Commentary on Brief Clinical Report: Laparoscopic Intragastric Resection
In an effort to avoid these more morbid operations for gastric submucosal tumors, Boulanger-Gobeil et al have developed a laparoscopic intragastric approach to resection of such lesions, which they have applied to 8 patients over 3 ½ years. Most were performed with the assistance of upper endoscopy. Most involved the use of a stapler to resect an intragastric lesion on a stalk (an “innie”), although 2 involved submucosal dissection of a tumor in the wall of the stomach. The authors are clear about the limitations of the technique, which is poorly suited to lesions extending beyond the submucosa and exophytic lesions (“outies”). Lesions for which microscopic margins are of concern or for which a formal lymphadenectomy is indicated (notably suspected or proven gastric adenocarcinoma) should be an absolute contraindication to this approach.
Is this a technique that can or should be widely adopted? Clearly, the intragastric approach has significant advantages for tumors that are not amenable to endoscopic resection or straightforward laparoscopic wedge gastrectomy. For very proximal or very distal tumors, this approach may avoid the need for distal or total gastrectomy. However, we should distinguish the advantages of the intragastric technique from those of its laparoscopic application as described by the authors. I am not convinced that a laparoscopic intragastric approach through an anterior gastrotomy is substantially more morbid than making 3 smaller gastrotomies for intragastric ports, although the angles involved may be awkward for some tumors. In hands that are not as laparoscopically skilled as the authors’, a small midline laparotomy may still be the best approach to still allow for an intragastric approach. However, for those surgeons with the laparoscopic skills to apply the laparoscopic intragastric technique safely, it provides one more operative strategy to avoid a more extensive, morbid resection.