The concept of gastrointestinal stromal tumors (GIST) was first introduced by Mazur and Clark in 1983 [1] as a non-epithelial mesenchymal tumor of gastrointestinal origin originating from Cajal cells. 95% of GISTs originate in the gastrointestinal tract: stomach (50%-60%), small intestine (20%-30%), large intestine (10%), and esophagus (5%). GIST is a gastrointestinal tumor with malignant potential. Current studies suggest that acquired functional mutations in the proto-oncogene, c-Kit, are the main molecular mechanism for the development of GIST [2]. In contrast, GIST without c-Kit mutations may be associated with PDGFR α acquired functional mutations [3]. CD117 is the expression product of the proto-oncogene Kit and is an immunohistochemical marker that distinguishes it from other mesenchymal tumors [4]. Imatinib (trade name: Gleevec), a tyrosine kinase inhibitor developed in recent years, has achieved tumor control rates of up to 85% in the treatment of GIST by blocking the Kit and tyrosine kinase within the PDGFR α membrane, and the application of Gleevec for the treatment of recurrent metastatic or inoperable GIST has achieved great success and its effectiveness has been unanimously confirmed by the new edition of the US NCCN and European The new NCCN and ESMO treatment guidelines have included Gleevec as a standard treatment for GIST. Although Gleevec is effective in the treatment of recurrent metastases or inoperable GIST, it should be noted that its response is mostly partial remission or stable disease, with few complete remissions (CR), with a CR rate of about 2% to 3% according to the literature [5]. This means that in most GISTs, griseofulvin can only control tumor growth but not completely destroy the tumor. Gastric mesenchymal tumors are not sensitive to chemotherapy or radiotherapy, and the only effective treatment is to remove the tumor. Therefore, complete and radical surgery remains the treatment of choice for primary GIST, both in the past and at present. I. Principles of surgical treatment of GIST Surgical treatment of GIST requires complete tumor resection with negative margins as the standard. Complete tumor resection with negative cut margins requires resection at least 1 to 2 cm from the tumor [6-7]. This ensures that both macroscopic and microscopic tumor metastases are effectively resected. Gastrointestinal patency and function should be preserved as much as possible without sacrificing the cost of complete and radical surgery. Since GIST is mainly metastasized by abdominal implantation and hematogenous metastasis and rarely through lymphatic route, routine lymph node dissection is not advocated [8-9]. In cases where GIST invades surrounding tissues and can be resected “in its entirety”, combined organ resection can be performed according to the principle of complete tumor resection. In recent years, total resection has also been preferred in terms of depth of resection, rather than endoscopic or laparoscopic enucleation of the GIST mass. Due to the potentially malignant nature of GIST, surgery must follow the “non-contact, less compression principle” and intraoperative manipulation should avoid tumor rupture that could lead to abdominal implantation and liver metastasis. Laparoscopic treatment of GIST must also follow the above-mentioned surgical principles. The feasibility and safety of laparoscopic treatment of gastric mesenchymal stromal tumor have been confirmed by many domestic and foreign literature, so we are not going to repeat them here. The following is an overview of the current common surgical methods. We advocate an individualized design scheme for the resection method of laparoscopic surgery. Based on the preoperative ultrasound gastroscopy and imaging (GI, CT, MRI) data, especially the intraoperative gastroscopic localization diagnosis to determine the site and size of the tumor, as well as the relationship with the cardia and pylorus to develop different surgical treatment plans. 1.Laparoscopic wedge resection (LWR): It is the most commonly used procedure to treat gastric mesenchymal tumor. When the tumor is located in the anterior wall of gastric body and fundus, it can be easily accomplished by applying Endo GIA; for mesenchymal tumor located at the greater curvature, the lateral omentum of the greater curvature of the stomach can be separated outside the vascular arch of the gastric omentum first, and if necessary, the splenogastric ligament can be separated, and the short gastric artery and vein can be coagulated and cut with ultrasonic knife, and then the specimen can be resected and anastomosis can be completed directly by using Endo GIA. 2.Laparoscopic transgastric tumor-everting resection (LTGTER): It is mainly used for tumors in the posterior wall of the stomach. The anterior wall of the stomach is incised first, and the tumor is searched for and raised from the anterior wall opening and then resected under direct laparoscopic view or with the assistance of gastroscopy. It is generally safer and more convenient to use basal sleeve resection or direct resection with Endo GIA. The suture closure of the incision site can be done with a single interrupted or continuous suture by manipulation, or with Endo GIA cutting closure. 3.Laparoscopic sleeve gastrectomy (LSG): mainly used for large mesenchymal tumors on the side of the greater curvature of the gastric body or the fundus. The gastrocolic ligament and the splenogastric ligament are severed along the greater curvature of the stomach with an ultrasonic knife. From 6 cm from the pylorus on the greater curvature side to the left side of the cardia at the His angle, the greater curvature side of the stomach is resected upward with Endo GIA, preserving and forming a small curvature side of the tubular stomach about 3 or 5 cm wide. More normal gastric tissues can be preserved during surgery according to the principle of complete resection. 4.Laparoscopic endoscopic combined gastric intragastric resection, or laparoscopic intragastric resection (LIGR): It is mainly used for mesenchymal tumors in the posterior wall of the fundus adjacent to the esophageal cardia junction. Sekimoto et al [10] concluded that the surgical injury and abdominal contamination are less than that of the anterior gastric wall incision, and since the esophageal cardia junction is always in the operator’s view, the possibility of postoperative esophageal stenosis due to injury is minimal. The possibility of postoperative esophageal stricture due to injury is minimal because the esophageal cardia junction is always within the operator’s view. However, this procedure has the disadvantage of limited resection and easy damage to the outgrowth because the short gastric vessels are not disconnected, especially the upper pole of the outgrowth is not completely separated from the fundus. Walsh et al [11] reported 13 cases of combined laparoscopic endoscopic resection of intraluminal gastric mesenchymal tumors measuring 1.5-7.0 cm, all of which were benign or low-risk mesenchymal tumors, eight of which were located at the cardia-esophageal junction. Although the surgeon believes that this procedure is one of the safe and effective procedures for benign cases or low-risk mesenchymal tumors located at the esophageal cardia junction, there is still concern about postoperative tumor recurrence. 5.Laparoscopic extragastric gastric fundus resection (LEGGFR): It is our design for laparoscopic surgery to remove submucosal tumors from the fundus, especially near the esophageal cardia junction. The surgical steps include: freeing the omentum, entering the omental sac, separating the splenogastric ligament and completely separating the fundus from the superior pole of the spleen; freeing the left, anterior and right sides of the cardia to completely reveal the esophagocardia junction; and cutting the fundus with Endo GIA. The laparoscopic extragastric fundoplication wedge resection can be performed to avoid abdominal contamination, injury to the outgrowth and esophageal stricture, while the extent of gastrectomy is not limited. The key to this procedure is to adequately free the gap between the fundus and the superior pole of the spleen; when placing an Endo GIA close to the cardia, it is important to carefully examine the fundus to determine the extent of esophageal stenosis. It must be carefully examined to make sure that the esophageal cardia junction is not included. Since September 2000 to present, the minimally invasive surgery department of Shanghai Changhai Hospital has treated nearly 100 cases of submucosal tumors of the fundus by laparoscopic extragastric fundoplication [12-14], which confirmed that the procedure is safe, easy and beneficial. 6. laparoscopic gastroesophagectomy (LGE): mainly used for mesenchymal tumors in the gastroesophageal junction. dulucq et al [15] reported 3 cases with intraoperative resection of the lower esophagus and proximal stomach and anastomosis of the esophagus and the greater curvature of the stomach. the average operative time was 130±10 min and there were no intraoperative and postoperative complications. Granger et al [16] reported 4 cases of gastric mesenchymal tumors located at the gastroesophageal junction with gastric mesenchymal tumor enucleation + fundoplication. The surgery was successful and there were no significant postoperative acid reflux symptoms. 7. Laparoscopic antrectomy (LA): Laparoscopic distal gastrectomy with gastrojejunostomy can be chosen for larger mesenchymal tumors located in the gastric sinus. The operation is the same as the laparoscopic distal gastrectomy, and the size of the resected stomach can be determined according to the principle of complete resection of the mass, and there is no need to perform lymph node dissection during the operation, which makes the operation more convenient and fast. Minimally invasive surgery of Shanghai Changhai Hospital has been used to treat mesenchymal tumor of the gastric sinus in more than 10 patients by laparoscopic distal gastrectomy with gastrojejunostomy, with good results. Complications of laparoscopic surgery for gastric mesenchymal tumor and their management The incidence of complications of laparoscopic surgery for gastric mesenchymal tumor reported in the domestic and foreign literature is 0%-11% [17-19], and the main complications include bleeding from the incisional margin, incisional fistula, intra-abdominal bleeding, spleen or liver injury, food obstruction, and delayed gastric emptying. 1. Incisional margin bleeding and incisional margin fistula: often related to improper use of the cutting anastomosis, or excessive tissue pulling force during multiple cuts and tearing of the original incisional margin anastomosis. The interrupted suture can be strengthened by microscopic suturing of the rupture in time for intraoperative detection. Placement of drainage tubes can be observed in time for the occurrence of postoperative incisional margin fistula. 2, food obstruction: the mass is close to the cardia or pylorus, and injury to the cardia or pyloric sphincter during resection can lead to food obstruction after normal postoperative feeding, and such complications can often be cured by endoscopic dilatation therapy. 3, intra-abdominal hemorrhage: if the blood is oozing from the cutting edge, it is often less serious. If it is an accidental injury to a substantial organ or tissue vessel in the abdominal cavity, it is more difficult to deal with under lumpectomy, and in serious cases, it needs to be transferred to open abdominal treatment. 4, spleen or liver injury: spleen injury often occurs when the posterior gastric wall mass is removed. Tearing of the splenic envelope caused by pulling the splenic and gastric ligaments or direct poking by instruments can often be stopped by local compression followed by spraying bioprotein gel. Liver injuries are often caused by improper force during use of the liver pulling hook and can be hemostatic by local compression or electrocoagulation. In recent years, reports of complications from laparoscopic gastric mesenchymal tumor surgery have tended to decrease [19-23], which may be related to the learning curve of laparoscopic gastric mesenchymal tumor surgery operations. With the increasing maturity of the operation of laparoscopic gastric surgery and the continuous updating and development of surgical instruments, laparoscopic gastric mesenchymal tumor surgery will become safer and more effective.