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A task and performance analysis of endoscopic submucosal dissection (ESD) surgery



ESD is an endoscopic technique for en bloc resection of gastrointestinal lesions. ESD is a widely-used in Japan and throughout Asia, but not as prevalent in Europe or the US. The procedure is technically challenging and has higher adverse events (bleeding, perforation) compared to endoscopic mucosal resection. Inadequate training platforms and lack of established training curricula have restricted its wide acceptance in the US. Thus, we aim to develop a Virtual Endoluminal Surgery Simulator (VESS) for objective ESD training and assessment. In this work, we performed task and performance analysis of ESD surgeries.


We performed a detailed colorectal ESD task analysis and identified the critical ESD steps for lesion identification, marking, injection, circumferential cutting, dissection, intraprocedural complication management, and post-procedure examination. We constructed a hierarchical task tree that elaborates the order of tasks in these steps. Furthermore, we developed quantitative ESD performance metrics. We measured task times and scores of 16 ESD surgeries performed by four different endoscopic surgeons.


The average time of the marking, injection, and circumferential cutting phases are 203.4 (σ: 205.46), 83.5 (σ: 49.92), 908.4 s. (σ: 584.53), respectively. Cutting the submucosal layer takes most of the time of overall ESD procedure time with an average of 1394.7 s (σ: 908.43). We also performed correlation analysis (Pearson’s test) among the performance scores of the tasks. There is a moderate positive correlation (R = 0.528, p = 0.0355) between marking scores and total scores, a strong positive correlation (R = 0.7879, p = 0.0003) between circumferential cutting and submucosal dissection and total scores. Similarly, we noted a strong positive correlation (R = 0.7095, p = 0.0021) between circumferential cutting and submucosal dissection and marking scores.


We elaborated ESD tasks and developed quantitative performance metrics used in analysis of actual surgery performance. These ESD metrics will be used in future validation studies of our VESS simulator.

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This project was made possible by the Arkansas INBRE program, supported by a grant from the National Institute of General Medical Sciences, (NIGMS), P20 GM103429 from the National Institutes of Health. This project was also supported by National Institutes of Health (NIH) Grant NIH/NHLBI 1R01HL119248-01A1, NIH/NIBIB 2R01EB005807, 5R01EB010037, 1R01EB009362, R01CA197491 and 1R01EB014305.

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Correspondence to Tansel Halic.

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Tansel Halic reports grants from National Institutes of Health, during the conduct of the study. Cullen Jackson reports grants from NIH via subcontract from RPI, during the conduct of the study. Suvranu De grants from National Institutes of Health, during the conduct of the study. Sudeep Hegde reports grants from National Institutes of Health, during the conduct of the study; other from State University of New York at Buffalo, outside the submitted work. Daniel B. Jones reports personal fees from Allurion, outside the submitted work. Berk Cetinsaya, Mark A. Gromski, Sangrock Lee, Zhaohui Xia, Doga Demirel, Coskun Bayrak, Jonah Cohen, Mandeep Sawhney, Stavros N. Stavropoulos have no conflicts of interest or financial ties to disclose.

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Cetinsaya, B., Gromski, M.A., Lee, S. et al. A task and performance analysis of endoscopic submucosal dissection (ESD) surgery. Surg Endosc 33, 592–606 (2019).

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  • Endoscopic training
  • Endoscopic submucosal dissection
  • Colorectal cancer
  • ESD