Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

The overall goal of this procedure is to directly mark tumors with intraoperative gastroscopy during a total laparoscopic gastrectomy for early gastric cancer in the middle third of the stomach. This method can help answer key questions in the laparoscopy surgery field for early gastric cancer. The main advantage of this technique is that the exact location of early gastric cancer is identified during laparoscopy gastrectomy to preserve the proximal part of the stomach.

To being, place the patient on the operating table. And administer 100 milligrams of thiopental sodium. After intravenous injection of a muscle relaxant, insert the endotracheal tube through the oral cavity and start the anesthetic gas according to the text protocol.

Place the patient in a reverse trendelenburg position and stand at their right side. Make a 10 millimeter infraumbilical incision. And insert the first trocar into the abdominal cavity.

Immediately connect the carbon dioxide gas tube to the trocar and with a pressure of 15 to 18 millimeters of mercury, create a pneumoperitoneum. Next, insert a rigid 30 degree laparoscope through the trocar, and use a monitor to explore the abdominal cavity connected to a laparoscopic system. Insert a 12 millimeter trocar on the right upper side of the umbilicus in a working port.

Then insert three 5 millimeter trocars at working ports on the left upper side of the umbilicus and both upper outer quadrants of the abdomen. Using ultrasonic endoscopic scissors, dissect the gastrocolic ligament along the transverse colon, toward the inferior pole of the spleen. Then, using a laparoscopic clip, ligate the left gastroepiploic artery and vein originating from the splenic vessels at the root.

And use the scissor to resect them. With the scissors, dissect the peripyloric lymph nodes around the pylorus and the head of the pancreas. And resect the right gastroepiploic vessels at their origin.

Before resection of the first part of the duodenum, use a laparoscopic clamp to clamp the duodenum to prevent migration of gas into the small bowel during the gastroscopic procedure. To perform intraoperative gastroscopy, begin by moving to the left side of the patient's head. Then insert a gum shield into the patient's mouth.

A gum shield is inserted into the patient's mouth to avoid injury to the teeth, and to allow the gastroscope to be inserted smoothly. Turn the patient's head to the left side and through the mouth and esophagus, carefully insert the gastroscope into the stomach avoiding injury to the mucosa of the oral cavity, esophagus and stomach. Insufflate the stomach by injecting gas through the gastroscope to locate the primary lesion.

After approximating the distance between the proximal margin of the tumor and the esophagogastric junction according to the text protocol. And if total gastrectomy is not necessary, insert an endoscopic injector through a small hole in the gastroscope. Next, with the injector needle inserted obliquely two to three centimeters proximal from the tumor margin, slowly inject two to three milliliters of indigo carmine, avoiding intra or extraluminal leakage.

It is important to insert a needle of the injector into the gastric wall obliquely to avoid a perforation of the gastric wall by the needle. In addition, indigo carmine should injected very slowly to identify intraluminal leakage during the procedure. After the injection is complete, aspirate the inflation gas through the gastroscope to make the laparoscopic procedure easier.

After the gastroscopic procedure, return to the right side of the patient and in laparoscopic view, confirm the proximal portion of the tumor by identifying serosal staining by blue dye. While the dye is still present, using an endoscopic clip, mark the stained portion to be resected, avoiding involvement of the tumor at the resection margin. After resecting the duodenum, and dissecting the lymph node according to the text protocol, use two endoscopic staplers to resect the stomach at the proper location guided by the marking clip at least three centimeters proximal from the tumor margin.

As soon as the distal stomach is resected, insert the specimen into an endoscopic bag and withdraw it from the abdominal cavity through a two to three centimeter extension of the infraumbilical trocar site. Send the tissue from the proximal margin to pathology for intraoperative histological evaluation. Finally, after confirmation of tumor-free tissue in the proximal portion of the resected stomach, use intracorporeal linear staples to perform and anastomosis between the remaining stomach and the proximal duodenum.

Of the 20 patients who underwent intraoperative gastroscopy, 18 underwent distal subtotal gastrectomy guided by the findings during the gastroscopy. Total gastrectomy was performed on two patients because the proximal tumors were too close to the esophagogastric junction. At 3.5 centimeters and 2.5 centimeters respectively, as determined during intraoperative gastroscopy.

The total mean operative time for distal gastrectomy was 188 minutes. The mean time for tumor localization with intraoperative gastroscopy was 8.4 minutes. And it gradually decreased from 11.8 minutes to 4.6 minutes.

The mean tumor size in patients who underwent distal gastrectomy was 2.89 centimeters. Early gastric cancer was the final diagnosis in 16 patients, but one exhibited muscle invasion and another exhibited serosal invasion. The mean distance from the tumor to resection margin was 3.3 centimeters.

The most common histologic cancer identified type was signet ring cell carcinoma. There was no morbidity, except for gastric stasis and adhesive illius in two patients. Finally, there were no complications related to intraoperative gastroscopy.

Once mastered, this technique can be done in five minutes from insert of gastroscopy to injection of the blue dye into gastric wall, if it is performed properly. While attempting this procedure, it's important to remember to avoid the intra and extraluminal leakage during injection of the dye. After its development, this technique paved the way for researchers in the field of gastric cancer surgery to explore intraoperatively the exact location of early gastric cancers in a total laparoscopic gastrectomy without any laparotomy.

After watching this video, you should have a good understanding of how to use intraoperative gastroscopy to localize early gastric cancer in the middle third of the stomach during a total laparoscopy gastrectomy. Don't forget that working with the intraoperative gastroscopy can be extremely hazardous and the precautions such as preventing injury to the oral cavity or the throat should always be taken while performing this procedure.