Slave Transluminal Endoscopic Robot Research Articles

Erratum to “Development of a Novel Gastrointestinal Endoscopic Robot Enabling Complete Remote Control of All Operations: Endoscopic Therapeutic Robot System (ETRS)”

[This corrects the article DOI: 10.1155/2019/6909547.].

Development of a Novel Gastrointestinal Endoscopic Robot Enabling Complete Remote Control of All Operations: Endoscopic Therapeutic Robot System (ETRS).

Background and Objective The master and slave transluminal endoscopic robot and other flexible endoscopy platforms are designed primarily for the remote control of forceps, with manipulation of the endoscope itself still dependent on conventional techniques. We have developed an endoscopic therapeutic robot system (ETRS) that provides complete remote control of all forceps and endoscope operations. Method We carried out endoscopic submucosal dissection (ESD) in porcine stomachs using the ETRS. All procedures were completed with the endoscopist seated at the console the entire time. Results Total en bloc resection was achieved in all 7 cases with no complications. The mean total procedure time was 36.14 ± 14.98 min, the mean size of the resected specimen was 3.39 ± 0.66 cm × 3.03 ± 0.63 cm, and the mean dissection time was 14.91 ± 8.61 min. Conclusion We successfully used the ETRS to perform completely remote-controlled ESD in porcine stomachs.

Global Evaluative Assessment of Robotic Skills in Endoscopy (GEARS-E): objective assessment tool for master and slave transluminal endoscopic robot.

Background and study aims The Master and Slave Transluminal Endoscopic Robot (MASTER) is a novel robotic endosurgical system with two operating arms that offer multiple degrees of freedom. We developed a new assessment tool, the Global Evaluative Assessment of Robotic Skills in Endoscopy (GEARS-E), derived from existing tools in laparoscopic and robotic surgery, and evaluated its utility in the performance of procedures using MASTER. Methods This was a pilot study conducted in vivo and ex vivo on animals. Three operators (Novice-1, Novice-2 and Expert) performed a total of five endoscopic submucosal dissections (ESD) using MASTER. Novice operators had no MASTER experience and the expert had previously performed eight MASTER ESDs. Operator performance was assessed by four independent evaluators using GEARS-E, which has a maximum score of 25 for five domains representing various skill-related variables (depth perception, bimanual dexterity, efficiency, tissue handling and autonomy). Results The mean global rating scores for Novice-1 first attempt, Novice-1 second attempt, Novice-2 first attempt, Novice-2 second attempt and Expertʼs cases were 13.0, 16.0, 13.3, 15.5, and 21.5, respectively. The mean scores of each of the five domains were statistically higher for the second attempts compared to the first attempts for both Novice-1 and Novice-2. The mean scores of each of the five domains for the Expertʼs case were consistently higher than those for the two novice operators in both their first and second attempts. Conclusion Results using GEARS-E showed correlations between surgical experience and MASTER ESD. As an assessment tool for evaluation of surgical skills, GEARS-E has great potential for application in MASTER procedures.

Review of emerging surgical robotic technology.

The use of laparoscopic and robotic procedures has increased in general surgery. Minimally invasive robotic surgery has made tremendous progress in a relatively short period of time, realizing improvements for both the patient and surgeon. This has led to an increase in the use and development of robotic devices and platforms for general surgery. The purpose of this review is to explore current and emerging surgical robotic technologies in a growing and dynamic environment of research and development. This review explores medical and surgical robotic endoscopic surgery and peripheral technologies currently available or in development. The devices discussed here are specific to general surgery, including laparoscopy, colonoscopy, esophagogastroduodenoscopy, and thoracoscopy. Benefits and limitations of each technology were identified and applicable future directions were described. A number of FDA-approved devices and platforms for robotic surgery were reviewed, including the da Vinci Surgical System, Sensei X Robotic Catheter System, FreeHand 1.2, invendoscopy E200 system, Flex® Robotic System, Senhance, ARES, the Single-Port Instrument Delivery Extended Research (SPIDER), and the NeoGuide Colonoscope. Additionally, platforms were reviewed which have not yet obtained FDA approval including MiroSurge, ViaCath System, SPORT™ Surgical System, SurgiBot, Versius Robotic System, Master and Slave Transluminal Endoscopic Robot, Verb Surgical, Miniature In Vivo Robot, and the Einstein Surgical Robot. The use and demand for robotic medical and surgical platforms is increasing and new technologies are continually being developed. New technologies are increasingly implemented to improve on the capabilities of previously established systems. Future studies are needed to further evaluate the strengths and weaknesses of each robotic surgical device and platform in the operating suite.

Feasibility of performing esophageal endoscopic submucosal dissection using master and slave transluminal endoscopic robot.

Feasibility of performing esophageal endoscopic submucosal dissection using master and slave transluminal endoscopic robot.

Recent advances in natural orifice transluminal endoscopic surgery†.

Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.

Enhancing proficiency in performing endoscopic submucosal dissection (ESD) by using a prototype robotic endoscope.

Background and study aims: One of the challenges in performing endoscopic submucosal dissection (ESD) is the lack of counter traction during submucosal dissection. MASTER (Master and Slave Transluminal Endoscopic Robot) was designed to allow performance of complex endoluminal procedures using two arms with excellent control. This study aimed to compare the performance of ESD between endoscopists and novices using MASTER. Methods: This is a prospective study comparing the differences in performing ESD using MASTER in an ex vivo porcine stomach model among individuals with or without experience in surgery and endoscopy. Multiple standardized lesions of 20 mm2 were pre-marked on an ex vivo porcine stomach. Each participant received basic training in controlling MASTER before the ESD procedure. The operative time and size of specimen obtained by each participant were noted. Results: Nine individuals (three ESD expert endoscopists, three ESD non-expert endoscopists, and three non-clinician novices) participated in the experiment. All participants completed the ESD procedure for en bloc resection of standardized lesions using EndoMASTER without perforation. The mean times (mean ± SD) taken by ESD expert endoscopists, ESD non-expert endoscopists, and novices to complete Robotic ESD were 122 ± 58 s, 203 ± 150 s, and 561 ± 496 s, respectively. There was no statistically significant difference in the mean operative time to complete the ESD between the three groups (P = 0.242). When the performance of the six endoscopists was compared to that of the three novices, the endoscopists took an average of 162 ± 111 s to complete the ESD, while the non-clinicians required an average of 561 ± 496 s (P = 0.085). Conclusions: There was a trend to shorter operative time when comparing endoscopists to non-endoscopists in performing ESD using MASTER. The use of MASTER enabled the novice without endoscopy experience to complete the ESD procedure.

Development of a novel endoscopic manipulation system: the Endoscopic Operation Robot ver.3.

The next generation of flexible endoscopy platforms such as The Master and Slave Transluminal Endoscopic Robot (MASTER) is primarily for remote control manipulation of forceps, but manipulation of the flexible endoscope itself still depends on conventional techniques. We have developed the Endoscopic Operation Robot (EOR) ver.3, which incorporates haptic feedback to provide complete remote control flexible-endoscope manipulation. The present study aimed to evaluate the performance of the EOR ver.3. A colonoscopy training model was used with scope insertion to the cecum. Force during insertion and insertion time (seconds) to the cecum were evaluated. The data were compared by colon zone and experience level (trainee or expert). The mean insertion time into the cecum was 118.54 ± 89.42 seconds. Stronger force and torque were required for deeper insertion of the scope. Expert and trainee endoscopists differed in the insertion time to the cecum, maximum counterclockwise torque, mean clockwise torque, and mean counterclockwise torque. The EOR ver.3 has operability with which endoscopists can easily familiarize themselves.

496 Enhancing Proficiency in Performing Endoscopic Submucosal Dissection (ESD) by a Prototype Endoscopic Robotic Platform - a Comparison Between Expert and Novice Endoscopists

Background & Aim: One of the challenges in performing ESD is the lack of counter traction during submucosal dissection and difficulty in mastering the techniques. The MASTER (Master And Slave Transluminal Endoscopic Robot) was designed to allowed performance of complex endoluminal surgery using two arms with excellent control. This study aims to investigate whether the use of MASTER can enhance the performance of ESD among endoscopists with different background and experience.

Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by overstitch: a preclinical study

Gastric submucosal tumors are often treated by laparoscopic wedge resection. This study aimed to examine the feasibility of gastric full-thickness resection through a totally endoscopic approach using the master and slave transluminal endoscopic robot (MASTER), and closure of the luminal defect with an endoscopic suturing device. The operation was performed in two live porcine models under general anesthesia. First, the anterior wall of the stomach was slung to the abdominal wall using a percutaneous suturing device. An imaginary 5-cm lesion was marked using a needle knife. After the initial mucosal incision was made using an IT knife, the MASTER was introduced through a long overtube. A circumferential mucosal incision was completed with the MASTER to expose the muscularis propria which was grasped and incised to the serosal layer by electrocautery applied through the hook of the MASTER. The full-thickness resection of the gastric wall was completed with retraction using the grasper and dissection using the hook. While the defect was being created, the luminal space was maintained with traction of the percutaneous sutures. The defect was closed with suture plication using an Apollo Overstitch device. Two full-thickness gastric resections were performed in two nonsurvival porcine models (body weight = 30 and 35 kg, respectively) using the MASTER. The total procedure time was 56 min for the first model and 70 min for the second model. The luminal view was maintained during the whole procedure, and there was no damage to surrounding organs throughout the whole procedure. The gastric defects were closed successfully using Overstitch, with satisfactory gastric distension and no gas leakage afterward. The current experiment demonstrated the feasibility and safety of a totally endoscopic approach for the treatment of gastric submucosal tumors: full-thickness resection with the MASTER and successful closure of the defect using Overstitch.

Endoscopic submucosal dissection of gastric lesions by using a master and slave transluminal endoscopic robot: an animal survival study

The feasibility of performing endoscopic submucosal dissection (ESD) using the Master and Slave Transluminal Endoscopic Robot (MASTER), a robotics-enhanced surgical system, has been shown in our previous study. This study aimed to further explore, in an animal survival study, the 2-week outcome of using MASTER to perform ESD. In this prospective study, ESD was performed on five female pigs (weighing 32.4 - 36.8 kg) under general anesthesia using the MASTER. The animals were observed for 2 weeks before being humanely killed for necropsy examination. The main outcome measures were completeness of resection, procedure-related complications, and survival at 2 weeks. The procedure was successfully completed in all five pigs. It took a mean of 21.8 minutes (range 6 - 39 minutes) to complete the ESD of each gastric lesion. All lesions were excised en bloc; the average dimension of the lesions was 77 mm (range 25 - 104 mm). One pig sustained a small intraoperative perforation which was identified and successfully clipped. After completion of the ESD procedures, all pigs survived well for 2 weeks. Necropsy was performed, with intraoperative gastroscopy identifying all the ESD sites as healed. Histopathologic examination showed all ESD sites had healed with partial epithelialization. Microbiological tests of the peritoneal fluid showed only microbes typically found in pigs. Performing ESD with MASTER was feasible and safe in this 2-week animal survival study.

Robot-Assisted Endoscopic Submucosal Dissection Is Effective in Treating Patients With Early-Stage Gastric Neoplasia

Endoscopic submucosal dissection (ESD) is a new technique for endoscopic resection of early-stage gastrointestinal cancers. Though ESD achieves high rate of en bloc resection, it is technically difficult to master. The development of a novel robotic endoscopic system that has 2 arms attached to an ordinary endoscope-Master and Slave Transluminal Endoscopic Robot (MASTER)-has improved the performance of complex endoluminal procedures. We evaluated the efficacy of MASTER-assisted ESD in treatment of patients with early-stage gastric neoplasia. We performed a multicenter prospective study of 5 patients with early-stage gastric neoplasia, limited to the mucosa. After markings and circumferential mucosal incision, all submucosal dissections were performed using the MASTER system. We measured baseline demographics, tumor characteristics, and perioperative and clinical outcomes. All patients underwent successful MASTER-assisted ESD. The mean submucosal dissection time was 18.6 minutes (median, 16 minutes; range, 3-50 minutes). No perioperative complications were encountered. Three patients were discharged from the hospital within 12 hours and 2 on the third day after the procedures. Two patients were found to have intramucosal adenocarcinoma, 1 had high-grade dysplasia, 1 had low-grade dysplasia, and 1 had a hyperplastic polyp. The resection margins were clear of tumors in all 5 patients. No complications were observed at the 30-day follow-up examination. Follow-up endoscopic examinations revealed that none of the patients had residual or recurrent tumors. A flexible endoscopy robotic system can be used to perform ESD and effectively treat patients with early gastric neoplasia.

Robotics in gastrointestinal endoscopy

AbstractThe application of robotics in gastrointestinal endoscopy is a much anticipated technological advancement that is attracting an enormous amount of interest from innovators and end-users alike. Emerging robotics-enhanced endoscopy platforms for performance of various endoscopic interventional procedures are already in development and some are expected to be in the pipeline for commercialization in another few years’ time. In particular, the Master And Slave Transluminal Endoscopic Robot (MASTER) developed by a collaboration between the National University of Singapore and the Nanyang Technological University, Singapore is already in human trials for an endoluminal procedure, endoscopic submucosal dissection (ESD). The results on trials performed on five patients with early gastric neoplasia have demonstrated the feasibility and safety of using the system for such procedure, while also shortening the procedure time. This article will highlight the advantages of robotics innovations in gastrointestinal endoscopy, with the MASTER as an example, and explore some of the many possibilities for future applications of robotics-enhanced endoscopy.

Enhancement of a Master-Slave Robotic System for Natural Orifice Transluminal Endoscopic Surgery

A novel robotic platform for Natural Orifice Transluminal Endoscopic Surgery (NOTES) is presented in this paper. It aims to tackle two crucial technical barriers which hinder its smooth transition from animal studies to clinical trials: providing effective instrumentations to perform complex NOTES procedures and maintaining the spatial orientation for endoscopic navigation. The technical barriers are overcome by the design of the robotic system considering size, triangulation, dexterity, maneuverability and complexity. It is also shown that haptic feedback and interventional navigation system could solve the problem of off-axis manipulation of the camera angle and loss of spatial orientation upon entering the peritoneal cavity in transgastric NOTES procedure, respectively. Successful ESD (endoscopic submucosal dissection) and wedge hepatic resection have been performed on live pigs with our Master And Slave Transluminal Endoscopic Robot (MASTER) system, showing its capability to perform advanced endoscopic surgical and NOTES procedures. It is found that the MASTER exhibited good grasping and cutting efficiency. And the lesion resection time could be significantly reduced with more practice between the endoscopist and the robot operator. This study evaluates the feasibility of MASTER system as a platform overcoming the barriers to NOTES. It is also demonstrated that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures.

Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER)

Performing endoscopic submucosal dissection (ESD) by using standard endoscopy platforms is technically challenging because of the equipment's lack of dexterity. To explore the feasibility of using the Master and Slave Transluminal Endoscopic Robot (MASTER), a novel robotics-enhanced endosurgical system, to perform ESD. ESD was performed on simulated gastric lesions in 5 Erlangen porcine stomach models (ex vivo) and 5 live pigs (in vivo). Performance of ESD by using the MASTER was compared with that using the insulation-tipped (IT) diathermic knife. SMART Laboratory, Advance Surgical Training Centre, National University Hospital, Singapore. Five Erlangen porcine stomach models and 5 pigs, 5 to 7 months old, each weighing about 35 kg. ESD. Lesion resection time, grasper and hook efficacy grade, completeness of resection, and presence of procedure-related perforation. In the Erlangen stomach models, 15 simulated lesions from the cardia, antrum, and body were removed en bloc (mean dimension, 37.4 x 26.5 mm) by electrocautery excision using the MASTER. The mean ESD time was 23.9 minutes (range 7-48 minutes). There was no difference in the dissection times of lesions at different locations (P = .449). In the live pigs, the MASTER took a mean of 16.2 minutes (range 3-29 minutes) to complete the ESD of 5 gastric lesions, whereas the IT diathermic knife took 18.6 minutes (range 9-34 minutes). There was no significant difference in the times taken (P = .708). All lesions were excised en bloc; the mean dimensions of lesions resected by the MASTER and the IT diathermic knife were 37.2 x 30.1 mm and 32.78 x 25.6 mm, respectively. The MASTER exhibited good grasping and cutting efficiency throughout. Surgical maneuvers were achieved with ease and precision. There was no incidence of excessive bleeding or stomach wall perforation. Exploratory study with limited sample size. Performing ESD by using the MASTER is feasible.

Design of a master and slave transluminal endoscopic robot for natural orifice transluminal endoscopic surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an endoscopic surgical intervention technique for treatment within the intraperitoneal cavity, which utilizes natural orifices (i.e. mouth, vagina, anus, etc.) as the entry point. In line with minimally invasive surgery (MIS), NOTES aims to perform surgical procedures without skin incisions, thus eliminating unsightly scars. In this article, a master—slave robotic system is proposed to enable the endoscopist to perform demanding NOTES procedures, which are currently performed by surgeons in an opened or keyhole surgery setting. The robotic system consists of a master console and slave manipulators driven by tendon—sheath actuation. Force prediction at the slave end is also introduced in this article to provide force feedback to the surgeon. Using the developed robotic system, liver wedge resection has been conducted in animal trials with promising results.

Natural orifice transgastric endoscopic wedge hepatic resection in an experimental model using an intuitively controlled master and slave transluminal endoscopic robot (MASTER)

The lack of triangulation of standard endoscopic devices limits the degree of freedom for surgical maneuvers during natural orifice transluminal endoscopic surgery (NOTES). This study explored the feasibility of adapting an intuitively controlled master and slave transluminal endoscopic robot (MASTER) the authors developed to facilitate wedge hepatic resection in NOTES. The MASTER consists of a master controller, a telesurgical workstation, and a slave manipulator that holds two end-effectors: a grasper, and a monopolar electrocautery hook. The master controller is attached to the wrist and fingers of the operator and connected to the manipulator by electrical and wire cables. Movements of the operator are detected and converted into control signals driving the slave manipulator via a tendon-sheath power transmission mechanism allowing nine degrees of freedom. Using this system, wedge hepatic resection was performed through the transgastric route on two female pigs under general anesthesia. Entry into the peritoneal cavity was via a 10-mm incision made on the anterior wall of the stomach by the electrocautery hook. Wedge hepatic resection was performed using the robotic grasper and hook. Hemostasis was achieved with the electrocautery hook. After the procedure, the resected liver tissue was retrieved through the mouth using the grasper. Using the MASTER, transgastric wedge hepatic resection was successfully performed on two pigs with no laparoscopic assistance. The entire procedure took 9.4 min (range, 8.5-10.2 min), with 7.1 min (range, 6-8.2 min) spent on excision of the liver tissue. The robotics-controlled device was able to grasp, retract, and excise the liver specimen successfully in the desired plane. This study demonstrated for the first time that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures. With it, the triangulation of surgical tools and the manipulation of tissue became easy, and wedge hepatic resection could be accomplished successfully without the need for assistance using laparoscopic instruments.