This study was supported by a grant from the National R&amp;D Program for Cancer Control, Ministry of Health &amp; Welfare, Republic of Korea (1320270).

Ethik-Erklärung: Dieses Verfahren am Menschen wurde vom Institutional Review Board (IRB) an Ajou University Hospital genehmigt. 1. Vorbereitung für Chirurgie <ol><li> Lassen Sie eine weiche Kost einen Tag vor der Operation, mit nichts durch den Mund nach Mitternacht vor der Operation. Hinweis: Verwenden Sie keine Magensonde einsetzen, bevor und während der Operation. Dieses Protokoll verwendet keine Röhre um den Magen zu entleeren. Statt dass die intra-Magen-Gas kann durch Laparoskopie Punktionsnadel abgesaugt werden, wenn der Magen aufgetrieben wird eingeschränkte Sicht für die laparoskopische Chirurgie verursacht. </li><li> der Patient auf dem Operationstisch, zur Verwaltung der Induktionsmittel (Thiopental-Natrium, 100 mg) Nach der Platzierung. </li><li> Nach intravenöser Injektion eines Muskelrelaxans (Rocuroniumbromid, 1,0 mg / kg), legen Sie die Endotrachealtubus durch die Mundhöhle. </li><li> Starten Sie das Narkosegas (Sevofluran, 2 - 3%) über den Endotrachealtubus, dann überwachen the Patient für Stabilität während der Operation. </li></ol> 2. Chirurgische Verfahren vor intraoperative Gastros <ol><li> Der Patient wird in umgekehrter Trendelenburg-Position, und stehen auf der rechten Seite des Patienten. </li><li> Machen Sie 10 mm Schnitt am infraumbilical Bereich und legen Sie die erste Trokar in die Bauchhöhle. </li><li> Sobald der Trokar eingeführt wird, schließen Sie das Gasrohr für Kohlendioxid mit dem Trokar ein Pneumoperitoneum von 15 zu schaffen - 18 mm Hg. </li><li> Legen Sie eine starre 30 ° Laparoskop durch den Trokar, und erkunden Sie die Bauchhöhle auf einem Monitor mit dem laparoskopischen System verbunden. </li><li> Legen Sie 4 zusätzliche Trokare (ein 12 mm und drei 5 mm) als Arbeitsanschlüsse. Einsatz 12 mm Trokar an der rechten oberen Seite des Nabels. Legen Sie anderen drei 5 mm Trokare an der linken oberen Seite des Nabels und den beiden oberen äußeren Quadranten des Bauches. </li><li> Präparieren Sie die gastro-Band entlang der Querkolon in Richtung der inferioder Pol der Milz mittels Ultraschall-endoskopische Schere. </li><li> Ligieren der linken A. gastroepiploica mit Ursprung aus Milzgefäße an der Wurzel mit einer laparoskopischen Clip Vene und resect sie Ultraschall endoskopische Schere nach der Belichtung der oberen Grenze des Pankreasschwanz. </li><li> Mit Ultraschall-endoskopische Schere, sezieren die peripyloric Lymphknoten rund um den Pförtner und dem Kopf der Bauchspeicheldrüse, und die gastroepiploica Schiffe auf ihren Ursprung resezieren. </li><li> Vor Resektion des ersten Teils des Duodenums, klemmen das Duodenum mit einem laparoskopischen Klammer zu Migration von Gas in den Dünndarm während des gastroskopischen Verfahren verhindern (Abbildung 1). </li></ol> 3. Die intraoperative Gastros <ol><li> Bewegen Sie auf der linken Seite des Kopfes des Patienten intraoperative Gastroskopie durchzuführen. </li><li> Setzen Sie einen Mundschutz, die Zähne und das Zahnfleisch während der intraoperative Gastroskopie zu schützen. </li><li> Drehen Sie den head des Patienten auf der linken Seite zum Einführen des Gastroskop. </li><li> Legen Sie die Gastroskop in den Magen vorsichtig durch den Mund und die Speiseröhre, eine Schädigung der Schleimhaut der Mundhöhle, die Speiseröhre und den Magen zu vermeiden. </li><li> Insufflate den Magen durch Gas durch das Gastroskop Injizieren der primären Läsion zu lokalisieren. Hinweis: Die meisten Gastroskopen eine bestimmte Taste haben Gas in den Darm während des Verfahrens zu injizieren. </li><li> Ungefähre den Abstand zwischen dem proximalen Rand des Tumors und der gastroösophagealen Übergang mit Hilfe der Skala auf dem Gastroskop markiert (Abbildung 2), und führen Sie den gesamten Magen (wie zuvor beschrieben) , wenn der Abstand zu kurz ist , den proximalen Magen zu retten. 10 </li><li> Wenn Gastrektomie nicht notwendig ist, legen Sie eine endoskopische Injektor durch ein kleines Loch des Gastroskop und injizieren 2 - 3 ccm Indigokarmin in die Magenwand eine endoskopische Injektor in einem Bereich 2 mit - 3 cm proximal vom Tumorrand, Vermeidung von intra- oder extraluminaler Leckage (3A). <ol><li> Führen Sie die Nadel des Injektors in die Magenwand schräg die Perforation der Magenwand von der Nadel zu vermeiden. Darüber hinaus injizieren Indigokarmin sehr langsam intraluminale Leckage während der Injektion zu identifizieren. </li></ol></li><li> Nach dem Farbstoff Injektion zu aspirieren Füllgas durch das Gastroskop das laparoskopische Verfahren zu erleichtern. Hinweis: Die meisten Gastroskopen eine bestimmte Taste haben Füllgas während des Verfahrens zu aspirieren. </li></ol> 4. Verfahren nach intraoperative Gastros <ol><li> Rückkehr zur rechten Seite des Patienten nach der Gastroskopie Verfahren. </li><li> In der laparoskopischen Ansicht, bestätigen den proximalen Teil des Tumors durch serosal Färbung durch blauen Farbstoff (3B) zu identifizieren. </li><li> Markieren Sie den gefärbten Teil werden mit einem endoskopischen Clip reseziert, die Vermeidung Beteiligung der Tumor an der WiederAbschnitt Marge (4A). Anmerkung: Wir empfehlen, dieses Verfahren innerhalb von 5 - 10 min nach der Operation beginnt, da der Farbstoff manchmal während der nachfolgenden Verfahren ausgewaschen werden kann. </li><li> Wenn der Farbstoff nicht in der Serosa detektiert werden kann, sofort wieder einzuspritzen, den Farbstoff unter gastroskopischen Visualisierung. </li></ol> 5. Verfahren nach intraoperative Gastros <ol><li> Reseziert Duodenum und führen auch andere Verfahren zur Lympknotendissektion nach den japanischen Behandlungsrichtlinien. 11 </li><li> Nach Lympknotendissektion, den Magen an der richtigen Stelle mindestens 3 cm proximal von der Tumorrand reseziert, durch den Markierungsklipp geführt, unter Verwendung von 2 endoskopische Heftern. </li><li> Sobald das distale Magen reseziert, um die Probe in einem endoskopischen Tasche einsetzen und aus der Bauchhöhle durch ein 2 zurückziehen - cm Verlängerung der infraumbilical Trokar Website 3. </li><li> Senden Sie das Gewebe aus dem proximalen Rand zuPathologie für die intraoperative histologische Auswertung. </li><li> Nach Bestätigung der tumorfreien Gewebes in dem proximalen Abschnitt des resezierten Magen, eine Anastomose zwischen dem restlichen Magen und dem proximalen Jejunum mit intrakorporalen linear staplers (4B) durchführen. </li></ol>

<ol>
	<li>Kim, Y. W., Yoon, H. M., Eom, B. W., Park, J. Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=History+of+minimally+invasive+surgery+for+gastric+cancer+in+Korea.">History of minimally invasive surgery for gastric cancer in Korea.</a> J Gastric Cancer. 12, 13-17 (2012).</li><li>Kim, H. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Morbidity+and+mortality+of+laparoscopic+gastrectomy+versus+open+gastrectomy+for+gastric+cancer:+an+interim+report--a+phase+III+multicenter,+prospective,+randomized+Trial+(KLASS+Trial).">Morbidity and mortality of laparoscopic gastrectomy versus open gastrectomy for gastric cancer: an interim report--a phase III multicenter, prospective, randomized Trial (KLASS Trial).</a> Ann Surg. 251, 417-420 (2010).</li><li>Kim, M. C., Kim, K. H., Kim, H. H., Jung, G. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopy-assisted+by+conventional+open+distal+gastrectomy+and+extraperigastric+lymph+node+dissection+in+early+gastric+cancer.">Comparison of laparoscopy-assisted by conventional open distal gastrectomy and extraperigastric lymph node dissection in early gastric cancer.</a> J Surg Oncol. 91, 90-94 (2005).</li><li>Kim, Y. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Improved+quality+of+life+outcomes+after+laparoscopy-assisted+distal+gastrectomy+for+early+gastric+cancer:+results+of+a+prospective+randomized+clinical+trial.">Improved quality of life outcomes after laparoscopy-assisted distal gastrectomy for early gastric cancer: results of a prospective randomized clinical trial.</a> Ann Surg. 248, 721-727 (2008).</li><li>Kinoshita, T., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+laparoscopy-assisted+and+total+laparoscopic+Billroth-I+gastrectomy+for+gastric+cancer:+a+report+of+short-term+outcomes.">Comparison of laparoscopy-assisted and total laparoscopic Billroth-I gastrectomy for gastric cancer: a report of short-term outcomes.</a> Surg Endosc. 25, 1395-1401 (2011).</li><li>Song, K. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Is+totally+laparoscopic+gastrectomy+less+invasive+than+laparoscopy-assisted+gastrectomy?:+prospective,+multicenter+study.">Is totally laparoscopic gastrectomy less invasive than laparoscopy-assisted gastrectomy?: prospective, multicenter study.</a> J Gastrointest Surg. 12, 1015-1021 (2008).</li><li>Hyung, W. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+tumor+localization+using+laparoscopic+ultrasonography+in+laparoscopic-assisted+gastrectomy.">Intraoperative tumor localization using laparoscopic ultrasonography in laparoscopic-assisted gastrectomy.</a> Surg Endosc. 19, 1353-1357 (2005).</li><li>Jeong, O., Cho, S. B., Joo, Y. E., Ryu, S. Y., Park, Y. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Novel+technique+for+intraoperative+tumor+localization+during+totally+laparoscopic+distal+gastrectomy:+endoscopic+autologous+blood+tattooing.">Novel technique for intraoperative tumor localization during totally laparoscopic distal gastrectomy: endoscopic autologous blood tattooing.</a> Surg Endosc. 26, 1778-1783 (2012).</li><li>Kim, H. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intraoperative+portable+abdominal+radiograph+for+tumor+localization:+a+simple+and+accurate+method+for+laparoscopic+gastrectomy.">Intraoperative portable abdominal radiograph for tumor localization: a simple and accurate method for laparoscopic gastrectomy.</a> Surg Endosc. 25, 958-963 (2011).</li><li>Kim, H. I., Cho, I., Jang, D. S., Hyung, W. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracorporeal+esophagojejunostomy+using+a+circular+stapler+with+a+new+purse-string+suture+technique+during+laparoscopic+total+gastrectomy.">Intracorporeal esophagojejunostomy using a circular stapler with a new purse-string suture technique during laparoscopic total gastrectomy.</a> J Am Coll Surg. 216, e11-e16 (2013).</li><li>Japanese Gastric Cancer Association. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Japanese+gastric+cancer+treatment+guidelines+2010+(ver.+3).">Japanese gastric cancer treatment guidelines 2010 (ver. 3).</a> Gast Can. 14, 113-123 (2011).</li><li>Lee, H. H., Song, K. Y., Park, C. H., Jeon, H. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Training+of+surgical+endoscopists+in+Korea:+assessment+of+the+learning+curve+using+a+cumulative+sum+model.">Training of surgical endoscopists in Korea: assessment of the learning curve using a cumulative sum model.</a> J Surg Educ. 69, 559-563 (2012).</li><li>Cho, W. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hybrid+natural+orifice+transluminal+endoscopic+surgery:+endoscopic+full-thickness+resection+of+early+gastric+cancer+and+laparoscopic+regional+lymph+node+dissection--14+human+cases.">Hybrid natural orifice transluminal endoscopic surgery: endoscopic full-thickness resection of early gastric cancer and laparoscopic regional lymph node dissection--14 human cases.</a> Endoscopy. 43, 134-139 (2011).</li><li>Abe, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+full-thickness+resection+with+laparoscopic+assistance+as+hybrid+NOTES+for+gastric+submucosal+tumor.">Endoscopic full-thickness resection with laparoscopic assistance as hybrid NOTES for gastric submucosal tumor.</a> Surg Endosc. 23, 1908-1913 (2009).</li><li>Hoetker, M. S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Molecular+in+vivo+imaging+of+gastric+cancer+in+a+human-murine+xenograft+model:+targeting+epidermal+growth+factor+receptor.">Molecular in vivo imaging of gastric cancer in a human-murine xenograft model: targeting epidermal growth factor receptor.</a> Gastrointest Endosc. 76, 612-620 (2012).</li><li>Ishihara, R. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Infrared+endoscopy+in+the+diagnosis+and+treatment+of+early+gastric+cancer.">Infrared endoscopy in the diagnosis and treatment of early gastric cancer.</a> Endoscopy. 42, 672-676 (2010).</li></ol>

The authors have no conflicts of interest or financial ties to disclose.

In diesem Protokoll haben wir ein Verfahren für die intraoperative Gastroskopie, um genau und zuverlässig Tumorlokalisation in dem mittleren Drittel des Magens identifizieren. Wir konnten erfolgreich distale subtotale Gastrektomie über die Ergebnisse der intraoperativen Gastros Basis durchführen. Bis heute wurden verschiedene Verfahren angewandt, um die Lage der frühen Magenkrebs in der laparoskopischen Ansicht zu identifizieren. Die häufigsten Methoden der präoperativen gastroskopisc...

Die laparoskopische Chirurgie hat in der Behandlung der Wahl für Magenfrühkarzinomen ostasiatischen Ländern geworden, darunter Korea und Japan. 1 Der Vorteil dieser Operation wurde in mehreren klinischen Studien für Magenfrühkarzinomen (EGC) gut demonstriert. 2-4 Die meisten die Verfahren in diesen Studien wurden durch Laparoskopie durchgeführt, aber die Identifizierung des Tumorlokalisation, Resektion des Magens, einschließlich des Primärtumors und Rekonstruktion wurden via minilaparotomy durchgeführt. Daher wurde minilaparotomy hat Chirurgie erfordert Bezeichnung &quot;gastrectomy Laparoskopie-assistierte.&quot; Kürzlich haben jedoch chirurgische Verfahren entwickelt Trauma zu minimieren, für Patienten, die die postoperativen Verbesserung der Lebensqualität. Da dieses Konzept auch in der laparoskopischen Chirurgie für Magenkrebs, einige erfahrene laparoskopischen Chirurgen minilaparotomy zu vermeiden, haben angewendet wurde versucht. Völlig laparoskopische Gastrektomie (TLG) für gastric Krebs erfordert, dass alle Verfahren nur laparoskopischen Geräten vorgenommen verwenden, ohne dass eine zusätzliche minilaparotomy für die Proben Resektion und Anastomose erfordern. Da diese Art der Operation führt zu weniger Schmerzen und eine schnellere Erholung relativ zu öffnen oder Laparoskopie-assistierte Chirurgie, die Laparotomie benötigen, bevorzugen es mehr Chirurgen. 5,6 jedoch ein Hindernis für die TLG für Magenkrebs ist Tumorlokalisation ohne direkte Visualisierung oder Palpation den Bereich der Magen-Resektion zu bestimmen. Tumor Abwesenheit am Resektionsrand ist sehr wichtig, den Erfolg bei Magenkrebs Operation zu erreichen. Bei Tumorbeteiligung an der Resektionsrand während distalen Gastrektomie für Magenkrebs ist, ist eine zusätzliche Resektion benötigt in den verbleibenden Magen verlassen Tumor zu vermeiden. In offenen und Laparoskopie-assistierte Chirurgie, kann der primäre Tumor leicht durch Palpation oder direkte Visualisierung durch eine temporäre Gastrostomie lokalisiert werden. Da jedoch die Primary Tumor ist in der laparoskopischen Ansicht, die Bestimmung Resektionsrändern für EGC in TLG schwierig sein kann nicht leicht erkannt. Mehrere andere Verfahren zusätzliche präoperative Gastroskopie erfordern Resektionsrändern zu bestimmen , wurden vorgeschlagen. 7-9 jedoch weitere präoperative Gastroskopie kann für die Patienten unbequem sein. Wir führten ein Verfahren für die intraoperative Gastroskopie direkt Tumoren während TLG für Magenkrebs im mittleren Drittel des Magens zu markieren. In diesem Protokoll verwendeten wir die laparoskopische Chirurgie für Patienten mit frühen Magenkrebs bei den präoperativen Untersuchungen, die in absoluter Indikation sind nicht für die endoskopische Submukosa-Dissektion enthalten.

<table><tbody><tr><td>Pentothal Sodium</td><td>JW pharmatheutical Co.</td><td>644912100</td><td>It was used as induction asgent</td></tr><tr><td>Rocumeron</td><td>&amp;nbsp;Ilsung pharmatheutical Co.</td><td>655402960</td><td>It was used for general anesthestia as muscle relaxant.</td></tr><tr><td>SevoFRAN</td><td>Hana pharmatheutical Co.</td><td>657801060</td><td>It was used as general anesthetics</td></tr><tr><td>Endoscopy system</td><td>Olympus Corp.</td><td>CLV-260</td><td>It was used for intraoperative GFS</td></tr><tr><td>Laparoscopic surgery system</td><td>Striker Endoscopy</td><td>1488 HD 3-CHIP</td><td>It was a system for laparoscopic surgery</td></tr><tr><td>Ultrasonic scissor</td><td>Johnson and Johnson Medical Corp.</td><td>HAR23</td><td>It was used during tissue dissection</td></tr><tr><td>Laparoscopic clip</td><td>Johnson and Johnson Medical Corp.</td><td>ER420</td><td>It was used for ligation of the vessels.</td></tr><tr><td>Indigo carmine</td><td>Korea United Pharma</td><td>Carmine</td><td>It was injected into the gastric wall</td></tr><tr><td>Linear stapler</td><td>Johnson and Johnson Medical Corp.</td><td>ECHELON FLEX Powered Endopath Stapler</td><td>It was used for resection the stomach</td></tr><tr><td>Gastroscopic injector</td><td>TaeWoong Medical</td><td>Cobra injector</td><td>I was used for gastroscopic injection of blue dye</td></tr></tbody></table>

intraoperative gastroscopy for tumor localization in laparoscopic surgery for gastric adenocarcinoma

Bestimmen Resektionsrändern für Magenkrebs, die auf die Serosa-Oberfläche exponiert sind nicht im Magen, ist das wichtigste Verfahren in völlig laparoskopischen Gastrektomie (TLG). Ziel dieses Protokolls ist es, ein Verfahren für die intraoperative Gastroskopie, einzuführen, um direkt Tumoren während TLG für Magenkrebs im mittleren Drittel des Magens markieren. Patienten, die mit einem Adenokarzinom im mittleren Drittel des Magens diagnostiziert wurden, wurden in diesem Fall Serie eingeschrieben. Vor der Operation wird eine zusätzliche Gastroskopie für Tumorlokalisation nicht durchgeführt. Unter Vollnarkose wird laparoskopische Mobilisierung des Magens zuerst ausgeführt. Nachdem der erste Abschnitt des Duodenums wird aus der Bauchspeicheldrüse mobilisiert und eingespannt, der Chirurg bewegt sich zu der anderen Seite für die gastroskopischen Verfahren. Auf das Einführen eines Gastroskop durch die Mundhöhle in den Magen, 2 - 3 ml Indigokarmin wird über einen endoskopischen Injektor in den Magen verabreicht muscle Schicht am proximalen Rand des Magens. Die Lage von gefärbten serosa in der laparoskopischen Ansicht wird verwendet distale subtotale Gastrektomie zu führen, jedoch Gastrektomie durchgeführt wird, wenn der Tumor an der gastroösophagealen Übergang zu nahe ist. Eine Probe wird nach distalen Gastrektomie abgetastet, um eine ausreichende Länge von Resektionsrandes auf Tumor vor der Rekonstruktion bestätigen. In unserem Fall Serie hatten alle Patienten tumorfrei Margen und benötigt keine zusätzliche Resektion. Es gab keine Morbidität zur Gastroskopie Verfahren bezogen, und die Zeit für das Verfahren erforderlich ist allmählich auf etwa 5 Minuten verringert. Die intraoperative Gastroskopie für Tumorlokalisation ist eine genaue und tolerierte Methode für Patienten mit Magenkrebs total laparoskopische distalen Gastrektomie unterzogen.

Von 20 Patienten, die intraoperative Gastroskopie unterzogen, unterzog 18 distale subtotale Gastrektomie, durch die Ergebnisse bei der Gastroskopie geführt. Allerdings führten wir den gesamten Magen auf zwei Patienten, weil das proximale Tumorrand an der gastroösophagealen Übergang zu nahe war, als auf die intraoperative Gastroskopie bestimmt. Der Abstand vom Tumor zum proximalen Resektionsrand betrug 3,5 cm und 2,5 cm in diesen beiden Patienten (Tabelle 1). <p c...

Watch this Scientific Journal Video about Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma at JoVE.com

Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Die intraoperative Gastroskopie für Tumorlokalisation in der laparoskopischen Chirurgie für Adenokarzinom des Magens

Determining resection margins for gastric cancer, which are not exposed to the serosal surface of the stomach, is the most important procedure during ...

intraoperative-gastroscopy-for-tumor-localization-laparoscopic

Research

JoVE Journal

Medicine

12.7K Aufrufe.  Ajou University, School of Medicine. In early gastric cancer, the aim of surgery is to precisely remove the distal stomach including the primary tumor. To do this, accurate localization of the tumor is crucial, especially in totally laparoscopic surgery. This protocol describes a procedure for intraoperative gastroscopy in totally laparoscopic subtotal gastrectomy.

Serie: Intraoperative Gastroscopy for Tumor Localization in Laparoscopic Surgery for Gastric Adenocarcinoma

Multispectral Real-time Fluorescence Imaging for Intraoperative Detection of the Sentinel Lymph Node in Gynecologic Oncology

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical excision of the tumor with a full lymphadenectomy in the drainage area of the tumor. However, removal of lymph nodes is associated with increased morbidity due to infection, wound breakdown and lymphedema.4,5 As an alternative, the sentinel lymph node procedure (SLN) was developed several decades ago to detect the first draining lymph node from the tumor.6 In case of lymphogenic dissemination, the SLN is the first lymph node that is affected (Figure 1). Hence, if the SLN does not contain metastases, downstream lymph nodes will also be free from tumor metastases and need not to be removed. The SLN procedure is part of the treatment for many tumor types, like breast cancer and melanoma, but also for cancer of the vulva and cervix.7 The current standard methodology for SLN-detection is by peritumoral injection of radiocolloid one day prior to surgery, and a colored dye intraoperatively. Disadvantages of the procedure in cervical and vulvar cancer are multiple injections in the genital area, leading to increased psychological distress for the patient, and the use of radioactive colloid.
Multispectral fluorescence imaging is an emerging imaging modality that can be applied intraoperatively without the need for injection of radiocolloid. For intraoperative fluorescence imaging, two components are needed: a fluorescent agent and a quantitative optical system for intraoperative imaging. As a fluorophore we have used indocyanine green (ICG). ICG has been used for many decades to assess cardiac function, cerebral perfusion and liver perfusion.8 It is an inert drug with a safe pharmaco-biological profile. When excited at around 750 nm, it emits light in the near-infrared spectrum around 800 nm. A custom-made multispectral fluorescence imaging camera system was used.9.
The aim of this video article is to demonstrate the detection of the SLN using intraoperative fluorescence imaging in patients with cervical and vulvar cancer. Fluorescence imaging is used in conjunction with the standard procedure, consisting of radiocolloid and a blue dye. In the future, intraoperative fluorescence imaging might replace the current method and is also easily transferable to other indications like breast cancer and melanoma.

Fluorescence imaging is a promising innovative modality for image-guided surgery in surgical oncology. In this video we describe the technical procedure for detection of the sentinel lymph node using fluorescence imaging as showcased in gynecologic oncologicy. A multispectral fluorescence camera system, together with the fluorescent agent indocyanine green, is applied.

Multispectral Real-time Fluoreszenz-Imaging für die intraoperative Detektion des Sentinel Lymph Node in Gynäkologische Onkologie

The prognosis in virtually all solid tumors depends on the presence or absence of lymph node metastases.1-3 Surgical treatment most often combines radical ...

Forschung

Medizin

Low-Cost Single-Port (LoCoSP) Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains controversial. A transthoracic approach may improve lymph node dissection, but it has considerable morbidity and respiratory complications. Transhiatal access has been demonstrated as an efficient means of minimizing post-operative complications. Minimally invasive transhiatal esophagectomy may reduce operative trauma and morbidity as well as enhance postoperative recovery with no compromise in cancer recurrence or survival. Nevertheless, it has a technical limitation in terms of cervical esophagus dissection. Thus, a low-cost single-port device was developed to complete upper mediastinal dissection by a transcervical approach during minimally invasive transhiatal esophagectomy. This device uses a nasogastric tube, a number-eight sterile glove, a sterile sponge, and 3 permanent 5-mm trocars. The step-by-step process of transhiatal esophagectomy and the development of this device are described. This technique allows for the dissection of the upper mediastinum, as well as the esophagus over the aortic arch and behind the superior portion of the trachea. The harvesting of lymph nodes along the left recurrent laryngeal nerve and paratracheals was improved.

Low-Cost Single-Port LoCoSP Device for a Transcervical Approach in Minimally Invasive Transhiatal Esophagectomy

Here, we describe a step-by-step description of transhiatal esophagectomy and the development of a low-cost single-port device for a transcervical approach in a minimally invasive transhiatal esophagectomy.

Low-Cost Single-Port (LoCoSP) Gerät für einen transzervikalen Ansatz bei minimalinvasiver transhiataler Ösophagektomie

Esophagectomy remains the preferred option to achieve curative treatment in advanced esophageal cancer, but the choice of surgical approach remains ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

Laparoskopie-Endoskopie Kooperative Chirurgie zur Behandlung von Magen-Darm-Stromatumoren

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...

Clinical Application of Single-Surgeon, Three-Port, Laparoscopic Resection for Colorectal Cancer with Natural Orifice Specimen Extraction

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, laparoscopic radical resection for sigmoid colon or high rectal cancer with natural orifice specimen extraction surgery (NOSES) has the advantage of a small incision, quick postoperative recovery, and short hospital stay. Yet, there are still only a few reports on NOSES. This paper describes the indications, preoperative preparations, surgical steps, and precautions for single-surgeon, three-port, laparoscopic radical resection of the sigmoid colon and high rectal cancer, and intraoperative specimen collection through the natural orifice. 
The protocol focuses on the steps of radical dissection and the main technical points of resection and reconstruction. At the same time, a procedure for fixing an anvil seat by self-traction of extracorporeal silk thread, used for purse-string suture fixation after the proximal anvil was placed in the abdominal cavity, was creatively improved. This operation could effectively avoid problems such as an insufficient proximal intestinal tube, shaking off the anvil seat, and weak purse-string suture during a single operation. The surgical care had less variability and was easy to perform, effectively avoiding postoperative anastomotic leakage and bleeding due to excessive intraoperative anastomotic tissue. This surgery could be widely promoted in primary hospitals.

Here, we present a protocol to successfully perform single-surgeon, three-port, laparoscopic resection for colorectal cancer with natural orifice specimen extraction.

Klinische Anwendung der laparoskopischen Resektion mit einem Chirurgen und drei Anschlüssen bei Darmkrebs mit natürlicher Probenextraktion

Reduced-port laparoscopic surgery (RPLS) has been widely used for the radical resection of gastrointestinal tumors. Single-surgeon, three-port, ...

Modified Laparoscopic Anatomic Hepatectomy: Two-Surgeon Technique Combined with the Simple Extracorporeal Pringle Maneuver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to the anatomical characteristics of the liver, with intraoperative hemorrhage being a primary concern. Intraoperative blood loss is the leading cause of conversion to open surgery; therefore, effective management of bleeding and hemostasis is crucial for a successful LAH.
The two-surgeon technique is proposed as an alternative to the traditional single-surgeon approach, with potential benefits in reducing intraoperative bleeding during laparoscopic hepatectomy. However, there remains a lack of evidence to determine which mode of the two-surgeon technique yields superior patient outcomes. Besides, to our knowledge, the LAH technique, which involves the use of a cavitron ultrasonic surgical aspirator (CUSA) by the primary surgeon while an ultrasonic dissector by the second surgeon, has been rarely reported before.
Herein, we present a modified, two-surgeon LAH technique, wherein one surgeon employs a CUSA while the other uses an ultrasonic dissector. This technique is combined with a simple extracorporeal Pringle maneuver and low central venous pressure (CVP) approach. In this modified technique, the primary and secondary surgeons utilize a laparoscopic CUSA and an ultrasonic dissectorconcurrently to achieve precise and expeditious hepatectomy. A simple extracorporeal Pringle maneuver, combined with the maintenance of low CVP, is employed to regulate the hepatic inflow and outflow in order to minimize intraoperative bleeding. This approach facilitates the attainment of a dry and clean operative field, which allows for the precise ligation and dissection of blood vessels and bile ducts. The modified LAH procedure is simpler and safer due to its effective control over bleeding as well as the seamless transition between the roles of primary and secondary surgeons. It holds great promise for future clinical applications.

Here, we present a protocol to perform a modified laparoscopic anatomic hepatectomy using improved techniques and instruments.

Modifizierte laparoskopische anatomische Hepatektomie: Zwei-Chirurgen-Technik kombiniert mit dem einfachen extrakorporalen Pringle-Manöver

Laparoscopic anatomic hepatectomy (LAH) has become increasingly prevalent worldwide in recent years. However, LAH remains a challenging procedure due to ...

Advancing LRPS: Optimal Techniques for Challenging Liver Resections

Techniques of Laparoscopic Right Posterior Sectionectomy: Glissonian Approach and a Parenchymal Transection Technique

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver resections, including less blood loss, reduced wound pain, and shorter hospital stays with a comparable oncological outcome. However, laparoscopic resection of lesions in the right posterior section of the liver is challenging due to difficulties in bleeding control and visualizing the surgical field. In the past, laparoscopic right posterior sectionectomy (LRPS) was still in the exploration phase, with undefined risks in the Second International Consensus Conference on LLR in 2014. However, recent technological advancements and increased surgical experience have shown that LRPS can be safe and feasible. It has been found to reduce hospital stay and blood loss compared to open surgery. This manuscript aims to provide a detailed description of the steps involved in LRPS. The key factors contributing to our success in this challenging procedure include proper liver retraction and exposure, the use of an intrahepatic Glissonian approach for inflow control, a technique called the 'ultrasonic scalpel mimic Cavitron ultrasonic surgical aspirator (CUSA)' for parenchymal transection, early identification of the right hepatic vein, and meticulous bleeding control using bipolar diathermy.

Here, we present a protocol to perform laparoscopic right posterior sectionectomy, focusing on two key aspects: the intrahepatic Glissonian approach for inflow control and a parenchymal transection technique using an ultrasonic surgical aspirator.

Techniken der laparoskopischen rechten posterioren Sektionektomie: Glisson-Ansatz und eine parenchymale Durchtrennungstechnik

Laparoscopic liver resections (LLR) have been widely accepted as a treatment option for liver tumors. They offer several advantages over open liver ...

Transumbilical Endoscopic Resection of Intra-abdominal Mesenchymal Tumor

Gastrointestinal stromal tumors (GISTs) typically occur in the stomach and proximal small intestine but can also be found in any other part of the digestive tract, including the abdominal cavity, albeit rarely. In the present case, the tumor was resected endoscopically through the anterior gastric wall. Computed tomography (CT) scan and gastroscopy of a 60-year-old woman revealed submucosal lesions in the gastric body. The possibility of a stromal tumor was considered more likely. The endoscopic surgery was performed under endotracheal anesthesia. After a solution had been injected at the lesion site in the stomach, the entire gastric wall was dissected to expose the tumor. As the lesion was in the abdominal cavity and its base was attached to the abdominal wall, it was accessed using a sterilized PCF colonoscope. A sodium chloride injection was administered at the base. The tumor was then peeled along its boundaries using the hooking and excision knife combined with the precutting knife. Subsequently, the tumor was pulled into the stomach through the incision made in the stomach and then extracted externally through the upper digestive tract using the ERCP spiral mesh basket. After confirming the absence of bleeding at the incision site, the endoscope was returned to the stomach, and the stomach opening was closed using purse-string sutures. The patient recovered satisfactorily following the surgery and was discharged on day 4. Histological examination revealed a low-risk stromal tumor (spindle cell type, &lt;5 mitosis/50 high-power fields [HPF]). Immunohistochemistry revealed positive staining for CD34 and CD117, negative staining for SMA, positive staining for DOG1, and negative staining for S100. Additionally, the expression of ki67 was 3%.

The article introduces the surgical method, endoscopic submucosal dissection (ESD) for the complete removal of intra-abdominal tumors using natural orifice transluminal endoscopic surgery (NOTES). The procedure reaches the stomach by using gastrointestinal endoscopy, creating a controlled perforation for tumor removal, followed by stitching the gastric incision.

Gastrointestinal stromal tumors (GISTs) typically occur in the stomach and proximal small intestine but can also be found in any other part of the ...

Single Incision Plus One Port Laparoscopic Proximal Gastrectomy with Double Channel Anastomosis for Gastric Cancer Treatment

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for treating proximal gastric cancer. This technique includes comprehensive laparoscopic resection of the proximal stomach, lymph node dissection, and double-tract anastomosis. By integrating single-port laparoscopic surgery with an auxiliary operating hole, SILT-DT reduces procedural difficulty while facilitating the placement of an abdominal drainage tube. Compared to the traditional five-port laparoscopic gastrectomy, SILT-DT requires fewer ports and results in shorter incision lengths, contributing to reduced postoperative pain and faster recovery. A thorough preoperative evaluation was conducted to ensure procedural success, with factors such as tumor size, stage, location, and patient BMI carefully considered. This comprehensive assessment allowed for optimal patient selection and surgical planning. Postoperative follow-up demonstrated no significant complications, underscoring the safety and efficacy of SILT-DT. This innovative technique offers a promising minimally invasive alternative for managing proximal gastric cancer while maintaining excellent clinical outcomes.

The single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis was initially employed for the radical resection of proximal gastric cancer. This study demonstrated the feasibility of the procedure and laid a foundation for further research.

Einzelinzision plus laparoskopische proximale Gastrektomie mit einem Port und Doppelkanal-Anastomose zur Behandlung von Magenkrebs

Single-incision plus one-port laparoscopic proximal gastrectomy with double-channel anastomosis (SILT-DT) is a minimally invasive surgical approach for ...

Robotics in Surgery: A Modular Robotic Platform Driven Gastric Wedge Resection

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was approved for in-human use in Europe. Possible applications for this new robotic system are being explored, and standardized approaches are evolving. In lieu of this, a gastric wedge resection and the standardized setup for upper gastrointestinal procedures using this new system are presented here. This safe and feasible robotic procedure is demonstrated in a 69-year-old patient with a gastric tumor. All steps of the surgery are described in a detailed and reproducible manner. The article also details trocar positioning, arm adjustments, and required surgical instruments. Docking time amounted to 13 min, whereas the console time took 115 min. The patient was discharged after 4 days after ensuring an uneventful course. The presented method is also suitable for other surgical purposes, such as fundoplications or hiatoplasties, and ensures both generalizability and reproducibility.

Robotically assisted surgery has become highly popular in recent years. Presented here is the standard care for upper gastrointestinal procedures, including a demonstration of a robotic-assisted gastric wedge resection using a modular robotic device.

Robotik in der Chirurgie: Eine modulare, robotergestützte, plattformgetriebene Magenkeilresektion

Robotic-assisted surgery has become increasingly popular since the introduction of the first robotic platform. Recently, a modular robotic system was ...

Gastroscope-assisted Trans-Trocar Gastrostomy and Abdominal Exploration

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic interventions. Gastrostomy is a classic clinical technique for patients with swallowing impediments due to obstructions in the cardiac or esophageal regions and has evolved significantly with the establishment of percutaneous endoscopic gastrostomy (PEG). While PEG offers reduced trauma and swift recovery, it falls short of exploratory capabilities and risks damaging adjacent organs. Therefore, we developed an innovative approach-gastroscope-assisted trans-Trocar gastrostomy (GTTG), which not only takes full play to the advantages of PEG with less trauma and faster postoperative recovery but also takes into account the advantages of laparoscopic gastrostomy with a good exploration of the abdominal cavity. This technique is characterized by ease of operation, minimal trauma (including short operation time and no redundant incision), rapid recovery, the ability to explore the abdominal cavity, and avoidance of injury to adjacent organs, which is quite worthy of widespread promotion in clinical settings.

Here, we introduce a novel technique of gastrostomy, which integrates laparoscopic and gastroscopic techniques, offering a streamlined approach with reduced invasiveness, expedited recovery, and the capacity for abdominal exploration while minimizing the risk of adjacent organ injury.

Gastroskopisch assistierte Transtrokar-Gastrostomie und abdominale Exploration

Advanced endoscopic technologies have revolutionized gastrointestinal surgical procedures, transitioning from open or laparoscopic methods to endoscopic ...