Utility and applicability of endoluminal flexible robotic surgery in therapeutic gastrointestinal endoscopy. Compared to open surgeries, minimally invasive endoscopic procedures have lower adverse events and shorter hospital stays. However, some advanced endoscopic procedures like endoscopic submucosal dissection, notes, ESG, and suturing, they require more skill set, specialized training, and certain amount of experience to achieve competency. Limitations of conventional flexible endoscope are lack of dexterity required to perform useful maneuvers like triangulation of instruments and non-actual tissue manipulations. And the visual field is fixed by the direction of the scope, making visualization difficult when the field is constantly being reoriented with the movement of the scope. Owing to these limitations and long learning curves required for the technically challenging procedures, many different type of endoscopic robotic systems have been developed. Robotic platforms address these technical complexities, henceforth increasing patient access. Endoscopic robotic system consists of physician working console, video tower, and the endoscopic cart. Physician console has monitor, armrest, foot pedals, and right and left hand controllers. Monitor has live view feed of video scope and additional data of graphic user interface also called GUI. The dials in the upper, middle, and lower areas show instruments and video scope positions. Physician console allows the operator to control the instrument with left and right hands and control the camera and electrosurgical unit with the foot pedals. The system has unique two joint instruments at two points, proximal and distal segments, which give forearm as well as wrist maneuvers, allowing more wider angles and rotations at full 360 degrees as well as allowing more freedom of movement. Robotic simulator mimics the interface of actual robot, hence helps the physician to practice skills before using the actual controller. This simulator is composed exactly as the actual robot, having similarly designed hand controllers, monitor, footrest, and pedals. It works with a software which simulates multiple procedures and gives you different training exercises and tasks so that you can practice instrument maneuvering, lesion marking, dissection, needle passing, driving, etc. This helps yourself to evaluate, practice, and sharpen your skills to improve your level of maneuvering the robot before you actually go there. Case Description In this video, we are demonstrating the use of robotic system in ex vivo animal models. Robot Assisted EST. The method used to perform EST with the robotic system is similar to conventional EST technique. We first position and insufflate ex vivo bovine colon. Then we triangulate our instruments, in this case, pincher forceps in the left and scissors in the right hand. Then an injection needle is positioned with grasper assistant to inject the saline solution and the methylene blue to provide a mucosal lift. Lesion is then marked using energy. Then the grasper is used to hold the tissue and provide traction for better exposure and tissue tension to aid in dissection. With traction from grasper on one side, incision is made with scissors facing downwards and then we continue to dissect in submucosal plane all around the lesion until completion. Next we'll demonstrate robotic full thickness resections and defect closure using suturing. Lesions which do not lift or which involve tissue in the muscularis propria or are in difficult spots, they need full thickness resection. Transmural gastrointestinal defects after full thickness resection or even small perforations can easily be managed with endoluminal robot. Here we demonstrate the closure of a transmural defect after full thickness resection with running sutures in a bovine colon. The bimanual control and flexible arms are particularly useful for needle passing and suturing. We use a non-absorbable barbed suture with a round anchor at the end. The barbs on the suture help to keep the tension between stitches during suturing and also simplifies knot tying. With this setup we can perform any kind of suture patterns. Robotic endoluminal sleeve gastroplasty or RESG. Robotic system uses same principles like conventional ESG with suturing the anterior, greater curvature and posterior walls of stomach using an endoscopic full thickness suturing device. The endoscopic robotic system is introduced into the porcine stomach. First we mark the stitch sites on anterior and posterior walls using energy. Then we rotate the overtube to an angle which facilitates our suturing from posterior wall to anterior wall. As you see here the anterior wall is at 9 o'clock and posterior wall is at 3 o'clock positions. We start from the posterior wall at incisor level and start placing the running sutures from there. Subsequent stitches are placed at the greater curvature and then at the anterior wall as you see here which creates the first row in a running pattern. The second suture row is then made in a continuous V pattern. It is placed approximately to first suture with bites along the suture line from posterior to anterior wall. The third suture is done in a running pattern like the first row. Lastly we finish the procedure with reinforced suturing by placing the continuous sutures from distal to the proximal stomach on top of placation in a zigzag configuration. This helps to reduce the tension on each running suture and makes the lumen narrower. So what are the clinical implications? Flexible robot has multi articulating instruments, 360 degree of freedom for movement and it gives full thickness surgical quality suture placement. In nutshell, robotic endoscopy works by improving precision, effectiveness, control, ergonomics, safety, dexterity, visualization and even reliability to increase the proficiency of complex GI procedures. This enhances the interventional capability of endoscopist. The patients also benefit by decreased length of stay in the hospital, lower adverse events and improved quality of life. So to conclude, we demonstrated a fully robotic, flexible endoscopic system in ex vivo animal models showcasing its capability, range and precise suturing techniques. This system simplifies complex GI procedures using multi articulating instruments by improving visualization, exposure and tissue manipulation. It has a potential to shorten the learning curve and broaden the adoption of challenging procedures, henceforth improving the patient outcomes. Further studies are needed to prove the safety and efficacy of the system.

endoluminal flexible robotics

gastrointestinal endoscopy

360-degree movement

procedural precision

patient outcomes