Robotic endoluminal sleeve gastroplasty, procedure development and technical feasibility. Endoscopic bariatric therapy has emerged as an alternative minimally invasive treatment for patients with obesity. Endoscopic sleeve gastroplasty can provide good weight loss outcomes with a low adverse event rate. Basic principle of ESG involves suturing the anterior, greater curvature and posterior walls of the stomach using an endoscopic full thickness suturing device. This reduces the length and the width of the stomach leading to volume reduction and alteration of gastric emptying with resultant weight loss and comorbidity resolution. However, due to procedural and device complexities, the learning curve is long, limiting adoption of the conventional technique. Similar to surgery, robotic platforms may address many of the procedural challenges and allow more patients to benefit from this less invasive approach. The endoscopic robotic system consists of the two units, the physician working console and the endoscopic cart. The physician console allows the operator to control the instrument with left and right hands and control the camera and electro-surgical unit with the foot paddles. The endoscopic cart consists of an 18mm robotic overtube that has 4-way tip deflection. The overtube includes 6 channels, one 4.2mm channel for the camera, two 7mm channels for instruments, one 3mm accessory channel for the assistants and two insufflation channels. Also, the movement of the jointed instruments can facilitate suturing in difficult angles with improved precision. In this video, we demonstrate a novel approach to endoscopic sleeve gastroplasty using a fully robotic endoscopic system in a porcine stomach model. The endoscopic robotic system was first introduced into the porcine stomach. The heads-up display shows the position and status of the instruments. The dial to the left upper corner shows the amount of tip deflection. The dials in the middle row show the torque of left and right instruments which can aid in clutching and precise instrument manipulation. A hook caudry was used to mark the stiches side on the posterior and anterior wall of the stomach. The overtube was then rotated 90 degrees counterclockwise to facilitate suturing. As labeled here, the posterior wall is now located at the 3 o'clock position and the anterior wall at 9 o'clock position. The first suture was placed at the level of the incisora using a running suture pattern. As shown here, the first stitch was placed on the posterior wall of the stomach. We used a non-absorbable 3-hole barbed suture that came with a round anchor on one end. The barbs on the suture helped keep tension between stitches during suturing. Subsequent stitches were placed at the greater curvature then at the anterior wall which was located on the left hand side. It is important to keep the insufflation pressure to moderate. Over insufflation can cause the tissue folds to fall apart or loosen the placation. At the end of the suture we cut the needle part of the suture and created a surgical knot with another barbed suture to secure all the stitches. This is the first roll of suture with a total of 6 stitches placed in a running pattern. The second suture was performed using a continuous V pattern. The suture was placed approximately to the first suture. 7 bites were placed along the suture line from the posterior to the anterior wall of the stomach. At the tip of the V figure, we placed one backward suture and cut the needle. Due to the short length of the suture, we used another suture to finish this V pattern. Here we started sewing the other limb of the V-pattern on the posterior wall, proximal to the previous sewer. The total of 12 stitches were made in the continuous V-pattern. At the end of both sewers, surgical knot was made to connect the two sewers together to create a V-shape. The third suture was performed using a running suture pattern, similar to the first row of suture. Lastly, we finished the procedure with the reinforced suture by placing the continuous suture from the distal to proximal stomach, on top of the placation in a zigzag configuration. The reinforcement will help reduce the tension on each running sutures and also making the lumen more narrow. At the end of the suture line, replace another barb suture and complete it with a surgical knot. At the end of the procedure, the gastric lumen was reduced to about half compared to the pre-procedural state. Here is the final appearance of the endoscopic sleeve gastroplasty performed using the robotic system on the left and the conventional endoscopic suturing device on the right. And here is the external appearance of the post-scene stomach before and after the procedure. For the clinical implications, the multi-articulating instruments may better standardize the procedure and allow endoscopists with less experience to perform high-quality procedures. And by achieving consistent full-thickness surgical-quality suture placement, this may result in more durable restriction and improved weight loss outcomes. To the conclusion, this video demonstrates the technical feasibility of a fully robotic endoluminal sleeve gastroplasty. The endoscopic robotic system has potential to enhance procedural performance allowing a broader range of endoscopists to offer the technique. Further studies are needed to prove the safety and efficacy of this novel procedure.

Robotic endoluminal sleeve gastroplasty

minimally invasive procedure

obesity treatment

endoscopic full-thickness suturing device

weight loss outcomes