title: Total inverse transgastric resection with transoral specimen removal.
abstract: BACKGROUND
  Laparoscopic local excision is accepted for gastrointestinal stromal tumors (GIST) and benign lesions of the stomach. Yet, tumors at the gastroesophageal junction, on the posterior wall, or in the distal antrum are difficult to approach. Such tumors often must be exposed via gastrotomy or using a rendezvous maneuver. Our method of total intragastric laparoscopic resection using 'pneumogastrum', rigid laparoscope, and conventional laparoscopic instruments is described in an intuitive video.
  
  
  METHODS
  Two cases of total inverse transgastric resection involved resection of a submucosal GIST, one at the front wall of the cardia and the other on the posterior wall of the antrum. The third case required excision of a large prepyloric cystic lesion leading to a gastric outlet stenosis. After insertion of three trocars under laparoscopic control, a further trocar was introduced into the stomach and 'pneumogastrum' was established. Two additional 5-mm trocars were intragastrally placed. Intragastric endoscopy with a rigid optic provided an excellent view. The tumor was exposed resected with a linear stapler. The specimen was inserted into an Endo Pouch™ which was sutured to an orally inserted gastric tube. The Endo Pouch™ was gently pulled transorally. After removal of the intragastric trocars, the entrance points were laparoscopically closed.
  
  
  RESULTS
  From the first and second cases, we retrieved GIST tumors. In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful.
  
  
  CONCLUSIONS
  Gastric GIST should be resected laparoscopically if negative margins are safely achieved regardless of its size. Tumors at the frontwall and exophytic backwall GIST are addressed by laparoscopic wedge resection. Tumors at the gastrojejunal junction, in the prepyloric region, and fundus as well as submucous GIST of the gastric backwall are best approached by intragastric laparoscopic resection. Transoral specimen retrieval is an interesting option in smaller tumors.
authors.affiliation: Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland. sebastian.lamm@ksbl.ch.
authors.forename: Sebastian H
authors.initials: SH
authors.lastname: Lamm
authors.affiliation: Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland. daniel.steinemann@gmx.ch.
authors.forename: Daniel C
authors.initials: DC
authors.lastname: Steinemann
authors.affiliation: Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
authors.forename: Georg R
authors.initials: GR
authors.lastname: Linke
authors.affiliation: Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.
authors.forename: Dietmar
authors.initials: D
authors.lastname: Eucker
authors.affiliation: Department of General and Visceral Surgery, Klinik Sinsheim, Alte Weibstadter Strasse 2, 74889, Sinsheim, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Simon
authors.affiliation: Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.
authors.forename: Andreas
authors.initials: A
authors.lastname: Zerz
authors.affiliation: Department of Surgery, Kantonsspital Baselland, 4101, Bruderholz, Switzerland.
authors.forename: Reinhard
authors.initials: R
authors.lastname: Stoll
mesh_terms: D004943:Esophagogastric Junction / Q000601:surgery*; D005743:Gastrectomy / Q000295:instrumentation / Q000379:methods*; D005756:Gastritis / Q000601:surgery; D046152:Gastrointestinal Stromal Tumors / Q000601:surgery*; D006801:Humans; D020706:Laparoscopes; D010535:Laparoscopy / Q000295:instrumentation / Q000379:methods*; D013274:Stomach Neoplasms / Q000601:surgery*; D016896:Treatment Outcome
keywords: Abdominal; Cancer; Endoscopy; Surgical; Technical