Laparoscopic gastric resection for stromal tumor

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Laparoscopic gastric resection for stromal tumor

Authors

D Mutter, J Marescaux

Media type

Surgical video

Duration

07'00''

Publication

2005-08

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E-publication

WeBSurg.com, Aug 2005;5(08).
URL: http://www.websurg.com/doi-vd01en1681.htm

Laparoscopic gastric resection for stromal tumor

1. Case presentation 00'02''

This video demonstrates the case history of a female patient presenting with a tumoral mass at the level of the gastric antrum adjacent to the lesser curvature. Abdominal pelvic CAT-scan findings are consistent with the 4cm tumor located at the level of the antrum. As well MRI reveals the presence of a 4 by 3 by 2cm mass in this region developing along the posterior wall of the antrum consistent with the leiomyoma. Biopsy is consistent as well with a benign stromal tumor upon gastroscopy. Laparoscopic antrectomy is decided upon.

2. Patient and trocar positioning 00'42''

The patient is placed in a supine position. The surgeon stands between the patient’s legs, the first assistant to the right and the second assistant to the left of the patient. Five trocars are utilized. The optic trocar is placed at the peri-umbilical region, the 2 operative trocars approximately 10cm subcostal adjacent to the left and right mid-clavicular lines and 2 retracting subcostal trocars adjacent to the anterior axillary lines bilaterally. The patient is placed in reverse Trendelenburg. The procedure begins with the exploration of the abdominal cavity and identification of the limits of the lesser curvature in the gastric antrum. The tumor is posterior and not able to be localized during initial exploration.

3. Mobilization of the stomach 01'38''

The lesser peritoneal sac is opened with monopolar cautery. The vessel-sealing device Ligasure is used to free the gastric antrum and divide the gastroepiploic vessels supplying the greater curvature in this region. The lesser sac is then exposed and retracted and the anterior aspect of the pancreas and gastric antrum are clearly identified. The posterior surface of the stomach is freed using a Ligasure forceps and diathermy scissors. Stromal tumors are more common in the gastrum and increased size of greater than 6cm correlates with an increased risk of malignancy. Our patient’s tumor less than 4cm and in most cases the tumor arises from more proximally. However, our tumor arises in the antrum making the antrectomy the ideal procedure for this patient. Patient did note to have significant anemia and was traced positive under anemia hemocult test performed by the family practitioner. The Ligasure device is used quite extensively during this procedure as it adds significant time-savings in dissection through vascular planes. Traction and counter-traction maneuvers between the gastric antrum and the retrogastric tissue helped to find a correct dissecting plane without the risk of hemorrhage. The plane posterior to the proximal pylorus is now dissected with both the use of monopolar cautery and the Ligasure device.

4. Antrectomy 04'49''

The gastro-hepatic ligament is now noted and the scissors are used to open it creating the new circumferential dissection of the antrum.

5. Preparation of the anastomosis 05'19''

An additional port is placed to aid in the retraction of the liver. As seen here, the gastro-hepatic ligament is dissected further and dissection will begin on the lesser curvature of the antrum.

6. Gastroenteroanastomosis 06'04''

We ask the anesthesiologist to remove the nasogastric tube. This illustration shows the incisura angularis and the line of resection for antrectomy. Laparoscopic antrectomy is performed with sequential firings of the linear stapler device. One firing is required to fire across the distal stomach. The next operative step is to retract the transverse colon exposing the mesocolon. All these vessels are crucial in creating a mesocolic window. The gastric stump is approximated to the transverse mesocolon using 3 sutures to avoid herniation and allow for stability in performance of the gastroenteric anastomosis to come.

7. Specimen extraction 07'36''

Depending on the comfort of the surgeon, intra-or extra-corporeal knot-tying may be utilized. Once the stomach is fixed to the transverse mesocolon, an isoperistaltic gastroenteroanastomosis is performed. The identification of the proximal jejunum is then done and this is sutured to the posterior wall of the gastrum. An enterotomy is performed with the monopolar device as well as a gastrotomy. Note the stability of the operative field with the sutures placed previously. This aids in the placement of the Endo-GIA and the proper orientation of the viscera during the anastomosis. The Endo-GIA is now fired creating the anastomosis. To complete the closure of the gastroenteric anastomosis, 2/0 Vicryl sutures are then utilized. With the gastroenteric anastomosis, we find great success in beginning these patients, after an uneventful procedure, with liquids the following day. The ability to get the patient mobilized in ambulatory is greatly increased with the minimally invasive approach. The anterior mesocolic defect is now closed with suture to avoid herniation. The specimen is now removed with a bag. A benign stromal tumor was confirmed on histopathological analysis. This completes the procedure.