Laparoscopic Intra-Gastric Resection of Gastro-Esophageal Leiomyoma

The authors have previously described the use of laparoscopic intra-gastric resection in the management of gastro-esophageal junction cancers and leiomyoma. This technique is used in highly selected individuals. For cancers, full thickness resection is best for maximal margins. For leiomyoma, the authors often use the stapling technique. However, it is thought by some that full thickness resection without stapling results in deflation of the stomach. Depending on the location of the tumor, this most often does not occur, unless one is working on a free wall of the stomach (see Video 2).

Video 1 demonstrates the technique for full thickness resection without subsequent deflation of the stomach. This technique allows for resection of gastro-esophageal junction pathology with minimal disruption to the hiatus. The operative steps include initial port placement and evaluation for secondary trocars. Next, intra-operative esophagoscopy is performed, with placement of a balloon across the pylorus to obstruct air from flowing into the small intestine. The technique for resection and primary closure is demonstrated with the subsequent extraction of the tumor through the mouth and closure of the trocar sites.

This technique is not commonly performed, which is a reflection of the rarity of the pathology in this location. However, this technique has significant advantages for patients with leiomyoma at the hiatus. Although these are benign lesions, the patients that the authors have operated on are symptomatic: presenting with recurrent bleeding, as in this case, or pain from intussusception into the esophagus and obstruction. Pain likely occurs as secondary to the negative pressure from the chest.

In summary, the laparoscopic intra-gastric approach to these lesions allows for the successful management of this pathology, with the lack of disruption to the hiatus that would be associated with a more traditional approach. The authors observed no postoperative symptoms related to interruption or injury of the vagal branches, including nausea or bloating, or symptoms of reflux.

Video 1: This video demonstrates the technical aspects of a full thickness laparoscopic
intra-gastric resection of a symptomatic leiomyoma at the level of the gastro-esophageal
junction.

Video 2: This video clip demonstrates the technical challenges when working
intra-gastric, with full thickness resection of the gastric wall. Collapse of the stomach
is observed when there is communication between the stomach and free peritoneal
space.

Disclosure: M. Blair Marshall is a consultant for Ethicon and a member of the ClinicalKey Advisory Board.