Laparoscopic and Endoscopic Cooperative Surgical Technique for Two Duodenal Neuroendocrine Tumors

Abstract

Introduction:

Laparoscopic and endoscopic cooperative surgery (LECS) is a minimally invasive procedure for local resection of nonampullary duodenal tumors with appropriate and minimal surgical resection margins. This technique prevents perioperative perforation while completely resecting large duodenal tumors. ¹ However, LECS is technically challenging depending on the number and location of the duodenal tumors. ² This video demonstrates LECS in a patient with two duodenal neuroendocrine tumors (NETs).

Methods:

An 80-year-old woman presented with two duodenal submucosal tumors. Using esophagogastroduodenoscopy, the tumors were observed on the anterior wall of the duodenal bulb, close to the ampulla of Vater, along with a duodenal diverticulum in the descending portion of the duodenum. Pathologic examinations of the specimens removed by endoscopic mucosal resection revealed grade 1 NETs. LECS with full-thickness resection for two duodenal neuroendocrine tumors was performed. The patient was placed in a modified left lateral decubitus position. Five ports were placed. First, an endoscopic circumferential submucosal incision was made on the distal side of the tumor, paying particular attention to the ampulla of Vater and the duodenal diverticulum. Thereafter, a laparoscopic Kocher maneuver was performed until the vena cava was identified. The seromuscularis propria was partially incised endoscopically. Subsequently, the remnant seromuscularis propria was dissected along the incision line of the submucosal layer laparoscopically, and the specimen was resected. The defect in the duodenal wall was closed along the short axis of the duodenum using laparoscopic interrupted sutures. Moreover, the seromuscularis propria was covered with laparoscopic running sutures. Thereafter, the same procedure was performed for the proximally situated tumor. A drain was placed at Morrison's fossa.

Results:

The operation time was 260 minutes, and the estimated blood loss was 10 mL. The patient was discharged on postoperative day 10. Pathologic findings revealed no residual NET at either site. No recurrence or stricture was observed at 4 months after surgery.

Conclusion:

LECS enabled a safe and complete excision of two duodenal NETs. Technically, the strategy consists of two key points: (1) resecting the distal tumor first and (2) the timing of the Kocher maneuver intraoperatively.

No competing financial interests exist.

Runtime of video: 6 mins 32 secs

Funding Information:

This study was supported in part by JSPS KAKENHI (Grant No.: 21K08721).

Ethical Statement:

We have received and archived patient consent for video recording/publication in advance of video recording of procedure.