Single‐incision laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor arising from the duodenum

We report a case involving a minimally invasive single‐incision laparoscopic and endoscopic cooperative local excision of a duodenal gastrointestinal stromal tumor. A 59‐year‐old man presented with a 35‐mm lesion located in the second portion of the duodenum. A local resection was performed via single‐incision laparoscopic and endoscopic cooperative surgery. Intraluminal endoscopic dissection of the duodenal mucosa and submucosa was performed circumferentially around the tumor. The resection was then completed by laparoscopic dissection of the seromuscular layer around the tumor. The tumor was retrieved laparoscopically. After confirming that the resection achieved clear surgical margins, we closed the duodenal wall with a laparoscopic stapling device. There were no postoperative complications, including stenosis. Single‐incision laparoscopic and endoscopic cooperative surgery can be safely and effectively performed for a duodenal submucosal tumor.     

Laparoscopic resection of extra‐gastrointestinal stromal tumor of the transverse mesocolon

The patient was a 58‐year‐old man. A recent complete work‐up was done to find the cause of epigastric pain and revealed a nodule about 4 cm in diameter in the upper right abdomen on CT scans. Laparoscopic resection was performed to allow for a definitive diagnosis to be made and to treat the lesion. The tumor was located in the transverse mesocolon, and there was no communication between the lesion and the ascending or transverse colon. Spindle‐shaped tumor cells were arranged in palisades. The number of mitotic figures was only 1/50 HPF. The tumor was weakly positive for KIT and negative for CD34. From these findings, a diagnosis of extra‐gastrointestinal stromal tumor originating in the transverse mesocolon was made.     

Three‐dimensional laparoscopy‐assisted bowel resection for cavernous hemangioma of the rectum: Report of two cases

The safety and feasibility of 3‐D laparoscopy‐assisted bowel resection were demonstrated in the management of rectal cancer. However, this procedure’s role in the management of patients with diffuse cavernous hemangioma of the rectum has not been evaluated. Here, two patients were diagnosed with diffuse cavernous hemangioma of the rectum by colonoscopy and abdominal imaging. One case underwent pull‐through transection and coloanal anastomosis in 3‐D laparoscopy‐assisted surgery. In another patient, 3‐D laparoscopy‐assisted abdominoperineal resection was performed. The operations were safely performed in both cases. The two patients recovered uneventfully, and satisfactory postoperative outcomes were demonstrated. This report shows that 3‐D laparoscopy‐assisted bowel resection may be safe and feasible for patients with diffuse cavernous hemangioma of the rectum.     

Laparoscopy‐assisted distal gastrectomy for multiple adenocarcinomas in intrathoracic upside‐down stomach

Herein we report on a case of two adenocarcinomas arising from an upside‐down stomach in an elderly patient. An 83‐year‐old man was referred to our hospital with gastric cancer. Esophagogastroduodenoscopy showed two superficial depressed lesions in the stomach that were confirmed on biopsy as constituting a moderately differentiated tubular adenocarcinoma. CT and an upper gastrointestinal barium study revealed that the entire stomach and parts of the duodenum were located in the mediastinum. The patient underwent laparoscopy‐assisted distal gastrectomy and regional lymph node dissection with Billroth I reconstruction, followed by reduction of the migrated stomach. The hiatal defect was closed by primary suturing of the right and left crura at the anterior space of the esophagus. The patient's postoperative course was good, and follow‐up after discharge was uneventful. To the best of our knowledge, this is the first case report of multiple adenocarcinomas in an upside‐down stomach treated by laparoscopy‐assisted distal gastrectomy.     

Hybrid approach with laparoscopic wall-inversion surgery and single-incision intragastric surgery for intraluminal gastrointestinal stromal tumor: A case report

Laparoscopic wedge resection (LWR) for intraluminal gastrointestinal stromal tumor (GIST) leads to excessive resection of normal gastric wall. We report a case of GIST around the cardia successfully treated with full-thickness partial resection using a hybrid approach of laparoscopic surgery and single-incision intragastric surgery (SIIGS). A 69-year-old woman had a 5 cm intraluminal GIST at the posterior wall around the cardia. Submucosal injection of glycerin and indigo carmine was performed with transoral endoscopy. Circumferential seromuscular incision followed by placement of seromuscular sutures to invert the lesion into the stomach was performed under laparoscopy. By SIIGS, resection of the inverted mucosa and retrieval of the tumor were completed. A hybrid approach consisting of laparoscopic wall-inversion surgery and SIIGS was useful for intraluminal GIST and may expand the indications for laparoscopic wall-inversion surgery by removing size limitations.     

Endoscopy‐assisted laparoscopic submucosal dissection for a duodenal epithelial tumor

We present the case of a 46‐year‐old obese woman with a 3.5‐cm adenoma in the descending part of the duodenum who was treated with a totally laparoscopic approach. The preoperative examination revealed a pedunculated superficial tumor on the side of pancreas from the inferior duodenal angulus to 5 cm proximal to the papilla that was associated with massive blood flow. We chose not to perform endoscopic submucosal dissection, pancreaticoduodenectomy, or transduodenal tumor excision with laparotomy for this obese patient because of the poor exposure, risk of bleeding, and substantial invasiveness. We performed endoscopy‐assisted laparoscopic submucosal dissection as a novel laparoscopic‐endoscopic cooperative surgical approach in this patient. This surgery was surgically and oncologically safe.     

The hybrid procedure of thoracoscopic and hand-assisted laparoscopic resection of an esophageal gastrointestinal stromal tumor: A case report

Esophageal gastrointestinal stromal tumors (E-GIST) are very rare tumors, and there is no consensus regarding the optimal surgical approach for E-GISTs. Here, we report a case of a large E-GIST that was resected via video-assisted thoracoscopic surgery (VATS) and hand-assisted laparoscopic surgery (HALS). When examining for comorbidities of myasthenia gravis using computed tomography, a 7-cm-sized tumor was detected in the lower esophagus of a 68-year-old woman. Further examination revealed the tumor to be an E-GIST with high malignant potential, and thus, esophagectomy was performed. The hybrid procedure for VATS and HALS techniques was safe and minimally invasive for this E-GIST that required esophagectomy. Thus, esophagectomy with VATS and HALS is thought to be a reasonable surgical option for resecting large E-GISTs, for which enucleation is not recommended.     

First experience using the Senhance surgical system in laparoscopic local gastrectomy for gastrointestinal stromal tumor

Various innovative robotic systems have been developed to improve surgery precision. The Senhance Surgical System (SSS) is a digital laparoscopic system offering eye tracking and haptic feedback. Several reports have described application of the SSS to general surgeries, including cholecystectomy and colectomy. However, use of the SSS for gastric tumor has not been reported. We experienced a case of laparoscopic local gastrectomy (LLG) for gastrointestinal stromal tumor (GIST) with the SSS. A 74-year-old man diagnosed with GIST underwent LLG with the SSS. Operation, docking, and console times were 117, 11, and 59 minutes, respectively. No perioperative complications were encountered. This study is the first to report LLG for GIST with the SSS. LLG with the SSS was safe and feasible. The SSS can use reusable forceps and contribute to reducing medical costs. The development of instruments is also progressing, and various kinds of surgery are likely to be indicated.     

Video‐assisted segmental resection of an intrapulmonary bronchogenic cyst mimicking a middle mediastinal cystic tumor

We report a case of an intrapulmonary bronchogenic cyst that radiologically mimicked a cystic tumor of the middle mediastinum. During video‐assisted thoracoscopic surgery, the lesion was confirmed to be in the lung parenchyma rather than in the mediastinum. A video‐assisted thoracoscopic anterior basal segmentectomy was eventually performed, and an intrapulmonary bronchogenic cyst was the diagnosis based on histology.     

Successful treatment of large adenoma extending close to the papilla in the duodenum by laparoscopy‐assisted pancreas‐sparing duodenectomy

A 54‐year‐old man had a 65‐mm infrapapillary, circular, and laterally spreading tubular adenoma in the distal second and proximal third parts of the duodenum. The papilla was 15 mm from the proximal margin of the tumor. Because the patient requested organ‐preserving laparoscopic surgery, we conducted laparoscopy‐assisted pancreas‐sparing duodenectomy (LAPSD). LAPSD consists of five major procedures: (i) laparoscopic wide Kocher maneuver and transection of the proximal jejunum; (ii) laparoscopic separation of the duodenum from the pancreas; (iii) creation of a small upper median laparotomy; (iv) extracorporeal completion of the segmental duodenectomy; and (v) extracorporeal intestinal reconstruction. The postoperative course was uneventful, and the patient was discharged on postoperative day 8. Histopathological examination revealed that the circumferential margin of the specimen was negative for tumor cells. LAPSD provided a clear margin without damaging the papilla and eliminated the possibility of peritoneal or port‐site seeding of tumor cells because part of the procedure was performed extracorporeally. LAPSD is a useful alternative to pancreatoduodenectomy in patients with a large adenoma extending close to the papilla in the duodenum.     

Single‐incision laparoscopic surgery for small bowel resection with an intraumbilical arcuate incision in children

Single‐incision laparoscopic surgery (SILS) has been performed on children for various procedures. However, few reports are available about SILS for small bowel resection, particularly involving conventional instruments in the pediatric population. Herein, we report four cases of small bowel resection with single umbilical incision and a three‐trocar approach. From October 2010 to September 2011, we performed small bowel resection with SILS on four cases, including a boy with an intestinal duplication cyst and three children with Meckel's diverticulum. An intraumbilical arcuate incision was made to expose the abdominal wall fascia, and one 5‐mm and two 3.5‐mm trocars were inserted. It was not necessary to extend the initial incision to exteriorize the lesion except in one case in which we applied the so‐called Y‐V closure plasty. All procedures were successful and did not require conversion, and all patients recovered smoothly without any complications. Small bowel resection using the SILS approach is suitable for these diseases.     

Endoluminal resection of gastric intestinal stromal tumors (GIST)

Summary

Endoluminal surgery, the combination of flexible endoscopy and percutaneous transgastric laparoscopy, has expanded the role of minimally invasive surgery in treating foregut diseases. This imaginative technique blends the skills of endoscopist and laparoscopist. The stomach is well-suited for this technique as it is an expandable, large volume organ readily accessible to a flexible endoscope, and the relative ease of placing endoscopically or laparoscopically-guided percutaneous, transgastric ports provides access for laparoscopic instrumentation. The resection of gastric stromal tumors provides one of the few opportunities to integrate flexible endoscopy and laparoscopy. Proper training in the appropriate indications to utilize endoluminal techniques and familiarity with the multiple modifications from the original intragastric techniques described nearly a decade ago will allow surgeons to approach small, predominately endoluminal gastric stromal tumors with low malignant potential located in the cardia, along the posterior gastric wall, near the gastroesophageal junction or proximal to the pylorus.     

胃食管病变行内镜下全层切除术患者的护理

目的探讨行内镜下全层切除术患者的护理方法。方法通过对20例行内镜下全层切除术患者的护理,做好充足的术前准备与风险评估是治疗成功的关键,保证患者回室后充足的休息、逐步的饮食过渡、规律合理的用药、细致的病情观察及生活照顾等对预防并发症的发生,促进患者的康复起着重要的作用。结果所有患者均于1-2周出院,2个月后复查胃镜均提示创面愈合良好。结论该类患者的病变位置起源固有肌层,常与浆膜层紧密粘连,治疗后会形成人为穿孔,风险大,术后观察不慎,护理不到位会造成患者感染、出血甚至再次穿孔,而严密的病情观察、精心的护理能够预防或减少并发症的发生,促进患者早日康复。     

Combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy for synchronous double cancer of the rectum and the prostate

Here we report a combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy. A 74‐year‐old man was diagnosed with T4b low rectal and prostate cancer. The operation was performed after neoadjuvant chemotherapy for the rectal cancer. The procedure used eight ports in total, five for laparoscopic abdominoperineal resection and six for robotic‐assisted prostatectomy. First, laparoscopic total mesorectal excision including division of the inferior mesenteric artery was performed, and then, robotic dissection of the prostate was performed. The en bloc specimen was removed through the perineal wound. Then, robotic urethrovesical anastomosis was performed. An extraperitoneal end colostomy was created to finish the operation. The operating time was 545 min, and blood loss was 170 mL. The postoperative course was uneventful, and the patient discharged on postoperative day 17. The combined laparoscopic abdominoperineal resection and robotic‐assisted prostatectomy were performed safely without any additional technical difficulty, as both procedures shared port settings and patient positions.     

Laparoscopic distal gastrectomy for gastric cancer with simultaneous resection of para‐aortic schwannoma

An asymptomatic 74‐year‐old man was diagnosed with early gastric cancer during screening. Preoperative CT revealed a 25‐mm tumor surrounded by the abdominal aorta, inferior vena cava, and left renal vein. Based on the primary tumor stage, para‐aortic lymph node metastasis was considered to be unlikely but could not be ruled out. For this reason, we planned a concurrent diagnostic and therapeutic laparoscopic resection with gastrectomy. The gastric cancer and para‐aortic tumor were successfully resected laparoscopically. The tumor was diagnosed as a schwannoma. With care and skill, we were able to resect the para‐aortic schwannoma and gastric cancer simultaneously and safely by using laparoscopic techniques.     

Superior mesenteric artery syndrome treated with single‐incision laparoscopy‐assisted duodenojejunostomy

Superior mesenteric artery (SMA) syndrome is an uncommon disease resulting from compression and partial obstruction of the third portion of the duodenum from the SMA. A 77‐year‐old man, who did not have a history of surgery, experienced repeated vomiting and developed abdominal distension. Abdominal CT showed a narrowed third portion of the duodenum, with a distended stomach and proximal duodenum. The patient was diagnosed as having SMA syndrome and was initially treated conservatively, but his condition did not improve. Single‐incision laparoscopy‐assisted duodenojejunostomy was performed. The patient recovered well and was discharged from hospital on postoperative day 8. Laparoscopic treatment is feasible for the treatment of SMA syndrome given its safety and minimal invasiveness. This is a report of the first case of single‐incision laparoscopy‐assisted duodenojejunostomy. This procedure is safer and less invasive than a conventional laparoscopic approach in a patient with SMA syndrome.