What Kind of Gastric Tumor Is This?

Oscar M. Crespin, MD; Ali Kagan Coskun, MD; Brant K. Oelschlager, MD; Carlos A. Pellegrini, MD

Disclosures

January 15, 2014

Operative Technique

Video Clip: Laparoscopic surgery for gastric leiomyoma.

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Patient Position

The patient is placed in a supine, split-leg, or lithotomy position with padding, such as a surgical bean bag. Our preference is the lithotomy position for optimal ergonomics and access to the hiatus, while the surgeon stands between the legs. The patient is positioned in a steep reverse Trendelenburg position, which allows the stomach and other organs to fall away from the esophageal hiatus.

Abdominal Access and Port Placement

Abdominal access is obtained at the left upper quadrant just inferior to the costal margin. A pneumoperitoneum is established according to standard laparoscopic techniques. Four operative ports (2 for the surgeon, 1 for the assistant, and 1 for the scope) are then placed under direct visualization, and liver retraction is achieved using any preferred device.

Mobilization of the Stomach and Identification of the Tumor

After dividing the gastrohepatic ligament, the identification of the tumor directly on the lesser curvature was possible. We mobilized the lesser omentum right off the lesser curvature of the stomach by dividing the small left gastric artery and vein branches, with the objective of removing the lesser omentum from the gastroesophageal junction. We also mobilized some of the gastroesophageal junction and fat pad, which would remove the anterior vagus nerve and the nerve of Latarjet from the stomach and protect them.

Gastric Tumor Enucleation

When the overlying serosa of the tumor was exposed, we opened the serosa, found the tumor, and then gradually enucleated the tumor. We used 2-0 silk sutures deep in the tumor for retraction purposes. Because the tumor was bilobed down to the lesser curvature, we had to extend the gastric myotomy by at least 7-8 cm.

The tumor came out nicely, without any injury to the underlying mucosa. Both pieces were placed in a specimen retrieval bag and removed from the patient.

We closed the muscularis and serosa with interrupted 2-0 silk sutures. We closed the hiatus posteriorly with 2-0 silk sutures. We then performed flexible endoscopy while watching it laparoscopically to make sure that there was no air leak. We closed the access port site where the tumor was removed with a 0 Polysorb suture, and 4-0 Biosyn sutures were placed in the skin.

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