Posterior Wall Gastric Leiomyoma: Endoscopic Tattooing Facilitates Laparoscopic Resection, Allam M. METHODS The patient is a sixty-two year old Irish male with strong family history of gastric cancer. His father and two of his siblings died of gastric cancer before the age of sixty. During routine upper endoscopy, a lesion was seen in the posterior wall of the stomach. Using Indian ink, the area around the tumor was injected to facilitate intraoperative localization. Under general anesthesia the patient was placed in lithoto- my position. The peritoneal cavity was entered using a Veress needle through the umbilicus followed by a 10 mm trocar. Routine exploration of the intra-abdominal contents was grossly unremarkable, and there was no sign of metastatic disease. A 12 mm trocar was placed in the mid- clavicular line in the right subcostal area approximately one inch below the costal margin. Another 12 mm trocar was placed in the mirror image site in the left subcostal area. Utilizing an endo babcock, via the right side trocar, and a Harmonic scalpel, via the left side trocar, the gastrocolic lig- ament was divided and the lesser sac was entered. The posterior wall of the stomach was inspected for other lesions. The Indian ink marking was visualized and the babcock was applied to its center. Using endo GIA, an elliptical segment of the posterior gastric wall was resected with the Indian ink marking at its center. The specimen was placed in an Endo bag and brought outside the abdomen. The frozen section revealed benign leiomyoma, and the procedure was concluded. The pathology revealed 0.6 cm benign leiomyoma with tumor-free surgical margins. The patient was started on clear liquids on postoperative day one and was discharged to home on day two to be followed up by annual upper endoscopy. DISCUSSION Laparoscopic surgery is rapidly gaining the respect and approval of many surgeons. Even though the use of laparoscopy in some malignant tumors is still under debate, its use in managing benign tumors is quite acceptable. Two methods were described in recent publications to localize posterior-wall gastric leiomyoma. One described the per- formance of longitudinal anterior wall gastrostomy for local- ization. The other recommended the use of intraoperative endoscopy in an attempt to limit the size of the anterior gas- trostomy to the segment of the stomach that contains the lesion. The resulting anterior and posterior wall suture line will increase the chance of postoperative anastomotic leak. Also these techniques allow the gastric contents to enter the peritoneal cavity, which might increase the chances of infection. In our patient we used the known technique of tattooing to help localize the tumor. This technique has been used before in colon surgery, with acceptable levels of success.10 The tattooing method eliminates the need for either intraoperative upper endoscopy or anterior gastros- tomy. In actuality, the inside of the stomach is never visu- alized with no spillage of gastric contents. Rapid recovery in our patient is encouraging, and, in our opinion, this technique could be used for either anterior or posterior wall lesions. References: 1. Appelman HD, Helwig EB. Gastric epithelioid leiomyoma and leiomyosarcoma leiomyoblastoma. Cancer. 1976; 38:708- 728. 2. Malhotra R, Evans R, Bhawan J, Karzaria P, Silva W. Malignant gastric leiomyoblastoma presenting as an infected pseudocyst of the pancreas. Am J Gastroenterol. 1988;38(4):452-456. 3. Zerbi A, Braga M, Sironi A, Faravelli A, DiCarlo V. An uncom- mon cause of massive intraperitoneal bleeding leiomyoblastoma of the stomach. Tumori. 1988;74:365-367. 4. Graham SM, Ballantyne GH, Modlin IM. 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