1) Double combined mirror is that laparoscopic repair and endoscopic resection. As for muscularis propria, SMT endoscopic resection ESE/EFR needs skilled endoscopic techniques, and there is a risk that the perforation foci cannot be completely repaired[10–12]. Combined laparoscopic and endoscopic resection (CLER) provides a safety guarantee for patients with endospheric GIsT. When intraoperative acute perforation can't complete closure with endoscopic, we can relay on the laparoscopic repair to assist. Double combined mirror surgery for gastric stromal tumor has the advantages of rapid positioning, optimization of the surgical process, short operative time, small wound, small incision, small risk of exogenous infection, clear operative field, quick recovery, safety and effectiveness. And it is suitable for tumors with a diameter < 5 cm and difficult to be located by laparoscopy in surgery. However, laparoscopy also has limitations. For example, laparoscopic is difficult to operate when perforation locates in the posterior wall of the stomach. When abdominal pollution is serious and part of the operation needs open, it is higher requirements for the tumor location and the operation group members' cooperation. And it is necessary for experienced doctors to operate.
2) With the development of endoscopic resection, endoscopic perforation closure also appears. With the maturity of endoscopic resection and endoscopic closure, endoscopic muscularis dissection (EMD) includes: endoscopic submucosal excavation (ESE), endoscopic resection of the stomach wall full-thickness EFR, the invisible tunnel submucosal neoplasm STER, etc. They expand the depth and scope of the endoscopic. EFR is the key that the perforation is successfully repaired by microscope in surgery. Titanium clips directly clipped before. As for larger full-thickness defects, firstly, the omentum can be inhaled into the perforated gastric cavity by strong negative pressure suction. And then metal clips clip the omentum and gastric mucosa along the defective edge and effectively suture the defect. We often use titanium clips and nylon rope to suture. The biggest advantage of STER tunnel technology is that not only can it completely remove the intrinsic musculogist at once, but also it can maintain the integrity of the lining mucosa of the digestive tract. Although the perforation occurs in surgery, it can reduce the chances of gastrointestinal fistula and intra-abdominal infection by closing the tunnel opening. It is evident that the key of the entire EMD' successful is the site of the intraoperative perforation. At present, with the progress of endoscopic closure, laparoscopic assisted wound sutures gradually reduces and gradually transitions to endoscopic closure . Not only can doctors learn ESD, but also they need to be trained in animal experiments with acute perforation closure and the closure technology is constantly mature. Endoscopic closure reduces laparoscopic staff and instruments, and reduces costs and trauma. The surgery for musculoskeletal tumors will be independently performed by endoscopy. Therefore, double mirror combination is similar to the endoscopic resection alone in trauma, and the postoperative recovery time is no different from endoscopy. Endoscopic closure needs special training. On the one hand, young digestive endoscopy doctors are enthusiastic in learning ESD and other technologies; on the other hand, there is still a lack of special training on ESD and acute perforation disposal ability. Therefore, endoscopic closure of the acute perforation ability needs to be improved rapidly. In the clinical, application of acute digestive tract perforation endoscopic closure is still facing many problems. So before this technology skillfully apply into the clinic, "ESD practice of intraoperative acute perforation endoscopic closure" animal experimental study. "ESD and Perforation repair" training animal experiment design is very practical. Endoscopic doctors learn technology from unfamiliar to familiar, and they need standardized technical operation training. They will be evaluated safety and feasibility. And they accumulate experience and innovate constantly so that they can improve the endoscopic diagnosis and treatment effect. This project is funded by Wuxi Science and Technology Committee, and it provides practical experience and theoretical basis in the study of acute digestive tract perforation for clinical practice.
3) According to the predictability of perforation: it includes complications and therapeutic perforations. With the improvement of operating instruments and endoscopy, a minimally invasive new era must will be brought by endoscopic closure. The passive perforation changes into active perforation, and the perforation becomes a step of endoscopic resection, and we can finish the various operations of the gastrointestinal tract with endoscopic closure. Because gastroenteroscopy is performed on an empty stomach, as long as it is discovered in time and closed quickly with endoscopy. And the symptoms of acute perforative peritonitis are mild, traditional transabdominal surgery can be avoided. What's more, it can reduce the psychological and economic burden of both doctors and patients, shorten the course of disease, reduce the cost of hospitalization, and improve the cure rate quickly. There is no significant difference in the treatment of upper gastrointestinal musculoskeletal tumor with END between endoscopic closure and laparoscopic repair. And lt has the advantages of less trauma, faster recovery and lower cost. With the development of endoscopic closure of io-genic gastrointestinal perforation, the indications of endoscopic resection will continue to expand and it has good clinical developed value. It provides a evidence for the clinical application of endoscopic closure of acute gastric perforation. With the development of endoscopic suture technology, many perforations were treated by laparoscopy bofore, now It can be completed by endoscopic suture. And the application of LAET will be gradually reduced and may even be replaced by EFR and STER. However, the training and promotion of endoscopic closure will need the invention and application of a variety of simple endoscopic closure instruments.