Endoscopic Mucosal Resection (EMR) and Endoscopic Submucosal Dissection (ESD)
Like gastroscopy and colonoscopy, endoscopy can be used as an endoscopic imaging system as well as for surgery. For example, if the depth of tumor invasion does not exceed the submucosa, and patients do not have lymph node metastasis, partial excision can be performed by endoscopy to eliminate the pain associated with traditional surgery. Endoscopy can also be applied to endoscopic surgery biopsy interpretation, which is divided to endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) according to the depth of the excision.
Since 1983, when Japanese physician Masahiro Tada reported the first successful case of endoscopic resection of early gastric cancer, the endoscope has been widely used for more than twenty years. Chromoendoscopy, magnified endoscopy, and narrow band imaging (NBI) make it possible to determine whether endoscopic submucosal dissection is suitable for the treatment of tumors. This involves separating the tumor from the submucosa using a variety of endoscopic knives (such as needle knife, IT knife, IT2 knife, hook knife, dual knife, and flex knife), and then stopping the bleeding using an electrosurgical unit. Finally, the excised specimen is sent to pathologists for analysis.
Endoscopic Radiofrequency Ablation (ERFA)
Partial or cyclic radiofrequency ablation can be performed under endoscopic guidance to treat mucosal lesions, such as esophageal squamous cell neoplasm (ESCN) or Barrett's esophagus. Endoscopic radiofrequency ablation (ERFA) is an efficient treatment for early cancer and precancerous lesions, for which the patient under conscious sedation. Doctors use ablation catheters of various sizes and diameters and the operations are usually brief, thereby reducing pain and trauma. ERFA is safer than EMR and involves fewer complications (less than 0.22%).
The physician first uses endoscopy to locate anatomical landmarks. Based on previous test results, the physician then identifies markers and the therapeutic range, and measures the diameter of the esophagus and the length of lesions. The ablation catheter is inserted into the near edge of the target tissue through the pipeline of the endoscope. The ablation catheter then delivers ablation energy and moves to the distal end of the lesion to complete the treatment. Lugol's iodine solution (1.25%) is then applied to determine the scope of the treatment.
Laparoscopic Surgery
Laparoscopic surgery involves the insertion of cannula into one or multiple 0.5~1.5 cm incisions. Various instruments and/or a laparoscopic imaging lens is then passed through the cannula into the abdominal cavity to perform surgery. In the beginning of laparoscopic surgery, insufflation of carbon dioxide (CO2) into the peritoneal cavity produces a pneumoperitoneum that provides a space for surgeons to operate and observe. A laparoscopic video camera transmits images to a high-resolution display in the operating room during surgery, thereby enabling the surgeons to perform the same functions as traditional surgery but with a smaller surgical wound.
Several scarless abdominal laparoscopic surgical techniques have been developed. These include natural orifice transluminal endoscopic surgery (NOTES), which can be performed by passing an endoscope through a natural orifice (mouth, anus or vagina); single incision laparoscopic surgery (SILS, SPA or LESS), in which an endoscope passes through the navel; and the robot-assisted minimally invasive surgery like the da Vinci robotic surgical system that allows surgeons to perform many traditional laparoscopic surgical procedures through a small incision.
Video-Assisted Thoracic Surgery (VATS)
The same principle can be used for surgery in other body cavities, such as thoracoscopy and arthroscopy. The thoracic cavity is supported by the rib cage, thereby avoiding the need for carbon dioxide insufflation commonly used in laparoscopic surgery. Through the use of special anesthesia and one-lung ventilation, surgeons are able to make sufficient space for the operation to proceed and most specimens can be obtained through small cuts. These operations also produce small wounds (1-2 cm each wound, about 3-4 wounds), which enables quick recovery, and largely overcomes the problems associated with caring for post-surgical wounds, thereby shortening hospital stays to 3-5 days.
Endoscopic Surgical Robotic System
The da Vinci surgical robotic system uses 3D high-resolution video images, surgical instruments mimicking human joints, and a precise control system to reduce manpower and enhance the precision of complex operations. This method has been used widely in urology, gynecology, general surgery, colorectal surgery, cardiac surgery, thoracic surgery, otolaryngology-head and neck surgery, and other related operations. Traditional 2D laparoscopic surgery is unable to determine the depth of surgical position; however, robotic surgical systems feature 3D high-definition imaging that makes it possible to enlarge the field of view 10-fold to focus on important nerves, blood vessels, tissues, and organs, thereby reducing the associated risks. These devices can also be used for suturing during surgery.