Transgastric Large Organ Extraction; the Initial Experience

Takayuki Dotai, MD, Alisa Coker, MD, Luciano Antozzi, MD, Geylor Acosta, MD, Masayasu Aikawa, MD, Nikolai Bildzukewicz, MD, Marcos Michelotti, MD, Bryan Sandler, MD, Garth Jacobsen, MD, Mark Talamini, MD, Santiago Horgan, MD. Center for the Future of Surgery, Department of surgery, University of California, San Diego

Introduction
In laparoscopy, it is often the case that port sites are enlarged for specimen extraction. This leads to higher risk of trocar site complications such as infection or incisional hernia. Natural orifice surgery (NOTES) is beneficial for minimizing these complications, and this is emphasized when the extracted specimen is of large volume. We have been using transgastric technique for appendectomy, cholecystectomy, and laparoscopic sleeve gastrectomy (LSG). Of these transgastric operations, we focus on the one with relatively large organ extraction, i.e. LSG with TransOral Remnant Extraction (TORE). We describe the details and feasibility of this procedure and compare the outcomes to conventional LSG.

Methods and Procedures
All patients undergoing LSG were considered candidates for TORE, and were consented for this procedure if interested after an informed discussion. 18 LSGs with TORE (TORE group) and 10 conventional LSGs (non-TORE group) were performed from August 2010 to March 2011. We retrospectively compared these two groups for the age, sex, preoperative BMI, OR time, hospital stay, estimated weight loss (EWL), and trocar site complications.
Laparoscopic sleeve gastrectomy with TORE consists of conventional LSG and transgastric retrieval of the resected stomach. The procedure exceeds exactly the same manner as convenional LSG until the initial stapling of the stomach. For TORE, the gastrectomy is initiated 5cm proximal to the pylorus than usual LSG to save the space for the gastrotomy used for specimen retrieval. After the gastrectomy is completed, the full thickness of the distal most part of the staple line is incised open as wide as 2cm, using electric cautery or ultrasonic dissector. A flexible upper endoscope, which has been in the stomach already as a bougie for gastrectomy, is then guided into the peritoneal cavity through the gastrotomy. The specimen is grasped endoscopically with a snare and extracted transorally. Following this, the gastrotomy is closed laparoscopically. The final shape of the gastric sleeve is identical to the one of conventional LSG.
 

Results
There was no significant difference between the TORE and the non-TORE group for patients’ profile, OR time, hospital stay, and EWL. Neither group has experienced peri-operative complications. All the specimens were extracted readily and safely in the TORE group. Out of the 10 cases in the non-TORE group, 4 required extension of the trocar site. No trocar site complications were found in the TORE group, whereas the extended trocar site developed panniculitis in 2 cases of the non-TORE group; one requiring panniculectomy for refractory induration.
 

Conclusion
TORE can be safely and easily performed by surgeons with laparoscopic and endoscopic skill, and with commonly available instruments. While producing identical outcomes, our initial experience with the TORE technique demonstrates an advantage over traditional LSG in that it minimizes trocar site complications. Transgastric organ extraction is potentially applicable to other large organ extractions in laparoscopic surgery without added risks or resources. Larger case volume and longer follow-up period is awaited.