Post written by Felipe Ramos-Zabala, MD, PhD, from the Department of Gastroenterology, HM Montepríncipe University Hospital, HM Hospitales Group, and the Department of Clinical Sciences, School of Medicine, University of CEU San Pablo, Boadilla del Monte, Madrid, Spain.

In this video case report, we present a patient who was diagnosed with a subtle Paris 0-IIb lesion in the distal rectum, abutting the dentate line. Endoscopic submucosal dissection (ESD) of rectal lesions extending to the dentate line is technically challenging.

The patient was evaluated in a multidisciplinary team meeting, and it was decided to adopt an endoscopic approach due to the experience of the center in ESD and due to lesion characteristics. The lesion was very difficult to visualize due to the fact that it was a very subtle and flat. Surgeons preferred endoscopic treatment as the first option because of the limited field of view to identify the adenoma margins.

We performed a hydrodissection with a T-type hybrid knife in immersion assisted by using hemostatic forceps, in combination with an outside traction method. The post-procedural recovery was uneventful, and the patient was discharged from the hospital 24 hours after the endoscopic procedure.

Our video demonstrates relevant aspects in the endoscopic approach of polyps close to the dentate line. This case underscores the importance of a safe resection within a vascular area. Hybrid knife probe mode facilitated the progressive and safe cut in the submucosal plane. The hemostatic forceps were used to preemptively coagulate prominent blood vessels in the anal canal and submucosal space.

The second point we want to highlight is the use of the immersion technique, which enhances the magnification during dissection. This facilitates traction by flotation of the lesion and may minimize thermal damage to the muscle layer through a heat-sink effect.

The third point we would like to highlight in this video case report is the use of a combination of the standard hybrid type knife in combination with the hemostatic forceps to perform the dissection. Using coagulation forceps as a cutting knife within a vascular area is a very important technique. Preventing bleeding with the hemostasis forceps is a key step, but using the same forceps to cut can provide us with a faster and more effective response when unexpected bleeding is encountered. In addition, the forceps grip creates traction, enabling a safe cut. Using a horizontal approach to minimize thermal damage to the muscular layer was necessary.

The last point we would like to highlight in this video case report is that once the majority of the lesion was dissected we used surgical forceps for counter-traction (“transanal-traction” method). We were able to pull the lesion out of the anal canal and then continue with dissection in the submucosal space. Ensuring dynamic traction to maintain tension in the fibrous vascular tract of the submucosa and separating it from hemorrhoids is important.

This report illustrates the difficulty of performing dissection in the area of the dentate line and demonstrates that the hemostatic forceps used as a scissor-type knife can be an alternative in difficult situations. Furthermore, the immersion technique and the transanal-traction method can be simple and useful to assist in anorectal ESD.

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