Laparoscopic treatment of a stromal gastric tumour: transgastric access

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Laparoscopic treatment of a stromal gastric tumour: transgastric access

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Type de vidéo

Vidéo chirurgicale

Durée

20'00''

Publication

2005-05

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E-publication

WeBSurg.com, May 2005;5(05).
URL: http://www.websurg.com/doi-vd01en1774e.htm

Laparoscopic treatment of a stromal gastric tumour: transgastric access

1. Trocar placement 00'08''

This is a 75-year-old female patient with a history of anemia. Upon upper and lower endoscopic evaluation, a gastroscopy revealed the tumor on the posterior wall of the gastric fundus. The lesion is a non-ulcerated flat mobile pulp 6cm in diameter. The biopsy specimen was noted to be benign and consistent with this stromal tumor. The intervention begins with the laparoscopic exploration. We have placed a 5mm optical port supraumbilically along with 2 additional 5mm ports.

2. Suspending the gastric wall 00'35''

The laparoscopic intragastric surgery can be performed with gastroscopy to guide trocar placement into the gastric lumen. The stomach is first insufflated via the endoscope and specific 5 and 12mm ports with balloons on their shafts to be introduced through the abdominal wall directly into the distended stomach. In this case, endoscopy isn’t utilized and the access is done with a harmonic scalpel with tension provided by the suspension of the gastric wall anteriorly by sutures placed with a Keith needle. Several teams of surgeons have used gastroscopy and laparoscopy to treat large leiomyomas and benign polyps of the gastrum and esophagus,

3. Opening the gastric wall 01'25''

which otherwise would have required a formal laparotomy or thoracotomy. With this patient, a wedge resection appears to be possible for a lesion of the posterior wall using a transgastric approach. We feel this is possible because no extension on the side of the serosal layer is seen on the preoperative CAT-scan that was obtained. This transgastric approach with or without gastroscopy guidance has begun to gain acceptance by surgeons for benign tumors too large to be endoscopically removed.

4. Trocar positioning in the intragastric wall 02'00''

The balloon on the trocar holds the stomach against the anterior abdominal wall to provide access to the lumen for standard laparoscopic instruments. In this case, two 5mm ports will be utilized for the surgeon’s dissection of the tumor. Both of those ports like the optical port will have balloons on the tips of their shafts to aid in the gastric wall distension. The distended stomach allows one to have working space and at the same time to explore in the gastric cavity and duodenum. The lesion is identified and evaluation of the remainder of gastrum and distal esophagus and proximal duodenum is then completed.

5. Resection of leiomyoma 03'09''

We start the procedure by stabilizing the lesion with a grasper and to begin dissection with a harmonic scalpel. Some surgeons employ an epinephrine solution much like in gastric hemorrhage and inject into the submucosal layer for hemostasis and to possibly initiate a plane of dissection in the form of hydrodissection during the injection. Particularly if only a traditional cautery device is available, a pre-emptive maneuver such as this will go a long way by keeping blood loss to a minimum. We find the use of harmonic scalpel to be sufficient. The dissection of the tumor requires identification of the muscular and serosa layers of the gastrum. A small perforation of the serosal layer is made during the dissection. This will be re-approximated with resorbable suture to be utilized already in the mucosal repair. Upon completion of the dissection, the tumor will be put into an Endocatch bag and removed with an orogastric tube after being sutured to the bag.

6. Suturing the intragastric mucosa 04'33''

Prior to this, we do approximate the mucosa of the gastrum. We note that for tumors less than 6cm in size and of stromal tumor origination, the likely chance of it being malignant is rare. With this in mind and with this patient, we find that this approach will decrease the patient’s postoperative recuperation period as well as allow for decreased morbidity with the procedure itself. The endobag is then inserted into the gastrum via the 10mm port, and the tumor along with the needle utilized for the suture is then placed into the bag. The anesthesiologist at this time will then advance an orogastric tube for which he will suture the endobag to this tube. Also to note preoperatively in these patients to make sure that the gastric tumor is indeed within the serosal surface, as sometimes the tumors can become pedunculated within the abdominal cavity and extend making this procedure suboptimal for this type of tumor. The band is then advanced into the distal esophagus and retracted by the anesthesiologist as seen here. Confirmation of hemostasis is then done, and now we will close the gastric wall with interrupted resorbable sutures. Only one suture ligature will be required for each 5mm port site and for 12mm port site approximately 4 sutures were utilized. An alternative method of removing the tumor would be through the 12mm optic port site incision within the anterior gastric wall.

7. Extracting the specimen 07'30''

However, as you saw, the tumor is approximately 6cm and enlarging this incision in the gastrum would then be required. A benign stromal tumor was confirmed on pathological examination as no evidence of an increased number of mitotic figures was seen on histology.

8. Suturing the gastric wall 09'00''

The patient postoperatively was ambulating and tolerating a liquid diet on the first day. Minimal narcotics were required for the patient’s pain complaints and a discharge on the third postoperative day with oral iron supplementation for her anemia was then done. A follow-up endoscopy will be planned for 6 months postoperatively. This completes the procedure.