Alexandra W Elias, MD, Timothy A Woodward, MD, Steven P Bowers, MD. Mayo Clinic FL
This video demonstrates laparoscopic intragastric resection via combined laparoendoscopic technique with mucosal closure.
A 43-year-old female underwent an upper endoscopy for chronic nausea, and a submucosal tumor was revealed in the gastric cardia, just distal to the gastroesophageal junction. Endoscopic ultrasound and fine needle aspiration were consistent with a 2.7cm leiomyoma. CT demonstrated the mass abutting the GE junction without evidence of metastasis.
Laparoscopic intragastric resection was planned.
After the induction of general endotracheal anesthesia, the patient was placed supine.
An infraumbilical Hasson cannula was placed for exploratory laparoscopy, which demonstrated no sign of metastatic disease. A 5 mm port was placed to allow exposure of the anterior stomach by moving the omentum.
Endoscopy was performed to visualize the mass.
The abdomen was desufflated, and three one-step dilating ports were placed into the stomach through the abdominal wall.
An endoloop was used to lasso the mass to allow easier dissection, and the plane was initiated using an endoscopic retroflexed hook knife.
Initially we felt the dissection could be accomplished endoscopically with the assistance of laparoscopic intragastric retraction; however, due to concern for muscular involvement, we decided to use the larger laparoscopic hook on electrocautery for dissection.
We were able to enucleate the mass from the muscle, preserving the gastric sling fibers, by using the back of the hook to bluntly push muscle fibers away and the tip of the hook to deliver punctate cautery to lyse connections to the mass, taking care not to rupture the capsule.
Once the encapsulated mass was freed, it was placed into a Roth net and retracted flush against an endoscopic overtube, then removed through the mouth.
A 3-0 barbed suture was used to close the mucosal defect transversely, taking small bites of muscle to close the space.
The one-step trocars were exchanged for balloon-tipped trocars, and interrupted silk suture was used to closed the gastrotomy sites in a Witzel suture fashion.
The omentum was then replaced over the stomach.
The stomach was externally examined at the hiatus before repeating endoscopy, which confirmed our mucosotomy was closed securely and that there was no leakage from our gastrotomy sites.
Pathology revealed at 2.5 cm benign leiomyoma.
Upper GI study on postoperative day one demonstrated contrast flowing freely from the esophagus through the stomach without evidence of leak. The patient tolerated a blenderized diet and was discharged home.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 94767
Program Number: V185
Presentation Session: Video Loop Day 1
Presentation Type: VideoLoop