Sequenzen:
![Endoscopic 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.
![Marking](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-2.png)
After the lesion limits are clearly identified, marking is made with a ball tip shaped knife applying soft coagulation to the mucosa. It should be performed 2-3 mm away from the lesion to provide a safety margin.
![Submucosal injection](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-3.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-4.png)
Our group supports a complete circumferential mucotomy before starting the submucosal dissection.
![Submucosal dissection](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-5.png)
Submucosal dissection is carried out using the traction provided with the distal attachment. In this particular location, the dissection combines retroflex and forward view scope positions to achieve an en-bloc resection.
![Specimen extraction and extension](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-6.png)
Once the dissection is completed, the resected specimen can be retrieved with a Roth net and then extended to allow proper pathological assessment and subsequently determine the curative role of the procedure.
![Ulcer evaluation](https://www.endoscopy-campus.com/wp-content/uploads/Sequenz-7.png)
A thorough evaluation of the ulcer is performed to detect muscle layer defects that may require clipping or vessels which should be coagulated.