Surgical Endoscopy

, Volume 29, Issue 11, pp 3363–3366 | Cite as

Total inverse transgastric resection with transoral specimen removal

  • Sebastian H. LammEmail author
  • Daniel C. SteinemannEmail author
  • Georg R. Linke
  • Dietmar Eucker
  • Thomas Simon
  • Andreas Zerz
  • Reinhard Stoll



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.


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.


From the first and second cases, we retrieved GIST tumors. In the third case, we retrieved a gastritis cystica profunda. Postoperative course was uneventful.


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.


Abdominal Cancer Surgical Technical Endoscopy 



Drs. Sebastian H. Lamm, Daniel C. Steinemann, Georg R. Linke, Dietmar Eucker, Thomas Simon, Andreas Zerz, and Reinhard Stoll have no conflicts of interest or financial ties to disclose.

Supplementary material

Supplementary material 1 (MP4 252268 kb)


  1. 1.
    Warsi AA, Peyser PM (2010) Laparoscopic resection of gastric GIST and benign gastric tumours: evolution of a new technique. Surg Endosc 24(1):72–78CrossRefPubMedGoogle Scholar
  2. 2.
    Maker AV (2013) A technique for laparoendoscopic resection of posterior fundic gastric GISTs without need for a gastrotomy. Ann Surg Oncol 20(13):4238CrossRefPubMedGoogle Scholar
  3. 3.
    Schubert D et al (2005) Laparoscopic–endoscopic rendezvous resection of upper gastrointestinal tumors. Dig Dis 23(2):106–112CrossRefPubMedGoogle Scholar
  4. 4.
    Shim JH et al (2011) Intragastric approach for submucosal tumors located near the Z-line: a hybrid laparoscopic and endoscopic technique. J Surg Oncol 104(3):312–315CrossRefPubMedGoogle Scholar
  5. 5.
    Sahm M, Pross M, Lippert H (2011) Intraluminal resection of gastric tumors using intragastric trocar technique. Surg Laparosc Endosc Percutaneous Tech 21(4):e169–e172CrossRefGoogle Scholar
  6. 6.
    Walsh RM et al (2003) Combined endoscopic/laparoscopic intragastric resection of gastric stromal tumors. J Gastrointest Surg 7(3):386–392CrossRefPubMedGoogle Scholar
  7. 7.
    Uchikoshi F et al (2004) Laparoscopic intragastric resection of gastric stromal tumor located at the esophago-cardiac junction. Surg Laparosc Endosc Percutaneous Tech 14(1):1–4CrossRefGoogle Scholar
  8. 8.
    Tagaya N et al (2002) Laparoscopic intragastric stapled resection of gastric submucosal tumors located near the esophagogastric junction. Surg Endosc 16(1):177–179CrossRefPubMedGoogle Scholar
  9. 9.
    Demetri GD et al (2010) NCCN Task Force report: update on the management of patients with gastrointestinal stromal tumors. J Natl Compr Cancer Netw 8(Suppl 2):S1–S41 (quiz S42-4)Google Scholar
  10. 10.
    Blay JY et al (2005) Consensus meeting for the management of gastrointestinal stromal tumors. Report of the GIST Consensus Conference of 20–21 March 2004, under the auspices of ESMO. Ann Oncol 16(4):566–578CrossRefPubMedGoogle Scholar
  11. 11.
    Nishida T et al (2008) Clinical practice guidelines for gastrointestinal stromal tumor (GIST) in Japan: english version. Int J Clin Oncol 13(5):416–430CrossRefPubMedGoogle Scholar
  12. 12.
    Nishimura J et al (2007) Surgical strategy for gastric gastrointestinal stromal tumors: laparoscopic vs. open resection. Surg Endosc 21(6):875–878CrossRefPubMedGoogle Scholar
  13. 13.
    Koh YX et al (2013) A systematic review and meta-analysis comparing laparoscopic versus open gastric resections for gastrointestinal stromal tumors of the stomach. Ann Surg Oncol 20(11):3549–3560CrossRefPubMedGoogle Scholar
  14. 14.
    Valle M et al (2014) Gastrointestinal stromal tumors of the stomach: the role of laparoscopic resection. Single-centre experience of 38 cases. Surg Endosc 28(3):1040–1047CrossRefPubMedGoogle Scholar
  15. 15.
    Kim DJ, Lee JH, Kim W (2014) Laparoscopic resection for 125 gastroduodenal submucosal tumors. Ann Surg Treat Res 86(4):199–205PubMedCentralCrossRefPubMedGoogle Scholar
  16. 16.
    Anania G et al (2013) Totally laparoscopic resection of a very large gastric GIST. G Chir 34(7–8):227–230PubMedCentralPubMedGoogle Scholar
  17. 17.
    De Vogelaere K et al (2012) Laparoscopic resection of gastric gastrointestinal stromal tumors (GIST) is safe and effective, irrespective of tumor size. Surg Endosc 26(8):2339–2345CrossRefPubMedGoogle Scholar
  18. 18.
    Wilhelm D et al (2008) Simultaneous use of laparoscopy and endoscopy for minimally invasive resection of gastric subepithelial masses—analysis of 93 interventions. World J Surg 32(6):1021–1028CrossRefPubMedGoogle Scholar
  19. 19.
    Kakeji Y et al (2012) Laparoscopic resection for gastrointestinal stromal tumors in the stomach. Surg Today 42(6):554–558CrossRefPubMedGoogle Scholar
  20. 20.
    Hiki N et al (2008) Laparoscopic and endoscopic cooperative surgery for gastrointestinal stromal tumor dissection. Surg Endosc 22(7):1729–1735CrossRefPubMedGoogle Scholar
  21. 21.
    Sokolich J et al (2009) Expanding the indications for laparoscopic gastric resection for gastrointestinal stromal tumors. JSLS 13(2):165–169PubMedCentralPubMedGoogle Scholar
  22. 22.
    Pucci MJ et al (2012) Laparoscopic approaches to gastric gastrointestinal stromal tumors: an institutional review of 57 cases. Surg Endosc 26(12):3509–3514CrossRefPubMedGoogle Scholar
  23. 23.
    Sakamoto Y et al (2012) Safe laparoscopic resection of a gastric gastrointestinal stromal tumor close to the esophagogastric junction. Surg Today 42(7):708–711CrossRefPubMedGoogle Scholar
  24. 24.
    Moriyama H et al (2012) Robot-assisted laparoscopic resection for gastric gastrointestinal stromal tumor. Surg Laparosc Endosc Percutaneous Tech 22(3):e155–e156CrossRefGoogle Scholar
  25. 25.
    Li VK et al (2008) Laparoscopic intragastric approach for stromal tumours located at the posterior gastric wall. Asian J Surg 31(1):6–10CrossRefPubMedGoogle Scholar
  26. 26.
    Vecchio R et al (2013) Laparoscopic–endoscopic rendez-vous resection of iuxta-cardial gastric GIST. G Chir 34(5–6):145–148PubMedCentralPubMedGoogle Scholar
  27. 27.
    Conrad C et al (2014) Techniques of intragastric laparoscopic surgery. Surg Endosc. doi: 10.1007/s00464-014-3654-z
  28. 28.
    De Vogelaere K et al (2013) Intragastric SILS for GIST, a new challenge in oncologic surgery: first experiences. Anticancer Res 33(8):3359–3363Google Scholar
  29. 29.
    Huscher CG et al (2013) Transoral extraction of a laparoscopically resected large gastric GIST. J Laparoendosc Adv Surg Tech A 23(8):707–709CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Sebastian H. Lamm
    • 1
    Email author
  • Daniel C. Steinemann
    • 1
    Email author
  • Georg R. Linke
    • 2
  • Dietmar Eucker
    • 1
  • Thomas Simon
    • 3
  • Andreas Zerz
    • 1
  • Reinhard Stoll
    • 1
  1. 1.Department of SurgeryKantonsspital BasellandBruderholzSwitzerland
  2. 2.Department of General, Visceral and Transplantation SurgeryUniversity Hospital HeidelbergHeidelbergGermany
  3. 3.Department of General and Visceral SurgeryKlinik SinsheimSinsheimGermany

Personalised recommendations