TriangleTipKnife
Model KD-640L
Dr. Haruhiro Inoue / Dr. Hitomi Minami /
Dr. Yoshitaka Sato
Showa University Northern Yokohama Hospital
Interview With The Expert
What are the advantages of TriangleTipKnife?
First, it does not need any kind of axis alignment. It can hook effectively in any direction.
Also, by discharging spray coagulation, the submucosal layer will be dissected without any contact of the knife.
Are there any weak points of TriangleTipKnife?
When there is serious fibrosis in submucosal dissection,
it is better to use a hook because it has a thinner distal end than TriangleTipKnife.
Under what conditions do you use other devices as well?
If the dissected part of the mucosa starts dangling when you are about to resect,
it’s easier to complete the procedure using ITknife.
Applicability of TriangleTipKnife
Difficulty per region
◯ : Easy. No mark: Ordinary. △ : Difficult. ▲ : Very difficult.
| Cardiac region | △ | |
|---|---|---|
| Fornix | ▲ | |
| Lesser curvature of upper body | ||
| Greater curvature of upper body | △ | |
| Anterior wall of upper body | ||
| Posterior wall of upper body | △ | |
| Lesser curvature of middle body | ||
| Greater curvature of middle body | ||
| Anterior wall of middle body | ||
| Posterior wall of middle body | △ | |
| Lesser curvature of lower body | ||
| Greater curvature of lower body | ||
| Anterior wall of lower body | ||
| Posterior wall of lower body | △ | |
| Lesser curvature of anterior wall | ◯ | |
| Greater curvature of antrum | ◯ | |
| Anterior wall of antrum | ◯ | |
| Posterior wall of antrum | ◯ | |
| Pyloric ring |
Note for beginners: The most difficult regions are the upper part and posterior wall side of the stomach.
Sedation
| Intravenous anaesthesia | Premedication | General anaesthesia | Monitoring |
|---|---|---|---|
| Opistan (pethidine hydrochloride)* 35 mg + Horizon (diazepam)* 10 mg + Dormicum (midazolam)* Appropriately |
Buscopan, (scopolamine butylbromide)* 1 ampule |
Perform the procedures in the operating room under general anaesthesia when it is expected to take more than two hours. | SpO2, ECG and blood pressure are monitored in all cases. |
| Electrosurgical unit | VIO-300D （Erbe） |
ESG-100 （Olympus Medical Systems） |
|---|
Marking
| Device | Caution | Setting | |
|---|---|---|---|
| TriangleTip Knife |
Retract the knife and gently contact it to the mucosa and briefly supply current. | SprayCoag 60W Effect1 |
ForcedCoag1 20W |
Local injection
| Epinephrine | Indigo carmine | ||
|---|---|---|---|
| Glyceol (concentrated glycerin fructose)* |
Used 1 ampule per 200 ml |
Used (appropriate amount) |
Advantage: Low price Disadvantage: Short lifting time |
| Sodium hyaluronate |
Not used | Used | Advantage: Long lifting time Disadvantage: High price |
| Use saline in circumferential incision. For submucosal dissection, use hyaluronic acid to reserve the view with sufficient bulging, and perform dissection with the knife tip. | |||
Circumferential incision
| Device | Caution | Setting | |
|---|---|---|---|
| TriangleTip Knife |
For precutting, gently apply the triangular tip to the mucosa and briefly supply current in the EndoCut or PulseCut mode. Once the muscularis mucosae have been cut and the submucosal layer is exposed, advance the mucosal incision along the depth. For circumferential incision, hook the tip while applying tension to the mucosa using an attachment and supply current for further incision. For the tip to hook properly, be sure to supply sufficient tension. |
●EndoCutQ Effect 2 Cut duration1 Cut interval6 ●DryCut 50W Effect3 |
PulseCut slow 20W |
Submucosal dissection
| Device | Caution | Setting | |
|---|---|---|---|
| TriangleTip Knife |
Slide the endoscope into the submucosal layer using the attachment to apply tension. Then supply current while directly confirming the target. Avoid hooking the muscle layer during output. Use sodium hyaluronate for local injection. | SprayCoag 60W Effect1 |
ForcedCoag2 60W |
Haemostasis
| Device | Caution | Setting | |
|---|---|---|---|
| TriangleTip Knife |
For spurting type of bleeding, contact the knife tip to the bleeding point for coagulation. Also effective to do haemostasis by contacting the retracted knife tip to the bleeding point. | SprayCoag 60W Effect 1 |
ForcedCoag2 60W |
| Coagrasper | If haemostasis using the tip of TriangleTipKnife is difficult, use Coagrasper to grasp the bleeding point and supply current for 2 or 3 seconds in the SoftCoag mode. It is important to confirm the bleeding point to grasp it accurately. | SoftCoag 80W Effect5 |
SoftCoag 80W |
Preventive haemostasis
| Device | Caution | Setting | |
|---|---|---|---|
| TriangleTip Knife |
Coagulate the visible vessels in advance. Small vessels can be cauterised by performing coagulation with the tip of TriangleTipKnife. For large vessels, use Coagrasper to grasp and cauterise in SoftCoag mode. | SprayCoag 60W Effect1 |
ForcedCoag2 60W |
| Coagrasper | SoftCoag 80W Effect5 |
SoftCoag 80W | |
Perforation measure
| Method | Timing |
|---|---|
| A small perforation with a size of pinhole is to be obstructed with a clip for conservative treatment. | The basic is to obstruct the hole with a clip immediately after perforation. If clipping is difficult, it is sometimes recommended to incise or dissect a little further and retry clipping. |
* May not be available in your area.
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