Laparoscopic and transgastric stapled resection of a posterior gastric stromal tumor

This video is a 'live' recorded surgery performed by Dr Dallemagne during a digestive surgery course. The 4 cm tumor is delivered through a gastrotomy performed by laparoscopy. The tumor is then resected by application of an endoscopic stapler. Finally, the gastrotomy is closed. This is a simple technique applicable to the vast majority of digestive surgeons.

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Laparoscopic and transgastric stapled resection of a posterior gastric stromal tumor

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Abstract

This video is a 'live' recorded surgery performed by Dr Dallemagne during a digestive surgery course. The 4 cm tumor is delivered through a gastrotomy performed by laparoscopy. The tumor is then resected by application of an endoscopic stapler. Finally, the gastrotomy is closed. This is a simple technique applicable to the vast majority of digestive surgeons.

Keywords

tumour, gastrotomy, digestive, laparoscopy

Media type

Surgical video

Duration

11'34''

Publication

2007-04

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E-publication

WeBSurg.com, Apr 2007;7(04).
URL: http://www.websurg.com/doi-vd01en2108.htm

Laparoscopic and transgastric stapled resection of a posterior gastric stromal tumor

1. Gastrotomy 00'20''

My plan is to locate this tumor. We just have a small lesion at the serosal side of the stomach so I don’t know if it’s something related to this submucosal tumor. I’ve got the feeling when I palpate this area that I have a mass. We have this small lesion there and I don’t have the endoscopist now because he checked that endoscopically and he thought it was impossible to remove it from the stomach, so when I mobilize a little bit the stomach and try to palpate, you can see that there is probably a mass there. On the preoperative CT-scan or MRI, I think that it’s related to the anterior wall of the stomach, so probably what I’m going to do is a small gastrotomy there and check the size and extent of this tumor. We have the feeling that there is a small umbilication there so probably the tumor is there. Can we do a big wedge resection here with 2 triangular resections using 2 GIAs and afterwards you can open again your staplers? I’d do a free hand but I’d make the incision close to the lesion I think because it’s going to be difficult to close the stomach without making a narrow? But do you think it would help to have a flexible endoscope inside at the same time? I don’t think so because apparently this tumor when I’m mobilizing the gastric wall, we’ve the feeling that it’s located in this area. The most important thing is to watch and identify this tumor so to open here, I’m probably a little bit far from the tumor and then I can adapt my stapler to be sure that I’m removing everything. I’ll do my gastrotomy here and if I have to remove this part, it’s not a big deal. Again I’m coming with this very nice instrument because usually the gastric wall is bleeding quite easily. Do you have a gastric tube in the stomach? Yes initially, we start with the gastric tube inside. So we’ll grab the mucosa on the other side. This is the tumor. That’s too big to pull up the esophagus; yes indeed. Now I’m going to extract this tumor so I can staple from inside. Don’t you think it’s important to excise that dimpled part of the gastric wall? On the serosal side? I think so. My hole is a little bit too short so I’ll enlarge it a bit. Could you just excise all the way around and then close it transverse? I could do that but I prefer to do it with a stapler because it’s easier. I want to get it out and then staple from outside. I enlarge that a bit in order to manipulate it more easily.

2. Tumor resection 05'00''

You see that it’s quite large. We can control on the other side. So if I staple that, probably I’ll be OK. Probably the zone with the retraction is coming in my excision. What do you think of that? Do you think you got the serosal part? I think so! I’m good with margins on the inside, which look OK. We’ll put the bag and then check. This is a big kidney-type bag because of its impermeability or you’re concerned that you might damage this tumor when you’re removing it? Yes, it’s very strong. So you can see that we remove this little lesion from outside.

3. Closure of gastrotomy 07'12''

It looks good and doesn’t bleed too much because usually we’ve to check the staple line. Why didn’t you use the ultrasonic device to cut the stomach around the tumor base and you’d have one hole instead of 2 to suture? If I would have done it from outside, I should have had an intragastric control with the endoscope to make sure that my margins were good enough; in such conditions, I wouldn’t have opened the stomach but I like it this way because I can control exactly the margins but to do that, I need a hole. I’m uncomfortable with the fact that we still haven’t looked at the specimen because we don’t know exactly what the margins on the gastric wall is around the tumor. Would you open the specimen on the back table? Yes sure! I want to close my stomach first. Because if I’m extracting the tumor, by now I’ll have some leak on my trocar, and even if I have to redo it, I prefer do that now. It’s no big deal. Everything is closed. We’re just deferring the gradification. What are the security margin limits that you consider essential for GIST? I think 1cm. It’s true as long as the margin is free. We can do a frozen section as well.

4. Specimen extraction 09'45''

The suture line looks OK. Now we try to remove this bag. The most annoying part of the operation is that we need to extract this specimen. So I’ll divide the aponeurosis a little bit. This bag is good because it’s very strong. Usually you open the bag before getting it out. Do you want me to open the specimen? It looks really soft. Yes it is. I don’t think it’s a GIST. I think that because of the patient’s history with acute bleeding at the centre of the tumor usually it’s a lipoma with a little artery. You see the mucosa is not invaded as you can see clearly. Your margin is adequate. This is the serosal part and here the mucosal part so you see I’m very large. The stomach is closed. I’ll check for bleeding. It’s over.