Are GI Endoscopists ready for Endoluminal Robotics?
- Steve Bell
- 58 minutes ago
- 5 min read
I remember clearly when the first Multiport robot came onto the scene by da Vinci. A 3 arm da Vinci S (Standard). And at that time I had a clear vision of what the future would look like. And it was exactly as I'd imagined. Few around me "got it" - they saw it as a silly curiosity that "no one would ever pay for." That included at the time Bill Weldon, former CEO of Johnson & Johnson. He was curious but seemed to only see it as a cardiac toy.
Today I look at Endoquest Robotics and it takes me back to 2008 when myself, Brad Sharp, and Wayne Noda built one of the first NOTES companies called MINOS Medical. We created a few endoluminal systems as part of that company. One was a system to remove the appendix from inside the colon via inversion and looping. The other was a system to invert diverticulum and band them off. Both systems relied on manual scopes and dexterity. We created a set of rapid exchange cannulas (Megachannel) and a whole bunch of delivery devices for capturing the appendix, inverting it and looping it off.
We had magnetic ferrofluids for injection into the Gallbladder, and used it for manipulation via external Magnets (Take note Levita) It was a first type of lap rendezvous. We had trans vaginal scoping (way before Momentis) and gained access to the abdomen with Hysterosystem. We had all kinds of NOTES (Natural Orifice Transluminal Endoscopic Surgery) and NOS (Natural Orifice Surgery) systems. But they all relied on in line endoscopes - it was clunky and only a few top experts like Prof Chris Gasche could try to use the sysyems. And it was that in line, parallel, non triangulation, poor vision that I believe eventually killed the NOTES and NOS era at that time. Technology was not up there with ambition. I remember sitting in our lab in Irvine California and saying to the engineering genius Wayne - "If only we had a fucking robot!"
Interestingly we voyaged south from Irvine and went to see Transenterix in its early carnation with their Spider system. It was a sort of first generation Single port system that they were looking at. But that wasn't the answer we were looking for - which was a more flexible endoluminal robot.
We worked with Dennis McWilliams' Apollo Endosurgery and his team out of Austin with Overstitch - but that wasn't the answer either. For us it was too parallel and too specific.
What we needed back then was a bi-manual dextrous robot that delivered a stable platform and at least two triangulating instruments. We were 10 years too soon and that technology just didn't exist. And not only that, our team of engineers knew that to do such a robot was a pinnacle of robotics. The kinematics for the delivery system alone would be hard. But then having that work with the two flexible instruments - and have kinematics within kinematics (positioning) to keep everything synced; well that would be a challenge.
I first saw images of Endoquest - or rather ColubrisMX in early 2018. And thought "Oh why the F did we not have that." At the time most people laughed at the idea. What's interesting is that at the time they had a very interesting single port, but it was the flexible endoluminal robot that got me excited. I remember clearly that we heard about cases in LatAm and I can remember someone from a "big company" saying "What on earth are they doing with complicating endoscopy?" Again - big companies missing the boat - time and tiome again. Imagine if back then they would have seen the vision and got it just for the single port ?!!? You can take a horse to water.... you can't make it see beyond their current portfolio.
But anyone that lived through the NOTES era, and saw the potential of ESD (Endoscopic Submucosal Dissection) and then more - understood immediatly what this could mean. Not only that, but people from the NOTES and NOS teams could immediately understand how this changes things from surgery to pre surgery early treatment of diseases.. It shifts when the patient gets treatment with massive consequential savings on suffering, time, and money.
A huge challenge back in 2007 / 2008 was when we took our endoluminal system to BARD to show them. We sat with their BD team - showed them the future and all they said was "Reimbursement." And actually they were right - and that is something we need to meet head on. But the total patient costs savings of procatively closing off diverticulum before diverticulitis was huge. Remember three strikes and you are on a hemicilectomy - and 30% of left hemicolectomies are for diverticulitis. Imagine the immense cost savings if we could eradicate 30% of hemicolectomies, bags and reversals? Over the next months I'm going to dig deep how solve this issue of understanding future savings to bring them forwards and pay them now so we break this cycle. I'm not letting this one go this time. I'm on a crusade.
The second problem we had back in 2007 / 2008 (and I am going to warn the entire comminuty in a future positioning paper all about this) is that GI Endoscopists just were not ready to get away from 40 minute scope sessions for diagnosis - to do 4 hours procedures for curative therapy. The fact GI endoscopists may not be ready for this sweeping change that is coming is what inspired this conversation with Aust Chiang MD, MPH and CMO of Medtronic's GI division. He gets it!
There is a revolution coming... driven by systems like Endosquest. And we see JNJ has the Auris GI technology, Medtronic has acquired Fortimedix ,and has a full GI division. Intuitive has ION based off the Neoguide NOTES technology. Swan Endosurgical had the Olympus Endo Samurai technology and INEN Robotics has Robocath know how.
In my upcoming piece, if the GI endoscopists don't change their perspective - and embrace these new technologies, then this will slip from the hands of the GI endoscopists and fall to a niche group of enthusiastic surgeons. And well... the possibility of a revolution will be lost. I will drop a massive position paper on this from my soap box - urging the world to see this technology differently and not repeat the slow uptake of daVinci techologies through resistance. And lack of vision. We cannot have this game changing potential be missed because we all think these are surgical robots.
With Natural Orifice robots we will now have the unlock for the revolution that can change the face of healthcare for many patients - but it's going to take a bold vision. I'm on a crusade to push this technology - push this change... as I've seen back in 1998 what lack of vision did to robotics by the Big strategics. In 2007 I saw the lack of vision of the physicians and the lack of reimbursement vision of the health systems for NOS and NOTES. This time I'm not letting it go. I want to see the change needed to literally have a different pathway for patients. Who is joining me on this crusade that will be bigger than the first Robot 1.0 revolution?
These are simply opinions and thoughts from the Author and for education purposes only.
