Post written by Zaheer Nabi, MD, DNB, FASGE, FISG, FSGEI, from the Asian Institute of Gastroenterology, Hyderabad, India.

This video presents a series of coagulation forceps-sparing techniques used during third-space endoscopy, including peroral endoscopic myotomy. Using various electrosurgical knife-based and bipolar coagulation methods, we demonstrate how large blood vessels encountered during submucosal dissection can be safely and effectively sealed without requiring instrument exchange for coagulation forceps. Techniques include noncontact coagulation, saline immersion coagulation, contact coagulation with reduced energy settings, use of retracted knife tips, microwave-based bipolar coagulation, and application of self-assembling peptide gel.

Instrument exchange for coagulation forceps can interrupt procedural flow and increase cost and duration, particularly with third-space procedures. We aimed to highlight practical, reproducible alternatives that improve workflow efficiency, reduce accessory dependence, and potentially enhance safety. By sharing these techniques, we hope to encourage wider adoption of coagulation forceps-sparing strategies in therapeutic endoscopy.

Endoscopists can learn how to leverage electrosurgical settings, environmental modifications (eg, saline immersion), and anatomical precision to achieve effective vessel sealing without defaulting to forceps. This knowledge may help optimize procedural efficiency, minimize risk of delayed perforation from deep thermal injury, and facilitate a more cost-effective approach to third-space endoscopy.

This video review underscores the value of integrating electrosurgical physics into procedural decision-making. As endoscopic tools evolve, mastering multifunctional use of existing instruments—such as the endoscopic dissection knife—can significantly streamline complex procedures. Future comparative studies are warranted to validate these approaches in broader clinical settings.

Conceptual image depicting the effect of slow coagulation under different environment and using modified setting.

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