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Fig. 26.2 Localization and
palpation of the tumour.
Schematic (a) and close view
(b)
Fig. 26.3 Seromuscular
stitch placement in gastric
wall. Schematic (a) and close
view (b)
20926 Minimally Invasive Treatment of Gastric GIST
Fig. 26.4 Second stitch
placement. Schematic (a) and
close view (b)
210 C. Moreno-Sanz and M. A. Cuesta
Fig. 26.5 Gastrotomy.
Schematic (a) and close view
(b)
Fig. 26.6 Localization of
the tumour in the stomach
and a strong stitch at the top
of the tumour. Schematic (a)
and close view (b)
Fig. 26.7 Resection of
the GIST using stapler at
the basis of the tumour.
Schematic (a) and close view
(b)
Fig. 26.8 Retrieval of the specimen
21126 Minimally Invasive Treatment of Gastric GIST
Fig. 26.10 Gastrotomy closure using a stapler device
Fig. 26.9 Gastrotomy
closure by a runner suture.
Schematic (a) and close view
(b)
212 C. Moreno-Sanz and M. A. Cuesta
Fig. 26.11 Assessment and palpation of the GIST in order to deter-
mine the exact location
Fig. 26.12 Omental bursa is
open. Schematic (a) and close
view (b)
Fig. 26.13 Dissection of the distal part of the greater curvature
Fig. 26.14 Pars flaccida
is open. Schematic (a) and
close view (b)
Fig. 26.15 Division of the
stomach distal to the tumour
by means of linear stapler.
Schematic (a) and close view
(b)
21326 Minimally Invasive Treatment of Gastric GIST
Fig. 26.16 Division of the
stomach proximally to the
tumour. Schematic (a) and
close view (b)
214 C. Moreno-Sanz and M. A. Cuesta
Fig. 26.17 Retrieval of the
specimen (a). Examination of
the specimen (b)
Fig. 26.18 Reconstruction
by gastrojejunal Roux
Y anastomosis. Schematic (a)
and close view (b)
specimen. Pfannenstiel incision may be a good option at
this time (Fig. 26.17).
9. Reconstruction by gastrogastric anastomosis
Side-to-side anastomosis between proximal and distal gastric stumps is performed with linear stapler, followed by
closure of the opening with running suture. Sometimes, if
the distal resection line has been at the level of the proximal
duodenum, it’s necessary to perform a gastrojejunal Roux
Y anastomosis (Fig. 26.18).
References
1. Min KW. Gastrointestinal stromal tumour: and ultrastructural investigation on regional differences with considerations on their histogenesis. Ultrastruct Pathol. 2010;34:174–88.
2. Takahasi T, nakajima K, Miyazaki Y. Surgical strategy for the gastric gastrointestinal stromal tumors (GISTs) larger than 5 cm: laparoscopic surgery is feasible, safe and oncologically acceptable. Surg
Laparosc Endosc Percutan Tech. 2015;25:114–8.
3. Wilhelm D, von Delius V, Burian M. Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric
subepithelial masses-analysis of 93 interventions. World J Surg.
2008;32:1021–8.
4. Gayer CP, Edelman D, Curtis B. Combined endoscopic and
laparoscopic approach to Gastroesophageal tumour. JSLS.
2011;15:228–31.
5. Moreno-Sanz C, Cuesta MA. Minimally Invasive Treatment of
Gastric GIST. In Minimally Invasive Surgery for Upper Abdominal
Cancer. MA Cuesta, editor. Springer Nature. Pages 189–193.2017.
Minimally Invasive Surgery for Treatment of Complications of Gastroduodenal Ulcer
José A. Ramírez, M. Asunción Acosta and Marcos Bruna
27
27.1 Introduction
Actually, complications associated to gastroduodenal ulcer
are uncommon due to correct diagnosis and medical treatment for Helicobacter pylori. The main complications
related to this problem are bleeding, perforation and stenosis. Sometimes, emergency treatment for them is necessary,
and surgery is the only possibility.
Bleeding is the most common complication of gastroduodenal ulcer. Less than 5% of patients with bleeding will
need a surgical approach. In these cases, many times, they
are high-risk patients and mortality could increase to 30%.
In this situation, laparoscopic approach is difficult and some
complex technical skills are required. For all this, laparoscopic approach could be contraindicated according to hemodynamic stability and general situation of these patients.
Perforation occurs in 10–15% of gastroduodenal ulcers
and its incidence is 7–10 cases/100,000 population/year.
The associated mortality in gastric perforation (10–40%)
is higher than duodenal perforation (5–15%). Mouret et al.
performed first laparoscopic approach for perforated gastroduodenal ulcer in 1990 [1].
Laparoscopic approach is sure and feasible to treat perforated gastroduodenal ulcer when a surgical treatment is
Electronic supplementary material The online version of this
chapter (https://doi.org/10.1007/978-3-030-55176-6_27) contains
supplementary material, which is available to authorized users.
indicated [2]. In perforated ulcers, some studies show that
laparoscopic approach is associated with reduced use of
hospital resources [3]. A review published in 2010 concludes that laparoscopic approach should be the first treatment of choice in these cases, but could be contraindicated
in high-risk patients [4].
Stenosis is a rare complication of gastroduodenal ulcer
and there are few cases where surgical treatment is indicated.
Piloroplasty or pilomiotomy, tronchular vagotomy, supraselective vagotomy and gastroenteroanastomosis are options
for elective surgical treatment of this complication [5, 6].
Although elective surgery for duodenal ulcer is less frequent today, there is still a small proportion of patients who
should be considered for surgical treatment. The Taylor’s
procedure (posterior truncal vagotomy with anterior gastric
seromiotomy) and the Hill-Barker’s procedure (posterior
truncal vagotomy with anterior highly selective vagotomy)
have been the most accepted modalities of vagotomies when
they have been performed by laparoscopy because of their
efficacy, safety and simplicity. Diarrhoea and delayed gastric
emptying are the most frequent complications. The global
rate of recurrent ulceration is about 10% The low rates of
mortality, recurrence and functional disorders at long-term
added to the advantages of minimal invasive surgery confer
to laparoscopic vagotomies the condition of ideal treatment
for duodenal ulcer, when surgical treatment is indicated. In
this chapter, laparoscopic techniques for treatment of ulcer
perforation, bleeding and stenosis will be described.
J. A. Ramírez (*)
Clinica San Roque, Las Palmas de Gran Canaria, Gran Canaria,
Spain
e-mail: jarf@telefonica.net
M. A. Acosta
Unidad de Cirugia Esofago-gàstrica, Hospital Universitario de
Gran Canaria “Dr Negrìn”, Gran Canaria, Spain
M. Bruna
Department of Surgery, Hospital Universitario y Politécnico La Fé,
Valencia, Spain
© Springer Nature Switzerland AG 2021
M. Asunción Acosta et al. (eds.), Atlas of Minimally Invasive Techniques in Upper Gastrointestinal Surgery,
https://doi.org/10.1007/978-3-030-55176-6_27
27.2 Description of the Surgical Technique
(Videos 27.1 and 27.2)
27.2.1 Ulcer Perforation
1. Patient and trocar position
The patient is placed in lithotomy position, surgeon in
French position and 4 trocars of 5/12 mm are placed as
215
216 J. A. Ramírez et al.
dissection of inflammatory tissue around the perforation
must be performed.
In selected cases (gastric ulcer or diagnostic doubts), a
biopsy must be considered.
3. Closure of perforation
Single stiches are performed to close the perforation
(Fig. 27.3). In many cases, two or three stiches are nec-
essary to close the perforation vertically (Fig. 27.4).
Leak test could be performed in selected cases with air
or blue metilen through a nasogastric tube.
4. Omentoplasty (Graham patch)
A portion of the greater omentum is selected to cover the
suture and perforation area (Fig. 27.5).
27.2.2 Bleeding
1. Piloroduodenotomy or gastrotomy
Two reference stiches are co-located in the serosa near
to the bleeding area and a large pilorotomy, duodenot-
omy or gastrotomy is performed between these stiches
(Fig. 27.6).
2. Hemostatic stiches (gastroduodenal artery ligation)
Fig. 27.1 Position of patient and trocar’s placement
Usually uncontrolled endoscopic bleeding is due to gas-
troduodenal injury, and the bleeding area is located in
the posterior wall of the duodenum. After bleeding is
located, hemostatic stiches are performed (Fig. 27.7).
In some cases, proximal and distal ligation of gastroduodenal artery could be required to stop the bleeding.
Fig. 27.2 Duodenal perforation
shown in Fig. 27.1. This position is the same to treat all
the complications described in this chapter.
2. Exploratory laparoscopic, lavage and biopsy
First of all, it’s mandatory to realize a complete abdomi-
nal cavity visualization in order to find the perforation (Fig. 27.2). Then an abundant washing and a blunt
27.2.3 Stenosis
1. Evaluation of the length and morphology of the
stenosis
Macro and microscopic evaluation of the surrounded ste-
nosis tissue is required in some cases. To choose the best
surgical technique every local and general conditions
must be considered. There are multiple options, and
some of them will be described below.
2. Heineke-Mikulicz pyloroplasty (Fig. 27.8)
To perform this technique, wo reference stiches are
co-located in the serosa of the pylorus at the superior
and inferior margins of the pyloric ring for anatomic
orientation.
Then total pyloromiotomy is performed between these
stiches. A horizontal incision is made along the anterior
wall of the proximal duodenum and distal antrum, com-
pletely sectioning the pylorus. This incision is extended
approximately 2 cm on each side of the pyloric ring.
After that it’s necessary to close the pyloroplasty verti-
cally with single stiches.
Fig. 27.3 First stitch
placement to close the
perforation. Schematic (a)
and close view (b)
Fig. 27.4 Stiches to close
the perforation verticall.
Schematic (a) and close view
(b)
21727 Minimally Invasive Surgery for Treatment of Complications …
Fig. 27.5 Omentoplasty.
Schematic (a) and close view
(b)
3. Finney U-shaped piloroplasty (Fig. 27.9)
In this technique one traction suture is given at the upper
edge of the pylorus and two equidistant sutures, 5 cm
proximal and distal to it. After that, an inverted U-shaped
incision is made in the anterior gastroduodenal wall,
from 5 cm on distal antrum continuing to 5 cm in the
proximal duodenum. Sutures are made that approximate
the two halves of the lower edge of the incision and the
two halves of the upper edge of the incision, as a gas-
troduodenal anastomosis, in two layers.
218 J. A. Ramírez et al.
Fig. 27.6 Pyloroduodenotomy
Fig. 27.7 Hemostatic
stiches at the duodenal
posterior wall
Fig. 27.8 Heineke-Mikulicz pyloroplasty