We present the case of a gastric stromal tumor, 5 cm in size, that is rejected by laparoscopic-endoscopic cooperative surgery, LECS, a technique which combines laparoscopic rejection and endoscopic submucosal dissection. We would like to highlight the role of the endoscopist during the LECS procedure. Initially, the endoscopist is trying with biopsy forceps to pull out the intussusceptive tumor, which has been migrated into the duodenum. After repositioning of the mass in its natural position, incisura angularis of the stomach, the endoscopist highlights to the surgeon the borders of the lesion by translumination with the endoscope's light. From the surgical point of view, the area of the tumor is located and suitably marked. Here one can also notice the umbilicus on the external surface of the stomach, created by the gravity of the lesion. Subsequently, the endoscopist starts with a circumferential incision, at least 1 cm peripherally of the mass, as the first step of endoscopic submucosal dissection in the stomach. Dual knife J-type is used for opening the mucosa and submucosa layer. The incision is continuing on the distal side of the tumor in order to become complete circumferential incision. minimal intra-procedural bleedings are cauterized with COA grasper. Before proceeding to the next step of the rejection, the endoscopist has to confirm the complete nature of circumferential incision. One surgeon completes the ligation of all feeding vessels of the tumor. The endoscopist continues with an intended perforation on the previous ESD-created path. By making a hole through the illuminated muscularis propria. The perforation is carefully opened, not more than so that the laparoscopic scissor is able to be inserted in the stomach and start the dissection. At this point, the endoscopist acts as a scout for the surgeon in order to guide the rejection plane on the previous ESD-created clear margins. From the laparoscopic side of view, the dual knife is seen to perforate the stomach and then the scissor can easily be inserted inside the organ in order to start the surgical rejection. Upon the dissection of the larger part of the tumor, the plane opens and the surgeon is able to clearly see the ESD circumferential incision and continue on the pre-existing clear margins. After the completion of the resection, the gist is securely positioned into a laparoscopic retrieval bag, where it should stay sealed until the end of the procedure, avoiding the risk of seeding. Endoscopically, we can notice the peritoneal cavity and the retrieval bag through the rejected area. Subsequently, the surgeon places two levels of suturing in order to close securely the defect. Then the endoscopist insufflates CO2 in the stomach so as the surgeon can be able to confirm a negative leakage test. Before finishing LEX procedure, the endoscopist observes the stomach and faces minimal mucosal bleeding by endoscopic clip application. The mass is pulled through the umbilicus and positioned with pins on flat surface before fixing. In conclusion, LEX seems beneficial for the treatment of large gastric stromal tumors by lessening the surgical trauma, thus preserving the anatomy of the organ. Additionally, it allows faster mobilization and feeding for the patient.

laparoscopic-endoscopic cooperative surgery

gastric stromal tumor

endoscopist

translumination

circumferential incision