Summary
Novel techniques to minimize the risk of intraoperative bleeding during ESD of large rectal LSTs that extend to the dentate line with large internal hemorrhoids are described. First, the retroflex view approach enables dissection of the SM layer from the proximal tumor margin, avoiding contact with hemorrhoids. A differential level of SM dissection prevents inadvertent bleeding—shallow first to avoid large SM vessels, and then deeper above the muscular layer at the end to shut off blood supply to hemorrhoids by penetrating hemorrhoidal vessels. Last, we used a selective approach to vessels, with direct coagulation using the IT-nano for small vessels and with lateral exposure, posterior blunt dissection, double-vessel sealing, and transection between sealed segments for larger vessels