with Dr. Ana María Otero, Dr. Dulce Momblán
The surgical resection of GISTs seems to lend itself very well to laparoscopic resections, as unlike other gastrointestinal malignancies, wide margins and lymph node dissections are not necessary in their surgical management. While these factors facilitate their laparoscopic resection, great care must be taken when handling these tumors as rupture of their capsule confers a near 100% risk of recurrence.
The current studies support that laparoscopic resection is safe and effective for gastrointestinal GISTs and is associated with a significantly shorter hospital stay.
A 91 year old male patient with a previous history of HBP, with no other history of interest.
The patient presented with significant anemia and fatigue. An abdominal CT was performed showing a mass in the left lower quadrant, with a necrotic center and a fistula into the intestinal lumen. Diameter of 9cm x 6.5cm.
It is located in the distal jejunum - ileum proximal. Its appearance suggested GIST. This diagnosis was confirmed by positive pathology after CT-guided puncture.
The patient was placed in the supine position with open legs. A total of 5 trocars were used. A 12mm trocar was placed in the supraumbilical position for a 30° scope, and three 5 mm trocars served as working channels at the epigastrium and each flank.
First we can objectify the mass in the distal jejunum - ileum proximal. The mass is closely attached to the abdominal wall. We begin to perform careful dissection using the hook, releasing the tumor from the abdominal wall. Dissection must be very careful to avoid opening the tumor during surgery. We also use the LigaSure to complete the dissection and achieve a good hemostasis.
It is important to continue the dissection along the same plane to avoid injury in the abdominal wall, in the healthy small intestine and in the tumor capsule.
On the left side face, the tumor was closely adhered to the parietocolic so we had to perform a thorough dissection to avoid damaging the colon. At this point we can see how the cleavage plane is practically nonexistent. We continue with the mobilization of tumor, looking for the best place to facilitate the dissection.
At this time we ended up releasing the area adhered to the abdominal wall to gain access to the left lateral zone. Here we can see the limits of the tumor, that seemed not to invade the sigma, so we continued with the separation of the two.
During this part of the surgery all maneuvers are aimed at improving the view of the dissection and find the right plane to remove the tumor without damaging other structures. We have to make slow and careful movements to avoid bleeding or other complications. Finally we complete the resection.
Then we check the integrity of the colon after completing the resection of the tumor.
At this point, we prepare a side to side extracorporeal mechanical anastomosis. Both ends of the small bowel are transected with an EndoGIA™ and then a mechanical anastomosis with two other EndoGia™ was performed, checking hemostasis and its correct size.
Then we close the meso with a running suture, ending the surgery.
The surgery took 90 minutes.
The patient started oral intake 48 hours after the surgery and left hospital on the 5th postoperative day with no complications.
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