Abbreviation:
ESD (endoscopic submucosal dissection)Robot-assisted surgery was introduced more than 20 years ago. The procedure is associated with several benefits, including 6 degrees of freedom with the endowrist, 3-dimensional optics, eradication of hand tremor, and image-enhanced endoscopic views.
1
The approach is widely adopted in urological procedures and is increasingly adopted in general surgery.2
,3
However, evidence is lacking on what clinical advantages to the patient the robotic approach could provide over conventional minimally invasive surgery. Furthermore, the high overhead cost for purchasing the unit further precludes widespread adoption, particularly in low-income countries.Recently, the robotic concept has been applied to a few novel endoscopic platforms.
4
, 5
, 6
These systems share several design characteristics. First, all of the described robots adopted the “master and slave” platform. The platform requires 1 endoscopist to be with the patient, controlling the movement of the endoscope, while another endoscopist controls the movement of the 2 arms attached to the endoscopic robot with a control cart away from the patient. These endoscopic robots also possess endowrists, which allow 6 degrees of movement similar to that of a human wrist, allowing performance of complex movements with the arms. Outcomes of the Master and Slave Transluminal Endoscopic Robot (MASTER) system used to performed 5 gastric endoscopic submucosal dissections (ESDs) in humans has been reported.4
The resection margins were clear of tumors in all patients, and none of the patients experienced adverse events. This was the world’s first report confirming the feasibility of using a flexible endoscopy robotic system to perform ESD.Nevertheless, a few limitations need to be addressed before these systems can be adopted into routine endoscopic practice. The robotic endoscopic systems are large and need to be introduced with an overtube. This will limit the ability of the system to be inserted deeply in the GI tract. In addition, the arms need to be exchangeable to allow insertion of different devices for different parts of the procedure. Furthermore, the need of an additional endoscopist to control the endoscope movements adds to the complexity of the procedure and hinders easy adoption into clinical practice.
In the current study reported by Ji et al,
7
an alternative direction to the development of a robotic endoscopic system was adopted. A robotic retraction device controlled by an assistant was developed to improve retraction during ESD. By the use of the device, the total procedure time for performing ESD was significantly shorter, and this was achieved with a higher direct-vision dissection rate. This may potentially reduce the learning curve of ESD for beginners. The system also possesses several advantages over the “master and slave” platforms in that the device is an add-on to the endoscope, it can be easily be incorporated into clinical practice, and it allows the endoscopist to perform ESD as per usual. Furthermore, the cost of introducing the device would be significantly lower. Thus, this direction of developing robotic add-ons should be an approach that warrants further development.To be embraced by the endoscopic community, future endoscopic robots should deliver significant improvements that are not achievable with current endoscopic technologies. Consider a self-propelling colonoscope with artificial intelligence–assisted diagnosis incorporated, allowing automated diagnostic colonoscopies to be performed.
8
,9
The system should be able to perform diagnostic colonoscopy smoothly and safely, and it would require human control only when polyps are detected and polypectomy are to be performed. The development of such a system is more likely to be embraced by the community where the robot is used to perform simple repetitive tasks, alleviating the workload of the endoscopist. Furthermore, it can allow standardization and precision in performing the procedure that have not been possible previously.In conclusion, the development of robotic-assisted endoscopy is still in its infancy. There are many potential areas where robotics may be adopted to improve the ease and outcomes of endoscopic procedures. Studies similar to the current study will be required to confirm the clinical benefits of these units if they are to be adopted clinically.
Disclosure
Dr Teoh is a consultant for Boston Scientific, Cook Medical, Taewoong Medical, Microtech Medical, and M.I. Tech Medical.
References
- Future platforms of robotic surgery.Urol Clin North Am. 2022; 49: 23-38
Makary J, van Diepen DC, Arianayagam R, et al. The evolution of image guidance in robotic-assisted laparoscopic prostatectomy (RALP): a glimpse into the future. J Robot Surg. Epub 2021 Sep 4.
- Advanced robotic surgery: liver, pancreas, and esophagus - the state of the art?.Visc Med. 2021; 37: 505-510
- Robot-assisted endoscopic submucosal dissection is effective in treating patients with early-stage gastric neoplasia.Clin Gastroenterol Hepatol. 2012; 10: 1117-1121
- 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; 90: 290-298
- Endoluminal surgical triangulation 2.0: A new flexible surgical robo: preliminary pre-clinical results with colonic submucosal dissection.Int J Med Robot. 2017; 13
- Simplified robot-assisted endoscopic submucosal dissection for esophageal and gastric lesions: a randomized, controlled, porcine study (with videos).Gastrointest Endosc. 2022; 91: 140-147
- Artificial intelligence-assisted colonoscopy: a review of current state of practice and research.World J Gastroenterol. 2021; 27: 8103-8122
- A novel self-propelled disposable colonoscope is effective for colonoscopy in humans (with video).Gastrointest Endosc. 2016; 83: 998-1004.e1
Article info
Publication history
Published online: May 08, 2022
Identification
Copyright
© 2022 by the American Society for Gastrointestinal Endoscopy
ScienceDirect
Access this article on ScienceDirectLinked Article
- Simplified robot-assisted endoscopic submucosal dissection for esophageal and gastric lesions: a randomized controlled porcine study (with videos)Gastrointestinal EndoscopyVol. 96Issue 1
- PreviewEffective countertraction is a main challenging issue in endoscopic submucosal dissection (ESD). Several countertraction methods have been developed to address this issue. The aim of this study was to compare the efficacy of ESD using a novel simplified robot, the flexible auxiliary single-arm transluminal endoscopic robot (FASTER), with a traditional technique.
- Full-Text
- Preview
