V21 - Full-thickness Laparoendoscopic Excision (FLEX) of Ascending Colon Polyp: Bridging Endoscopic and Laparoscopic Surgery

Saturday, May 9, 2026

On-Demand

Video Presentation(s)

Jordan Martucci, MD

Resident
University of Southern California/ Los Angeles General
Keck Hospital of USC/ Los Angeles General Medical Center
Los Angeles, CA, United States

All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose

Author(s)

Alexis Peters, MD

Resident Physician
University of Southern California/Los Angeles General Medical Center
University of Southern California/Los Angeles General Medical Center
Los Angeles, CA, United States

Disclosure information not submitted.
Anthony Lim, MD

Resident Physician
University of Southern California/Los Angeles General Medical Center
Los Angeles, California, United States

All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose
Aubrey Swinford, MD

Research Fellow
Keck Medicine of USC
University of Southern California
South Pasadena, CA, United States

All disclosed relationships have been reviewed and managed prior to the start of this activity. Any relevant relationships will be listed below. This individual has no financial relationships to disclose

Senior Author(s)

Sang W. Lee, MD

Professor and Chief of Colon and Rectal Surgery
Keck School of Medicine of USC
Los Angeles, California, United States

Disclosure information not submitted.

CME Eligible

Purpose/Background: Polyp detection rates have been increasing over the last several years/decades as more people undergo screening colonoscopies, as the age of recommended screening colonoscopy has decreased, and as procedural quality has improved. Up to 15% of polyps are classified as "difficult" and require advanced endoscopic techniques or surgery for removal. Developments in advanced endoscopy and combined endoscopic-laparoscopic surgery have decreased the need for segmental colon resections for traditionally endoscopically unresectable polyps, reducing patient morbidity and mortality associated with colectomies. Full-thickness laparoendoscopic excision (FLEX) technique allowing for monitoring of laparoscopic wedge resection with colonoscopy. FLEX procedure has been shown to be safe for complex polyp excision and is being investigated for removal of low-risk T1 lesions. We present a video demonstrating FLEX procedure for the management of an ascending colon submucosal lesion.

Methods/Interventions: The patient was a 74-year-old female found to have an 8 mm submucosal lesion located in the ascending colon on screening colonoscopy which was not amenable for endoscopic removal. The area of the lesion was tattoo marked. Biopsy of the overlying mucosa was non-diagnostic. She was also found to have two small tubular adenomas that were removed. Endoscopic ultrasound showed a 4 mm x 7 mm intramuscular hyperechoic nodule. The patient was scheduled for removal of lesion with FLEX procedure. The surgery began with laparoscopic mobilization of the right colon and hepatic flexure. Next, a CO2 colonoscopy was performed to the cecum to identify the submucosal lesion with tattoo mark and ensure the remainder of the colon was free of pathology. The colon wall was then laparoscopically sutured overlying the polyp to allow for sleeve resection of the colon wall containing the polyp using several fires of a laparoscopic GIA 60 mm stapler. CO2 colonoscopy was used to pass beyond the sleeve resection to confirm the resection did not significantly narrow the colon and that no residual polyp was seen. An air leak test was performed by submerging the staple line in saline and insufflating the colon. The specimen was removed, opened on the back table, and noted to have negative margins.

Results/Outcomes: The patient was discharged home on the day of surgery after recovery in the post-anesthesia care unit. At her post-operative clinic visit she was recovering well and reported normal bowel movements. Final pathology showed a benign submucosal lesion without evidence of carcinoma or neuroendocrine tumor. No further treatment was indicated.

Conclusion/Discussion: Full-thickness laparoendoscopic excision is a promising colon-preserving approach for the management of complex colon polyps.