1. Introduction

In the last decade, LECS has been performed all over the world in association with the invention of new operative techniques. Approaches are grouped into three major categories: laparoscopy-assisted endoscopic resection (LAER) in which resection is performed primarily by the endoscopic team under laparoscopic control; endoscope-assisted laparoscopic resection (EALR), where the laparoscopic teams perform the resection under endoscopic monitoring; and combined laparoscopic endoscopic resection (CLER), which is performed by the laparoscopic and the endoscopic teams. Description of these approaches and the details about CLER, especially LECS, nonexposed endoscopic wall-inversion surgery (NEWS), and a combination of laparoscopic endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) are described in the following chapters. Various LECS techniques for GIST are recently established, and the application of this approach to early stage gastric cancer, which is difficult to resect with the ESD technique because of severe scars or ulcers, is described. LECS for other

© 2016 The Author(s). Licensee InTech. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and eproduction in any medium, provided the original work is properly cited. © 2018 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

organs such as the duodenum or colorectum is also being attempted, but only with expert technique and specialist knowledge. LECS plus biopsy of sentinel lymph node for early gastric cancer is planned as a clinical trial.

1. Endoscope-assisted wedge resection:

Under endoscopic monitoring, tumor location is confirmed, and blood vessels in the excision area around the tumor are prepared and if necessary the omentum is dissected, and the greater curvature of the stomach is mobilized by the laparoscopist. Several seromuscular sutures are placed around the lesion (Figure 2) and by pulling the stitches upward with laparoscopic forceps (Figure 3), the tumor is removed with laparoscopic linear stapling devices (Figures 4 and 5). According to laparoscopic surgeons, the staple line can be reinforced with a hand sewing suturing. The abovementioned technique is the most commonly combined surgery in the world, with more than 500 cases published [11–17]. Although the complication rate is 0–3% [11], the main problem can be excessive gastric resection by the laparoscopic linear stapling devices resulting in transformation or stenosis.

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When the tumor is located along the posterior gastric wall, it is difficult for the laparoscopist to obtain a visual field, so a transgastric technique is often used. Under endoscopic monitoring, the laparoscopic surgeons make an incision in the anterior abdominal wall (Figures 6 and 7). The laparoscopic team directly confirms the lesion and removes it with

2. Endoscope-assisted laparoscopic transluminal (transgastric) surgery:

Figure 2. Several seromuscular sutures are placed around the lesion.

Figure 3. Surgeons pull the stitches upward with laparoscopic forceps.

#### 1.1. Laparoscopy-assisted endoscopic resection

Endoscopic resection is performed under laparoscopic control [1–3]. The endoscopist performs an endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with laparoscopic assistance (Figure 1). Laparoscopic support has many advantages. First, when accidental complications such as perforation or massive bleeding occur during the endoscopic resection, laparoscopic surgeons can treat them immediately. Second, if the endoscopist has difficulty in resecting the tumor as a result of tumor location, the laparoscopic team can reposition the stomach with manipulation of the serosal side. Although laparoscopy-assisted endoscopic resection (LAER) requires a laparoscopic team and general anesthesia in addition to endoscopy, the advantage is greater safety; therefore, perforation risk is high in ESD because of massive tumor or duodenal location, LAER is preferred. Irino et al. reported LECS for duodenal tumors in three patients using LAER, demonstrating feasibility of this approach [4]. A unique point of their method is that the laparoscopist places seromuscular sutures to reinforce the thinned duodenal wall in order to prevent postoperative perforation or bleeding. Seromuscular reinforcement is performed for all cases. As such, these techniques can be grouped into the CLER. The perforation rate for duodenal-ESD is still much higher than for gastric-ESD, esophageal-ESD and colorectal-ESD [5–10], so LAER or CLER are good alternatives.

### 1.1.1. Endoscope-assisted laparoscopic resection

In this category, laparoscopic surgeons mainly resect the tumor with endoscopic support as follows:

Figure 1. The endoscopist performs an endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with laparoscopic assistance.

1. Endoscope-assisted wedge resection:

organs such as the duodenum or colorectum is also being attempted, but only with expert technique and specialist knowledge. LECS plus biopsy of sentinel lymph node for early gastric

Endoscopic resection is performed under laparoscopic control [1–3]. The endoscopist performs an endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) with laparoscopic assistance (Figure 1). Laparoscopic support has many advantages. First, when accidental complications such as perforation or massive bleeding occur during the endoscopic resection, laparoscopic surgeons can treat them immediately. Second, if the endoscopist has difficulty in resecting the tumor as a result of tumor location, the laparoscopic team can reposition the stomach with manipulation of the serosal side. Although laparoscopy-assisted endoscopic resection (LAER) requires a laparoscopic team and general anesthesia in addition to endoscopy, the advantage is greater safety; therefore, perforation risk is high in ESD because of massive tumor or duodenal location, LAER is preferred. Irino et al. reported LECS for duodenal tumors in three patients using LAER, demonstrating feasibility of this approach [4]. A unique point of their method is that the laparoscopist places seromuscular sutures to reinforce the thinned duodenal wall in order to prevent postoperative perforation or bleeding. Seromuscular reinforcement is performed for all cases. As such, these techniques can be grouped into the CLER. The perforation rate for duodenal-ESD is still much higher than for gastric-ESD, esophageal-ESD and colorectal-

In this category, laparoscopic surgeons mainly resect the tumor with endoscopic support as

Figure 1. The endoscopist performs an endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD)

cancer is planned as a clinical trial.

24 Gastric Cancer - An Update

1.1. Laparoscopy-assisted endoscopic resection

ESD [5–10], so LAER or CLER are good alternatives.

1.1.1. Endoscope-assisted laparoscopic resection

follows:

with laparoscopic assistance.

Under endoscopic monitoring, tumor location is confirmed, and blood vessels in the excision area around the tumor are prepared and if necessary the omentum is dissected, and the greater curvature of the stomach is mobilized by the laparoscopist. Several seromuscular sutures are placed around the lesion (Figure 2) and by pulling the stitches upward with laparoscopic forceps (Figure 3), the tumor is removed with laparoscopic linear stapling devices (Figures 4 and 5). According to laparoscopic surgeons, the staple line can be reinforced with a hand sewing suturing. The abovementioned technique is the most commonly combined surgery in the world, with more than 500 cases published [11–17]. Although the complication rate is 0–3% [11], the main problem can be excessive gastric resection by the laparoscopic linear stapling devices resulting in transformation or stenosis.

2. Endoscope-assisted laparoscopic transluminal (transgastric) surgery:

When the tumor is located along the posterior gastric wall, it is difficult for the laparoscopist to obtain a visual field, so a transgastric technique is often used. Under endoscopic monitoring, the laparoscopic surgeons make an incision in the anterior abdominal wall (Figures 6 and 7). The laparoscopic team directly confirms the lesion and removes it with

Figure 2. Several seromuscular sutures are placed around the lesion.

Figure 3. Surgeons pull the stitches upward with laparoscopic forceps.

an inverted wedge resection using laparoscopic stapling devices. The opened gastric wall

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Indication for this technique is the same as for transgastric surgery approaching the posterior gastric wall. This technique was first reported by Ohashi et al. in [18], and a modified procedure was described by Dong et al. in [19]. All laparoscopic trocars are placed in the gastric cavity, penetrating both the abdominal and stomach walls. All trocars are fixed with balloon inflation of the stomach and the abdominal wall (Figures 8 and 9). The laparoscopist secures a visual field in the gastric lumen, and the tumor is removed by full-thickness resection or laparoscopic stapling devices. The trocar holes are closed with

is closed with laparoscopic staplers or hand sewing sutures.

3. Endoscope-assisted laparoscopic intraluminal (intragastric) surgery:

sutures or clips. Figures 1–9 are excerpted from Dimitrios's report.

Figure 7. The laparoscopic surgeons make an incision in the anterior abdominal wall.

Figure 8. It is difficult for laparoscopist to approach the tumor.

Figure 4. The appropriate incision line is determined under endoscopic monitoring.

Figure 5. The tumor is removed with laparoscopic linear stapling devices.

Figure 6. The tumor is located along the posterior gastric wall.

an inverted wedge resection using laparoscopic stapling devices. The opened gastric wall is closed with laparoscopic staplers or hand sewing sutures.

3. Endoscope-assisted laparoscopic intraluminal (intragastric) surgery:

Figure 4. The appropriate incision line is determined under endoscopic monitoring.

26 Gastric Cancer - An Update

Figure 5. The tumor is removed with laparoscopic linear stapling devices.

Figure 6. The tumor is located along the posterior gastric wall.

Indication for this technique is the same as for transgastric surgery approaching the posterior gastric wall. This technique was first reported by Ohashi et al. in [18], and a modified procedure was described by Dong et al. in [19]. All laparoscopic trocars are placed in the gastric cavity, penetrating both the abdominal and stomach walls. All trocars are fixed with balloon inflation of the stomach and the abdominal wall (Figures 8 and 9). The laparoscopist secures a visual field in the gastric lumen, and the tumor is removed by full-thickness resection or laparoscopic stapling devices. The trocar holes are closed with sutures or clips. Figures 1–9 are excerpted from Dimitrios's report.

Figure 7. The laparoscopic surgeons make an incision in the anterior abdominal wall.

Figure 8. It is difficult for laparoscopist to approach the tumor.

endoscopic mucosal incision is made. Artificial perforation is performed by endoscopic forceps, and the seromuscular layer is dissected using laparoscopic and endoscopic forceps. The gastric wall defect is closed with laparoscopic stapling devices. Hiki described his LECS

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2. "Blood vessels in the excision area around the tumor were prepared by laparoscopy."

3. "Endoscopic submucosal resection around the tumor and artificial perforation was perfo-

4. "Operation device was inserted into the perforation hole, and seromuscular dissection

procedure in detail, and the following are excerpted from his writing.

(Figure 11)

rmed." (Figure 12)

began by laparoscopy." (Figure 13)

Figure 10. Tumor location was confirmed by intraluminal endoscopy.

1. "Tumor location was confirmed by intraluminal endoscopy." (Figure 10)

Figure 11. Blood vessels in the excision area around the tumor were prepared by laparoscopy.

Figure 9. All laparoscopic trocars are placed in the gastric cavity, penetrating both the abdominal and stomach walls. All trocars are fixed with balloon inflation of the stomach and the abdominal wall. The Figures 1-9 are excerpted from Dimitrios's report.
