Laparoscopic Resection of Gastric GIST Tumor
2. Preparation and Visualization of Surgical Field
- Incision and Placement of Ports
- Liver Retraction
- Identify Tumor Location
- Placement of Additional Ports
3. Wedge Resection
- Dissect Around Nerves of Latarjet
- Maneuver Tumor
- Insert Staples
- Insert Endo-Catch Bag
4. Port Resection Endoscopy
5. Extraction of Stomach Wedge
6. Wound Closure
TranscriptionsPlease note that, unless otherwise stated, these transcriptions have been auto generated and therefore we can not guarentee their complete accuracy
Hi my name is David Rattner, surgeon at Mass General. We're going to do a laparoscopic resection of the gastric GIST tumor. This case is an 80 year old woman who had some gastrointestinal bleeding and was found to have a submucosal tumor in the stomach. It's probably a GIST tumor, and we're going to take it out laparoscopically. It seems to be an appropriate location. What we’ll do is we’ll explore laparoscopically sort of determine where it is on the stomach, confirm it with an upper GI endoscopy, and then try to do a wedge excision. If it's on the Lesser curvature of the stomach, then we’ll be mindful of the nerves of latarjet - to try to keep them intact. If you injure the nerves of latarjet, then you can get delayed gastric emptying. So if it's not close the nerves it's easy. If it's close to the latarjet nerves, then they have to be preserved.
Let's have a knife please. Just a little in from umbilical, so we have a little extra room today. 12 mm trocar please. Thank you. I hate to be a pain in the butt, but the screen’s is way over there. Thank you - yeah it will be okay. I’ll take two low stands too - maybe want them.
Let's go into reverse Trendelenburg. Can I get the liver retractor please? The post for the liver retractor? That's good. Let’s have a knife and a 5. Can I have a blank grasper please? Just make sure what we're seeing is real. Your OG tube I don't think it's in the stomach. It’s all peristalsis my dead. Let me see the liver retractor please.
A knife and a five please down here. We’re going to be right there okay. Here? Yeah. Can we go green here please? Take my grasper and let's start feeling around here. It feels like stomach. See - I agree, so I think this is it right here - that’s it right there. This is it right here. But that's it - see the extra little vessels on it? A lot of it is inside now, see that?
This is going to work here to get at this probably something like this'll work here. We're going to need a stapler and a suture. This will be a little too high - let’s go right about here. 12 - 12. Actually, let’s do a 5 - put a 5 there first. Okay, good. Straight - straight up the canal. About the angles. Let me have another - you have another 5 or is it 12? Could you open one more 5 for me please? I'm going to hold off on that for the extra 12 for just a minute.
I put this here. and then what we're going to have to do is to take down all the vessels in that area. I had a very interesting complication for one of these in the - I’ll show you as we get to do it. I bagged the nerves of latarjet. Oh really? Which is quite understandable - and then the patient had delayed gastric emptying, and it's just massive stomach pushing her diaphragm up.
Probably have to be right about here. Now that's why they do it. I mean I know in the Philippines, I did a colectomy in 45 minutes as it was no fat so easy. Sinful. I want you to take the stomach about here and pull that down there okay. Bring the camera here and let's look right in through here.
So this right here - pull back on the camera just a touch - that’s crows foot right there. See the nerves of latarjet come right down into this crows foot area. Saving them is going to be hard, but we're going to try. So you see these little white things here? That's - those are called the nerves of latarjet, the little branches of the vagus. Maybe grab right - that's - what you just did is awesome. Do it again. Sabrina improve the focus a little bit. Yes staple. I may put a few stitches in yes. Send us a little bit closer. See one of the tricks here is you really really have to clean this off, and you also use up much more length in space than you think. I’ve never felt that I clear - I don't remember a case where I felt like I cleared off more than I needed. It always seems like you get ready to put a stitch in and then you realize: oops, I need to clear up a little bit more.
K - there’s the other nerve of latarjet. That's the posterior bundle. The anterior is there. This is the posterior one right there. Of course, again just remind me that the tumor is in there. Just grab that. Yep.
Just don’t see - come in a little closer. The muscle really ends there - I think it’s right there. You want me to grab where your scrubbing? Just get the specimen first here. There we go, that’s in the lesser sac. So this is lesser Sac underneath here. That means this has to go. Keep the traction on - you were doing great - it’s me that's fumbling - here we go. That's good - so where is this lesion again - it's up in here. Maybe at the point. Got to make sure that it's actually on the anterior wall too - that's the other thing you could get faked out - could be posterior. It’s actually right there. Could be in here. We get a 5mm scope please?
K - I'm going to have you take this scope out - I’m going to have you put the scope here, and I'm going to suture through there for a minute. First have just a blank grasper for a minute. Then I’ll take a stitch.
Now it might be time for scope. Just need to make sure this is not posterior wall - I don't think it is - I think it's got to be on the anterior wall. We also still have not decompressed the stomach. Did you get anything out of your OG tube? Cuz I don't think you're in the stomach. So that would seem to be it right there, right? Yeah - no, it just slid away from you there. Now I've got it up there. I think so too. If I pull on it - what happens if you replace that with this - take that out. What I want you to do is get under it the way I did and just milk it up - so you squeeze it up like that, okay. Like that - I like that. Keep going - oh, do that again. Right yeah - nice. Okay, stay right there. I'm going to want purple loads - stitch please - 60 purple reticulating. Stitch.
We’re losing it. We’re losing the mass here. Squeeze it up again. There we go. This would make Mullen crazy - this is actually the way to do it. Alright. Let’s see the dolphin please. Now I’m - what we’re going to do next - Amy - I think is to have you scope and confirm that when I fall in this stitch that I've got the mass, okay? So we don't have any swing and missed stuff going on here today. Then we're going to get off this stapler. Fire it. And then we are going to Harvard Gardens.
So you use the stitches as a traction - you got it. So this way we don't lose it. You can hold off on the OG tube for a minute cuz we're going to do an endoscopy now, okay? Very awkward suture down there. We’ll get this done. Okay, can I have scissors now please? How am I lined up? Not bad really. I'll just whack this thing off just like this. I think. That’s halfway across right there without area. See we can just sniff this off right here, and that should work.
See we’ve of got all this stomach over here, so I don't think I'm really going to narrow it. And you could put another stitch in there if you wanted us to spend it two ways, but see now, we've got control of it. It’s just sort of you know bobbing around beforehand.
Good, okay - good, alright - fine, that's good. Did you want me to part it here? We're going to - we’re going to leave it in the esophagus. Okay can we tape this to the bed here? Hold that straight up in the air. Okay, let me have a blank grasper now please? Get the purple load there. Okay first thing I want to do is take one more trial - trial run at this with the intestinal grasper. Just try to get a good angle. Let's see the intestinal grasper first. That's better like that. And now we can come across the stomach transversely to. Don't like that double fold - that's the only thing about it I'm not crazy about. Let’s see, if I go that way, is it better? That looks better. I think so too - okay, I like that better. One, two, remember. Yeah, exactly. Got it. Just hold it right there at 5,11 like we have it. Okay, stapler. We're going to need one more purple.
Okay pull that towards you, so let's look on the other side of the stapler. So this needs to be pulled towards you this way. That's good. K I think that way we've got margin. I think that should be fine and then the next one we can start to go up a little bit. Yep. Okay. Don't pull too hard, okay, cuz we don’t want to distort the orientation here. Okay, let’s have another cartridge? Just take a quick look - see what we have to do. Okay, that's perfect - it’s going to be awesome.
Okay, that’s good. I want you to hold that up in the air - straight up in the air like. You did - but we just want to - in terms of the actual surgery here. Let's get this back to this position here okay. Let’s get that on some stretch like that so I can see the crotch. I want - what I want to do is make sure my staple line hits the crotch of the other staple line. Can you provide a little bit of traction on this - one more time. I’m just pretty good there.
Let's try something different here - let go of the mass for just a minute okay. Instead can you grab the fundus over there on this side - just lay it out - yeah. I’m happier with that. I looks better - much better.
Now let’s take a close look here and just a second - close look at our staples. Looks really good. This corner right here - I got staples all the way to the bitter end. It should be fine. I think so. Okay, let's have the endocatch bag now please. We're done except for an endoscopy. Alright, you want to see what he can get around the corner this time? Yeah. Snapper Kelly on that please. Thank you.
Just about almost slid in right there. Push there it is - it’s right there. Push. Not - you're not still not quite in - and get the lumen in the center - yes! Okay, now blow it - blow in the air. Just let the stomach get real distended. Alright, Nikolet, run some saline over that, so watch the screen up there okay. And now, Sarah push the scope and closer. Run some more saline over it. Good. Now the stomach is very well distended. Good. Alright.
One of the reasons you’re maximally flexed is because the stomach is distended. The more distended - the more in the shape of a J it is - and the harder you make things for yourself. So I’m a - just a little bit concerned about having this press staple line and sort of torquing too much. There is it right here. Nothing's bleeding. Look up - the stomach’s pretty while decompressed. So I’m going to grab it here - from here cuz I'm going to come out at this way. See kind of an angle. See kind of against. I think we have to change the angle of it. Now that's awesome - that's A+ prime. Alright, does that make everyone happier? Yeah me too. Room lights on please.
Alright, skin knife please. That’s fine - you can just go to the belly button right there. Bovie please. Awesome - see whether this will come out or not here. That’s saline - there you go - feel that.
We can close with zero vicryl - that's fine. Great. Debrief. Laparoscopic resection of gastric mass and upper GI endoscopy. Any concerns on recovery. Not really - on my part, I'm okay. Yep. Yep. Are all set. Thank you.
The case was a good illustration of how to do wedge resection of gastric tumor with a favorable location on the anterior wall in the lesser curvature. We were able to see the nerve of latarjet nicely as the patient was not obese and preserve them and then confirm that our staple line was airtight with a post resection endoscopy.
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