Laparoscopic partial gastrectomy for GIST

This video shows a laparoscopic partial gastrectomy of a gastrointestinal stromal tumor (GIST) with a low mitotic count located at the lesser curvature of the stomach. This low-grade tumor was found as the patient complained of chronic abdominal pain. The CT-scan evidenced the presence of a 5 by 6cm lesion at the lesser curvature between the anterior and posterior aspect of the stomach. No metastatic lesion was found during the preoperative work-up. Gastroscopy showed an extrinsic lesion at the lesser curvature of the stomach and an approximately 5 by 6cm GIST was suspected. This is why the laparoscopic approach was decided upon.

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Laparoscopic partial gastrectomy for GIST

Authors

F Costantino, B Dallemagne, L Soler, J Marescaux

Abstract

This video shows a laparoscopic partial gastrectomy of a gastrointestinal stromal tumor (GIST) with a low mitotic count located at the lesser curvature of the stomach. This low-grade tumor was found as the patient complained of chronic abdominal pain. The CT-scan evidenced the presence of a 5 by 6cm lesion at the lesser curvature between the anterior and posterior aspect of the stomach. No metastatic lesion was found during the preoperative work-up. Gastroscopy showed an extrinsic lesion at the lesser curvature of the stomach and an approximately 5 by 6cm GIST was suspected. This is why the laparoscopic approach was decided upon.

Keywords

Laparoscopic partial gastrectomy, GIST

Media type

Surgical video

Duration

11'00''

Publication

2010-07

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E-publication

WeBSurg.com, Jul 2010;10(07).
URL: http://www.websurg.com/doi-vd01en2983.htm

Laparoscopic partial gastrectomy for GIST

1. Clinical case presentation 00'16''

We report the case of a female patient undergoing a partial gastrectomy for a gastrointestinal stromal tumor (GIST) with a low mitotic count located at the lesser curvature of the stomach. This low-grade tumor was found as the patient complained of chronic abdominal pain. The CT-scan evidenced the presence of a 5 by 6cm lesion at the lesser curvature between the anterior and posterior aspect of the stomach. The lesion is drained by terminal branches of the left gastric artery. Here the CT-scan image demonstrates a 5 to 7cm-diameter lesion in its anterior posterior position. No metastatic lesion was found during the preoperative work-up. Gastroscopy showed an extrinsic lesion at the lesser curvature of the stomach and an approximately 5 by 6cm GIST was suspected. This is why the laparoscopic approach was decided upon.

2. Trocar placement 01'15''

As can be observed, a 10mm optical port is placed at the level of the umbilicus. A 5mm port is placed at the crossing between the left mid-clavicular line and the umbilicus. This port will allow for an adhesiolysis using ultrasonic scissors (Ultracision™). Another 5mm port is placed half-way between the optical port and the xiphoid appendix. It helps to identify the lesion protruding on the anterior aspect of the stomach. The adhesiolysis is carried on towards the right hypochondrium, reaching the region where this patient had a cholecystectomy. The dissection is carried on toward the anterior aspect of the stomach and its upper extremity. At this moment, a temporary suture fixation is placed with Vicryl 2/0 material. The anterior aspect of the stomach is sutured to the upper portion of the tumor area and to the peritoneum, which can be found there. This allows for a correct exposure without using any additional port.

3. Anterior aspect of stomach dissection 02'42''

As we may well know, this suspected GIST lesion is drained by the terminal branches of the left gastric artery. This is why these branches are directly and progressively approached at the lesser sac or the lateral border of the lesser omentum (pars vasculosa). The dissection is carried out using ultrasonic scissors (Ultracision™). The objective is to entirely free the anterior aspect of the stomach and to expose both the anterior and posterior aspects of the stomach, which will define the division area. As this is an extrinsic lesion, a part of the mucosa will be resected to obtain sufficient safety margins during the pathological examination.

4. Lesser omentum dissection 04'29''

The procedure is continued with the dissection of the superficial layer of the peritoneum at the level of the lesser omentum. As can be seen here, one of the branches of the left gastric artery is controlled using Ultracision™. A direct branch that we thought to be correctly skeletonized is controlled. Our coagulation did not prove sufficient. It is why ultrasonic scissors are used once again, in conjunction with bipolar cautery. Therefore, bleeding control is achieved effectively. The dissection is carried on all along the lesser omentum for the final exposure. As can be noted here, attention is turned to the upper pole of the lesion. At this time of the procedure, we will consider whether or not the application of the mechanical suture will allow for an atypical resection. This is why the dissection is continued on the lower pole of the lesion until reaching the posterior aspect of the lesser curvature of the stomach. As previously performed, the terminal branches of the left gastric artery are controlled. These branches will only supply the area to be resected. Here, the lesser sac is freed.

5. GIST resection 07'27''

Next, the tumoral mass will be resected. To do so, a 60mm, articulated Endo-GIA linear stapler, blue cartridge, is fired through the right hypochondrium port. The temporary fixation suture that had been placed earlier is divided. It will allow for the correct orientation of the linear stapler, hence avoiding any stenosis. A second cartridge is fired and a small zone will be resected by applying a 45mm Endo-GIA linear stapler. Here a small bleeding is visible at the division line. An abdominal gauze pad will be used first. The specimen will then be placed in a plastic bag for extraction purposes. This will allow to reduce the risks of parietal contamination at the level of the specimen extraction site. As can be noted here, the first staples that had been fired first are partially closed. The closure of the serosal defect with Vicryl polyfilament 2/0 suture material is decided upon. The mucosal defect has already been correctly closed with the staples. As there is a bleeding at the stapling line, 3/0 PDS material is applied to make a burying running suture on the first division line. The running suture is terminated at the lower portion of the division line. Consequently, hemostasis is achieved.

6. Specimen extraction 10'25''

Next, the specimen is extracted through the left flank port. Hemostatic control is performed. A plastic wound protector is used. No drainage is placed. Here is the external view of the 6 to 7cm specimen along with the gastric portion of the lesser curvature and the lesion. The pathological examination confirmed the presence of a GIST with a low mitotic count.