JSLS Posterior Wall Gastric Leiomyoma: Endoscopic Tattooing Facilitates Laparoscopic Resection Medhat E. Allam, MD,1 Dhiren Mehta, MD,2 Johnathan Zelen, MD,3 Richard Fogler, MD4 ABSTRACT Objective: To demonstrate the application of tattooing for the intraoperative localization of posterior wall gastric leiomyoma during laparoscopic resection. The preopera- tive injection of Indian ink in the tumor-bearing area of the posterior gastric wall eliminates the need to perform ante- rior wall gastrostomy or intraoperative upper endoscopic tumor localization. Methods: A patient with posterior wall gastric leiomyoma was marked with Indian ink during preoperative upper endoscopy. The dye was visualized intraoperatively facili- tating wedge resection of the tumor-bearing area with the Endo GIA. Results: The patient had an uneventful surgery and recovery. Complete excision of the tumor was accomplished. Conclusion: The preoperative endoscopic marking of gastric lesions, facilitates the intraoperative localization and resection of these lesions. Key Words: Laparoscopy, Gastric leiomyoma, Endoscopic tattoo. 1,3Southampton,NY 11968 2Riverhead, NY 11901 4Brooklyn, NY 11212 Address reprint requests to: Medhat E. Allam, MD, 325 Meeting House Lane, Suite #2, Southampton, NY 11968, USA. INTRODUCTION Gastric leiomyomas are the most common benign smooth muscle tumor of the stomach constituting 80% of all gastric smooth muscle tumors.1 They commonly present with bleeding due to mucosal ulceration.2-4 The differentiation between leiomyoma and leiomyosarcoma on gross exami- nation is difficult. Surgical resection of these lesions is the treatment of choice.5 Biopsy during upper endoscopy is not recommended as it will cause adhesions between the tumor and the mucosa rendering enucleation without entering the stomach impossible.6 As laparoscopic surgery gains acceptance, benign lesions may be managed with decreasing difficulty. Patients will probably benefit from the advantages of minimally invasive surgery (i.e., less pain, faster recovery, and early return to work). Mistakes in determining the segment of the stomach that bears the tumor are less frequent compared to colonoscopy.7,8 Without tattooing, intraoperative localiza- tion of these tumors during laparoscopy is difficult for many reasons. For the anterior wall tumor, there is submucosal location and the loss of tactile ability. There are additional difficulties when resecting posterior wall tumors. The sur- geon must work through the small space the lesser sac pro- vides, and the posterior gastric wall might not easily lend itself to inspection. For laparoscopic colon resection, dif- ferent methods have been recommended to alleviate iden- tification difficulties (i.e., endoscopic tattooing or intraoper- ative colonoscopy).9,10 For laparoscopic gastric surgery, some authors have recommended the performance of a long anterior wall gastrostomy through which the posterior wall is thoroughly inspected and lesions localized.11 Others have recommended the use of intraoperative upper endoscopy localizing the segment of the stomach that con- tains the tumor followed by appropriate resection through a smaller anterior gastrostomy.12 Such techniques usually result in both anterior and posterior gastrostomy, increasing the chance of suture line problems. We believe that pre- operative tattooing of gastric lesions makes the process of localization easier and helps avoid multiple gastrostomies, excessive suture lines, and needless delays in completing the resection. JSLS (1998)2:83-84 83