4. LECS with crown method

5. "After resecting the tumor, the incision line was closed using laparoscopic stapling devices."

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

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,

(Figures 14 and 15). Figures 10–15 are excerpted from Hiki's report.

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

30 Gastric Cancer - An Update

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 several stitches, abdominal cavity contamination is prevented. This technique was named crown method because pulled-up stomach wall looks like a crown (Figure 16). Using the traction of the stitch, the resected specimen is inverted to the intragastric cavity. This technique

to remove the tumor without the contamination of abdominal cavity. Figures 16 and 17

Laparoscopic Endoscopic Cooperative Surgery: Current Status and Perspective

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

33

Classical LECS with crown method is an improved technique that reduces the risk of cancer cell dissemination. However, it can be difficult to completely prevent the contamination because of transmural communication during the procedure. Nonexposed endoscopic wallinversion surgery (NEWS) was first reported by Goto et al. in 2011 with the goal of minimizing transmural communication during the operation [26]. They performed NEWS in an ex vivo porcine model and described the usefulness of this procedure. By inverting the tumor into the inside of the stomach without opening the gastric lumen, complete resection with nonexposure

1. "Markings around a model lesion are made with electrocautery knife."

2. "A circumferential seromuscular incision is made from the outside."

are excerpted from Nunobe's report.

was achieved. The procedure is as follows:

5. NEWS

Figure 16. Surgeons pull up the incision line of the stomach with several stitches and pulled up stomach wall looks like a crown.

Figure 17. The stitches are also used as a supporting tool when the incision line is closed with a laparoscopic stapling device. The Figures 16 and 17 are excerpted from Nunobe's report.

was named inverted LECS. Inverted LECS with crown method is not only useful for preventing tumor seeding into peritoneal cavity, but also for securing the visual field during the operation. The stitches are also used as a supporting tool when the incision line is closed with a laparoscopic stapling device (Figure 17). Although nonexposed endoscopic wallinversion surgery (NEWS) [26] and a combination of laparoscopic endoscopic approaches to neoplasia with a nonexposure technique (CLEAN-NET) [27] are described later as nonexposure procedures, inverted LECS with crown method has few limitations such as tumor size or tumor location in comparison with NEWS or CLEAN-NET. As such, it can make it possible to remove the tumor without the contamination of abdominal cavity. Figures 16 and 17 are excerpted from Nunobe's report.
