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Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
HK Yang, SH Kong
Surgical intervention
4 years ago
2210 views
119 likes
0 comments
03:36
Laparoscopic wedge resection of gastric gastrointestinal stromal tumor (GIST) with linear staplers in a transverse direction
This video presents a case of laparoscopic wedge resection for a gastric gastrointestinal stromal tumor (GIST). Exogastric resection using a stapler is effective for most GIST cases. However, there is a risk of gastric lumen narrowing after stapling in case of endophytically growing tumor unless the direction of the stapler is aligned transversely, which means in a perpendicular direction to the long axis of the stomach. This video shows how to access the tumor located at the posterior wall of the stomach, usefulness of the intraoperative endoscopy to identify the location of the tumor, and the presence of intraluminal bleeding from the staple line, and how to apply the linear stapler in a transverse direction in a laparoscopic wedge resection for gastric GIST.
Management of transpyloric invagination of a gastrointestinal stromal tumor (GIST)
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs are most commonly found in the stomach (40-70%), but can occur in all other parts of the GI tract, with 20 to 40% of GISTs arising in the small intestine and 5 to 15% from the colon and rectum.
They typically grow endophytically, parallel to the bowel lumen, commonly with overlying mucosal necrosis and ulceration. They also vary in size, from a few millimeters to 40cm in diameter. Many GISTs are well defined by a thin pseudo-capsule.
Over 95% of patients present with a solitary primary tumor, and in 10 to 40% of these cases, the tumor directly invades neighboring organs. Gastric GISTs are usually presented with GI bleeding and abdominal pain. However, most patients are symptom-free and the lesions are discovered incidentally during an upper endoscopy performed for other reasons (chronic abdominal pain and intermittent gastric obstruction in this patient).
Surgery remains the mainstay of curative treatment.
Surgical resection of localized gastric GISTs is the preferred treatment modality, as resection of the tumor renders the only chance for cure at this time. Historically, a 1 to 2cm margin was thought to be necessary for an adequate resection. However, more recently, DeMatteo et al. demonstrated that tumor size and not negative microscopic surgical margins determine survival.
It is therefore accepted that the surgical goal should be a complete resection with gross negative margins only.
Given this, wedge resection has been advocated by many investigators for the majority of gastric GISTs.
J D'Agostino, Gf Donatelli, S Perretta, J Marescaux
Surgical intervention
7 years ago
2103 views
18 likes
0 comments
04:15
Management of transpyloric invagination of a gastrointestinal stromal tumor (GIST)
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs are most commonly found in the stomach (40-70%), but can occur in all other parts of the GI tract, with 20 to 40% of GISTs arising in the small intestine and 5 to 15% from the colon and rectum.
They typically grow endophytically, parallel to the bowel lumen, commonly with overlying mucosal necrosis and ulceration. They also vary in size, from a few millimeters to 40cm in diameter. Many GISTs are well defined by a thin pseudo-capsule.
Over 95% of patients present with a solitary primary tumor, and in 10 to 40% of these cases, the tumor directly invades neighboring organs. Gastric GISTs are usually presented with GI bleeding and abdominal pain. However, most patients are symptom-free and the lesions are discovered incidentally during an upper endoscopy performed for other reasons (chronic abdominal pain and intermittent gastric obstruction in this patient).
Surgery remains the mainstay of curative treatment.
Surgical resection of localized gastric GISTs is the preferred treatment modality, as resection of the tumor renders the only chance for cure at this time. Historically, a 1 to 2cm margin was thought to be necessary for an adequate resection. However, more recently, DeMatteo et al. demonstrated that tumor size and not negative microscopic surgical margins determine survival.
It is therefore accepted that the surgical goal should be a complete resection with gross negative margins only.
Given this, wedge resection has been advocated by many investigators for the majority of gastric GISTs.
Laparoscopic resection of the 3rd and 4th portion of duodenum for a gastrointestinal stromal tumor (GIST)
This video demonstrates the rather difficult procedure of laparoscopic resection of the distal duodenum. The duodenum is dissected from both above and below the transverse mesocolon. A hand-sewn duodenojejunal anastomosis restores bowel continuity. This video is recommended for upper GI surgeons.
The patient is in the dorsal position with arms outstretched and legs abducted. The surgeon stands between the patient’s legs. Mobilization begins with adhesiolysis and then moves onto dissection of the duodenum with a Kocher's maneuver. The author completely mobilizes the third portion of duodenum. Once the surgeon identifies the third and fourth portions of the duodenum, ultrasound helps define the resection margins, initially marked with metallic clips. The procedure continues with division of the ligament of Treitz and resection of the first jejunal loop with a vascular stapler.
F Corcione
Surgical intervention
12 years ago
211 views
33 likes
0 comments
07:30
Laparoscopic resection of the 3rd and 4th portion of duodenum for a gastrointestinal stromal tumor (GIST)
This video demonstrates the rather difficult procedure of laparoscopic resection of the distal duodenum. The duodenum is dissected from both above and below the transverse mesocolon. A hand-sewn duodenojejunal anastomosis restores bowel continuity. This video is recommended for upper GI surgeons.
The patient is in the dorsal position with arms outstretched and legs abducted. The surgeon stands between the patient’s legs. Mobilization begins with adhesiolysis and then moves onto dissection of the duodenum with a Kocher's maneuver. The author completely mobilizes the third portion of duodenum. Once the surgeon identifies the third and fourth portions of the duodenum, ultrasound helps define the resection margins, initially marked with metallic clips. The procedure continues with division of the ligament of Treitz and resection of the first jejunal loop with a vascular stapler.
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
S Perretta, D Ntourakis, J Marescaux
Surgical intervention
5 years ago
1934 views
54 likes
0 comments
06:43
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
SH Kong
Lecture
4 years ago
2157 views
122 likes
1 comment
22:10
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
Laparoscopic resection of gastric gastrointestinal stromal tumours
We demonstrate two minimally invasive approaches for the management of gastric gastrointestinal stromal tumours (GIST). GISTs are the most common mesenchymal neoplasms of the gastroinstestinal tract. About 50% of GISTs are located in the stomach which makes it the most frequent location. GISTs can be totally intraluminal or extraluminal. In this film, we demonstrate two approaches for the removal of gastric GIST, depending upon the site of tumour. The majority of patients are diagnosed incidentally or present with vague symptoms. GISTs can also present with upper gastrointestinal bleeding as in our first case. We demonstrate that laparoscopic GIST resection is safe and effective.
SA Naqi, S Rajendran, M Arumugasamy
Surgical intervention
6 years ago
3566 views
94 likes
0 comments
13:47
Laparoscopic resection of gastric gastrointestinal stromal tumours
We demonstrate two minimally invasive approaches for the management of gastric gastrointestinal stromal tumours (GIST). GISTs are the most common mesenchymal neoplasms of the gastroinstestinal tract. About 50% of GISTs are located in the stomach which makes it the most frequent location. GISTs can be totally intraluminal or extraluminal. In this film, we demonstrate two approaches for the removal of gastric GIST, depending upon the site of tumour. The majority of patients are diagnosed incidentally or present with vague symptoms. GISTs can also present with upper gastrointestinal bleeding as in our first case. We demonstrate that laparoscopic GIST resection is safe and effective.
Transgastric laparoscopic resection of a GIST
Laparoscopic intragastric surgery (LIGS) represents a minimally invasive technique for lesions that mainly exist in the gastric lumen or at the gastroesophageal junction. Ohashi initially described this technique in 1995 to resect early gastric cancers that could not be treated by Endoscopic Mucosal Resection (EMR). Since then, it has evolved with respect to both technological advances (e.g., development of cuffed ports) and tactical innovations. As the peritoneal cavity represents the working space for laparoscopic surgeons, they have imagined to work directly into the stomach by respecting the same principles of basic laparoscopy, namely insufflation to create a new operating space, introduction of surgical instruments through working ports and the use of different techniques of dissection. The aim of this video is to describe the technical principles of this new approach as it offers a valuable option for the surgeon in the management of gastric tumors and early cancers. It may avoid major surgical procedures, especially for the management of lesions located at the esophagogastric junction. Selected indications have to be identified thanks to adequate preoperative workup including endoscopy, endoscopic ultrasonography, and conventional imaging (CT-scan and MRI).
Our standard approach for a laparoscopic intragastric surgery is represented by multiple intragastric ports approach. Resection can be performed as a standard submucosal dissection, but most of the time, the use of stapling is preferred for many reasons, including speed, safety and reliability as illustrated in this video. In well-selected cases (pedunculated tumors), the advantage of this technique is to obtain resection and hemostasis simultaneously, with the same instrument. However, achieving adequate margins can be difficult, and the risk of tumor rupture might be increased, particularly in case of gastrointestinal stromal tumors (GISTs).
When all inclusion criteria and technical principles are respected, this new minimally invasive approach offers major benefits for patients. It ensures the preservation of an almost normal anatomy by preserving the gastroesophageal junction as well as a simple postoperative course.
D Mutter, M Nedelcu, J Marescaux
Surgical intervention
5 years ago
2725 views
51 likes
0 comments
06:36
Transgastric laparoscopic resection of a GIST
Laparoscopic intragastric surgery (LIGS) represents a minimally invasive technique for lesions that mainly exist in the gastric lumen or at the gastroesophageal junction. Ohashi initially described this technique in 1995 to resect early gastric cancers that could not be treated by Endoscopic Mucosal Resection (EMR). Since then, it has evolved with respect to both technological advances (e.g., development of cuffed ports) and tactical innovations. As the peritoneal cavity represents the working space for laparoscopic surgeons, they have imagined to work directly into the stomach by respecting the same principles of basic laparoscopy, namely insufflation to create a new operating space, introduction of surgical instruments through working ports and the use of different techniques of dissection. The aim of this video is to describe the technical principles of this new approach as it offers a valuable option for the surgeon in the management of gastric tumors and early cancers. It may avoid major surgical procedures, especially for the management of lesions located at the esophagogastric junction. Selected indications have to be identified thanks to adequate preoperative workup including endoscopy, endoscopic ultrasonography, and conventional imaging (CT-scan and MRI).
Our standard approach for a laparoscopic intragastric surgery is represented by multiple intragastric ports approach. Resection can be performed as a standard submucosal dissection, but most of the time, the use of stapling is preferred for many reasons, including speed, safety and reliability as illustrated in this video. In well-selected cases (pedunculated tumors), the advantage of this technique is to obtain resection and hemostasis simultaneously, with the same instrument. However, achieving adequate margins can be difficult, and the risk of tumor rupture might be increased, particularly in case of gastrointestinal stromal tumors (GISTs).
When all inclusion criteria and technical principles are respected, this new minimally invasive approach offers major benefits for patients. It ensures the preservation of an almost normal anatomy by preserving the gastroesophageal junction as well as a simple postoperative course.
Treitz laparoscopic resection with intracorporeal anastomosis with a new barbed suture
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract. Life-threatening hemorrhage or intestinal obstruction are the most common presenting symptoms. In the last year, we observed four patients affected by GIST of the small bowel presenting with a massive bleeding. After the endoscopic diagnosis, all the neoplasms were ink marked.
We present a video showing a Treitz’s GIST treated with a laparoscopic resection, followed by a mechanical latero-lateral intracorporeal anastomosis and enterotomy closure using a new kind of self-anchoring barbed suture (V-Loc® advanced wound closure device-Covidien, Mansfield, MA).
M Scatizzi, E Lenzi, M Baraghini, KC Kröning, F Menici, S Cantafio, F Feroci
Surgical intervention
8 years ago
2360 views
16 likes
0 comments
07:26
Treitz laparoscopic resection with intracorporeal anastomosis with a new barbed suture
Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms of the gastrointestinal tract. Life-threatening hemorrhage or intestinal obstruction are the most common presenting symptoms. In the last year, we observed four patients affected by GIST of the small bowel presenting with a massive bleeding. After the endoscopic diagnosis, all the neoplasms were ink marked.
We present a video showing a Treitz’s GIST treated with a laparoscopic resection, followed by a mechanical latero-lateral intracorporeal anastomosis and enterotomy closure using a new kind of self-anchoring barbed suture (V-Loc® advanced wound closure device-Covidien, Mansfield, MA).
Combined endoscopic and laparoscopic transgastric single port (TriPort) access for a gastric tumor
Intragastric tumors represent a challenging pathology to treat with a minimally invasive approach because of their position and size. The possibility to combine both endoscopy and intragastric endoscopic surgery is of great value in these cases. This video shows such a combined endoscopic and laparoscopic approach to treat a stromal gastric tumor of the cardia. The endoscopy allows to choose a perfect position of laparoscopic access, depending on the tumor location. Furthermore, it provides the vision at the beginning of the intervention. After ablation of the tumor, a Triport is inserted into the stomach to close the gastric mucosa, allowing multiple transgastric access through a single gastrotomy.
J Leroy, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
11 years ago
357 views
21 likes
0 comments
04:23
Combined endoscopic and laparoscopic transgastric single port (TriPort) access for a gastric tumor
Intragastric tumors represent a challenging pathology to treat with a minimally invasive approach because of their position and size. The possibility to combine both endoscopy and intragastric endoscopic surgery is of great value in these cases. This video shows such a combined endoscopic and laparoscopic approach to treat a stromal gastric tumor of the cardia. The endoscopy allows to choose a perfect position of laparoscopic access, depending on the tumor location. Furthermore, it provides the vision at the beginning of the intervention. After ablation of the tumor, a Triport is inserted into the stomach to close the gastric mucosa, allowing multiple transgastric access through a single gastrotomy.
Laparoscopic resection of an esophageal leiomyoma
Leiomyomas represent a hyperproliferation of interlacing bundles of smooth muscle cells that are well demarcated by adjacent tissue or by a smooth connective tissue capsule. They usually arise as intramural growths and rarely cause symptoms when they are smaller than 5cm in diameter. In the distal esophagus, they may reach large proportions and may encroach on the cardia of the stomach. The majority of leiomyomas have been discovered during evaluation for dysphagia.
The traditional open thoracotomy for the enucleation of larger symptomatic esophageal leiomyomas has been gradually replaced by thoracoscopic or laparoscopic approaches. The video demonstrates the laparoscopic resection of a leiomyoma in a 50-year-old woman with a history of reflux esophagitis presenting with dysphagia.
J Torres Bermúdez, FC Becerra García, S del Valle Ruiz , AA Carrillo Sánchez, G Sánchez de la Villa
Surgical intervention
6 years ago
1245 views
8 likes
0 comments
09:13
Laparoscopic resection of an esophageal leiomyoma
Leiomyomas represent a hyperproliferation of interlacing bundles of smooth muscle cells that are well demarcated by adjacent tissue or by a smooth connective tissue capsule. They usually arise as intramural growths and rarely cause symptoms when they are smaller than 5cm in diameter. In the distal esophagus, they may reach large proportions and may encroach on the cardia of the stomach. The majority of leiomyomas have been discovered during evaluation for dysphagia.
The traditional open thoracotomy for the enucleation of larger symptomatic esophageal leiomyomas has been gradually replaced by thoracoscopic or laparoscopic approaches. The video demonstrates the laparoscopic resection of a leiomyoma in a 50-year-old woman with a history of reflux esophagitis presenting with dysphagia.
Laparoscopic excision of a large leiomyoma of the esophagogastric junction
Esophageal leiomyomas represent a benign pathology that usually affects the distal third and the esophagogastric junction, and that is perfectly suitable for a laparoscopic enucleation. A correct preoperative diagnosis is mandatory, as the most common differential diagnosis in this localization is represented by gastrointestinal stromal tumors (GIST), a pathology that could benefit from neo-adjuvant therapy. Occasionally, leiomyomas can be adherent to the mucosal layer, in which case-limited mucosal excision is necessary.
We present a laparoscopic enucleation of a large leiomyoma of the esophagogastric junction, requiring the use of an endostapler for complete resection.
C Balagué Ponz, EM Targarona Soler, S Mocanu, S Fernandez Ananin, F Marinello, M Trías Folch
Surgical intervention
7 years ago
1507 views
7 likes
0 comments
09:00
Laparoscopic excision of a large leiomyoma of the esophagogastric junction
Esophageal leiomyomas represent a benign pathology that usually affects the distal third and the esophagogastric junction, and that is perfectly suitable for a laparoscopic enucleation. A correct preoperative diagnosis is mandatory, as the most common differential diagnosis in this localization is represented by gastrointestinal stromal tumors (GIST), a pathology that could benefit from neo-adjuvant therapy. Occasionally, leiomyomas can be adherent to the mucosal layer, in which case-limited mucosal excision is necessary.
We present a laparoscopic enucleation of a large leiomyoma of the esophagogastric junction, requiring the use of an endostapler for complete resection.
Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus
Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.
B Dallemagne, J Marescaux
Surgical intervention
10 years ago
767 views
15 likes
0 comments
13:18
Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus
Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.