Flexible Endoscopic Robotic Rectal ESD altered by Tiago Souza, Manuel Galvão Neto, Vitor Sagai, Eduardo Greco, Luis Quadros, Eric Wilson, Todd Wilson and Fawes Maluf. Those are the group disclosures, as well as the keywords. The video case is about a 62-year-old female subject with 20 mm polyploid lesions at 10 cm of anal verge that was stated by digital chemoscopy as having a 3L on Kudug-like classification and by endosonography as T1N0MX that fulfills the study inclusion criteria being aged and clinically fit, with lesions from 4 to 17 cm of anal verge at T2N0MX. This is the pre-op colonoscopy, as stated, where we can see the various types of digital chemoscopy that can define the lesion as well of some of the vessels that is interesting for the resection, even this new one trying to address those irrigations. And also the endosonography that can show us the polyploid lesion without signs of invasion. At the moment of the case, per protocol, we perform a colonoscopy to confirm the previous findings, check the colon prep, and also confirm that flexible robotic procedure is a goal. After that, we dock the robot and its optics, we navigate up to the lesion, insert the robotic instrument under direct vision, then we inject a solution of voluvene, indigo carmine to lift the lesion, and a robotic ESD is performed with hemostasis at the end. On the following, we present some images in how the system works, so we have the master scope, and also have a video scope, as you can see here, that we can amplify the movements 60 degrees to each side, in addition to the 60 degrees that the endoscope has itself. You can see also how the instruments can move inside and outside, and can rotate and translate. And we have some automated movements that we are about to show, that is right now, so you have the neutral position, and also have this ready position that put us with triangulation ready. Now is the case itself. And on these three images, you can see the console and the robots, and also you see the lesion, now we are lifting the lesion, you can see that on the console we have the younger from the team, and on the robot we have the more senior. And what we are using right now, we lift the lesion with a pinching forceps, and we have this scissor that can dissect, can cut, can apply monopolar coagulation as well, so you can clearly see that the movements are precise, and the dissection is carried on in a very controlled way. So, specifically in that case, after the initial use of the scissor, we lift again the submucosal space, and we proceed with a ball-chip knife that we are about to show to you, and the intention was to lift circumferentially all the lesion, and with the ball-chip knife cut in a circumferential way, as we can see here. That after lifting, we proceed with traction and contraction, exposing the tissue, allowing a circumferential dissection, and keeping the bird-eye view in exposure of the lesion. That is quite different from the traditional ESG carry-out by the regular and traditional scopes. And again, we're lifting the lesion, cutting again, and you can see here that this is a very controlled way, and we are about to close the circle around the lesion. And the interesting is to see how the traction and contraction can help expose the lesion, and again, in a very different way of the traditional ESG, so we can clearly identify the muscular layer from the submucosal space, and we continue with the dissection. This is a controlled dissection, as you can see, even parts that you have some fibrosis, we can clearly define the muscular layer and the submucosal space, and keeping the triangulation that we miss a lot from the traditional endoscopic methods, so it's pretty much what we are used to, the laparoscopic robotics. So, we got up to the end of the dissection, freeing the lesion itself. Now, we're going to apply some coagulation to possible points of further bleeding, and you can see again the team on the robot, the team on the console, and now we get a rot net, we acquire the lesion, and we can extract the lesion to the video scope port without needing to withdraw the lesion. So, now we can clearly see, without the instruments, all the dissection, with no further bleeding, and the robot is withdrawn under direct vision. Now, we see the aspects of the retrieved specimen. In terms of clinical implications, the use of robotic platform brings to endoscopy the ability of having traction, contra traction in a surgical fashion. Triangulation, a long time-desired capability that flexible and robotic brings to endoscopy as well, and the bird-eye vision give us a different perspective of the lesion. And besides not use it on that case, the platform allows endoscopic suturing. And we will conclude by saying that the pathology results identify a T1 adenocarcinoma in a R0 resection, and this feasibility video demonstrate that flexible endoscopic cryoactoESD can be done effectively and in a safe manner.

flexible endoscopic robotic rectal ESD

polyploid lesions

62-year-old female patient

robotic system

dissection