oncological safety. Although solid evidence has not yet been established, many institutions are performing LPD for pancreatic cancer patients, with continuous efforts to ensure oncologic safety. In this video, we demonstrated a case of standard LPD combined with vascular resection in pancreatic cancer.