Endoscopic submucosal dissection (ESD) of large and compact esophageal lesions is technically demanding, especially in the later stages of the procedure. The partially dissected specimen often becomes floppy and obscures the dissection field. This loss of visualization and traction limitation makes precise submucosal dissection challenging. Conventional traction methods, especially at this stage of the procedure, provide only limited axis movements and cannot be easily repositioned.

The novel EndoRobotics Alligator (ROBOPERA & TraCloser) device is designed for flexible multipoint traction. The device provides true four-axis independent movements (grip, wrist, arm, and rotational movements), enabling multidirectional traction. The operator can lift, rotate, pull, or push the lesion in multiple directions and reposition at any time, maintaining continuous exposure of the submucosal layer and preventing the partially dissected specimen from obstructing the field. This multidirectional control improves visualization, optimizes tissue tension, facilitates efficient and precise dissection, and allows safe en-bloc specimen retrieval using the same device.

We report the first case of an EndoRobotics Alligator–assisted esophageal ESD of an 11 cm early Barrett’s adenocarcinoma extending over 70% of the circumference, with a compact component of 3–4 cm. The use of this novel device was authorized by the Institutional Review Board.

After circumferential incision and completing dissection of 70% of the lesion, visualization and access to the dissection plane worsened. The Alligator device was used at this later stage of the procedure to lift the compact specimen in order to re-visualize the dissection plane, maintain tension, and finalize the dissection.The lesion was successfully resected en bloc. R0 resection was histologically confirmed. No intra- or post-procedural adverse events occurred.

Alligator-assisted robotic traction is a valuable tool during esophageal ESD, particularly in challenging cases involving large or compact lesions. By providing dynamic multidirectional traction, it complements conventional ESD techniques and enhances visualization, stability, and dissection efficiency. This case demonstrates that integrating robotic traction into ESD can support safer and more controlled tissue handling.