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Laparoscopic enucleation of leiomyoma of the GE junction

Authors

B Dallemagne, C Callari, L Soler, J Marescaux

Abstract

Gastric leiomyoma is an uncommonly found benign submucosal neoplasm that may cause bleeding in rare cases. This video demonstrates a laparoscopic enucleation of a leiomyoma of the GE junction.

Keywords

leiomyoma, cardia

Media type

Duration

12'32''

Publication

2011-10

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E-publication

WeBSurg.com, Oct 2011;11(10).
URL: http://www.websurg.com/doi-vd01en3465.htm

Laparoscopic enucleation of leiomyoma of the GE junction

1. Clinical case 00'19''

In this video, we report the case of a 59-year-old patient who does not have any particular past medical history, except gastroesophageal reflux. During gastroscopy, a voluminous submucosal tumor was found at the gastroesophageal junction. CT-scan and 3D reconstruction demonstrated its volume and localization just at the level of the junction. Differential diagnosis suggests that it is either a leiomyoma or a GIST. However, the shape delineated at reconstruction allows to suspect the presence of a leiomyoma. A GIST would have a more regular shape.

2. Laparoscopic approach 01'05''

A laparoscopic approach is used. Five ports are placed for surgery of the gastro-esophageal junction. Port placement is conventional and similar to the one used in surgery for reflux or achalasia. Entrance into the peritoneal cavity is easy. Palpation helps to feel the tumor located just at the gastroesophageal junction. Based on preoperative imaging, the decision is made to approach the anterior gastric wall.

3. Gastric fundus mobilization 02'05''

The extremity of the gastric fundus is prepared in order to improve the mobility of the gastroesophageal junction and to facilitate dissection.

4. Intraoperative endoscopy 02'20''

An intraoperative endoscopic exploration is performed to perfectly locate the tumor and to opt for the most appropriate approach at the level of the gastric wall. The whole dissection is performed using the Ligasure® device. Only the superior portion of the gastric fundus is mobilized in order to improve access. As soon as the mobilization is complete, endoscopy is used to guide the dissection. Palpation helps in identifying the shape of this submucosal tumor. Its stretched and multilobar aspect is evocative of a leiomyoma.

5. Tumor location 03'17''

Gastroscopy confirms the anterior location of the tumor. Therefore, the approach will be carried out through the anterior gastric wall and the anterior wall of the gastroesophageal junction. As soon as the lesion has been identified, the endoscope is withdrawn in the esophagus. Indeed, an additional control may be necessary during the intervention.

6. Precardial fat dissection and jonction exposure 03'50''

The anterior wall of the junction is exposed by dissecting the precardial fat pad. During exposure, it is necessary to respect the anterior vagus nerve, which will be grasped into the fat pad and retracted to the right of the esophagus. By definition, leiomyomas develop at the level of the muscular wall of the stomach or of the esophagus. It is possible to approach them by opening the muscular wall. An endoscopic approach is also possible once the mucosa has been incised. This is however a recent technique that has not been validated. The gastroesophageal junction is now perfectly exposed. As a reminder, the vagus nerve is preserved in the mobilized precardial fat pad.

7. Muscular layer incision 05'05''

The muscular layer of the gastro-esophageal junction will be incised. This incision will allow to access the leiomyoma. A leiomyoma is a benign mesenchymal tumor. Its elective enucleation appears to be the treatment of choice. In such situations, it is unnecessary to perform partial gastrectomies, except in very particular locations. The incision is carried out by means of a hook as for a myotomy for achalasia. Pressure on the gastric wall allows to bulge the leiomyoma. Its shape and macroscopic aspect are typical. One can see that this tumor has developed at the level of the muscular fibres, which are perfectly visualized thanks to the high definition camera.

8. Leiomyoma dissection 06'33''

The cleavage in the mucosa of the junction should be well identified. Dissection should be carried out without tearing the mucosa. To do so, a thread is passed into the leiomyoma, thus facilitating mobilization during the cleavage process, which should be achieved progressively. The cleavage can be performed in different ways. Generally speaking, the coagulating hook allows for the most accurate possible dissection. As a matter of fact, dissection by means of the cold scalpel or the scissors can lead to rapid bleeding and loss of the landmarks in the cleavage plane. The cleavage plane can be well seen here. It is located between the mucosa and the leiomyoma, which is progressively removed and enucleated. Careful traction should be exerted on the leiomyoma so as not to break it off, since removing the whole leiomyoma remains the main objective of the procedure. Here you can see again an excellent view on the cleavage plane in the mucosa. Traction exerted at the level of the mucosa should be extremely careful so as not to perforate it. In case of perforation, the treatment is quite simple: a stitch should be placed on the mucosa and then buried by the suture of the muscular layer of the junction. The extremity of the leiomyoma can progressively be seen here as well as the cleavage plane. The latter allows to assess the whole removal.

9. Endoscopic control after dissection 10'04''

As previously discussed, the endoscope is used to identify the location of the tumor and is left in place in the esophagus. It will be used to check that there is no leakage at the level of the GE junction mucosa after resecting the tumor.

10. Myotomy suturing 10'42''

The myotomy area will be sutured using a Vicryl 3/0 absorbable running suture. The tumor is placed in an extraction bag. It will be removed at the end of the procedure. The suture is started on the superior portion of the myotomy. The mucosa looks intact. It could be left that way but this would imply a risk of pseudo-diverticulum associated to mucosal bulging through the myotomy. It is therefore preferable to repair the muscular structure of the junction. The endoscopic control allows to eliminate any lesion in the mucosa. The myotomy suture is then completed. The intraoperative gastroscopy also allows to rule out the presence of stenosis during the myotomy suture. No drainage is placed at the end of the procedure. The trocars are removed under visual control, and the bag containing the specimen is taken out through one of the openings made for trocar insertion.

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