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Abstracts
| Limited Gastric Resection* Jo Buyske, MD Reports of laparoscopic wedge resection for small tumors of the stomach first appeared in the literature in 1991. The first formal gastrectomy was reported in 1992 by Dr. Peter Goh, of Singapore, who performed a laparoscopic hemigastrectomy for chronic ulcer disease. Since then there have been multiple case reports and small series of both formal gastrectomy and laparoscopic wedge resections. Excision of benign gastric lesions can be technically quite straightforward. Lesions located on the greater curve of the stomach, away from either the cardia or the pylorus, are ideal for laparoscopic wedge resection. Lesions throughout the stomach, including those on the posterior wall or adjacent to the cardia or pylorus, can also be approached laparoscopically, but may require an endoluminal or transgastric approach, and are somewhat more difficult. Preoperative work-up should include endoscopy with biopsy, endoscopic ultrasound if available, and MRI or CT imaging to demonstrate the benign nature of the lesion with as much certainty as possible prior to surgery. If there exists a high degree of suspicion for the presence of malignancy even if it cannot be proven preoperatively, a plan should be made for formal resection rather than simple wedge. Techniques for resection of benign or low-grade tumors of the stomach vary slightly according to the location of the tumor. In general, the camera is placed at the umbilical port, and a 30-degree laparoscope is used. For lesions of the anterior wall in the body of the stomach, as few as two additional trocars may be used. Working ports are placed in the upper abdomen at a minimum distance of 8 cm from each other, and from the camera. They are ideally placed such that the location of the camera, the working ports, and the location of the lesion as transposed to the abdominal wall form a diamond. The stomach overlying the lesion is grasped and elevated with a Babcock, or alternatively it can be secured with a heavy suture, which can be used for retraction. A linear stapler is fired across the tented-up stomach below the lesion. The specimen is then placed in a bag and brought out through an enlarged trocar site. Lesions of the posterior wall can be removed in a similar manner where feasible. The greater momentum is divided using either ultrasonic shears or clips. In some cases the posterior wall can then be grasped and pulled away as described for anterior wall lesions. Frequently, however, this maneuver is awkward, in which case lesions of the posterior wall can be approached through an anterior gastrotomy. A small gastrotomy immediately overlying the lesion is made using an electrocautery. This is then enlarged by firing an endoscopic stapler, thus making a hemostatic gastrotomy. The lesion is then grasped through the gastrotomy and everted, thus tenting up the posterior wall of the stomach. A stapler is fired across the stomach below the lesion, and the lesion is placed in a bag and set in the right upper quadrant to be removed at the conclusion of the procedure. The gastrotomy is then closed either by suture or stapler. Lesions near either the pylorus or the gastroesophageal junction pose special problems. Simple wedge resection may result in unacceptable narrowing of either the inlet or the outlet of the stomach. Under these circumstances an endo-organ approach may help guide the extent and approach of the resection. |
