Single-Port access transgastric technique for a gastric GIST

Martin Gascon, MD, Jesus Garijo, MD, Cesar G Llorente, MD, Alberto Pueyo, MD, Matias Cea, MD. Hospital de Torrejon de Ardoz, Madrid, Spain.

OBJECTIVE OF THE STUDY
Gastrointestinal stromal tumors (GISTs) are the commonest type of mesenchymal neoplasms of the gastrointestinal tract. 60% occur in the stomach. GIST of 20 mm or larger in size should be surgically resected while the attitude facing a tumor lesser in size remain controversial. Depending on their location, different laparoscopic wedge resections techniques have been increasingly used in the last years.
Single-Port access is a minimally invasive surgical procedure which leaves only a single scar, generally undetectable. Compared to conventional laparoscopy, it may be associated with less postoperative pain, faster recovery time, fewer complications and better cosmetic results.
We communicate the excision of a gastric GIST utilizing a SPA transgastric procedure.

DESCRIPTION OF THE METHOD
Surgery started with an endoscopic examination to locate the tumor. The anterior gastric wall where the incision was planned was endoscopically illuminated and brought to the anterior abdominal wall, where a 25 mm incision was performed in the midline, 2 cm above the umbilicus. Several points fixated the stomach to the anterior abdominal wall. The gastric wall was then vertically incised 2 cm under direct vision thus allowing the introduction of the QuadPort through the gastrostomy. A 5 mm 30 degree videolaparoscope was used, combined with 5 mm laparoscopic non-articulated graspers and shears. The tumor was evident and transected. Two sequencial cartridges were required. The specimen was removed maintaining its anatomical integrity.
Hemostasia of the operative field was ensured with 5 mm surgical clips. The QuadPort was removed, the defect was handsewn closed and the stomach was loosened from the abdominal wall.

RESULTS
There was no need of optional accesses. Operative time was 80 minutes and the patient was discharged 75 hours after surgery without specific analgesia requirements (only on-request conventional analgesia). Cosmetic appearance of the incision was very satisfactory.
A firm, well circumscribed tumor of 29x 28x 25 mm in size was sent to patological examination. Histologic analysis yielded positive results for KIT (CD117) and CD34 and negative for S-100. Besides, mitotic rate was <5 mitoses/50 HPFs. Pathologic diagnosis was benign GIST with negative lateral and vertical margins.

CONCLUSION AND EXPECTATIONS
With the SPA transgastric approach that we describe, a direct exposition of the tumor is ensured and the tumor can be easily excised with appropiate margins, avoiding the transection og large sections of healthy stomach. On the other hand, it offers reduced operative times when compared with combined laparoendoscopic procedures. Finally, potential advantages of SPA surgeries may also be applied.

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