Colorectal cancer (CRC) is the fourth most commonly diagnosed type of cancer globally and the second most common cause of cancer deaths. Over several decades, endoscopic screening programs performed for CRC have decreased the death rate and incidence among patients over 50 years. Meanwhile, the incidence of polyp detection is increasing in parallel with the widespread application of screening programs. While most patients with polyps are treated with conventional endoscopic polypectomy, polyps with advanced features (size, morphologic features, difficult localization, etc.) are referred for surgery.

Although the surgery rate for non-malignant polyps has decreased recently, such resections still have high complication and mortality rates.1 While the literature lacks a study comparing surgical versus endoscopic management of colorectal mucosal neoplasm treatment outcomes, there is a significant difference in complication rates for both techniques. Moreover, final pathology has a low incidence of cancer.1,2 The above-described factors have been the cornerstone behind the need for research and advancement for endoluminal surgery.

Without a doubt, endoluminal surgery including endoscopic mucosal resection (EMR), endoscopic submucosal dissection (ESD) and hybrid ESD may offer organ preservation for patients with large mucosal colorectal neoplasms (pre-malignant or early malignant neoplasms) that are not treatable with standard polypectomy techniques. EMR is typically unsuccessful for en-bloc removal of lesions greater than 20 mm in diameter and usually results in piecemeal resection of the lesions with a higher recurrence rate that is reported between 6.8% - 23.5% when compared to ESD.3, 4, 5

Besides endoluminal surgery harbors some confounders that limit its widespread utility worldwide. In the late 1980s, en-bloc removal of mucosal neoplasm was first described in Japan. Soon, ESD gained popularity in Eastern countries and nowadays is considered the gold standard in the Eastern hemisphere for the treatment of early mucosal neoplasms throughout the gastrointestinal tract. Meanwhile, ESD was, and still is, relatively slow-spreading and not recognized widely in the Western hemisphere. The main obstacles were the long learning curve, technical expertise, demanding skills, long procedure times, and lack of dedicated teams and instruments.6