Laparoscopic Transgastric Excision of leiomyoma of esophagogastric junction Dr. Mark Pleatman demonstrates placement of a laparoscope through the abdominal wall into the stomach for resection of a benign leiomyoma at the esophagogastric junction. This photo shows the endoscopic view of the tumor with the gastroscope retroflexed upon itself. The tumor can be seen bulging beneath the mucosa. The tumor is mobile and has not enlarged significantly over a 9-month period. The patient has suffered pain and difficulty swallowing. A surgeon at a major university Medical Center had recommended thoracotomy with enucleation of the tumor. The patient is a Jehovah's Witness and requested a minimally invasive approach. She also had symptomatic gallstones.   After removal of the gallbladder, a gastroscope is inserted through the mouth and into the stomach. The stomach is inflated with air, and the first of 3 laparoscopic ports are inserted into the stomach as shown here.   The mucosa over the tumor is first injected with 15 ml. of local anesthetic with epinephrine to reduce bleeding (not shown). The mucosa is incised with electrocautery, and we begin to dissect the tumor away from the underlying mucosa.  The black object at lower left is the gastroscope entering the stomach through the esophagus.   The tumor is elevated as the dissection proceeds. One can see the filmy strands of connective tissue which easily peel away from the tumor.   Only a few attachments remain.   The tumor is now free. The multilobulated appearance is not the result of careless dissection, but was the nature of the tumor!   The freed tumor is shown again with the light of the gastroscope illuminating it from the esophagus.   This shows the defect remaining after removal of the tumor.   The defect is sutured closed.   The gastroscope entering through the esophagus again shows its relationship to the tumor's location.