Laparoscopic techniques and strategies for gastrointestinal GISTs

The laparoscopic approach is widely accepted surgical treatment for gastrointestinal submucosal tumors (SMTs). In this chapter, we will introduce laparoscopic techniques and strategy for gastrointestinal SMTs, in accordance with those for gastrointestinal stromal tumors (GISTs). The indication for a laparoscopic approach has been related to tumor size. The upper limit of tumor size has increased, according to recent trends, and there is no established guideline for a lower limit. All patients undergoing laparoscopic surgery receive preoperative examinations including gastrofiberscopy, upper gastrointestinal radiography, computed tomography (CT), and endoscopic ultrasonography (EUS). Gastric tumors <20 mm in diameter measured by EUS or CT are preoperatively localized by gastrofiberscopic clipping of the mucosa covering the SMT. While maintaining the principle of local resection with a negative resection margin, different surgical techniques are required depending on the location and configuration of the tumor. A single dose of a second-generation cephalosporin is administered to patients as a prophylactic antibiotic before or immediately after operation. If a patient undergoes wedge resection, a semi-bland diet will be provided within 48–72 hours. However, in cases of proximal or distal gastrectomy, the diet will be restricted for several days. A “no-touch” technique, by which the risk of tumor dissemination can be minimized, includes grasping the surrounding tissues, holding the threads sutured at the normal serosa around the tumor, and using a laparoscopic stapler or bag during laparoscopic resection.