Key points

Introduction

In the era of minimally destructive surgery, 2 important points must be considered: removal of the target lesion without removing normal tissue and obtaining a sufficient resection margin. These 2 aims seem to be contradictory, but advances in surgical procedures and therapeutic endoscopic technology allow operators to accomplish these difficult tasks in a stepwise manner. The development of laparoscopy paved the way for minimally invasive surgery. Laparoscopic wedge resection of the stomach is used to remove stomach tumors, such as gastrointestinal stromal tumors (GISTs), neuroendocrine tumors, and adenocarcinoma. However, it is difficult to determine the appropriate incision line from the outside of the stomach when these lesions are intraluminal. Excessive gastric resection might result in transformation of the stomach, with consequent gastric stasis during food uptake. Furthermore, the open approach was used for large tumors and tumors located at specific locations, such as the posterior gastric wall, esophagogastric junction, and the area near the pylorus, to ensure negative margins. Surgeons have used various methods to determine the appropriate incision line for local resection of the stomach, such as lesion-lifting gastrectomy, hand-assisted laparoscopic surgery, the tumor eversion method, and laparoscopic-endoscopic rendezvous resection. In addition to these methods, endoscopic submucosal dissection (ESD) has been used to transform organ-saving treatment into a minimally destructive surgical procedure. Currently, these 2 techniques are being merged with the aim of developing less invasive and less destructive treatments in the future.

Laparoscopic and endoscopic cooperative surgery (LECS) was developed as a less invasive and less destructive surgical technique that overcomes the disadvantages of laparoscopy-only procedures. Currently, LECS is evolving such that endoscopy has a more significant role (ie, it is not used to simply guide laparoscopic resection; rather, it has an active role in the resection itself). Following the development of the original LECS procedure, many researchers investigated several modified LECS procedures. Laparoscopy-assisted endoscopic full-thickness resection (LAEFR) was developed to manipulate lesions that cannot be easily approached via LECS. Several nonexposure techniques, such as inverted LECS, a combination of laparoscopic and endoscopic approaches to the treatment of neoplasia with a nonexposure technique (CLEAN-NET), nonexposed endoscopic wall-inversion surgery (NEWS), and laparoscopic transgastric surgery (LTGS), have been developed to avoid creating an opening in the gastric wall leading to the peritoneal cavity. Use of LECS and its variants has resulted in minimal resection of the normal gastric wall, with minimal gastric transformation.

As techniques have advanced, several attempts have been made to achieve local removal of gastric cancer (GC) or colorectal cancer (CRC) with laparoendoscopic full-thickness resection. Evaluating lymph node metastasis is another important issue that must be considered when laparoendoscopic full-thickness resection is used to remove GC and CRC rather than subepithelial tumors (SETs) such as GISTs, because laparoendoscopic full-thickness resection is essentially predicated on limited lymph node dissection based on sentinel lymph node (SN) mapping. SN navigation of GC and CRC has not been performed universally because of the complicated lymphatic flow from the stomach and colon and skip metastases, which sometimes occur in GC and CRC. However, laparoscopy-assisted endoscopic resection (LAER) and other techniques have been consistently used for colon polyp removal. Use of the colon collaborative technique eventually allowed the achievement of full-thickness laparoendoscopic excision (FLEX) and eversion full-thickness laparoendoscopic excision (eFLEX) using a new thread device.

Currently, laparoendoscopic full-thickness resection procedures are being combined with natural orifice transluminal endoscopic surgery (NOTES). These combined procedures are commonly referred to as “hybrid NOTES” because additional laparoscopic or thoracoscopic surgical instruments are used to assist with the endoscopic surgical procedure. Laparoendoscopic full-thickness resection performed with LECS and LECS variants nearly achieved the goals of removing a smaller specimen and obtaining a sufficient resection margin. Furthermore, a simultaneous laparoscopic approach has the potential to concomitantly remove SNs or SN basins. It is thought that these collaborative procedures satisfy the concept of minimally destructive surgery. In this article, we investigate the theoretic basis and technical feasibility of laparoendoscopic full-thickness resection for muscular propria (MP)-origin SETs, GC, and CRC. Furthermore, we analyze the advantages and limitations of laparoendoscopic full-thickness resection compared with endoscopic full-thickness resection (EFTR), as well as the role of laparoendoscopic full-thickness resection as a bridge technique for pure NOTES.