Okay. Thank you. So, I'm going to talk about the robotic-assisted ESD. So, it might be a future of ESD. This is my disclosure slide. So, this is the study by Dr. Stavros' group looking at the number of ESD cases to achieve mastery. So, when the mastery is defined as a fast dissection, unblock resection, and R0 resection. So, he concluded that we need to express 170 cases of esophageal ESD, 160 cases of gastric ESD, 280 cases of colonic ESD, and then 70 cases of rectal ESD to achieve mastery. So, what makes the ESD challenging? So, this is one of the video of the fellows trying to do ESD. So, one of the most challenging portion is to utilize the cap to stabilize the target tissue. We don't have a second hand to hold the mucosal flap, and then we need to use the cap. But right now, we have the traction method. So, but conventional ESD, we typically do not have those assistive techniques. So, that's the one of the challenging part of the ESD. So, if you look at the design of the current flexible endoscopes, there are a few issues. So, we only have the single channel that only allows us to use one device at a time. And also, if you look at the movement of the scope, we only have the up and down, and the left and right, and then left and right torque, and advance and move backwards. So, this is one of the limitation of the current flexible endoscope. But we are required to perform complex procedures by using this therapeutic single channel endoscopes. So, but if you look at the surgery, as you can see here, so basically, you can see the surgeon's scissors, and also surgeon's left hand is holding the tissue for the traction, and their assistant is holding the tissue for the counter traction. So, this will create a very stable condition during the surgery. So, which is the basically the dissection, which basically needs to be done during the ESD. If you look at the video, like a bottom video, you can also see that the surgeon's left hand is continuously moving to apply the traction, and also open up the dissection plane. So, this is the ideal situation for those dissection, and also hemostatic procedures. Also, this is the video showing the difference between the laparoscopic suturing, and also the robotic suturing. So, in the laparoscopic suturing, you can see that the surgeon is having difficulty just catching the needle. This is because there is a length, so you need to use the grasping part to do the maneuver of the very like a small tip of the laparoscopic tools. But if you look at the right side video, which shows the robotic suturing, because there are a lot of joints on the robotic parts, you have like a very precise maneuver, and then the surgical field is very stable. And then that robotic technology gives you the dexterity to do these fine procedures. So, in the past, probably it's like 20, no, 15 years ago, there are a few new surgery platforms, including transport from USGI, anabescope from Cardstords, and the endosamurai from Olympus, and the DDS from Boston Scientific. But all of these didn't become the standard of use because of the lack of the technology at that time. So, currently, we have this mesorobotic, I think that this actually company has bankrupted. But as you can see, this is the like allows the bi-manual control of the device, which is the most important part for these trans-intraluminal surgery. So, what do we have for the next generation robotic system? Oh, sorry. So, we also did the study employing by employing the five fellows with no experience in the conventional ESD as well as the robotic ESD. And then the robotic ESD showed significantly higher complete resection rate, and also the significantly shorter procedure time, and a lower perforation rate. So, it suggests that there's a possibility that these robotic technology might improve the learning curve to achieving the mastery in ESD. So, I'm going to just introduce this is not still FDA approved. But this is the company from Texas developed this very new endoscopic robotic system, which used to be called Colbriss MX, but now it's called EndoQuest. So, it consists of this flexible robot, and then surgeons console and the HD display. And we are allowed to use different type of devices, including needle driver, pinching forceps, cardio forceps, needle knife, and curved scissors, and grasping forceps. So, we have two arms and also one like eye from with the ultrasound endoscope. And then it's the maneuver itself is the same as that of the da Vinci system. So, surgeons have the ability like precise control, like up and down, and the left and right and the rotate. So, and then you can change the target device. And also you can take pictures. And also you can see cut and quark pedal. So, this is the actual maneuver of the device on the top, left and right, you can see the whole picture of the device. And then the middle left and right, you can see what which devices are used. And then the bottom you can see the mother and the daughter scopes movement. So, you can see that it allows the triangulation of the device. And also that has the potential to have the attraction and counter attraction for endoscopic surgery. So, this is actually the video. It's a little fast forward, but done by surgeon doing ex vivo and EST type procedures. So, as you can see, the left hand is holding the target tissue, while the right hand is dissecting the submucosa. And then for the closure, it is allow us to do the surgical type of procedures. And we have extra assistive device to hold the suture. And then the running stitch can be done by using this robotic system. Okay, so this system looks promising. But so basically, the robotic technology has the potential to facilitate the adoption of EST by providing the precision, stability and also dexterity to the surgical tools. However, there are a few possible limitations of the robotic platform, including the training. So, is it for GI or surgeons or and also the cost that to take cost probably over a million by one system and also the target organ. So, with the current design, we cannot put the scope to the especially for the right colon or distal stomach. So, there are a few significant kind of limitations of this robotic system. Thank you very much. Thank you. Any questions? So, Dr. Yehaghi, you can speed up your video. So, instead of 11 minutes, it will take two minutes like the surgeon. Yeah, I know that that system has a 20 millimeter diameter for now. So, yeah, they're working on getting smaller. So, so the limitation is that the scope is mounted on the robotic system. So, you will not be able to like, like advance the scope through the patient body. So, that's the biggest limitation. Okay, thank you very much. Thank you.

robotic-assisted endoscopic submucosal dissection

ESD procedures

flexible endoscopes

EndoQuest

bi-manual control