Laparoendoscopic hybrid procedure – Oncologically safe and feasible option for gastrointestinal stromal tumours of the stomach

Abstract

Minimally invasive resection of gastrointestinal stromal tumours of the stomach is a feasible alternative to the traditional open approach, without the need for advanced laparoscopic training, as lymph node dissection is not necessary and excision with a negative margin is the only requirement. The loss of tactile feedback is a known drawback of laparoscopic surgery, causing difficulty in assessing the margin of resection. Earlier described laparoendoscopic techniques require advanced endoscopic procedures, which are not readily available in all places. We present a novel method wherein we use an endoscope to guide the resection margins during laparoscopic surgery. In our experience of five patients, we were able to successfully use this technique to get the negative margins pathologically. This hybrid procedure can thus be used to ensure adequate margin, keeping all the benefits of laparoscopic surgery.

INTRODUCTION

The stomach is the most common site of gastrointestinal stromal tumours (GISTs) where surgical resection is the mainstay of treatment. The surgery with a histologically negative margin, by wide local excision, is considered the standard of care. Oncological principles must be followed during surgery by taking care not to rupture the tumour or spillage into the peritoneal cavity. Lymph node dissection is not warranted for gastric GIST as in gastric adenocarcinoma.

Meta-analysis of retrospective data comparing laparoscopic versus open wedge resection of gastric GIST has shown better short-term outcomes such as reduced blood loss, early resumption of oral diet and decreased hospital stay, with similar long-term oncological outcomes.^[1] Laparoscopic surgery poses the challenge of identifying the tumour and ensuring adequate margins of resection, which were overcome by the introduction of laparoendoscopic hybrid procedures.^[2] We describe a different hybrid method that is relatively easy to perform with proper oncological principles and also does not require advanced endoscopic procedures.

METHODOLOGY (OPERATIVE TECHNOLOGY)

The patient is placed in a supine position with their arms by the side. The surgeon and the camera assistant stand on the right side of the patient, facing the laparoscopic monitor near the left shoulder of the patient. The second assistant stands on the left-hand side of the patient. The endoscopist stands near the head end of the patient on the right side, facing the endoscopic monitor, which is placed on the left side of the patient along with the laparoscopic monitor [Figure 1a].

Figure 1: (a) Operation theatre setup for performing laparoendoscopic procedures of the stomach with placement of endoscopic and laparoscopic monitors for simultaneous intraluminal and intraperitoneal views. (b) Placement of ports for mobilisation of stomach and resection of gastric GIST. GIST: Gastrointestinal stromal tumour

Four laparoscopic ports are placed in the abdomen [Figure 1b]. The 12-mm umbilical port is used for the camera; the 15-mm midclavicular line port on the left is used as a working port and for the endostapler. The 5-mm paramedian port on the right side is also used as a working port. Another 5-mm port in the midclavicular line on the right side is used as a working port. An additional fifth port (5/10 mm) can be put in the right subcostal region for liver retraction if required.

After carrying out the diagnostic laparoscopy (to rule out metastatic disease), the stomach is mobilised along the greater curvature, using a vessel sealing device or a bipolar cautery (as per availability), by entering into the lesser sac inferior to the gastroepiploic vessels. If the tumour is located along the lesser curvature or posterior surface close to the gastro-oesophageal (GE) junction or antrum, then lesser curvature mobilisation is also done by ligation of the left gastric vessels where the gastroepiploic vessels are spared to maintain the blood supply to the stomach. After complete gastric mobilisation, the stomach is assessed for any signs of tumour location such as serosal involvement, an extraserosal component and a bulge in the gastric wall. At this point, the endoscope is introduced into the stomach to localise the tumour and to assess the extent of mucosal involvement. Endoscope light and laparoscopic camera light are then used as a guide for marking with a cautery over the gastric serosa for tumour-free margin [Figures 2 and 3]. An endoscopic stapler (Green) is then introduced through the 15-mm port for resection of the tumour while avoiding any excess removal of the gastric wall. While the tumour location, close to the GE junction or antrum, poses challenges for this procedure. However, with proper localisation by the endoscopy, the approach starts away from the GE junction or antrum and by pulling the stapled cut end away from the gastric wall procedure can be performed. In this method, the endoscopist has more roles to play by assessing the tightness of the lumen while application of the stapler.

Figure 2: Simultaneous visualisation of endoscopic and laparoscopic views to visualise the tumour and assess the margin adequacy

Figure 3: (a) Visualisation of gastric mass on j-manoeuvre in the fundus, close to the gastro-oesophageal junction. (b) Laparoscopic light being seen through the gastric wall in relation to the mass. (c) Mass not visualised after application of endostapler. (d) Staple line visible after excision of the mass, with no residual mass seen

The specimen is then removed using a wound protector through the 15-mm left midclavicular line port, which may require an extension of the incision in case of larger tumours. The specimen is then opened by removal of staples to ensure an adequate margin [Figure 4].

Figure 4: (a) Specimen after wedge resection of the fundus of the stomach. (b) Gastric GIST after the opening of staple line showing adequate margins. GIST: Gastrointestinal stromal tumour

DISCUSSIONS (BENEFITS)

We have performed laparoendoscopic excision of gastric GIST in five patients, out of which one patient underwent laparoscopic excision with endoscopic guidance for adequate margin and closure of the stomach opening with an endostapler because of large (10 cm) tumour size to avoid larger gastric wall resection. In the patient with a 10-cm tumour, exposure of the tumour to the peritoneal surface was minimised by placing the specimen in an endobag before closing the gastric wall. In all patients, the tumours were located by the light source of the endoscope, which was a guide for laparoscopic resection. All patients had a negative resection margin on microscopy with a mean gross margin of 2 cm. The median tumour size was 4.5 cm. All patients had a nasogastric tube placed intraoperatively, which was kept on drainage for 24 h postoperatively, after which oral feeding was started.

GIST is a relatively rare entity, and there are no randomised trials comparing open surgery with laparoscopic surgery for GIST. Retrospective long-term data have shown similar long-term outcomes with both approaches.^[3] Various laparoscopic and endoscopic cooperative surgery (LECS) techniques have been described for the resection of gastric GISTs. Earlier techniques (classic LECS) resulted in the exposure of the tumour to the peritoneal cavity as they involved opening the full thickness of the gastric wall for tumour resection.^[2] Subsequently, multiple methods such as inverted LECS, endoscopic wall inversion surgery without tumour exposure and combined laparoscopic and endoscopic approach for neoplasia without tumour exposure, techniques are being used by many surgeons in different settings.^[4] These new methods require advanced endoscopic skills for submucosal dissection, which are not widely available in resource-limited settings.

To conclude, this novel, simple and inexpensive technique follows all the oncological principles, ensures adequate margin without sacrificing extra gastric wall and is practically possible in all resource-limited centres where advanced endoscopic procedures are not available.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.