The Center for the Future of Surgery, University of California San Diego, 9500 Gilman Drive, MET Building, CFS, La Jolla, CA 92093, USA.
Surg Endosc. 2013 Feb;27(2):394-9. doi: 10.1007/s00464-012-2473-3. Epub 2012 Jul 18.
In laparoscopy, it often is the case that port sites are enlarged for specimen extraction. This leads to higher risk of trocar site complications, such as infection or incisional hernia. Natural orifice surgery (NOTES) is beneficial for minimizing these complications, and this is emphasized when the extracted specimen is of large volume. We have been using transgastric technique for appendectomy, cholecystectomy, and laparoscopic sleeve gastrectomy (LSG). Of these transgastric operations, we focus on the one with relatively large-organ extraction: LSG with transoral remnant extraction (TORE). We describe the details and feasibility of this procedure and compare the outcomes to conventional LSG.
All patients undergoing LSG were considered candidates for TORE and were consented for this procedure if interested after an informed discussion. Eighteen LSGs with TORE (TORE group) and ten conventional LSGs (non-TORE group) were performed from August 2010 to March 2011. We retrospectively compared these two groups for the age, sex, preoperative body mass index, operating room time, hospital stay, excess weight loss (EWL), and trocar site complications. Laparoscopic sleeve gastrectomy with TORE consists of conventional LSG and transgastric retrieval of the resected stomach. The procedure exceeds exactly the same manner as conventional LSG until the initial stapling of the stomach. For TORE, the gastrectomy is initiated 5 cm proximal to the pylorus than usual LSG to save the space for the gastrotomy used for specimen retrieval. After the gastrectomy is completed, the full thickness of the distal most part of the staple line is incised open as wide as 2 cm by using electric cautery or ultrasonic dissector. A flexible upper endoscope, which has been in the stomach already as a bougie for gastrectomy, is then guided into the peritoneal cavity through the gastrotomy. The specimen is grasped endoscopically with a snare and extracted transorally. Following this, the gastrotomy is closed laparoscopically. The final shape of the gastric sleeve is identical to the one of conventional LSG.
There was no significant difference between the TORE and the non-TORE group for patients' profile, operating room time, hospital stay, and EWL. Neither group has experienced perioperative complications. All specimens were extracted readily and safely in the TORE group. Of the ten cases in the non-TORE group, four required extension of the trocar site. No trocar site complications were found in the TORE group, whereas the extended trocar site developed panniculitis in two cases of the non-TORE group; one required panniculectomy for refractory induration.
TORE can be safely and easily performed by surgeons with laparoscopic and endoscopic skill, and with commonly available instruments. While producing identical outcomes, our initial experience with the TORE technique demonstrates an advantage over traditional LSG, because it minimizes trocar site complications. Transgastric organ extraction is potentially applicable to other large-organ extractions in laparoscopic surgery without excessive risk or resources. Larger case volume and longer follow-up period is awaited.
在腹腔镜手术中，通常需要扩大端口以提取标本。这会导致更高的套管部位并发症风险，如感染或切口疝。自然腔道手术（NOTES）有利于最大限度地减少这些并发症，当提取的标本体积较大时，这一点尤为重要。我们一直在使用经胃技术进行阑尾切除术、胆囊切除术和腹腔镜袖状胃切除术（LSG）。在这些经胃手术中，我们专注于提取相对较大器官的手术：经口残胃取出的 LSG（TORE）。我们描述了该手术的详细信息和可行性，并将其结果与传统 LSG 进行了比较。
所有接受 LSG 的患者均被视为 TORE 的候选者，如果在知情讨论后对此程序感兴趣并同意，他们将被纳入该程序。2010 年 8 月至 2011 年 3 月期间，我们共进行了 18 例经口残胃取出的 LSG（TORE 组）和 10 例传统 LSG（非 TORE 组）。我们回顾性比较了这两组患者的年龄、性别、术前体重指数、手术室时间、住院时间、体重减轻过量（EWL）和套管部位并发症。经口残胃取出的 LSG 由传统的 LSG 和经胃切除切除的胃组成。该手术的操作与传统的 LSG 完全相同，直到胃的初始吻合。对于 TORE，胃切除术从幽门近端开始，比常规 LSG 长 5 厘米，为标本取出用的胃切开术留出空间。胃切除术完成后，用高频电刀或超声刀将最远端的全层缝线切开，宽 2 厘米。已经作为胃切除术引导器的柔性上内窥镜通过胃切开术进入腹腔。标本通过圈套器经口内窥镜抓取并经口取出。随后，腹腔镜下关闭胃切开术。胃袖的最终形状与传统 LSG 的形状相同。
TORE 组和非 TORE 组患者的一般资料、手术室时间、住院时间和 EWL 无显著差异。两组均未发生围手术期并发症。TORE 组所有标本均安全、顺利取出。非 TORE 组 10 例中有 4 例需要扩大套管部位。TORE 组未发生套管部位并发症，而非 TORE 组有 2 例发生扩展套管部位的脂膜炎；1 例因难治性硬结需要行脂膜切除术。
有腹腔镜和内镜技能以及常用器械的外科医生可以安全、轻松地进行 TORE。在产生相同结果的同时，我们对 TORE 技术的初步经验表明，它优于传统的 LSG，因为它可以最大限度地减少套管部位的并发症。经胃器官取出术可能适用于腹腔镜手术中其他大型器官的取出，而不会增加过多的风险或资源。我们正在等待更大的病例数量和更长的随访时间。
