Preface: Embracing a New Era of “Super Minimally Invasive Surgery”

At this critical juncture as super-minimally invasive medicine enters a new era, the publication of Endoscopic Therapeutics: Super Minimally Invasive Surgery is a milestone. It is not merely a compendium of technical procedures but a sublimation of therapeutic philosophy. In my capacity as president of the World Endoscopy Organization, I wholeheartedly recommend this book to all pioneers dedicated to shaping the next medical era. It will undoubtedly become an essential classic illuminating the path ahead, guiding us to jointly write a new chapter of preservation and cure.

Preface: Pioneering the SMIS Philosophy

As a witness to SMIS’s evolution, I attest that this field remains dynamically evolving, brimming with unexplored potential. May this book, Super Minimally Invasive Surgery, bridge global collaborations, inviting broader engagement to refine SMIS theory and practice. Let us embark with technological innovation as our vessel and patient welfare as our sail, navigating the vast currents of human health to inscribe yet more brilliant chapters in medical history.

Super Minimally Invasive Surgery: An Inevitable Choice for Humanity

It is not only a technological upgrade but also a return to the humanistic spirit of medicine. It responds to humanity’s most fundamental attachment to and guardianship of its own integrity. In moments when surgical intervention is unavoidable, choosing super minimally invasive surgery means choosing to eliminate illness while respecting—as much as possible—the original design of life and preserving the patient’s right and dignity to return to a normal life. Thus, on the path toward the future of medicine, super minimally invasive surgery is undoubtedly humanity’s inevitable and optimal choice.

Part One　General Introduction to Super Minimally Invasive Surgery

Chapter 1　The Birth and Significance of Super Minimally Invasive Theory

1.1　The Rapid Development of Gastrointestinal Surgery, the Emergence of the Super Minimally Invasive Theory

Traditional surgery (figure 1.1), also called operation, commonly known as cuts, refers to the therapeutic process whereby surgeons or other professionals enter the human body or other biological tissues using surgical equipment or surgical instruments to excise lesions, alter the composition or implanting foreign substances, etc., using techniques involving external force. When it first came out is hard to define exactly, but there have been some important development nodes: in the 17th century BC, eye surgery regulations, recorded in the Ninevitic Code of Hammurabi, constitute the earliest surgical operation recorded in human civilization. Superficial mass excision and drainage of abscess are known since the time of Hippocrates, in about 400 BC; anatomy as well as debridement and suturing began to emerge at the time of the Renaissance. In 1809, an American doctor performed the first cavity operation without antibiotics. In the 1840s, the subsequent emergence of anesthesia with diethyl ether and asepsis made the rapid development of surgical operation possible and allowed one to enter the organ resection time. At this time, operations were usually conducted by skin incision, and needed to excise the affected parts or all organs, which was followed by the reconstruction of the human anatomical structure. Such methods can cure diseases, but they change the normal structure of the human body and sacrifice part of the normal physiological function. In addition, traditional surgery also has drawbacks such as big wounds, slow recovery, high cost, and the relatively high cost of subsequent complications.

FIG. 1.1 — Traditional ‘organ resection + anatomical reconstruction’ surgical technique. Note: Traditional surgery involves skin approach, lesion and organ excision + anatomical reconstruction, with big trauma, slow recovery.

Based on the limitations of traditional surgery, endoscopic surgery began to develop (figure 1.2). Endoscopic surgery introduces surgical instruments, physical energy or chemical drugs into the body by a minimal incision or by the natural cavities of the human body, and is used to carry out surgical operations to inactivate, excise, repair the body’s internal lesions, abnormalities and trauma, or to reconstruct organs to reach the purpose of treatment. The history of the development of endoscopic surgery can be dated back to 1901: the Russian gynecologist Ott made small incisions in the front abdominal wall to insert a vaginal speculum into the abdomen, and penetrated the abdomen to carry out examinations with the aid of a reflected beam of light from the front, meanwhile the German surgeon Kelling introduced a cystoscope in the abdomen of a dog to make examinations, and called such operation the endoscopic laparoscope examination; all were animal experiments; at the same year, Jacobaeus in Stockholm, Sweden, used the word ‘laparoscopy’ for the first time, and created a pneumoperitoneum using a trocar, and named it ‘laparothorakoskopie;’ this is the first such experiment on a human body ever recorded. In 1933, Ferver reported having used biopsy devices and inustion to loosen intraabdominal adhesion by laparoscopy, which marks the beginning of the use of the endoscope in the treatment of diseases. In 1987, the French gynecologist Mouret successfully conducted the first laparoscopic cholecystectomy known to the general public, opening a new era in the history of endoscopic surgery therapy. In April 1989, at the annual meeting of the American Society for Gastrointestinal Endoscopy, Professor Dubois presented a video on laparoscopic cholecystectomy, which generated a great deal of interest, and launched a craze for laparoscopic cholecystectomy. However, endoscopic surgery essentially does not change traditional surgery techniques, still involving the excision of lesions while partial organs are sometimes removed, changing the integrity of the anatomical structure, which may affect the postoperative quality of life.

FIG. 1.2 — Endoscopic ‘organ resection + anatomical reconstruction’ surgical technique. Note: Endoscopic surgery can be performed on the skin, the nose, the gallbladder or the vaginal route; it is more minimally invasive, with faster recovery, but it does not change the ‘excision lesion + organ’ mode.

Minimally invasive surgery (MIS) is a medical science branch allowing us to conduct surgical operations inside the human body by using a micro-incision or route (figure 1.3). This surgical mode completes the treatments of the body’s internal lesions, deformities and trauma, etc., by special instruments, physical energy or chemical agents, including inactivation, excision, repair or reconstruction, aiming at achieving the treatment objective. The development history of minimally invasive surgery can be traced back to 1985, when the British urologist Payne and Wickham used for the first time the word of “minimally invasive procedure” in the treatment of urinary stones. After that, the French genecologist Mouret proposed the concept of “minimally invasive surgery” in 1987, initiating a new chapter in the history of minimally invasive treatment. After 1990, with the continuous refinement of the endoscopic surgery, minimally invasive surgery has been widely used in fields like general surgery, thoracic surgery, gynecology and obstetrics, urinary surgery, and pediatric surgery, etc.

FIG. 1.3 — Endoscopic ‘organ resection + anatomical reconstruction’ surgical technique. The concept of minimally invasive surgery is general, including therapeutic endoscope, robot and soft endoscopic surgery, but still with ‘excision of lesion + organ’ as the surgical technique.

Although gastrointestinal surgery has experienced multiple development phases, the essence of the treatment is still “excision of lesion + partial or total organ resection + anatomical reconstruction.” With the continuous development of modern medicine and the humans’ quest to improve their quality of life, they cannot be satisfied with traditional open operation, laparoscopic surgery, and minimally invasive surgery: though these can meet curing demand, they cannot restore the human body to the state it was in before the onset of the disease. Therefore, it is necessary to seek a new surgical technique to guide the development of future surgical therapeutics. Such a surgical technique should eliminate diseases under the condition of maintaining unchanged the original anatomical structure of the human body, and make the patient return after the operation to his/her normal state before he/she fell ill. In 2016, Prof. Linghu Enqiang of PLA General Hospital, noting the drawbacks of the traditional surgical technique based on “partial or total organ resection + anatomical reconstruction,” first proposed a super minimally invasive surgical technique aiming at “curing diseases while preserving organs, not changing the human body’s overall anatomical structure, and maintaining normal physiological functions” (figure 1.4). Since then, the transformation of traditional surgical techniques into such an ideal surgical mode, which has been widely implemented, and the objective has been gradually extended to other related areas of surgical treatment.

FIG. 1.4 — Super minimally invasive ‘preserving organ + eliminating disease’ surgical technique. Note: Based on of keeping the organ’s structure unchanged, super minimally invasive surgery eliminates lesions, not resecting organs, not affecting anatomical structure, and not affecting the postoperative quality of life.

1.2　Super Minimally Invasive Theory Has Profound Guiding Significance for Future Surgical Therapeutics

Based on anatomy, modern medicine decomposes the human body according to organs and systems, while conducting research and treatment. However, the human body is a complex whole, and its metabolism is complex and coordinated. Such a segmented research method may cannot totally capture the wholeness of the human body. In addition, minimally invasive surgery of human organs usually needs to excise lesions and organs, and it will inevitably bring a significant negative impact on the human body (figure 1.5). Some negative impacts can be obviously observed after the operation, for example, refractory reflux esophagitis, malnutrition, and lifestyle change, etc. after proximal gastrectomy. Research has evidenced that gastrectomy may have a significant impact on the activity of the posterior cingulate cortex. Other effects are not fully understood, such as whether the operation may affect the physiological functions of other organs, and its impact on human metabolism. Therefore, the chain effect of losing one particular organ may be beyond our current cognitive scope, so the maximum goal of illness treatment is to try to keep the original anatomical structure unchanged.

FIG. 1.5 — Connection axis among human organs.

1.3　Guided by the Super Minimally Invasive Theory, Super Minimally Invasive Surgery is Booming

Super minimally invasive surgery has developed by leaps and bounds in clinical work, particularly by its wide application in the field of gastrointestinal endoscopy (figure 1.6). Since the “super minimally invasive” concept was proposed in 2016, it has been widely accepted by the medical colleagues and the patients. In 2019, the Association of Gastrointestinal Endoscopy, Chinese Society of Medicine, has established the “super minimally invasive collaboration group,” laying a solid foundation for the international development of super minimally invasive surgery. In the same year, the World Endoscopy Organization (WEO) established a “super minimally invasive” committee, and the China National Committee for Terminology in Science and Technology also listed the “super minimally invasive” professional terminology in the book Chinese Terms in Digestive Endoscopology. In 2022, super minimally invasive surgery obtained financial assistance from the 14th Five-Year National Key Research and Development Program of China and used the funds for the “establishment of the curative effect evaluating system of the super minimally invasive surgery for gastrointestinal tumors and research of the application model.” On that basis, research for new surgical technique has been continuously carried out to standardize and optimize the current operation plans and has been actively promoted and applied nationwide.

FIG. 1.6 — History of the development of super minimally invasive surgery.

References

Chapter 2　The Super Minimally Invasive Theoretical System

2.1　The Definition and Implementation Principles of Super Minimally Invasive Surgery

2.2　The Four Channels of Super Minimally Invasive Surgery

This refers to surgeries that enter the human’s naturally opening orifice and are performed in a natural cavity conforming to super minimally invasive requirements. For instance, through human natural channels such as the nasal cavity, the auditory meatus, the respiratory tract, the mouth, the anus, the vagina, the urinary tract, etc. Let’s take the example of single-channel SMIS surgery of the digestive tract (figure 2.1).

FIG. 2.1 — SMIS through a natural channel.

(1) A modified endoscopic resection of the entire thickness of a gastrointestinal stroma tumor: A new sealing technique based on the principles of super minimally invasive surgery (video 2.1 (See online resources)).

. .

(2) Novel endoscopic papillectomy technique for reducing postoperative adverse events (video 2.2 (See online resources)).

. .

(3) Successful endoscopic transgastric retrieval of a plastic stent that migrated into the abdominal cavity during pancreatic fistula drainage (video 2.3 (See online resources)).

. .

(4) Endoscopic retrieval of a migrated lumen-apposing metal stent into the abdominal cavity during transluminal drainage (video 2.4 (See online resources)).

. .

(5) Incidental discovery of a pancreatic ductal adenocarcinoma during percutaneous cholangioscopy through a T-tube tract (video 2.5 (See online resources)).

. .

(6) Three pancreatic duct lesions discovered at an early stage in a patient by cholangioscopy (video 2.6 (See online resources)).

. .

This refers to the operation that meets the super minimally invasive requirements in the artificially created space by reaching the surgical site through an artificially established channel in the tissues. For instance, thyroid surgery and breast surgery through subcutaneous channels, mediastinal surgery via a supraclavicular channel, surgery for lumbar disc herniation through the back channel, and a series of operations using the gastrointestinal endoscopic tunnel technique. The following text will take the SMIS through the digestive tunnel technique as an example to present this channel (figure 2.2).

FIG. 2.2 — SMIS through a tunnel channel.

(1) Autologous skin-grafting surgery for the prevention of esophageal stenosis after complete circular endoscopic submucosal tunnel dissection (video 2.7 (See online resources)).

. .

(2) Challenging  use of the digestive endoscopic tunnel technique to treat schwannoma originating in the trachea (video 2.8 (See online resources)).

.

(3) Endoscopic submucosal tunnel dissection with an elastic traction device for a circumferential superficial esophageal neoplasm (video 2.9 (See online resources)).

.

(4) Magnetic multi-directional anchoring-guided endoscopic submucosal tunnel dissection for large gastric lesions (video 2.10 (See online resources)).

.

(5) Simultaneous performance of one-tunnel per-oral endoscopic myotomy, submucosal tunnel endoscopic resection, and peroral diverticulotomy (video 2.11 (See online resources)).

.

(6) Peroral endoscopic myotomy with simultaneous submucosal and muscle dissection for achalasia with severe interlayer adhesions (video 2.12 (See online resources)).

.

(7) Moving the knife’s tip on the thoracic aorta: high-risk submucosal tunneling endoscopic resection procedure for a puzzling submucosal tumor in the esophagus ((video 2.13 (See online resources)).

.

(8) Prepyloric submucosal tunneling endoscopic resection for a case of inflammatory mass (video 2.14 (See online resources)).

.

(III) Approach via the puncture channel

This refers to the operation that meets the super minimally invasive requirements by entering the lacunar or lumen through the puncture route. For instance, laparoscopic, thoracoscopic, arthroscopic-aided operations, related operations after body surface guided puncture bile duct, gallbladder, related operations conducted after ultrasonic endoscopic guided puncture chambers, etc. (figure 2.3).

FIG. 2.3 — SMIS through a puncture channel.

(1) Rendezvous-assisted endoscopic retrograde pancreatography in a patient with annular pancreas and coexisting pancreas divisum (video 2.15 (See online resources)).

.

(2) Novel treatment of pancreatic cystic neoplasms: EUS-guided radiofrequency ablation combined with lauromacrogol ablation (video 2.16 (See online resources)).

.

(3) Spyglass discovery of a mucinous cystic neoplasm by introducing an optical fiber into the cyst  through a 19G needle during EUS examination (video 2.17 (See online resources)).

.

This refers to the operation that is performed in the lacuna and is carried out in accordance with super-minimally-invasive requirements through more than two channels, and with more than two endoscopes. For example, duodenoscope combined with laparoscopic surgery, gastroscopy combined with thoracoscopic surgery, etc. Let us take the example of the SMIS of the multilacunar dual channel of the digestive system (figure 2.4).

FIG. 2.4 — SMIS through a multiple-cavity channel.

3. Video of a classic case. Flexible choledochoscopy via the cystic duct combined with laparoscopic cholecystectomy for the treatment of cholelithiasis (video 2.18 (See online resources)).

.

2.3　The Techniques of Super Minimally Invasive Surgery

(1) Endoscopic mucosal resection (EMR) (figure 2.5). First, the precise boundaries of the lesion are accurately determined under endoscopy and marked. Next, submucosal injection or other methods are used to separate the submucosa from the muscularis propria. Subsequently, the total or partial mucosal lesions are removed with a snare, and the diseased tissue is collected. Finally, the necessary treatment techniques are applied to the surface of the wound.

FIG. 2.5 — Operating steps of SMIS–EMR.

(2) Precutting endoscopic mucosal resection (precutting-EMR) (figure 2.6). First, the boundaries of the lesion are accurately determined under the endoscope and marked. Submucosal injections of substances such as normal saline solution or methylene blue, etc., are then administered in the area of the lesion to achieve full lift of the lesion. After that, the mucosa is incised circumferentially around the lesion using an electric knife or the tip of the snare. In this step, the submucosal layer does not need to be separated. Subsequently, the lesion was loop-ligatured directly with a snare, resected and collected. Finally, after excision, the wound is treated accordingly. Precutting-EMR has been validated as a technique by The Japan Gastroenterological Endoscopy Society.

FIG. 2.6 — Operating steps of SMIS-precutting-EMR.

(3) Piecemeal endoscopic mucosal resection (piecemeal-EMR) (figure 2.7). First, the lesion is carefully observed using an endoscope to determine the part that cannot be completely removed at one time only. Next, the boundaries of the lesion are determined and marked around the lesion for accuracy and to enable visualization in subsequent operations. After that, a submucosal injection is performed around the marked lesion to lift up the tissue in the lesion so that it can be easily operated and removed. Then, starting from the lesion’s side, piecemeal snare resection is performed subsequently. The lesion is gradually dissected by removal of the block of tissue surrounding it, while ensuring that the dissected tissues are recycled for subsequent pathological examinations and analyses. Finally, after completing lesion resection, appropriate treatment is carried out on the surface of wound, which can include steps like hemostasis, cleaning and sealing, etc., to ensure the wound’s healing and recovery.

FIG. 2.7 — Operating steps of SMIS piecemeal EMR.

(4) Cap-assisted endoscopic mucosal resection (cap-assisted EMR, EMRC for short) (figure 2.8). First, the lesion is carefully observed using endoscopy to determine and mark the boundaries of the lesion. After that, submucosal injection is administered in the area of the lesion to fully lift it. Then, the snare is prepositioned inside the cap, to attract the lesion into the cap. After that, the lesion is removed with a snare and collected. Finally, the wound is treated with hemostasis and sealed, etc. At first, EMRC was proposed by Hiroshi Inoue, a Japanese endoscopist, to improve EMR for the treatment of esophageal cancer.

FIG. 2.8 — Operating steps of SMIS-cap-assisted EMR.

(5) Ligation-assisted endoscopic mucosal resection (ligation-assisted EMR) (figure 2.9). The operating steps are as follows. First, the shape and extent of the lesion are determined under endoscopy, and its boundaries are marked using an electric knife or argon gas. After that, a mixture of normal saline solution and methylene blue is injected into the submucosa of the lesion area in order to fully lift it. Subsequently, the lesion to be ligated is directly attracted with a ligation device containing a ligation ring, and the red color of the endoscopic visual field indicates that the lesion is fully attracted in the cap. Then the lesion is removed with a snare at the bottom of the ligation ring and tissue samples are collected. Finally, the surgeon observes the wound to detect any bleeding and perforation, in order to determine the appropriate technology to treat it. At first, ligation-assisted EMR was proposed by M.A. Soehendra and S.L.S.J.D. Haese. This technique, which was firstly introduced in 1993, has been used since then to improve the effect of endoscopic mucosal resection.

FIG. 2.9 — Operating steps of SMIS ligation-assisted EMR.

(6) Multi band mucosa resection (MBM) (figure 2.10). First, the lesion boundary is determined and marked endoscopically. After that, mucosa ligation is carried out using a specially designed multi-ring ligation device. After that, the mucosa is removed with a snare. Note that each lesion attracted is removed by the snare, and the operation of attraction-ligation-excision is repeated several times to achieve piecemeal resection and recover of the whole lesion. Finally, the wounds are treated.

FIG. 2.10 — Operating steps of SMIS–ESD.

(8) Endoscopic submucosal dissection with traction (ESD with traction) (figure 2.11). Marking and submucosal injection are performed in the same way as in the case of submucosal dissection. After that, partial lesions are dissected by the pull of an external force, which makes it possible to completely separate the mucosal layer of the lesion from the muscularis propria to obtain a better surgical field of view. Subsequently, the tissue between the muscularis mucosa of the lesion and the muscularis propria is gradually separated using an electric knife until complete dissection. Finally, the lesion is collected and the wound is treated.

FIG. 2.11 — Operating steps of the SMIS–ESD technique with traction.

(1) Endoscopic full-thickness resection (EFTR) (figure 2.12). This method allows for the complete resection of lesions originating from the wall of the digestive tract, especially those located deep in the muscularis propria, the tumor must be resected along with the entire wall of the digestive tract. Initially, Thomas Rösch and Klaus W. D. R. W. described the method of using endoscopic techniques for full-thickness resection. This technique is mainly used for the endoscopic treatment of gastrointestinal tumors, especially lesions that are difficult to dissect using traditional methods.

FIG. 2.12 — Operating steps of the SMIS–EFTR technique.

(2) Hybrid ESD and FTR methods (figure 2.13). The operating process is as follows. First, the boundaries of the lesion are clearly observed under the endoscope, indigo carmine is sprayed, and the first circle is marked with argon gas 0.5 cm away from the lesion; Mark the second circle is marked with argon gas at a distance of 1 cm from the lesion, and another point is marked on the oral side. Next, after submucosal injection, the edge of the lesion is lifted, the marked outer mucosa is circumferentially incised, and part of the submucosal is removed. Then, two sets of tissue clips and dental floss traction are applied to make the boundary between mucosa and muscularis propria clear, and a submucosal injection is carried out while the submucosal dissection is carried out up to the inner ring mark. Subsequently, the traction line is pulled up together with the muscularis propria, and tissue clips are applied to locate and seal the marked inner-ring muscularis propria, then full-thickness resection is performed; after active perforation, tissue clips are applied to seal the perforation, while full-thickness resection is carried out until the lesion of the inner circle is completely detached from the wound. Finally, the wound is carefully healed, tissue clips are added to seal the wound strictly, and biological protein glue is sprayed to cover the wound again.

FIG. 2.13 — Operating steps of the hybrid ESD and FTR technique.

(a) Super minimally invasive drainage for infection of the digestive tract with one side blind. This is a surgical procedure that aims to cure a blind end of the digestive tract infection by draining it while preserving the integrity of the original tissue and organ anatomical structure. It includes:

Esophageal mediastinal fistula gastric tube insertion method: Under the guidance of a guide wire, a gastric tube is temporarily inserted into the mouth of the esophageal mediastinal fistula through oral endoscopy to drain pus from the mediastinum. Transanal super minimally invasive surgery for appendicitis (transanal SMIS for appendicitis), a surgery involving intubation, contrast, irrigation, and drainage of the appendix by transanal endoscopy to relieve appendiceal obstruction and treat appendicitis (figure 2.14). Currently, the effect of this treatment is basically equivalent to that of surgery.

FIG. 2.14 — Operating steps of transanal super minimally invasive surgery for appendicitis.

(1) Endoscopic submucosal tunnel dissection (ESTD) (figure 2.15). First, the boundaries of the lesion are accurately identified by endoscopy and marked on its oral and anal sides, respectively. Next, a routine submucosal injection is performed to lift the mucosal layer, and an incision is made in the mucosa on the oral and anal sides of the lesion. Then the endoscope enters the submucosal to dissect through the oral side tunnel, the tunnel between the mucosal layer and the muscularis propria is established while dissecting. Subsequently, after having been dissected up to the lateral anal opening, the entire lesion is resected in the tunnel on both sides. Finally, the specimen is collected and the wound is treated. In 2009, Professor Linghu Enqiang accidentally established a submucosal tunnel from the lesion mouth to the anus during an endoscopic resection of high-grade epithelial neoplasia around the esophagus in 2009. This tunnel helped him safely and quickly remove the lesion. At the same year’s Beijing Gastrointestinal Endoscopy Annual Conference, Professor Linghu Enqiang gave a special report on the topic and named it ESTD surgery. And then he modified it in 2013, proposing single-tunnel, double-tunnel, and multi-tunnel approaches for the treatment of esophageal large area early cancer. Numerous studies have shown that ESTD has a better effect and a lower complication rate in the treatment of early gastric cancer, esophageal cancer, and other digestive diseases.

FIG. 2.15 — Operating steps of SMIS–ESTD.

(3) Submucosal tunnel endoscopic resection (STER). The operating steps are the same as in the tunnel endoscopic resection if the muscularis propria. A tunnel opening is created, the submucosal tunnel is established, the tumor is resected, the wounds are treated and the tunnel opening is sealed (figure 2.16). In 2011, Professor Linghu Enqiang officially published a feasibility study on esophageal resection through a tunnel in the muscularis propria. Professor Xu Meidong published the submucosal tunnel endoscopic resection (STER) technique in 2012. Professor Inoue named this technique peroral endoscopic tumor resection (POET).

FIG. 2.16 — Operating steps of SMIS–STER.

(a) Peroral endoscopic myotomy (POEM) (figure 2.17). After submucosal injection 7–12 cm from the cardia, the mucosal layer is incised to create the tunnel opening. The endoscope enters the submucosal layer through the tunnel opening to dissect and establishes a tunnel between the muscularis mucosa and the muscularis propria; in the tunnel, the muscularis propria of the lower esophagus and the cardia are cut with an electric knife, and the tunnel opening is sealed, then the wound is treated. The procedure combines surgical myotomy and endoscopy techniques to avoid the trauma of traditional surgery.

FIG. 2.17 — Operating steps of SMIS–POEM.

(b) Gastric peroral endoscopic myotomy (G-POEM) (figure 2.18). After submucosal injection at about 5 cm from the pyloric opening, the mucosal layer is incised to create the tunnel opening, then the endoscope enters the submucosal layer to dissect through the tunnel opening and establishes a tunnel until it crosses 1 cm of the pyloric canal; in the tunnel, the pyloric sphincter is incised with an electric knife, and finally the wound is treated and sealed. This technique, in which a tunnel is created at the gastric prepyloric area to perform submucosal tumor resection, was first reported in 2012 by Professor Linghu Enqiang in his book Digestive Endoscopic Tunnel Technique Therapeutics.

FIG. 2.18 — Operating steps of SMIS–G-POEM.

(c) Submucosal tunneling endoscopic septum division (STESD). A tunnel entrance is created 3 cm from the diverticular septum by the tunnel technique, then a short tunnel is established at the submucosal layer, the diverticulum in the tunnel is fond and completely exposed; finally, the division incision of the esophageal septum is completed. The technique was reported by Professor Zhou Pinghong in 2013. Its advantages lie in the fact that it allows the diverticular septum to be sectioned while preserving the integrity of the mucosal layer, reducing the risk of postoperative perforation, infection, and lowering the risk of complications; it allows the muscular layers between the esophageal wall and the diverticulum to be fully exposed and the muscle in the septum division to be completely and thoroughly incised (figure 2.19).

FIG. 2.19 — Operating steps of SMIS–STESD.

1) Endoscopic ultrasound-guided pancreatic pseudocyst drainage (EUS–PPD). This is a the method in which an endoscopic ultrasound-guided puncture needle is inserted into the pseudocyst, by placing a guide wire; the drainage stent or nasobiliary duct is placed in the cyst to drain the cystic fluid into the pseudocyst. This can be divided into internal drainage and external drainage. The placement of a stent between the cyst and the stomach or duodenum constitutes a fistula channel, which is an internal drainage system; one end of the nasobiliary duct is placed outside the body, so it belongs to the category of external drainage (figure 2.20). In 1992, H. Grimm et al. in Germany first proposed the application of EUS-guided drainage for the treatment pancreatic pseudocyst, which overcame the problems of high pancreatitis recurrence rate, high postoperative infection rate and death rate, etc., associated with percutaneous puncture drainage.

FIG. 2.20 — Operating steps of SMIS–EUS–PPD.

1) Gastrointestinal puncture (figure 2.21). Super minimally invasive gastropuncture surgery mainly includes gastropancreatic, gastrogallbladder, gastrojejunal surgeries. The puncture path can be either intrahepatic or extrahepatic. The intrahepatic approach utilizes mainly the gastropuncture channel, which involves puncture and intubation of the intrahepatic biliary tree. This channel can be used for EUS-guided rendezvous (EUS–RV), anterograde stent placement (EUS–AS) or hepatogastrostomy (EUS–HGS). The extrahepatic channel utilizes mainly the duodenal puncture channel. EUS-guided puncture enters directly the common bile duct (CBD) through an extrahepatic channel, and can be used in EUS–RV. It is most commonly used for choledochoduodenostomy (EUS–CDS). In these two methods, the stent can be placed across the narrowing and/or the papillae, while respecting anatomy (EUS–RV, EUS–AS), or connecting two organs and creating a new anastomosis (EUS–CDS, EUS–HGS). In case ERCP fails, EUS–BD will provide good results. Therefore, EUS–BD is also regarded as the preferred drainage strategy for distal malignant obstruction. In addition, SMIS of the duodenal puncture channel mainly includes EUS-guided choledochoduodenostomy and ablative therapy of pancreatic cystic tumors (the same as with the operating methods of the gastro puncture channel).

FIG. 2.21 — Surgical operation through the SMIS-gastrointestinal puncture channel.

References

Chapter 3　Nomenclature in Super Minimally Invasive Surgery and Surgical Record Rules

3.1　Rules of Surgical Nomenclature

3.2　Recording Rules for Super Minimally Invasive Surgery

3.2.1　SMIS Excision Methods and the Nomenclature of Endoscopic Techniques

3.2.2　Examples of SMIS Surgical Records

3.3　Surgical Items and Diseases

References

Chapter 4　Common Super Minimally Invasive Surgery Operations

4.1　Super Minimally Invasive Closure

4.1.1　SMIS Wound Closure Method

(I) Endoscopic closure with metal clips (figure 4.1).

FIG. 4.1 — An endoscopic metal clip-closure system.

The endoscopic sutures currently available in the market for closing perforations and fistulas include Over Stitch by Apollo Endosurgery (figure 4.2). It mimics surgical suture technology by first grasping the tissue with an anchor device, followed by penetrating it on one side with a curved needle fitted with suture thread, before finally capturing the suture thread on the opposite side. Through repeated operations, it can complete the intermittent or continuous suture of the tissue, and finally a special device is used to fix the suture. The perforation closure process must be completed without tying. Compared to metal clips, it can provide a more effective and reliable suturing effect, but its operational process is complicated and lacks flexibility while being costly. It is not widely applied clinically. Recently, Osamu Goto et al. reported a new suturing device in the magazine Endoscopy. They inserted a curved needle with sutures and a special needle-holding device into the body and sutured in vitro the wound in the digestive tract. The process was similar to surgical suturing and good results have been obtained in animal and human studies. In addition, a variety of special suture instruments for use on animals or humans are currently being studied.

FIG. 4.2 — Overstitch device.

1. Nylon rope reinforcement after metal clip suturing (figure 4.3). This method is generally used for wound clamping by means of a metal clip after full-thickness resection and ESD perforation. It can be used if one is unsatisfied with metal clip suture or worries that the metal clips will fall out. By using a double-forceps channel endoscope, the foreign-body forceps are inserted into one hole and the nylon rope into the other. The nylon rope is stretched, the foreign body forceps was passed through the nylon rope string to widen it and clamp the sutured wound, which is lifted up to make the mucosa around the wounds swell; the nylon rope string is tightened, and one tries to wrap all sutured wounds in the nylon rope. Although this method reinforces the suture, care and caution as well as moderate force are needed in the operating process, so as to avoid rupture of the wound after it has been sutured by the metal clip. Someone also used a single-forceps endoscope for nylon rope reinforcement. By suction, this makes the mucosa relax and swell around the wound, which then can be ligatured with a loop. Or one can make a loop using only the metal clip as a support point, tightening slowly, making the metal clips on the wound to come together, to obtain a reinforcement effect.

FIG. 4.3 — Realization of a suture reinforced by a nylon rope following a suture made using an SMIS metal clip.

2. Metal clip combined with purse-string suture with nylon rope (figure 4.4). This method is the most economic and effective method so far for suturing defects in the wall of the digestive tract after endoscopic full-thickness resection and ESD perforation. The method of implementing double-forceps endoscopic purse-string suture in a defective digestive tract is as follows: the nylon rope is sent through one forceps channel, the nylon rope loop string is stretched, its position is adjusted to fit the wound; the titanium clip is sent into the other forceps channel of the endoscope, and the nylon rope is anchored to the first titanium clip at the edge of the wound, and one tries to make the titanium clip solidly fixed. After that, titanium clips are inserted and the above steps are repeated until the titanium clips anchored at the edge of the wound are evenly distributed over its entire surface, with the goal of achieving equal spacing and bilateral symmetry; then the nylon rope loop string is tightened to completely close the wound, and several pieces of tightened titanium clip piling are found by endoscopy. There is no need for a lot of titanium clips; otherwise there would be a risk of the sutured wound spreading after tightening the nylon cord, which would affect the healing of the wound.

FIG. 4.4 — SMIS suturing method using a metal clip combined with a nylon rope.

4. Metal clip combined with nylon rope intermittent suturing method (figure 4.5). The nylon rope and the first titanium clip are inserted through the double-forceps channel of the endoscope. The nylon rope and the titanium clip are adjusted to the proper angles and directions, the distal end of the nylon rope is clamped by using the first piece of titanium clip, one tries to press firmly against the wall of the digestive tract over the full thickness of the defective distal end edge to clamp and fix it at a vertical angle. Insert the second titanium clip, clamp and hold the proximal nylon rope, and secure it to the digestive tract wall near the edge of the defect. The nylon rope is closed and narrowed, the distal side of the wound and the proximal side of the defect are pulled together. The above steps are repeated if necessary, the wound is closed completely. The residual wound can also be further closed by simply adding several titanium clips sequentially. Then the gastric tube is placed for decompression.

FIG. 4.5 — SMIS method of intermittent suturing using a metal clip combined with a nylon rope.

This technique is used to close the wound after full-thickness or non-full-thickness resection of wounds, by applying surgical threads and tissue clips to close them. The specific operating steps (figure 4.6) are as follows:

FIG. 4.6 — SMIS suture-assisted complete suturing method.

The tissue-holder with a thread protruding from the endoscopic forceps channel is fixed on the oral side of the mucosa.

The first tissue-holder is fixed with a thread to the anal side mucosa with the second tissue clips (without thread).

The thread is pulled to make the tissue clips closer.

The suture is reinforced, the tissue-holder (without thread) is added for occlusion.

The thread is cut off with endoscopic special scissors after full occlusion.

4.1.2　Hot-Spot Issues and Progress in the Search for a Consensus

4.2　Super Minimally Invasive Surgery for the Prevention and Therapy of Gastrointestinal Bleeding

4.2.1　Endoscopic Common Super Minimally Invasive Hemostatic Method

4.2.2　Hot-Spot Issues in the Consensus and Research Progress

4.3　Super Minimally Invasive Auxiliary Traction Method

4.3.1　Clip–Thread Combined Traction Method

This is an external traction technique (figure 4.7). SureClip is basically used nowadays. Auxiliary equipment includes surgical sutures, dental floss, snare, magnetic beads, gravity hammers, springs, elastic rings, etc. But due to its high risk, dental floss is used now. Dental floss is cheap, easy to get, with moderate tension, and reduces the pressure and risks on sites such as the esophageal inlet, the cardia, thus improving safety and operability.

FIG. 4.7 — Clip–thread combined traction method.

4.3.2　Clip–Elastic Ring Combined Traction Method

This is an internal traction technique (figure 4.8). It has been reported in the literature that ESD uses metallic clip–elastic ring combined traction, but as the controllability of the tension of the spring is not good, ESD tension is high at the beginning, and there is no tension when it approaches the end. So this combination is not widely used.

FIG. 4.8 — SMIS clip–elastic ring combined traction method.

4.3.3　Other Combinations

A relatively less used combined method, but which can be tried, is the internal or external traction technique (figure 4.9). Both methods include clip snare combination, clip gravity hammer combination, clip ‘pulley’ combination, magnetic traction, etc. These traction-enhancing techniques include: Clip-snare combination, Clip-counterweight assembly, Clip-pulley configuration and Magnetic traction systems. These specialized approaches provide targeted traction forces through unique mechanical advantages when conventional methods prove inadequate, particularly in complex anatomical situations requiring precise tissue manipulation. The clip-pulley configuration. This technique demonstrates superior traction mechanics compared to basic clip-dental floss assemblies, offering enhanced control over both traction force magnitude and directional application through its integrated pulley system’s mechanical advantage and vector control capabilities.

FIG. 4.9 — External magnetic traction method.

4.3.4　Hot-Spot Issues in the Consensus and Research Progress

References

Chapter 5　Conditions for Performing Super Minimally Invasive Surgery

5.1　Site and Anesthesia Rules for Super Minimally Invasive Surgery

The setup of super minimally invasive operating rooms must adhere to the consensus guidelines (figure 5.1). Apart from the standard diagnostic and treatment tools or gastrointestinal endoscopy, specific attention should be given to the unique requirments of super minimally invasive surgery, which requires a variety of accessories and equipment for endoscopic treatment that should be in line with the basic requirements of surgical anesthesia, and should include routine monitoring, oxygen supply and inhalation devices, independent negative pressure suction devices, routine airway management equipment, and intravenous infusion devices, as well as emergency medications and relevant medical apparatus.

FIG. 5.1 — Organization of super minimally invasive surgery centers.

5.1.1　Site Facility

5.1.2　Anesthesia Rules for Super Minimally Invasive Surgery

5.2　Manning and Requirements for Performing Super Minimally Invasive Surgery

5.2.1　Surgeon

5.2.2　Anesthetist

5.2.3　Nurse

5.2.4　Operating Room Assistant

5.2.5　Operating Room Head Nurse

5.2.6　Cleaner

5.2.7　Operation Room Technician

5.2.8　Pathologist

5.3　Instruments and Parameters of Super Minimally Invasive Surgery

To maximize the advantages of super minimally invasive surgery, it is necessary to carry out sufficient preparation work well before performing the operation. Selecting the good super minimally invasive surgical device is a prerequisite work for the success of the subsequent operations. Therefore, gastrointestinal endoscopy with water supply function is selected (figure 5.2). Meanwhile, matching the instrument with the cap allows sufficient exposure of the visual field, increases operating space and reduces operating time. The equipment required for super minimally invasive surgery includes an electrosurgical device, a digestive endoscope and its accessories, etc.

FIG. 5.2 — With water supply equipment and cap.

5.3.1　Electrosurgical Device

The electrosurgical device, also known as electric knife or electrosurgical instrument, is an important tool of modern medical treatment, which is widely used in modern medical procedures. It incises and stops bleeding by the effect of the high temperature generated by the high-frequency electrical current, which makes it a faster and more precise surgical tool for super minimally invasive surgery. We will discuss each aspect of the electrosurgical device below (figure 5.3).

FIG. 5.3 — Electrosurgical device.

Depending on the application scenarios and functions, there is a variety of types of electrosurgical device, including laser knife, radiofrequency knife, ultrasonic knife, cryoprobe, high-frequency electric knife, bipolar electric knife, etc. These devices play an important role in surgery: they improve the efficiency of surgery, reduce bleeding, relieve pain, etc. The types of electrosurgical devices and the products of some major manufacturers will be detailed below (figure 5.4).

FIG. 5.4 — Some common instruments and articles for super minimally invasive surgeries.

5.3.2　Surgical Equipment for Endoscopic Therapy

5.4　Common Instruments and Articles for Super Minimally Invasive Surgery

5.5　Standardized Operation and Management of the Cleaning and Disinfection of Gastroendoscopes

References

Chapter 6　Standard Process of Super Minimally Invasive Surgery

6.1　Informed Consent Prior to Super Minimally Invasive Surgery

6.1.1　Legal Basis and Moral Consideration of the Informed Consent

6.1.2　The Contents and Requirements of Super Minimally Invasive Surgery

6.1.3　Practical Implementation of Informed Consent in Super Minimally Invasive Surgery

6.1.4　Postoperative Follow-Up Visit and Feedback

6.1.5　Difficulties and Strategy of Informed Consent in Super Minimally Invasive Surgery

6.2　Preoperative Conversation Skills in Super Minimally Invasive Surgery

6.2.1　Patient Psychological Profiling and Intervention of Super Minimally Invasive Surgery

6.2.2　Doctor–Patient Communication in Super Minimally Invasive Surgery

6.2.3　Information About Super Minimally Invasive Surgery (Surgical Purpose, Surgical Risk and Special Condition Inform)

6.2.4　Example of Informational Conversation on Super Minimally Invasive Surgery

6.2.5　Complication Management Principle

6.3　Standards for the Surgical Record of Clinical Cases

6.3.1　Basic Requirements for the Surgical Record

6.3.2　Specific Contents of the Surgical Record in Super Minimally Invasive Surgery

6.3.3　Postoperative Treatment and Medical Order

6.3.4　Notice and Follow-Up Visit

6.3.5　Writing Norm and Notice

6.3.6　Specific Writing Skills

6.4　Perioperative Diagnosis and Treatment Criteria

6.4.1　Preoperative Preparation

6.4.2　Intraoperative Operation

6.4.3　Postoperative Nursing

6.4.4　Prevention of Complications

6.4.5　Management of Follow-Up Visits

References

Chapter 7　Preoperative Preparation and Treatment of Complications in Super Minimally Invasive Surgery

7.1　Preparation Before the Endoscopic Operation

7.1.1　Preparation of the Endoscopic Operation of the Upper Digestive Tract

7.1.2　Preparation of the Endoscopic Operation of the Lower Digestive Tract

7.1.3　Preparation Before an Enteroscopic Operation

7.1.4　Preparation Before an Operation by Duodenoscopy

7.1.5　Preparation Before the Ultrasonic Endoscopy Examination

7.1.6　Preparation Before the SpyGlass Operation

7.1.7　Hot-Spot Issues in the Consensus

7.2　Preoperative Preparation of the Patient for Super Minimally Invasive Surgery

7.2.1　Medical Preparation

7.2.2　Nursing Preparation

7.2.3　Hot-Spot Issues in the Consensus

7.3　Wound Pre-Treatment and Infection Prevention in Super Minimally Invasive Surgery

7.3.1　Wound Pre-Treatment Plan in Super Minimally Invasive Surgery

7.3.2　Antibiotic Application in Super Minimally Invasive Surgery

7.3.3　Hot-Spot Issues in the Consensus

7.4　Prevention and Treatment of Intraoperative Complications in Super Minimally Invasive Surgery

7.4.1　Complication Prevention and Treatment

7.4.2　Hot-Spot Issues in the Consensus

7.5　Prevention and Treatment of Postoperative Complications in Super Minimally Invasive Surgery

7.5.1　Complication Prevention and Treatment

7.5.2　Hot-Spot Issues in the Consensus

7.6　Postoperative Nursing in Super Minimally Invasive Surgery

7.6.1　Peroral Super Minimally Invasive Surgery

7.6.2　Psychological Nursing

7.6.3　Health Education

7.6.4　Transanal Super Minimally Invasive Surgery

7.6.5　Hot-Spot Issues in the Consensus

References

Part Two　Specific Discussion of Super Minimally Invasive Surgery

Chapter 8　Super Minimally Invasive Surgery of Esophageal Diseases

8.1　Early Esophageal Carcinoma and Super Minimally Invasive Surgery

8.1.1　Introduction

8.1.2　Peroral Super Minimally Invasive Surgery with Non-Full-Thickness Resection for the Treatment of Early Esophageal Carcinoma

8.1.2.1　Endoscopic Submucosal Dissection (ESD)

(7) Specimen treatment: the sediment attached to the specimen’s surface must be gently removed with the gauze and placed on a sponge board for fixation. The surface of the membrane must be placed upward, the spread of the specimen must be consistent with the size of the tumor observed by endoscopy; the sample is then pinned to the board, and the oral and anal sides of the lesion are marked. Lugol’s iodine is applied to stain again in order to confirm whether the lesion is completely resected.

FIG. 8.1 — Operating steps of the resection of early esophageal carcinoma by peroral super minimally invasive surgery. A. The lesion refuses to stain after iodine staining. B. The marked lesion. C. Circumferentially incised membrane. D. Submucosal dissection. E. The wound after resection. F. Lesion specimen after resection.

8.1.2.2　Endoscopic Submucosal Dissection with Traction

1. Clip-floss traction. After dissection of the oral-side end part of the early esophageal carcinoma, tissue clips and dental floss should be attached to the mucous layer separated from the oral-side end, then external traction should be applied to separate the mucous layer from the muscularis layer.

FIG. 8.2 — SMIS operative steps of early esophageal carcinoma: dental floss/tissue clips with traction, endoscopic submucosa dissection. A. Early esophageal carcinoma after iodine staining. B. Circumferentially incised lesions. C. Tissue clips/dental floss are applied for traction at oral-side end. D. After traction, submucosal layer must be fully exposed, whereas submucosal dissection should be continued. E. Postoperative wound. F. Tissue specimen.

2. ‘8’-loop traction (figure 8.3). After partial dissection of the oral-side end of the lesion, eight-loop/tissue clips should be attached to mucous layer at the oral-side end, the other end being attached to the normal membrane at the opposite side (anal side) of the lesion, by applying tissue clips to obtain the traction effect.

FIG. 8.3 — Operating steps of the SMIS endoscopic submucosal dissection of an early esophageal carcinoma using a ‘8’-loop and traction. A. Early esophageal carcinoma after iodine staining. B. Circumferentially incised lesions. C. After submucosal dissection of the oral-side end, the lesion mucosa contractures, and dissection is difficult. D. ‘8’-loop/tissue clips for traction. E. The mucous layer is clearly separated from the muscle layer after traction. F. Postoperative wound.

After an adequate preoperative evaluation, an improvement in nutritional status, and the signing of informed consent for surgery, the patient underwent a peroral super minimally invasive resection of an early esophageal carcinoma (Refer to video 8.1, Peroral super minimally invasive resection for early esophageal carcinoma (See online resources)).

.

8.1.2.3　Cap-Assisted Endoscopic Mucosal Resection

8.1.3　Non-Full-Thickness Resection of Early Esophageal Carcinoma by Per-Tunnel Super Minimally Invasive Surgery

(1) The extent and depth of the lesion must be determined (figure 8.4). First, a routine endoscopy should be performed to determine the foci’s site, size and shape, which should be combined with staining and magnifying endoscopy to determine the foci’s extent, nature and infiltration depth.

FIG. 8.4 — Super minimally invasive resection of early esophageal carcinoma through a tunnel channel to determine the lesion scope. A. Esophageal flat lesion seen in white light; B. NBI to observe the lesion. C. Dye-repellent zone found after iodine staining; D. Circumferential marking.

(8) Treatment of postoperative wounds (figure 8.6): hemostasis must be carried out on the wound vessels by using argon knife or electrocoagulation forceps. If the membrane has been dissected deeply or if there are injuries to the muscle layer, one or multiple titanium clips should be used for occlusion to prevent hemostasis. Fibrin glue can be sprayed if needed.

FIG. 8.5 — Steps of the dissection of esophageal early carcinoma in the tunnel by super minimally invasive resection through a tunnel channel. A. Lesion bulge after submucosal injection. B. Marginal incision. C. Submucosal dissection. D. Bare exposed blood vessels.

FIG. 8.6 — Resection of an early esophageal carcinoma lesion and wound treatment by super minimally invasive resection through a tunnel channel. A. Electric coagulation hemostasis of the exposed blood vessels. B. Complete submucosal dissection. C. Incised membranes on both sides of the tunnel. D. Tissue glue is sprayed on the wound to protect it.

(9) Double-tunnel ESTD operating method: it is basically similar to the single-tunnel ESTD operating method. (figure 8.7). After incising the oral and anal margins, create two tunnels approximately 1.5 cm wide. Apply the cap and establish two tunnels to dissect the lesion using the same method (figure 8.8).

FIG. 8.7 — Operating steps of single-tunnel ESTD surgery therapy. A. Mark the lesion’s extent and incise the anal-side membrane. B. Incise the oral-side membrane. C. Tunnel established. D. Dissection to the anal-side margin. E. Incise the edge of the side. F. After lesion dissection.

FIG. 8.8 — Operating steps of double-tunnel ESTD surgery therapy. A. Incision on the anal side. B. Incision on the oral side. C. First tunnel. D. Second tunnel; E. After dissection of the lesion. F. Resected specimen.

After full preoperative evaluation, improving nutrition condition and signing the surgery informed consent form, the early esophageal carcinoma per-single-tunnel channel SMIS resection was performed on the patient (Refer to video 8.2, Early esophageal carcinoma resection by super minimally invasive surgery through a tunnel channel (See online resources)).

.

8.1.4　Esophageal Skin Grafting by Digestive Endoscopic Super Minimally Invasive Surgery

(1) For esophageal circumferential early carcinoma, double-tunnel ESTD is usually used, which mainly includes the following four steps: firstly, circumferential marking of the lesion’s anal-side and oral-side membranes; secondly anal-side and oral-side opening, successively; then submucosal dissection from the lesion’s oral side to its anal side; creation of two submucosal tunnels; finally, incision of the side edge. After complete resection of the lesion, prophylactic hemostasis must be performed on the wound.

FIG. 8.9 — Schematic diagram of esophageal skin grafting by digestive endoscopic super minimally invasive surgery. A. Endoscopic staining with Lugol’s iodine showed staining rejection of the circumferential esophageal mucosa. B. Esophageal wound after circumferential ESTD surgery. C. The epidermal skin graft should be taken on the external side of the patient’s right thigh. D. The graft is sewn into a cuff shape with absorbable thread. E. Suture of the cuff skin graft onto the esophageal covered stent. F. The transplanted skin graft must totally cover the esophageal wound.

Refer to video 8.3, Digestive endoscopic super minimally invasive esophageal skin grafting surgery-1 (See online resources).

.

(3) Application of stents by injection: the placement method is the same as with the routine stent, i.e. under continuous hormone treatment by injection through the drug-injection hole to alleviate stenosis.

FIG. 8.10 — Structure and application of a drug-eluting stent. A. Design of the drug-eluting stent. B. Stent covered with a skin graft. C. The stent is placed into the wound after esophageal circumferential resection. D. Anti-reflux valve of the drug-eluting stent. E. Injection of the mixed solution of hormones and methylene blue into the storage capsule of the drug-eluting stent. F. Re-checking the state of growth of the esophageal skin graft after the operation.

Refer to video 8.4, Digestive endoscopic super minimally invasive esophageal skin grafting surgery-2 (See online resources).

.

8.2　Super Minimally Invasive Surgery of Esophageal Subepithelial Lesions

8.2.1　General Introduction

8.2.2　Peroral Super Minimally Invasive Resection of Esophageal Subepithelial Lesions

(5) As membranes covering the SEL is also resected, the artificial ulceration cannot be closed with clips in many occasions. If possible, artificial ulcerations should be closed to reduce the possibility of perforation, infection and delayed hemorrhage. For lesions with deeper MP layers or thinner artificial ulcer walls, clips must be used to prevent perforation. Fibrin sealant is used to close the wound in some patients.

FIG. 8.11 — Operating steps of peroral super minimally invasive endoscopic resection of esophageal subepithelial lesions. A. Esophageal lesions found under white light. B. The membrane is incised to expose the lesion. C. The wound after the lesion is resected. D. Wound closed by tissue clips.

8.2.3　Per-Tunnel Super Minimally Invasive Resection of Esophageal Subepithelial Lesions

(1) Establishment of the tunnel opening (figure 8.12): the gastroscope the inserted up to the target site, and the tunnel entrance is established 5 cm away from the lesion site. A submucosal injection of 6–8 ml of a mixture of methylene blue, normal saline solution and adrenaline is administered, then an inverted T-shaped incision is made to create the tunnel entrance. Inverted T incision: such inverted T-shaped incision was combined with a horizontal incision of 0.8 cm and a vertical incision of 1.0 cm. This tunnel incision was similar to the inverted ‘T’ incision. Thanks to the tunnel’s large space, it is very convenient for the endoscope to enter and exit and for the incision’s postoperative closure, as well as for external gas evacuation and drainage, thus reducing the occurrence of gas-related complications resulting from tunneling.

FIG. 8.12 — Positioning and establishment of the tunnel entrance in per-tunnel super minimally invasive resection of esophageal subepithelial lesions. A. Gastroscopy to locate submucosal tumors. B. Endoscopic ultrasound shows the lesion. C. Submucosal injection after determining the tunnel entrance. D. Making the inverted T incision.

(4) Closure of the incision site: clips are used for closing the incision. The horizontal incision and the reverse T incision are closed in a vertical fashion. SELs with a diameter of <1.5 cm can be extracted directly by endoscopic suction, whereas a snare or a basket should be used to extract SELs with a diameter of ≥1.5 cm.

FIG. 8.13 — Resection in the tunnel and wound treatment in per-tunnel super minimally invasive resection of esophageal subepithelial lesions. A. Dissection of a submucosal tumor in the tunnel. B. The tumor is taken out with a snare. C. The wound after tumor resection. D. Closure of the tunnel entrance with tissue clips.

After full preoperative evaluation, improvement of the nutrition state and signing of surgery informed consent, the patient was performed peroral super minimally invasive resection of esophageal subepithelial lesions (Refer to video 8.5, Peroral super minimally invasive resection of esophageal subepithelial lesions through a tunnel channel (See online resources)).

.

8.2.4　Super Minimally Invasive Resection Per-Multi Cavity of Esophageal Subepithelial Lesions

Treatment: the tumor was exfoliated through an endoscopic submucosal tunnel, with resection of the tumor’s root to ensure the integrity of the membrane. Then the tumor was completely separated and resected by laparoscopy. The postoperative pathological findings suggested an esophageal leiomyoma. The final en bloc resection size was 7 cm × 4 cm × 4 cm.

FIG. 8.14 — Operating steps of super minimally invasive resection per multiple cavity of esophageal subepithelial lesions. A. CT showed gastroesophageal junction tumor. B. Esophageal submucosal eminence observed endoscopically. C. Circumferential endoscopic ultrasound image. D. 3D image reconstruction. E. Laparoscopic surgery. F. Completely resected tumor.

8.3　Super Minimally Invasive Radiofrequency Ablation for Intraepithelial Neoplasia

8.3.1　Principle of Radiofrequency Ablation

8.3.2　Indications and Contraindications of Super Minimally Invasive RFA Surgery

(1) After strict and standard magnetifying endoscopic screening + biopsy, according to WHO/Vienna assessment standards, the pathological results evidence esophageal LGIN (the pathological diagnosis must be co-diagnosed by two senior physicians from the pathology department)—in case of disagreement, the final confirmation will be made by a third senior physician from the pathology department).

FIG. 8.15 — Device for radiofrequency ablation.

FIG. 8.16 — Electrode plate for radiofrequency ablation (electrode plate to achieve local current reflux).

8.3.3　Preoperative Preparation

8.3.4　Surgical Operation and Skills

8.3.5　Postoperative Treatment

Postoperative fasting food for 4–6 h, with appropriate fluid supplement, will be prescribed; subsequently, a cool liquid diet will be given, and switching gradually to a semifluid, full diet; the patient will orally take PPIs and a mucosa protector for one month after the operation.

FIG. 8.17 — Super minimally invasive radiofrequency ablation of a low-grade intraepithelial neoplasm. A. After radiofrequency ablation, the lesion surface appears as a white coagulated necrosis. B. Scraping of necrotic mucosal tissues of the lesion’s surface after radiofrequency ablation.

Refer to video 8.6, Super minimally invasive radiofrequency ablation of low grade intraepithelial neoplasia (See online resources).

.

8.3.6　Postoperative Follow-Up Visit

8.3.7　Hot-Spot Issues in the Consensus and Progress of the Study

8.4　Super Minimally Invasive Surgery for Esophageal Stricture

Esophageal stricture refers to a situation in which a standard endoscope cannot pass through the esophageal stenosis with varying degrees of dysphagia, often accompanied by reflux, retrosternal pain, and weight loss. According to the nature of the stricture, it can be divided into malignant esophageal stricture and benign esophageal stricture. Esophageal malignant stenosis is commonly seen in esophageal carcinoma or is caused by external pressure from malignant tumors of non-esophageal origin. Due to poor general health and distant tumor metastasis, radical resection cannot be conducted on most patients, so conservative therapy can be used to alleviate the symptom of difficulty in swallowing. Esophageal benign stenosis is often caused by large esophageal lesions after ESD surgery, anastomotic stenosis after surgery, ulcerative lesions, chemical corrosion or radiation damage. Large esophageal lesions usually refer to those with an estimated resection circumference of ≥3/4 and a resection length of ≥3 cm, including circumferential esophageal lesions. Previous studies have reported that the incidence of esophageal stenosis after endoscopic resection of non-circumferential lesions is no less than 56%, while the incidence of postoperative stenosis of circumferential esophageal lesions is as high as 100% (figure 8.18).

FIG. 8.18 — Endoscopic observation of a mucosa defect and severe recurrent stricture after ESD. A. Mucosa defect exceeding 3/4 of the circumference. B. Repetitive occurrence of esophageal stricture, shown as needles.

8.4.1　Esophageal Stenosis Peroral Super Minimally Invasive Incision + Submucosal Injection

(3) Hormones must be injected after the stenosis is incised: the injection needle must be placed through the endoscope’s forceps channel, then 1 ml of triamcinolone acetate (10 mg/ml) will be injected into each of the four limits at the narrowest part of the esophageal stenosis. The wound’s hemorrhage condition will be observed.

FIG. 8.19 — Schematic diagram of esophageal stenosis and surgery by injection of submucosal hormones. A. The diameter of the esophageal stenosis is about 3 mm. B. Longitudinal radial incision along the esophageal lumen with a hook. C. Removal of scar tissues after radial incision. D. Injection of hormones after the stenosis is incised.

Postoperative fasting for food and water, intravenous acid suppression, fluid supplement were prescribed for three days, the patient gradually resuming a normal diet. The situation was re-examined by gastroscopy one month after the operation: the esophageal is clearly less significant than before.

FIG. 8.20 — Contrast image before and after incision of the esophageal stenosis and submucosal injection surgery. A. The postoperative anastomosis of an esophageal carcinoma is narrow and the endoscope cannot pass through it. B. After stenosis incision and injection of hormones for one month, the stenosis appears significant less severe.

8.4.2　Peroral Super Minimally Invasive Dilation of Esophageal Stenosis

The balloon’s total length, effective length and diameter are 120 mm, 80 mm and 18 mm, respectively (figure 8.21). The tip of the balloon catheter is fixed with a protective hose, while air (30–35 ml) is used instead of water to inflate the balloon, increasing its safety and convenience. After the balloon is endoscopically placed, the patient can operate it by himself, avoiding repeated visits to the hospital. The syringe must be used to inflate it 4–5 times a day, about 15–20 min each time, and the balloon should be removed according to the degree of wound healing evidenced during reexamination.

FIG. 8.21 — Schematic diagram of an external self-dilating balloon. A. The patient can operate the balloon by himself. B. The parameters associated with the balloon.

(1) Pre-dilation: as the actual pressure of the new balloon is less than that of the traditional dilated balloon, it is impossible to mechanically tear the mucosa in the esophageal stenosis quickly and effectively. Therefore, before placing this balloon, the routine traditional water balloon is generally chosen (figure 8.22), or the technique of endoscopic radial incision (figure 8.23), so as observe and assess whether there is a risk of delayed perforation and hemorrhage from the wounds.

FIG. 8.22 — A. Stenosis diameter about 2 mm. B. Use of traditional EBD to dilate.

FIG. 8.23 — Operating steps of super minimally invasive dilation of esophageal stenosis. A. Stenosis diameter of about 3 mm. B. Endoscopic radial incision.

(2) Place in the balloon: the placement method is similar to that of the gastric retention tube, using liquid paraffin to lubricate the balloon, which must be slowly inserted along the selected nostril, asking the patient to make a swallowing movement. The balloon’s position must be adjusted under endoscopic observation, so as to ensure that the balloon is located in the middle part of the stenosis (figure 8.24A).

.

(3) Fixing the balloon: the balloon must be attached to the side of the patient’s nose and the attachment place recorded (figure 8.24B). Refer to video 8.7, Super minimally invasive prevention and treatment of peroral esophageal stenosis (See online resources).

FIG. 8.24 — Operating steps of the super mini-invasive implantation of a self-expanding balloon for the treatment of esophagal stenosis. A. Endoscopy-assisted insertion of a self-dilating balloon. B. External fixation of the balloon.

After full preoperative evaluation, the patient was explained the benefits and risks of the various treatment methods of refractory stenosis available currently. The patient chose the external self-dilating balloon method. After signing the surgery informed consent form, after performing endoscopic traditional balloon dilation on the patient, the self-dilating balloon was inserted to prevent esophageal stenosis (figure 8.25).

FIG. 8.25 — Treatment of refractory esophageal stenosis by using a self-dilating balloon. A. The diameter is less than 1 mm at the narrowest at the esophageal stenosis. B. When inserting the self-dilating balloon, the stenosis diameter is of about 3 mm. C. After using traditional EBD therapy, the self-dilating balloon is inserted. D–F. When rechecking 20 days, two months, three months after the operation, the standard endoscope passed smoothly, whereas a shallow ulceration formation was found locally. G. After taking out the balloon four months after the operation, the wound was basically cured. H. At the eighth month after the operation, no stenosis formation was found.

8.5　Super Minimally Invasive Surgery for Gastroesophageal Reflux Disease

8.5.1　Introduction

8.5.2　Peroral Super Minimally Invasive Radiofrequency Ablation to Cure Gastroesophageal Reflux Disease

6) The above steps are repeated to carry out the ablation again.

FIG. 8.26 — Schematic diagram of peroral super minimally invasive radiofrequency ablation for gastroesophageal reflux disease. A. Observe the site of gastroesophageal junction. B. Insert the measuring balloon catheter by guide wire. C. Insert the balloon ablation catheter. D. Conduct the radiofrequency therapy after balloon inflation. E. Treatment by points. F. Withdraw the guide wire after treatment. Pictures come from Internet: Methods of endoscopic therapy of gastroesophageal reflux disease _Stretta (sohu.com).

(2) For patients with postoperative pain, 500–1000 mg of paracetamol can be given according to needs, not exceeding four times each day. For patients whose pain is not relieved by paracetamol, 50 mg of diclofenac can be added, without exceeding twice each day. If the occurrence of other serious complications is suspected, related examinations should be performed timely (e.g., emergency gastroscope, X-ray filming or CT).

FIG. 8.27 — Images of peroral super minimally invasive radiofrequency ablation for gastroesophageal reflux disease. A, B. Endoscopic radiofrequency therapy under direct vision. C. After endoscopic radiofrequency therapy under direct vision. D. Endoscopic image after traditional non-direct radiofrequency therapy.

8.5.3　Peroral Incisionless Fundoplication for Gastroesophageal Reflux Disease

2. TIF’s long-term effect is still not validated. Currently, most of the research results on TIF are compared with data relating to PPI treatment, and comparative studies with gold standard laparoscopic Nissen fundoplication and long-term follow-up studies with large samples are still lacking. A clinical study of 151 TIF2.0 patients who underwent nine years of postoperative follow-up showed that GERD symptoms had been continuously alleviated, with 69%–80% of patients having reduced their treatment and proton pump inhibitor intake.

FIG. 8.28 — Peroral incisionless fundoplication (TIF). The gastroscope is inverted to observe the valves at the gastroesophageal junction. B. Fundoplication by using the TIF device. D. Gastroesophageal valves after TIF reconstruction.

8.5.4　Peroral Super Minimally Invasive Mucosa Resection for Gastroesophageal Reflux Disease

(3) The endoscope must be inverted, and EMR or ESD be performed along the lesser curvature of the cardia, the mucosa must be incised in a crescent shape over 1/2–3/4 of the circumference, with the cardiac valves on the side of the greater curvature of the cardia being preserved. The length of the incision is approximately 3 cm, with the EGJ as the limit, including the esophageal side (1 cm) and the gastric side (2 cm).

FIG. 8.29 — Peroral super minimally invasive mucosa resection for gastroesophageal reflux disease. A1, A2. ARMS preoperative endoscopic images. B1, B2. ARMS postoperative endoscopic images.

8.5.5　Clip Band Ligation Anti-Reflux Therapy for Gastroesophageal Reflux Disease

2. Operating steps (figure 8.30)

FIG. 8.30 — Schematic diagram of super minimally C-BLART. A. Cardia’s relaxing state before operation. B. The ligation ring is released to contract the cardiac mucosa. C. Clips are used to fix the root of the elevated mucosa. D. Postoperative constriction of the cardia.

(2) Root fixation: disposable metal soft tissue clips must be fixed at the root of the ligation ring (figure 8.32).

FIG. 8.31 — Sucking and ligation steps of peroral super minimally invasive cardiac constriction for gastroesophageal reflux disease. A. Cardia’s relaxing state before operation; B. Hiatal hernia at the cardia (inverted view); C. The ligation ring is released to contract the cardiac mucosa.

The patient should fast for food and water for three days, be given treatments like acid suppression, fluid supplement, nutrition support, etc.; then he/she must follow a gradual transition diet: liquid diet → semiliquid diet → full diet, eat liquid food for one week; postoperatively, continue to take oral PPIs for 14 days; avoid spicy foods for one month after the operation.

FIG. 8.32 — Root fixation steps of peroral super minimally invasive cardiac constriction for gastroesophageal reflux disease. A. Ready-to-release clips. B. Clips fixing the root of the elevating mucosa. C. Two clips placed at the level of the cardia.

After full preoperative evaluation and having signed the surgery informed consent form, the patient has undergone C-BLART therapy (Refer to video 8.8, Super minimally invasive cardiac constriction for gastroesophageal reflux disease: Cardiac orifice narrowing via Band Ligation and Additional Reinforcement Techniques (See online resources)).

.

8.6　Super Minimally Invasive Peroral Myotomy of Esophageal Diverticula

8.6.1　Diagnosis of Esophageal Diverticula

8.6.2　STESD’s Indication and Contraindication

8.6.3　Preoperative Preparation

(1) Establishment of the tunnel entrance (figure 8.33): a submucosal injection is conducted at 3 cm above the diverticular septum; the tunnel entrance is established by incising the mucosal layer and exposing the submucosal layer.

FIG. 8.33 — The steps for establishing the tunnel entrance in peroral super minimally invasive myotomy for esophageal diverticulum. A. Fluid retention observed in a lower esophageal diverticulum. B. Esophageal diverticulum found by contrast. C. Submucosal injection was performed 3cm above the diverticulum; D. Creation of the tunnel entrance by an inverted T-shape incision.

(3) Transverse ridge (figure 8.35): interdiverticular ridges are completed and exposed, the muscle layer is crossed endoscopically to the diverticular base in the middle of the ridges using a knife.

FIG. 8.34 — In-tunnel dissecting steps of peroral super minimally invasive myotomy of an esophageal diverticulum. A. The tunnel is entered by the cap against the mucosal valves along the incision. B. Dissection near the intrinsic muscle layer inside the tunnel. C. Electrocoagulation hemostasis of the thicker vessels. D. Exposed interdiverticular ridges.

(4) The mucosa is incised with metal clamps: once the liquids in the ‘tunnel’ and the esophageal lumen have been completely sucked, the wounds must be rinsed, bleeding spots and small vessels must be electrocoagulated, and the surface mucosa of the ‘tunnel’ must be checked. The endoscope musty be withdrawn through the tunnel’s opening, and the “tunnel entrance” must be occluded by metal clips. After the operation, the dilated esophageal lumen appears without interdiverticular ridges.

FIG. 8.35 — Steps of muscle layer incision in peroral super minimally invasive myotomy for an esophageal diverticulum. A. The mucosa is separated at both ends, the diverticular ridge is exposed. B. Transverse incision made at the esophageal ridge. C. The incised diverticular ridge. D. Closed tunnel entrance.

After full preoperative evaluation, improving nutrition state and signing the surgery informed consent form, the patient was performed peroral endoscopic super minimally invasive myotomy for Zenker’s diverticulum (Refer to video 8.9, Per-tunnel super minimally invasive myotomy for esophageal Zenker’s diverticulum (See online resources)).

.

After full preoperative evaluation and signing the surgery informed consent form, the patient was performed achalasia POEM surgery and STESD surgical therapy for giant esophageal diverticulum (Refer to video 8.10, Per-tunnel super minimally invasive myotomy for lower esophageal diverticulum (See online resources)).

.

8.7　Super Minimally Myotomy for Achalasia

8.7.1　Introduction

8.7.2　Per-Tunnel Super Minimally Myotomy for Achalasia

3) Creation of the submucosal tunnel: an injection should be made from top to bottom while dissecting the submucosal layer, form a tunnel space, dissect below 2–3 cm of the EGJ. The width of the tunnel must be fully widened to prevent the tunnel from ‘deflecting.’ Vascular bleeding or mucosal defect must be timely treated if any (figure 8.37).

FIG. 8.36 — Steps for building the tunnel entrance in per-tunnel super minimally myotomy for achalasia. A. Endoscopic preventricular stenosis of a patient with achalasia patient. B. A submucosal injection above the stenosis. C. Creation of a tunnel opening with a triangle knife. D. Longitudinal incision to establish a tunnel opening.

FIG. 8.37 — Steps for establishing a submucosal tunnel in per-tunnel super minimally myotomy for achalasia. A. Dissection along the submucosal layer after entering the tunnel. B. Dissection along the submucosal layer near the cardia. C. The establishment of the tunnel is completed. D. Circular muscle layer incision.

5) Closure of the wound: Adequate hemostasis of potential bleeding spots and small vessels must be carried out from the anal to the oral side of the tunnel. After sucking the gas and liquids in the tunnel completely, wounds will be closed from the anal side to the oral side successively by using soft tissue clips (figure 8.38).

FIG. 8.38 — Steps of myotomy and tunnel opening and closure in per-tunnel super minimally myotomy for achalasia. A. The incision is continued until 2 cm below the cardia. B. Endoscopy exits the tunnel and enters the gastric cavity smoothly through the esophagus. C. The tunnel opening is closed. D. Completion of the closure of the tunnel opening.

2) Creation of the tunnel: one should try as much as possible to separate and extend the submucosal tunnel to the site where the serious submucosal layer attaches. At this time the tunnel does not arrive 2 cm below the cardia (figure 8.39).

FIG. 8.39 — Steps of creation of a tunnel in per-tunnel super minimally myotomy for achalasia. A. Creation of the opening of an inverted T-shaped tunnel; B. Digging into the submucosal layer to dissect. C. Bare vessels and hemostasis. D. Supplementary injection at the serous adhesion site of the original surgical site.

4) Hemostasis in the tunnel and closure of the entrance: hemostasis is completed with a hemostat, the endoscope can easily pass the cardia, and then the tunnel’s opening is closed with metal clips (figure 8.40).

FIG. 8.40 — Steps of muscle layer incision and closure of the tunnel entrance in per-tunnel super minimally myotomy for achalasia. A. Separation along the serous adhesion area and superficial dissection at the level of the serous adhesion area of the original operation. B. Circular incision in the muscle. C. Full-thickness incision until the tunnel’s end. D. Closure of the tunnel entrance.

Refer to video 8.11, Per-tunnel super minimally myotomy for achalasia-1 (See online resources).

.

After full preoperative evaluation, improving nutrition condition and signing the surgery informed consent form, the patient was performed achalasia POEM surgery (Refer to video 8.12, Per-tunnel super minimally myotomy for achalasia-2 (See online resources)).

.

References