Essential Techniques for Hemostasis, Closure & Traction (And the Single-Use Scope Advantage)
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Endoscopic Submucosal Dissection (ESD) has become the first-line minimally invasive treatment for precancerous and early cancerous lesions of the digestive tract. Throughout the entire ESD procedure, one tiny tool plays an outsized role: the metal clip. It stops bleeding, closes perforations, marks lesion boundaries, and enables tissue traction. Mastering these four applications can dramatically improve surgical efficiency and patient safety.
01: Hemostasis—Stopping the Bleed, Fast
With continuous endoscopy innovation, direct-vision metal clip application has significantly improved the safety and success rate of GI bleeding management. For both intraoperative and postoperative ESD bleeding, metal clips offer a highly effective mechanical solution.
The mechanism mirrors surgical ligation: the clip's mechanical force ligates the bleeding vessel together with surrounding tissue, physically blocking blood flow. The key is accurately grasping the bleeding vessel stump.
During ESD, transection of submucosal vessels is inevitable. Blood pooling obscures the field; delayed bleeding from clot sloughing or inflammation can strike postoperatively. For pulsatile arterial bleeding, large venous oozing, or bleeding from a site where electrocautery risks delayed perforation, metal clips should be your first choice.
Step-by-Step Technique:
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Irrigate the wound with saline to clear the field and locate the bleeding point.
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Load the clip onto the handle, advance through the channel, and expose the clip tip.
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Open the clip to maximum angle, align it perpendicular to the bleeding site (90° is ideal for maximum grip).
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Press both prongs firmly against the mucosa on either side of the vessel, then tighten.
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A distinct "click" confirms closure. Withdraw the applicator.
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Place additional clips as needed based on hemostasis assessment (Fig. 1). A rigid, immobile clip indicates secure anchorage.
Critical Caveats:
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Don't over-clip before lesion removal. Excessive clips early in the procedure reduce working space.
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Perpendicular contact (90°) is most secure. Deploy with both prongs pressing evenly into the mucosa.
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If the field is obscured by active bleeding, irrigate and suction, then place clips on suspected sites. If the view clears after placement, you've partially or fully captured the vessel.
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The first clip matters most. A poorly placed first clip occupies prime real estate and complicates subsequent attempts.
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Post-clip oozing between clip prongs can be managed with sclerosing agent injection.
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Clips can dislodge, so monitor for delayed rebleeding.
02: Tissue Closure—Managing Perforation
Perforation is the complication that keeps endoscopists awake at night. Because the GI wall—especially the colon's muscularis propria—is thin, ESD dissection can easily breach the muscle layer. Timely clip application can close small perforations endoscopically, preventing peritoneal leakage and avoiding emergency surgery.
When to Clip:
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Small perforations where the muscularis is breached but the serosa remains intact.
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Suspicious thinning after excessive coagulation or APC, where delayed perforation is a risk (Fig. 2).
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Key Principle: Never clip directly onto a perforation hole or paper-thin tissue—this may enlarge the tear. Instead, grasp healthy, viable tissue on either side. Align the clip arms perpendicular to the tear's long axis.
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For larger defects: Start from the edges and progressively approximate the tissue, "zippering" the defect closed (Fig. 3).
2025 Guidelines Snapshot (Gastric ESD Perioperative Management):
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Perforation ≤1 cm: Metal clips through the scope channel achieve >99% closure success.
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Perforation 1–3 cm: Consider Over-the-Scope Clip (OTSC).
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Perforation >3 cm: Omental patching—use clips to anchor suctioned omentum to the wound edges.
Post-closure management requires fasting, GI decompression, antibiotics, and nutritional support. If closure fails clinically, prompt surgical evaluation is mandatory.
03: Radiographic Marking—Guiding the Surgeon
Metal clips are visible under X-ray. In ESD, they can delineate lesion margins for subsequent dissection. When ESD cannot achieve complete resection and surgical backup is required, placing one or two clips at the lesion site provides a crucial radiographic beacon for laparoscopic or open exploration.
04: Tissue Traction—Exposing the Submucosa
Traction techniques using metal clips revolutionize ESD by exposing the submucosal layer, significantly improving speed and safety. Two dominant approaches exist:
1. Clip-with-Line Traction (Fig. 4)
Ideal for esophageal, gastric, and colorectal ESD.
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After circumferential mucosal incision, withdraw the scope.
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Attach a long thread (e.g., dental floss) to one arm of a metal clip. Retract the loaded clip into the applicator sheath.
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Re-insert the scope, grasp the mucosal edge with the tethered clip.
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The free end of the line remains outside the patient; gentle external traction exposes the dissection plane.
Pro Tips:
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Ensure the clip assembly is fully sheathed during insertion to prevent mucosal injury.
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Secure the line tightly to the clip arm.
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Avoid traction during scope advancement to prevent premature dislodgement.
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Use moderate traction force—too much will pull the clip off.
2. Clip-and-Snare Traction ("Yo-Yo Technique," Fig. 5-7)
First described by Baldaque-Silva et al. in 2012, this method uses a snare anchored by clips to deliver dynamic, multi-point traction. The 2018 multi-point fixation variant by Zhang et al. allows simultaneous traction at multiple mucosal edges, further accelerating dissection.
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Suited for large lesions in the esophagus, stomach, and colon.
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Transforms single-point traction into distributed, multi-vector exposure.
The Equipment Factor: Why Your Scope Choice Matters
These advanced ESD techniques demand an endoscope that delivers: crisp optics for pinpoint clip placement, reliable channel function for clip deployment, and consistent maneuverability for complex traction maneuvers. Reusable endoscopes degrade over repeated sterilization cycles, and a compromised scope in the middle of a bleeding perforation case is a risk no team should face.
As a platform connecting global buyers directly with Chinese source factories, we specialize in soft, single-use flexible endoscopes that offer:
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Pristine Image Quality Every Case: No accumulated fiber damage.
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Zero Cross-Contamination Risk: Pre-sterilized, single-patient use.
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Uninterrupted Workflow: No reprocessing downtime between cases.
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Predictable Economics: Fixed per-procedure cost, ideal for high-volume centers.
Master the techniques. Elevate your outcomes. Browse our catalog of single-use endoscopy solutions, sourced directly from verified Chinese manufacturers, designed for the demands of modern ESD.