Endolumenal robotic Endoscopes - Where is it going?
- Steve Bell
- Sep 10, 2024
- 13 min read
Updated: Jul 30
A growing segment of healthcare is in medical robotics - and that can get divided down into various categories. One of those is Endolumenal robotics. Which basically means a Robot that drives inside a tube.
Now that category can be further subdivided into vascular and no vascular “tubes”. (Endovascular).
Using the vascular tubes you can arrive at the heart or the brain using robots.
So you end up with Endovascular / cardiovascular robots for the heart (stents, PFO, Valves etc etc) - and you can also have endo brain robots (Endovascular / Neurovascular robots)
None of those I’m going to talk about today as it’s a different field from the “Endoscopes” I’m going to talk about - BUT much of the primary catheter advancement and “driving” technology can be used to get catheter tips where you want them to go. However there is little need for “seeing” directly by an endoscope in the vasculature (lot of blood) - and the dimensions of the catheters can be quite different. So for today just park the endovascular - but flip back in every so often to understand the navigation technology can absolutely come across…
So the companies I talk about today - could create cross over devices into endovascular robotics. (Think for the future.)
In fact - if you look at Hansen Medical and Auris - the synergies were clear back then to Fred Moll.
But today I’m going to dig into endolumenal robots that see - diagnose - and eventually treat using "robotic endoscopes" !
And for a very good reason, most of these systems start threirtechnlogy in the lung - take a journey to the urological tract and eventually find themselves in the GI space. Follow my journey here.
The endolumenal endoscope robots
I’m going to categorise them like this as they have visualisation systems - and in all of the areas we talk about today many flexible endoscopes are already used - and they have vision because it helps to do what the operator needs to do. They are bronchoscopes - Urethroscopes - GI Endoscopes (colonoscopes, gastroscopes etc).
They generally have an imaging system on a drivable flexible shaft that also has “working channels” to get long flexible instruments down (needles, probes, graspers, baskets etc etc)
The clinician manually advances the scope and under visual guidance navigates the “tube” around the bends and corners to get to the target. (Oh that sounded basic. The clinicians will hate me.)
When they get there - they take a look or biopsy - or do something more adventurous (grab - poke - cut) etc
So if they do that today, and doit well, then why on God’s earth do we need expensive robots to do this?
And that is a great question… but it has a very good clinical and user answer (you’ll be glad to know.)
Robotic bronchoscopy the first frontier
If you are following this space at all you will know that a lot of the usual suspects in main frame, surgical robotics (Intuitive, Johnson & Johnson, Microport Medbot) are also looking at endolumenal robotics. many already have systems on the market.
Intuitive has their Ion system, JNJ (their former Auris) Monarch system, and Microport has their Trans-brochial surgical robot.
Plus you have a few smaller starts ups - but one to mention is the Noah Medical Galaxy system which has some cool features.
I’ll dig into each in details later so you can see what they are and know a little more about them.
The reasons why anyone would move from a manual bronchoscopy to a robotic bronchoscopy may not seem clear at first - because surely all pulmonologists can drive one of their scopes to where it needs to go? Right?
Well not everyone in every lung to every lesion. You have to imagine the lung’s "tubing" is like a tree - it starts at the trunk and branches smaller and small and more numerous as you go further out into the lung. It becomes not only harder to advance the scope to the small terminal branches of the respiratory tree - but you get “left or right” decisions like a maze every time you advance - and finding your way to the right next branch is not easy. You need navigation… And well robots are very good at following navigation - or assisting the user (for now) to navigate faster and more easily.
I’ll come back to this in details.
The next problem a user of a standard bronchoscope has is that one hand holds and advances the scope while they dial around with finger and thumb wheels on the handle to go up down - left right.
Then when they get there they have to advance say a “needle” through the working channel - and with their third hand (joke) - do the biopsy. While holding the tip of the bronchoscope right where they need it - at the angle they need it - pop the needle forwards - biopsy. Pull out the biopsy needle - and get the next one down the channel to the target - which in most cases (with all that manual manoeuvring) the tip has moved - so they spend time getting the biiopsy angle right again. It's all a bit... well "manual."
So the issue with manual bronchoscopes is they don’t retain the memory of the pathway and most importantly do not have “shape locking” technology that holds the endoscope fixed in space - rigid - to allow needle exchange (Tool exchange) without losing the target (a small target at that.)
Robots are phenomenal at stability and positioning - and as “the robot does it” by it's drive system, it frees up the user's hands to do the tool swaps - quickly and accurately.
The 3D stability is just massive. And that will become even more important to have that stability - and rigid strength in GI endolemenal surgery with more complex procedures like ESDs. (Endoiscopic submucosal dissection.)
But why chose the lung first? The pulmonologist is not the core target of ISRGs robots.. right? So that mans they would need an entirely new sales force.
Correct - but there are very good technical reasons and market reasons why you go to the lung first.
Firstly it is a massive market with millions of patients that need biiopsies. Beyond that, a lot of patients need better, earlier treatment, diagnosis of the lung nodules - it’s a big big big market need.
It’s also heavily diagnosis front end loaded. What I mean is you need to deliver a needle and take a biopsy and that is all you need to do to get to a massive market. Later will come delivering therapeutic catheters - but the bar to (regulatory) entry is lower, but stillgives access to a big lucrative business. It is a simple, needle biopsy. And that is important for a Multi Platform Program. Start with the easy accessories - focus on getting the robot right - the navigation tools right. Then build on complexity and accessories.
Next point - rigid structures are good at being imaged pre operatively and still being in the same place peri-operatively. If I do a cat scan of your lung and then get a computer to reconstruct that into a 3D model today - next week that model is still valid. The tubes will all be in the same relative place to each other - and the lesion will be in the same relative space. So when I come to do the procedure, it all still lines up with the model I built a week ago. And that means that navigation software can follow that path to the lesion just as we planned out a week ago.
If I do that in your small bowel - nothing where it was last week is where it is this week… it all moves around even preoperatively. Loops move and corners move - so naviagtion planning is very hard.
In the lung - it all stays relatively and specially fixed. So that means if you want to develop a big part of your robots value though navigation... Start in the lung vs the gut or the urological anatomy - it is way way way easier. (The engineers are cursing at me now for diminishing the difficulty of the navigation software they took years to develop.)
But market size, need size, benefits it brings and technical complexity all point to the lung as the first frontier for endolumenal robotics. And that is why everyone is there doing a land grab - well except Medtronic (well they do have part of the system the superDimension navigation system. So they will be getting in on the bandwagon for sure.) Galaxy?
ION by Intuitive
Most of the systems are going to look ands smell very similar in some respects.
The basics are:
They have a navigation platform - which can do pre-operative planning and perioperative guidance to get the catheter to the lung. Well today it guides the physician that drives the catheter to where it needs to go via a “track pad”. It indicates “go left go right” on the ancillary screen and under the direct visualisation of the scope is shows “go left down that rabbit hole.”
The robot arm does a few jobs- it holds the entire robotic bronchoscope - it advances it (knowing where it is in. Real time) - it also takes the user inputs and translates that into catheter tip deflections to go up down left right as the user steers and advances.
It does all of this is in a very precise and stable way - which is a massive advantage.
It then also helps to guide the Cather tip (bronchoscope tip) right to the lesion with a 3D imaging that helps to ensure that multiple biopsies are done accurately across the lesion. The stability of the tip and the ability to shape lock and then change anglewith precision is critical.
Monarch by Ethicon (JNJ)
In a similar way Monarch (former Auris) uses a similar set up of navigation control panel - and then the robot. They have opted for a different arm architecture which is about using a guide catheter and bronchoscope in fixed relation - but allowing independent tip control and bronchoscope advancement. All variants on an IP crowded theme I'm sure.
Again a controller is used (like a game controller) to advance the catheter and navigate it down the tract - with all sorts of smarts to help to user find the most efficient and fastest path to the lesion to be biopsied.
(Now.. there is a 3 arm version for EndoUrology - but let’s leave that for the next frontiers)
Again the system has pre operative planning - preoperative stability and today delivers biopsy needles as the first and simple end effectors. Diagnostic - not therapeutic.
But wait….. Ethicon has a microwave ablation system called NeuWave - and in April 2023 they enrolled their first patient into a clinical trial under FDA breakthorugh device designation. And what this tells you is that not only do these companies want to be able to diagnose the lung nodules - but if the rapid histology comes back positive / negative - right there and then they could ablate small enough lesions - so now this gets interesting.
It's interesting for patient benefit first and foremost - but it is incredibly interesting for changing the dynamic of how valuable the robot is to deliver accurate stability vs manual scopes. Theerapies require way more accuracy and stability than point biopsies.
It now gives the robot significantly more meaning - and opens up the systems to therapeutic tool pathways which have meaning for endo urological (lasers and energy) and then when we get eventually to the GI tract.
I am going to put my neck out here and say I think in this space... JNJ is leading with the endolumenal robotics.
Galaxy by Noah Medical
Once upon a time in a Galaxy far far…. Sorry.
So one of the smaller entrants to this space (Take note Medtronic) is Noah medical and their cooly named Galaxy system. Again all the traits of a standard bronchoscopy robot - with a navigation element - a planning element and a drive robotic arm that does advance and retract up and down and left and right.
But here’s the intriguing things they have. First they have a disposable robotic bronchoscope - and that “reuse” has been painful for the other companies in making the reprocessing work - with shipments back to base - strip down - reprocess - and ship out. It limits the number of procedures and so far has been an issue for cost of procedure for the companies - making a diagnostic profitable is not as easy as people think. Volumes are high - reimbursement is low - so pricing is low and profit is low.
Noah has a cute disposable so all of that pain of reprocessing goes away.
Next they have what they call TiLT - which is a targeting system to ensure you are in the lesion. But to be honest it’s a nice acronym but the other systems seem to have different ways they make sure you are in the right cone of the biopsy. But hey.
Microport MedBot Bronchial Robot
Quick picture here is about all I have - and that is not high res (sorry). But what it looks to me (and will be cute if it is) - is that much like they Toumain and their Single port robot - they seem to be leveraging the arm architecture of the Toumai - and the interfaces.
And I want to mention that - as Auris on iPlatform tried a similar thing so the arms could carry both lap instruments and flexible endoscopic instruments. It looks to me like Medbot may have actually done that with their system - and that would mean - perhaps - you could create a combination Toumai and Flexible system that hangs off one chassis - which was the original goal of Auris and iPlatform. (BTW)
Don’t hold me to this - but that looks sneakily like they are at least trying to do this. Or it just makes good COGS becasue it dsalavages from the parts bin of Toumai?
AI Navigation- next?
Now one thing to always think about is dissociating technological ability with regulatory ability. It is often (for autonomy and AI) easier to get a technological software solution than a regulatory approval - as the regulators have very high standards when you take the human out of the control loop. The software needs to be way way way safer.
Unlike “Full autonomous surgery” which is a moonshot two decades away IMHO - autonomous path following and navigation is a little easier. Even poking forwards and backwards a needle - or even advancing a microwave probe and holding it there throughout the therapy is within our grasp today - as it’s relatively easy compared to multi- arm surgery. Easy… okay you know what I mean.
But what I see next in bronchial approaches will be a steady advance towards step automation and then full autonomy. I do see that within five years we could easily see self navigating bronchoscopes that will do fully autonomous biopsies (under supervision of course) - But I think this is closer than we may all think.
Endolumenal Robots Beyond the Bronch
So the next technological step is to use the same diameter catheters within a fairly simple and well defined conduit - which is the urinary tract. Urethra - bladder - Ureter - kidney fairly straight path.
In fact the monarch system has already gained clearance for use in Endo-Urology. (I told you JNJ was ahead.) You drive the robot up to the kidney and basket stones out of the way - or break them up with a laser - or both. It’s done today with Urethroscopes manually. But again the beauty of the robot is stability - memory - and that gives excellent “rapid exchange” capabilities for guide wires - for baskets - for laser fibres in a super stable platform way. That creates accuracy and possible time savings.
The length of the catheters - optics - channels - is all pretty similar. The diameter of the catheter to handle and control is the same - so software is pretty much the same.
So it makes sense to go after the urologists next.
The structures are not a rigid as the lung so complexity goes up - put the pathway has less "lfet n right" so you win on that.
Hey hang on. Urologists - isn’t that already a sweet spot of Intuitive? Oh yes.
So, now we get into leverage of the DaVinci sales force and clinical teams. Now we start to see synergy (more so than pulmonologists - but that’s not 100% true.. but I’m not going into it today.)
I personally can immediately also see combo daVinci and ION / Ottava and Monarch procedures for renal work to get to a very precise set of minimal invasive (different than minimal access) procedures - and tissue sparing procedures beyond simple stone removal.
See my post on Rendezvous. Where combined approaches improves accuarcay.
You might also think what I said earlier about Toumai - where you dedicate one working arm to the flexible Urethroscope during a 3 arm abdominal and 1 arm flexible rendezvous. Ohh nice. All from the same console (perhaps) with some modifications and a side car flexible control pad.
But think of this - a nice DV5 “virtual OR space with your head in the console” able to bring in the navigation imagery - combine with the HUD of the abdominal space - flick between the two (you need 10,000 X comp power for this kind of thing…just saying.)
Now solo operators doing rendezvous urological procedures… maybe? Well it's cool in my head.
If not then ION in Endo-urology is next. And soon all the systems will be doing more complex endourological procedures and with some parts in percutaneous guided outside approaches combined with endolumenal.
Oh- did I say that Microprt MedBot also has a percuatneous robot… or did that slip my mind.
Look it opens up possibilities for precision guided - minimally invasive therapies. Local guided and delivered agents, energy, focal therapies etc etc - All can be thought of once you have a super stable - highly precise - image guided navigation robotic flexible platform.
Make a big one for the GI tract.
This is where technically it does start to get a bit different than a bronchoscope or a urethroscope. You will need bigger and stronger and eventually longer. You’ll need twin channels - maybe snaking cameras that pop out of the end of the endoscope (does any company have one of those — or several of them - oh that’s right the SP camera and the Toumai single port camera.)
Long flexible “wristed” instruments. Hang on this is sounding suspiciously like EndoQuest?
Well if you take the ION and Monarch to the nth degree... you end up with a system that can replicate what an Endoquest does - it starts to blend the console of the daVinci - with the catheter navigation of the ION - with the tools and know how of the SP.
This is what Fred Moll dreamed of with iPlatform - and he even had small procedures like ESD ready to go. But that horse stumbled at the gate. It will now be down to Monarch to do ESD etc - and maybe a beefier version to take us all the way to full surgical Endolumenal GI procedures - and then a combo with Ottava to get to full rendezvous (what he called Concomitant) procedures. Oh I'm excited.
I believe we are well and truly on that road. This will be a multi generation product platform approach with variants that all work around central architectures that exist today. And on top of all this we will see the application of AI and autonomy combined with next generation imaging - specific molecules - next generation energy devices and paired up guidance systems. (robots that see robots through tissue.)
It really is limitless - and we are on track - and teams around the world are already doing a lot of this stuff in labs at their company HQs.
The sludge in the works wil (as always)l be regulatory clearances and then payments and then laggards saying “this is stupid.” Until it’s not. but damn these are exciting times.
These are just opinions of the author for education purposes - and he will opine soon on how this same technology actually opens up the doors the some quite interesting endo vascular - cardiac and neurovascular opportunities. Who did Abiomed get bought by? And when will Edwards team up with Intuitive? (That last one was a joke…)
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