Will the robot take over endoscopy?

 

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The performance of an endoscopy typically involves the introduction by an endoscopist of a flexible endoscopic system into the gastrointestinal (GI) tract [1]. A conventional endoscope is composed of a flexible shaft, a bending section, and a control body. During the endoscopy procedure, the endoscope is inserted with the aim of achieving a complete examination of the GI tract through manipulating the flexible shaft and steering the bending section using knobs on the control body that are moved by the endoscopist. Skillful insertion of a colonoscope, which will certainly reduce the discomfort felt by the patient, is typically dependent on adequate visualization of the GI lumen and haptic sensation in manipulating the colonoscope. Excessive force when manipulating the colonoscope can induce significant discomfort and may cause perforation.

The development of capsule endoscopy can offer less invasive endoscopic examination of the GI tract [2]. However, the current design of capsule endoscopes means the technique is passive, without control, and treatment cannot be performed. Active capsule endoscopy is now under development, including the use of a magnetically manipulated capsule endoscope [3] and possible therapeutic protocols [4].

Since the introduction of natural orifice transluminal endoscopic surgery (NOTES) in 2004 [5], the development of a multitasking endoscopic platform to enhance the performance of endoscopic surgery has been a major issue. In the past decade, multitasking endoscopic platforms, including the Anubisope, the EndoSamurai, and the Direct Drive Endoscopic System (DDES), have aimed to perform surgical treatment via two mechanically driven arms [6]. These systems have certain mechanical limitations in their degrees of freedom, especially when the end effector is far from the control unit.

The application of robotic technologies in the development of these flexible endoscopic platforms has greatly enhanced the performance of complex surgical procedures, such as endoscopic submucosal dissection (ESD), within the confined GI lumen [7]. However, these systems have focused on the therapeutic issues, without redesign of the structure of the flexible shaft, and most of these platforms are larger than ordinary endoscopes, making insertion difficult, especially in the colon [8].

Snake-like robots, such as the wire-driven flexible robot [9] and the highly articulated robotic probe (HARP) [10], are highly flexible and have the potential to navigate in a confined anatomical environment with minimal interaction. The wire-driven flexible robot has multiple consecutive bending sections, providing a much greater degree of freedom than the typical endoscope bending section. The HARP offers a greater degree of freedom by being able to alternate between stiff and limp modes.

The current study by Kume et al. [11] in this issue of Endoscopy is an excellent illustration of the application of robotic technology to improve endoscopic manipulation, bringing with it several benefits. First, the endoscopist can use one hand to steer the flexible endoscope intuitively, so releasing the other hand. Second, the monitored forces and torques during the insertion can be used to provide haptic feedback and evaluate the performance of the insertion. A threshold set for the forces means that perforation due to excessive force being applied to the bowel wall can be prevented. Smaller insertion forces will also induce less discomfort for the patient. Third, in a therapeutic procedure the robot will fix the position of the flexible endoscope and provide a steady platform for more complex procedures.

However, the Endoscopic Operation Robot (EOR) ver.3 is quite bulky in its current form. Moreover, the endoscopist needs to switch off the circuit when the master unit reaches its range limit. Technologies in teleoperated robots can be borrowed, such as the flexible robot is controlled using the cost-effective Novint Falcon haptic device [12]. This may be able to simplify the master input device and reduce the cost.

The current study compared the performance of colonoscopy using this EOR between experts and trainees, and the examination time was significantly shorter for experts than for trainees. One of the important findings was that the experts used rotational torque more effectively than the trainees did. The measurements of forces and torque taken in this study demonstrate that experience and skills are important even in the manipulation of a robotically driven colonoscope.

A recent analysis of 31 088 colonoscopies, data form the English Bowel Cancer Screening Programme by Lee et al. [13], showed that technical factors which increased the adenoma detection rate included cecal intubation, increased withdrawal time, high quality bowel preparation, use of antispasmodics, earlier procedure start time, and performance of the procedure by experienced colonoscopists. The current system will provide a platform to improve colonoscope insertion and cecal intubation with less patient discomfort. The system will improve particularly the performance of colonoscopy by trainees. However, it will not replace the experience of the endoscopist in performing colonoscopy, which has a significant impact on both patient discomfort and adenoma detection.

Just as the performance of minimally invasive surgery has been revolutionized by the introduction of robotic surgical systems, we believe, in the not too distant future, robot technologies will be widely adopted for the performance of both diagnostic and advanced therapeutic endoscopy. The current study illustrates the potential of such technology; however, there are still major limitations in the design and control of the platform that must be overcome before full clinical application can be realized. The next development is likely to be a refined design for the robotically driven endoscopic platform to allow enhanced manipulation by endoscopists.

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