Robotics in endoscopy

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.

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.

Clinical adoption of robotics in endoscopy: Challenges and solutions

The endoscope was traditionally used as a diagnostic instrument. In past decades, it has increasingly been adapted for therapeutic intents. Subsequently, the master–slave robotic concept was introduced into the field of endoscopy to potentially reduce the difficulty and complication rates of endoscopic therapeutic procedures. As interest in robotic endoscopy intensified, progressively more robotic endoscopic platforms were developed, tested, and introduced. Nevertheless, the future of robotic endoscopy hinges on the ability to meet specific clinical needs of procedurists. Three aspects are vital in ensuring continued success and clinical adoption of the robotic endoscope—demonstration of clinical safety and cost‐efficacy of the device, widespread availability of directed training opportunities to enhance technical skills and clinical decision‐making capabilities of the procedurist, and continued identification of new clinical applications beyond the current uses of the device. This review provides a brief discussion of the historical development of robotic endoscopy, current robotic endoscopic platforms, use of robotic endoscopy in conventional therapeutic endoscopic procedures, and the future of robotic endoscopy.

Robotics in flexible endoscopy: current status and future prospects

PURPOSE OF REVIEW

Advanced endoscopy procedures are technically challenging and require extensive training. Recent technological advances made in computer science and robotics have the potential to enhance the performance of complex intraluminal and transluminal interventions and potentially optimize precision and safety. This review covers the different technologies used for robot-assisted interventions in the gastrointestinal tract, organized according to their clinical availability, and focusing on flexible endoscopy-based systems.

RECENT FINDINGS

In the curvilinear gastrointestinal anatomy, robotic technology can enhance flexible endoscopes to augment effectiveness, safety, and therapeutic capabilities, particularly for complex intraluminal and transluminal interventions. Increased visual angles, increased degrees of freedom of instrumentation, optimized navigation, and locomotion, which may lead to a reduced physician learning curve and workload, are promising achievements with the promise to ultimately replace conventional endoscopy techniques for screening and therapeutic endoscopy.

SUMMARY

The majority of these devices are not commercially available yet. The best clinical applications are also currently being researched. Nonetheless, robotic assistance may encourage surgeons to use flexible endoscopes to administer surgical therapies and increase interest among gastroenterologists in advanced therapies. Robotics may be a means to overcome the technical obstacles of incisionless natural orifice procedures and favor an increased adoption of complex endoscopic procedures such as third-space therapies.

The Future of Robotic Surgery in Pediatric Urology: Upcoming Technology and Evolution Within the Field

Since the introduction of the Da Vinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) in 1999, the market for robot assisted laparoscopic surgery has grown with urology. The initial surgical advantage seen in adults was for robotic prostatectomy, and over time this expanded to the pediatric population with robotic pyeloplasty. The introduction of three-dimensional visualization, tremor elimination, a 4th arm, and 7-degree range of motion allowed a significant operator advantage over laparoscopy, especially for anastomotic suturing. After starting with pyeloplasty, the use of robotic technology with pediatric urology has expanded to include ureteral reimplantation and even more complex reconstructive procedures, such as enterocystoplasty, appendicovesicostomy, and bladder neck reconstruction. However, limitations of the Da Vinci Surgical Systems still exist despite its continued technological advances over multiple generations in the past 20 years. Due to the smaller pediatric market, less focus appears to have been placed on the development of the smaller 5 mm instruments. As pediatric urology continues to utilize robotic technology for minimally invasive surgery, there is hope that additional pediatric-friendly instruments and components will be developed, either by Intuitive Surgical or one of the new robotic platforms in development that are working to address many of the shortcomings of current systems. These new robotic platforms include improved haptic feedback systems, flexible scopes, easier maneuverability, and even adaptive machine learning concepts to bring robotic assisted laparoscopic surgery to the next level. In this report, we review the present and upcoming technological advances of the current Da Vinci surgical systems as well as various new robotic platforms, each offering a unique set of technological advantages. As technology progresses, the understanding of and access to these new robotic platforms will help guide pediatric urologists into the next forefront of minimally invasive surgery.

Haptic feedback is useful in remote manipulation of flexible endoscopes

Background and study aims  We developed the Endoscopic Operation Robot (EOR) version 3, offering built-in haptic feedback and manipulation of the entire scope with one hand. Manipulation of the flexible endoscope is done entirely remotely. However, inclusion of haptic feedback places a huge burden on the system. Our purpose in this study was to determine whether haptic feedback is needed in remote manipulation of a flexible endoscope. Methods  Five endoscopists performed total colonoscopy using a colonoscopy training model. A trial was conducted in which the endoscope was inserted up to the cecum five times with haptic feedback and five times without haptic feedback. Insertion time, maximum and mean haptic force, and incidence of sigmoid colon overstretching were compared between groups. Results  Insertion time was significantly shorter with haptic feedback than without, and overstretching of the sigmoid colon was less frequent. Insertion could thus be performed without using excessive force. Conclusion  Haptic feedback is useful for remote control manipulation of flexible endoscopes.

Flexible robotic endoscopy: current and original devices

Two current major research topics concern the incorporation of flexible robotic endoscopy systems developed for natural-orifice translumenal endoscopic surgery (NOTES), primarily for the purpose of remote forceps operation, into endoscopic submucosal dissection (ESD) and other flexible endoscopic treatments and the use of robots for the manipulation of flexible endoscopes themselves with the aim of enabling the remote insertion of colonoscopes, etc. However, there are still many challenges that remain to be addressed; the ideal robotic endoscope has not yet been realized. This article reviews the ongoing developments and our own efforts in the area of flexible robotic endoscopy.

Review of emerging surgical robotic technology

BACKGROUND

The use of laparoscopic and robotic procedures has increased in general surgery. Minimally invasive robotic surgery has made tremendous progress in a relatively short period of time, realizing improvements for both the patient and surgeon. This has led to an increase in the use and development of robotic devices and platforms for general surgery. The purpose of this review is to explore current and emerging surgical robotic technologies in a growing and dynamic environment of research and development.

METHODS

This review explores medical and surgical robotic endoscopic surgery and peripheral technologies currently available or in development. The devices discussed here are specific to general surgery, including laparoscopy, colonoscopy, esophagogastroduodenoscopy, and thoracoscopy. Benefits and limitations of each technology were identified and applicable future directions were described.

RESULTS

A number of FDA-approved devices and platforms for robotic surgery were reviewed, including the da Vinci Surgical System, Sensei X Robotic Catheter System, FreeHand 1.2, invendoscopy E200 system, Flex® Robotic System, Senhance, ARES, the Single-Port Instrument Delivery Extended Research (SPIDER), and the NeoGuide Colonoscope. Additionally, platforms were reviewed which have not yet obtained FDA approval including MiroSurge, ViaCath System, SPORT™ Surgical System, SurgiBot, Versius Robotic System, Master and Slave Transluminal Endoscopic Robot, Verb Surgical, Miniature In Vivo Robot, and the Einstein Surgical Robot.

CONCLUSIONS

The use and demand for robotic medical and surgical platforms is increasing and new technologies are continually being developed. New technologies are increasingly implemented to improve on the capabilities of previously established systems. Future studies are needed to further evaluate the strengths and weaknesses of each robotic surgical device and platform in the operating suite.

Robotic-assisted flexible colonoscopy: preliminary safety and efficiency in humans

BACKGROUND AND AIMS

The flexible endoscope is used as a platform for minimally invasive interventions. However, control of the conventional endoscope and multiple instruments is difficult. Robotic assistance could provide a solution and better control for a single operator. A novel platform should also enable interventions in areas that are currently difficult to reach. This study evaluates the safety and efficacy of a robotic platform that guides a conventional endoscope through the large bowel.

METHODS

Adult patients scheduled for routine diagnostic colonoscopy were included in this feasibility study. The endoscope was introduced using a robotic add-on to provide tip bending and air/water actuation. The endoscopist directly controlled the endoscope shaft. Upon cecal intubation, the add-on was detached and the procedure continued using conventional control. Primary evaluation parameters were the number of serious adverse events and the percentage of successful cecal intubations.

RESULTS

The procedure was performed on 22 consecutive patients who all gave informed consent. There were no serious adverse events. Cecal intubation was successful in 15 patients (68%) using the robotic add-on. Six cases were completed after conversion to conventional control: 3 cases were converted to pass sharp angulation in the flexures and 3 cases were converted after technical difficulties. One case was not successful with either technique because of severe diverticulosis.

CONCLUSIONS

The robotic add-on steering module allows safe endoscope intubation to reach intervention sites throughout the large bowel. The next step is to clinically evaluate complementary instrument and shaft-guiding modules in therapeutic procedures.