Technical details of five minimally invasive approaches for resection of gastric stromal tumors

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Technical details of five minimally invasive approaches for resection of gastric stromal tumors

Authors

S Sereno, J Leroy, D Mutter, B Dallemagne, D Coumaros

Media type

Surgical video

Duration

07'20''

Publication

2006-10

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E-publication

WeBSurg.com, Oct 2006;6(10).
URL: http://www.websurg.com/doi-vd01en1941.htm

Technical details of five minimally invasive approaches for resection of gastric stromal tumors

1. 1st case 00'12''

The first lesion is in the fundus of the stomach. It is 1cm and it’s positioned anteriorly. A combined endoscopic and laparoscopic approach was used. This is the MRI scan. Here we see the endoscopist and now the inside laparoscopic view.

2. Endoscopic view 00'32''

Here we have the endoscopic view showing the lesion in the fundus of the stomach.

3. Laparoscopic view and treatment 00'44''

A suture is placed laparoscopically. This is in order to enable the wall of the stomach to be introduced into the jaws of the stapler.

4. 2nd case 01'02''

The 2nd lesion is in a similar position. However, this time it was located posteriorly.

5. Laparoscopic wedge resection 01'11''

We decided to adopt a laparoscopic gastric wedge resection approach. The procedure starts with opening of the gastrocolic omentum using monopolar diathermy. This then allows us into the lesser sac. The posterior wall of the stomach is grasped using a suture. This is once again used as a retractor in order to draw the posterior wall of the stomach into the jaws of the stapler, and by this method this GIST tumor is resected.

6. 3rd case 01'49''

The 3rd lesion is shown here. Cross-sectionally you can see it’s a large 5cm posteriorly positioned lesion. We use a transcutaneous transgastric approach.

7. Transcutaneous transgastric approach 02'05''

In order to perform this successfully, we must first of all draw the anterior surface of the stomach up onto the abdominal wall. This is done using transcutaneous sutures which will act as retractors in order to ensure the anterior abdominal wall is kept in close contact with the stomach. The next thing we do is to make a small gastrotomy using the Ultracision. The next stage is to introduce specialized laparoscopic port with a balloon at the end of it. This is introduced through the abdominal wall and then into the gastric cavity itself. We get an inside view of the stomach now and see the lesion. Following this, further ports are introduced into the stomach. This allows us to perform a transgastric resection of the lesion. Ultracision is used once again. The mucosa of the stomach is opened. Then gentle dissection is performed underneath the lesion to remove it in its entirety. The mucosal defect is then closed using intragastric suturing. The lesion is placed in a bag. The bag is then sutured to the nasogastric tube which is then retrieved by the anesthetist. By this method, the GIST is retrieved per-orally. The bag is now being retrieved. We can see the lesion which is approximately 6cm in diameter. Finally the gastrotomies that were made in order to introduce the trocars are closed by intracorporeal stitches.

8. 4th case: laparoscopic gastrotomy 04'22''

The 4th case is a prepyloric lesion. This was a pedunculated lesion situated posteriorly. A laparoscopic gastrotomy is used. We can see the port sites arranged here and now the internal view. A large pedunculated lesion within the stomach is seen. The stomach is opened using ultrasonic dissection and now we can see the lesion which is popped out through the gastrotomy we have made into the abdominal cavity. The lesion is resected using the stapler. Following this, the gastrotomy is closed with intracorporeal suturing. The lesion was 5cm in diameter and here we can see an internal view.

9. 5th case: laparoscopic antrectomy 05'40''

The 5th case is a 5cm antral lesion, and this was removed by laparoscopic antrectomy with Roux-en-Y reconstruction. We see here the CT-scan showing the lesion. Dissection is started using the LigaSure device. Once the antrum is being mobilized, it can then be resected. We do this using the stapler once again. This is the largest resection we had to perform in order to remove the GIST in this series. Once the antrum is being removed, we then open up to go through the mesocolon and we can perform the Roux-en-Y reconstruction. The posterior wall of the stomach is sutured and secured to the mesocolon. Following this, the anastomosis is performed. There were no complications in this series and all pathological reports confirmed the presence of GIST which had been completely resected with at least a 1cm margin.