Minimally invasive surgery in the elderly population in Korea: temporal trends across major abdominal surgeries

Abstract

Korea’s rapid transition toward a super-aged society has markedly increased the demand for major abdominal surgery in older adults. Although minimally invasive surgery (MIS) provides perioperative advantages, including reduced surgical trauma, lower blood loss, and accelerated postoperative recovery, it also introduces pathophysiological challenges that require preoperative evaluation and risk stratification. This presidential lecture summarizes trends in geriatric surgery in Korea, highlights perioperative considerations for elderly patients undergoing MIS, and presents longitudinal outcomes from Severance Hospital. Surgical trends and perioperative outcomes were evaluated for major abdominal procedures, including gastrectomy, colectomy, major hepatectomy, and pancreatoduodenectomy (PD), in patients aged ≥70 years. Analyses demonstrated a progressive transition from open surgery toward minimally invasive approaches. Laparoscopic and robotic techniques have become the predominant approaches for gastrectomy and colectomy, including in octogenarians, while MIS adoption for complex procedures, such as major hepatectomy and PD, has also expanded substantially. Comparative analyses within this elderly cohort demonstrated that MIS was associated with superior perioperative outcomes compared with open surgery, including significantly reduced estimated blood loss, shorter hospitalization, and lower rates of clinically significant complications, such as postoperative pancreatic fistula, without compromising procedural safety. Advances in surgical technology and accumulated institutional expertise have established MIS as a feasible, standardized approach for major abdominal surgery in older adults. Integrating comprehensive preoperative assessment, particularly frailty screening, with the selective application of MIS may represent the optimal strategy for reducing operative risk and promoting postoperative functional recovery in geriatric surgical care.

INTRODUCTION

Population aging is fundamentally reshaping the global surgical landscape. As life expectancy increases and the proportion of older adults continues to rise, the demand for major abdominal surgery in this population has expanded substantially. This demographic transition is particularly pronounced in Korea, where population aging is occurring at a markedly faster rate than in most developed countries (Fig. 1) [1,2]. The proportion of the Korean population aged ≥65 years increased from 11.0% in 2010 and is projected to reach 38.2% by 2050, representing one of the most accelerated transitions toward a super-aged society worldwide [2].

Fig. 1.

Projected trends in the elderly population ratio in Korea compared with Japan, France, and the United States. Korea is expected to experience one of the most rapid demographics aging transitions, reaching super-aged society status (>20%) earlier than many countries. Data represent the projected proportion of the population aged 65 years or older. The figure was adapted from official population projection data sources [1,2].

This demographic transformation has generated an increasingly significant socioeconomic and healthcare burden. As of 2024, healthcare expenditures for older adults accounted for nearly 45% of total national medical spending, while the average monthly medical expenditure per geriatric patient reached approximately US$415, nearly threefold higher than that of the general population [3]. With progressive increases in healthcare utilization and life expectancy, surgical interventions in older adults are becoming increasingly prevalent, positioning geriatric surgical care as a major clinical and public health priority.

Older adults undergoing surgery require specialized perioperative consideration because chronological age alone inadequately reflects operative risk. Reduced physiological reserve, frailty, multimorbidity, polypharmacy, and increased susceptibility to postoperative functional decline collectively influence perioperative outcomes. To reduce surgical trauma and facilitate postoperative recovery, minimally invasive surgery (MIS) has been increasingly incorporated into geriatric surgical practice. Nevertheless, MIS also introduces distinct physiological stressors. The hemodynamic and respiratory consequences associated with prolonged carbon dioxide pneumoperitoneum, steep operative positioning, and extended operative duration may impose substantial physiological strain on older adults with diminished compensatory capacity.

Therefore, I would like to share my clinical experience at Severance Hospital and review surgical trends for the elderly in Korea, as well as perioperative considerations for MIS in elderly patients (Fig. 2).

Fig. 2.

The 22nd president of the Korean Society of Endo-Laparoscopic & Robotic Surgery, Professor Kyung Sik Kim.

MAIN DISCUSSION

Definition of old age

Old age is traditionally defined using chronological thresholds, with 65 years commonly used to classify older adults in clinical research, healthcare systems, and public policy. However, this definition is largely derived from demographic convention and social policy rather than from a uniform biological transition. In modern surgical practice, chronological age alone provides limited insight into operative risk because the physiological manifestations of aging vary considerably among individuals. A more clinically meaningful framework incorporates biological and functional age, including frailty status, comorbidity burden, cognitive function, nutritional status, sarcopenia, mobility, and activities of daily living. These domains more accurately reflect physiological reserve and vulnerability to surgical stress than chronological age alone [4]. This distinction is especially relevant in geriatric abdominal surgery, in which patients of identical chronological age may differ substantially in their ability to tolerate major resection, pneumoperitoneum, postoperative rehabilitation, and recovery of baseline functional status. Consequently, surgical decision-making in older adults should extend beyond chronological age thresholds and incorporate multidimensional assessment of biological and functional capacity to optimize patient selection, perioperative management, and risk stratification.

Physiologic changes in the aging process

This individualized approach is necessary because aging is associated with progressive alterations across multiple organ systems, including declines in cardiopulmonary reserve, musculoskeletal strength, bone mass, and metabolic function.

With increasing age, several variables progressively decline [5]. These include basal metabolic rate, maximal heart rate, resting cardiac output, muscle strength, bone mineral mass, maximal cardiac output, vital capacity, and maximal oxygen consumption (VO₂ max). Among these, VO₂ max and vital capacity show relatively steep decreases, indicating a marked reduction in aerobic capacity and respiratory function with aging.

In contrast, some parameters increase with age. Heart weight, diastolic blood pressure, body weight, and heart volume tend to rise, particularly after middle age. Blood volume, however, shows a slight decline in later life. Overall, the figure demonstrates that aging is associated with reduced cardiopulmonary reserve, decreased musculoskeletal function, and compensatory or structural cardiovascular changes.

Measures of cardiopulmonary performance, including maximal oxygen consumption, vital capacity, and maximal cardiac output, demonstrate some of the most pronounced age-related reductions, approaching approximately 50% of baseline values by 80 years of age. Additional physiological parameters, including muscle strength, bone mineral mass, maximal heart rate, resting cardiac output, and basal metabolic rate, also decline progressively with advancing age.

In contrast, selected structural and hemodynamic parameters may increase or fluctuate over time. Heart weight and cardiac volume tend to increase modestly with aging, whereas diastolic blood pressure and total body weight may rise during middle age before stabilizing or declining later in life. Blood volume generally remains stable until midlife, followed by a gradual reduction in older age.

These physiological alterations carry important implications for geriatric surgical care. Reduced cardiopulmonary and musculoskeletal reserve limits the capacity of older adults to tolerate anesthesia, blood loss, postoperative immobility, systemic inflammatory responses, and major operative stress. In abdominal MIS, pneumoperitoneum and operative positioning may further compromise venous return, cardiac output, pulmonary compliance, and gas exchange. Accordingly, age-related physiological decline should be carefully incorporated into preoperative risk assessment, intraoperative management, and postoperative recovery planning in elderly surgical patients.

Current trends in major abdominal surgery in Korea

Driven by rapid demographic aging and the physiological complexities associated with older surgical populations, the demand for surgical care in Korea has increased substantially. National analyses comparing surgical volumes between 2004 and 2014 demonstrated a marked rise in operative procedures among older adults [6]. Although the absolute number of operations remained greatest among patients in their 60s and 70s, the relative rate of increase was most pronounced in the oldest age groups. During this period, the number of surgical procedures performed on patients in their 70s increased approximately 2.5-fold, from 168,000 to 429,300. Procedures performed in patients in their 80s increased more than threefold, from 47,400 to 148,200, whereas procedures among individuals aged ≥90 years increased more than fourfold, from 3,400 to 14,200 (Fig. 3).

Fig. 3.

Rapidly increasing number of elderly surgical patients in Korea. Data were redrawn from the table presented in the Korea Economic Daily article by Lee and Cho [6]. The original data were based on National Health Insurance Service statistics.

According to the 2024 Major Surgery Statistical Yearbook published by the National Health Insurance Service (NHIS) [7], approximately 682,000 major surgical procedures were performed in patients aged ≥65 years. Cataract surgery accounted for the largest proportion of procedures, representing 62.3% of the total surgical volume. Spinal surgery and joint replacement comprised 15.0% and 11.4% of procedures, respectively. Among general and oncologic operations, cholecystectomy accounted for 6.6% of procedures, whereas major cancer surgeries represented 4.7%. Collectively, these findings indicate that surgical care in older adults is driven predominantly by age-related conditions, while major abdominal and oncologic procedures continue to represent a substantial component of the overall surgical burden.

Fig. 4 summarizes national trends in selected major abdominal procedures based on the 2024 NHIS statistical yearbook. Patients aged ≥65 years accounted for more than half of all gastrectomies, colectomies, and hepatectomies, representing 56.4%, 53.9%, and 52.1% of cases, respectively. In contrast, older adults accounted for 35.4% of cholecystectomies, despite cholecystectomy representing the highest absolute procedural volume among the abdominal surgeries analyzed. Among patients aged ≥65 years, 92.4% of cholecystectomies were performed laparoscopically.

Fig. 4.

Current practice of major abdominal surgery in Korea. (A) Gastrectomy, (B) colectomy, (C) hepatectomy, and (D) cholecystectomy. The figure was generated by the author using data for patients aged 65 years or older extracted and summarized from the 2024 Major Surgery Statistical Yearbook published by the National Health Insurance Service (NHIS) [7].

Across all analyzed procedures, surgical volume progressively declined with advancing age beyond 65 years. Nevertheless, important procedure-specific and sex-specific patterns were observed. Gastrectomy and hepatectomy demonstrated persistent male predominance across elderly age groups. In colectomy and cholecystectomy, male predominance was evident in younger elderly cohorts, although the sex disparity progressively narrowed with increasing age. Among patients aged ≥85 years, the number of colectomies and cholecystectomies performed in women exceeded those performed in men. These findings underscore the substantial and heterogeneous nature of major abdominal surgery in older adults and highlight the importance of age-, sex-, and procedure-specific approaches to perioperative evaluation and risk stratification.

Safety of minimally invasive surgery in the elderly

To address the increasing surgical burden in this vulnerable population, MIS has emerged as a central component of contemporary geriatric surgical care. Multiple studies have demonstrated the feasibility and safety of MIS in older adults [8]. Despite concerns related to advanced age, diminished physiological reserve, and multiple comorbidities, laparoscopic and robotic approaches have achieved perioperative morbidity and mortality rates comparable to those associated with conventional open surgery [9].

The advantages of MIS are primarily attributable to reduced operative trauma, which contributes to lower intraoperative blood loss and decreased cardiopulmonary complications. In addition, MIS may facilitate more rapid postoperative recovery, shorter hospitalization, and earlier restoration of baseline functional status [10]. Importantly, these perioperative benefits do not appear to compromise therapeutic or oncologic efficacy, as MIS has demonstrated oncologic outcomes comparable to those of open surgery, including overall survival and disease-free survival, in appropriately selected elderly patients.

Pathophysiological challenges of minimally invasive surgery in the geriatric population

Despite its substantial perioperative advantages, MIS introduces distinct pathophysiological stressors that are primarily related to carbon dioxide pneumoperitoneum and extreme operative positioning, including the steep Trendelenburg position. In older adults, age-related reductions in physiological reserve impair compensatory responses, rendering these intraoperative stressors particularly consequential.

Pneumoperitoneum induces significant cardiovascular and respiratory alterations. Elevated intra-abdominal pressure (IAP) reduces venous return and cardiac output while simultaneously increasing systemic vascular resistance through both mechanical compression and neuroendocrine activation. Concurrently, cephalad displacement of the diaphragm decreases pulmonary compliance and functional residual capacity, thereby increasing the risk of atelectasis and ventilation-perfusion (V/Q) mismatch. These respiratory disturbances may be further exacerbated by systemic hypercapnia resulting from continuous carbon dioxide absorption [11]. Extreme operative positioning introduces additional neurologic and ophthalmologic concerns. The steep Trendelenburg position promotes upper-body venous congestion, markedly increasing both intracranial pressure and intraocular pressure, which may predispose vulnerable patients to cerebral edema or ischemic optic neuropathy [12]. Furthermore, elevated IAP may compress the renal parenchyma and mesenteric vasculature, reducing splanchnic perfusion and potentially contributing to transient oliguria [13].

To minimize these physiological disturbances and reduce the risk of perioperative decompensation, meticulous anesthetic and surgical management is essential. Current recommendations emphasize the use of low-pressure pneumoperitoneum (≤12 mmHg), gradual positional adjustments to facilitate hemodynamic adaptation, and minimization of the duration of steep operative positioning [14].

Optimal preoperative assessment of the geriatric surgical patient

To safely manage the physiological stress associated with major surgery, preoperative evaluation in older adults requires a multidimensional approach that extends well beyond routine history taking and physical examination [15]. Because perioperative outcomes in geriatric patients are influenced by the complex interaction between aging, multimorbidity, diminished physiological reserve, and functional vulnerability, comprehensive assessment is essential for accurate risk stratification and perioperative optimization.

Neurocognitive and psychiatric assessment represents a critical component of preoperative evaluation. Baseline cognitive function and decision-making capacity should be carefully assessed, while clinicians should proactively screen for depression, substance dependence, and risk factors for postoperative delirium to reduce the likelihood of neurologic complications. In parallel, physiological risk stratification should incorporate targeted cardiovascular assessment and identification of age-related systemic risk factors that may influence perioperative tolerance and recovery.

Equally important is the evaluation of geriatric-specific vulnerabilities. Assessment should include documentation of baseline functional capacity, fall history, and validated frailty measures. Nutritional evaluation is also essential to identify patients at risk for malnutrition, while a comprehensive medication review is necessary to address polypharmacy and potential drug-related complications. In addition, perioperative planning should remain aligned with patient-centered goals, expectations, and anticipated postoperative quality of life. Evaluation of family and social support systems is similarly important to facilitate safe discharge planning and postoperative recovery. Collectively, these multidimensional assessments guide individualized diagnostic evaluation and support the development of tailored perioperative management strategies for older surgical patients.

The FRAIL scale

Within this multidimensional framework, frailty assessment plays a particularly important role. The FRAIL scale is a practical and validated screening instrument designed to objectively evaluate physiological vulnerability in older adults [16]. This self-administered questionnaire assesses five domains (Fatigue, Resistance, Ambulation, Illnesses, and Loss of weight) [17]. Each affirmative response is assigned 1 point. Based on the cumulative score, patients are categorized as robust (0 points), pre-frail (1–2 points), or frail (3–5 points), with increasing scores associated with progressively greater risk of adverse health outcomes (Table 1).

Table 1.

The FRAIL Scale for frailty screening [17]

Category	Component	Assessment criteria	Score
F	Fatigue	How much of the time during the past 4 weeks did you feel tired?	0: None or some of the time 1: All or most of the time
R	Resistance	By yourself and not using aids, do you have any difficulty walking up 10 steps without resting?	0: No 1: Yes
A	Ambulation	By yourself and not using aids, do you have any difficulty walking several hundred yards?	0: No 1: Yes
I	Illnesses	Did a doctor ever tell you that you have the following diagnosis (such as angina, chronic lung disease, arthritis, diabetes, asthma, heart attack, stroke, kidney disease, cancer, hypertension)?	0: 0–4 1: 5–10
L	Loss of weight	Have you had a weight loss of >5% from your weight 1 year ago?	0: No 1: Yes

Scoring and interpretation (total score, 0–5): 0 points = robust (normal); 1–2 points = pre-frail (at risk of developing frailty); 3–5 points = frail (high risk for adverse health outcomes).

Adapted from Kim et al. [17], according to the Creative Commons License.

Early identification of pre-frail and frail patients permits implementation of targeted interventions, including physical prehabilitation and nutritional optimization, which may partially reverse physiological decline before surgery. The prognostic significance of frailty assessment has been demonstrated in multiple clinical studies. In an analysis of 982 older adults undergoing robotic surgery, frail patients experienced significantly longer hospitalization and higher postoperative complication rates than non-frail individuals [18]. Furthermore, advanced age (≥85 years) independently predicted major complications, whereas body mass index and performance status demonstrated strong associations with 90-day mortality. These findings underscore the substantial influence of frailty on perioperative risk and highlight the importance of routine frailty screening and careful patient selection in geriatric surgical practice.

Current trends in surgical approaches (open, laparoscopic, and robotic) for major abdominal surgeries at Severance Hospital

Supported by advances in perioperative management and the expanding safety profile of MIS, surgical practice patterns at Severance Hospital have evolved considerably over time. Fig. 5 illustrates the longitudinal transition in operative approaches for major abdominal resections performed at the institution. Overall, the data demonstrate a progressive shift from conventional open surgery toward minimally invasive techniques, although adoption patterns differ substantially according to organ system and procedural complexity. Since the early 2010s, the proportion of open gastrectomies has declined markedly, accompanied by rapid expansion of laparoscopic and robotic approaches (Fig. 5A). Similarly, laparoscopic colectomy has remained the dominant operative strategy throughout the study period, with open colectomy comprising only a limited proportion of cases (Fig. 5B). In contrast, hepatobiliary and pancreatic procedures have demonstrated more gradual transitions because of their technical complexity and challenging anatomy. Hepatectomy continues to be performed predominantly through open approaches, although laparoscopic hepatectomy has progressively increased in recent years (Fig. 5C). Notably, although pancreatoduodenectomy was historically performed almost exclusively via open surgery, robotic pancreatoduodenectomy has expanded rapidly since 2019 and has emerged as a major minimally invasive alternative (Fig. 5D).

Fig. 5.

Current trends in surgical approaches (open, laparoscopic, and robotic) for major abdominal surgeries at Severance Hospital, Yonsei University College of Medicine. (A) Gastrectomy, (B) colectomy, (C) hepatectomy, and (D) Pancreatoduodenectomy.

Comparable trends are also evident among octogenarian patients at Severance Hospital, Yonsei University College of Medicine (Fig. 6). In gastrectomy, minimally invasive approaches, particularly laparoscopic and robotic surgery, have progressively replaced conventional open procedures. Although hepatectomy is performed less frequently in this advanced-age population, a gradual increase in minimally invasive approaches remains apparent. Collectively, these findings demonstrate the expanding feasibility and increasing acceptance of minimally invasive techniques, even among very elderly patients undergoing major abdominal surgery.

Fig. 6.

Longitudinal trends of surgical approaches for gastrectomy and hepatectomy in octogenarians at Severance Hospital, Yonsei University College of Medicine. (A) Gastrectomy and (B) hepatectomy.

Perioperative outcomes of minimally invasive vs. open surgery in elderly patients

To further evaluate the clinical impact of this transition toward minimally invasive techniques, perioperative outcomes were compared between MIS and open surgery in patients aged ≥70 years undergoing major hepatectomy and pancreatoduodenectomy at Severance Hospital, Yonsei University College of Medicine (Table 2). In major hepatectomy, MIS was associated with significantly lower estimated blood loss (EBL) (133.5 ± 157.8 mL vs. 447.4 ± 449.0 mL, p < 0.001) and shorter hospitalization (7.6 ± 2.2 days vs. 13.6 ± 10.5 days, p < 0.001) compared with open surgery. Although major complication rates were numerically lower in the MIS group (3.8% vs. 8.1%), this difference did not reach statistical significance (p = 0.679). Similarly, among patients undergoing pancreatoduodenectomy, MIS significantly reduced median EBL (250 mL [interquartile range (IQR), 100–400] vs. 350 mL [IQR, 200–600], p < 0.001) and hospital length of stay (16.1 ± 13.2 days vs. 21.1 ± 13.5 days, p < 0.001). Importantly, MIS was also associated with a significantly lower incidence of clinically relevant postoperative pancreatic fistula (International Study Group of Pancreatic Fistula grade ≥B) (6.3% vs. 11.6%, p = 0.015). Collectively, these findings suggest that MIS improves perioperative recovery and clinical outcomes in older adults undergoing highly complex hepatobiliary and pancreatic surgery.

Table 2.

Perioperative outcomes of MIS vs. open surgery in elderly patients aged ≥70 years at Severance Hospital, Yonsei University College of Medicine

Procedure	Outcome	Open surgery	MIS	p-value
Major hepatectomy	EBL (mL)	300 (200–550)	100 (50–150)	<0.001
	Hospital stay, days	13.6 ± 10.5	7.6 ± 2.2	<0.001
	Major complication	7 (8.1)	1 (3.8)	0.679
Pancreatoduodenectomy	EBL (mL)	350 (200–600)	250 (100–400)	<0.001
	Hospital stay, days	21.1 ± 13.5	16.1 ± 13.2	<0.001
	CR-POPF (ISGPF grade ≥B)	60 (11.6)	21 (6.3)	0.015

Values are presented as median (interquartile range), mean ± standard deviation, or number (%)

MIS, minimally invasive surgery; EBL, estimated blood loss; CR-POPF, clinically relevant postoperative pancreatic fistula; ISGPF, International Study Group on Pancreatic Fistula.

SUMMARY

Rapid population aging has substantially increased the demand for surgical care in older adults. Given the physiological vulnerability, frailty burden, and high prevalence of comorbid conditions within this population, comprehensive preoperative assessment remains essential for accurate perioperative risk stratification and appropriate patient selection. In carefully optimized patients, MIS provides several important clinical advantages, including reduced operative trauma, fewer perioperative complications, and accelerated postoperative functional recovery. Importantly, these benefits appear to be achieved without compromising oncologic or therapeutic efficacy, with outcomes comparable to those of conventional open surgery. Accordingly, integration of rigorous preoperative evaluation, including frailty assessment, with the selective application of minimally invasive techniques represents a key strategy for optimizing surgical safety and postoperative recovery in geriatric patients.