[Full-layer resection of the gastric wall, focusing on the "nonexposure technique"]

Recently, endoscopic submucosal dissection (ESD) has been widely accepted as a curative, less-invasive treatment for early-stage gastric cancer. Laparoscopic gastrectomy is generally indicated in cases in which ESD could not be completed. When severe scar formation occurs in intramucosal cancer, it is often difficult to complete ESD and laparoscopic surgery must be performed. However, laparoscopic gastrecctomy for intramucosal cancer with deep ulcer scars may be overtreatment. Therefore, we developed a combined endoscopic and laparoscopic technique to perform full-thickness resection of the gastric wall. Laparoscopic and endoscopic cooperative surgery (LECS) has recently been highlighted by Hiki et al. LECS has been performed in various clinical situations, and the lesion-lifting method reported by Ohgami et al. is a beneficial application of the LECS technique. CLEAN-NET is a combination of laparoscopic and endoscopic approaches to neoplasia with a nonexposure technique. CLEAN-NET allows us to perform full-thickness gastric wall resection without any leakage of gastric contents into the abdominal cavity. We have so far performed CLEAN-NET in 39 consecutive patients. The results were clinically satisfactory, indicating that CLEAN-NET may have the potential to become a standard treatment option for T1N0 gastric cancer.