Shuji Kitashiro, Kazuyuki Yamamoto, Kurumi Iwaki, Takanobu Onoda, Masaya Kawada, Yoshinori Suzuki, Yo Kawarada, Tetuyuki Okubo, Shunichi Okushiba, Hiroyuki Katoh, Tetsuya Sumiyoshi, Hitoshi Kondo, Ayano Mori
KKR Tonan Hospital Sapporo Japan
AIMS To determine our indication for collaboration of laparoscopic and endoscopic methods for the resection of gastric submucosal tumors.
METHODS AND PROCEDURES Hiki et al proposed a method called Laparoscopic Endoscopic Cooperative Surgery (LECS) in 2007, which combined intraluminal endoscopy and laparoscopic method for resection of the submucosal tumors. This allowed surgeons to resect the tumors with minimal margin. Our center has been routinely applying this method for gastric submucosal tumors since May 2010. We have also been doing the same procedure using multiple trocar single port laparoscopic method whenever possible. In this study, 13 cases treated between May 2010 and June 2012 were reviewed.
The location of the tumor is confirmed laparoscopically and endoscopically. Blood vessels and other tissues near the tumors are dissected laparoscopically, skeletonizing the the tumor area. Mainly we treated the 13 cases in the full-thickness incision or seromyotomy.
For most of the submucosal tumors, endoscopist marks the mucous layer around the tumor using needle knife. Glycerine dyed with ink is then injected in submucosal layer. IT knife is then used to dissect the mucous layer around the tumor. After this, the whole layer of gastric wall is cut from the caudal side of the tumor along the cut edge of mucosa. This procedure is assisted laparoscopically and is continued until the tumor can be overturned into abdominal cavity. Rest of the gastic wall around the tumor is dissected using ultrasonic coagulating shears following the mark endoscopist earlier set. The defect area is generally closed by intracorporal continuous suture using absorbable sutures for the mucosal layer and interrupted suture of non-absorbable sutures for serous and muscular layer. In the case of GIST with ulcerative lesions, we apply modified version, considering the risk of dissemination. After the location of tumor is confirmed, glycerin dyed with ink is injected endoscopicaly in the submucosal layer of the Serous and muscular layer around the tumor is dissected laparoscopically until we reach the submucosal layer. Once submucosal layer is exposed all around the tumor, the tumor is pulled outwards towards the intra-abdominal cavity and the mucosa around the tumor is closed using the stapler. We add interrupted sutures in serosal and muscular layer if not closed by the stapler.
RESULTS The tumor was located in the upper in 9, the middle in 3, the lower in 1 in 13 patients. We could treated regardless of location. Average size of tumor is 37.6mm in the 8 patients treated in full-thickness incision and 31.5mm in the 4 patients treated in seromyotomy. But we often choosed full-thickness incision if tumor was 3 cm and over. We have 5 cases using multiple trocar single port laparoscopic method. All procedure was performed with negligible blood loss. Post-operative course of the patients were uneventful. All the tumors were resected with negative margin.
CONCLUSION By collaborating laparoscopy and endoscopy we have been able to do minimally invasive surgery to resect gastric submucosal tumors with minimum possible margin safely and have been able to preserve the function of stomach.
Session: Poster Presentation
Program Number: P526
