Abstract
Minimally Invasive Surgery (MIS) imposes a trade-off between non-invasive access and surgical capability. Treatment of early gastric cancers over 20 mm in diameter can be achieved by performing Endoscopic Submucosal Dissection (ESD) with a flexible endoscope; however, this procedure is technically challenging, suffers from extended operation times and requires extensive training. To facilitate the ESD procedure, we have created a deployable cable driven robot that increases the surgical capabilities of the flexible endoscope while attempting to minimize the impact on the access that they offer. Using a low-profile inflatable support structure in the shape of a hollow hexagonal prism, our robot can fold around the flexible endoscope and, when the target site has been reached, achieve a 73.16% increase in volume and increase its radial stiffness. A sheath around the variable stiffness structure delivers a series of force transmission cables that connect to two independent tubular end-effectors through which standard flexible endoscopic instruments can pass and be anchored. Using a simple control scheme based on the length of each cable, the pose of the two instruments can be controlled by haptic controllers in each hand of the user. The forces exerted by a single instrument were measured, and a maximum magnitude of 8.29 N observed along a single axis. The working channels and tip control of the flexible endoscope remain in use in conjunction with our robot and were used during a procedure imitating the demands of ESD was successfully carried out by a novice user. Not only does this robot facilitate difficult surgical techniques, but it can be easily customized and rapidly produced at low cost due to a programmatic design approach.
Highlights
Endoscopic Submucosal Dissection (ESD) is a novel surgical technique for removal of large early gastric cancers with no risk of lymph node metastasis (Kang et al, 2011)
ESD enables en bloc and histologically complete resection of cancers over 20 mm in diameter, which would be removed in separate parts, known as piecemeal removal, if Endoscopic Mucosal Resection (EMR) were used
These disadvantages arise because of the technical difficulty associated with ESD, which is evidenced by the high number of supervised procedures that are necessary to learn the technique (Najib Azmi et al, 2016)
Summary
Endoscopic Submucosal Dissection (ESD) is a novel surgical technique for removal of large early gastric cancers with no risk of lymph node metastasis (Kang et al, 2011). The STIFF-FLOP project was one of the first that demonstrated the use of soft robotics in minimally invasive surgery and has inspired a great deal of research Despite their intrinsic safety benefits, common limitations of soft devices include low force exertion, poor controllability, a lack of integrated sensors and complex manufacture (Rus and Tolley, 2015). Using a laser welding manufacturing technique, we have the capability to rapidly and economically produce low-profile inflatable structures by heat-sealing thermoplastic sheet material in specific weld patterns This means devices can have a smaller size when not in use. The variable stiffness properties, force exertion capabilities and pre-clinical testing are described
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