Minimally Invasive Therapy. 2015;24:37–44

REVIEW ARTICLE

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Flexible endoscopic robot

DAVIDE LOMANTO1, SUJITH WIJERATHNE2, LAWRENCE KHEK YU HO3 & LOUIS SOO JAY PHEE4 1

Department of Surgery, Minimally Invasive Surgical Centre (MISC), Khoo Teck Puat Advanced Surgery Training Centre (ASTC), National University Hospital, Singapore, 2Department of Surgery, National University Health System, Singapore, 3Department of Gastroenterology & Hepatology, National University Health System, Singapore, and 4 School of Mechanical & Aerospace Engineering, Nanyang Technology University, Singapore

Abstract Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical procedure during which abdominal operations can be performed with an endoscope passed through a natural orifice through an internal incision in the stomach, vagina, bladder or colon. NOTES is still evolving and many barriers stand on its way before it can gain acceptance in modern surgical practice. Effective access to the peritoneal cavity, closure techniques of the natural orifice access sites, development of a multitasking platform to accomplish procedures and support for special orientation are only a handful of its known limitations. Although the endoscope and conventional tools are useful for simple procedures, many important and complicated procedures are currently not possible due to limitation of degree of freedom (DOF) of the end effectors. We have developed a Master and Slave Transluminal Endoscopic Robot (MASTER) with nine degrees of freedom (DOF) in end effectors, which are long and flexible so as to enhance endoscopic procedures and NOTES. Using MASTER we have successfully performed endoscopic sub-mucosal dissections (ESD) to segmental hepatectomies in animal models. Thus, the MASTER robotic system shows great potential to perform new surgical procedures that are otherwise not possible with conventional endoscopic tools.

Key words: NOTES, robotic surgery, flexible endoscopy, surgical technology, minimally invasive surgery

Introduction The 20th century has evolved with the development of minimal access surgery and in particular with flexible endoscopy and endo-laparoscopic techniques that have been associated with less pain, shorter hospital stays, and fewer complications than conventional open surgery. These techniques have reached the gold standard in approaching most of the diseases and also improved themselves with mini-laparoscopy, needlescopy, and combined endoscopic-laparoscopic approach, all focused in being less and less invasive. In 2005, early experimental reports described a natural orifice transluminal endoscopic surgery (NOTES). NOTES involves the intentional puncture of the viscera of the stomach, rectum or vagina with an

endoscope to access the abdominal cavity to perform an intra-abdominal operation (1). In the abdominal cavity, the internal organ of interest is operated on endoscopically. When the treatment is completed, the endoscope is used to mend back the incision made on the viscera before being removed from the patient’s body. In 2004, Kalloo et al. (2) introduced NOTES to the medical community in a study of the feasibility and safety of an oral transgastric endoscopic approach to the peritoneal cavity with long-term survival in a porcine model. In 2009 Gumbs et al. (3) performed the first pure NOTES transvaginal cholecystectomy in a human. Many pathologies in the abdomen, retroperitoneal cavity, and the mediastinum could now be accessed and treated with the state-of-the-art

Correspondence: D. Lomanto, Department of Surgery, Minimally Invasive Surgical Center (MISC), Khoo Teck Puat Advanced Surgery Training Center (ASCT), National University Hospital, Level 2, Kent Ridge Wing 2, 5 Lower Kent Ridge Road, 119074, Singapore. Fax: +65 67746077. E-mail: [email protected]; [email protected] ISSN 1364-5706 print/ISSN 1365-2931 online  2015 Informa Healthcare DOI: 10.3109/13645706.2014.996163

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NOTES technology, although most are still in preclinical stages. NOTES is currently still considered as an experimental surgery rather than an accepted routine clinical practice in the surgical community. There are many obstacles that hinder its smooth introduction from animal experiments to clinical trials. Effective access to the peritoneal cavity, near-perfect gastric (intestinal) closure, prevention of infection, development of suturing and anastomotic (non-suturing) devices, support for spatial orientation, development of a multitasking platform to accomplish procedures, control of intra-peritoneal hemorrhage, management of iatrogenic events, identification and management of physiologic untoward events, compression syndromes and training providers have been identified as significant barriers in NOTES evolution (4). NOTES has brought a totally new paradigm shift that could redefine modern surgery. But we strongly believe that, as happened for laparoscopic surgery in the 80’s, for NOTES to move forward a complete new platform should be developed and designed. The future with the development of new robotic platforms seems to be the only way to overcome the challenges of this new surgical approach such as navigation, dexterity, lack of triangulation, closure, dissection and retraction.

Mechanical systems for NOTES Presently, many robots and mechanical systems have been developed to facilitate the performance of NOTES easily and safely. These mechanical devices can be divided into two categories; namely directdriven and actuator-driven mechanical systems. The differences between the two systems are that, for the direct-driven robots the actuating force comes from the endoscopist, while the actuator-driven robots are driven by actuators based on information from a master platform. Direct-driven robots are less bulky and are considerably cheaper because they do not require actuators. However, the downside of directdriven systems is that the degree of freedom (DOF) is generally limited. Since the control and actuation means are in the same device, this makes the system less likely to be anthropomorphic. This makes it less intuitive for the surgeon to control the mechanical system. Furthermore due to the friction within the sheaths and tool channels, there are backlash and delays in actuating the systems. For actuator-driven robots, due to the use of master and slave system, the controls for the endoscopist are separated from the actuating means, making their design simpler and more ergonomic. Another advantage is the ability

to use sensors and computers to increase the functionality of the system. The problems of friction, delay and haptic feedback could be compensated with advanced algorithm, sensing means and the use of computers. In NOTES, although the endoscope and conventional tools are useful for simple procedures, many important and complicated procedures are currently not possible due to limitation of DOF of the end effectors. If an effective tooling platform is developed, more variety of surgical manipulation could be performed with greater ease via NOTES. Loss of spatial orientation is another challenge during transgastric access to the abdominal cavity in NOTES. The exact position of the endoscopic tip, its orientation with respect to the puncture site, and relations of other organs adjacent to the stomach, such as liver and colon, cannot be judged intuitively and accurately. These uncertainties during surgery increase the risk of inadvertent injury to the organ, tissue or even major blood vessels. Therefore, a complete solution for supporting spatial orientation for the surgeon during NOTES will enhance its safety and efficiency, and at the same time reduce its complication and complexity.

Multi-tasking platforms In 2012, Yeung and Gourlay in their review article (5) classified flexible multi-tasking platforms as mechanical and robotic systems. Purely mechanical systems included the dual channel endoscope (DCE) (Olympus, Tokyo, Japan), R-Scope (Olympus, Tokyo, Japan), the EndoSamurai (Olympus, Tokyo, Japan), the ANUBISCOPE (Karl-Storz, Tuttlingen, Germany), Incisionless Operating Platform (IOP) (USGI Medical, San Clemente, CA, USA), and DDES system (Boston Scientific, Marlborough, MA, USA). Robotic systems include the MASTER system (Nanyang Technological University, Singapore) and the ViaCath (Hansen Medical, Mountain View, CA, USA). The DCE, the R-Scope, the EndoSamurai and the ANUBISCOPE have integrated visual function and instrument manipulation function. The IOP and DDES systems rely on the conventional flexible endoscope for visualization, and instrument manipulation is integrated through the use of a flexible, often lockable, multichannel access device. Due to the anatomical constraints of the pharynx, systems are designed to have a diameter of < 20 mm. All systems are controlled by a traction cable system actuated either by hand or by robotic machinery. Boston Scientific had developed a direct drive endoscopic system (DDES) for endoluminal and NOTES applications. The system consists of a three-channel, steerable guide sheath accepting a 6 mm endoscope

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Endoscopic robot and two 4 mm articulating instruments with a total of six DOF. The system’s overall design enables the interventionist to operate instruments bimanually from a stable platform, conveying a laparoscopic paradigm to the functional working space at the distal end of the flexible guide sheath (6). Olympus developed an endoscope with two large tool channels to insert the five-DOF mechanical system arms (EndoSamurai). The EndoSamurai can provide great advantages by enabling traction and counter-traction through its independently movable arms and drive handles that transmit the movement of the operator’s hands to the arms. Each arm with forceps has an articulating configuration with five DOF (7). In 2009 Spaun et al. (8) conducted a benchtop comparison of a DCE and EndoSamurai. The study aimed to measure whether the new platform would improve performance for bimanual coordination compared with a standard dual-channel scope using a benchtop simulation. They found that EndoSamurai enhances performance times and accuracy in complex surgical tasks compared with the conventional therapeutic endoscope. The ‘‘Cobra’’ device has been developed by USGI Medical to solve the issue of triangulation (9). It made use of its 18 mm outer diameter endosurgical operating system to hold the endoscope as well as providing the tool channels to allow two multi-DOF mechanical arms to work on the patient. However it is commented that the controls for the Cobra are imprecise and the tools are not interchangeable during surgeries (10). The ANUBISCOPE consists of a flexible, 110 cm long, four-way articulating endoscope with a 16 mm articulating vertebrae section and an 18 mm distal tip. The arms function similar to a blunt tip trocar when in the closed position and, when open, create triangulation of the working channels for the two-way articulation instruments. In 2012, Perretta et al. (11) successfully completed a cholecystectomy on a human in 60 minutes using the ANUBISCOPE. The ViaCath system is an actuator-driven master slave robot. It consists of a flexible overtube that runs alongside a standard gastroscope or colonoscope with two distal articulated robotic instruments that are tendon-driven based on serially linked joints (12). The University of Nebraska-Lincoln had developed another actuator-driven robot, which is much different from the other mechanical systems (13). This robot does not make use of wire rope actuation but instead motors are attached directly onto the robot. First, the traditional endoscope performs a gastrotomy to enter the peritoneal cavity and then assists to attach the robot to the top of the stomach wall. The robot is then held to the stomach wall by the external magnets located outside the abdominal cavity. In this

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case the vision and environment of the robot resembles that of a laparoscopic environment instead of NOTES. Each arm consists of approximately three DOFs while the gross positioning of the robot is by making use of the external magnet handle. The Medrobotics FLEX System (Medrobotics Inc., Raynham, MA, USA) is a highly articulated platform that features a multilink endoscope allowing minimally invasive procedures in target organs located deep within the body and otherwise difficult or previously impossible to reach through a single port. Johnson et al. (14) in their demonstration of transoral surgery in cadaveric specimens concluded that the Medrobotics FLEX System demonstrates great potential as a surgical tool in head and neck oncology. Compared to other surgical robots, the FLEX System offers facilitated access, vision, and triangulation of flexible tools for procedures in the endolarynx. Single port instrument delivery extended reach (SPIDER()) surgical system is a revolutionary surgical platform that allows triangulation of the surgical instruments while eliminating the crossing of instruments, the problematic characteristic of single access laparoscopic surgery. Noel, Nedelcu and Gagner performed single trocar sleeve gastrectomy in ten patients using SPIDER() with no conversion to classic laparoscopy or open surgery (15). They concluded that The SPIDER() surgical platform seems to be a usable and effective method for performance of minimally invasive single-access sleeve gastrectomy, offering an easy and efficient operative procedure compared to other single-port systems.

“MASTER” robot for NOTES The Master and Slave Transluminal Endoscopic Robot (MASTER) from Nanyang Technological University and National University Health System was designed to perform complicated NOTES procedures. This prototype is two-armed and has a nine-DOF slave manipulator that is tendon-sheath actuated. For this prototype, the surgeon controls the seven motorized DOFs of the slave manipulator while the endoscopist controls the two non-motorized DOFs. Figure 1 shows the various components of the MASTER robotic system. It consists of the patient, the surgeon and the endoscopist and also includes the robotic component such as the slave manipulator, the master console, the computer console, the actuator housing and the magnetic tracker. The patient could be in a partially or fully anesthetic state and the patients’ body position could be adjusted for easier and safer access of the endoscope. The

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D. Lomanto et al. Master console

Endoscopic vision

Surgical navigation system

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Patient

Slave manipulator

Fucidals

Magnetic tracker

Surgeon Endoscopist Origin for picture on surgical navigation system: Forschungszentrum karlsruhe

Actuator housing

Computer console

Figure 1. An overview of the MASTER robotic system.

endoscopist’s role is to introduce the endoscope into the patient and steer the endoscope until it reaches the correct location in the GI tract to perform the necessary treatment. Using the endoscope, he could also provide the necessary suction and inflation of the organ as needed. He also assists in the procedure by controlling the macro positioning and orientation of the endoscope during the medical intervention. The endoscopist does not have control over the master interface but instead has direct control of the endoscope. The surgeon controls the master interface and operates the slave manipulator to perform the treatment. He does not control the endoscope but instead controls the actions of the slave manipulator. Once the endoscopist has positioned the endoscope, the surgeon then controls the finer motion of the robotic slave to perform treatment. Both endoscopist and surgeon have to communicate, cooperate and coordinate together in order for the surgery to be successful since the endoscope controls the general position of the robot while the surgeon controls the movements of the robot. The robotic system can be divided into four different parts: the master console, microprocessor, actuator housing and slave manipulator. The master console system is a specially designed haptics device for the surgeon to manipulate and control the slave manipulator. Sensors attached to the master console sense the movements from the surgeon’s hands and arms and send out the necessary information to the computer console which interprets the signals from the sensors and gives out the right amount of motion for the actuators to move. The actuator housing consists of various electronics systems and prime

movers that receive information from the microprocessor component and actuates the slave manipulator accordingly to perform the desired treatment on the patient. The most critical component of the robotic system is the slave manipulator (Figure 2) since it is the portion of the robotic system that performs the surgery on the human body. It has to be small, long and flexible enough to transverse within the human patient, produces enough force to perform surgical actions on the patient, does not block the vision from the endoscope excessively and is biocompatible to work inside the human body. Due to the unique characteristics of size, length, force and flexibility for the slave manipulator, tendon sheath actuation is chosen. Actuators that generate high power are usually bulky and heavy, making them unsuitable to be deployed on the slave manipulator. With tendon sheath actuation, the actuators could be situated away from the end effector, thus allowing it to be very small and light. Compared to other modes of power transmission such as hydraulic, pneumatic and magnetic, tendon sheath actuation requires smaller size, generates greater force and is safer to be used inside the human body. DOF is allocated for the arms to be closed in when it is inserted through the human’s natural orifice and the arms open up after it reaches the site of interest. Another DOF for the two arms of the robotic system is the translation of the arms forward and backward. This DOF resembles the endoscopic tools used during the operation whereby tools could be pushed in or pulled out during the procedure. The rest of the DOFs for the proposed manipulator resemble the DOFs for a simplified human wrist. It has a supination/ pronation DOF

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Supination/pronation Flexion/ hyperextension

Opening/ closing

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Translation

Supination/pronation

Double flexion/ hyperextension Opening/ closing Translation

Figure 2. The slave manipulator and its degrees of freedom (DOF).

followed by the hyperextension/flexion of the wrist. Since it is anthropomorphic, it is easier to visualize the movements of the slave manipulator and the user can control it naturally with his hands. In order to perform the task of NOTES, it is necessary for the robotic manipulator to be able to cut and grip at the same time. Therefore one of the end effectors is proposed to be in the form of a cauterizing hook while the other is in the form of a gripper. In order for the gripper to open and close, the last DOF is allocated as the opening and closing of the gripper. Because the size of the right tool channel of the endoscope is bigger, the left arm is in the form of the cauterizing hook while the right arm is in the form of the gripper. The overall size of the slave manipulator is approximately 16 mm when the arms are straight and it can be easily pushed through a Guardus overtube. Therefore the size of the endoscope and slave manipulator of this prototype is suitable for use on humans. The length of the slave manipulator in front of the endoscope is 40 mm and the thickness of each arm is approximately 6 mm. Using the information of the length of each link as well as the configuration of the DOF, the workspace formed by the two arms of the slave manipulator can be seen in Figure 3. The blue and red space is where the end of the arms can work on. As can be seen the workspace for both arms is relatively big and can reach in front of the endoscope to perform treatment to the patient. The master console can be visualized as a multiDOFs joystick that resembles and controls the slave manipulator. Due to the similarity between the DOFs of the master and slave, the user can easily visualize the control of the master that maps to the movement of the slave. It is also ergonomically designed and the user will not feel tired after using it to control the robot for a prolonged period of time.

Animal trials conducted using MASTER robot In order to have a successful application of MASTER in NOTES, we started with endoscopic submucosal dissection (ESD), a common surgical procedure for en bloc removal of large gastric lesions to reduce the risk of a local recurrence caused by removing the lesions piecemeal. Since there is no transluminal incision into the peritoneal cavity for ESD, we deemed ESD as a simplified version of NOTES to accumulate our experience in MASTER. With the new slave manipulator, intensive experiments were conducted to verify the feasibility of the robotic system. Together with the help of experienced endoscopists, 15 ex vivo ESDs, five in vivo ESDs and two in vivo NOTES had been performed successfully on pigs. Fifteen simulated lesions from the cardia, antrum, and body were removed en bloc (mean

Locus of points from wrist DOFs with opening/closing Locus of points from wrist rotation and hyperextenson/flexion

Locus of points for the two arms inclusive of translation DOFs

Figure 3. Workspace of the prototype.

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Cauterizing hook

Edge cauterised Hook proceed by hook with cut

Injection of saline into submucosal layer Marked circumference of lesion Gradually cauterising lesion till ESD is completed

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Gripper

Needle injector

Gripper pinches lesion

Last edge before ESD is completed

Site where ESD has been performed

Lesion is removed

Figure 4. ESD procedure with MASTER.

dimension, 37.4  26.5 mm) by electrocautery excision using the MASTER. The mean ESD time was 23.9 minutes. There was no difference in the dissection times of lesions at different locations. In the live pigs, the MASTER took a mean of 16.2 minutes to complete the ESD of five gastric lesions. All lesions were excised en bloc; the mean dimensions of lesions resected by the MASTER were 37.2  30.1 mm. The procedure for performing ESD is illustrated in Figure 4. 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 (16). The robot was subsequently used to perform liver wedge resection on the live pigs. The procedure for performing NOTES is illustrated in Figure 5. Using the MASTER, transgastric wedge hepatic resection was successfully performed on two pigs with no laparoscopic assistance. The entire procedure took 9.4 minutes (range, 8.5–10.2), with 7.1 minutes (range, 6–8.2) spent on excision of the liver tissue. The roboticscontrolled device was able to grasp, retract, and excise the liver specimen successfully in the desired plane. The study demonstrated for the first time that the MASTER could effectively mitigate the technical constraints normally encountered in NOTES procedures (17). In 2012 an animal survival study was conducted to further explore the two-week outcome of using MASTER to perform ESD (18). ESD was performed on five female pigs (weighing 32.4 - 36.8 kg) under general anesthesia using the MASTER. The animals were observed for two weeks before being humanely killed for necropsy examination. The procedure was

successfully completed in all five pigs. It took a mean of 21.8 minutes to complete the ESD of each gastric lesion. All lesions were excised en bloc; the average dimension of the lesions was 77 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 two weeks. Necropsy was performed, with intraoperative gastroscopy identifying all the ESD sites as healed. Histopathology examination showed all ESD sites had healed with partial epithelialization. In 2014 Chiu et al. (19) discussed the feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by Overstitch in a pre-clinical study. Two full-thickness gastric resections were performed in two non-survival porcine models using the MASTER. The total procedure time was 56 and 70 minutes, respectively. 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. They demonstrated that the totally endosopic approach for the treatment of gastric submucosal tumors with full thickness resection with the MASTER and closure of the defect with Overstitch is feasible and safe.

MASTER robot on humans In 2012, Phee et al. (20) conducted a multicenter prospective study of five patients with early-stage gastric neoplasia. The lesions were limited to the mucosa and after markings and circumferential mucosal incision,

Endoscopic robot

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Entry through the hole that was cut Pulling flesh to right

Reached peritoneal cavity through hole made

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Cauterizing entry point Gripper providing tissue tension

Piercing through the middle of the site

Cauterizing the edge below

Hook proceeding with cut to top edge

Liver wedge cut through at the middle

Cut is completed Coagulating with hook

Figure 5. NOTES procedure with MASTER.

all submucosal dissections were performed using the MASTER system. The mean submucosal dissection time was 18.6 minutes (median, 16; range, 3–50). No perioperative complications were encountered. Three patients were discharged from the hospital within 12 hours and two on the third day after the procedures. Two patients were found to have intramucosal adenocarcinoma, one had high-grade dysplasia, one had low-grade dysplasia, and one had a hyperplastic polyp. The resection margins were clear of tumors in all five 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.

Discussion NOTES is still evolving and a platform to overcome its barriers and to perform complex procedures using NOTES is still a challenge to engineers and physicians. Manyrobotic systemshavebeendevelopedfor NOTES.

Among all the mechanical and flexible robotic devices, MASTER seems the most developed and the only one with some good experimental and clinical validation. The MASTER robotic system which consists of a master console, microprocessor, actuator housing and slave manipulator with nine DOF end effectors with long and flexible arms has shown promising results in animal studies. From the animal trials, it could be concluded that the robotic system had met its objectives on performing NOTES on live animals successfully. The system offers an alternative method to perform complicated endoscopic surgical procedures with added advantages over conventional methods. The robotic system shows great potential to perform new surgical procedures that are otherwise not possible with conventional endoscopic tools. The limited studies on humans have shown that it can be used to perform ESD and effectively treat patients with early gastric neoplasia. Extensive research and long-term follow-up studies would still be required to comment on the safety and feasibility of using MASTER robot in NOTES in humans.

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In conclusion the 20th century has evolved with the development of minimal access surgery and in particular with flexible endoscopy, endo-laparoscopic surgery, microsurgery, and robotic surgery that have been associated with less operative trauma, less pain, shorter hospital stays, and fewer complications than conventional surgery. These techniques have reached the gold standard in approaching most of the diseases and also improved themselves with mini-laparoscopy, micro-robotic, natural orifice surgery and the latest single port surgery, all focused in being less and less invasive for the patients. These changes have been possible due to fast development of technologies such as information technology, robotics, digital imaging etc. The technological innovations in surgery are only beginning. The future will be very attractive, the potential is enormous, the path is minimal, and the science fiction movies depicting robots replacing mankind may soon become a reality. Declaration of interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper. References 1. Pearl JP, Ponsky JL. Natural orifice translumenal endoscopic surgery: a critical review. J Gastrointest Surg. 2008;12: 1293–300. 2. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004;60:114–17. 3. Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, et al. Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique. Ann Surg. 2009;249:908–12. 4. Rattner D, Kalloo A; Group ASW. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005. Surg Endosc. 2006;20:329–33. 5. Yeung BP, Gourlay T. A technical review of flexible endoscopic multitasking platforms. Int J Surg. 2012;10:345–54. 6. Thompson CC, Ryou M, Soper NJ, Hungess ES, Rothstein RI, Swanstrom LL. Evaluation of a manually driven, multitasking platform for complex endoluminal and natural orifice transluminal endoscopic surgery applications (with video). Gastrointest Endosc. 2009;70:121–5.

7. Ikeda K, Sumiyama K, Tajiri H, Yasuda K, Kitano S. Evaluation of a new multitasking platform for endoscopic fullthickness resection. Gastrointest Endosc. 2011;73:117–22. 8. Spaun GO, Zheng B, Swanstrom LL. A multitasking platform for natural orifice translumenal endoscopic surgery (NOTES): a benchtop comparison of a new device for flexible endoscopic surgery and a standard dual-channel endoscope. Surg Endosc. 2009;23:2720–7. 9. Karimyan V, Sodergren M, Clark J, Yang GZ, Darzi A. Navigation systems and platforms in natural orifice translumenal endoscopic surgery (NOTES). Int J Surg. 2009;7: 297–304. 10. Bardaro SJ, Swanstrom L. Development of advanced endoscopes for Natural Orifice Transluminal Endoscopic Surgery (NOTES). Minim Invasive Ther Allied Technol. 2006;15: 378–83. 11. Perretta S, Dallemagne B, Barry B, Marescaux J. The ANUBISCOPE(R) flexible platform ready for prime time: description of the first clinical case. Surg Endosc. 2013;27:2630. 12. Shang J, Payne CJ, Clark J, Noonan DP, Kwok KW, Darzi A, et al. Design of a multitasking robotic platform with flexible arms and articulated head for minimally invasive surgery. Rep USA. 2012;2012:1988–93. 13. Lehman AC, Dumpert J, Wood NA, Redden L, Visty AQ, Farritor S, et al. Natural orifice cholecystectomy using a miniature robot. Surg Endosc. 2009;23:260–6. 14. Johnson PJ, Rivera Serrano CM, Castro M, Kuenzler R, Choset H, Tully S, et al. Demonstration of transoral surgery in cadaveric specimens with the medrobotics flex system. Laryngoscope. 2013;123:1168–72. 15. Noel P, Nedelcu M, Gagner M. SPIDER (R) sleeve gastrectomy–a new concept in single-trocar bariatric surgery: initial experience and technical details. J Visc Surg. 2014;151:91–6. 16. Ho KY, Phee SJ, Shabbir A, Low SC, Huynh VA, Kencana AP, et al. Endoscopic submucosal dissection of gastric lesions by using a Master and Slave Transluminal Endoscopic Robot (MASTER). Gastrointest Endosc. 2010;72:593–9. 17. Phee SJ, Ho KY, Lomanto D, Low SC, Huynh VA, Kencana AP, et al. Natural orifice transgastric endoscopic wedge hepatic resection in an experimental model using an intuitively controlled master and slave transluminal endoscopic robot (MASTER). Surg Endosc. 2010;24:2293–8. 18. Wang Z, Phee SJ, Lomanto D, Goel R, Rebala P, Sun ZL, et al. Endoscopic submucosal dissection of gastric lesions by using a master and slave transluminal endoscopic robot: an animal survival study. Endoscopy. 2012;44:690–4. 19. Chiu PW, Phee SJ, Wang Z, Sun Z, Poon CC, Yamamoto T, et al. Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by Overstitch: a preclinical study. Surg Endosc. 2014;28:319–24. 20. Phee SJ, Reddy N, Chiu PW, Rebala P, Rao GV, Wang Z, et al. Robot-assisted endoscopic submucosal dissection is effective in treating patients with early-stage gastric neoplasia. Clin Gastroenterol Hepatol. 2012;10:1117–21.

Flexible endoscopic robot.

Natural orifice transluminal endoscopic surgery (NOTES) is a novel surgical procedure during which abdominal operations can be performed with an endos...
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