Living surgical reference
The operations on the table, worked end to end: the decision to operate, the exposure, the steps, the instrument in each hand, and what goes wrong, grouped by the service where you meet the case. It grows as the rotation does, so new procedures get added as they come up, and every one closes with a quiz to test yourself against.
Where you'll see it Foundational anatomy for the hepatopancreatobiliary and upper GI cases in this group.
Before either operation makes sense, the blood supply and the ducts have to be clear. Almost every step in both procedures is dictated by these relationships.
The head and uncinate process are fed by the anterior and posterior pancreaticoduodenal arcades. These arcades come partly from the gastroduodenal artery, a branch of the common hepatic artery off the celiac trunk, and partly from the inferior pancreaticoduodenal artery off the superior mesenteric artery. The same arcades feed the duodenum, which is why the head and the duodenum cannot be separated and must come out together. The body and tail, by contrast, are fed by branches of the splenic artery as it runs along the top edge of the gland toward the spleen. Because the supply splits at the neck, the neck is the natural and relatively bloodless place to divide the gland.
The superior mesenteric vein and the splenic vein join behind the neck of the pancreas to form the portal vein. This confluence sits directly under the neck, and the plane in front of it is usually free of branches, which lets the surgeon tunnel under the neck before dividing it. Tumor involvement of this confluence is what often makes a head cancer borderline resectable and may require vein resection and reconstruction.
The main pancreatic duct runs the length of the gland and joins the common bile duct at the ampulla of Vater, emptying into the duodenum. The distal bile duct passes directly through the head of the pancreas, which is the other reason a head resection has to take the bile duct and rebuild it.
Where you'll see it HPB or surgical oncology service, in the OR at a tertiary or academic center, usually after a multidisciplinary tumor board.
A resection of a block of organs followed by a full reconstruction of the gut. It is the longest and most demanding of the pancreatic operations, often 6 to 8 hours or more.
Adenocarcinoma of the head, uncinate, or neck is the classic indication. It is also the operation for other periampullary cancers, meaning ampullary, distal bile duct, and duodenal tumors, as well as some neuroendocrine tumors, an IPMN involving the head, and occasionally a mass forming chronic pancreatitis. Borderline or locally advanced disease is often treated with chemotherapy first, then reassessed for surgery.
The patient is supine in some reverse Trendelenburg. After pneumoperitoneum, ports are spread across the upper abdomen for the camera, three instruments, and a bedside assistant. The surgeon usually does a staging look first to exclude liver or peritoneal spread that imaging missed, because finding spread changes the plan on the spot. The patient cart is then docked, and from that point the table cannot move until the arms are released.
The specimen comes out in a bag. The bile duct, pancreatic neck, and superior mesenteric artery margins are commonly sent for frozen section, and the resection is extended if a margin is positive.
A limb of jejunum is brought up and three connections are made, in this order.
Drains are left near the pancreatic and biliary connections to detect a leak early.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it HPB or surgical oncology service, the same setting as the Whipple.
The mirror image operation, and a fundamentally simpler one because there is no reconstruction. The gland is divided at the neck, everything to the left is removed with the spleen, and the cut end is closed. Often 3 to 5 hours.
Body and tail lesions are the indication: adenocarcinoma, neuroendocrine tumors, mucinous cystic neoplasms, solid pseudopapillary neoplasms, and intraductal papillary mucinous neoplasms.
An intraductal papillary mucinous neoplasm is a mucin producing cystic tumor that grows from the lining of the pancreatic ducts. The crucial idea is that it is a precursor lesion, not necessarily cancer yet, sitting on a spectrum from low grade dysplasia up to invasive carcinoma. It comes in three forms: main duct, branch duct, and mixed. Main duct and mixed types carry the highest risk of harboring or becoming cancer and are generally resected. Branch duct lesions are usually less aggressive at any given size and may be watched, unless they show worrisome features or high risk stigmata such as a large size, a solid nodule, a dilated main duct, or a rising tumor marker. Because the lesion can hide high grade change, the surgeon typically sends the pancreatic transection margin for frozen section and extends the resection if dysplasia or invasive disease reaches the cut edge.
The splenic artery comes off the celiac trunk and runs a tortuous course along the upper border of the body and tail. The splenic vein runs along the back of the gland to join the confluence behind the neck. Controlling these two vessels safely is the heart of the operation. The transection point is the neck, over the same venous confluence as in the Whipple.
The patient is supine, often with reverse Trendelenburg and the left side tilted up so gravity helps expose the tail. Ports are oriented toward the left upper quadrant. A staging look is done, the cart is docked, and intraoperative ultrasound is frequently used to pinpoint the lesion and the duct before dividing the gland.
For cancer the spleen comes out because the nodes track along the splenic vessels. For benign disease the spleen can sometimes be saved, either by preserving the splenic artery and vein, which is the Kimura technique, or by dividing them and relying on the short gastric vessels to perfuse the spleen, which is the Warshaw technique. Neither spleen preserving option is appropriate for cancer.
Losing the spleen raises lifelong risk of overwhelming infection from encapsulated bacteria. Patients need vaccination against pneumococcus, meningococcus, and Haemophilus influenzae type b, ideally about two weeks before an elective operation. Watch also for a high platelet count after surgery and the small risk of portal or splenic vein thrombosis.
Removing the gallbladder is not a standard part of a distal pancreatectomy, so it is worth confirming why it is on the plan. The usual reasons are concurrent gallstones seen on imaging, prophylaxis ahead of certain medications, or other incidental gallbladder pathology.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it HPB or surgical oncology, at centers with a dedicated regional chemotherapy program.
An implanted pump that delivers chemotherapy continuously and directly into the liver, month after month, through a catheter tapped into the artery. It runs on the same blood supply trick as chemoembolization, and it borrows two moves from the operations already in this document: it lives on the gastroduodenal artery, and it requires a cholecystectomy.
Normal liver tissue gets most of its blood from the portal vein, but liver tumors are fed almost entirely by the hepatic artery. So if you infuse the drug into the hepatic artery, you concentrate it on the tumor and largely spare the healthy liver. The pump uses a specific drug, floxuridine, chosen because the liver extracts almost all of it on the first pass through, which means you can run a very high dose locally while very little escapes into the rest of the body. Delivered this way, the drug can reach concentrations in the tumor many times higher than the same drug given through a vein.
The main use is colorectal cancer that has spread to the liver, in three settings: as added therapy after the liver metastases have been resected to lower the chance of recurrence, as conversion therapy to shrink unresectable liver disease enough to become resectable, and as palliative control of liver dominant disease. It is also used for intrahepatic cholangiocarcinoma, a bile duct cancer inside the liver, and it is being studied for liver metastases from pancreatic cancer, which ties it back to the disease running through this document.
The pump is a hockey puck sized device implanted in a pocket under the skin of the abdominal wall, connected to a catheter whose tip sits in the gastroduodenal artery right where it meets the hepatic artery. It delivers drug at a constant flow and is refilled in clinic with a needle through the skin, typically in cycles of a couple of weeks of drug alternating with heparinized saline to keep it open. No part of it needs to be externalized, so the patient lives normally between fills.
It shares the tumor versus healthy liver blood supply logic with chemoembolization, and like that treatment it needs a patent portal vein to keep the liver alive. The difference is delivery: the pump gives a continuous, refillable infusion over months from an implanted device, while chemoembolization is an episodic treatment done through a catheter by interventional radiology. It is increasingly placed robotically rather than open, with a lower rate of converting to an open operation than the laparoscopic version.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Investigational, seen only in a trial setting or a device and HPB research rotation.
A different kind of pancreatic operation. Not a resection at all, but the implant of a small device that drives chemotherapy straight into a tumor that cannot be removed. This is the Continuity Biosciences system, currently in a first in human trial.
Pancreatic tumors are densely fibrotic and poorly vascularized, which chokes off the blood vessels that would carry chemotherapy to the tumor. When gemcitabine is given through a vein, very little of it actually reaches the cancer, while the rest exposes the whole body to toxicity. Roughly 40 percent of patients are inoperable at diagnosis because the tumor has grown into nearby major vessels or nerves. This device is built for exactly that gap.
Iontophoresis uses a mild electric current to push charged drug molecules into tissue. The implant holds a drug reservoir and an electrode against the tumor. When a low voltage current is applied, it drives gemcitabine directly into the tumor tissue rather than relying on blood flow to carry it there. In animal and early models this delivered far more drug into the tumor with very little systemic exposure, and the amount delivered scaled with the current applied.
The current trial enrolls patients with locally advanced, nonmetastatic pancreatic cancer that is not resectable, typically after first line systemic chemotherapy. The hope is to raise the drug concentration inside the tumor enough to shrink it away from the blood vessels and possibly convert it to a resectable tumor, since surgery remains the only path to cure.
This is not a cancer resection and removes no pancreas. It is a delivery device placed in patients who cannot have a Whipple or distal resection, with the goal of downstaging the tumor so that a resection might become possible later.
Primary references: the trial listing at ClinicalTrials.gov NCT07481383, and a plain language overview at CURE.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Endocrine surgery, sometimes minimally invasive surgery or urology, referred from an endocrinology clinic.
A different region entirely, but the same robot and the same minimally invasive logic. The adrenal glands are small, paired, intensely vascular endocrine glands that sit like caps on top of each kidney, deep in the retroperitoneum. The operation removes one gland, or part of one, for a tumor.
For this case the indication is primary hyperaldosteronism: an aldosterone producing adenoma, also called Conn syndrome, which is the most common reason to remove an adrenal gland. The tumor pumps out aldosterone independent of normal control, driving high blood pressure and often a low potassium that medication struggles to control, and taking the gland out can cure or greatly improve the hypertension. A key step beforehand is adrenal venous sampling, which confirms that one gland is the source so the right side is removed. The other functioning tumors are a cortisol producing adenoma causing Cushing syndrome, and a pheochromocytoma, which pours out catecholamines. Beyond the functioning tumors, surgery is offered for nonfunctioning masses that are large or growing, for adrenal metastases in selected patients with limited spread, and for masses that look suspicious for cancer.
As a rough rule, size benign nonfunctioning tumors are removed once they reach about 4 cm or show meaningful growth, since the larger they are the more likely they are to be malignant. Large, locally invasive adrenocortical carcinoma is usually done open rather than robotically.
The danger and the difficulty both come from the venous drainage, and the two sides are not symmetric.
The main decision is front versus back.
The lateral transperitoneal version, which differs by side because the exposure and the vein are different.
This is where adrenal surgery is as much endocrinology as it is dissection.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Breast surgical oncology, an ambulatory OR case with radiology placing the seed beforehand.
The problem here is a lesion the surgeon cannot feel. Screening now finds many breast cancers and precancers while they are still non palpable, so before removing one you have to answer a basic question: how do you find an invisible target and take it out with a clean margin? Radioactive seed localization is one elegant answer, and it runs on the same gamma probe logic as the sentinel node.
A non palpable lesion, a cluster of calcifications or a small mass seen only on mammogram or ultrasound, cannot be found by touch in the operating room. The old solution was wire localization, where a radiologist threads a hooked wire into the lesion with the end sticking out through the skin, done the same morning as surgery. Wires migrate, complicate scheduling, and force the surgeon to dissect along the wire through normal tissue. Seed localization improved on all of that.
A radiologist places a tiny titanium seed, about the size of a grain of rice, containing radioactive iodine 125, into the center of the lesion under ultrasound or mammographic guidance. Because the seed's signal lasts, this can be done days before surgery rather than the same morning. In the operating room the surgeon sweeps a handheld gamma probe over the skin, finds the point of highest count, and uses that to plan the incision and guide the excision straight to the target. A useful detail: the seed emits at a different energy than the technetium tracer used for sentinel node mapping, so if a node biopsy is also needed the probe can tell the two signals apart in the same operation.
It guides breast conserving surgery, a lumpectomy, or an excisional biopsy for a non palpable lesion, and the operation is the same whether the lesion is in the right or the left breast. That lesion may be a biopsy proven cancer, ductal carcinoma in situ, or an indeterminate or high risk finding that needs to come out to be sure. It is also used to mark a tumor before chemotherapy so it can still be found afterward if it shrinks.
Done with the patient supine, the arm out, which also gives access to the axilla if a node biopsy is planned.
This is the same point source and gamma probe idea as the sentinel node in the melanoma section, just aimed at a tumor rather than a lymph node. Several newer localization devices do the same job without radioactivity, using a magnetic seed, a radar reflector, or a radiofrequency tag, which sidestep the radiation handling rules while keeping the wire free advantage.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Breast surgical oncology, frequently alongside plastic surgery for reconstruction.
Two operations that travel together but answer different questions. Where the lumpectomy conserves the breast, a simple mastectomy removes all of it. Alongside it sits a separate decision tree about the lymph nodes in the armpit: whether to sample them, and whether to clear them. This case does both, the breast and the axilla.
A simple, or total, mastectomy removes the entire breast, the breast tissue with the overlying nipple and areola and an ellipse of skin, without taking the chest muscles or the axillary nodes as part of the specimen. That distinguishes it from a modified radical mastectomy, which adds a full axillary dissection, and from the skin sparing and nipple sparing variants that keep the skin envelope for reconstruction. The usual reasons to remove the whole breast rather than conserve it are extensive or multicentric disease, a tumor large relative to the breast, disease not suited to radiation, a strong preference or a risk reducing indication such as a BRCA mutation, or recurrence after a prior lumpectomy. Technically the surgeon makes an elliptical incision, raises skin flaps in the plane between the breast and the fat, lifts the breast off the pectoral fascia, removes it, leaves drains, and closes.
What to do with the nodes is its own question, and the field has moved steadily toward doing less.
The sentinel node mapping is the same technique used in the melanoma section, and the seed that localizes a clipped node is the same technology as the breast lesion seed, just aimed at a node. The steady move toward less nodal surgery mirrors the same story in melanoma, where a positive sentinel node no longer automatically leads to clearing the whole basin.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Colorectal surgery, in the OR.
A robotic resection of the sigmoid colon, the S shaped segment where the descending colon meets the rectum. Same robot as the pancreatic cases, different territory: the left lower abdomen and the pelvic brim, where the work is removing the diseased segment while protecting the ureter and the pelvic nerves, then reconnecting the bowel.
The most common benign reason is recurrent or complicated diverticulitis. It is also done for sigmoid cancer, sigmoid volvulus, large polyps that cannot be removed endoscopically, and rectal prolapse. The disease changes how the blood vessels are handled, which is the main branch point below.
This is the key vascular decision and it follows the diagnosis. For cancer the surgeon takes a high tie, dividing the inferior mesenteric artery at its origin off the aorta with a full lymph node harvest for oncologic clearance. For diverticulitis many surgeons spare the main artery and take only the sigmoid branches, preserving the left colic and superior rectal arteries to protect blood flow to the anastomosis and preserve rectal and nerve function.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Colorectal surgery, at an inflammatory bowel disease or specialized pouch center.
The most involved colorectal operation in this set, and a good one to run on the da Vinci 5. It removes the entire colon and rectum, then rebuilds a way to pass stool by fashioning a reservoir out of the small intestine and joining it to the anus, all protected by a temporary ileostomy. The deep pelvic part is exactly where the robot earns its place.
The two classic indications are ulcerative colitis that has failed medical therapy or developed dysplasia or cancer, and familial adenomatous polyposis, where the colon is otherwise destined to become cancer. It is generally not done for Crohn disease, because pouch complications and outright pouch failure are much higher there. The appeal is that it removes all the disease bearing colon and rectum and yet, unlike a proctocolectomy with a permanent stoma, restores the ability to pass stool the normal way.
In an elective, healthier patient it is often two stages: the first removes the colon and rectum, builds the pouch, makes the pouch to anus join, and adds a protective loop ileostomy; the second, weeks later, closes the ileostomy once a contrast study confirms the pouch is intact. In a sick patient on steroids or with acute severe colitis it becomes three stages: first just remove the colon and bring up an end ileostomy to get them out of danger and off immunosuppression, then later do the rectum, pouch, and IPAA, then finally close the stoma. Staging lets inflammation settle and drugs wash out, which lowers the risk of a leak.
The result is not a normal bowel pattern: most patients settle at several soft bowel movements a day, but they stay continent and avoid a permanent bag. The pelvic dissection is where straight laparoscopy struggles in the narrow pelvis, so the articulating instruments, 3D view, and the da Vinci 5 force feedback help with the nerve sparing work, with lower conversion rates. The pelvic proctectomy shares its plane and nerve concerns with rectal cancer surgery and with the sigmoidectomy earlier in this document.
Technique level, one question at a time. Answer as the surgeon at the console, then pick an option to see whether it holds up.
Where you'll see it Colorectal surgery, usually a short ambulatory anorectal case.
This is almost certainly what the "sphincterectomy" on your list refers to, since removing a sphincter is not a standard operation but cutting one is. It is a small, elegant procedure for a chronic anal fissure. Where the colorectal cases are about removing bowel, this one is about relieving muscle spasm so a stubborn tear can finally heal.
A chronic anal fissure is a longitudinal tear in the lining of the anal canal, most often in the posterior midline, that causes severe pain with defecation and bleeding. It becomes a vicious cycle: the tear triggers spasm of the internal anal sphincter, the high resting pressure chokes off blood flow to that poorly supplied posterior midline, and without blood flow the fissure cannot heal. Relax the muscle and the fissure heals.
The internal anal sphincter is smooth, involuntary muscle, a continuation of the circular muscle of the rectum, and it provides most of the resting tone that holds the anus closed at rest. The external anal sphincter is skeletal, voluntary muscle used to squeeze and hold. The operation cuts only part of the internal sphincter, enough to lower the resting pressure without destroying continence.
Surgery is not first. The initial treatment is medical: fiber and sitz baths, plus agents that relax the sphincter, either topical nitroglycerin or a calcium channel blocker such as diltiazem, or an injection of botulinum toxin. A sphincterotomy is for the fissures that fail all of that.
Healing rates are high, above ninety percent.
It is a myotomy, a controlled cut in a muscle to relieve spasm, the same principle behind operations like the Heller myotomy for a tight esophageal sphincter. And it is the mirror image of the resection cases in this document: nothing is removed, the therapeutic act is a single measured cut.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Colorectal surgery, an ambulatory anorectal case.
An operation for an anal fistula, an abnormal tunnel running from inside the anal canal out to the skin near the anus. The two parts are two different tools for the same problem: the fistulotomy lays a tract open, and the seton is a loop threaded through it. The governing tension is the same one from the sphincterotomy next door, curing the tract without cutting so much sphincter that continence suffers.
Most fistulas begin as a blocked anal gland that forms a perianal abscess. When that abscess drains, the tunnel it leaves behind becomes the fistula. It has an internal opening, usually at a crypt at the dentate line, an external opening out on the skin, and a tract between them that often runs through part of the sphincter muscle.
To cure the fistula you have to deal with the tract, but the tract passes through the sphincter, and cutting too much muscle causes incontinence. So how much sphincter the tract crosses decides what is safe to do. A low fistula that crosses little muscle can be cured simply, while a high one that crosses a lot cannot be laid open without risking control.
For a fistula that is partly low and partly high, the surgeon can lay open the low part and place a seton around the deeper part that crosses more muscle, either to drain it or to cut through it slowly. In many complex cases the seton is stage one, controlling the problem and letting inflammation settle, with a definitive sphincter sparing repair such as a LIFT procedure or an advancement flap done later.
This shares the continence versus cure balance with the sphincterotomy, and setons plus staged sphincter sparing repairs are how higher fistulas are handled without one big muscle cut. A fistula caused by Crohn disease is treated more conservatively, usually with a draining seton and medical therapy rather than laying it open.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Surgical oncology, often with plastic surgery, out of a melanoma or cutaneous oncology clinic.
The one open operation here, and a combined surgical oncology and reconstructive effort. It bundles three linked jobs into a single trip to the operating room: remove the cancer with a safe margin, sample the first draining lymph node to stage it, and rebuild the defect that excision leaves behind.
After a melanoma is diagnosed on biopsy, the scar and the surrounding skin are removed again with a measured margin of normal tissue, taken down through the fat to but not including the deep fascia. The margin is set by how deep the original melanoma went, the Breslow thickness, and it is measured clinically at the time of surgery rather than by the pathologist afterward.
On an arm or leg the excision is drawn as an ellipse along the long axis of the limb, which makes it possible to close the wound and follows the direction of lymphatic drainage.
Melanoma tends to spread first through the lymphatics, so the sentinel node, the first node a tumor would drain into, is sampled to look for hidden spread. This is for staging and prognosis and to guide whether the patient needs additional drug therapy, not a treatment in itself. It is offered for melanomas thicker than about 0.8 to 1 mm, or thinner ones with high risk features such as ulceration or a high mitotic rate, and it is skipped for very thin lesions without those features, where the chance of a positive node is under 5 percent.
Taking out all the remaining nodes, a completion dissection, is no longer routine. Trials showed it improves control within the nodal basin but does not improve melanoma specific survival compared with watching the basin closely by ultrasound. So a positive sentinel node now usually leads to surveillance plus modern drug therapy rather than a big dissection.
A wide excision often leaves a defect too large or in too awkward a spot, the face, scalp, or over a joint, to simply stitch edge to edge. Adjacent tissue transfer rearranges nearby skin and the fat beneath it as a local flap, sliding, rotating, or transposing it into the defect. The advantage over a skin graft is that the hole is filled with neighboring tissue that matches in color, thickness, and texture and keeps better contour and function. Smaller defects are closed directly, and when there is not enough nearby tissue a skin graft is used instead.
This one is usually a separate, later operation rather than part of the cancer surgery, done for established lymphedema, the chronic limb swelling that can follow a full node dissection or radiation. It is a microsurgical free transfer: a small packet of healthy lymph node bearing tissue is harvested on its own artery and vein, moved to the affected limb, and the vessels are reconnected under the microscope. Over the following months the transferred nodes re-establish drainage by sprouting new lymphatic channels and by acting as a pump and a sponge for the stagnant fluid.
Donor sites include the groin, the lateral chest, above the collarbone, under the chin, and the omentum inside the abdomen, the last of which can be taken laparoscopically. Reverse lymphatic mapping is used at the donor site to identify and spare the nodes that drain the nearby limb, so the operation does not simply move the lymphedema from one place to another. It is sometimes paired with a lymphovenous anastomosis for earlier disease, or combined with a DIEP flap when breast reconstruction is also planned, and it usually runs about 4 to 6 hours. After a sentinel node biopsy alone the lymphedema risk is low, so this is far more relevant after a completion dissection.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it General surgery, dermatology, or surgical oncology, frequently in an outpatient or minor procedure room.
The workhorse skin cancer operation, and the general case behind the melanoma section. Most malignant lesions on the trunk or arm are non-melanoma skin cancers, a basal cell or a squamous cell carcinoma, and they are treated by cutting the lesion out with a margin of normal skin and closing the defect. It is simpler than the melanoma operation, with no sentinel node in the routine case, but the logic is the same: clear the tumor, then reconstruct.
The margin of normal skin taken around the lesion depends on the tumor type and its risk features. For a small, well-defined basal cell carcinoma, roughly 4 mm clears it in about 95 percent of cases, with wider margins for large, aggressive, infiltrative, or recurrent tumors. For squamous cell carcinoma the margin is a little larger, around 4 to 6 mm, and wider still for high risk lesions. The deep margin goes down through the subcutaneous fat. Melanoma margins are much wider and set by the tumor's thickness, which is why it lives in its own section.
The excision is planned as a fusiform, or elliptical, shape, a spindle with about a three to one length to width ratio and narrow tip angles, so the defect closes as a clean straight line without puckering at the ends, the so-called dog-ears. The ellipse is oriented along the relaxed skin tension lines, and on a limb often along its long axis. Most trunk and arm defects then close directly in layers, with the edges undermined for a tension free result; larger ones need a local flap, the adjacent tissue transfer seen in the melanoma section, or a skin graft. The specimen is oriented with a marking suture and sent for pathology, so that if a margin comes back involved it can be re-excised in exactly the right spot. Mohs micrographic surgery, which checks the full margin during the operation, is reserved mainly for high risk or cosmetically sensitive sites, usually on the face rather than the trunk or arm.
Usually under local anesthesia, with the patient positioned to expose the lesion.
This is the general skin cancer excision; the melanoma section is the more aggressive special case, with wider margins and sentinel node mapping. The reconstruction toolkit is the same, primary closure, a local flap, or a graft. And for a squamous cell carcinoma with high risk features the surgeon also checks the draining nodes, echoing the nodal logic of the melanoma case.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Where you'll see it Surgical oncology, at a dedicated peritoneal surface malignancy program.
The most extreme oncology operation in this set, and really two operations back to back. First, cytoreductive surgery to physically remove every visible speck of cancer from the lining of the abdomen. Then, immediately, the abdominal cavity is bathed in heated chemotherapy to kill what the eye cannot see. It shares the regional, high-dose delivery logic of the infusion pump and the iontophoresis implant, applied here to the entire peritoneal surface.
Peritoneal carcinomatosis is cancer that has seeded the peritoneum, the lining of the abdomen and its organs, rather than spreading to distant sites. It was long considered unresectable and treated only palliatively, partly because the peritoneum acts as a barrier that keeps intravenous chemotherapy from reaching these surface deposits well. Cytoreductive surgery with HIPEC turns a carefully selected subset of these cases into potentially curable ones.
The best established indications are appendiceal cancer, especially pseudomyxoma peritonei, the mucinous spread that has the best prognosis, and peritoneal mesothelioma of the epithelioid type. It is used selectively for colorectal cancer with peritoneal metastases and, in chosen cases, ovarian and gastric cancer. Patient selection is everything: a good performance status, disease confined to the peritoneum, and disease that can actually be removed completely.
Inflow and outflow catheters and temperature probes are placed in the abdomen and connected to a circuit with a pump and a heat exchanger. The chemotherapy perfusate is heated to about 42 degrees and circulated for roughly 30 to 120 minutes, usually around 90. There are two techniques: the open or coliseum method, where the skin edges are suspended on a retractor and the surgeon manually agitates the abdomen to distribute the fluid, and the closed method, where the abdomen is temporarily shut and the solution circulated inside. The drug is chosen by disease, mitomycin C for appendiceal and colorectal, oxaliplatin for colorectal, and cisplatin with or without doxorubicin for mesothelioma, ovarian, and gastric. The heat matters because it enhances the drug's penetration and its killing power and is itself toxic to cancer cells, and the intraperitoneal route matters because it delivers a very high local dose with limited absorption into the bloodstream, so the surfaces get a big dose with fewer whole-body side effects.
This is the same regional, high-dose delivery idea as the hepatic artery infusion pump and the iontophoresis implant, put the drug where the disease is and spare the rest of the body, applied to the whole peritoneal surface. It is also the surgical answer to peritoneal spread from the gastrointestinal cancers elsewhere in this document, the appendix and the colon. It is mostly an open operation, though minimally invasive cytoreduction and laparoscopic HIPEC are used in selected cases.
Technique level, one question at a time, from the preoperative decision to the instrument in your hand at each step. Pick an option to see whether it holds up.
Both operations run on the same machine. It is a teleoperation system: your hands never touch the patient, the instruments have no intelligence of their own, and every motion is a relay from hand to tip with a 3D image coming back.
Operative and explanatory video only, grouped by operation. Start with the first item in each group.
Robotic Whipple
The best single resource. A narrated operative video walking the standardized steps, from the group that pioneered the procedure.
An operative video supplement with the key steps and tips laid out clearly.
A talk focused on pitfalls and how to make the case run smoothly.
Short and high level, showing the surgeon at the console driving the arms.
Robotic distal pancreatectomy and splenectomy
A full operative video of the splenectomy version, the closest match to this kind of case.
Operative video with annotated steps: port placement, vein identification, and pancreatic transection.
A useful contrast. The same left sided operation when the spleen is kept rather than removed, which makes the splenectomy steps clearer by comparison.
Hepatic artery infusion pump
A full length, narrated case that walks the whole placement, arterial dissection, cholecystectomy, cannulation, and the dye perfusion check. The best watch for the operation itself.
The robotic version of the operation, with port placement and the procedural steps on the console.
A short surgeon explainer of what the pump is, how treatment works, and why it helps. Good for the concept before the operative videos.
Robotic adrenalectomy
The best single resource. One video covers a left aldosteronoma, a large right tumor pressing on the cava, partial adrenalectomy, and the use of intraoperative ultrasound.
Good for the pheochromocytoma specific nuances, including gentle handling and early vein control.
A clean left sided transperitoneal walkthrough of the exposure and dissection.
Shows the posterior retroperitoneal approach step by step, the alternative to going through the abdomen.
Breast seed localization
A full length, narrated left breast case using seed localization, with the probe technique, shave margins, cavity marking, and specimen handling shown. The closest match to this kind of case.
A freely viewable preview of the same case if the full article is behind access.
Mastectomy and axillary surgery
A short narrated video of the sentinel node mapping and biopsy, the nodal staging step in this case.
A step by step demonstration of the mastectomy itself, from incision and flap raising through closure and drains.
A short explainer of how the mastectomy types differ, useful for the concept and for talking with patients.
Robotic sigmoidectomy
A full case for diverticulitis, showing the medial to lateral dissection, ureter identification, vessel control, and the stapled anastomosis. The closest match to this kind of case.
Focuses on the intracorporeal anastomosis technique, useful for seeing how the bowel is rejoined inside the body.
Proctocolectomy and ileal pouch
The full robotic operation, colectomy through pelvic dissection, pouch construction, and the anastomosis. The closest match to this kind of case.
A clear patient facing explainer of the staging, the pouch, and the side effects, useful for the concept before the operative video.
Lateral internal sphincterotomy
Shows the approach, finding the intersphincteric groove, and the measured division of the internal sphincter under local anesthesia.
Fistulotomy and seton
A clear academic animation and narration of the anatomy, the tract, and how a seton is placed. The best starting point.
A focused explanation of the two seton types and when each is used, which is the key concept in this operation.
Melanoma excision and sentinel node
A full length, narrated case that walks the wide excision and the sentinel node mapping and biopsy together, with the rationale explained. The closest match to this kind of case.
Two short animations covering the lymphatic system and exactly what the mapping and biopsy involve. Good for the concept before the operative video.
Shows how a lymph node flap is harvested and where from, which makes the lymph node transfer concept concrete.
Skin cancer excision
A canonical narrated demonstration of the fusiform excision, from margin marking and orientation through the layered closure. The best single watch for the technique.
Cytoreduction and HIPEC
A clear walk through the concept, the two-part treatment and why heated chemotherapy is used, before the operative footage.
Shows the operation and the perfusion setup, with the surgical team explaining each stage.
The pioneer of the technique demonstrating the five peritonectomy procedures of a complete cytoreduction in detail.
The platform
Embedded video of the console, the arms, and the instruments in motion.