Safety and application of transumbilical single-incision laparoscopic gastrectomy for GIST: SILS in benign gastric disease

Is single incision laparoscopic surgery (SILS) for gastric gastrointestinal stromal tumor (GIST) dependent on the location of the tumor?

BACKGROUND

We compared the surgical outcomes of single-incision laparoscopic surgery (SILS) and conventional laparoscopic surgery (CLS) for gastric gastrointestinal stromal tumor (GIST).

METHODS

We performed single-incision gastric wedge resection on prospectively-enrolled 15 consecutive patients with gastric GIST between November 2020 and April 2022 in a single tertiary center. The early perioperative outcomes of these patients were compared to those of patients who underwent CLS. The indications did not differ from those for conventional laparoscopic procedures for gastric GIST.

RESULTS

In total, 30 patients were assigned to the SILS (n = 15) and CLS (n = 15) groups. There were no significant differences in the estimated blood loss and intraoperative blood transfusion between the SILS and CLS groups. There were no intraoperative complications or conversions to multiple-port or open surgery in the SILS group. Proximally located tumors were more commonly treated with CLS than with SILS (P = 0.045). GISTs located in the greater curvature were more commonly treated with SILS than with CLS, although the difference was not statistically significant (P = 0.08). The mean incision length in the SILS group was 4.1 cm shorter than that in the CLS group (3.2 ± 0.7 and 7.3 ± 5.2 cm, respectively, P = 0.01). The postoperative analgesic dose was significantly lower in the SILS than in the CLS group (0.4 ± 1.4 and 2.1 ± 2.3, respectively P = 0.01). Also, the duration of postoperative use of analgesic was shorter in SILS than in CLS (0.4 ± 0.7 and 2.0 ± 1.8, respectively, P = 0.01). There were no significant differences in the early postoperative complications between the groups.

CONCLUSIONS

SILS is as safe, feasible, and effective for the treatment of gastric GIST as CLS with comparable postoperative complications, pain, and cosmesis. Moreover, SILS can be considered without being affected by the type or location of the tumor.

Evaluation of the result of single-incision laparoscopic surgery for gastrointestinal stromal tumors in the stomach

BACKGROUND

Single-incision laparoscopic surgery (SILS) has recently been used for the management of gastrointestinal stromal tumors (GIST). Here, the feasibility and effectiveness of SILS for GIST and indications for SILS according to tumor location were investigated.

CASE PRESENTATION

From July 2009 to May to 2013, a total of 14 patients underwent SILS for GIST. In 14 patients, 5 patients had tumor near the esophagogastric junction, 4 patients on the lesser curvature, 2 patients on the anterior wall, 2 patients on the posterior wall, and 1 patient on the greater curvature. The surgery of one patient with lesser curvature tumor was converted to conventional laparoscopic surgery because of technical difficulties. Another patient required re-operation because of a posterior wall tumor causing gastric obstruction. There was no complication in patients with tumors on the anterior wall and greater curvature.

CONCLUSIONS

Because SILS for GISTs located mainly on the anterior wall was feasible, SILS may be considered the most appropriate type of laparoscopic surgery for GISTs in this location. However, for GISTs on the posterior wall or with lesser curvature, which require more complex management, SILS is challenging and should be carefully adapted.

Technical innovation: Intragastric Single Port Sleeve Gastrectomy (IGSG). A feasibility survival study on porcine model

PURPOSE

To perform technically the laparoscopic sleeve gastrectomy (LSG) using a unique Intragastric Single Port (IGSG) in animal swine model, evidencing an effective and safe procedure, optimizing the conventional technique.

METHODS

IGSG was performed in 4 minipigs, using a percutaneous intragastric single port located in the pre-pyloric region. The gastric stapling of the greater curvature started from the pre-pyloric region towards the angle of His by Endo GIA™ system and the specimen was removed through the single port. In the postoperative day 30, the animals were sacrificed and submitted to autopsy.

RESULTS

All procedures were performed without conversion, and all survived 30 days. The mean operative time was 42 min. During the perioperative period no complications were observed during invagination and stapling. No postoperative complications occurred. Post-mortem examination showed no leaks or infectious complications.

CONCLUSION

Intragastric Single Port is a feasible procedure that may be a suitable alternative technique of sleeve gastrectomy for the treatment of morbid obesity.

Single-incision laparoscopic resection of small bowel tumours: Making it easier for patient and surgeon

BACKGROUND:

Patients with small bowel tumours frequently require surgical intervention. Minimally invasive techniques require advanced skills and may not be offered to many patients. We present a laparoscopic single-incision technique that is minimally invasive without requiring intracorporeal anastomosis.

MATERIALS AND METHODS:

The cases of all patients with laparoscopic small bowel resections performed by one surgeon from 2008 to 2012 were reviewed. A single-port technique was introduced after it became available at our institution in 2009. Before that, conventional laparoscopy (LAP) was performed with extension of the periumbilical incision to allow externalisation of the bowel.

RESULTS:

Totally, 10 patients were identified who underwent laparoscopic resection of small bowel tumours: 9 in the small bowel and 1 in the terminal ileum near the cecum. Three tumours were resected before 2009 using LAP, and 7 were resected using the single-port technique. Median length of stay was 3 days, median follow-up was 16.5 months, and no patients had a recurrence. Operative time, post-operative complications, hospital length of stay, and narcotic utilisation were similar between the single-port and traditional laparoscopic groups.

CONCLUSION:

Laparoscopic removal of small bowel tumours with a small, periumbilical trocar incision is both effective and feasible without advanced technical skill.

Endoscopically Assisted Transumbilical Single-Incision Laparoscopic Gastric Resection for GIST Treatment

PURPOSE

Complete surgical resection with negative margins without lymphadenectomy is the treatment of choice for nonmetastatic Gastrointestinal Stromal Tumors (GISTs). Laparoscopic resection of gastric GISTs <5 cm is an acceptable and oncologically feasible, safe, and effective treatment. We present our experience of an endoscopically assisted minimally invasive transumbilical single-incision laparoscopic (SILS) technique for gastric GISTs resection.

METHODS

Four patients with small gastric GISTs ≤5 cm located on the greater curvature or the anterior wall were resected with SILS by using a lesion-lifting technique under the guidance of flexible gastroscopy.

RESULTS

The technique was feasible and safe and offered significant advantages in locating the tumor and controlling the resection margins. There were no major intraoperative or postoperative complications, conversions, or tumor ruptures. Pathology showed low-risk GISTs resected with disease-free margins without tumor rupture. No recurrences have been observed.

CONCLUSION

The endoscopically assisted SILS wedge gastrectomy is a feasible, safe, and advantageous technique for the treatment of the greater curvature or anterior wall gastric GISTs.

Feasibility and safety of single-incision laparoscopic surgery in gastric benign and malignant diseases

We systematically searched Medline and Cochrane Library and the related references occurred in the citations until February 2013 and included all the cases who suffered from gastric benign and malignant diseases where single incision laparoscopic surgery was performed. A total of 69 cases with gastric diseases undergoing SILS surgery were reviewed to evaluate the feasibility, safety, and potential benefits of SILS for the gastric diseases. Demographic data, morphologic characterisation of the lesion, and perioperative parameters were analyzed retrospectively. The initial experience with SILS for benign gastric diseases and early gastric cancer showed that it is feasible and safe when performed by experienced laparoscopic surgeons. Despite the limited number and technical difficulties it can be proposed in selected patients.

Single incision versus conventional laparoscopic resection in gastrointestinal stromal tumors: a retrospective cohort analysis at a single tertiary care center

BACKGROUND

Single-incision laparoscopic surgery (SILS), an advanced form of minimally invasive surgery, has recently been used for surgical management of gastrointestinal stromal tumors (GIST). The literature comparing SILS to conventional laparoscopic surgery for treatment of this disease is limited. This study aimed to evaluate the feasibility and effectiveness of SILS compared with conventional laparoscopic resection for GIST.

METHODS

A retrospective case-cohort study compared the benefits and outcomes of SILS and conventional laparoscopic partial gastrectomy for GIST. Between April 2008 and December 2012, 39 patients underwent laparoscopic gastrectomy for gastric stromal tumors in our department. All operations were performed by a single experienced surgeon. The medical records of these patients were reviewed retrospectively with regard to tumor size, operating time, and other clinical features.

RESULTS

SILS resection was performed on 19 patients, whereas 20 patients had conventional laparoscopic resection. Compared with the conventional laparoscopic group, the operative time for the SILS group was shorter, but the time for recovery of gastrointestinal function and postoperative hospital stay for the SILS group was similar to that of the conventional laparoscopic group. No intraoperative or postoperative complications were recorded in either group.

CONCLUSION

Compared with the conventional laparoscopic procedure, SILS in gastric stromal tumors is as feasible and safe when performed by experienced surgeons.

Liver retraction using n-butyl-2-cyanoacrylate glue during single-incision laparoscopic upper abdominal surgery

BACKGROUND

Liver retraction is critical in single-incision laparoscopic upper abdominal surgery. Several techniques have been reported. Some need an additional port, whereas others are complicated and time-consuming.

METHODS

n-Butyl-2-cyanoacrylate (NBCA) glue was applied to bond the left lateral lobe of the liver to the diaphragm in different single-incision laparoscopic upper abdominal procedures. Liver adhesion time and duration of operation were recorded, and preoperative and postoperative liver function tests carried out.

RESULTS

All procedures were completed successfully without additional ports or special instruments. The technique provided adequate workspace and a clear view. Mean liver adhesion time was 1·5 min. The maximum operating time was 310 min. Levels of alanine and aspartate aminotransferases were raised on day 1 after surgery but had returned to normal by day 7.

CONCLUSION

Creating adhesion between the left lateral lobe of the liver and the diaphragm using NBCA glue is a simple, safe and effective way of achieving liver retraction in single-incision laparoscopic upper abdominal surgery.

Single-incision laparoscopic partial gastrectomy for gastric submucosal tumors without compromising transumbilical stapling

INTRODUCTION

Although SILS has become an increasingly popular type of surgery, its application for gastric submucosal tumors (SMT) has been only sporadically reported. We herein describe 12 recent cases with gastric SMT located in the greater curvature or anterior wall. The aim is to validate technical feasibility and safety of single-incision laparoscopic partial gastrectomy. Thus far, this is one of the largest series of patients with gastric SMT who underwent SILS.

METHODS

From July 2009 to April 2013, single-incision laparoscopic partial gastrectomy was attempted in 12 consecutive patients with gastric SMT. Three trocars were assembled in the umbilical incision, and the lesion was mobilized and staple-resected with endoscopic stapling devices.

RESULTS

SILS surgery was successfully completed without any additional trocars. The median operating time was 96.5 min, and median blood loss was 7.5 mL. The median tumor size was 30 mm, with histopathologic diagnosis of gastrointestinal stromal tumor (10) and schwannoma (2). There was no immediate postoperative morbidity. During a median follow-up of 12 months, all patients were on full regular diet without any gastrointestinal symptoms.

CONCLUSION

SILS with transumbilical gastric stapling is a safe and practical alternative to conventional multiport laparoscopy in patients with gastric SMT, except for cases originating in the lesser curvature and close to the cardia/ pylorus.

Feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body endoscopic submucosal dissection: a porcine model

BACKGROUND

Total gastrectomy is performed for early gastric cancer in the upper body of the stomach because of the high complication rate of endoscopic submucosal dissection (ESD). The aims of the present animal study in pigs were to verify: (1) the feasibility of the trans-umbilical route compared with the trans-oral route in gastric upper body ESD; (2) the non-inferiority of single port laparoscopic lymph node dissection (LLND) compared with multiport LLND; and (3) the safety of 2-basin LLND (upper greater and lesser curvature).

METHODS

We separated the pigs (~40 kg each) into two groups: conventional and experimental (n = 5 per group). We performed ESD in the fundus and upper body anterior wall (UBAW) via the trans-oral route and multiport LLND in the conventional group, and via the trans-umbilical route and single port LLND in the experimental group.

RESULTS

The completion rates, tissue weights, and specimen diameters of both routes showed no statistical differences in either the fundus or the UBAW. The operative time was shorter with the trans-umbilical route than with the trans-oral route in both areas (p < 0.05). In LLND, there were no differences in surgical outcomes between the multiport and single port groups. Intraoperative perforation was seen in the trans-oral route group (n = 1). Delayed perforation was observed in 30 % of the ESD sites.

CONCLUSIONS

The trans-umbilical route is feasible and has lower complication rates than the trans-oral route in gastric upper body ESD. Additionally, single port LLND is not inferior to multiport LLND, and one-side-basin dissection is safer than two-side.

Surgical treatment of gastric gastrointestinal stromal tumor

Gastrointestinal stromal tumor is the most common mesenchymal tumor in the gastrointestinal tract and is most frequently developed in the stomach in the form of submucosal tumor. The incidence of gastric gastrointestinal stromal tumor is estimated to be as high as 25% of the population when all small and asymptomatic tumors are included. Because gastric gastrointestinal stromal tumor is not completely distinguished from other submucosal tumors, a surgical excisional biopsy is recommended for tumors >2 cm. The surgical principles of gastrointestinal stromal tumor are composed of an R0 resection with a normal mucosa margin, no systemic lymph node dissection, and avoidance of perforation, which results in peritoneal seeding even in cases with otherwise low risk profiles. Laparoscopic surgery has been indicated for gastrointestinal stromal tumors <5 cm, and the indication for laparoscopic surgery is expanded to larger tumors if the above mentioned surgical principles can be maintained. A simple exogastric resection and various transgastric resection techniques are used for gastrointestinal stromal tumors in favorable locations (the fundus, body, greater curvature side). For a lesion at the gastroesophageal junction in the posterior wall of the stomach, enucleation techniques have been tried preserve the organ's function. Those methods have a theoretical risk of seeding a ruptured tumor, but this risk has not been evaluated by well-designed clinical trials. While some clinical trials are still on-going, neoadjuvant imatinib is suggested when marginally unresectable or multiorgan resection is anticipated to reduce the extent of surgery and the chance of incomplete resection, rupture or bleeding.