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Transgastric laparoscopic resection of a GIST

D Mutter, MD, PhD, FACS M Nedelcu, MD J Marescaux, MD, FACS, Hon FRCS, Hon FJSES, Hon FASA, Hon APSA
Epublication WebSurg.com, Jan 2014;14(01). URL: http://websurg.com/doi/vd01en3723

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  • 2014-01-06
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Laparoscopic intragastric surgery (LIGS) represents a minimally invasive technique for lesions that mainly exist in the gastric lumen or at the gastroesophageal junction. Ohashi initially described this technique in 1995 to resect early gastric cancers that could not be treated by Endoscopic Mucosal Resection (EMR). Since then, it has evolved with respect to both technological advances (e.g., development of cuffed ports) and tactical innovations. As the peritoneal cavity represents the working space for laparoscopic surgeons, they have imagined to work directly into the stomach by respecting the same principles of basic laparoscopy, namely insufflation to create a new operating space, introduction of surgical instruments through working ports and the use of different techniques of dissection. The aim of this video is to describe the technical principles of this new approach as it offers a valuable option for the surgeon in the management of gastric tumors and early cancers. It may avoid major surgical procedures, especially for the management of lesions located at the esophagogastric junction. Selected indications have to be identified thanks to adequate preoperative workup including endoscopy, endoscopic ultrasonography, and conventional imaging (CT-scan and MRI). Our standard approach for a laparoscopic intragastric surgery is represented by multiple intragastric ports approach. Resection can be performed as a standard submucosal dissection, but most of the time, the use of stapling is preferred for many reasons, including speed, safety and reliability as illustrated in this video. In well-selected cases (pedunculated tumors), the advantage of this technique is to obtain resection and hemostasis simultaneously, with the same instrument. However, achieving adequate margins can be difficult, and the risk of tumor rupture might be increased, particularly in case of gastrointestinal stromal tumors (GISTs). When all inclusion criteria and technical principles are respected, this new minimally invasive approach offers major benefits for patients. It ensures the preservation of an almost normal anatomy by preserving the gastroesophageal junction as well as a simple postoperative course.