ESD Brochure (PDF 881.5 KB) - ERBE Elektromedizin GmbH

E L E C T R O S U R G E R G Y / W A T E R J E T S U R G E R Y 

E S D W o r k s t a t i o n w i t h H y b r i d K n i f e 

Endoscopic Submucosal Dissec tion – 

fast, safe and easy with the HybridKnife.

introduction 

ERBE TechnOLOgy 

Endoscopic submucosal resection spares the patient 

open surgery and with it possible intra- and postoperative 

complications. Using the EMR (endoscopic 

mucosal resection) and the ESD (endoscopic submucosal 

dissection) methods, such minimally invasive 

interventions have found application for the treatment 

of early carcinomas, adenomas and lesions in 

the gastrointestinal tract in general for some years. 

ERBE Elektromedizin has advanced the development 

of this precise ESD method in collaboration with 

leading Japanese and European experts. Safety aspects 

have been improved considerably, the surgical 

procedure has been simplified, and operating times 

have been reduced. 

Internationally renowned gastroenterologists already 

work using this method. More and more users 

convinced of its merits will adopt it, applying it for 

lesions of the stomach and increasingly also of the 

colon and the esophagus. 

With its VIO GI workstation, Erbe Elektromedizin 

has established itself in the field of gastroenterology 

worldwide and has many years of profound know 

how in interventional endoscopy. 

The system consists of the VIO electrosurgical unit, 

which acts as the master module, as well as an Argon 

Plasma Coagulation unit for devitalizing gastrointestinal 

structures and coagulating diffuse bleeding. 

The ERBEJET 2 waterjet surgical unit is a new, additional 

system component for ESD. 

Both technologies, electrosurgery and waterjet surgery, 

are activated and applied using the ERBE HybridKnife as 

a combination instrument. For the first time, all working 

steps involved in the ESD procedure can be performed 

with just one instrument: marking of the resection margin, 

elevation of the mucosa, incision/dissection of the submucosa 

and coagulation of the resection bed. 

In this brochure we wish to demonstrate to you the 

advantages of the ESD method using the Hybrid- 

Knife, describe the steps involved in the procedure, 

and provide you with additional information and 

useful adviced. 

Medical progress never stands still. Thus we not only 

aim to provide what is currently the most effective, 

state-of-the-art procedure for endoscopic resection. 

We will continue to keep abreast of clinical insights 

and incorporate them into our research and development 

so that you obtain even better results in the 

treatment of your patients in the future. 

Important note 

ERBE Elektromedizin GmbH has taken the greatest possible 

care when compiling these recommendations. 

Nevertheless, it is impossible to exclude the possibility 

that errors may be contained herein. The information 

and recommendations given here may not be construed 

as constituting any basis for any claims against ERBE 

Elektromedizin GmbH. Should legal regulations stipulate 

liability, such liability shall be limited to intentional 

misconduct or gross negligence. 

The data respecting recommended settings, areas of 

application, application duration or the use of instruments 

is based on clinical experience, although it is 

important to remember that individual centers and 

physicians may favor settings which differ from the recommended 

settings given here. All values are merely 

guidelines and their applicability must be verified by the 

operator. Depending on the circumstances, it may be 

necessary to deviate from the values and settings given 

in this brochure. 

Medical science is subject to a process of permanent 

change based on research and clinical experience. It 

may therefore also be appropriate to deviate from the 

values and settings given in this brochure on the basis 

of the results of such research and experience. 

02 HybridKnife

ERBE VIO electrosurgical unit 

ENDO CUT Q 

This electrosurgical unit provides the cutting and coagulation 

modes necessary to obtain the tissue effects 

required for ESD and EMR. 

ENDO CUT Q 

DRY CUT 

FORCED COAG 

The ENDO CUT Q fractionated cutting mode with alternating 

cutting and coagulating cycles was specifically developed 

for endoscopic interventions. The ENDO CUT Q 

is employed for snare ablation as well as circular incision 

and resection of lesions using an electrosurgical cutting 

electrode. 

The voltage and arc regulation which the VIO generator 

technology features allow for high quality and reproducible 

cutting effects. During the entire cutting process, 

controlled cutting and reliable hemostasis as well as low 

risk of perforation are ensured. The principle – as much 

coagulation as necessary (prevention of bleeding), as little 

as possible (prevention of perforation). 

U 

Voltage 

Figure 1: 

GI workstation: VIO 200 D electrosurgical 

unit, APC 2 Argon Plasma 

Coagulation unit, ERBEJET 2 waterjet 

surgical unit and EIP 2 endoscopic 

irrigation pump 

Coagulation cycle 

Cutting cycle 

t 

Time 

Figure 2: 

ENDO CUT Q fractionated cut 

The alternating cutting and coagulation cycles which 

characterize ENDO CUT Q can be varied dependent on 

size, shape and localization of the lesion in question – in 

terms of levels of effect, cutting duration and cutting interval. 

(For more detailed information on ENDO CUT Q 

consult ERBE brochure no. 85800-117.) 

HybridKnife 

03

DRY CUT 

ERBEJET 2 waterjet surgical unit 

This mode provides a cut with high coagulation effect and 

ensures reliable hemostasis even when relatively large 

blood vessels are involved. Reproducible effects with 

low degree of smoke plume formation can be obtained 

through voltage regulation. 

In numerous disciplines, waterjet surgery has clear 

advantages over alternative surgical procedures. Its 

classic application is hepatic surgery. ERBE has gathered 

many years of experience with this technology 

– in other surgical disciplines as well. 

Figure 1: 

Marking of the lesion margin 

Figure 3: 

Layer-specific elevation of the mucosa 

using the waterjet 

FORCED COAG 

Marking of the lesion is carried out using FORCED COAG. 

During resection, bleeding can be coagulated using the 

FORCED COAG mode and also any necessary post-coagulation 

of the resection bed. 

APC 2 Argon Plasma Coagulation 

Apart from classic electrosurgical modes, another GI module, 

the APC 2 Argon Plasma Coagulation unit, provides 

safe methods for marking the lesion margins and can also be 

used for hemostasis during and after the resection process. 

The APC 2 unit enables non-contact coagulation; thus 

there is no risk of tissue adhesion. Coagulation depth is limited, 

controlled and homogenous. This almost completely 

rules out any risk of perforation. The resection bed can be 

coagulated with the APC completely and homogenously. 

The waterjet pressure can be adjusted from effect 1 to effect 

80 (this corresponds approximately to 1-80 bar). For 

gastroenterology applications, an effect between 10 and 

50 should be selected for the specific organ in question. 

Please consult the table on page 10 for precise setting recommendations. 

At low effect settings blood vessels and 

nerves are spared, as are adjacent tissue structures and organs, 

for the waterjet procedure works tissue-selectively 

without producing any thermal effects. 

These very features are what makes waterjet technology 

ideally suited for mucosal elevation before endoscopic resection: 

the selective waterjet penetrates the mucosa and 

separates the tissue layers without use of needles while 

respecting anatomical layers. The separation medium accumulates 

in the submucosa located beneath the mucosa, 

forming a fluid cushion between the mucosa and the muscularis. 

The mucosa with the infiltrated lesion is elevated 

and can be resected without the muscularis being injured. 

For further information on waterjet surgery, argon plasma 

coagulation and the endoscopic irrigation pump please go 

to www.erbe-med.com or consult individual brochures. 

Figure 2: 

Surface coagulation with APC 2 

04 HybridKnife

HybridKnife 

The flexible, multi-function probe combines both technologies, 

electrosurgery and waterjet surgery, in one 

instrument. The four working steps – marking, elevation, 

incision/dissection and coagulation – require no change 

of instrument. 

The variably adjustable tip of the HybridKnife has a diameter 

of 0.7 mm and a micro-capillary. 

For the various segments of the gastrointestinal 

tract we recommend using needles in the following 

lengths: 

Figure 3: 

Needleless elevation of mucosa 

using the HybridKnife 

Stomach, approx. 3 mm 

Colon, approx. 1.5 mm 

Esophagus, approx. 2 mm 

The probe has an overall length of 190 cm; its external 

diameter of 2.3 mm makes it suitable for use with any 

standard endoscope. 

Needleless waterjet elevation raises the mucosa particularly 

quickly and it creates a considerably larger fluid cushion 

than one created by conventional needle injection. 

Figure 4: 

HybridKnife, I-type 

Figure 5: 

HybridKnife, T-type 

Figure 1: 

Elevation using waterjet function 

Figure 6: 

HybridKnife, O-type 

Figure 2: 

Marking, incision/dissection and coagulation using the electrosurgical 

electrode tip which varies in length and finds versatile application in 

the esophagus, stomach and colon 

HybridKnife 

05

PROCEDURE 

Figures 1+2: 

Piecemeal method used in EMR for 

relatively large lesions 

EMR and ESD are interventional procedures for 

treating early carcinomas and lesions which potentially 

constitute focal carcinomas. The prerequisite 

for a curative approach is complete resection of the 

lesion (R0 resection). 

Limits of EMR 

Using the EMR method, only lesions measuring up to 2 cm 

can be removed en bloc. For lesions with a diameter of 

more than 2 cm, only successive partial resection (piecemeal 

method) is possible using the EMR method. The disadvantage 

is that EMR harbors the risk of lesions larger 

than 2 cm in diameter not being ablated completely with 

a safe resection margin and carcinogenic cells remaining 

in the mucosa. 

When ESD is used, the lesion can be resected en bloc 

with a safe resection margin. From this perspective it is 

plausible that in the case of EMR, the recurrence rate is 

much higher than for the more precise but more difficult 

to learn ESD method. 

Figures 3+4: 

Complete resection of lesion using 

ESD with R0 approach 

ESD method using the HybridKnife 

The advantages of the ESD method developed by ERBE 

derive from synergetic utilization of waterjet technology 

in connection with electrosurgery. 

The individual working steps – marking, elevation, incision/dissection 

and coagulation – can be performed with 

the multi-function HybridKnife without change of instrument 

while achieving the highest possible degree of 

safety. 

06 HybridKnife

The working steps 

Figure 1: 

Marking 

Step 1: Marking 

Before elevation, the lateral safety margin is marked with 

coagulation points at smallest possible intervals with the 

lesion demonstrating a peripheral zone of 5-7 mm. The 

APC non-contact method using the PULSED APC mode is 

also suitable for this procedure. 

Step 2: Elevation 

The HybridKnife is positioned on the mucosa with a slight 

amount of pressure and an application angle of approx. 

20°. The waterjet penetrates the soft mucosa and accumulates 

in the collagenous fibers of the submucosa, which 

becomes bloated in a pillow-like fashion. The muscularis, 

which lies below the submucosa, is not penetrated until 

considerably higher amounts of pressure are reached than 

those required to penetrate the mucosa. Tissue elevation 

occurs on the basis of differing tissue consistencies layer-selectively 

and safely and, when performed properly, 

without any risk of perforating the organ. 

Figure 2: 

Elevation 

The “cushioned” submucosa forms a safety margin to the 

muscularis, thus minimizing the risk of perforation during 

initial and circular incision of the lesion when the ESD 

method is used and when the EMR snare ablation method 

is employed. The submucosal cushion also provides protection 

against thermal damage of the muscularis. 

The cushion remains intact during dissection and resection 

and additional fluid can be added if necessary to ensure 

its protective function throughout the entire course 

of the ESD procedure. Since the blood vessels are compressed 

by the fluid cushion, risk of bleeding is minimized. 

The operation can be performed with little bleeding and a 

good view of the target area. 

Figure 3: 

Incision/dissection 

Step 3: Incision/dissection 

VIO modes ENDO CUT Q and DRY CUT, which are used 

for initial and circular incision and resection of the lesion, 

provide optimal cutting features. 

Figure 4: 

Coagulation 

Step 4: Coagulation 

Blood vessels and leakages are coagulated during and 

after resection with FORCED COAG. Hemostasis is enhanced 

by the compressive fluid cushion. 

You will find recommendations for settings on page 10. 

HybridKnife 

07

APPLICATION 

In the following we wish to take a closer look at some 

special aspects concerning elevation and dissection 

of the mucosa and demonstrate some further advantages 

of the ESD method using the HybridKnife. 

Diagnosis/localization 

Reduction of bleeding 

During elevation of the mucosa, initial diagnostic prognoses 

in terms of tumor infiltration can be made because tumor-infiltrated 

lesions which occur in the colon in particular 

cannot be elevated. Should no elevation be detected 

during waterjet activation, despite having set the effect 

correctly, this is indicative of a tumor which has infiltrated 

deeper tissue layers. In this case, the indication for curative 

ESD is no longer given. 

Through the water pressure, small capillary blood vessels 

within the submucosa cushion are compressed. The result: 

bleeding is reduced and the view of the target area 

remains unimpaired. 

Unlike needle injection, use of the waterjet practically 

rules out risk of injury to blood vessels. This aspect ensures 

additional reduction of possible bleeding. 

An additional diagnostic tool which facilitates the detection 

and visual identification of tumor boundaries is a 

contrast medium which can be added to the separation 

medium. The altered tissue of the lesion already becomes 

visible through elevation alone. However, the contrast 

medium makes the difference between healthy and pathological 

tissue even more distinct. 

Should any bleeding nevertheless occur, it can be rinsed 

using the waterjet and coagulated afterwards electrosurgically. 

Figure 1: 

The tumor is visualized using 

contrast medium 

Figure 2: 

Reduction of bleeding, thus good 

view of the operating field 

08 HybridKnife

Protection against perforation 

R0 resection of relatively large lesions 

In the case of needle injection, the separation medium is 

injected underneath the mucosa. Here the risk of injuring 

blood vessels arises. 

When performing the needle-injection procedure, a 

change of instrument is required if fluid is added in the 

course of the intervention, and thus the tendency is to 

perform resection using a less pronounced submucosal 

cushion. This in turn increases the risk of thermal and mechanical 

perforation of the muscularis. 

Using the ESD method, large-surface tissue lesions can 

also be resected en bloc. The resection bed has a smooth 

resection surface which heals homogenously and with 

practically no scarring approximately 4 weeks post-operatively. 

Since waterjet elevation can be performed at any time, it 

is possible to keep the cushion volume constant during 

and after dissection and resection. Thus the safety margin 

to the muscularis is preserved. 

Figure 1: 

Waterjet elevation is possible at 

all times 

Figure 2: 

Homogenous resection bed 

free of bleeding after ESD with 

HybridKnife 

Aspects of cost 

The separation medium used for ERBEJET 2, a common 

physiological saline solution, is much more cost-economic 

than the solution enriched with additives which is used for 

needle injection. Administering needle injections requires 

force, in particular when fluids with a high degree of viscosity 

are involved. And a further aspect of cost-efficiency 

is that when using the waterjet method, no additional personnel 

is required for assisting in the elevation process. 

As a multi-function probe, the HybridKnife performs all 

four working steps: marking, elevation, incision/dissection 

and coagulation. No additional two-channel endoscope is 

needed for performing ESD with the HybridKnife; a singlechannel 

endoscope fulfills all the requirements. 

HybridKnife 

09

RECOMMENDED SETTINGS 

The following tables give you guideline values for 

the various gastrointestinal segments. These values 

should provide you with some orientation in selecting 

settings for waterjet pressure and CUT and 

COAG modes. 

ERBEJET 2 

VIO system 

ESOPHAGUS 

Mucosal elevation 

Effect: 30-50 

Marking 

PULSED APC, 20 Watts 

FORCED COAG, effect 1, 20 Watts 


ENDO CUT Q, effect 2, cutting duration 3, cutting interval 3 

DRY CUT, effect 2, 80 Watts (higher degree of hemostasis) 

Coagulation 


STOMACH 


Effect: 30-50 

Marking 






Coagulation 


right COLON 


Effect: 10-15 

Marking 


FORCED COAG, Effekt 1, 20 Watts 




Coagulation 


rectum 

left COLON 


Effect: 20-30 

Marking 


FORCED COAG, Effekt 1, 20 Watts 




Coagulation 


10 HybridKnife

advise on use 

BIBLIOGRAPHY 

On the basis of previous applications we have gathered 

some valuable experience which should help 

simplify the use of the HybridKnife for you. 

Position of the patient 

The patient should always be positioned in such a way 

that gravity causes the lesion to fall away from the wall. 

Kaehler GF, Sold MG, Fischer K, Post S, Enderle M. Selective fluid 

cushion in the submucosal layer by water jet: advantage for endoscopic 

mucosal resection. European Surgical Research 2007; 39: 

93-97. 

Schumacher B. Therapie von Magenadenomen und Frühkarzinomen. 

Endoluminal Therapy of Adenoma and Early Stomach Cancer. Endoskopie 

heute 2007; 20(4):236-240. 

Flexible endoscope with transparent cap 

We recommend using an elastic, transparent cap which is 

placed on the distal end of the endoscope. This ensures 

a better view of the resection surface and the already resected 

mucosa segment can be kept away from the lens 

and the tip of the instrument in this way. 

Distance between marking points 

We recommend as short a distance as possible, with the 

individual marking points being 2-3 mm apart. This facilitates 

a good overview of the operating site and increases 

the reliability of R0 resection. 

Schumacher B, Neuhaus H, Enderle MD. Utilisation expérimentale 

d’un nouvel instrument de mucosectomie. Acta Endoscopica 2007; 

37(5):673-678. 

Schumacher B, Deinert K, Philipper M, Neuhaus H. Experimetal 

testing of a new Hybrid Knife for endoscopic submucosal dissection 

(ESD) in the esophagus. Gastrointestinal Endoscopy 2007; 65(5): 

AB278. 

Fernandez-Esparrach G, Matthes E, Maurice D, Enderle MD, 

Thompson CC, Carr-Locke D. A Novel Device for Endoscopic Submucosal 

Dissection That Combines Water-Jet Submucosal Hydrodissection 

and Elevation with Electrocautery. Gastrointestinal Endoscopy 

2008; 67(5):AB141. 

Extension of elevation 

The lesion need not be completely elevated before dissection 

is performed. When using the ESD method, it can 

prove advantageous to alternate between elevation and 

dissection in segments. 

Adding another dye (such as indigo carmine) to the NaCl 

solution may be helpful as a means of improving contrast. 

Ryou M, Shaikh SN, Yao M, Fernandez-Esparrach G, Henry FP, 

Kochevar I, Maurice D, Matthes EL, Enderle MD, Carr-Locke DL, 

Redmond RW, Christopher C. Thompson CC. Next Generation Access 

and Closure for NOTES: Tissue-Selective Hydro-Dissection for 

Efficient Gastric Flap Access with Photochemical Tissue Bonding for 

Secure Closure. Gastroenterology 2008; 134(4):A105. 

Sold MG, Grobholz R, Post S, Enderle MD, Kaehler GF. Submucosal 

cushioning with water jet before endoscopic mucosal resection: 

Which fluids are effective Surgical Endoscopy 2008; 22: 443-447. 

Yahagi N, Neuhaus H, Schumacher B, Neugebauer A, Kaehler GF, 

Schenk M, Fischer K, Fujishiro M, Enderle MD. Comparison of Standard 

Endoscopic Submucosal Dissection (ESD) Versus an Optimized ESD 

Technique for Colon: An animal study. Endoscopy, 2009, accepted. 

Kähler et al. Combination of Water-Jet Dissection and Needle-Knife 

as a HybridKnife Simplifies Endoscopic Submucosal Dissection. Surgical 

Endoscopy 2009, accepted. 

Neuhaus H, Mayershofer R, Wirths K, Seelhoff A, Vieth M, Schumacher 

B. First clinical trial of endoscopic submucosal resection 

(ESD) of early gastric neoplasia with a water-jet HybridKnife (ESDH). 

Abstract accepted for DDW 2009. 

Neuhaus H, Wirths K, Schenk M, Enderle MD, Schumacher B. Randomized 

controlled study of endoscopic mucosal resection (EMR) 

versus endoscopic submucosal dissection with a water-jet Hybrid- 

Knife (ESDH) of esophageal lesions in a porcine model. Gastrointestinal 

Endoscopy 2009 Mar 13 (Epub ahead of print). 

Hyett B, Maurice, D, Matthes E, Carr-Locke D. Needle-Less Elevation 

for Endoscopic Mucosal Resection (EMR) in the Esophagus, 

Stomach and Colon. Abstract accepted for DDW 2009. 

HybridKnife 

11

ERBE Elektromedizin GmbH 

Waldhoernlestraße 17 

72072 Tuebingen 

Germany 

Phone +49 7071 755-0 

Fax +49 7071 755-179 

info@erbe-med.com 

www.erbe-med.com 

85800-123 12.10 © ERBE Elektromedizin GmbH 2010

ESD Brochure (PDF 881.5 KB) - ERBE Elektromedizin GmbH

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