Post written by Masaya Uesato, MD, PhD, Yoshihiro Kurata, MD, PhD, Yasunori Matsumoto, MD, PhD, Shunsuke Kainuma, MD, Takuya Hirosuna, MD, Ryota Otsuka, MD, PhD, Koichi Hayano, MD, PhD, and Hisahiro Matsubara, MD, PhD, from the Department of Frontier Surgery, Chiba University Graduate School of Medicine, Chiba, Japan.

We show you a case with a 6-mm-diameter submucosal tumor in the duodenal bulb. A neuroendocrine tumor was proven by biopsy. Because the tumor was suspected on EUS to have invaded the muscle layer, localized whole-layer resection by laparoscopic endoscopic cooperative surgery (LECS) was performed.

However, the tumor was not visible laparoscopically. This study describes a novel technique for reliably projecting the position from inside the lumen to the outside. We suggest special use of the fluorescent clip (ZEOCLIP FS; Zeon Medical Co, Ltd, Tokyo, Japan). Adjusting the protruding length of this clip, we used resin from the forceps for rough positioning and pointing.

In the full version where the entire clip is pushed out of the forceps, the tumor location was confirmed from the anterior wall of the duodenal bulb to the superior wall (Fig. 4). In the tip version where the tip of the clip protrudes 1 to 2 mm from the forceps, the tumor border can be observed as a dot (Fig. 5, white allow). Similar to a flying firefly, this technique allowed for minimal resection.

LECS is conducted using both inside and outside approaches, significantly reducing the extent of resection. However, minimal deviations on both sides decrease LECS accuracy.

Near-infrared optical observation through the adjustment of the protruding length of the fluorescent clip resin section from the forceps can allow easy confirmation of the intraluminal tumor position from a rough to a precise location on the laparoscopic side. Although this technique is simple, it is anticipated to enhance the accuracy of surgery.

In the full version, the tumor location was confirmed from the anterior wall of the duodenal bulb to the superior wall.

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