OEM and endoscopic fundoplication using bipolar radiofrequency and microwave energy platform. we have no relevant disclosures. POEM is an established modality for ophthalasia cardia. POEM with endoscopic fundoplitation has encouraging results for prevention of post-POEM reflux. Monopolar energy is predominantly used for endoscopic surgical procedures like POEM and POEM-F. Bipolar radium frequency and microwave energy platforms have demonstrated superiority over monopolar energy for surgical and laparoscopic procedures. Feedbot combines bipolar and microwave energies. Earlier reports have established its use for ESD and POEM. Feedbot device has bipolar energy for cutting, high frequency microwave energy for coagulation, integrated injection needle, insulated hull for protection from unwarranted thermal injury. This device uses separate electrosurgical generator compatible with the bipolar 9. POEM with endoscopic fundoplitation is performed intraperitoneally. Therefore, these advantages are likely to be better utilized while performing this procedure using this technology. This video demonstrates POEM-F using bipolar radio frequency and high frequency microwave coagulation energy platform and highlights its advantages for peritoneal dissection. The patient was a 47-year-old female. EGD and manoeuvres suggestive of achalasia cardiata type 2 and POEM with endoscopic fundoplitation was planned using this energy platform. Specific gastroscope to accommodate 10 friends feedbot device. Additional instruments for fundoplitation like trans-nasal ultraslim gastroscope, reconstrainable flips, detachable endo loop and various needles for abdominal paracentesis and a second endoscopist. Using integrated needle, submucosal injection was done on interior wall at 12 o'clock position. The device was rotated to appropriately orient the lateral cutting edges. Tip and lateral cutting edges of the device were used to make a mucosal incision. Subsequently, tunnel entry was obtained. Device was rotated so that hull faces mucosa to prevent unwarranted injury and submucosal dissection was done 2 cm beyond GE junction. Full thickness myotomy was done 2 cm beyond the GE junction. After completing myotomy, large peritoneal vessel was identified, which was preemptively coagulated using lateral edges. Later, trans-nasal ultrasound gastroscope was introduced for assisting endoscopic fundoplication. Peritoneal fat was seen, which was carefully dissected along with coagulation of micro vessels. Entry was gained into the peritoneal cavity. Lateral border of anterior surface of fundus was grasped with the help of endoclip and it was pulled into the tunnel near the right edge of myotomy to simulate a fundoplication raft. Raft was seen with the help of slim gastroscope in retroverted position. Identified location for raft creation was marked on gastric cirrhosa. Later scope was withdrawn and detachable endoloop was grasped in endoclip. Endoloop was carried alongside scope through the tunnel into the peritoneal cavity. Endoloop was fixed to the marked location on the gastric cirrhosa using three endoclips. Two endoclips were used to distribute the tension. Proximal end of the endo loop was fixed to the right edge of the myotomy using three additional endoclips. Endo loop was gradually tightened. Tail of the loop was cut using endoscopic scissors. After confirming hemostasis, mucosal incision was closed with endoclips. Adequate fundoplication graft was achieved. After procedure, patient was kept nilper oral for 12 hours. Diet was gradually resumed and patient was discharged after 24 hours. At 4 weeks follow up, patient was asymptomatic, EGD showed healthy incision site and 24 hours pH metric showed DMS of 9. OMF could be considered as technically challenging. Our group has previously presented modification to simplify this procedure. We recommend Double scope trans elimination to identify suitable location to open peritoneum. Decompress gastric fundus to facilitate grasping of fundus. Mark location on fundus for fixing endo loop. Do not include perigastric fat. Use detachable endo loop for fixation. Use clips with short tail for endo loop fixation. Abdominal parasynthesis to reduce capnoperitoneum. Being a complex procedure, selection of an optimal energy device is crucial. Conventional monopolar energy devices cause significant charring. Dissection field gets obscured. There is increased risk of bleeding and injury risk to adjacent organs. Using well energy platform, we could mitigate this risk. Several other advantages of the speedboard device have been established. Limitations are It is a 10-inch stiff instrument. Requires therapeutic scope. Retroflexion is difficult. Learning curve to use the instrument. Energy source presently can be used only with speedboard device. To conclude, this video demonstrates technique of OM with endoscopic fundoplication with special emphasis on its technical tips and highlights advantages of novel bipolar radio frequency and microwave energy platform. Peritoneal dissection and entry during POMF is facilitated using this device. The utility of this device can be further explored for use for other intraperitoneal procedures like EFTR or nodes.

POEM-F

Peroral Endoscopic Myotomy

Endoscopic Fundoplication

Feedbot

Achalasia Cardia Type 2