经脐单切口腹腔镜胃大部切除治疗胃、十二指肠溃疡

2010年11月～2011年1月我科对3例胃、十二指肠溃疡疑有恶变,幽门狭窄造成梗阻的患者行经脐单切口腹腔镜胃大部切除术,手术时间分别为250、280、350 min,术中出血量分别为150、200、300 ml,无术后出血、吻合口漏及吻合口梗阻等并发症发生。分别于术后7、8、7 d出院。术后切口愈合良好。3例分别随访7、8、9个月,患者无腹痛、呕吐等症状出现。经脐单切口腹腔镜胃大部切除术治疗良性消化性溃疡安全、可行,有良好的美容效果。     

A Simple and Safe Method for Billroth I Reconstruction in Single-Incision Laparoscopic Gastrectomy Using a Novel Intracorporeal Triangular Anastomotic Technique

The intracorporeal anastomosis is one of the most difficult procedures in single-incision laparoscopic gastrectomy for gastric cancer. We describe a simple technique for intracorporeal triangular Billroth I anastomosis in transumbilical single-port surgery. After adequate lymphadenectomy, the stomach and duodenum were staple-transected. Small incisions were made to the remnant stomach and the duodenum. The anvil of a linear stapler and a staple compartment were inserted through the holes, and then both ends were stitched up together by stapler. This staple line would be the bottom of the triangular anastomosis. The second and third lines were created by closure of the common hole and with simultaneous removal of three staple lines (stumps of the stomach and duodenum and the ventral side of the first anastomosis) using two linear staplers, respectively, completing the triangular anastomosis. We performed this technique in 45 patients between March and December 2011. All procedures were completed in single-port approaches. There were no postoperative anastomotic complications such as anastomotic leak and stricture. The median postoperative hospital stay was 7 days. Our technique for intracorporeal Billroth I reconstruction is safe and feasible. This technique could be a useful surgical option in all laparoscopic reconstructive procedures using linear stapling devices.     

单切口经脐腹腔镜减重手术

目的近来,人们将单一切口腹腔镜胃减重手术的方法,视为除经自然腔道内镜手术之外的另一种选择。单一切口经脐腹腔镜胃减重手术的优势在于能隐藏手术瘢痕,获得较好的美容效果。然而,由于器械操作空间有限及肝脏牵引困难,此项技术一直受到很大限制,仅被认为适用于简单胃减重手术。本研究中,通过采用特殊技术和操作以期改善手术的安全及有效性,使其应用于更广泛的领域。方法自2008年12月起,我院采用LST装置（liver-suspension tape）及′Ω形脐孔成形术成功开展单一切口经脐胃减重手术。至2009年7月,共完成40例患者45例次手术,包括5例次胆囊切除术,2例胃束缚带放置,6例次胃袖状切除,32例次Roux-en-Y胃转流术（Roux-en-Y gastric bypass,RYGB）,记录术后住院天数及并发症情况。结果平均手术时间89.9min,平均术后住院1.15d。无一例发生术中或术后并发症,无死亡病例。所有病人均满意手术的美容效果。结论采用本技术施行单一切口经脐胃减重手术是安全、可行的,有进一步推广应用于更多外科手术的价值。     

经脐单孔与多孔法腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的比较研究

目的 探讨经脐单孔腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的安全性和可行性.方法 2008年1月至2011年12月,行腹腔镜手术治疗贲门失弛缓症及食管裂孔疝患者17例.其中,单孔法组7例,多孔法组10例.收集两组围手术期资料进行比较分析.结果 全部患者均顺利完成腹腔镜手术.单孔组手术时间115 ～ 180 min,出血量50～110ml,术后住院时间5～7d;多孔组手术时间100～ 155 min,出血量40～ 90 ml,住院时间5～9d.所有患者均无术后出血、食管漏、发热感染等并发症发生.单孔组患者术后脐部切口愈合良好,美容效果明显.结论 对于有经验的腹腔镜外科医师,单孔腹腔镜手术治疗贲门失弛缓症及食管裂孔疝是安全可行的,并具有极佳的美容效果.其临床应用价值仍需进一步研究证实.     

Transumbilical single incision laparoscopic sigmoidectomy for benign disease

Background  Transumbilical single incision laparoscopic surgery (SILS) has made its initial forays into clinical minimally invasive surgery. SILS combines in part the cosmetic advantage and decrease parietal trauma of natural orifice surgery, but allow operative realization with standard and validated laparoscopic instruments. We report here the first clinical transumbilical SILS sigmoidectomy for benign disease.
Method  Preliminary experience with transumbilical single incision laparoscopic surgery (or embryonic natural orifice transluminal endoscopic surgery) sigmoidectomy in a female patient (34 years, BMI 22 kg/m²) with sigmoid stenosis caused by nodular endometriosis was reported. Transumbilical SILS treatment of pelvic endometriosis was performed during the same operation through cauterization.
Results  Transumbilical single incision laparoscopic sigmoidectomy was feasible with conventional laparoscopic instruments. The combined uses of straight and articulated laparoscopic instruments allow the avoidance of transparietal sling suture for exposition. Operative time for sigmoidectomy and endometriosis therapy was 125 min. No intra-operative or postoperative complications were recorded. SILS achieved excellent cosmetic results and may be associated with accelerated recovery.
Conclusion  Transumbilical single incision laparoscopic sigmoidectomy is feasible by experienced laparoscopic surgeons using conventional laparoscopic instruments and staplers. The combined uses of strait and articulated instruments allow transumbilical SILS sigmoidectomy without the need for additional incision or transparietal sling suture. SILS sigmoidectomy may have the clinical advantage over NOTES of offering the safety of laparoscopic colectomy and the avoidance of vaginal access. It has to be determined if SILS offers benefit to the patient, except in cosmesis, compared with standard laparoscopic sigmoidectomy.     

Transumbilical single-incision laparoscopic subtotal gastrectomy and total intracorporeal reconstruction of the digestive tract in the treatment of benign peptic ulcers

Background

Single-incision laparoscopic surgery is being applied increasingly in many surgical specialties. However, few reports are available regarding its use in the treatment of benign peptic ulcer disease.

Methods

We report here on nine patients with gastric or duodenal ulcers who underwent transumbilical single-incision laparoscopic subtotal gastrectomy (SILSG) between November 2010 and June 2013. All procedures were performed with conventional laparoscopic instruments placed through a single operating portal of entry created within the umbilicus. Total intracorporeal gastrojejunostomy or gastroduodenostomy was then performed for reconstruction of the digestive tract.

Results

Only one case required conversion from single-incision to multiple-incision surgery. Among the eight patients who successfully underwent SILSG, total intracorporeal gastroduodenostomy was performed in two and gastrojejunostomy in six. The mean operation time was 290 ± 50 min (range 230–360 min), and blood loss was 200 ± 66 mL (range 100–300 mL). The patients recovered fully, and the single umbilical scars healed well.

Conclusions

We believe this is the first report of SILSG with total intracorporeal gastrojejunostomy or gastroduodenostomy in the treatment of benign peptic ulcers. On the basis of this initial experience, SILSG for this indication in the hands of experienced surgeons appears to be feasible and safe.     

Intracorporeal esophagojejunal anastomosis after laparoscopic total gastrectomy for patients with gastric cancer

Background  To facilitate acceptance of laparoscopic total gastrectomy (LTG) for patients with upper gastric cancer, a simple, secure technique of reconstruction is necessary. The authors developed a new technique for intracorporeal esophagojejunal anastomosis that does not require hand sewing. Methods  From September 2006 to January 2008, 16 patients (11 men and 5 women) with gastric cancer underwent LTG at the authors’ institution. Laparoscopic esophagojejunal anastomosis using the following method was attempted for all patients. The esophagus was transected while being rotated by about 45° counterclockwise to make the subsequent anastomosis easier. After the Y-anastomosis was created, an endoscopic linear stapler was applied to create a side-to-side anastomosis between the left dorsal side of the esophagus and the jejunal limb. The entry hole was first closed roughly with hernia staplers. Subsequently, an endoscopic linear stapler was applied so that all hernia staplers could be removed and the closure completed. Results  Laparoscopic esophagojejunal anastomosis was successfully performed for 15 patients. Intracorporeal anastomosis failed for one patient because a nasogastric tube was caught between the jaws of an endostapler, which resulted in a conversion to open procedure. No postoperative anastomotic complications occurred. Conclusions  Using the new technique, intracorporeal linear-stapled esophagojejunal anastomosis can be performed easily and securely. This technique could become one of the standard methods for reconstruction after LTG, facilitating the acceptance of LTG as a surgical option for patients with upper gastric cancer.     

Single Incision Laparoscopic Pancreas Resection for Pancreatic Metastasis of Renal Cell Carcinoma

Background:

Transumbilical single incision laparoscopic surgery (SILS) offers excellent cosmetic results and may be associated with decreased postoperative pain, reduced need for analgesia, and thus accelerated recovery. Herein, we report the first transumbilical single incision laparoscopic pancreatectomy case in a patient who had renal cell cancer metastasis on her pancreatic corpus and tail.

Methods:

A 59-year-old female who had metastatic lesions on her pancreas underwent laparoscopic subtotal pancreatectomy through a 2-cm umbilical incision.

Results:

Single incision pancreatectomy was performed with a special port (SILS port) and articulated equipment. The procedure lasted 330 minutes. Estimated blood loss was 100mL. No perioperative complications occurred. The patient was discharged on the seventh postoperative day with a low-volume (20mL/day) pancreatic fistula that ceased spontaneously. Pathology result of the specimen was renal cell cancer metastases.

Conclusion:

This is the first reported SILS pancreatectomy case, demonstrating that even advanced surgical procedures can be performed using the SILS technique in well-experienced centers. Transumbilical single incision laparoscopic pancreatectomy is feasible and can be performed safely in experienced centers. SILS may improve cosmetic results and allow accelerated recovery for patients even with malignancy requiring advanced laparoscopic interventions.     

经脐单孔腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的临床体会

目的：总结经脐单切口腹腔镜手术治疗贲门失弛缓症及食管裂孔疝的经验,提高腹腔镜临床应用的水平。方法：2010年3月—2011年10月分别对3例贲门失迟缓症进行单切口腹腔镜食管Heller肌切开、Dor胃底折叠术,对4例食管裂孔疝患者进行单切口腹腔镜食管裂孔疝修补、Nissen胃底折叠术。结果：7例手术均顺利完成。手术时间115～180 min;出血量50～110 mL;住院时间5～7 d。所有患者均无术后出血、食管漏、发热感染等并发症。患者术后脐部切口愈合良好,美容效果明显。结论：对于有经验的腹腔镜外科医生,单切口腹腔镜手术治疗贲门失弛缓症及食管裂孔疝是安全可行的,并具有极佳的美容效果。     

小儿免钉合器腹腔镜胃空肠缝合吻合术

目的探讨腹腔镜下胃空肠缝合吻合手术的方法、安全性和有效性。方法2005年5月～9月，对3例小儿胃流出道梗阻病儿进行腹腔镜下胃空肠缝合吻合术，2例幽门狭窄继发于消化性溃疡同时行高选择性迷走神经切断术。将一段空肠经结肠前上提靠近胃窦部，先浆肌层连续缝合胃空肠固定在一起，超声刀切开胃壁和毗邻空肠，分别连续全层缝合胃空肠侧壁，再间断浆肌层缝合加固。结果3例全部在腹腔镜下完成胃空肠缝合吻合，手术时间分别为135、150、180min，3例术后住院时间均为6d。无并发症发生。各随访8、10和12个月饮食正常，营养状况良好。结论腹腔镜胃空肠缝合吻合术是一种安全可行的技术，创伤小，恢复快且美观。     

经脐单孔腹腔镜乙状结肠癌根治术安全性及近期疗效分析

目的:评价经脐单孔腹腔镜乙状结肠癌根治术的可行性及安全性。方法:回顾分析2010年3月至2010年7月7例经脐单切口腹腔镜乙状结肠癌根治术与17例常规腹腔镜根治术的临床资料,对比分析两组患者手术安全性、术后恢复情况、并发症及术后近期随访结果。结果:7例单孔手术均获成功,无一例中转手术。手术时间平均(64.2±26.3)min,术中出血量平均(20.1±3.4)ml,切口长度平均(2.2±1.3)cm,平均清扫淋巴结(13.2±3.3)枚,术后患者无需镇痛,肛门排气时间平均(1.2±0.6)d,下床活动时间平均(1.5±0.4)d,术后平均住院(5.8±3.2)d。1例患者术后4 d出现切口感染,予以换药治愈。术后随访7～12个月,平均8.8个月,无复发、转移。与常规腹腔镜结肠癌根治术相比,单孔组切口小(P<0.05),手术时间较长(P<0.05)。结论:经脐单切口多通道腹腔镜结肠癌根治术安全、可行,具有患者创伤小、瘢痕小等优点,但技术要求较高。     

经脐单孔腹腔镜脾切除术的临床应用：单中心经验总结（附视频）

目的：总结经脐单孔腹腔镜脾切除术的临床应用经验,提高腹腔镜治疗脾脏疾病的有效性和安全性。 方法：收集2010年3月至2013年1月13例实施经脐单孔腹腔镜脾切除术患者的临床资料进行分析,其中脾破裂1例,脾动脉瘤1例,特发性血小板减少性紫癜1例,先天性溶血合并胆囊结石1例,脾血管瘤2例,脾囊肿2例,肝硬化合并门静脉高压症5例。 结果：13例患者均顺利完成手术, 无中转开腹手术,平均手术时间（165±41）min,平均出血量（298±25.8）ml,其中6例术中输入血液制品。术后平均住院时间（8.8±2.7）d,1例出现进行性血红蛋白水平下降,再次行腹腔镜探查止血术,其余患者均无出血及感染等并发症发生。患者恢复均良好,切口美容效果极佳。 结论：经脐单孔腹腔镜脾切除术对于有丰富腹腔镜经验技术的普外科医生来说是安全可行的。     

Laparoscopic gatrojejunostomy for palliation of gastric outlet obstruction in unresectable gastric cancer

Background: Gastric bypass through laparotomy is required traditionally when gastric outlet obstruction occurs secondary to a disease process (e.g., unresectable cancer). The recent trend toward minimally invasive procedures has led us to apply laparoscopic bypass surgery for gastric obstruction caused by unresectable advanced gastric cancer. Methods: From March 1998 to February 2000, 78 gastrojejunostomies (GJ) (45 open [OGJ] and 33 laparoscopic [LGJ] procedures) were performed for palliation of gastric outlet obstruction caused by advanced gastric, duodenal, papilla of vater, and pancreatic cancers at the Asan Medical Center. In 68 patients with advanced gastric cancer, OGJ (n = 38) and LGJ (n = 30) were performed. Of these, 10 OGJ patients were compared with 10 diagnosis-matched LGJ control subjects who underwent surgery during the same period in terms of age, gender, American Society of Anesthesiology (ASA) grading, previous abdominal surgery, operating time, time to oral food intake, pain-killer consumption, postoperative hospital stay, immune response, morbidity, and mortality. Immune parameters including serum white blood cells (WBC) count, tumor necrosis factor-a (TNF-a), interleukin-6 (IL-6), cortisol, and erythrocyte sedimentation rate (ESR) levels were assessed preoperatively and on postoperative days 1 and 3 between the two groups. With the patients under the general endotracheal anesthesia, we applied an upper midline incision in OGJ and inserted four trocars in LGJ. Side-to-side gastrojejunostomy was performed in a standard fashion. In LGJ, intracorporeal suture using 2-0 vicryl was performed to repair the gastrotomy and jejunotomy site after gastrojejunostomy using a 30-mm or 45-mm Endo-GIA stapler. Results: There were no significant differences between OGJ and LGJ in terms of gender, age, ASA grading, and previous abdominal surgery. In OGJ, antecolic isoperistaltic GJ was performed in 10 cases, but 8 antecolic and 2 retrocolic approaches were performed in LGJ with no conversion to open surgery. Operating time (113.5 ± 11.2 vs 100.5 ± 9.8 min), pain-killer consumption (540 ± 123.2 vs 430 ± 58.2 mg), and postoperative hospital stay (12.5 ± 3.9 vs 8.5 ± 2.9 days) were reported, respectively. Serum WBC and cortisol levels were slightly increased in both groups preoperatively and on postoperative days 1 and 3. Serum ESR, TNF-a, and IL-6 levels were significantly increased in the OGJ patients. Postoperative complications (9 with OGJ and 2 with LGJ) and postoperative death (1 in each group) occurred. During the follow-up period (3–23 months), there was one case of readmission in each group because of anemia and generalized pain. Conclusions: Laparoscopic GJ for the palliation of unresectable advanced gastric cancer can achieve excellent results with less suppression of immune function, lower morbidity, greater improvement of hemodynamic activities, and earlier recovery of bowel movements than OGJ.     

Endoscopic stenting versus operative gastrojejunostomy for malignant gastric outlet obstruction

Background  

Malignant gastric outlet obstruction represents a terminal stage in pancreatic cancer. Between 5% and 25% of patients with pancreatic cancer ultimately experience malignant gastric outlet obstruction. The aim in palliating patients with malignant gastric outlet obstruction is to reestablish an oral intake by restoring gastrointestinal continuity. This ultimately improves their quality of life in the advanced stages of cancer. The main drawback to operative bypass is the high incidence of delayed gastric emptying, particularly in this group of patients with symptomatic obstruction. This study aimed to compare surgical gastrojejunostomy and endoscopic stenting in palliation of malignant gastric outlet obstruction, acknowledging the diversity and heterogeneity of patients with this presentation.     

Laparoscopic choledochojejunostomy and gastrojejunostomy in a porcine model

BACKGROUND: Surgical extirpation remains the only known curative treatment for cancer of the pancreas. Because of locally advanced or metastatic tumor, up to 80% of patients are unresectable at the time of initial diagnosis [13]. Other investigators previously have suggested that laparoscopy before laparotomy aids in the diagnosis of unresectable pancreatic cancer in a fair number of patients even after negative computed tomography scans [3, 17]. Many surgeons are reluctant to incorporate laparoscopy into the workup of patients with cancer of the pancreas because of the frequent need for surgical bypass in the management of either biliary tract obstruction or gastric outlet obstruction [9, 13]. Previous studies have demonstrated the feasibility of laparoscopic cholecystojejunostomy combined with gastrojejunostomy in a porcine model, as well as the individual accomplishment of laparoscopic choledochojejunostomy. The purpose of this study was to document the feasibility of performing laparoscopic choledochojejunostomy with gastrojejunostomy. METHODS: Under general anesthesia, seven pigs underwent laparoscopic choledochojejunostomy and gastrojejunostomy using an intracorporeal hand-sutured technique. RESULTS: The mean operating time ranged from 150 to 450 min. All the animals recovered completely from the operation and had patent anastomoses at the time of necropsy. One pig died of gastric bleeding on postoperative day 13, and two animals had intraabdominal fluid collections discovered at the time of necropsy. CONCLUSIONS: These results suggest that synchronous laparoscopic bypass of biliary and gastric outlet obstruction is feasible, and can be performed in a manner similar to that used in open operations. We believe this lends support to the argument promoting laparoscopy in the evaluation of pancreatic cancer.     

经脐单一部位腹腔镜胰体尾切除术的初步体会

目的探讨经脐单一部位腹腔镜胰体尾切除术的可行性。方法 2009年6月～2011年10月对8例胰体尾部良性病变施行经脐单一部位腹腔镜胰体尾切除手术,其中保留脾脏3例,联合脾切除5例。超声刀游离周围韧带及远端胰腺,切割闭合器将胰体尾及脾血管切断,标本经脐取出。结果 7例经脐单一部位腹腔镜胰体尾切除术成功,1例因胰尾囊肿与周围粘连严重中转为多孔手术。手术时间130～240 min,(155±38)min;出血量50～250 ml,(101.3±71.6)ml;住院时间6～9 d,(7.4±1.1)d。所有患者均无术后出血、静脉血栓、发热感染等并发症。1例持续性胰漏,开腹手术修补。术后脐部切口愈合良好,美容效果明显。8例术后随访3～28个月,(14.3±8.6)月,均恢复正常工作及生活,预后良好。结论对于有经验的腹腔镜外科医生,经脐单一部位腹腔镜胰体尾切除术是可行的,并具有极佳的美容效果。     

单孔腹腔镜与非单孔腹腔镜胆囊切除术安全性及有效性的荟萃分析

目的系统评价单孔腹腔镜与非单孔腹腔镜胆囊切除术安全性及有效性。方法计算机检索Pubmed和万方数据库中有关单孔腹腔镜与非单孔腹腔镜胆囊切除术的随机对照实验(RCT)文献,依据Cochrane评价手册评价偏倚风险,并提交手术时间、术后疼痛评分、术后并发症发生率及术后美容评分等的相关数据进行荟萃分析。结果纳入4篇RCT文献,共236例患者。荟萃分析结果显示相比非单孔腹腔镜胆囊切除术,单孔腹腔镜技术不会显著性影响手术并发症的发生(OR 1.47;95%CI 0.73～2.97;P=0.28),且具有更高的术后美容评分(SMD 0.70;95%CI 0.40～0.99;P<0.00 001)。结论单孔腹腔镜胆囊切除术具有更好的美容效果和一定的安全性。但评价该术式和非单孔腹腔镜胆囊切除术在其他发面的优劣势,仍需要更多设计严谨和大样本的随机对照研究。     

New: Single-incision transumbilical laparoscopic surgery

Summary  BACKGROUND: On the way to "no-scar" techniques novel single-incision laparoscopic methods are developed, which result in a non-visible postoperative scar. METHODS: A total of 136 patients (age 10–86a; 68f/68m) underwent single-incision laparoscopic surgery at our Department for diseases of the appendix, gallbladder, colon, esophagus, liver, adrenal gland, inguinal hernia, or symptomatic adhesions. The entire operations were carried out transumbilically following the standardized procedural principles. RESULTS: Operative time ranged from 17 to 218 min. In 16 patients (11.8%) additional trocars were inserted for procedural safety. No intraoperative adverse event or significant perioperative complication was noticed. Operative estimated blood loss yielded minimal, blood suction was needed only for liver resection and adrenalectomy. Specimen retrieval was carried out either by means of an endo-bag or directly utilizing a transumbilical protection sheet. Patients resumed oral intake at the day of surgery after cholecystectomy, hernia repair or appendectomy, or within 24 h after major surgery according to the principles of fast-track abdominal surgery. Patients' discharge was on postoperative days 1–12 (Mean 3.8 d). At follow-up after 1–4 weeks patients presented with an optimal cosmetic result without apparent scarring. CONCLUSIONS: Single-incision transumbilical laparoscopy allows further reduction of the surgical trauma and to obviate any visible scar in various procedures.      

经脐单切口微型腔镜胆囊切除术与传统腹腔镜胆囊切除术的比较

目的比较微型腔镜下经脐单切口胆囊切除术与传统腹腔镜胆囊切除术（laparoscopic cholecystectomy,LC）的临床效果,探讨应用常规器械行经脐单切口微型腔镜胆囊切除的可行性。方法 2010年6～11月60例胆囊良性疾病按手术日分为2组,由同一手术组医师分别施行经脐单切口微型腔镜胆囊切除术与传统LC,前者除换用3 mm尿道镜外,余均使用同样的设备和操作器械,比较2组手术时间、术中出血量、术后疼痛评分、术后并发症、总住院费用及术后住院时间。结果 2组均完成胆囊切除,无中转开腹手术,术后无并发症发生。传统组手术时间（47.7±21.6）min明显短于单切口组（62.6±30.6）min（t=2.179,P=0.033）,2组术中出血量、术后疼痛评分、总住院费用及术后住院时间无显著性差异（P〉0.05）。结论 微型腔镜下单切口胆囊切除术可行,不仅具有传统LC的优点,还具有切口隐蔽性好,更好的美容效果等特点。     

Laparoscopic ultrasound-guided resection of gastric submucosal tumors

Background The laparoscopic resection of gastric stromal tumors is being performed with increased frequency. Wedge resection of anterior wall lesions is generally performed. The treatment of posterior wall lesions is still controversial. Methods We report three cases of gastric submucosal tumors treated by a laparoscopic wedge resection of the stomach. All lesions were localized anterior gastric wall by intraoperative ultrasound on the. In the first patient the resection was performed with an endoscopic stapler; in the other patients, ultrasonic coagulation in association with an intracorporeal suture has been used. Results All patients were successfully treated laparoscopically; there were no conversions to open surgery. In all cases the operative course was uneventful. The postoperative hospital stay ranged from 6 to 8 days. Conclusions The results suggest that laparoscopic surgery is an adequate strategy for gastric submucosal neoplasms including gastrointestinal stromal tumors (GIST). Intraoperative ultrasound is very useful in the selection of the technical approach with or without the endoscopic stapler. This article contains a supplementary video.