Laparoscopic Intragastric Full-thickness Excision (LIFE) of Early Gastric Cancer Under Flexible Endoscopic Control—Introduction of New Technique Using Animal

Abstract

We have developed a new method for the treatment of stomach lesions in early gastric cancer, which we refer to as laparoscopic intragastric full-thickness excision under flexible endoscopic control. In this procedure, the diseased lesion of the gastric wall is pulled inwards and removed under endoscopy and laparoscopy guidance. A lesion in the anterior wall of the stomach, for which a direct percutaneous transgastric puncture can be performed, is a good indication for laparoscopic intragastric full-thickness excision, similarly to the lesion-lifting method. The purpose of the study is to describe the surgical techniques in the procedure and to assess the clinical relevance of the approach. Three trocars are used in the normal procedure. To perform sentinel lymph node navigation surgery, indocyanine green is injected into the submucosal layer in 4 quadrants under endoscopy. The periphery of the lesion is punctured with the first trocar (trocar(1)) by the percutaneous transgastric route. The wire of the T-bar is introduced into the stomach through trocar(1). The tip of the wire is pulled into the stomach using the forceps of the endoscope. The T-bar, after passing through the abdominal wall, is fixed outside the gastric wall. The second trocar (trocar(2)) is placed at the subumbilical region in the abdominal cavity to accommodate the laparoscope, whereas the third trocars (trocar(3)) are percutaneously punctured into the abdominal cavity. The indocyanine green-colored sentinel lymph node is detected using instruments positioned through trocar(1) and trocar(3), and the absence of lymph node metastasis is quickly confirmed by pathologic examination. Trocar(3) is repositioned in the stomach by the percutaneous transgastric route. The stomach anterior wall is pulled inwards by the T-bar, and the lesion is removed by several excisions with laparoscopic stapling devices inserted through trocar(3); extraction of the specimen is achieved through trocar(3). The gastrotomy site is sutured using instruments positioned through trocar(1) and trocar(3) under laparoscopy. The stomach surgery is performed under gastroscopic guidance, whereas the intra-abdominal procedures are performed under laparoscopy. On the basis of the introduction of new technique using pigs, we believe that this procedure is useful for intramucosal carcinoma, which exceeds the standard indication for endoscopic mucosal resection, and for carcinoma invading the submucosa without lymph node metastasis.