Externally Applied "Through-the-Scope" Clip Closure During Endorobotic Submucosal Dissection.

Abstract

Endorobotic submucosal dissection (ERSD) is a recent, novel technique combining submucosal dissection and robotic transanal approach. We strongly believe that ERSD increases precise dissection and dexterity, improves visuality, and enables the dissection to be completed in the submucosal plane. However, during these procedures, adverted defects and bleeding can occur. These complications can be managed by suturing and/or coagulation using the da Vinci SP® surgical system (Intuitive Surgical, Sunnyvale, CA, USA). Closing defects with sutures can be time-consuming and technically more demanding. Nevertheless, through-the-scope (TTS) clips can manage these complications faster and potentially more cost-effectively. This prevents using additional robotic instruments (needle driver) and barbed sutures. This video aims to show using externally applied TTS clips for defect closure with robotic assistance following ERSD. TTS clips are flexible endoscopic clips in the market. They are designed for hemostasis, endoscopic marking, and defect closure in endoscopic procedures. The TTS clips are sent to the surgical field through the GelPOINT® Path transanal platform (Applied Medical, Rancho Santa Margarita, CA, USA), and it can be controlled with a robotic instrument indirectly. The TTS clips were used in 3 patients who underwent ERSD due to rectal lesion, and informed consents were obtained. The first patient was a 49-year-old woman referred with a rectal lesion at 12 cm from the anal verge found on screening colonoscopy. After submucosal injection, dissection was started, and the lesion was removed successfully. The mucosal defect in the upper rectum was successfully closed with a single externally placed TTS clip. The second patient was a 39-year-old man with a 40-mm recurrent polyp extending from 6 to 10 cm of the anal verge. Due to submucosal fibrosis, a larger defect area was left at the end of the tissue resection, and two TTS clips were used to approximate this defect. The last patient was a 53-year-old woman with a 35 mm lesion at 11 cm from the anal verge. Some bleeding was observed during the excision, and multiple TTS clips were used to prevent post-procedure bleeding. TTS clips were placed successfully in all cases. All 3 patients were discharged home the same day without complication. Histopathology revealed benign lesions with free deep and radial margins. No morbidity was detected after the procedures. Our video demonstrates the successful application of externally applied TTS clips for defect closure and hemostasis following ERSD in varying cases. The externally applied clip management is a viable alternative for accelerated, reliable, and inexpensive defect closures after ERSD. See Video Vignette.