Masses within the anterior wall of the stomach are frequently amenable to wedge resection with a linear endoscopic GI anastomotic stapler as described previously [10, 16, 17]. If the tumor is extraluminal, it is usually visualized on initial inspection with the laparoscope. Those lesions that are intraluminal are often identified by a characteristic dimpling of the gastric serosal surface or by bimanual palpation of the stomach with laparoscopic instruments. As mentioned previously, intraluminal visualization by a flexible endoscope assists with tumor localization and may guide resection to ensure adequate margins and to safeguard against comprising the gastric inlet or outlet. After identifying the lesion itself, the short gastric vessels are divided with ultrasonic coagulating shears. By elevating the gastric wall with two seromuscular sutures placed opposite each other within 1 cm of the mass to accomplish a no-touch technique laparoscopic gastric wedge resection and to ensure that the stitches do not penetrate or perforate the tumor. The sutures are elevated simultaneously and the stapler is placed just under the sutures to resect the tumor and a small margin of the normal stomach.

Another technique is to circumferentially excise the gastric tumor and a surrounding margin of the normal tissue using ultrasonic coagulating shears [19]. This technique is simplified by insufflating the stomach with a flexible endoscope, allowing the site where the stomach is to be opened to be determined by observing the tumor both endoscopically and laparoscopically. Typically, the incision into the stomach is made 2 cm from the lesion to make certain that the tumor is not lacerated. This technique allows for a more precise excision of the normal tissue at the margins of the tumor compared to the technique utilizing an endoscopic GIA stapler. The gastrotomy can be closed by laparoscopic intracorporeal suturing or by placing two to four full-thickness traction sutures along the cut edge of the gastrotomy and using an endoscopic linear stapler to reapproximate (“close”) the gastrotomy.

Posterior wall lesions are commonly approached through the lesser sac [10, 16, 17]. Exposure of the posterior surface of the stomach is achieved following division of the gastrocolic omentum and short gastric vessels allowing the greater curvature to be elevated and rotated cephalad. The lesion can then be resected similar to the technique described for anterior lesions [19]. An alternative approach to the posterior gastric wall tumor entails creating an anterior gastrotomy over the lesion after it is endoscopically localized. As described previously, the location of the gastrotomy is determined by visual cues from the gastroscope and laparoscope while simultaneously palpating the gastric wall with laparoscopic graspers. Through the anterior gastrostomy, normal gastric tissue adjacent to the tumor is grasped with laparoscopic bowel grasper or, alternatively, traction sutures can be placed on each side of the tumor much as described for anterior gastric tumors. The tumor and the surrounding margin of normal stomach are elevated through the gastrotomy and resected by an endoscopic linear stapler. The staple line is examined for bleeding and any bleeding points are oversewn. The anterior gastrotomy is closed with the GIA stapler or sutures.

Intraluminal posterior wall lesions such as those near the gastroesophageal junction not amenable to the above treatment are approached via a percutaneous, laparoscopic, intragastric resection. Laparoscopic intragastric or “endoluminal” surgery, as described previously in this chapter, involves the placement of balloon or mushroom-tipped laparoscopic trocars (2–10 mm) percutaneously into the stomach (insufflated by a flexible endoscope) similar to the placement of a percutaneous endoscopic gastrostomy tube [29]. The pylorus may be occluded with a balloon-tipped nasogastric tube but is infrequently needed. An angled laparoscope, positioned through one of the percutaneous gastric trocars, is preferred for visualization of the operative field, but a flexible endoscope can be used in combination with two working trocars. A dilute epinephrine solution (1:100,000) is injected circumferentially around the tumor as a tumescent to aid in the dissection of the submucosal plane surrounding the tumor and to limit bleeding. The lesion is enucleated from the submucosal-muscular junction using an electrocautery hook as needed. The mucosal defect is left open to heal or can be closed with laparoscopic intragastric suturing. The tumor is placed in a retrieval bag and removed trans-orally.

Simple wedge resection with an endoscopic linear stapler is commonly the preferred approach for lesions near the greater and lesser curvatures [10, 16, 17]. For all lesions located on the greater curve, the greater omentum needs to be divided and similarly for the lesser omentum/gastrohepatic ligament for those tumors located on the lesser curve. Ultrasonic coagulation shears or Ligasure allows for a hemostatic division of the short gastric vessels on the greater curvature and likewise the branches of the left gastric artery and coronary vein on the lesser curvature. Appropriate positioning during laparoscopy such as rotating the stomach so that the stromal tumor faces anteriorly can facilitate the ease of the resection. The tumor is resected using an endoscopic linear stapler and then removed through an extraction bag via an enlarged 12-mm trocar site.

Masses in the proximity of the gastroesophageal (GE) junction can be managed similar to tumors near the pylorus. The goals remain, if possible, to achieve an adequate surgical margin while maintaining the normal function of the lower esophageal sphincter mechanism. Lesions found more than 2–3 cm from the GE junction are approached according to their location, as an anterior, posterior, or greater/lesser curve mass, as previously described. The resection of a tumor at the GE junction is more difficult. If it is a mucosal or submucosal lesion, enucleation is a viable option and is one that we have used effectively on multiple occasions. Endoscopic ultrasound (EUS) verification of the tumors’ depth of penetration is invaluable in determining the tactics of resection for these masses. Posterior lesions at the gastroesophageal junction are easier to approach in this fashion because the instrument angle coming down from the abdominal wall is naturally pointing toward the posterior GE junction.

In this technique, the vessels around the fundus and cardia of the stomach are usually not transected, but they can be if needed. If the upper portion of the greater curve needs to be mobilized, the assistant on the left gently retracts the gastrosplenic ligament toward the lateral abdominal wall with a laparoscopic bowel grasper placed through the left lateral port. The surgeon uses the upper mid-line port to pull the stomach medially and inferiorly and the mid-right subcostal port to coagulate and transect the short gastric vessels using the ultrasonic coagulating shears. The anterior gastrotomy can be made linearly or horizontally, but one needs to remember that the gastrostomy closure must not constrict the upper stomach. Enucleation proceeds with an electrocautery hook after submucosal, peritumoral injection with dilute epinephrine. After removal of the lesion within an entrapment sac, we typically close the mucosa of the GE junction, but, on occasion, we have left it open to heal on its own.

A novel technique we described for small gastroesophageal junction stromal tumors is a laparoscopic or minilaparoscopic intragastric resection [18], which has been somewhat described in this chapter. The technique is similar to the endoluminal technique, although the minilaparoscopic or laparoscopic intragastric resection utilizes the flexible endoscope as the “camera” and insufflator nearly always. We again perform a local injection with dilute epinephrine via a 7-in., 22-gauge spinal needle placed through one of the 2-mm ports or by injection needle though the endoscope. An electrocautery hook is used to enucleate the gastroesophageal junction tumor and the mass is removed transorally with the flexible endoscope.

If the gastric stromal tumor is located in the cardia or at the gastroesophageal junction, it may not be amenable to a wedge resection technique [16, 17]. An esophagogastrectomy can be performed, although this is a technically demanding procedure to perform laparoscopically. In short, following division of the short gastric vessels and the lesser curve attachments, the mobilization of the proximal esophagus is necessary well into the mediastinum with meticulous dissection utilizing the visible plane between the pleura and the esophagus with a combination of blunt and electrosurgical dissection. Once complete, the distal esophagus is transected proximal to the gastrointestinal stromal tumor with an endoscopic linear stapler. The vasculature of the stomach is taken circumferentially using the Ligasure or other vascular sealing device. The duodenum is transected distal to the pylorus using a GIA stapler. For reconstruction, a Roux-en-Y esophagojejunostomy. This portion of the operation is initiated by taking the patient out of Trendelenberg’s position and maintaining them in a more neutral orientation. The omentum is rolled upward and over the colon and a colonic epiploica is grasped and pulled upward to expose the full undersurface of the transverse colon mesentery and to identify the ligament of Treitz. We measure approximately 30–45 cm distal to the ligament of Treitz and roll this portion of the jejunum upward to the distal esophagus. If the intestine easily reaches the distal esophagus, an anticolic route will be chosen. To facilitate the anticolic positioning of the jejunal limb, one can split the omentum midline in a caudal-cranial fashion using the ultrasonic coagulating shears. Otherwise, a small window can be made in the avascular area of the transverse mesocolon just above and lateral to the ligament of Treitz. The loop of the jejunum can be brought through the mesocolon easily in a retrocolic, retrogastric fashion. The anastomosis is performed in an isoperistaltic manner. We then complete the esophagojejunostomy with a 25 mm EEA stapler with facilitation of the anvil to the distal esophagus by way of securing it to the end of a 16-French orogastric tube and initial passage of the proximal end of the tube which is then pulled through an enterotomy made in the distal esophagus and brought out through the abdomen via a trocar site. An existing trocar site is enlarged to allow access of the EEA stapler trasnabdominally and advanced through an enterotomy on the antimesenteric border of the jejunum antegrade through the Roux limb. After the stapler and anvil are fastened, tightened, and fired, the Roux limb enterotomy can be closed with sutures or an endoscopic linear stapler. This anastomosis can also be performed using laparoscopic linear staplers alone with anastomosis of the Roux limb to the posterior esophagus. Again, the common enterotomy is closed with either sutures or an endoscopic linear stapler. The mesenteric defects are closed using 2–0 suture.

Small tumors in the prepyloric region may be excised by wedge resection with an endoscopic linear stapler as previously described [17]. Tumors near the pylorus, but not truly involving the pylorus, are approached using methods to achieve negative margins while not obstructing the pylorus. Posterior lesions that lie 1½–2 cm from the pylorus and whose depth of penetration is limited to the mucosa or submucosa can usually be removed without compromising the pylorus. We have found EUS confirmation of the tumors’ depth of penetration invaluable in planning our approach to pyloric masses. Our usual approach is through a horizontal, anterior gastrotomy, which can be effectively performed with the ultrasonic shears. The position of the gastrotomy is again localized with the aid of an endoscope, but the gastric opening is made no closer than 3–4 cm from the pylorus. Traction sutures are then placed proximally and distally within a centimeter or so of the tumor, and it is pulled through the anterior gastrotomy out into the abdominal cavity. The mass can then be enucleated with an electrocautery hook or it can be elevated and removed with an endoscopic linear stapler. The enucleation site is closed with a running suture. If the tumor is to be enucleated, we frequently we inject a dilute epinephrine solution (1:100,000) circumferentially around the tumor as described for the endoluminal technique. As a rule, the horizontal, distal, anterior gastrotomy is closed vertically so as to not compromise the luminal diameter of the distal stomach. Two to four full-thickness traction sutures are used to approximate the gastric wall and a thick-tissue (4.8 mm) GIA cartridge(s) is used to close the stomach. The endoscope, which is usually pulled back into the proximal stomach during the resection, is used to insufflate the stomach in order to evaluate the resection site and gastrostomy closure for bleeding, check the patency of the distal stomach, and to assess the integrity of the gastrostomy closure.