Multivisceral Resections in GI Oncology: Where to Draw the Line?

Abstract

Background:

Multivisceral resection (MVR) in gastrointestinal (GI) oncology represents one of the most formidable undertakings in surgical practice, demanding meticulous technical execution, multidisciplinary coordination and the courage to operate at the very limits of oncologic feasibility.

Objective:

This review synthesises the latest evidence (2000–2025) on the indications, contraindications, technical nuances, outcomes and ethical considerations of MVR, with a focus on defining the decision-making boundaries that separate justified surgical aggression from undue risk.

Methods:

A comprehensive search of PubMed and Embase was conducted, emphasising systematic reviews, meta-analyses, randomised controlled trials and large multicentre cohort studies relevant to MVR in GI cancers. Evidence was evaluated for technical approaches, survival outcomes, perioperative morbidity and ethical dimensions.

Results:

Contemporary literature supports the selective use of MVR in locally advanced gastric, colorectal and pancreatic cancers, achieving acceptable morbidity and mortality in high-volume centres when R0 resection is feasible. Advances in minimally invasive techniques, perioperative optimisation and enhanced recovery protocols have improved outcomes; however, complications remain significant. Patient selection, accurate preoperative staging and multidisciplinary tumour board input are paramount to success.

Conclusion:

MVR remains a powerful but high-risk tool in the surgical oncologist’s armamentarium. This review provides a framework for surgeons to identify the threshold between justified aggression and undue risk in MVR for GI malignancies.

Keywords

Gastrointestinal neoplasms multivisceral resection (MVR)pelvic exenteration gastrectomy pancreatectomy hepatopancreatoduodenectomy (HPD)minimally invasive surgical procedures treatment outcome

Introduction

Multivisceral resection (MVR) is the en bloc removal of a primary gastrointestinal (GI) malignancy with one or more directly invaded adjacent organs, aiming for a margin-negative (R0) resection. Once rare and reserved for exceptional cases, MVR is now an established option in selected patients, supported by advances in imaging, perioperative care, anaesthesia and reconstructive techniques, alongside evidence that complete tumour clearance can yield survival rates comparable to less advanced disease when applied judiciously.^[1,2]

Historically, locally advanced GI tumours crossing organ boundaries were deemed unresectable due to prohibitive risks and incomplete clearance. The adoption of standardised oncologic principles, especially en bloc resection to prevent tumour spillage, has shifted this paradigm. Modern MVR is guided by anatomical feasibility, tumour biology, patient fitness and the potential for durable disease control.^[3]

The core dilemma lies between oncologic ambition and surgical restraint. While negative margin resection remains the most critical determinant of long-term survival, it often requires complex multi-organ dissection, prolonged surgery and greater physiological stress, factors contributing to higher morbidity and mortality compared to standard resections.^[4]

With no universally accepted criteria for ‘where to draw the line’, practice varies widely. This review synthesises contemporary indications, principles, outcomes, innovations and ethical considerations for MVR in GI oncology, aiming to equip surgeons and multidisciplinary teams with a structured framework to determine when aggressive surgery is justified and when restraint better serves the patient.^[5]

Background and Rationale

Locally advanced GI malignancies often invade adjacent structures due to anatomical proximity and lack of anatomical barriers. Tumours of the stomach, pancreas, colon and rectum may encroach upon the liver, spleen, kidney, major vessels or abdominal wall, making complete resection challenging.^[6,7]

MVR aims to achieve an R0 resection when organ involvement is contiguous and resection is technically feasible. Several series and meta-analyses from high-volume centres report that, in well-selected patients, MVR can deliver survival outcomes approaching those of non-locally advanced cases, particularly when negative margins are achieved.^[8]

However, these benefits come with increased perioperative risk, resource utilisation and potential functional impairment.^[9] The decision to proceed must weigh oncologic benefit against operative risk and postoperative quality of life (QoL). A multidisciplinary evaluation incorporating surgical oncology, medical oncology, radiology, anaesthesia and critical care perspectives remains essential to individualising treatment.^[10]

Surgical Principles of Multivisceral Resection (MVR)

Oncologic Principles

MVR in GI oncology is anchored in two imperatives: uncompromising oncologic clearance and preservation of patient safety. The cornerstone is en bloc removal of the tumour with all directly invaded structures, avoiding piecemeal excision that risks tumour spillage and local recurrence.^[11] The primary objective is an R0 resection, as positive or close margins markedly diminish survival benefit. Margin clearance should be guided by preoperative imaging and intraoperative judgement, since tumour spread often follows tissue planes rather than concentric growth. Adequate lymphadenectomy, tailored to tumour location, serves both staging and therapeutic goals and must not be compromised.^[12] Tumour handling should be minimal, with resection planes respecting oncologic anatomy rather than convenience.

Anatomical Considerations

Complex multiorgan dissection demands a precise understanding of regional vascular and visceral anatomy, especially when critical structures such as the superior mesenteric vein, portal vein or celiac axis are involved. Vascular resection and reconstruction should only be performed by teams with specialised expertise.^[13] Reconstruction, whether GI, urological or biliary, should be planned preoperatively, with contingency strategies for unexpected findings.

En Bloc Versus Staged Approaches

En bloc resection remains the gold standard for achieving margin-negative status. Staged procedures are rarely indicated, generally reserved for patients whose physiological reserve or intraoperative instability preclude completion of the intended MVR.^[14] Key indications and contraindications are summarised in Table 1.

Table 1.

Indications and contraindications for multivisceral resection (MVR) in gastrointestinal oncology

Indications	Contraindications
Locally advanced tumour with adjacent organ invasion confirmed by high-quality imaging/EUS	Distant metastases are not amenable to curative resection
High probability of achieving R0 resection	Poor performance status (ECOG ≥3)
No prohibitive comorbidities	Severe cardiopulmonary compromise
Patient fit for prolonged, complex surgery	Unreconstructable vascular involvement
Multidisciplinary consensus supporting surgery	Rapid disease progression despite neoadjuvant therapy

Note: Key decision-making criteria for offering MVR in patients with locally advanced gastrointestinal tumours, integrating tumour factors, patient fitness, anatomical feasibility and multidisciplinary consensus, alongside absolute and relative contraindications. ECOG, Eastern cooperative oncology group; EUS, Endoscopic ultrasound.

Preoperative Optimisation and Prehabilitation

High-resolution computed tomography (CT) or magnetic resonance imaging (MRI) is essential for defining tumour extent; positron emission tomography–computed tomography (PET-CT) can help exclude occult metastases. Functional organ assessment, nutritional optimisation and comorbidity management are integral to risk reduction. Prehabilitation programmes combining nutrition, exercise and psychological support can lower complication rates and shorten recovery.^[15] Critical technical and perioperative considerations are detailed in Table 2.

Table 2.

Key technical and perioperative considerations in multivisceral resection (MVR) for gastrointestinal malignancies

Domain	Critical Considerations	Practical Implications
Preoperative imaging	High-resolution CECT/MRI, 3D reconstruction, PET-CT for select tumours	Defines the extent of invasion, vascular involvement and resectability
Nutritional optimisation	Albumin ≥3.5 g/dL, prehabilitation and micronutrient correction	Reduces wound complications and shortens recovery
Anaesthetic preparedness	Invasive monitoring, blood conservation protocols and goal-directed fluid therapy	Minimises intraoperative hemodynamic instability
Surgical exposure	Extended midline or rooftop incision; possible thoracoabdominal approach	Improves access for complex multi-organ resections
Organ preservation	Avoid resection of uninvolved structures when oncologically safe	Decreases operative time and morbidity
Vascular control	Proximal and distal control of major vessels before organ transection	Reduces risk of catastrophic bleeding
Reconstruction strategies	Pre-planned sequence for GI continuity and organ-specific reconstruction	Prevents unplanned delays, reduces ischaemia time
Postoperative monitoring	Early detection of leaks, bleeding and organ dysfunction	Improves salvage rates in complications

Notes: Structured summary of essential preoperative, intraoperative and postoperative factors that influence safety, oncologic adequacy and patient outcomes in MVR. Emphasises preoperative optimisation, meticulous surgical planning and postoperative surveillance to minimise morbidity while maximising survival benefit. CECT, Contrast-enhanced computed tomography.

Surgeon and Institutional Expertise

Outcomes of MVR correlate strongly with surgeon experience and hospital volume. Centralisation to high-volume centres with multidisciplinary teams reduces morbidity and mortality, underscoring the need for technical capacity to match oncologic ambition. A stepwise, multidisciplinary decision pathway is depicted in Figure 1.

Figure 1.

Note: Stepwise clinical workflow outlining patient evaluation, multidisciplinary review, selection criteria assessment, contraindication screening, surgical planning, intraoperative ‘go/no-go’ decision-making and postoperative care pathways.

Indications in GI Oncology (By Cancer Type)

The decision to undertake MVR depends on anatomical feasibility, tumour biology, patient fitness and the probability of achieving durable oncologic benefit. While en bloc resection principles are universal, specific indications vary by malignancy.

Oesophageal Carcinoma

Reserved for select T4b tumours invading the diaphragm, pericardium, trachea or aorta. Neoadjuvant chemoradiotherapy can enable resection in cases previously deemed inoperable.^[16] Best outcomes occur in high-volume thoracoabdominal centres with strict selection based on cardiopulmonary reserve and absence of metastases.

Gastric Carcinoma

Indicated for T4b disease invading the spleen, pancreas, colon or diaphragm. Common extensions involve the distal pancreas and spleen, often requiring subtotal or total gastrectomy with distal pancreatectomy and splenectomy.^[17] Survival benefit is linked to R0 resection, achievable in experienced units irrespective of the number of additional organs removed.

Colorectal Carcinoma

Locally advanced T4b colorectal cancers may require resection of the bladder, uterus, small bowel, abdominal wall or pelvic sidewall. In rectal cancer, pelvic exenteration remains key for achieving local control. When R0 margins are attained, survival can approximate that of earlier-stage cases, albeit with higher morbidity.^[18]

Pancreatic Cancer

Considered when an adjacent organ (stomach, colon or adrenal) or venous structure (portal vein or superior mesenteric vein) invasion is present. Vascular resection and reconstruction are accepted in high-volume pancreatic units, particularly post-neoadjuvant therapy for borderline resectable disease.^[19] Arterial resections remain rare and controversial.

Cholangiocarcinoma and Hepatobiliary Tumours

Advanced perihilar cholangiocarcinoma or gallbladder carcinoma with contiguous organ or major vascular invasion may require hepatopancreatoduodenectomy (HPD). This technically demanding procedure carries substantial morbidity but offers survival benefit in node-negative, well-selected patients.^[20]

Rare Scenarios and Salvage Surgery

Retroperitoneal sarcomas invading the GI tract and salvage resections for recurrent malignancies may necessitate MVR when other options are limited. Here, weighing symptom relief and survival gain against operative risk is paramount.

Oncologic Outcomes

The central rationale for undertaking MVR in GI oncology is the potential for long-term disease control through complete tumour clearance. Across tumour types, the most powerful predictor of survival remains the achievement of a negative (R0) margin, a principle that has been repeatedly validated in contemporary literature.^[21,22]

Survival Benefit

In colorectal cancer, multiple prospective and retrospective series demonstrate that, when R0 resection is achieved, 5-year overall survival (OS) after MVR for T4b tumours can approach 50%–70%, comparable to outcomes for stage-matched patients undergoing standard resections.^[21,23] In a systematic review of 23 studies, pooled analysis confirmed that margin-negative MVR conferred a statistically significant survival advantage over non-operative or incomplete resection approaches, without a disproportionate increase in cancer-specific mortality.^[24]

For gastric cancer, large cohort data suggest a median survival of 28–43 months after MVR, with 5-year OS rates ranging from 20% to 40% in R0 cases.^[25] The number of additional organs resected has not been shown to independently worsen prognosis when an R0 resection is achieved, highlighting the primacy of margin status over extent of resection.^[26]

In rectal cancer, pelvic exenteration in expert centres yields 5-year OS of 40%–60% for primary disease and 25%–35% for locally recurrent tumours, with durable local control in over 80% of R0 cases.^[27] Long-term QoL has also been shown to recover to near population norms within 12–24 months postoperatively in selected patients.^[28]

For pancreatic ductal adenocarcinoma, MVR, including venous resection, can achieve a median survival of 22–30 months after neoadjuvant therapy, compared with 12–15 months for unresected locally advanced disease.^[29] However, arterial resections remain associated with lower R0 rates and increased perioperative mortality, limiting their role to exceptional scenarios.^[30]

In biliary malignancies, particularly HPD for locally advanced perihilar cholangiocarcinoma, recent series from high-volume centres report 5-year OS rates of 20%–35% in node-negative patients, reinforcing the importance of careful staging and selection.^[31]

Recurrence Patterns

Recurrence after MVR can be local, regional or distant, with patterns largely dictated by tumour biology. In colorectal cancer, local recurrence rates after R0 MVR are reported at 5%–15%, compared to 30%–40% after R1 or R2 resections.^[21,24] Gastric cancer recurrences are more frequently peritoneal or hepatic, often within 2 years of surgery.^[25,26] Rectal cancer recurrence following exenteration is uncommon in the pelvis when margins are negative, but distant metastases, particularly to the lungs, remain a concern.^[27,28] For pancreatic and biliary cancers, early distant relapse predominates, underscoring the need for effective systemic therapy integration.^[29–31]

Comparative Data: MVR Versus Standard Resection

When outcomes are adjusted for tumour stage and biology, multiple studies show no statistically significant difference in long-term survival between patients undergoing MVR for locally advanced tumours and those having standard resections for less extensive disease, provided R0 status is achieved.^[22,24,26] This finding underscores that, in appropriately selected cases, local tumour invasion should not be an absolute contraindication to curative surgery.

Conversely, incomplete resections (R1 or R2) offer little to no survival benefit over non-resectional strategies, reinforcing the principle that MVR is justified only when a clear technical path to complete clearance exists.^{[21,22,25,29]}

Morbidity and Mortality

While MVR offers potential oncologic cure in selected patients, its magnitude of surgical trauma and physiological stress makes it inherently high-risk. Reported morbidity ranges from 30% to 65%, with perioperative mortality between 2% and 15%, varying by tumour type, extent and institutional expertise.^[32,33] Acceptable safety outcomes rely on careful patient selection, meticulous planning and execution in high-volume centres with integrated perioperative pathways.^[34] Major complication categories and mitigation strategies are outlined in Table 3.

Table 3.

Major complication categories and mitigation strategies following multivisceral resection (MVR)

Complication Category	Common Causes in MVR	Mitigation Strategies
Anastomotic leak	Prolonged operative time, poor tissue perfusion and malnutrition	Intraoperative perfusion assessment with ICG, tension-free anastomosis and nutritional optimisation
Postoperative bleeding	Vascular reconstruction site, raw dissection areas	Meticulous hemostasis, drain placement near high-risk zones and early re-exploration if required
Intra-abdominal abscess	Contaminated field, anastomotic dehiscence	Adequate irrigation, targeted antibiotic prophylaxis and timely image-guided drainage
Respiratory complications	Prolonged surgery, high incision and pain-limited ventilation	Epidural analgesia, early mobilisation and physiotherapy
Renal dysfunction	Massive transfusion, hypotension and nephrotoxic drugs	Goal-directed fluid therapy and nephroprotective measures
Delayed gastric emptying	Pancreatic or gastric resections	Pyloric drainage procedures, prokinetics and nutritional support
Wound complications	Poor nutritional status and long incision	Layered closure and negative pressure dressings
Venous thromboembolism	Prolonged immobility and malignancy	Pharmacologic prophylaxis and early mobilisation

Notes: Overview of the most common postoperative complications encountered after MVR, their underlying causes and practical strategies for prevention and early management. Highlights the importance of targeted perioperative planning and multidisciplinary care to reduce complication-related mortality.

Early Postoperative Morbidity

Frequent complications include surgical site infections, anastomotic leaks, intra-abdominal abscesses, haemorrhage and postoperative ileus.^[32,35] Respiratory events, particularly after thoracoabdominal procedures and biliary or pancreatic fistulas in pancreatic or hepatobiliary MVR remain significant concerns.^[36] Reoperation rates can exceed 10%, highlighting the importance of intraoperative precision and hemostasis.^[33]

Mortality Trends

Advances in anaesthesia, monitoring and enhanced recovery after surgery (ERAS) protocols have reduced mortality to 2%–5% for colorectal or gastric MVR and 5%–8% for pancreatic or HPD in high-volume centres.^[32,37] Mortality is substantially higher in low-volume or non-specialist settings, reinforcing centralisation.^[34,38]

Long-term Morbidity and Functional Outcomes

Chronic sequelae may include malabsorption, diarrhoea, nutritional deficiencies, urological or sexual dysfunction and ventral hernias.^[28,36] In rectal cancer pelvic exenteration, permanent stomas and urinary diversion affect QoL, though adaptation is common within 2 years.^[28]

Risk Factors for Adverse Outcomes

Advanced age, poor performance status, hypoalbuminemia, comorbidities and prolonged operative time are independent predictors.^[33,36] Aggressive histology and incomplete resections (R1 or R2) correlate with higher perioperative mortality.^[35,38]

Impact of Enhanced Recovery Pathways

ERAS protocols tailored to MVR reduce pulmonary complications, length of stay and readmissions without increasing leak or mortality.^[37,39] Core elements include early mobilisation, multimodal analgesia, optimised fluids and early enteral feeding, ideally supported by prehabilitation.

Comparative Perspective

Compared to standard resections, MVR has higher morbidity and mortality, though these differences narrow in specialised multidisciplinary centres, justifying the risk when R0 resection is feasible.^[32–34,37]

Technical Considerations and Innovations

The complexity of MVR lies in combining vascular, visceral, reconstructive and occasionally orthopaedic or plastic surgical techniques into a seamless oncologic procedure. Advances in imaging, instrumentation and perioperative planning have broadened the scope of safe resection while reducing morbidity.

Preoperative Planning and 3D Reconstruction

High-resolution CT and MRI remain standard, but 3D reconstruction and virtual reality planning increasingly aid visualisation of tumour-structure relationships, resection planes and potential vascular reconstructions.^[40] These tools can improve precision and shorten operative time in complex cases.

Minimally Invasive and Robotic Approaches

Laparoscopic and robotic-assisted MVR are feasible in select colorectal and gastric cancers. Robotic systems offer enhanced dexterity and visualisation in confined spaces.^[41] Hybrid techniques, laparoscopic mobilisation followed by open en bloc resection, combine minimal access benefits with oncologic thoroughness.

Vascular Resection and Reconstruction

Portal and superior mesenteric vein resections are routine in high-volume pancreatic centres, with grafts restoring continuity.^[42] Arterial resections (celiac axis or superior mesenteric artery [SMA]) remain selective, usually after a favourable neoadjuvant response in expert vascular centres.^[43]

Reconstruction Strategies

Complex reconstructions may involve GI, urinary and biliary continuity restoration, as well as abdominal wall repair. Biological meshes and component separation techniques reduce hernia rates.^[44] Plastic surgical input is vital for extensive soft tissue repair.

Perfusion Assessment Technologies

Intraoperative indocyanine green (ICG) fluorescence angiography assesses bowel perfusion, biliary integrity and anastomotic viability,^[45] reducing leak rates in complex MVR.

Intraoperative Navigation and Augmented Reality (AR)

Augmented reality (AR) integration with intraoperative imaging is under trial for hepatic and pancreatic MVR, overlaying 3D maps into the surgical field to improve margin accuracy and safety.^[46]

Multidisciplinary ‘Co-surgeon’ Model

MVR often benefits from a co-surgeon approach, pairing two specialists, such as a surgical oncologist and a hepatobiliary or urologic surgeon, to handle distinct components of the procedure concurrently. This can shorten operative times, minimise blood loss and enhance reconstructive quality.^[47]

Ethical Considerations and ‘Where to Draw the Line’

The phrase ‘where to draw the line’ in MVR reflects the balance between surgical ambition and ethical responsibility. While technical feasibility continues to expand, the surgeon’s mandate is to act in the patient’s best interest, preserving QoL and avoiding futile interventions.

Principle of Surgical Justifiability

Oncologic surgery is guided by beneficence, acting to benefit the patient and non-maleficence, avoiding undue harm. The survival benefit of MVR must outweigh immediate risks and long-term deficits. Performing an extensive resection with little prospect of cure or meaningful palliation violates these principles.^[48]

Patient Selection and Informed Consent

Appropriate candidate selection is central to ethical MVR. Objective fitness assessments (e.g., cardiopulmonary exercise testing and nutritional scoring) and multidisciplinary review help avoid overestimating benefit.^[49] Informed consent should cover not only operative risks but also functional changes, potential stomas, nutritional dependence and QoL impact.^[50]

Futility and Non-beneficial Surgery

Ethical boundaries are crossed when benefits are marginal, R0 likelihood is low or biology suggests imminent systemic failure. Incomplete resections (R1 or R2) rarely confer a survival advantage and may prolong suffering.^[51] In such cases, systemic therapy, symptom control or minimally invasive palliation may better align with patient-centred care. The spectrum from justified oncologic aggression to futile extension is illustrated in Figure 2.

Figure 2.

Notes: Conceptual diagram illustrating the spectrum from justified oncologic aggression to futile surgical extension. Highlights the transition from high-benefit, ethically justified operations to procedures exceeding acceptable morbidity and mortality thresholds with minimal survival advantage.

Quality of Life (QoL) Versus Survival

While survival is the primary aim, ethical decision-making demands equal attention to postoperative QoL. Studies in rectal cancer exenteration and gastric MVR show that some survivors endure lasting functional impairment, outweighing survival gains.^[52,53] Incorporating validated QoL metrics aligns surgery with patient values.

Equity and Resource Allocation

In low- and middle-income countries, MVR consumes disproportionate surgical and critical care resources. Ethical stewardship requires balancing individual benefit against population-level access, especially in publicly funded or resource-limited settings.^[54]

Role of Multidisciplinary Governance

An ethically sound framework integrates input from surgical oncology, medical oncology, radiology, pathology, anaesthesiology and palliative care. Multidisciplinary tumor boards (MDTBs) act as ‘ethical filters’, ensuring MVR is offered only with a high likelihood of oncologic and functional benefit.^[49,54]

Drawing the Line in Practice

In practical terms, the line should be drawn where:

R0 resection is technically improbable.

Tumour biology predicts early systemic failure.

Functional reserve is inadequate.

Expected QoL is disproportionately poor relative to survival gain.

Ultimately, the surgeon’s ethical compass must be calibrated by both evidence and compassionate realism.

Future Directions and Conclusion

Future Directions

The evolution of MVR in GI oncology will be driven by advances in tumour biology, imaging, surgical technology and perioperative care.

Integration of Precision Oncology

Molecular profiling and circulating tumour DNA analysis will refine selection criteria, distinguishing patients likely to benefit from aggressive surgery from those better served by systemic therapy.^[55]

Neoadjuvant and Conversion Therapy

Modern neoadjuvant regimens, including triplet chemotherapy and targeted agents, show promise in downstaging borderline or locally advanced tumours. Ongoing trials are evaluating ‘conversion MVR’ strategies to maximise R0 rates.^[56]

Technological Disruption

AI-driven image analysis may surpass human accuracy in predicting resectability and vascular involvement. Coupled with intraoperative AR, this could lower positive margin rates.^[57]

Enhanced Recovery and Remote Monitoring

ERAS protocols tailored for MVR, combined with wearable sensors and telemonitoring, may detect complications earlier and hasten recovery.^[58]

Global Collaboration and Data Sharing

International registries with detailed operative, pathological and functional data will enable benchmarking, define best practices and establish acceptable morbidity and mortality thresholds.^[59]

Conclusion

MVR occupies a unique position in GI oncology, balancing curative ambition with the ethical imperative to ‘do no harm’.

Advances in selection, technique, perioperative optimisation and multidisciplinary governance have shifted MVR from last-resort to planned strategy in select patients.

The decision to proceed must weigh tumour biology, technical feasibility and patient readiness. The ‘line’ is not fixed but a dynamic intersection of science, skill and compassion. Drawing it wisely ensures MVR remains a potent yet judicious tool, offering cure, when possible, palliation when necessary and dignity always.

Footnotes

Acknowledgements

The authors acknowledge the support of Miss Dipti Mittal, the Department of Surgical Gastroenterology and GI Oncology, Medanta Super Speciality Hospital, Noida, for facilitating literature access and academic discussion during manuscript preparation.

Declaration of conflicting interests

The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

Institutional ethical committee approval number

Not applicable for narrative review articles.

Informed consent

Not applicable. This study did not involve human participants or patient data.

Credit author statement

Supreet Kumar: Conceptualisation, literature review, manuscript drafting, critical revisions and final approval.

Sonam Gupta: Literature review, drafting specific sections, preparation of tables and figures and final approval.

Vivek Tandon: Critical review of surgical content, data interpretation, manuscript editing and final approval.

Deepak Govil: Senior academic oversight, conceptual guidance, critical revisions and final approval.

Data availability

No new data were generated or analyzed for this review. All information is derived from previously published studies cited in the references.

Guarantor

Dr Supreet Kumar accepts full responsibility for the integrity and accuracy of the content.

Use of artificial intelligence

No generative AI tools were used in the analysis, writing, or creation of the manuscript. The final version was entirely authored and verified by the listed human authors.

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