Laparoscopic partial gastrectomy for stromal tumor

In this video, a young woman presenting with abdominal pain was investigated. The diagnosis of an 8cm GIST tumor was established through imaging studies and endoscopic biopsy. A laparoscopic partial gastrectomy was carried out preserving the antrum. The resection involved 3 staplers and allowed to keep a 2cm safety margin. The postoperative course was uneventful. Pathological findings confirmed a high-grade GIST tumor.

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Laparoscopic partial gastrectomy for stromal tumor

Authors

D Mutter, L Soler, J Marescaux

Abstract

In this video, a young woman presenting with abdominal pain was investigated. The diagnosis of an 8cm GIST tumor was established through imaging studies and endoscopic biopsy. A laparoscopic partial gastrectomy was carried out preserving the antrum. The resection involved 3 staplers and allowed to keep a 2cm safety margin. The postoperative course was uneventful. Pathological findings confirmed a high-grade GIST tumor.

Keywords

Laparoscopic partial gastrectomy, stromal tumor

Media type

Surgical video

Duration

08'32''

Publication

2012-04

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E-publication

WeBSurg.com, Apr 2012;12(04).
URL: http://www.websurg.com/doi-vd01en3665.htm

Laparoscopic partial gastrectomy for stromal tumor

1. Clinical case 00'22''

This is the case of a 40-year-old woman who was referred to our department for epigastric pain. Endoscopic and CT-scan studies demonstrate a tumor localized at the lesser curvature of the stomach.

2. Imaging studies 00'35''

The 3D reconstruction shows that this tumor is attached to the anterior aspect of the stomach at the lesser curvature. However, imaging combined with 3D reconstruction do not allow to clearly determine the possibilities of resection. The laparoscopic exploration will make it possible to decide whether a segmental gastric resection or a gastrectomy to restore digestive continuity will be performed.

3. Surgical procedure 01'00''

Five ports are placed using conventional landmarks. The exploration helps to identify the tumor, 8cm in diameter, attached to the anterior aspect of the stomach in contact with the lesser curvature. The posterior aspect of the stomach is preserved completely. It is therefore envisaged to resect the tumor using partial gastric stapling, by preserving the integrity of the antrum.

4. Dissection of lesser curvature 01'32''

Preparation of the resection requires the freeing of the fundus and of the lesser curvature of the stomach. The lesser curvature is first freed. In immediate contact with the lesser curvature, the direct vessels are controlled be means of a Ligasure™ vessel-sealing device. The objective is to preserve the innervation of the pylorus. The anterior peritoneal reflection is opened first as the small direct vessels are controlled by means of the Ligasure™ device. The lesser sac can then be accessed, once again in close contact with the stomach. The pancreas can be identified posteriorly.

5. Dissection of greater curvature 02'21''

Progress is then made towards the fundus. The same kind of preparation is carried out: the vessels supplying the fundus in contact with the stomach are ligated making sure that the gastro-epiploic vessels are preserved. Once again, coagulation is performed by means of the Ligasure™ device in contact with the stomach. Devascularization performed over a short distance does not pose any vascular-related problem and will not impede the scarring process, and especially so in a young patient with good general health conditions and without any other associated diseases.

6. Exposure of tumor 03'13''

The only problem one is faced with in front of such a large-sized tumor is the exposure so as to make sure that there is a sufficient safety margin. Considering the size of the tumor, it is evocative of a stromal tumor with a non-negligible malignancy, which absolutely requires a safety margin greater than 1cm. A stitch to suspend the gastric wall will be used. It will be passed transparietally to suspend the stomach and facilitate its exposure. The stitch is made using a right needle so that the thread is passed very easily through the wall. Traction placed on the thread helps with exposing the base of the tumor and allows to envisage stapling. The objective of the stapling is to avoid any median gastric stenosis. The thread combined with the use of a forceps allow for an appropriate exposure of the anterior aspect of the stomach.

7. Resection by stapling 04'23''

A stapler with a blue cartridge is used in order to obtain a satisfactory hemostasis of the division line. The stapling is made at least 2cm from the base of the tumor as it can be palpated. The tumor’s positioning is uneasy and the positioning of the second row of staples is carried out very meticulously in order to avoid dividing large vessels at the lesser curvature. It is also essential to preserve a sufficient margin while avoiding any gastric stenosis. The safety margin is preserved by respecting the entire posterior aspect of the fundus. Once again, the stapling is carried out in a healthy area on the stomach. It is necessary to reposition the stapler multiple times to be sure it is well placed, ensuring a sufficient resection while preserving the integrity of the stomach. As soon as adequate positioning is obtained, a second row of staples may be fired. A last centimetre-wise segment remains in place and it will be controlled using a third stapler for safety purposes.

8. Extraction 06'00''

For specimen extraction, a 15mm bag will be used. Here one can see that the fashioned gastric tube is sufficiently big to allow for food passage. No stenosis can be noted when manipulating either the anterior or the posterior aspect of the stomach. The bag is introduced through the port introduction site at the midline scar. It is introduced directly and not through a port so as not to be forced to immediately enlarge the defect. The specimen will be extracted by means of a short counter-incision, hence enlarging the port introduction site over 3cm. It will allow for the en bloc specimen extraction in order to secure an appropriate pathological exam.

9. Macroscopic examination of specimen 07'10''

Before the end of the procedure, the base of the specimen will be opened in order to secure a safe implantation base away from any division area. Here one can see that there is a 2cm margin. Pathological findings will confirm the existence of a stromal tumor with a 2cm safety margin.

10. Final control of resection line 07'33''

The staple line is then controlled once more. Any potential bleeding at the level of the staple line will be controlled strictly by means of bipolar cautery to avoid necrosis in contact with the staples. Two small additional cauterizations will be carried out. Postoperative outcome is uneventful. Food intake is resumed on the day following the intervention. The patient is discharged on postoperative day 4. The patient will receive complementary medication and will be administered Gleevec systematically because of the tumor’s stage.