Laparoscopic Staging in Gastric Cancer

taging in any form of cancer has been an integral part in the management of this disease, especially so in gastric cancers. Gastric cancer has a high incidence in the Asian region and comes with a poor prognosis if not detected early. Gastric cancer remains the second leading cause of cancer related deaths in the world. Laparoscopy was introduced more than four decades ago and has been utilized in various surgical fields. Laparoscopy in gastric cancer has revolutionized its management and offers a more comprehensive way of dealing with this dreaded disease. A simple and quick method of staging, laparoscopy detects metastatic disease and can alter the course of treatment. Laparoscopic staging complements other staging modalities like a CT scan. A diagnostic laparoscopy can also avoid unnecessary laparotomy which will increase the morbidity of an ill patient. urgery has been the mainstay form of treatment for gastric cancer worldwide. Majority of patients present with an advanced disease in many parts of the world. Surgical resection is dependent on the staging of the disease. It was reported in Malaysia that 82% of patients presented with Stage IV disease [1]. In a substantial number of patients, not even a palliative procedure was offered. Accurate preoperative staging can help reduce the number of unnecessary surgeries and decide other options of treatment. When surgery is indicated, laparotomy has always represented the traditional technique to ascertain and confirm the resectability of gastric cancer. Preoperative staging is of utmost importance because an exploratory laparotomy not followed by radical surgery due to unresectability or metastatic spread will be followed by considerable morbidity and mortality (13–23% and 10–36% respectively) [2]. Research regarding neoadjuvant protocols for locally advanced cancers is ongoing, which makes accurate staging imperative. Even after modern preoperative imaging screening like CT scan, PET scan, endoscopic ultrasound, many patients are found to have unsuspected, unresectable disease at surgery. External imaging methods are poor at detecting incurable disease in gastric cancer, because resection is commonly precluded by either direct local invasion or peritoneal metastasis. In regard to the detection of liver metastasis, competing methods such as PET –CT, ultrasound and CT scan have become popular because unlike laparoscopy, they are non invasive techniques. Infiltration of gastric serosa, peritoneum, lymph nodes and liver are valid prognostic factors and they can remarkably modify the survival curves [3]. They represent the difference between a localized neoplasm, surgically resectable and an advanced disease. The method of diagnostic laparoscopy at our center is standard as in many other centers. We place the patient in a supine position and a 12mm trocar is inserted at the subumblical region under general anaesthesia. A 30 degree, 5mm telescope is inserted into the peritoneal cavity for inspection. Another 5mm trocar is inserted into the left hypochondrial region to assist in lifting the stomach and other organs to asses mobility and if present tumour infiltration. The liver is also inspected for overt secondaries not seen on CT scan. The peritoneum is inspected for metastasis and if present biopsies are taken. The diaphragm and diaphragmatic pillars specifically for cardiac neoplasms are inspected in order to detect the evidence of micrometastases or carcinomatosis of omentum and peritoneum not detected before. The possible local extent and infiltration of gastric serosa is evaluated by diS