1. NOTES & Gastric Cancer Research Soonchunhyang University, Seoul, Korea
Hybrid NOTES - Simultaneous Endoscopic-Laparoscopic Surgery for Gastric Submucosal Tumor in Human -
Joo Young Cho, Yong Jin Kim, Youn Sun Park
Jin-Oh Kim, Won Young Cho, So Young Jin
NOTES & Gastric Cancer Research Soonchunhyang University, Seoul, Korea

2. 박 O O M/68 Chief complaint : Indigestion Present illness Lab
: 타병원에서 하체부 대만의 점막하종양으로
정밀 검사 위해 전원됨.
Lab
CBC ,300/uL-13.7g/dL-289K/uL
AST/ALT 30/19 IU/L
BUN/Cr /0.7 mg/dL

3. Chest PA with Lt. lat.
Within normal limit

4. Homogenous hypoechoic lesion
GFS & EUS
12 MHz
22.2 X 14.5 mm
Distal body, GC-PW
SMT
Origin: pm layer
Homogenous hypoechoic lesion

5. Materials Endoscopy Laparoscopy
1 High-Definition Endoscope (EPIK-I®, Pentax)
Endoscopic knives : flex-knife ®, IT Knife-2®,Olympus : fork-knife®
Hemostatic forcep
Modified transparent cap
Electrosurgical Unit (VIO300D®, ERBE)
Laparoscopy
Disposable Trocar
LigaSureTM
Verres needle
EthiconTM

6. Methods
IRB approved
OP team : Endoscopist – stoods at anesthesiologist’s side
: Laparoscopic Surgeon – Rt. Side of patient
Procedures
General anesthesia, Supine position
Demarcation of Submucosal tumor area ESD technique
Puncture of Stomach wall - Endoknives
Randezvous resection; endo-laparoscopic approach
Laparoscopic closure of punctured stomach

7. Endo-Laparoscopic approach (I)
Endoscopic approach
: Margin incision
Laparoscopic approach
: Visualization of SMT lesion

8. Endo-Laparoscopic approach (II)
Endoscopic approach
: Full thickness incision
Laparoscopic approach
: Visualization of IT-2 knife
& gastric wall incision site

9. Endo-Laparoscopic approach (III)
Endoscopic approach
: Insertion laparoscopic device
through incision site
Laparoscopic approach
: Complete removal of SMT
Laparoscopic approach
: Gastric wall incision along
Endoscopic incision site

10. Endo-Laparoscopic approach (IV)
Endoscopic approach
: Endoscopic view of Suture site
Laparoscopic approach
: Suturing

11. Pathology Complete resection H&E stain : Gastric stromal tumor
( Leiomyoma)
Immunohistochemical stain : not reported

12. Discussion (I) Stomach puncture method Limitation ESD method
Techically feasible and safe
Limitation
Endoscopic suturing devices; not available in Korea
Laparoscopist dominant procedure

13. Discussion (II) Endoscopy-Laparoscopic approach Technically safe
Reasonable operation times
Adequate cutting lines independent of tumor location
Alternative gastric wedge resection procedure
with minimal transformation of the stomach.
A step to advance
Endoscopic Full-Thickness Resection(EFTR) of submucosal invasive EGC

14. NOTES 연구회 소화기내과 외 과 해부병리과 조주영 김진오 이준성 김완중 조원영 이태희 김현건 박윤선 김재준 허경열 김용진
조성우
최동호
해부병리과
진소영
진윤미