Sequenzen:
![Lesion evaluation](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-1-1.png)
Before starting any endoscopical procedure, in particular an endoscopic submucosal dissection, a proper and extensive evaluation of the lesion must be accomplished.
![Submucosal injection](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-2.png)
An osmotic agent is injected in the submucosal space outside the lesion margins. We prefer using a Voluven® based solution with indigo carmine and adrenaline, because it lasts more than saline but is less expensive than sodium hyaluronate.
![Mucotomy](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-3.png)
After completing the submucosal space injection, the needle is exchanged for an endoscopic knife. In this case we used a ball tip shaped one with the ability to inject the previously described solution.
![Submucosal dissection](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-4.png)
Submucosal dissection is carried out using the traction provided with the distal attachment.
![Rectal ulcer evaluation](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-5.png)
A thorough evaluation of the ulcer is performed to detect muscle layer defects that may require clipping or vessels which should be coagulated.
![Specimen extension](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-6.png)
Tissue extension of the lesion prevents shrinking and allows a proper pathological assessment in order to evaluate margins and subsequently determine the curative role of the procedure.