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Laparoscopic resection of gastric stromal tumor
Journal of Visceral Surgery (2010) 147, e359—e363
SURGICAL TECHNIQUE
Laparoscopic resection of gastric stromal tumor S. Al Rasheedi , H. Mosnier ∗ Department of Digestive Pathology, Deaconess Croix-Saint-Simon Hospital Group, 125, rue d’Avron, 75020 Paris, France Available online 18 November 2010
Introduction The surgical resection of gastric stromal tumors can usually be performed laparoscopically. The excision should strictly observe two principles: resection with tumor-free margins and avoidance of tumor fragmentation. This technique is therefore not suitable for voluminous tumors. In addition to endoscopy that evokes the diagnosis and echo-endoscopy that helps to confirm it, a preoperative CT scan is useful to assess the size of the lesion and define its extent. The difficulties of surgery vary with the location of the tumor within the stomach. We describe different strategies of laparoscopic resection for gastric stromal tumors up to 5 cm in diameter. After resection, oral feeding is usually resumed the next day.
∗
Corresponding author. E-mail address: [email protected] (H. Mosnier).
1878-7886/$ — see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2010.10.002
e360
S. Al Rasheedi, H. Mosnier
1
Various tumor localizations
2
Patient positioning, trocar placement, and instrumentation
Tumors situated away from the lesser curvature, cardia, and pylorus pose few problems for laparoscopic resection. It is sufficient to be able to obtain a sufficient margin of normal stomach. By contrast, resection of tumors located near the gastroesophageal junction (especially posteriorly), along the lesser curvature (and thus close to the nerves of Latarjet which may result in impaired antropyloric motility), or close to the pylorus (red zone) may pose specific problems which will be detailed here.
Trocar placement depends largely on the position of the tumor. In general, trocars should be placed somewhat low with a 10-mm optical trocar placed at or below the umbilicus. A 12-mm trocar for the introduction of a transecting linear stapler is usually placed in the left hypochondrium. In the right upper quadrant, a 5-mm trocar is usually sufficient, but do not hesitate to replace it with a 12-mm trocar in the event of difficulties in applying the transecting linear stapler. A 5-mm epigastric trocar is useful to retract and display the stomach. If the tumor requires an endogastric approach, an additional optical trocar may be placed superior to the initial optical trocar. An oblique viewing telescope is especially useful for tumors situated in inaccessible locations. The resected tumor is always placed in a retrieval bag for extraction.
Laparoscopic resection of gastric stromal tumor
3
Exposure of the tumor, preventive hemostasis
4
Tumor resection
The first step is to locate the tumor, with the help of findings from the initial endoscopy and CT scan. The tumor may be difficult to identify if it is mainly endoluminal. In this case, intraoperative endoscopy with partial desufflation of the pneumoperitoneum can be useful. Once the tumor has been localized, preventive hemostasis is performed using bipolar forceps to cauterize the vessels around its periphery.
For the most common tumor localizations, resection is performed using a linear cutting stapler, usually with a blue cartridge of 3.5 mm staples. The stapler should be applied, leaving a margin of healthy tissue of 5 to 10 mm. It is necessary to thoroughly expose the side of the tumor opposite to the side from which the stapler is introduced. If there are difficulties in applying the stapler, one should not hesitate to add an additional trocar or transparietal traction suture. It is often useful to place suture ligatures for additional hemostasis.
e361
e362
S. Al Rasheedi, H. Mosnier
5
Tumors situated on the vertical part of the lesser curvature
6
Tumors situated near the cardia
7
Endogastric resection
In this particular localization, the problem is to avoid injury to the nerves of Latarjet which descend in the adjacent lesser omentum. The stomach wall and the tumor must therefore be freed from the lesser omentum by dissection along the gastric margin, as well as by preventive hemostasis with bipolar forceps of vessels branching off the vascular arcade of the lesser omentum. Only then can the resection be performed, usually by a transverse application of the linear cutting stapler.
Tumors of the anterior surface of the cardia can often be addressed in the same manner as tumors of the body of the stomach. Some large tumors of the posterior cardia present a completely different problem which may require at least a partially endogastric approach. To avoid the need for complete mobilization of the cardia, it may be useful to perform the resection endogastrically. An additional optical trocar with a balloon is introduced midway along the xiphoidumbilical line. This trocar traverses both the abdominal wall and the anterior wall of the stomach. The stomach is held in suspension by inflating the balloon and CO2 is insufflated into the stomach.
The right and left upper quadrant trocars are advanced through the stomach wall. Now the resection can be performed in the usual manner with a linear stapler. The retrieval bag is inserted into the stomach to extract the resected specimen. The defects in the stomach wall are repaired as the intragastric trocars are backed out. This technique can also be extended to other difficult-toaccess locations such as the posterior aspect of the lesser curvature.
Laparoscopic resection of gastric stromal tumor
8
Resection of a juxta-pyloric tumor
9
Gastric repair after juxta-pyloric excision
The lack of an adequate margin of gastric wall in juxtapyloric locations often requires resection by scissor dissection with hemostasis of submucosal vessels using biplor forceps. Indeed, in this case, a linear cutting stapler may not function well because of the varying thickness of the gastric wall; stapler application may also damage the pylorus.
The repair of the gastric wall is performed by manual suturing. If there is any doubt about the quality of the suture line, it may be tested for leaks by insufflating the stomach through the nasogastric tube. Antral tumors situated on the horizontal portion of the lesser curvature and inaccessible to an anterior or endogastric approach may require a partial gastrectomy.
e363
SURGICAL TECHNIQUE
Laparoscopic resection of gastric stromal tumor S. Al Rasheedi , H. Mosnier ∗ Department of Digestive Pathology, Deaconess Croix-Saint-Simon Hospital Group, 125, rue d’Avron, 75020 Paris, France Available online 18 November 2010
Introduction The surgical resection of gastric stromal tumors can usually be performed laparoscopically. The excision should strictly observe two principles: resection with tumor-free margins and avoidance of tumor fragmentation. This technique is therefore not suitable for voluminous tumors. In addition to endoscopy that evokes the diagnosis and echo-endoscopy that helps to confirm it, a preoperative CT scan is useful to assess the size of the lesion and define its extent. The difficulties of surgery vary with the location of the tumor within the stomach. We describe different strategies of laparoscopic resection for gastric stromal tumors up to 5 cm in diameter. After resection, oral feeding is usually resumed the next day.
∗
Corresponding author. E-mail address: [email protected] (H. Mosnier).
1878-7886/$ — see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2010.10.002
e360
S. Al Rasheedi, H. Mosnier
1
Various tumor localizations
2
Patient positioning, trocar placement, and instrumentation
Tumors situated away from the lesser curvature, cardia, and pylorus pose few problems for laparoscopic resection. It is sufficient to be able to obtain a sufficient margin of normal stomach. By contrast, resection of tumors located near the gastroesophageal junction (especially posteriorly), along the lesser curvature (and thus close to the nerves of Latarjet which may result in impaired antropyloric motility), or close to the pylorus (red zone) may pose specific problems which will be detailed here.
Trocar placement depends largely on the position of the tumor. In general, trocars should be placed somewhat low with a 10-mm optical trocar placed at or below the umbilicus. A 12-mm trocar for the introduction of a transecting linear stapler is usually placed in the left hypochondrium. In the right upper quadrant, a 5-mm trocar is usually sufficient, but do not hesitate to replace it with a 12-mm trocar in the event of difficulties in applying the transecting linear stapler. A 5-mm epigastric trocar is useful to retract and display the stomach. If the tumor requires an endogastric approach, an additional optical trocar may be placed superior to the initial optical trocar. An oblique viewing telescope is especially useful for tumors situated in inaccessible locations. The resected tumor is always placed in a retrieval bag for extraction.
Laparoscopic resection of gastric stromal tumor
3
Exposure of the tumor, preventive hemostasis
4
Tumor resection
The first step is to locate the tumor, with the help of findings from the initial endoscopy and CT scan. The tumor may be difficult to identify if it is mainly endoluminal. In this case, intraoperative endoscopy with partial desufflation of the pneumoperitoneum can be useful. Once the tumor has been localized, preventive hemostasis is performed using bipolar forceps to cauterize the vessels around its periphery.
For the most common tumor localizations, resection is performed using a linear cutting stapler, usually with a blue cartridge of 3.5 mm staples. The stapler should be applied, leaving a margin of healthy tissue of 5 to 10 mm. It is necessary to thoroughly expose the side of the tumor opposite to the side from which the stapler is introduced. If there are difficulties in applying the stapler, one should not hesitate to add an additional trocar or transparietal traction suture. It is often useful to place suture ligatures for additional hemostasis.
e361
e362
S. Al Rasheedi, H. Mosnier
5
Tumors situated on the vertical part of the lesser curvature
6
Tumors situated near the cardia
7
Endogastric resection
In this particular localization, the problem is to avoid injury to the nerves of Latarjet which descend in the adjacent lesser omentum. The stomach wall and the tumor must therefore be freed from the lesser omentum by dissection along the gastric margin, as well as by preventive hemostasis with bipolar forceps of vessels branching off the vascular arcade of the lesser omentum. Only then can the resection be performed, usually by a transverse application of the linear cutting stapler.
Tumors of the anterior surface of the cardia can often be addressed in the same manner as tumors of the body of the stomach. Some large tumors of the posterior cardia present a completely different problem which may require at least a partially endogastric approach. To avoid the need for complete mobilization of the cardia, it may be useful to perform the resection endogastrically. An additional optical trocar with a balloon is introduced midway along the xiphoidumbilical line. This trocar traverses both the abdominal wall and the anterior wall of the stomach. The stomach is held in suspension by inflating the balloon and CO2 is insufflated into the stomach.
The right and left upper quadrant trocars are advanced through the stomach wall. Now the resection can be performed in the usual manner with a linear stapler. The retrieval bag is inserted into the stomach to extract the resected specimen. The defects in the stomach wall are repaired as the intragastric trocars are backed out. This technique can also be extended to other difficult-toaccess locations such as the posterior aspect of the lesser curvature.
Laparoscopic resection of gastric stromal tumor
8
Resection of a juxta-pyloric tumor
9
Gastric repair after juxta-pyloric excision
The lack of an adequate margin of gastric wall in juxtapyloric locations often requires resection by scissor dissection with hemostasis of submucosal vessels using biplor forceps. Indeed, in this case, a linear cutting stapler may not function well because of the varying thickness of the gastric wall; stapler application may also damage the pylorus.
The repair of the gastric wall is performed by manual suturing. If there is any doubt about the quality of the suture line, it may be tested for leaks by insufflating the stomach through the nasogastric tube. Antral tumors situated on the horizontal portion of the lesser curvature and inaccessible to an anterior or endogastric approach may require a partial gastrectomy.
e363