Intracorporeal vs laparoscopic-assisted resection for uncomplicated diverticulitis of the sigmoid

Background: Minimally invasive surgery for uncomplicated diverticulitis of the sigmoid (UDS) may be performed either as an intracorporeal procedure (LICR) or as laparoscopically assisted colon resection (LACR). Methods: Prospectively collected data of 40 selected patients who had undergone LICR for UDS between 1992 and 1994 were compared retrospectively with those of 34 diagnosis-matched LACR controls operated on at the same hospital between 1995 and 1996 to assess the short-term outcome. Results: There were no mortalities. LICR and LACR patients were well matched for age, gender, weight, American Society of Anesthesiologists (ASA) grade, duration of symptoms, and number of previous admissions. There were no significant differences in conversions (one vs three), mobilization of splenic flexure (11:29 vs 9:25), anastomotic distance from anal verge (12 vs 13 cm), estimated blood loss (270 vs 285 ml), passage of flatus (3.1 vs 3.8 days), operating room (OR) costs ($3,040 vs $2,820), and total hospital costs ($9,250 vs $10,050) in LICR and LACR patients, respectively. Suprapubic skin-incision length (36 vs 60 mm, p << 0.01), size of circular stapler 28:31 mm (1:39 vs 6:28, p= 0.03), specimen length (21 vs 11 cm, p << 0.01), complication rates (6 vs 5, p= 0.02), OR time (180 vs 244 min, p < 0.001), resumption of oral solid food intake (3.2 vs 5.8 days, p < 0.001), hospital stay (4.6 vs 9.9 days, p < 0.001), and ward costs ($2,360 vs $4,950, p < 0.001) were significantly different in LICR and LACR patients, respectively. Conclusion: The immediately recognizable advantages of LICR over LACR surmised from this study need further evaluation in a prospective randomized setting. LICR remains a procedure of considerable technical complexity requiring high surgical skills. Received: 20 May 1999/Accepted: 23 November 1999/Online publication: 17 April 2000     

Natural history of uncomplicated sigmoid diverticulitis

While diverticular disease is extremely common, the natural history(NH) of its most frequent presentation(i.e., sigmoid diverticulitis) is poorly investigated. Relevant information is mostly restricted to populationbased or retrospective studies. This comprehensive review aimed to evaluate the NH of simple sigmoid diverticulitis. While there is a clear lack of uniformity in terminology, which results in difficulties interpreting and comparing findings between studies, this review demonstrates the benign nature of simple sigmoid diverticulitis. The overall recurrence rate is relatively low, ranging from 13% to 47%, depending on the definition used by the authors. Among different risk factors for recurrence, patients with C-reactive protein 240 mg/L are three times more likely to recur. Other risk factors include: Young age, a history of several episodes of acute diverticulitis, medical vs surgical management, male patients, radiological signs of complicated first episode, higher comorbidity index, family history of diverticulitis, and length of involved colon 5 cm. The risk of developing a complicated second episode(and its corollary to require an emergency operation) is less than 2%-5%. In fact, the old rationale for elective surgery as a preventive treatment, based mainly on concerns that recurrence would result in a progressively increased risk of sepsis or the need for a colostomy, is not upheld by the current evidence.     

Laparoscopic vs open colectomy for sigmoid diverticulitis

Background: The aim of this prospective comparative study was to assess the outcome of laparoscopic and open colectomy for sigmoid diverticulitis in patients aged ≥75 years. Methods: From January 1993 to December 1998, all patients 75 years of age and older undergoing an elective colectomy for sigmoid diverticulitis were included in the study. The patients were divided into the following two groups: group 1 (n= 22) consisted of patients who underwent a laparoscopic procedure; group 2 (n= 24) consisted of patients who underwent an open procedure. Results: In group 1, there were 12 women and 10 men with a mean age of 77.2 years (range, 75–82); in group 2, there were 14 women and 10 men with a mean age of 78 years (range, 76–84) (p= 0.37). There was no difference between the groups in ASA classification. The operative time was shorter in group 2 (136 vs 234 mins). The postoperative period during which parenteral analgesics were required (5.4 vs 8.2 days, p= 0.001), postoperative morbidity (18% vs 50%, p= 0.02), postoperative length of hospital stay (13.1 vs 20.2 days, p= 0.003), and the inpatient rehabilitation (6 vs 15 patients, p= 0.01) were significantly shorter for group 1 than for group 2. There were no perioperative deaths. The conversion rate was 9% in group 1. Conclusion: The data from the present study suggest that laparoscopic colectomy for sigmoid diverticulitis can be applied safely to older patients with fewer complication, less pain, shorter hospital stay, and a more rapid return to preoperative activity levels than that seen with open colorectal resection. Received: 22 November 2000/Accepted: 22 February 2000/Online publication: 7 September 2000     

Elective laparoscopic-assisted sigmoid resection for diverticular disease

Background: Although the laparoscopic-assisted approach to colorectal cancer remains controversial, its use for benign diseases can have important advantages. The purpose of this study is to determine the feasibility of this approach for the treatment of elective diverticular disease and to identify preoperative and perioperative factors which can help to select the best procedure for each patient: either assisted laparoscopic resection (ALR) or dissection-facilitated laparoscopic resection (DLR). Methods: From November 1991 to the present, we conducted a prospective study of 41 patients approached electively for diverticular disease. Results: Twenty-nine patients underwent an ALR, seven were approached by DLR, and another five patients were converted to laparotomy (15%). Morbidity was 17.5% and there was no mortality in this series. The mean hospital stay after operation was 6.5 days. Conclusions: Because of the complexity of this inflammatory process, choice of either an assisted or a more invasive laparoscopic facilitated approach is necessary. The decision is based on the technical difficulty as determined by data collected both preoperatively and during laparoscopy. Received: 26 August 1996/Accepted: 26 November 1996     

Laparoscopic surgery for inflammatory complications of acute sigmoid diverticulitis.

From March 1995 through March 2000, we treated patients with the laparoscopic approach who had emergent and urgent indications for surgery. We report a series of 17 procedures in 16 patients in the acute category excluding those with active bleeding. One case of morbidity (DVT) but no moralities occurred, with 3 of 17 patients converted to an open approach. The postoperative course and subsequent recoveries compare favorably with the open approach to this disease process. Three other series are discussed for comparison, all showing similar favorable results. We concluded that given sufficient experience in minimally invasive colon surgery, surgeons can manage acute inflammatory complications of sigmoid diverticulitis laparoscopically with potential benefit to the patient.     

Laparoscopic surgery for diverticulitis

Background: Resection of diverticular disease may be quite challenging; the acute inflammatory process, thick sigmoid mesentery, and any associated fistula or abscess can make this procedure technically demanding. The aim of this study was to compare the results between laparoscopic and laparotomy-type resections stratified by disease severity and thereby predict outcome and possibly a subset of patients who may benefit from a laparoscopic approach. Methods: From August 1991 to December 1995, all patients with diverticular disease were classified according to a modified Hinchey classification system. The laparoscopic group included 18 patients who underwent a laparoscopic assisted colectomy, one with a loop ileostomy. The identical procedures were performed in 18 patients by laparotomy. The mean age of the two groups were 62.8 and 67.1 years, respectively (p= NS). Results: Seven of 18 patients in whom laparoscopy was attempted (38.9%) had conversion to laparotomy. Six of seven (85.7%) conversions were directly related to the intense inflammatory process. Laparoscopic treated patients with Hinchey IIa or IIb disease had a morbidity rate of 33.3% and a conversion rate of 50% while all patients with Hinchey I disease were successfully completed without morbidity or conversions to laparotomy. However, after the first four cases, the intraoperative morbidity and postoperative morbidity rates were zero and 14.3% and after ten cases they were zero and zero, respectively. Furthermore, the median length of hospitalization for Hinchey I patients after laparoscopy was 5.0 days vs 7 days after laparotomy (p < 0.05). In Hinchey IIa and IIb patients, the median length of hospitalization was almost 50% shorter with a laparoscopic approach (6 days vs 10 days, p < 0.05). Conclusion: In conclusion, laparoscopic resection of diverticulitis can be performed without additional morbidity particularly in Hinchey I patients and with a reduced length of hospitalization in patients with class I or II disease. Patients with class I disease, and after initial experience even those with class II disease, can benefit from the reduced morbidity and length of hospitalization associated with laparoscopic treatment. Received: 25 March 1996/Accepted: 17 July 1996     

Two-trocar technique for terminal sigmoid colostomy in a patient with complex pelvic fracture

We report a multiple trauma case with complex pelvic fractures and perineal wounds. The patient had a laparoscopic abdominal exploration with a simultaneous laparoscopic colostomy using the same wounds. Only two trocars were needed to perform both procedures. The technique is detailed here. The procedures were performed in less than an hour, with excellent postoperative recovery, achieving complete diversion of the rectal fecal contents. Received: 3 April 1997/Accepted: 10 July 1997     

Alterations in hepatic function during laparoscopic surgery

Background: Very few studies have been done on the consequences of pneumoperitoneum on hepatic function. At present, there is no consensus on the physiopathological hepatic implications of pneumoperitoneum. The purpose of this clinical study was to evaluate the effects of pneumoperitoneum on hepatic function in 52 patients treated with laparoscopic procedures. Methods: Thirty-two laparoscopic cholecystectomies and 20 nonhepatobiliary laparoscopic procedures were performed in 52 patients (12 men and 40 women) with a mean age of 44 years (range, 15–74). All patients had normal values on preoperative liver function tests. The anesthesiologic protocol was uniform, with drugs at low hepatic metabolism. The 32 cholecystectomies were randomized into 22 performed with pneumoperitoneum at 14 mmHg and 10 performed at 10 mmHg. All nonhepatobiliary laparoscopic procedures were performed with a pneumoperitoneum of 14 mmHg. The postoperative serologic levels of AST, ALT, bilirubin, and prothrombin time were measured at 6, 24, 48, and 72 h. The serologic changes were related to the procedure, the duration, and the level of pneumoperitoneum. Results: Mortality and morbidity were nil. All 52 patients had a postoperative increase in AST, ALT, bilirubin, and lengthening in prothrombin time. Slow return to normality occurred 48 or 72 h after operation. The increase of AST and ALT was statistically significant and correlated both to the level (10 versus 14 mmHg) and the duration of pneumoperitoneum. Conclusions: The duration and level of intraabdominal pressure are responsible for changes of hepatic function during laparoscopic procedures. Although no symptom appears in patients with normal hepatic function, patients with severe hepatic failure should probably not be subjected to prolonged laparoscopic procedures. Received: 23 May 1997/Accepted: 28 October 1997     

Factors associated with complications of open versus laparoscopic sigmoid resection for diverticulitis.

BACKGROUND: This study critically reviews sigmoid colon resection for diverticulitis comparing open and laparoscopic techniques. METHODS: We conducted a retrospective review of all open and laparoscopic cases of diverticulitis between 1992 and 2001. Data analyzed included the following: indications for operation, postoperative complications, and incidence of laparoscopic conversion to laparotomy. Major and minor complications were analyzed in relation to patients' preoperative diagnosis, age, presence or absence of splenic flexure mobilization, length of stay, and laparoscopic sigmoid resection versus open sigmoid resection. RESULTS: Over a 10-year period, 166 resections for diverticulitis were performed including 126 open cases and 40 laparoscopic cases. No significant differences existed in patient characteristics between the groups. Major complications occurred in 14% of patients, and the laparoscopic conversion rate was 20%. The presence of abscess, fistula, or stricture preoperatively was associated with a higher complication rate only in patients > or =50 years old undergoing open sigmoid resection. The length of stay between patients undergoing laparoscopic resection was significantly less than in patients having open resection. CONCLUSION: Advanced laparoscopic sigmoid resection is an alternative to open sigmoid resection in patients with diverticulitis and its complications. Open sigmoid resection in patients >50 years may have a higher complication rate in complicated diverticulitis when compared with laparoscopic sigmoid resection (all patient ages) and open sigmoid resection (patients <50 years old). Regarding complications, no difference existed between the length of stay in patients with open vs. laparoscopic resection.     

Laparoscopic reconstruction of vagina using sigmoid autograft

With the advent of advanced laparoscopic techniques in surgery, new applications have been found, which have expanded the role of laparoscopy in the gynecological field. The aim of this paper is to introduce our laparoscopic technique of taking a sigmoid colon autograft for colpopoiesis in a patient with congenital agenesis of the vagina. This technique is less invasive and is easy to perform, and it may be the best choice of operation in respect to the naturalness and the permanency of the vagina that results. The success of this laparoscopic technique of taking a sigmoid autograft for colpopoiesis suggests diverse possible applications in the future.     

Diagnosis and treatment of diverticular disease

Background: With the aim of resolving the current controversy over the diagnosis and treatment of diverticular disease, this consensus development conference set out to summarize the actual state of the art. Methods: A multidisciplinary panel of international experts (n= 16) was selected to take part in the consensus process. Prior to the conference, all experts were asked to answer a series of questions on diverticular disease. The consensus statement compiled out of these evaluations was modified during a joint meeting of the panel members, then presented for discussion in a public session, and finally revised by the expert panel. The finalized statement was mailed to all panel members for approval (Delphi method). Results: Asymptomatic diverticulosis, diverticular disease (with actual or recurrent symptoms), and complicated diverticular disease were defined separately. No agreement was reached on whether barium enema or colonoscopy is the better choice as an initial diagnostic tool in uncomplicated cases. In complicated cases, computed tomography is recommended for diagnosis. After two attacks of diverticular disease, elective resection should be considered. For patients in whom a concomitant carcinoma cannot be excluded and those with chronic complications (fistula, stenosis, or bleeding) surgery is also indicated. Laparoscopic sigmoid colectomy is recommended only for uncomplicated and, after percutaneous drainage of abscesses, Hinchey stage I and II cases. Conclusions: Laparoscopic surgery has already begun to influence the management of diverticular disease, but the randomized controlled trials needed to support therapy decisions are largely missing.     

The use of intraoperative ultrasound in laparoscopic adrenal surgery

Background: Laparoscopic adrenalectomy has been shown to be a safe and effective therapy for benign adrenal lesions. We review our experience with this procedure, including the use of laparoscopic ultrasound. Methods: We retrospectively reviewed our experience with 36 patients who underwent resection of 42 adrenal glands. Data gathered included preoperative evaluation and diagnosis, operative time, blood loss, complications, and follow-up status. Laparoscopic ultrasound was used to guide dissection and characterize a variety of adrenal lesions. Results: Thirty-five of 36 patients underwent successful laparoscopic adrenalectomy. There was one conversion to the open procedure in a patient with bilateral adrenal metastases from an endometrial cancer. For the bilateral laparoscopic procedure, the operative time averaged 262 mins, blood loss was 160 cc, and hospital stay was 3.0 days. For unilateral cases, operative time averaged 193 min, blood loss was 108 cc, and hospitalization was 1.1 days. Six patients experienced perioperative complications, most of which were minor and transient. Laparoscopic ultrasound was useful to define anatomy and to identify the adrenal vein, especially on the left side. Conclusions: Laparoscopic adrenalectomy is the procedure of choice for benign adrenal disease. Laparoscopic ultrasound is useful to localize and aid in the dissection of the left adrenal vein. Received: 24 December 1998/Accepted: 12 February 1999     

Laparoscopic surgery during pregnancy

Background: Laparoscopic surgery is known for its many advantages, but the use of this modality during pregnancy is still under discussion. Methods: The subjects in this discussion are the unknown influence of the pneumoperitoneum and the fear of damaging the uterus while inserting the Veress needle and trocars. In a review of recent literature describing laparoscopic surgery during pregnancy, no complications were seen. We performed four laparoscopic appendectomies and three laparoscopic cholecystectomies between 12 and 33 weeks estimated gestational age (EGA). Results: All pregnancies passed without complications and ended in at-term deliveries of healthy babies. Conclusions: The risks, precautions to avoid them, and the safety of laparoscopic surgery during pregnancy are discussed in the light of our experience and reports in recent literature. Received: 26 September 1995/Accepted 3 May 1996     

Laparoscopic surgery for splenic disorders

Laparoscopic splenectomy (LS) has recently been gaining acceptance as an alternative to open splenectomy. However, several aspects, such as learning curve, residual splenic function, and management of large spleens, remain controversial. In this paper we present the analysis of technical details and immediate and late outcome of a consecutive series of 64 cases of splenic disorders approached by laparoscopy. Between Feb-1993 and April-1997, 64 patients with a wide range of splenic disorders were treated by laparoscopy, and prospectively recorded. Age, body mass index, operative time, number of trocars, perioperative transfusion, spleen weight, conversion rate, mode of spleen retrieval (bag or accessory incision), postoperative analgesia, stay and morbidity were analyzed. Late failures after LS were reevaluated with ^99mTc-heat-damaged red blood cells scintigraphy and CT. LS was performed in 61 patients, and two cases with splenic cyst and one splenic artery aneurysm received a laparoscopic partial cystectomy and aneurysmectomy. LS was performed through an anterior approach in 12 patients and laterally in 49. Conversion rate was 6.5%. Accessory spleens were found in 7 patients (7/61, 11.5%). Morbidity was 16%. There was no correlation between the weight of the spleen, platelet count or obesity with operative time. A lateral approach was associated with a decrease in operative time (p < 0.002), postoperative stay (p < 0.001), transfusion (p < 0.04) and number of trocars (p < 0.001). Operative time was significantly longer in large spleens (>1000 gr) (p < 0.001). However, there were no differences in transfusion rate, stay, morbidity or conversion rate. After a follow up of 12 m, 10 patients revealed a low platelet count. Scintigraphy showed residual splenic tissue in 3 (ITP). A wide range of splenic disorders can be treated by laparoscopy, including enlarged spleens. This technique should be continually audited, but initial results reflect the approach's safety and advantages provided that great technical care is taken and an exhaustive search for accessory spleens is conducted. Received: 29 January 1997/Accepted: 22 May 1997     

Laparoscopic surgery for abdominal aortic aneurysms

Background: Laparoscopic surgery for infrarenal aortic aneurysms is based on the principle of retroperitoneal exclusion of the aneurysm sac with aortofemoral or aortoiliac bypass. Methods: Of 22 patients who met the selection criteria, 20 successfully underwent laparoscopic aortic surgery at Morristown Memorial Hospital between February and October 1997. Technical elements and steps of this operation are described and illustrated. Results: Within 30 days of surgery, 2 patients died and 9 had various major and minor perioperative complications. As a group, the laparoscopic patients had less postoperative pain, needed fewer hours of ventilator support, had shorter intensive care unit (ICU) and hospital lengths of stay, and resumed diet and normal activity earlier than the historical norms for patients undergoing transabdominal or retroperitoneal aortic resections at the same institution. Conclusions: These early observations suggest that the laparoscopic treatment of infrarenal abdominal aneurysms may have several significant potential benefits. Long-term results and randomized prospective studies with patients matched by risk stratification will be needed to confirm these impressions. Received: 23 June 1997/Accepted: 11 December 1997     

Needle and trocar injury during laparoscopic surgery in Japan

Background: With the growth and sophistication of laparoscopic surgery, increased attention is now being focused on safety and complications. Methods: In an attempt to address questions regarding the safety of laparoscopic surgery, a retrospective study of the time period from January 1991 to December 1995 was conducted by the Study Group of Endoscopic Surgery in Kyushu, Japan. Results: The response rate was 84.4% (152 of 180 hospitals). During the last 5 years 17,626 patients underwent endoscopic operations and 87.5% (15,422 patients) had laparoscopic surgery while 12.5% (2,204 patients) underwent thoracoscopic surgery. In 96.6% of the hospitals a minimal open laparotomy was used. Among the various operations, a cholecystectomy was performed in the largest number of patients (13,787). The total number of complications was 415 (2.7%), of which 156 (37.6%) were related to needle or trocar insertion. Visceral injury was found in 22 patients (0.14%): major vessel injury in 10, gastrointestinal tract injury in 11, and liver injury in one patient. Abdominal wall injury was seen in 79 patients (0.52%), bleeding in 70 (0.46%), and a hernia in 9 (0.06%). Extraperitoneal insufflation occurred in 55 patients (0.36%). There was no mortality. The complication rate significantly decreased year by year after the use of laparoscopic surgery began. Conclusions: The most common complications of laparoscopic surgery are related to needle and trocar insertion. These are preventable by placement under direct vision with verification of the intraperitoneal location of the needle and trocar. Received: 10 February 1997/Accepted: 22 May 1997     

Evidence-based surgery: diverticulitis – a surgical disease?

Sigmoid diverticulitis is an increasingly common disorder. While there is no gender difference, the incidence increases with age. Many reports have been published on the topic, but there is no consensus on certain aspects of treatment. We conducted a literature search covering the past 30 years and report our own data. Two major areas of controversy exist. One concerns indications for elective surgery for symptomatic diverticulitis. The consensus is that there is no indication for prophylactic surgery. The first attack should be treated conservatively; elective surgery is considered following a second attack, but in immunocompromised patients earlier. The second controversy concerns surgical strategy in peritonitis from perforation. Three-stage operations have generally been abandoned. The question is whether to perform a sigmoid resection with primary anastomosis. One end of the spectrum is recent perforation which can be treated safely by resection and anastomosis. The other end is advanced feculent peritonitis in high-risk patients. In this situation a Hartmann procedure is recommended. Although data from prospective randomized studies are lacking, there seem to be indicators in the individual situation that allow a rational selection of the appropriate procedure. Diverticulitis can thus be treated surgically for a broad range of its forms of presentation. Received: 16 August 1999 Accepted: 8 December 1999     

Laparoscopic hand-assisted surgery for hepatic and pancreatic disease

Herein I describe my initial experience with the use of a novel device, the Omniport, in 15 patients undergoing hand-assisted laparoscopic surgery (HALS) on the liver and pancreas. The device, which essentially consists of a hand cuff with a spiral inflatable valve, enables withdrawal and reinsertion of the hand without loss of pneumoperitoneum during the operation. The cuff's effective sealing pressure is equal to the pneumoperitoneal pressure; hence, hand comfort is maintained during the intervention. The device was effective in maintaining pneumoperitoneum in all cases. All but one operation was completed with the HALS approach. The one conversion was due to bleeding from the superior mesenteric vein during a 90% pancreaticosplenectomy. Immediate effective control of the bleeding by compression between the thumb and index finger was achieved, and the cuff of the Omniport was deflated as the incision was enlarged. There were no postoperative complications. The HALS approach has distinct advantages in terms of exposure and safety over the total laparoscopic technique for major surgery on the liver and pancreas, and it is recommended for these interventions. Received: 4 August 2000/Accepted: 4 August 2000/Online publication: 20 October 2000     

Perioperative tumor localization for laparoscopic colorectal surgery

Background: Because of the inability to palpate colonic tumors during laparoscopy, their location must be precisely identified before resection is undertaken. Method: A retrospective study was performed of 58 patients in order to be able to describe our methods of tumor localization for laparoscopic colorectal operations and to review their effectiveness. Results: In all patients, the entire colon was examined preoperatively by colonoscopy. In one patient, preoperative colonoscopic localization was inaccurate. In 31 patients, tumors were easily detectable at surgery. In five patients with the tumor in the right colon, even though the lesion was not detectable at surgery, right colectomy was performed without marking because preoperative colonoscopy reliably identified the lesion adjacent to the ileocecal valve. Twenty-two patients required some type of procedure to localize the tumor. The procedures and their problems were as follows: preoperative tattoo (five)—tattoo not visualized (one); intraoperative colonoscopy alone (six), combined with intraoperative tattoo (four) or clip (three)—poor operative exposure due to bowel distension (nine), hard to see the clip (three), dislodged clip (two), inadequate resection margin (one); intraoperative proctoscopy alone (two), combined with laparoscopic stitch (two)—no problems. In no patient was tumor present at a resection line and in no patient was the wrong segment resected. Conclusions: Reliable preoperative identification of the tumor adjacent to the ileocecal valve can permit right colectomy without marking. Lesions in the upper rectum can be approached via intraoperative proctoscopy ± suture placement. If the surgeon anticipates intraoperative localization may be difficult, lesions other than rectal or cecal ones should probably be marked by preoperative tattooing. Further studies regarding the technique of tattooing are warranted. Received: 18 July 1996/Accepted: 10 March 1997     

Transgastrostomal endoscopic surgery for early gastric carcinoma and submucosal tumor

Background: Laparoscopic intraluminal surgery of the stomach is now widely used for a lesion on the posterior wall. However, this procedure has some technical limitation related to the intricate introduction of the surgical instruments into the gastric lumen. In this article, we report our newly developed technique of transgastrostomal endoscopic surgery that overcomes this limitation and is also suitable for full-thickness gastric wall resection of a lesion in the wall. Methods: After making a 4-cm-long temporary gastrostomy, a Buess-type endoscope is inserted into the gastric lumen through the gastrostomy. The operation is performed inside the gastric lumen under video camera guidance using electrocautery, scissors, and forceps. After resection, the wound in the mucosa or the wound after full-thickness resection is endoluminally sutured. Mucosal resection was performed in six cases of early gastric carcinoma, two cases of atypical epithelium, and one case of ectopic pancreas. Full-thickness wall resection was performed in four cases of a leiomyoma. Results: In all 13 cases, the lesion could be precisely located by the video camera. All lesions were then resected endoluminally. The mean duration of the operation was 148 min. The postoperative course in all cases was uneventful. Conclusions: Transgastrostomal endoscopic surgery is minimally invasive and an efficient tissue-preserving technique for the removal of early gastric carcinoma or submucosal tumor. Received: 7 September 1996/Accepted: 27 January 1997