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Laparoscopic small bowel resection for bleeding GIST

Authors

Abstract

Gastrointestinal stromal tumors (GIST) are rare tumors and can be a cause of gastrointestinal bleeding when others causes have already been excluded. This video shows the laparoscopic resection of an ileal GIST using a three-port approach.

Keywords

Laparoscopy, small bowel resection, bleeding GIST

Media type

Duration

17'40''

Publication

2011-12

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Audio

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E-publication

WeBSurg.com, Dec 2011;11(12).
URL: http://www.websurg.com/doi-vd01en3452.htm

Laparoscopic small bowel resection for bleeding GIST

1. Introduction 00'16''

This video presents the case of a patient with digestive bleeding, which manifests itself by melena and chronic anemia. The patient has a history of left colon surgery for cancer. He benefited from a segmental colectomy with adjuvant therapy. It is essential to point out that a small bowel resection for tumoral adhesions was carried out during the colectomy. The patient was admitted to our department for anemia. The examinations revealed a normal gastroscopy as well as a normal colonoscopy. CT-scan images revealed a suspicious mass at the level of the small bowel loops. The CT-scan shows this lesion in a sagittal plane as well as in a transverse plane. A video-capsule is carried out. It demonstrates some bleeding, but without visualizing any tumor. A double-balloon enteroscopy can allow for the visualization of the tumor, but the biopsies are not contributory. In the setting of an active bleeding, a surgical resection is decided upon.

2. Trocar placement 01'22''

A laparoscopic approach is used, with three trocars put in place, one umbilical trocar, and two trocars in the patient’s right flank, in order to obtain a triangular approach towards the lesion, which is suspected to be located in the left side of the abdomen. The proximal small bowel is initially unrolled in order to locate the tumor.

3. Tumor identification 01'42''

Given its size, the tumor is quickly identified. It represents an important mass with an infiltration of the mesentery, and what seem to be a few adenopathies at the level of the mesentery’s root corresponding to the lesion. Macroscopically it is difficult to say which type of lesion this is, given the patient’s colonic history, it could be a lymph node metastasis. A wide resection is thus decided upon, removing the corresponding meso for curative purposes.

4. Ileal resection 02'30''

The distal level of the resection is identified. An incision is made into the mesentery using the Ligasure® vessel-sealing device, and a division of the bowel is carried out using the Endo-GIA® linear stapler. The limits of the resection are marked at the level of the mesentery. It corresponds to a triangular resection targeting the vascular pedicle, which corresponds to the lesion. The lesion’s vascular pedicle seems large. When the limits of the resection have been determined, the Endo-GIA® stapler is applied at the level of distal resection of the tumor. Resection margins are well preserved. The tumor and the corresponding small bowel will then be mobilized. This tumor is unrolled in order to clearly identify its anterior and posterior limits and confirm the extension of the area which should be resected. The proximal resection level is therefore determined. The proximal loop is fixed to an omental adhesion, to allow for its easy localization after the resection. The digestive division will also be carried out using a white cartridge Endo-GIA® stapler since it is applied on the small bowel. It should be pointed out that no suspicious secondary lesion was found in the patient’s colonic cancer staging. The bowel was resected proximally and distally. The intervention should then be carried on towards the vascular pedicle. This dissection is facilitated by the use of the Ligasure® vessel-sealing device, especially in a fairly adipose mesentery. All secondary vascular branches are easily controlled by means of the Ligasure® device, but the main pedicle is very dense, and a mere use of the Ligasure® device does not seem sufficient. Therefore, the ligature of the mesentery’s origin will be carried out using the Endo-GIA® stapler as well. During the dissection, it is essential to keep vascular landmarks with regards to the position of the superior mesenteric vessels, which may be drawn and retracted on the meso, and therefore present a risk during this dissection. The main vascular pedicle of the considered small bowel segment is identified and the Endo-GIA® stapler is applied. A vascular white cartridge is once again used. It allows for a sharp and safe division of this voluminous vascular pedicle. The specimen is placed into an Endocatch™ bag. It will be extracted through one of the trocars’ introduction site after additional placement of a parietal wound protector. The previously attached proximal loop is easily identified. The distal division level is also identified. The absence of twist at the level of the mesentery is controlled. A small segment of the distal small bowel will be once again resected considering the presence of small vascular disorders and to ensure a safe anastomosis.

5. Anastomosis 07'21''

The anastomosis will be performed in a side-to-side fashion using a mechanical stapler. The proximal segment of small bowel is freed. The proximal and distal segments will be approximated and attached by two stitches, which will allow for an easy manipulation of the stapled area. The anchoring stitches allow for an easy handling of the 2 bowel segments, and especially so during introduction of the Endo-GIA® linear stapler. Several techniques of anastomosis exist but it seems to us that the latter is one of the most adequate and the easiest to perform. The Endo-GIA® linear stapler will once again be equipped with a white vascular cartridge, generally recommended for small bowel anastomosis or division of the small bowel.

6. Closure of enterotomies 08'48''

Two short enterotomies are carried out using the hook, which is a precise and appropriate instrument in the present case. Consequently, the enterotomies will be easily re-sutured once the anastomosis has been performed. The Endo-GIA® linear stapler is introduced through a 12mm port located in the patient’s left iliac fossa. The entire procedure has been performed with 3 ports only. As soon as the anastomosis has been carried out, the enterotomy should be sutured. The running suture that is carried out is made up of 3/0 monofilament material. Once the enterotomy has been closed, it is extremely important to control the mesenteric defect to prevent any internal herniation. The closure of the mesenteric defect will also be performed by means of an absorbable monofilament suture. As soon as the mesentery has been closed, the specimen, which had been placed into an Endocatch™ bag, is extracted as mentioned earlier through an enlarged trocar introduction site in the right iliac fossa. The patient’s postoperative outcome was uneventful. The patient was discharged on postoperative day 3. Pathological findings confirmed the presence of a 5cm gastrointestinal stromal tumor with 17 lymph nodes identified at the level of the mesentery without any tumor involvement. It corresponds to a GIST classified as 6A in the Miettinen classification—which is a risk classification for such tumors. The pathological examination confirmed a KIT exon 9 mutation. In this patient presenting with a risky GIST tumor, an adjuvant Gleevec (imatinib) therapy has been proposed.

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