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• W2950820171 abstract "Minimally invasive endoscopic procedures are associated with lower adverse events and shorter hospital stays compared with conventional open surgery.1Lomanto D. Wijerathne S. Ho L.K. et al.Flexible endoscopic robot.Minim Invasive Ther Allied Technol. 2015; 24: 37-44Crossref PubMed Scopus (30) Google Scholar, 2Farias G.F.A. Bernardo W.M. De Moura D.T.H. et al.Endoscopic versus surgical treatment for pancreatic pseudocysts: systematic review and meta-analysis.Medicine (Baltimore). 2019; 98: e14255Google Scholar However, some advanced endoscopic procedures, including endoscopic submucosal dissection (ESD), natural orifice transluminal endoscopic surgery (NOTES), and suturing, have typically required specialized training and a certain amount of experience to achieve competency. Therefore, these procedures are not widely performed in nonspecialized centers.3Boškoski I. Costamagna G. Endoscopy robotics: current and future applications.Dig Endosc. 2018; 31: 119-124Google Scholar, 4de Moura D.T.H. Sachdev A.H. Thompson C.C. Endoscopic full-thickness defects and closure techniques.Curr Treat Options Gastroenterol. 2018; 16: 386-405Crossref PubMed Google Scholar, 5Yeung B.P. Chiu P.W. Application of robotics in gastrointestinal endoscopy: a review.World J Gastroenterol. 2016; 22: 1811-1825Crossref PubMed Scopus (57) Google Scholar, 6De Moura D.T. Mestieri L.H. Cheng S. et al.Natural orifice transluminal endoscopic surgery to salvage a migrated stent during EUS-guided hepaticogastrostomy.Gastrointest Endosc. 2016; 83: 656-657Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar Despite the availability of a wide range of accessory devices, including distal attachment caps, electrosurgical knifes, hemostatic forceps, and suturing devices, the conventional flexible endoscopes used in clinical practice struggle to support the performance of advanced endosurgical procedures. They lack the dexterity required to perform useful maneuvers, such as triangulation of instruments and nonaxial tissue manipulation. Transmission of force from operator to point of action is often suboptimal because of the instability of the flexible endoscope. Additionally, the visual field is fixed by the direction of the endoscope, making visualization difficult when the field is constantly reoriented with any movement of the endoscope.3Boškoski I. Costamagna G. Endoscopy robotics: current and future applications.Dig Endosc. 2018; 31: 119-124Google Scholar, 5Yeung B.P. Chiu P.W. Application of robotics in gastrointestinal endoscopy: a review.World J Gastroenterol. 2016; 22: 1811-1825Crossref PubMed Scopus (57) Google Scholar, 7Wong J.Y.Y. Ho K.Y. Robotics for advanced therapeutic colonoscopy.Clin Endosc. 2018; 51: 552-557Crossref PubMed Scopus (13) Google Scholar, 8Hourneax de Moura D.T. Aihara H. Jirapinyo P. et al.Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video).Gastrointest Endosc. 2019; (Epub Mar 25)Google Scholar Owing to the limitations of conventional flexible endoscopes and the long learning curves required for some technically challenging procedures, many different types of endoscopic robotic systems have been developed.3Boškoski I. Costamagna G. Endoscopy robotics: current and future applications.Dig Endosc. 2018; 31: 119-124Google Scholar The main goal of robotic endoscopy is to improve precision, effectiveness, safety, and reliability to enhance the interventional capabilities of endoscopists and to augment the field of possible interventions. Available instruments include dissection tools, graspers, electrocautery devices, and sutures. However, some problems still need to be addressed, including locomotion and instrument control, along with better understanding of clinical applications.1Lomanto D. Wijerathne S. Ho L.K. et al.Flexible endoscopic robot.Minim Invasive Ther Allied Technol. 2015; 24: 37-44Crossref PubMed Scopus (30) Google Scholar, 3Boškoski I. Costamagna G. Endoscopy robotics: current and future applications.Dig Endosc. 2018; 31: 119-124Google Scholar, 5Yeung B.P. Chiu P.W. Application of robotics in gastrointestinal endoscopy: a review.World J Gastroenterol. 2016; 22: 1811-1825Crossref PubMed Scopus (57) Google Scholar, 7Wong J.Y.Y. Ho K.Y. Robotics for advanced therapeutic colonoscopy.Clin Endosc. 2018; 51: 552-557Crossref PubMed Scopus (13) Google Scholar, 8Hourneax de Moura D.T. Aihara H. Jirapinyo P. et al.Robot-assisted endoscopic submucosal dissection versus conventional ESD for colorectal lesions: outcomes of a randomized pilot study in endoscopists without prior ESD experience (with video).Gastrointest Endosc. 2019; (Epub Mar 25)Google Scholar In this video (Video 1, available online at www.VideoGIE.org), possible benefits of robotic assistance applied to complex tissue dissection and defect closure are demonstrated. Equipment characteristics, indications, contraindications, limitations, and possible adverse events are also discussed. The original Flex Robotic System (Medrobotics, Raynham, Mass, USA) was developed for head and neck surgery to provide robotic positioning of flexible instruments and cutting devices. The system did not originally have a seal to maintain insufflation, which is required for GI procedures.9Lang S. Mattheis S. Hasskamp P. et al.A European multicenter study evaluating the flex robotic system in transoral robotic surgery.Laryngoscope. 2017; 127: 391-395Crossref PubMed Scopus (69) Google Scholar, 10Peters B.S. Armijo P.R. Krause C. et al.Review of emerging surgical robotic technology.Surg Endosc. 2018; 32: 1636-1655Crossref PubMed Scopus (275) Google Scholar, 11Persky M.J. Issa M. Bonfili J.R. et al.Transoral surgery using the Flex robotic system: initial experience in the United States.Head Neck. 2018; 40: 2482-2486Google Scholar Recently, the device has been modified to maintain insufflation, allowing transanal access to the sigmoid colon and the deployment of compatible articulating instruments to facilitate tissue dissection. This system was cleared by the U.S. Food and Drug Administration in 2017.12Paull J.O. Pudalov N. Obias V. Medrobotics Flex transanal excision of a rectal gastrointestinal stromal tumour: first video of the transanal Flex robot used in a human - a video vignette.Colorectal Dis. 2018; 20: 1048-1049Google Scholar, 13Atallah S. Hodges A. Larach S.W. Direct target NOTES: prospective applications for next generation robotic platforms.Tech Coloproctol. 2018; 22: 363-371Crossref PubMed Scopus (18) Google Scholar The robot has a flexible and steerable insertion tube, providing access to lesions up to 25 cm from the anal verge, and in the oropharynx, hypopharynx, and larynx. The dimensions of the flexible robotic endoscope are 18 mm × 28 mm, including two 4-mm working channels. The device provides bimanual control, which facilitates the use of 2 instruments. Additionally, a complete set of 2.0-mm to 4.0-mm instruments for grasping, cutting, and suturing are available (Fig. 1). This system also has automatic light control and 3-dimensional visualization with improved depth of field. A system including a longer insertion tube is currently under development, targeting procedures in the upper GI tract and proximal colon. In this video, we demonstrate the use of the robotic system in ex-vivo animal models as it is applied to 4 different procedures. In this procedure, the robot provides a stable position for instrument triangulation in a rather small space. A grasper is used to better expose the tissue planes, and an electrocautery spatula is used to perform the myotomy (Fig. 2). The method used to perform ESD with the robotic system is similar to conventional ESD technique. First, an injection needle is positioned with grasper assistance to inject saline solution and methylene blue to provide a mucosal lift. Next, the grasper is used to hold the tissue and provide traction for better exposure and tissue tension to aid in dissection. In this case, scissors were used to perform the incision and submucosal dissection. However, this procedure can also be performed with other devices such as a spatula or needle-knife (Figure 3, Figure 4, Figure 5).Figure 4Robot-assisted endoscopic submucosal dissection providing better exposure of tissue layers, facilitating dissection.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Endoscopic submucosal dissection by use of a grasper to improve visualization and a scissors to dissect the tissue.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The bimanual control provided by the robotic system was particularly helpful in full-thickness resection. First, an incision was performed with a needle-knife, then traction was applied by use of a grasper, as with the previous ESD procedure. Subsequently, full-thickness resection was performed by use of a spatula, with the help of triangulation to avoid trauma to deep structures (Fig. 6). Another advantage of the system is the ability to close the defect with suturing after resection. The bimanual control and flexible arms are particularly useful for suturing. When a curved needle and barbed suture are used, most suture patterns are possible. The barbed suture also simplifies knot tying. In this video we demonstrate the closure of a transmural defect after full-thickness resection with running sutures (Figs. 7 and 8). The suturing applications for this device are likely broad and may also include antireflux and bariatric procedures.Figure 8Final appearance after suturing a transmural defect after full-thickness resection.View Large Image Figure ViewerDownload Hi-res image Download (PPT) Because of the relatively large size of the equipment, introduction and removal should be performed with caution. Additionally, as with any other therapeutic endoscopic procedures, adverse events such as perforation and bleeding can occur. Robotic-assisted surgical endoscopy is technically feasible. This system appears to simplify complex procedures by improving visualization, exposure, and tissue manipulation. It has the potential to shorten the learning curve and broaden the adoption of challenging procedures, including tissue dissection, NOTES, suturing, and other techniques. Further clinical studies are warranted." @default.
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• W2950820171 title "Robotic-assisted surgical endoscopy: a new era for endoluminal therapies" @default.
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