Colonic endoscopic submucosal dissection using a novel robotic system (with video)

Prospective single-arm trial on feasibility and safety of an endoscopic robotic system for colonic endoscopic submucosal dissection

BACKGROUND

The development of the EndoMaster "Endoluminal Access Surgical Efficacy" (EASE) system aims to enhance the safety and efficacy of colonic endoscopic submucosal dissection (ESD) through two flexible robotic arms. This is the first clinical trial to evaluate the performance of colorectal ESD using EndoMaster.

METHOD

Patients with early mucosal colorectal neoplasia that was not suitable for en bloc resection with snare-based techniques were recruited. The EndoMaster EASE robotic system consisted of an independently designed flexible robotic platform with two robotic arms. The primary outcome was the complete resection rate using EndoMaster. Secondary outcomes included operating time, hospital stay, procedure-related complications, and oncologic outcomes.

RESULTS

43 patients underwent robotic ESD, with a median robotic dissection time of 49 minutes. The technical success rate was 86.0%, while en bloc resection rate among cases with technical success was 94.6%. The complete resection rate was 83.8% and the median size of specimen was 35 mm (range 15-90 mm). The median hospital stay was 2 (range 1-7) days and there was one delayed bleed after 4 days, which was controlled endoscopically. One patient sustained perforation during the procedure, which was completely closed using clips without sequelae. Two patients were treated by salvage surgery.

CONCLUSION

This first clinical trial confirmed the safety and efficacy of performing colorectal ESD using the EndoMaster EASE robotic system.

Evaluation of current and emerging endoluminal robotic platforms using the IDEAL framework

BACKGROUND

Robotic-assisted endoluminal systems are rapidly evolving within the field of minimally invasive surgery. The IDEAL framework (Idea, Development, Exploration, Assessment, and Surveillance) can be used to evaluate novel technologies. This review provides a summary of current and emerging endoluminal systems using the IDEAL framework.

METHODS

A scoping review was conducted to include all existing and developing robotic-assisted endoluminal systems. Data was collected via virtual interviews, questionnaires, biomedical databases, company websites, and peer-reviewed articles. Key metrics were reported, enabling the assignment of each system to an IDEAL stage.

RESULTS

The review identified 17 distinct systems from 16 companies. Nine systems received regulatory approval in their respective countries. Our evaluation showed that two systems were at the pre-IDEAL Stage 0. Seven systems were in the Idea stage (Stage 1), six systems were in the Development stage (Stage 2) and two systems completed Stage 3. No system underwent long-term study evaluation (Stage 4).

CONCLUSIONS

There is a gap in long-term clinical data of robotic-assisted endoluminal systems, indicated by the absence of systems at Stage 4. Collaborative efforts amongst the medical community, regulatory bodies, and industry specialists are vital to ensure the delivery of evidence-based medicine in the discipline of robotics.

Endoluminal robotics

The search for less-invasive approaches led to the birth of endoluminal surgery 40 years ago. The limited dexterity of flexible endoscopic systems generated an interest in the development of robotic platforms to encourage the adoption of surgical-like, bimanual techniques involving manipulation of tissues, thus favoring organ preservation. Nevertheless, the road ahead for endoluminal surgery is still at the beginning.

Robotics in interventional endoscopy-evolution and the way forward

The integration of robotics into gastrointestinal (GI) endoscopy represents a transformative advancement and bears the potential to bridge the gap between traditional limitations by offering unprecedented precision and control in diagnostic and therapeutic procedures. This review explores the historical progression, current applications and future potential of robotic platforms in GI endoscopy. Originally designed for surgical applications, robotic systems have expanded their reach into endoscopy, potentially enhancing procedural accuracy and reducing ergonomic strain on practitioners. Natural Orifice Transluminal Endoscopic Surgery (NOTES) emerged as a promising technique, leveraging natural orifices to perform minimally invasive surgeries. Despite its initial potential, several factors, including limitations of the available instrumentations and lack of reliable closure techniques, hindered its widespread adoption and progress. Conventional endoscopic tools often fall short in terms of triangulation, traction and degrees of freedom, necessitating the adoption of robotic interventions. Over recent decades, robotic endoscopy has significantly evolved, focusing on both diagnostic and complex therapeutic procedures such as endoscopic sub-mucosal dissection (ESD) and endoscopic full-thickness resection (EFTR). Various robotic platforms demonstrate enhanced safety and efficiency in GI procedures. As the field progresses, the emphasis on clinical validation, advanced training and the exploration of new applications remains crucial. Continuous innovation in robotic technology and endoscopic techniques promises to overcome existing limitations, further revolutionizing the management of GI diseases and improving patient outcomes.

Efficacy of robot arm-assisted endoscopic submucosal dissection in live porcine stomach (with video)

Endoscopic submucosal dissection (ESD) is technically challenging and requires a high level of skill. However, there is no effective method of exposing the submucosal plane during dissection. In this study, the efficacy of robot arm-assisted tissue traction for gastric ESD was evaluated using an in vivo porcine model. The stomach of each pig was divided into eight locations. In the conventional ESD (C-ESD) group, one ESD was performed at each location (N = 8). In the robot arm-assisted ESD (R-ESD) group, two ESDs were performed at each location (N = 16). The primary endpoint was the submucosal dissection speed (mm2/s). The robot arm could apply tissue traction in the desired direction and successfully expose the submucosal plane during submucosal dissection in all lesion locations. The submucosal dissection speed was significantly faster in the R-ESD group than in the C-ESD group (p = 0.005). The blind dissection rate was significantly lower in the R-ESD group (P = 0.000). The robotic arm-assisted traction in ESD enabled a significant improvement in submucosal dissection speed, blind dissection rate which suggests the potential for making ESD easier and enhancing procedural efficiency and safety.

A Novel Retractable Robotic Device for Colorectal Endoscopic Submucosal Dissection

Background/Aims

: Appropriate tissue tension and clear visibility of the dissection area using traction are essential for effective and safe endoscopic submucosal dissection (ESD). In this study, we developed a retractable robot-assisted traction device and evaluated its performance in colorectal ESD.

Methods

: An experienced endoscopist performed ESD 18 times on an ex vivo porcine colon using the robot and 18 times using the conventional method. The outcome measures were procedure time, dissection speed, procedure-related adverse events, and blind dissection rate.

Results

: Thirty-six colonic lesions were resected from ex vivo porcine colon samples. The total procedure time was significantly shorter in robot-assisted ESD (RESD) than in conventional ESD (CESD) (20.1±4.1 minutes vs 34.3±8.3 minutes, p<0.05). The submucosal dissection speed was significantly faster in the RESD group than in the CESD group (36.8±9.2 mm2/min vs 18.1±4.7 mm2/min, p<0.05). The blind dissection rate was also significantly lower in the RESD group (12.8%±3.4% vs 35.1%±3.9%, p<0.05). In an in vivo porcine feasibility study, the robotic device was attached to a colonoscope and successfully inserted into the proximal colon without damaging the colonic wall, and ESD was successfully performed.

Conclusions

: The dissection speed and safety profile improved significantly with the retractable RESD. Thus, our robotic device has the potential to provide simple, effective, and safe multidirectional traction during colonic ESD.

Ultra-minimally invasive endoscopic techniques and colorectal diseases: Current status and its future

Colorectal diseases are increasing due to altered lifestyle, genetic, and environmental factors. Colonoscopy plays an important role in diagnosis. Advances in colonoscope (ultrathin scope, magnetic scope, capsule) and technological gadgets (Balloon assisted scope, third eye retroscope, NaviAid G-EYE, dye-based chromoendoscopy, virtual chromoendoscopy, narrow band imaging, i-SCAN, etc.) have made colonoscopy more comfortable and efficient. Now in-vivo microscopy can be performed using confocal laser endomicroscopy, optical coherence tomography, spectroscopy, etc. Besides developments in diagnostic colonoscopy, therapeutic colonoscopy has improved to manage lower gastrointestinal tract bleeding, obstruction, perforations, resection polyps, and early colorectal cancers. The introduction of combined endo-laparoscopic surgery and robotic endoscopic surgery has made these interventions feasible. The role of artificial intelligence in the diagnosis and management of colorectal diseases is also increasing day by day. Hence, this article is to review cutting-edge developments in endoscopic principles for the management of colorectal diseases.

Novel miniature transendoscopic telerobotic system for endoscopic submucosal dissection (with videos)

BACKGROUND AND AIMS

The lack of tissue traction and instrument dexterity to allow for adequate visualization and effective dissection were the main issues in performing endoscopic submucosal dissection (ESD). Robot-assisted systems may provide advantages. In this study we developed a novel transendoscopic telerobotic system and evaluated its performance in ESD.

METHODS

A miniature dual-arm robotic endoscopic assistant for minimally invasive surgery (DREAMS) was developed. The DREAMS system contained the current smallest robotic ESD instruments and was compatible with the commercially available dual-channel endoscope. After the system was established, a prospective randomized controlled study was conducted to validate the performance of the DREAMS-assisted ESD in terms of efficacy, safety, and workload by comparing it with the conventional technique.

RESULTS

Two robotic instruments can achieve safe collaboration and provide sufficient visualization and efficient dissection during ESD. Forty ESDs in the stomach and esophagus of 8 pigs were completed by DREAMS-assisted ESD or conventional ESD. Submucosal dissection time was comparable between the 2 techniques, but DREAMS-assisted ESD demonstrated a significantly lower muscular injury rate (15% vs 50%, P = .018) and workload scores (22.30 vs 32.45, P < .001). In the subgroup analysis of esophageal ESD, DREAMS-assisted ESD showed significantly improved submucosal dissection time (6.45 vs 16.37 minutes, P = .002), muscular injury rate (25% vs 87.5%, P = .041), and workload (21.13 vs 40.63, P = .001).

CONCLUSIONS

We developed a novel transendoscopic telerobotic system, named DREAMS. The safety profile and technical feasibility of ESD were significantly improved with the assistance of the DREAMS system, especially in the narrower esophageal lumen.

A novel miniature flexible robotic system for endoscopic mucosal dissection: an animal experimental study

Endoscopic submucosal dissection (ESD) is a standard treatment for early gastrointestinal cancer due to its higher rate of en-bloc resection and lower recurrence rate. However, the technical challenges lead to long learning curve and high risks of adverse events. A gastrointestinal flexible robotic-tool system (GIFTS) was proposed to reduce the difficulty and shorten the learning curve of novices. This is an animal study to evaluate the feasibility of GIFTS in ESD. The GIFTS provides a total of 13 degrees of freedom within 10 mm in diameter and variable stiffness function to achieve endoscopic intervention and submucosal dissection with the cooperation of two flexible robotic instruments. One esophageal and four colorectal ESDs in five porcine models were performed. In all five ESD procedures, the GIFTS was successfully intubated and submucosal dissection was completed without perforation or significant bleeding, and there was no system fault. The mean operative time was 99 min, and the mean size of the specimen was 151 mm2. The fifth experiment showed significantly better results than the first one. In vivo animal experiments confirmed the feasibility of GIFTS in performing ESD. The control of GIFTS is friendly to inexperienced beginners, which will help reduce the technical challenges of ESD and shorten the learning curve of endoscopists.

The Role of Specialized Instruments for Advanced Endoscopic Resections in Gastrointestinal Disease

INTRODUCTION

Advanced endoscopic therapy techniques have been developed and have created alternative treatment options to surgical therapy for several gastrointestinal diseases. This work will focus on new endoscopic tools for special indications of advanced endoscopic resections (ER), especially endoscopic submucosal dissection (ESD), which were developed in our institution. This paper aims to analyze these specialized instruments and identify their status.

METHODS

Initially, the technical process of ESD was analyzed, and the following limitations of the different endoscopic steps and the necessary manipulations were determined: the problem of traction-countertraction, the grasping force needed to pull on tissue, the instrument tip maneuverability, the limited angulation/triangulation, and the mobility of the scope and instruments. Five instruments developed by our team were used: the Endo-dissector, additional working channel system, external independent next-to-the-scope grasper, 3D overtube working station, and over-the-scope grasper. The instruments were used and applied according to their special functions in dry lab, experimental in vivo, and clinical conditions by the members of our team.

RESULTS

The Endo-dissector has a two-fold function: (1) grasping submucosal tissue with enough precision and strength to pull it off the surrounding mucosa and muscle, avoiding damage during energy application and (2) effectively dividing tissue using monopolar energy. The AWC system quickly fulfills the lack of a second working channel as needed to complete the endoscopic task on demand. The EINTS grasper can deliver a serious grasping force, which may be necessary for a traction-countertraction situation during endoscopic resection for lifting a larger specimen. The 3D overtube multifunctional platform provides surgical-like work with bimanual-operated instruments at the tip of the scope, which allows for a coordinated approach during lesion treatment. The OTSG is a grasping tool with very special features for cleaning cavities with debris.

CONCLUSIONS

The research and development of instruments with special features can solve unmet needs in advanced endoscopic procedures. The latter may help to increase indications for the endoscopic resections of gut lesions in the future.

Flexible robotic endoscopy for treating gastrointestinal neoplasms

Therapeutic flexible endoscopic robotic systems have been developed primarily as a platform for endoscopic submucosal dissection (ESD) in the treatment of early-stage gastrointestinal cancer. Since ESD can only be performed by highly skilled endoscopists, the goal is to lower the technical hurdles to ESD by introducing a robot. In some cases, such robots have already been used clinically, but they are still in the research and development stage. This paper outlined the current status of development, including a system by the author’s group, and discussed future challenges.

A Look into the Future of Endoscopic Submucosal Dissection and Third Space Endoscopy: The Role for Robotics and Other Innovation

Endoscopic resection has been widely applied especially in endoscopic submucosal dissection and third space endoscopy (TSE). Flexible endoluminal robotics allow performance of endoscopic submucosal dissection with exposure of the submucosal plane for precise dissection using two robotic arms. The introduction of TSE revolutionized the horizon of therapeutic endoscopy to the submucosal space beneath and beyond the mucosa. Advantages of TSE include avoidance of full thickness incision in gastrointestinal tract through the submucosal tunneling for performance of peroral endoscopic myotomy and submucosal tunneling endoscopic resection. In future, robotic-driven devices should be developed to enhance performance of complex endoluminal procedures and TSE.

Endoscopic surgery robot that facilitates insertion of the curved colon and ensures positional stability against external forces: K-COLON

BACKGROUND

Although various endoscopic surgery robots developed in previous studies are versatile and have high lesion accessibility, they have limitations in terms of reaching the target lesion through the curved path in the large intestine and providing a stable tasking environment for the operator.

METHODS

An endoscopic surgery robot was developed for performing surgery in the large intestine. The robot was easily inserted into the target lesion in the curved colon through the mounted soft actuator and demonstrated high structural stiffness through the insertion of the sigmoidal auxiliary tendons.

RESULTS

The robot was able to access the target lesion in the curved colon through teleoperation alone. Further, it was confirmed that the high structural stiffness overtube improved the overall task performance in the user test.

CONCLUSIONS

The proposed robotic system demonstrated the possibility and potential of performing advanced endoscopic surgery in the large intestine.

Robotics in therapeutic endoscopy (with video)

Since its inception, endoscopy has evolved from a solely diagnostic procedure to an expanding therapeutic field within gastroenterology. The incorporation of robotics in gastroenterology initially addressed shortcomings of flexible endoscopes in natural orifice transluminal endoscopy. Developing therapeutic endoscopic robotic platforms now offer operators improved ergonomics, visualization, dexterity, precision, and control and the possibility of increasing proficiency and standardization of complex endoscopic procedures including endoscopic submucosal dissection, endoscopic full-thickness resection, and endoscopic suturing. The following review discusses the history, potential applications, and tools currently available and in development for robotics in therapeutic endoscopy.

Novel Colorectal Endoscopic Submucosal Dissection With Double-Endoscope and Snare-Based Traction

BACKGROUND

Colorectal endoscopic submucosal dissection is technically demanding, and the traction offered by gravity, cap, or clip-with-line during conventional endoscopic submucosal dissection remains unsatisfactory. Robotic systems are still under development and are expensive. We proposed double-scope endoscopic submucosal dissection with strong and adjustable traction offered by snaring the lesion with additional scope.

OBJECTIVE

This study aimed to test the novel double-scope endoscopic submucosal dissection with snare-based traction.

DESIGN

This was a retrospective study that reviewed double-scope endoscopic submucosal dissection compared with matched conventional endoscopic submucosal dissection, and size, location, morphology, and pathology between groups were compared.

SETTINGS

This study was conducted in a referral endoscopy center in a local hospital.

PATIENTS

This study included patients with colorectal lesions receiving double-scope endoscopic submucosal dissection and matched conventional endoscopic submucosal dissection.

MAIN OUTCOME MEASURES

The pathological completeness, procedure time, and complications were analyzed.

RESULTS

Fifteen double-scope endoscopic submucosal dissection procedures, with 11 lesions located in the proximal colon with a median size of 40 mm, were performed. The median procedure time of double-scope endoscopic submucosal dissection was 32.45 (interquartile range, 16.03-38.20) minutes. The time required for second scope insertion was 2.57 (interquartile range, 0.95-6.75) minutes; for snaring, 3.03 (interquartile range, 2.12-6.62) minutes; and for actual endoscopic submucosal dissection, 28.23 (interquartile range, 7.90-37.00) minutes. All lesions were resected completely. No major complication was encountered. The procedure time was significantly shorter than that of 14 matched conventional endoscopic submucosal dissections (54.61 [interquartile range, 33.11-97.25] min; p = 0.021).

LIMITATIONS

This was a single-center, single-operator, retrospective case-controlled study with limited cases.

CONCLUSIONS

This study confirmed the feasibility of double-scope endoscopic submucosal dissection with snare-based traction to shorten procedure time and to simplify endoscopic submucosal dissection. Additional trials are required.

Minimally Invasive Endoscopic and Surgical Management of Rectal Neoplasia

Rectal cancer demonstrates a characteristic natural history in which benign rectal neoplasia precedes malignancy. The worldwide burden of rectal cancer is significant, with rectal cancer accounting for one-third of colorectal cancer cases annually. The importance of early detection and successful management is essential in decreasing its clinical burden. Minimally invasive treatment of rectal neoplasia has evolved over the past several decades, which has led to reduced local recurrence rates and improved survival outcomes. The approach to diagnosis, staging, and selection of appropriate treatment modalities is a multidisciplinary effort combining interventional endoscopy, surgery, and radiology tools. This review examines the currently available minimally invasive endoscopic and surgical management options of rectal neoplasia.

Endoscopic submucosal dissection: How to be more efficient?

Endoscopic submucosal dissection (ESD) allows an "en bloc" resection with safety margins (R0 resection) regardless of the size of the lesion. However, while R0 brings a real benefit for the patient, it is not considered sufficient by many experts to justify the technical difficulties and the longer procedure time compared to piecemeal mucosectomy. The aims of this review are to provide several technical and strategical tips to help you save time and become comfortable during ESD procedures. ESD is divided into several intertwined phases: injection, incision, access to the submucosae, and submucosal dissection itself. During injection there are some mistakes that should not be made: a superficial injection, or on the contrary, a too deep injection. A good needle and good injection technique are mandatory. Some techniques, such as repeated injection or prolonged lifting solution, can help maintain the lift. After this step, mucosal incision can be made, taking care to have a good margin to allow an R0 resection. Starting the mucosal incision from a small point allows calibration of the depth of the incision and then obtaining a nice incision. Trimming is also very important to widen submucosal access. Then comes the submucosal dissection itself. Strategies such as the tunnel strategy or the pocket creation method can help to facilitate dissection, but more importantly, traction systems have become unavoidable, especially in the stomach and colon. Most common complications are bleeding and perforation, and they usually can be managed endoscopically.

Robotic Surgery: At the Crossroads of a Data Explosion

BACKGROUND

For the last 20 years, controversies in robotic surgery focused on cost reduction, development of new platforms and technologies, creation and validation of curriculum and virtual simulators, and conduction of randomized clinical trials to determine the best applications of robotics [Leal Ghezzi and Campos in World J Surg 40:2550-2557, 2016].

METHODS

This review explores the robotic systems which are currently indicated for use or development in gastrointestinal/abdominal surgery. These systems are reviewed and analyzed for clinical impact in these areas. In a MEDLINE search of articles with the search terms abdominal, gastrointestinal, review and robotic surgery, a total of 4306 total articles as of 2021 were assessed. Publicly available information, highest cited articles and reviews were assessed by the authors to determine the most significant regarding clinical outcomes.

RESULTS

Despite this increased number of articles related to robotic surgery, ongoing controversies have led to limitation in the use of current and future robotic surgery platforms [Connelly et al. in J Robotic Surg 14:155-165, 2020]. Newer robotic platforms have limited studies or analysis that would allow meaningful definite conclusions. A multitude of new scenarios are possible due to this limited information.

CONCLUSION

Robotic surgery is in evolution to a larger conceptual field of computationally enhanced surgery (CES). Various terms have been used in the literature including computer-assisted surgery or digital Surgery [Ranev and Teixeira in Surg Clin North Am 100:209-218, 2020]. With the growth of technological changes inherent in CES, the ability to validate these improvements in outcomes will require new metrics and analytic tools. This learning feedback and metric analysis will generate the new opportunities in simulation, training and application [Julian and Smith in Int J Med Robot 15:e2037, 2019].