Combined laparoscopic and fibroscopic fundus wedge resection

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Combined   laparoscopic   and   fibroscopic   fundus   wedge   resection

Authors
J Leroy, D Mutter, M Smith-Savu
Mots-clés
operation,gastrectomy
Type de vidéo
Durée
05'00''
Publication
2004-09
Popularité
Favoris
Favorites Media
Audio
en
Sous-titres
en
E-publication
WeBSurg.com, Sept 2004;4(09).
URL: http://www.websurg.com/doi-vd01en1138e.htm

Combined   laparoscopic   and   fibroscopic   fundus   wedge   resection

1. Case presentation 00'18''
In this video, we will show a laparoscopic partial gastric resection performing a wedge resection of the posterior aspect of the fundus for the treatment of a submucosal metastatic melanocarcinoma, which was detected preoperatively by endoscopy. First, we make an exploration of the abdominal cavity to rule out any further metastases. We will now perform an intraoperative gastroscopy to make sure that we can adequately locate the nodule on the anterior aspect of the stomach as well as rule out the presence of any other metastatic melanoma nodules. We use an atraumatic clamp on the distal aspect of the stomach in order to keep the leakage of the gas used during insufflation of the stomach for the endoscopy. Once this is achieved, we insufflate the stomach. We decrease the amount of intra-abdominal light from the endoscope itself and then we will introduce a fibroscope orally and pass down into the stomach. At this point, we can adequately explore the interior of the stomach and search for any more metastases that were not detected previously as well as to precisely locate the previously detected nodule. Once we have done this exploration, we will now open the gastro-omental ligament between the gastric inferior aspect and the omentum to open the lesser sac, being careful to preserve the vasculature of the greater curvature of the stomach. As we progressively open the lesser sac, we can see the posterior aspect of the stomach progressively being seen here. With a wide opening of the lesser sac, we have easy access to the posterior aspect of the stomach and with the use of our intraoperative endoscopy, we will localize the nodule on the interior of the stomach. We can also further explore this area for any other signs of metastases. Once we have located the nodule on the interior of the stomach, we place a stitch on the exterior aspect of this so that we were sure of our localization. This is a precise way to localize the nodule and we can ensure an adequate wedge resection. We use the same stitch to elevate the posterior aspect of the stomach bringing it through the previously made incision of the gastro-omental ligament. This approach is a useful one because we can perform a resection without opening the stomach and therefore avoid contamination of the abdominal cavity. We can use 1 or 2 cartridges of staplers in order to make our resection and in this case, we will use 2 cartridges to make the complete resection of the tumor. We are able to achieve a wide resection away from the nodule due to our intraoperative localization of the nodule and you will see here that we use the 2nd stapler to complete our dissection. This procedure is easily reproduced and is particularly useful for the mobile aspect of the fundus of the stomach on the posterior part as we see here but also on the anterior aspect of the stomach. After the wedge resection is completed, the specimen may be removed directly from the trocar site itself as in this case or better after introducing in into a plastic bag to avoid contamination particularly in the case of cancer or metastasis. Once removed, the specimen will be opened and pathologically examined.