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Less than 2% of gastric neoplasms that are resected surgically are of smooth-muscle origin. Gastric leiomyomas are not encapsulated, and the distinction of benign from malignant leiomyoma may be difficult. Some of these tumors manifest malignant behavior. The histological basis for the diagnosis of benign or malignant smooth-muscle tumor is not entirely satisfactory, and misclassification occurs in some cases. The aggressiveness of those tumors reported as malignant is usually low, and the term "malignant leiomyoma" is usually used rather than the more ominous "leiomyosarcoma." A case is presented of a patient with a 4.5-cm leiomyoma of the gastric antrum resected by the laparoscopic approach. Four laparoscopy trocars were used and multiple applications of the Endo-GIA were needed. Satisfactory margins of resection were obtained. The patient made an excellent recovery with minimal pain. She promptly returned to work and full physical activity.

Gastric stromal tumors represent a small percentage of gastric neoplasms. Establishing a diagnosis when these lesions are encountered usually is not possible with limited biopsies. Benign and malignant gastric stromal tumors require only local excision for definitive treatment. However, most lesions are not amenable to endoscopic excision. As a result, laparoscopic local excision offers the ideal method to establish a diagnosis and to treat patients with gastric smooth muscle tumors. We present a minimally invasive local excision of a gastric stromal tumor. We also review the previously published management of gastric stromal tumors and show how it is being influenced by laparoscopy.

Laparoscopic gastric surgery is gaining momentum, especially in the treatment of benign disease. Simultaneous endoscopy and laparoscopy allow precise localization of lesions. Because of the stomach's size, mobility, and distensibility, relatively large lesions can be safely excised. Wedge resection for anterior lesions and a transgastric or intragastric approach for posterior lesions are feasible laparoscopically. Two cases of posterior gastric leiomyomas successfully resected laparoscopically are presented. The use of stapling devices greatly facilitates this procedure.

Our two-step technique for endoscopic treatment of gastric leiomyomas is illustrated. From January 1979 to June 1991, nine symptomatic patients with sessile leiomyomas of the stomach were treated at the Endoscopy Division of Istituto Nazionale Tumori, Milan. The diagnosis was achieved by means of endoscopic observation of the lesion and, when possible, by ultrasound endoscopy. This new technique consists of first removing superficial portion of the tumor by electrosurgical snare. Second, a cleavage plane is found within the proper muscle layer; the tumor is enucleated as much as possible by tightening the snare around it and creating a pseudo-stalk. No major complication occurred nor were any recurrences observed at 21.8 months in the 7/9 patients treated by endoscopy alone. Endoscopic therapy was performed on an outpatient basis and only large lesions required short hospitalization.

Laparoscopy has added a new perspective to the diagnosis and treatment of abdominopelvic disease. A wide variety of gastric procedures have been completed with laparoscopy in the past several years. The authors here present successful resection of a submucosal gastric leiomyoma laparoscopically with the combined use of intraoperative gastroscopy for localization. A 2.5 x 2.0 cm submucosal gastric nodule is resected with ample margins laparoscopically. Intraoperative endoscopy is used for accurate localization because the lesion was not visible to the laparoscope on the serosal surface of the organ. Laparoscopic surgery can be applied to the traditional surgical principles with equal efficacy in selected patients.

Laparoscopic intragastric resection of gastric leiomyoma was performed using needlescopic instruments. The patient was a 71-year-old man who had a 2-year history of gastric submucosal tumor 2 cm in diameter located near the esophagocardiac junction. After getting informed consent, we performed a laparoscopic intragastric tumor resection under an oral endoscope. There were no intra- or postoperative complications. The patient was discharged uneventfully. Histopathologic diagnosis of the tumor was leiomyoma. Laparoscopic intragastric resection of a benign gastric submucosal tumor using needlescopic instruments is technically feasible and as safe as a less invasive procedure.