With the rapid development of minimally invasive treatment technology, endoscopic submucosal dissection (ESD) has become the standard treatment for early gastrointestinal cancer, but due to the difficulty of operation, long learning curve, and relatively high risk of intraoperative bleeding and perforation, the endoscopic submucosal dissection (ESD) has become the standard treatment for early gastrointestinal cancer. Limiting its spread around the world. At present, a variety of traction techniques still have different degrees of shortcomings, so the digestive endoscopic surgery robot came into being.
According to the availability of endoscopic carrying platforms, digestive endoscopic surgical robots can be divided into specialized endoscopic robots that need special design and production and general endoscopic integrated robots that can be assembled with general endoscopes.
Special digestive endoscope robot
(1) STRAS System (STRAS)
The endoscope module of the system mainly includes a main mirror and two operating arms, which can realize the operation triangle during ESD, with good flexibility, high safety, and simple and fast assembly. Three end effectors can be provided in the operation process to realize the functions of grasping, cutting and wound suture, effectively saving operation time and meeting the requirements of dexterity and accuracy.
However, this system also has many limitations: it cannot be flexibly assembled with traditional endoscopes, and its manufacturing cost is high. It can only reach the descending colon through the anus or the proximal stomach through the mouth, and it cannot complete the resection of lesions at further sites.
(2) Bionic flexible robot system
A Bioinspired Flexible Robot has 2 degrees of freedom to enable the end to be fixed in any direction, with 2 diameters of 6mm and 2 diameters of 4mm for a total of 4 working channels. Compared with the STRAS system, this system can effectively prevent tissue damage during the endoscopic process, and the end of the actuator can be effectively fixed by the sleeve, increasing the stability of the robot arm, thus improving the surgical safety.
However, this system cannot be used for routine gastrointestinal examination, and limited by the inner diameter of the channel, the video endoscope used is too small to observe the field of view beyond the robot arm, which affects the overall cognition of the surgeon on the lesion and its surrounding environment, and increases the surgical risk.
(3) Flex Surgical Robot System (Flex)
The third system improvement was approved for use in digestive system ESD in 2017. The endoscope module of the system consists of a primary mirror and two external channels with a diameter of 4mm, through which the flexible manipulator can reach the operation site, and the robot arm can move nearly 180°, and can grasp, cut and sew in 3D high-definition visualization.
The system is easy to operate, and its activities are not limited by the end shell, and the flexibility is higher. However, proper sealing with a special rectal port is still required to maintain inflation, and the operating length of the robotic endoscope is relatively short, allowing removal of lesions only within 25cm of the anal edge.
General digestive endoscope integrated robot
(1) Master-Slave Endoscope Robot System (MASTER)
The system end effector comprises an "L" type hook knife and a gripper. The parallel manipulator of the MASTER second-generation system can improve the freedom of operation, expose the surgical field more fully, and effectively reduce the incidence of common complications such as bleeding and perforation. However, this system also has some limitations. When operations other than the lifting and cutting functions of the robotic arm are required during the operation, the robot body needs to be removed from the patient and ordinary endoscopes replaced for operation.
(2) Endoscopic Submucosal Resection System (TASER)
The system consists of GelPoint platform, one therapeutic endoscope (GIFH260) and two laparoscopic instruments. Simple assembly, lightweight device, easy to move, and strong practicability, TASER may become one of the new treatment methods for complex rectal polyps that are difficult to treat under ordinary endoscopy in the future, but the current application of this system is limited to the rectum, which limits its application and promotion to a certain extent.
(3) Portable Endoscopic Robot System (PETH)
The main system of PETH is composed of an ordinary endoscope and 1 or 2 robotic arms, which are external mounted and can achieve two independent bending of more than 100° in each direction, so that the end of the robotic arm can reach any point within the visual range of the endoscope, and realize multi-direction traction and grasping. The number and orientation of robotic arms attached to standard endoscopes can be flexibly adjusted according to the type of endoscopic surgery. The rotation Angle of the robot arm is proportional to the inclination of the master hand of the thumb stick, which can increase the flexibility of the endoscopist. A graphic simulator was developed to show the position of the robotic arm in the gastrointestinal tract. However, due to the addition of a robotic arm to the system, the diameter of the endoscope increases, which reduces the tolerance of patients to endoscopic treatment.
(4) Rotary Joint based Auxiliary Endoscopic Robot System (REXTER)
Mounted in tandem on a universal endoscope (GIF2T240), the robotic arm has two connecting rods of 15mm each and four degrees of freedom to complete the complex operations required for surgery. Similar to TASER and PETH, the system can be flexibly assembled or disassembled with ordinary endoscopes, and the system is simple to assemble and convenient to use. However, compared with the above three systems, this system can only perform tissue pulling during the operation, and cannot achieve incision, suture, intraoperative hemostasis and other operations, which is not conducive to the treatment of intraoperative complications.
Domestic digestive endoscopic surgery robot
Digestive endoscopic surgical robot is in its initial stage of development in China.
(1) Fiberendoscopic robot system
In 2002, Wang Dangxue et al. designed a robotic system for fiber endoscopy, but the system was mainly used to control the handle of the gastroscope, which was difficult to apply to ESD and other therapeutic operations.
(2) YunSRobot system for flexible endoscopic robot
In 2016, Professor Yang Yunsheng's team independently developed the YunSRobot system, a flexible endoscope robot, which can be integrated with ordinary digestive endoscopes and is controlled in a master-slave mode. Endoscopists can control the robotic arm delivered from the mirror body and the robotic arm operated by the mirror through the master handle.
(3) EndoPicasso robot system
In 2018, the EndoPicasso robotic system developed by Professor Li Yanqing and his team from Qilu Hospital of Shandong University is also a master-slave control system that can be integrated with ordinary digestive endoscopy. It is an external robotic arm with a diameter of 2.5mm and a flexible surgical arm with 4 degrees of freedom, which can significantly shorten the peel time and reduce complications such as muscle injury.
ROBO medical digestive endoscopic surgical assistance robot
EndoFaster digestive endoscopic surgery assistance robot developed by ROBO Medical is the world's first single-arm digestive tract flexible surgical robot system, the world's first surgical robot system specifically developed for the pain points of minimally invasive digestive endoscopic surgery, and the world's first digestive endoscopic surgery assistance robot operating system that has completed human registration clinical trials.
The EndoFaster assisted robot for digestive endoscopic surgery adopts an innovative design of micro-continuum flexible robotic arm, which brings a new breakthrough for the operation of digestive endoscopic surgery. By using the movement of the robotic arm to achieve traction and lifting of the diseased tissue during endoscopic surgery, the operation is closer to the doctor's intuition, thus shortening the operation time and reducing the probability of intraoperative complications.
At present, we have completed all prospective, multi-center, parallel controlled clinical trials for domestic registration jointly participated by Shandong University Qilu Hospital, Shanghai Changhai Hospital, Binzhou Medical College Affiliated Hospital, Zhejiang Provincial Hospital of Traditional Chinese Medicine, Zhejiang Provincial People's Hospital and Zibo Central Hospital.
In November 2023, the digestive endoscopic surgery auxiliary robot and its supporting disposable digestive endoscopic surgery flexible arm passed the special review application for innovative medical devices of the National Medical Products Administration (NMPA) and entered the special review procedure.
At present, many experimental research data show that the introduction of digestive endoscopic robot technology can greatly improve the accuracy and stability of ESD surgery, reduce the difficulty of operation, improve the learning curve, improve the quality of surgery, and lead the reform of minimally invasive endoscopic surgery technology.
With the advancement of technology, artificial intelligence will more and more complete a variety of medical work. The birth of surgical robots represented by the ROBO medical EndoFaster digestive endoscopic surgery assistance robot also accelerates the promotion and application of ESD technology in the world and benefits patients.
References:
Li Qingmin, Zuo Xiuli, Ji Rui. Current situation and prospect of digestive endoscopic surgical robot [J]. Chinese Journal of Digestive Endoscopy, 2023, 40(3) : 173-177. (in Chinese)
DOI: 10.3760/cma.j.cn321463-20211206-00684.