Endolumenal robotics moves ahead with Endoquest and Virtuoso Surgical
- Steve Bell
- May 20
- 9 min read
Updated: Sep 9
Much of the future of surgical robotics of course is in the laparoscopic and thorascopic fields. With system like Intuitive DV5, Medtronic Hugo RAS, Johnson & Johnson Ottava and the host of other credible systems out on the market, or in development.
But a parallel field that will change the rules on “when and how” surgery is done has taken big steps ahead this week.
Endolumenal surgery has been screaming for robotics since 2007 - I know we tried this without robots at MINOS medical . But only now has technology, robotics, regulatory, software all come together to give us the tantalising taste of this new type of surgery.
Okay - let me be clear here. Endolumenal robots for diagnostics and minimal see n treat have been with us for a while with systems in the bronchial space like Intuitive’s ION, JNJs Monarch, and Noah’s Galaxy.
But last week we saw the first big advances clinically of surgical endolumenal robotics. Or robots with arms and end effectors to start to do genuine surgical manoeuvres from within the lumen of the patient.
This is a game changer as we went from open surgery (big incisions) to Minimal Access Surgery (lots of small incisions) to Single incision surgery (one relatively small incision.) But Natural orifice surgery (rather deeper than just TORS or transanal) means you eliminate incisions all together, and use natural access points to get deep into the patient.
This week we saw two very different, and equally exciting, First in Human experiences with two novel endolumenal surgical robotics systems.
Endoquest pioneers Endo GI Robotics
First we have Endoquest, and their endolumenal GI operating system. Imagine a hyper flexible colonoscopy like device that can deploy an articulating camera and two fully controllable articulated and wristed instruments. A system that can drive deep into the colon and perform very complex surgeries of the bowel wall... but from inside the bowel.
This is a potential game changer for colorectal cancer - why?
It is well known that flat (or sessile) polyps are one of the early stages of colorectal cancer. Once identified those polyps need to be removed.
Now, it needs some context for those that are not familiar with this (slight pun there for those in the know.) But most people think of polyps as like a mushroom. Polyp on a stalk.
These pedunculate polyps are relatively easy to deal with by looping and excising - as they are up off the bowel wall. That means you can loop or lasso them to remove them.
But sessile polyps are flat and buried in the bowel wall. That means they need to be cut out, and removed. And then the defect in the bowel wall needs to be closed. Not easy with standards colonoscopes and their in line instruments.
By removing sessile polyps we reduce the risk of cancer growing in that part of the bowel. But it is super difficult, and only for certain experts to do. Get it wrong and you can end up with bleeding, or a full thickness peforation of the colon. Neither are good.
But Endoquest makes that excision “easier.” And I put in quotes as it is not “easy” but it means that anyone able to control the robot will have precise control of scissors, needle drivers, graspers. Plus a triangulated field of view. That makes it “easier” to perform the complex manoeuvres to excise these sessile polyps, and then suture close the defect.
The stable platform, raised vision, instrument triangulation all combines with a console control of the instruments - and well you bring da Vinci “like” robotics inside the lumen of the bowel.
It’s hard to state what this advance in GI surgery does. But it opens up earlier potential cancer treatment to way more GI experts and colorectal surgeons. It means we open up the possibility of patients getting this procedure - Endoscopic Submucosal Dissection - by more clinicians in more places. And that could literally reduce colorectal abdominal surgery rates. And give a way better experience and quality of life for patients. It’s simply a game changer. Avoiding removal of a segment of colon, anastamosis and invasion of the abdomen is very important.
Last week: Dr. Eric Haas: "He is Chief of Colorectal Surgery at HCA Houston Healthcare Medical Center where the procedures were performed. Dr. Haas is also the Chief of Colorectal Surgery at Houston Methodist Hospital, the Program Director for Minimally Invasive Colorectal Surgery at the University of Texas at Houston, and a world-renowned pioneer in robotic colorectal surgery."
He performed the first clinical patients as part of a controlled trial called, Prospective Assessment of a Robotic Assisted Device in Gastrointestinal Medicine (PARADIGM). He performed two ESDs using the Endoquest technology - known as the Endolumenal Surgical System (ELS).
The procedures performed in the rectum and sigmoid went well, and Dr Hass was delighted with the system.
I cannot stress enough that this is not a replacement for something like a Da Vinci. It is an adjunct technology that uses a very different approach. But if this takes off then we could see a reduction in some of the colorectal cancers that would have been destined to da Vinci. It will take decades to see the full impact - but as more surgery moves this way, it could prevent the need of the more invasive abdominal procedures we see on robots today.
This will not be lost on either Intuitive or Johnson & Johnson. Both have their endolumenal platforms - and let’s not forget: Intuitive hold the IP and prototypes of NeoGuide. Go google it, as this was( I think) used to create the basis for ION. But it was really a GI platform for endolumenal and NOTES (Natural Orifice Translumenal Endoscopic Surgery.) And let's not forget, the heart of JNJs Monarch was from Auris - which was hyper focused on endolumenal GI surgery; and has a lot of know how in this space. In fact the original 6 arm Auris version of Ottava was to have an endolumenal component.
Other companies in this space such as Olympus must be watching carefully and seeing if their old EndoSamurai technology should come back. Plus you have Neptune medical in the works, INES, and others that are working out how to get into this space. Why? I’ll come back to that later.
But Endoquest has the drop on everyone so far. And having talked with CEO Eduardo Fonseca - It is clear that the barrier to this technology is 50% in the robot and control at a distance. But the bigger technological barrier is how to reprocess the instruments to make the cases economically viable. And having worked in this space… I can attest that ain’t easy!!! Remember the economics in GI Endoscopy are very different, so having reliable multiple use instruments will be the key that allows this to fit into reimbursements.
This is a HOT space in surgical robotics and this breakthrough last week should see a massive interest from companies, surgeons, GI endoscopists and investors.
Virtuoso Surgical robotically approaching the baldder
From the world of long flexible natural orifice surgery to the world of shorter rigid natural orifice surgery.
Duke Herrell and team have also taken a very clever approach to surgical robots. Finding another huge area where da Vinci does not touch directly. Bladder cancer is a common cancer - highly prevalent in smokers (don’t smoke) and often removed either via large open incisions, or more commonly now, it can be treated transabdomnal with a robot. Either multiport or increasingly now with single port. The entire bladder can be removed, but better for the patient are bladder sparing procedures where the tumour is excised from inside the bladder. catch it early - cut it out.
Even that today is sometimes done trans-abdominal, by entering the bladder with say a da Vinci SP (going trans-bladder.) Operating inside the bladder and then stitching up the otomy when you come out.
But this invades the abdomen, and is often reserved for larger tumours. It is definately not easy.
An alternative is to use a rigid endoscope - transurethral (natural orifice) - go onto the bladder and use limited capability instruments to try and excise the tumour from inside the bladder. It is not easy - and often takes both time and skill. Plus there are just limits to the size of the tumour you can tackle when working totally parallel from the rigid endoscope.
Step in Virtuoso. This novel system that consists of a small diameter rigid endoscope with lights and camera plus two working channels for some of the smallest robotic instruments to date. They are based on concentric tube technology - so not “wristed” as such but what it allows is triangulation - and spreading the instruments far apart - needed for counter traction.
They have a unique controller for the operator to manipulate the end effectors much like any robotic system. But it is designed with this parallel paradigm in mind.
This is a game changer for performing the En-Bloc procedures that were pioneered by Dr Herrell himself.
It’s a game changer as it brings a form of robotic surgical capabilities to in-line rigid endoscopes. (Think of all the places this could be used… just saying.) It’s all about allowing a small diameter end on approach - yet then allowing traction, counter traction, precision and stability within a cone of the endoscope.
No you cannot do this with a da Vinci - Xi, DV5 or SP. Why - because Virtuoso eliminates the incision in the abdomen. It’s endolumenal - and that is a big advance for patients.
Of course this en-bloc dissection is done by experts across the world today. But this tool is the breakthrough to make that procedure “easier” and more widely adopted. The technique has been waiting for the tool.
Again - it does not directly replace a cystectomy by an abdominal robot. But if enough tumours are removed early on - the number of abdominal approaches should fall. So does it compete with Intuitive. Yes and no. Key is it is not a direct competitor.
And that is what I want to get to in the next chapter. Avoiding directly going head to head with Intuitive - or Medtronic - or JNJ and their abdominal robots is probably smart.
Don’t run into the wall
I've talked extensively with Eduardo (Endoquest) and Duke (Virtuoso) and both have had the same revelation. Going up against Intuitive in their turf is the realm of monster competitors like JNJ and Medtronic... and few others. Plus the space is crowded with over 30 laparoscopic system robots and growing. IP is tough, marketing is tough, differentiation is tough etc etc.
As a small startup you often have to go the need that is not crowded.
Endoquest has spotted that need in flexible endoscopic robotics for GI surgery.
Virtuosos has spotted that need in rigid endoscopic robotics for bladder surgery.
Both massive markets - and importantly markets they can “lead” in. Do not underestimate a first mover advantage. And by both companies last week successfully completing FIH cases - and moving the pathway towards FDA (whilst gaining real world insights into the use of their systems,) you cannot underestimate how import this is for surgical robotics.
I appeal to the investment community to back these systems - and back them hard. They are not running into the wall of Intuitive. It is different. Yet meaningful. These parallel robotics companioes need investments to create these massive new categories.
The smart robotics companies (not talking AI here yet) are the ones that will nibble around the edges. Not having to put millions into marketing shoutouts just to be heard in a crowded laparoscopic space.
Of course they have some heavy lifting to do to build their categories. But I think the glass ceiling on “robotics in surgery” has now been broken - so these types of companies will be accepted way easier than 1998 Intuitive was. No one will argue that robots are not the enabler. And in these cases - you really cannot do what they are doing (at scale) without the robot.
This is why Eduardo, and his predecessor (and Todd Wilson et all) have been smart and visionary.
This is why Duke and his team have played this intelligently and found that space.
They saw the need that ONLY a robot can genuinely fix by empowering the clinicians. It moves from" nice to have" to "must have" - and in a blue ocean space where they can lead. Often the pioneer path is ridiculed - or brushed off. But sooner or later everyone will say “It was obvious. In fact I had that same idea in 2010.”
I’ve shouted loud that 2025 is the year where we depart from the paradigm of da Vinci style robots; and we see a mushrooming of new robotic applications in areas that “need” robots. Endo GI, Endo Urological, Endo Vascular, Endo Cardiac (Go Capstan).
Robots are about to break out of the laparoscopy mould: and both Endoquest and Virtuoso are showing us how to do it.
Congratulate them - support them - invest in these emerging categories - invest in them as the pioneers. This is an amazing win for patients - startups - investors and the community at large.
These are the musings of the author - and for educational purposes only.
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