A long journey with minimally invasive surgery

Abstract

Minimally invasive surgery (MIS) has transformed surgical oncology practice over the past four decades. This narrative reflects on Korea’s pioneering role in MIS, particularly in colorectal surgery, chronicling its evolution from early laparoscopic cholecystectomy to advanced robotic procedures. Through personal experience, institutional milestones, and landmark clinical trials—including the COREAN trial—this Presidential Lecture at KSERS 2025 reviews the challenges, milestones, and future direction of MIS. It underscores the need for evidence-based surgical innovation and sustained commitment to clinical trials.

INTRODUCTION

Since the mid-1980s, minimally invasive surgery (MIS) has revolutionized surgical disciplines globally. Korea’s trajectory, while uniquely shaped by its own pioneers, mirrors and occasionally anticipates international advances. This article offers a retrospective of a surgeon’s 35-year journey with MIS—from the earliest laparoscopic procedures to cutting-edge robotic techniques. It also marks the historical role of the Korean Society of Endo-Laparoscopic & Robotic Surgery (KSERS) as a crucible for innovation, training, and evidence-based surgical standards.

THE BEGINNING OF MINIMALLY INVASIVE SURGERY: GLOBAL AND KOREAN MILESTONES

Laparoscopic surgery began with Erich Mühe’s laparoscopic cholecystectomy in 1985 and progressed rapidly with Jacques Mouret’s laparoscopic colectomy in 1988, Moisés Jacobs’ laparoscopic right hemicolectomy and Dennis Fowler’s laparoscopic anterior resection in 1990. In Korea, the first laparoscopic cholecystectomy was performed by Professor Sang Jhoon Kim at Chung-Ang University on September 8, 1990, followed very shortly, 19 days later by Professor Sung-Gyu Lee at Ulsan University [1,2].

By March 1992, Korea had entered the era of laparoscopic colorectal surgery, led by Professor Jae-Gahb Park at Seoul National University with a segmental sigmoid colectomy for sigmoid villous adenoma (Fig. 1). Subsequent cases at National Medical Center and Korea University further established MIS as a viable modality, including for colorectal cancer [3–5]. As in many other surgical fields, the adoption of MIS in colorectal surgery gradually expanded over the following years. This steady integration of minimally invasive techniques into clinical practice laid the foundation for the creation of a dedicated academic society, such as KSERS.

Fig. 1.

A news article reporting the first domestic case of a successful colectomy performed via laparoscopic surgery at Seoul National University Hospital. The article highlights the procedure’s minimal invasiveness without major complications.

EARLY EXPERIENCE AS A SURGICAL ENDOSCOPIST

KSERS was founded in 1996, with its inaugural meeting at the Hilton Hotel in Seoul. I have long believed that surgical endoscopists possess unique advantages in the field of gastrointestinal endoscopy. Our deep anatomical knowledge and extensive experience in the operating room provide us with superior spatial awareness and procedural confidence—particularly when navigating complex lesions or performing therapeutic interventions. These attributes not only enhance the safety and efficacy of procedures but also contribute to more intuitive decision-making during endoscopic treatment.

It was with this perspective that I began formal training in colonoscopy in the mid-1990s. This journey eventually led to the development of dedicated surgical endoscopy units, including the Gastrointestinal Endoscopy Center at the National Cancer Center (NCC) and, later, the Integrated Gastrointestinal Endoscopy Center at Seoul National University Hospital. Establishing these units was not without its challenges. We encountered significant institutional and logistical barriers in differentiating surgical endoscopy from gastroenterology-led services. Nevertheless, we succeeded in building platforms where surgeons could receive structured endoscopic training.

One such milestone was the founding of the Colonoscopy Academy of NCC (CAN) in 2003, which formalized the role of surgical endoscopy in clinical education and research. It became a steppingstone for the next generation of surgical trainees to receive comprehensive endoscopic instruction. Looking back, I believe these early efforts helped secure a firm place for surgeon-endoscopists in Korea’s evolving MIS landscape.

TRANSITION TO LAPAROSCOPIC COLORECTAL SURGERY

I was luckily engaged as 18 inaugural surgeons who established the Korean Laparoscopic Colorectal Surgery Study Group on November 24, 2000. My first laparoscopic colorectal surgery was conducted on June 22, 2001—an arduous 680-minute procedure for a large sigmoid adenoma. Although technically demanding, these early experiences served as a critical foundation. As I became more familiar with the technique, operative times gradually decreased, and my confidence in performing laparoscopic resections steadily grew.

Between April 2001 and April 2025, I performed approximately 4,830 colorectal resections. Of these, 2,850 cases (59.0%) were completed using a laparoscopic approach. In the most recent 8-year period, MIS became the predominant method; of around 740 cases performed during this time, over 90% were carried out via MIS—specifically, 89.3% laparoscopic and 4.9% robotic resections. The overall conversion rate remained under 2%, underscoring the maturity and consistency of the MIS platform in clinical practice.

INNOVATIONS: SINGLE-INCISION LAPAROSCOPIC SURGERY, NEEDLESCOPIC AND TRANSANAL MINIMALLY INVASIVE SURGERY

The journey into advanced modalities included single-incision laparoscopic surgery (SILS), published in Endoscopy in 2011 [6] and Journal of Laparoendoscopic & Advanced Surgical Techniques. Part B, Videoscopy in 2011 [7], as well as needlescopic surgery using 3-mm trocars and instruments [8]. These approaches are primarily aimed to minimize surgical trauma by reducing the number and size of incisions, ultimately seeking to decrease postoperative pain while maintaining surgical and oncologic safety (Fig. 2A–C). My team also explored transanal approaches: transanal endoscopic microsurgery (TEM), published in Surgical Endoscopy in 2009 [9], and transanal total mesorectal excision (TaTME), published in Surgical Endoscopy in 2016 [10] (Fig. 2D).

Fig. 2.

Evolution of minimally invasive surgical approaches for colorectal procedures. (A, B) Picture of single-incision laparoscopic surgery and postoperative skin incision. (C) Needlescopic surgery instruments, 3-mm trocar. (D) Picture for transanal total mesorectal excision

ROBOTIC SURGERY: EARLY SKEPTICISM AND INTEGRATION

Initially, I was skeptical of robotic surgery’s utility in colorectal procedures, especially concerning the much higher cost and technical difficulty of pelvic dissection compared to laparoscopic surgery. However, experience transformed this view. In January 2014, I performed my first robotic low anterior resection with the Da Vinci SI (Intuitive Surgical, Inc.). By 2025, I had completed 49 robotic colorectal surgeries, including low anterior resections, abdominoperineal resections, and right hemicolectomies using various platforms (Xi, SP, Si).

COREAN TRIAL: LANDMARK IN GLOBAL RECTAL CANCER SURGERY

As the principal investigator (PI), I led the COREAN (Comparison of Open versus laparoscopic surgery for mid or low REctal cancer After Neoadjuvant chemoradiotherapy) trial, the first randomized controlled trial (RCT) comparing open versus laparoscopic surgery for advanced rectal cancer following neoadjuvant chemoradiotherapy. The trial initially demonstrated comparable short-term oncologic outcomes and quality of life, with added benefits favoring the laparoscopic group (The Lancet Oncology, 2010) [11]. Subsequent midterm results confirmed the safety and effectiveness of laparoscopic surgery when performed by experienced surgeons (The Lancet Oncology, 2014) [12]. Finally, a 10-year follow-up further validated these findings, showing no difference in long-term oncologic outcomes between the two groups (The Lancet Gastroenterology & Hepatology, 2021) [13]. Unlike earlier Western trials such as CLASICC or COLOR II—which either focused primarily on colon cancer or raised concerns about positive circumferential resection margin and conversion rates in rectal cancer—the COREAN trial provided a focused evaluation exclusively in clinical stage II to III mid-to-low rectal cancer patients [14,15]. All participants received standardized neoadjuvant chemoradiotherapy, and only high-volume laparoscopic surgeons with experience in over 50 laparoscopic TME procedures were enrolled to ensure surgical consistency. The trial was conducted across 12 Korean institutions, highlighting not only the technical feasibility but also the oncologic safety of laparoscopic TME following chemoradiotherapy. Collectively, these results provided robust evidence that laparoscopic surgery is not inferior to open surgery in terms of safety and oncologic outcomes, supporting its use as a standard approach in the general population of rectal cancer patients. The COREAN trial thus helped dispel early skepticism regarding laparoscopic TME in rectal cancer and established Korea’s leadership in advancing high-quality minimally invasive colorectal surgery on the global stage.

ONGOING TRIALS AND THE FUTURE

Currently, we lead the TV-LARK trial (Total neoadjuvant therapy with short-course radiotherapy Versus Long-course neoadjuvant chemoradiotherapy in locally Advanced Rectal cancer, Korean trial) as the PI, a Phase II multicenter RCT comparing conventional neoadjuvant chemoradiotherapy with total neoadjuvant therapy (TNT) in rectal cancer. Traditionally, the gold standard for treating locally advanced rectal cancer (LARC) has been long-course radiotherapy with chemotherapy after surgery. However, distant metastasis remains a major challenge, and compliance with postoperative chemotherapy can be suboptimal. TNT, which delivers chemotherapy and radiotherapy before surgery, has emerged as a promising strategy to treat occult micrometastases earlier, improve the pathologic complete response rate, and expand opportunities for organ preservation [16]. The TV-LARK trial is designed to determine whether short-course radiotherapy followed by chemotherapy can provide superior outcomes compared to the standard long-course chemoradiotherapy. The findings are expected to help establish an optimal TNT strategy for LARC. As of March 2025, 83% of the 348-patient target has been enrolled. The protocol of our trial was published on BMC Cancer in 2023 [16].

In addition to the TV-LARK study, we are also conducting research on applying the Enhanced Recovery After Surgery (ERAS) protocols following MIS called ‘REQUIS (Beyond ERAS Program Combined Risk-stratified ERAS and QPS [QUality Improvement and Patient Safety] for Colorectal Cancer Patients) trial, as the main PI. ERAS protocols aim to promote early recovery, shorten hospital stay, and improve perioperative outcomes. In Korea, the implementation of a certified ERAS program offers an opportunity to rigorously evaluate its real-world impact on recovery after minimally invasive colorectal cancer surgery. The REQUIS trial integrates a prospective registry with a randomized controlled component, applying risk-stratified ERAS pathways and embedding QPS measures to optimize perioperative care and ensure high-quality, patient-centered outcomes.

These ongoing works reflect my belief that MIS must be grounded in rigorous clinical validation.

CONCLUSION

Over 35 years, I have been privileged to participate in the evolution of MIS across nearly every modality—laparoscopic, endoscopic, NOTES, SILS, TEM, TaTME, and robotics. As we move forward, our duty is to uphold evidence-based surgical standards. The future of MIS lies not just in technological adoption, but in our commitment to training, clinical research, and patient-centered care. Surgeons must remain actively involved in developing, testing, and disseminating innovations through clinical trials. The next generation of MIS depends on our resolve to lead with science and compassion.