3. Classical LECS

Hiki et al. first reported classical LECS in 2006 [20] for local resection of GISTS in order to prevent excessive gastric resection followed by transformation, stenosis or stasis of food after surgery. In classical LECS, the incision line is determined by the endoscopist, and an 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 procedure in detail, and the following are excerpted from his writing.


Figure 10. Tumor location was confirmed by intraluminal endoscopy.

2. History of the LECS technique

Dimitrios's report.

28 Gastric Cancer - An Update

3. Classical LECS

Although surgical local resection with laparotomy or laparoscopic surgery is performed for gastric submucosal tumor (SMT), it is difficult when tumors are small or have an intramural growth pattern. It is difficult to determine the appropriate incision line from the abdominal cavity side, so excessive gastric resection might result in transformation or stenosis. LECS is a newly developed technique, first reported by Hiki et al. in [20] for local resection of GIST. This procedure is further categorized into CLER, which is an approach that combines ESD and laparoscopic gastric resection to determine the incision line, to resect the tumor and to close the stomach wall. As LECS can minimize the resected region and preserve the function of the stomach after surgery, the procedure was added to the national insurance list in Japan in 2014, and subsequently rapidly diffused throughout the surgical community [21–24]. Further applications of LECS then developed, so the first version is named classical LECS to distinguish it from subsequent modified LECS techniques. Classical LECS involves whole layer resection using laparoscopy and endoscopy. However, this technique may lead to contamination of and seeding of tumor cells into the peritoneal cavity, especially when the tumor is associated with an ulcer or epithelial lesion. To prevent peritoneal spread, modified LECS procedures now include inverted LECS with crown method [25], nonexposed endoscopic wall-inversion surgery (NEWS) [26] and a combination of laparoscopic

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

endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) [27].

Hiki et al. first reported classical LECS in 2006 [20] for local resection of GISTS in order to prevent excessive gastric resection followed by transformation, stenosis or stasis of food after surgery. In classical LECS, the incision line is determined by the endoscopist, and an

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

Figure 12. Endoscopic submucosal resection around the tumor and artificial perforation was performed.

Figure 13. Operation device was inserted into the perforation hole, and seromuscular dissection began by laparoscopy.

LECS makes it possible to preserve the postoperative function of the stomach. Hiki maintains that removal of the tumor must be performed carefully with a specimen retrieval bag in order

Figure 15. LECS technique can minimize the resected region. The Figures 10-15 are excerpted from Hiki's report.

Figure 14. After resecting the tumor, the incision line was closed using laparoscopic stapling devices.

Laparoscopic Endoscopic Cooperative Surgery: Current Status and Perspective

http://dx.doi.org/10.5772/intechopen.76983

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In order to reduce the transmural communication during the operation, Nunobe et al. reported the crown method and inverted LECS [25]. By pulling up the incision line of the stomach with

to prevent peritoneal and port-site dissemination of tumor.

4. LECS with crown method

5. "After resecting the tumor, the incision line was closed using laparoscopic stapling devices." (Figures 14 and 15). Figures 10–15 are excerpted from Hiki's report.

Although modified LECS techniques are used, the Hiki procedure is a basic concept that is employed throughout low invasive surgery for GISTs. By minimizing the resected region,

Laparoscopic Endoscopic Cooperative Surgery: Current Status and Perspective http://dx.doi.org/10.5772/intechopen.76983 31

Figure 14. After resecting the tumor, the incision line was closed using laparoscopic stapling devices.

Figure 15. LECS technique can minimize the resected region. The Figures 10-15 are excerpted from Hiki's report.

LECS makes it possible to preserve the postoperative function of the stomach. Hiki maintains that removal of the tumor must be performed carefully with a specimen retrieval bag in order to prevent peritoneal and port-site dissemination of tumor.
