We reported the outcomes of 14 patients who underwent SILS for GIST.
In our reports, though all patients were operated by endoscopic surgical skill qualification system of Japan Society of Endoscopic Surgery qualified surgeons, operative time was longer than other reports from Japan and other countries [6, 7]. Recent development of surgical devices such as the three-dimensional monitor and linear stapler may enable us to shorten the operative time.
SILS has some advantages such as better cosmetic outcomes because the use of trans-abdominal ports results in fewer wounds. The cosmetic benefit of SILS for GIST resections, which leaves only a single umbilical scar, may increase patient satisfaction [9, 10]. Deveci et al. reported that patients who underwent SILS for cholecystectomy had higher cosmetic satisfaction relative to those who underwent laparoscopic surgery involving three ports . Furthermore, Ceci et al. reported that SILS for appendectomy was associated with a lower risk of postoperative wound infection . Considering the effectiveness of SILS, it has the potential to become the first choice for GISTs, providing that technical difficulties are surmounted.
On the other hand, SILS has some disadvantages, including conflicts between the laparoscope and instrument, limited movement of instruments, limited organ retraction, and difficulty maintaining the operative field . To address these problems, we constructed the following devices. A suture was placed across the gastric wall at the anal side of the tumor, and the thread was pulled out from the abdominal cavity to enhance the operative field. A second method to prevent the liver obscuring the operating field was to raise the left lateral segment of the liver with a narrow retracting device (Fig. 1).
In conventional laparoscopic surgery, the linear stapler is inserted from the left or right side of the port, whereas in SILS, it is only inserted from the umbilical port. However, stapler insertion may be difficult if the transumbilical space is overcrowded with instruments. Attempts to adjust the resection line by moving the stapler are often unsuccessful. As an alternative, Takata et al. recommended the “move the ground” technique, in which the lesion is brought toward the stapler using an articulated grasper . Despite these improvements, challenges in SILS are often related to the location of the tumor, for example, the need for complicated manipulation by the operator’s left forceps to turn over the posterior wall. In the present study, although there were only two patients with GIST on the posterior wall, gastric obstruction following re-operation occurred in one of the two cases. According to the postoperative finding by computed tomography and a contrast medium, we considered the deformation of the stomach occurred due to twisted resection by staple. Stapler use was restricted, and assistance from the left forceps was necessary to turn the gastric posterior wall, which may have caused this severe local complication. In using stapler on tumors on the posterior wall or lesser curvature, handling of the stapler is sometimes difficult. Therefore, we should take care of the resection line not to lead to deformation of the stomach, considering the technical difficulties; SILS for GIST on the posterior wall should be carefully adapted.
In a previous study, we reported the safety of SILS for gastric SMTs near the EGJ, which is challenging due to the risk of EGJ narrowing . During SMT resections, endoscopic observations were used to maintain a sufficient margin from the mucosal side. Furthermore, by opening the lumen of the EGJ using the endoscope as a bougie, the gastric obstruction was prevented. Surgical outcomes of SILS for GISTs located mainly on the anterior wall did not include severe complication. However, because the gastric antrum is narrower than the cardia, it was not possible to adapt SILS in the three cases with GISTs near the pylorus ring. In specific cases, for example, when the tumor location is anterior, SILS may be a safe option for GISTs near the pylorus ring if performed by an experienced surgeon.
Intraluminal tumor is sometimes more difficult than extraluminal tumor because adding seromyotomy and bringing tumor outside of the gastric wall were necessary before resection. As we showed in Table 1, though we could resect the intraluminal tumor as safely as the extraluminal tumor, we took relatively long operative time in SILS of intraluminal tumor compared with that of extraluminal tumor, which may indicate the difficulty of SILS for intraluminal tumor. Considering these results, SILS on extraluminal tumor may be feasible; on the other hand, other operative methods such as laparoscopic and endoscopic cooperative surgery may be superior to SILS for intraluminal tumor.