Laparoscopic gastric diverticulum resection: a novel approach

John M Shellenberger, MD, Arthur Rawlings, MD, MDiv, Wayne Hudec, MD, Jason Mizell, MD. University of Missouri – Columbia.

Introduction:
Gastric diverticuli are infrequent, and rarely symptomatic. Those causing symptoms are most often treated medically. Surgical treatment has been described, including laparoscopic methods. We present a novel laparoscopic method to resect a symptomatic posterior gastric diverticulum.

Case Report:
A 43-year old female presented with a one-year history of postprandial nausea, epigastric pain, dysphagia and weight loss. Esophagram showed a normal esophagus with a gastric diverticulum. Computed tomography scanning revealed normal findings. We performed an esophagogastroduodenoscopy, confirming a large, broad-based posterior gastric diverticulum with mild gastritis. Antral, duodenal and random biopsies were unremarkable. Laparoscopic diverticulectomy was then performed via a pars flaccida technique, avoiding lateral dissection and short gastric ligation. Four laparoscopic ports were utilized. The liver was elevated and the lesser sac entered with the ultrasonic shears. The 8 x 3cm diverticulum was identified and retracted medially, then resected using several gastric staple loads using the endoscopic stapler. The patient was discharged the following morning tolerating a regular diet. At follow up, her symptoms had completely resolved, and no longer required proton pump inhibitors.

Discussion:
Previous reports of laparoscopic gastric diverticulectomy have focused on lateral approaches, requiring short gastric vessel ligation. We, however, proceeded with a medial approach, through the lesser sac along the lesser gastric curve. More than 75% of gastric diverticuli are located along the posterior aspect of the stomach. Our approach allows for excellent access and visualization to perform diverticulectomy for these posteriorly located lesions. Additionally, we avoid traction injury to the short gastric vessels and the spleen through the medial approach, decreasing risk of hemorrhage or conversion to open. Further, most reported cases utilized intraoperative endoscopy to aid visualization laparoscopically. We found this unnecessary with the medial approach.

Conclusion:
Gastric diverticuli are rare lesions that, when symptomatic, may be safely and successfully resected using a novel laparoscopic approach through the lesser sac.