Surgical Gastric Illustration Series: Procedure Illustrations

Written and illustrated by Laura Maaske, MSc.BMC, Medical Illustrator

I drew the surgical illustrations below to reveal a specific technique for a surgical resection procedure to remove a stomach tumor. The procedure is a Laparoscopic Intra-Gastric Resection for Submucosal Proximal Gastric Tumor. My illustrations reflect the particular surgical approach taken by Dr. Julie Hellet of Sunnybrook Health Sciences Centre, Toronto, Canada, for whom I prepared the drawings. The description below is my own endeavor to explain the procedure based on conversations with Dr. Hallet.

Overview of the Laparoscopic Intra-Gastric Resection for Submucosal Proximal Gastric Tumor

The procedure as depicted for Dr. Julie reflects the actual surgical case of a 59 year old patient with a tumor mass on the gastroesophageal junction (GEJ), which is defined as the point where the lower esophagus joins the top of the stomach. Particularly, the tumor was localized to the lesser curve of the stomach, below the GEJ. The patient did not have symptoms of a tumor. The tumor was found coincidentally by clinicians during during workup when the patient was first diagnosed with chronic kidney disease. A 5.3 cm tumor was discovered during ultrasonic and endoscopic exploration.

Illustration: Gastroesophageal junction (GEJ)

Steps in the Procedure

1. Patient Positioning and External Port Placement

The patient is placed in the most suitable position to allow access to the tumor. Six ports are placed so that the best access to this particular tumor can be obtained.

Insertion of Intragastric Gastric Ports

The endoscopic tools are passed through the wall of the abdomen, and then into the stomach. An optical port is placed. Transabdominal sutures stabilize stomach wall for surgical movements, and allow it to be opened and pulled it toward the abdominal wall. First, a small gastrotomy hole is placed in the stomach wall to allow access of a balloon. Then, a balloon trochar is placed into the stomach to expand the gastric space for continued surgical work.

An endoscopic arrangment called triangulation allows two maipulation tools to be used in conjunction with a camera to create a clear visual field of the surgical scene, and also to create a sense of depth perception.

2. Visualizing and Locating the Tumor

Using the endoscopic triangulation, the tumor is explored and made visible to the camera, as well as its relationship to the GE junction. The tumor is carefully dissected, protecting the GEJ, and resected (removed) using electrocaudery. The tumor itself cannot be touched directly by tools, to reduce the risk of tumor cells spreading through the abdomen.

3. Intragastric Resection

Sutures are placed on either side of the tumor to pull and facilitate the action of a linear rotating stapler.

4. Closing the Wound

After resection is complted, the intragastric parietal wound is closed with a running stitch and autolocking suture. During this process the endoscopes are kept in place.

5. Extracting the Tumor Specimen

The specimen is then extracted, protected in an endobag, through the 10mm port or other gastrotomy. Finally the gastric port sites are closed.

Summary

The procedure offers an alternative for submucosal gastric tumors which are located in challenging locations.

Video

Dr. Hallet has posted a video of her procedure on Youtube:

January 28, 2016