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Page 8 of 20 Nakamura et al. Mini-invasive Surg 2022;6:50 https://dx.doi.org/10.20517/2574-1225.2022.38

Figure 4. Scope positioning for ESD. ESD: Endoscopic submucosal dissection.

Figure 5. A. The lesion on the anti-gravity side is spontaneously flipped up by gravity. B. In the lesion on the ipsilateral side of gravity,
mucosal incision is started from the gravity side (①) as the mucosal tension from the opposite side (②) helps open the incised
mucosal line. C If the mucosal incision starts from the anti-gravity side (①), the mucosal incision on the gravity side becomes difficult.
D. A lesion on the gravity side is the most difficult, and the traction device or changing the patient’s position can be a possible solution.

interferes with the operation field. In this case, the traction device is useful. Changing the patient’s position
to the right lateral is also worth considering as a possible solution [Figure 5D].

In the endoscopic view, with the use of scope torque and angulation, a lesion is principally positioned at the
6-7 o’clock location where a working channel exists because a device can be applied under good
visualization of the mucosa in this position.