Endoluminal Robotics - what it really is

“Endoluminal robotics isn’t a better way to do today’s procedures — it’s how GI becomes an interventional, programmable organ system.”

Preface

One of the key strategic failings we can all face in medtech is that we tend to look backwards to predict the future. We also usually think in linear progressive steps to shape that future. The main danger of using these frameworks is that endoluminal robotics will be defined as “What surgical robotics did” by looking backwards… and “how endoscopy can be better” by looking forwards.

Instead endoluminal robotics should be viewed in an independent way as the enabler to an entirely new way of thinking about interventions. This breakthrough technology should be looked at as a leap towards treating diseases in an entirely different way, at an earlier time in disease progression, and new modalities for new therapies along the GI tract.

Let us explore why this is inevitable.

I will start in the near term future and the grounded (and massive) procedures to be done today. But I need you to let go of your current thinking, and I will take you on a future looking opportunity that will clearly say why GI endoscopists must be the target and not surgeons. But let me be clear. I don’t mean to exclude surgeons from this future; I mean to say that to gain the massive benefits of what this technology can bring we must have GI Endoscopists be the leaders of the collaboration. It will become clear why later.

The current framing of the advanced GI market

I want to stress that this starting point analysis is in no way reflective of where this vast opportunity leads. But I want to ground us in the current situation. As this is “investible” and worth pursuing on its own, with none of my future gazing predictions needed to come true. Just with what we do today we have a massive opportunity to change healthcare.

Our simplest starting point is to see where manual endoluminal GI procedures stand today. There is no single, defined market report that accurately captures the current market size for many of these endoluminal procedures. So I’v pulled some different report numbers together to get to these aggregate numbers.

ESG — Endoscopic Sleeve GastroplastyAn endoscopic bariatric procedure that sutures the stomach from the inside to shrink volume (sleeve-like) without cutting or removing tissue. Weight-loss via restriction, no incisions, reversible-ish.

EMD — Endoscopic Mucosal DissectionOften used loosely, but generally means dissection/resection of the mucosal layer for superficial GI lesions. Shallower than ESD, deeper and more controlled than simple EMR. (Endoscopic Mucosal Resection)

ESD — Endoscopic Submucosal DissectionAdvanced endoscopic cancer technique. Precisely dissects in the submucosal layer to remove large or high-risk lesions en bloc (one piece). Technically demanding, longer cases, higher perforation risk—but gold standard for curative resection of early GI cancers.

To keep it simple in your mind:

ESG = metabolic/obesity therapy

EMD = mucosal-layer lesion removal (umbrella-ish term)

ESD = deep, precise oncologic resection

These are the core procedures performed today, manually, by highly skilled endoscopists. Many of the procedures are supported by specialist tools and systems - such as the Boston Scientific Overstitch system which helps to grab tissue and place sutures. But it is not limited to just this device. There are many assistive devices such as Over The Scope Clips, and more.

When we discuss these procedures for EMD & ESD - we will often look to the Asian markets which are considered leaders in the training, skill sets and numbers of procedures:

For ESD

Japan is a considered thought leader in this field with an estimated 40,000 ESD procedures per year (MHLW report) - They have a very high disease incidence and developed many of the procedures.Korea for Gastric EMR & ESD combined is estimated at 29,000 procedures per year (one report stating that between 2012 -2017 175K procedures were performed (Nature article)

Korea for colorectal ESD is over 6000 procedures per year.

Globally today Japan and South Korea are the leaders in these EMR, ESD procedures - but it should be noted that China is seen as a rapid adopting country based on large population combined with screening and early cancer pathways. Open source data for their volumes is hard to find.

For EMR

EMR is a simpler procedure and much more common, especially for colorectal lesions. But a confounding factor is that the procedure is rarely reported as “EMR” in a standardised way across countries. (It is muddied by polypectomy / various resection codes.) So it is easy to underestimate this current market.

Countries leading this procedure are often countries with large screening programs - USA. and large Western European health systems (UK, FR, GE, IT, ES), plus Australia.

However due too an “Advanced resection culture” Japan/ Korea still dominate overall endoscopic oncological throughput.

It is annoying there is no single larger registry for all procedures - so this could be a data opportunity for a company in the future

For ESG

The best sources are based around “procedures performed to date” reporting as opposed to annual incident reports.

An average of clinical summaries state >40,000 ESG procedures performed to date worldwide. But this is approximative - however, indicative of the volumes to dates.

North America - especially the USA is often sited in multiple industry reports as the biggest market in terms of cases and opportunity.  (Eg. Research intelo)

Brazil is a country that shows up in multiple clinical data sets and has been reported by ScienceDirect.

But in practice we also see ESG adoption in parts of Europe (Spain, UK, France) and a growing number in Middle East private systems.

Summary for the base case today: ESD > Japan #1, Korea #2, China emergingEMR > US, Western Europe, Australia lead on sheer colorectal screening driven volume (Nature)

ESG > USA leads with notable activity in Brazil and expanding elsewhere.

Much of this is driven by screening programs, training pipelines and device availability.

Base case and growth limits today

As we have no super detailed registry based, or national consensus databases - plus combined with disjointed coding and recording we need to think in orders of magnitude not absolute numbers. Sorry peeps.

EMR (mostly colorectal) 0.5 to 1 Million cases per year

ESD (Gastric & colorectal) 80K - 120K cases per year

ESG 40K -50K cumulative to date (< 15K year current run rate

These numbers do not feel very big, and seem constrained to geographical areas where there is a culture, training expertise or screening program. It is crucial we dig deeper into the factors that stop this being more widely spread, because it is NOT about demand and numbers of patients.

First - Operator dependency is probably the primary constraint

It is well recorded that ESD outcomes are operator skill limited. The training curve alone is 50-100 cases to get to the most basic proficiency rates. And very few western endoscopists are willing to (or can afford the practice cost) of that sort of commitment.

So in reality - indications exists but cases don’t happen in most countries.

Second - Procedure time & economics

Endoscopy is a very fast volume driven, turnover measured area of clinical practice. Throughput and room usage are critical for any endoscopy practice. The painful truth is that today - with manual ESD - it is 2-4X longer than a simple EMR and far less predictable for room utilisation.

Maybe the most important consequence and driver of the low uptake outside of Asia is the very poor ROI for hospitals. Hospitals actually do cap volumes of ESD procedures to “ESD preferred”

And where it is capped a simpler, faster less costly, less skill dependent EMR is performed. (But note that if we get a robot more EMR should / could be converted to ESD.)

Third - Risk tolerance

If we compare a piecemeal EMR (nibbling away) as opposed to a thicker en-bloc ESD resection - there is no comparison for perforation and bleeding fear. In less skilled and experienced operators - it is better to do a less invasive EMR and expect higher recurrence but give more surveillance. What it also does it push many disease states downstream (to say surgery) - with a known increased ultimate cost… but often in someone else’s budget bucket. (Budget thinking needs to change!)

Fourth - some ESG specific issues

One of the biggest issues today is reimbursement fragmentation, budgeting and a strong bias to lifestyle changes or bariatric weight loss surgery.

Of course recently we do see some impact of GLP-1 use as well - but where an intervention is still the correct option ESG is not always the weapon of choice.

Why - because ESG requires almost surgical like suturing and very few endoscopists are equipped, skilled or comfortable doing it.

In dissecting many of the reasons holding back advanced EMR, ESD and ESG - we can see that operator comfort, tools available and skill sets are limiting factors. The logistics to do these procedures is often constrained by skill, tools, time and (importantly) reimbursement.

For the current reality - why do endoluminal robots change the game?

By introducing a flexible endoscopic robotics platform (not a robotic endoscope) we get three immediate and critical unlocks that expand the current procedure TAM enormously.

I need to state agin that we are talking endoscopic robots with two or more controllable - bi manual - flexible instruments - NOT a robotic version of an endoscope

1. Skill compression

The technical skills required to manually hold the current endoscopes, deliver them, stabilise them, and be able to actually work in a semi operative way is beyond the reach of most endoscopists.

Remember - as we go from basic EMR to ESD and then to more advanced procedures for en-bloc resections - and full thickness resections -  an operator requires stability, multiple instruments with triangulation, traction and counetrtraction, and independent tissue manipulation - all under a wide panoramic view.

What endoscopic robotic surgical platforms deliver, are the pre requisites for the closure of the skill gap.

The robot delivers a steerable delivery platform that is then locked in place offering a stable operative platform. (This is not an inline robotic scope.)

From the platform a panoramic snake like camera is delivered that allows top down viewing as opposed to the limited “end on” endoscopy view today. This alone changes the entire concept of visualisation in endoluminal surgery.

The system also has (at least) two fully elbowed and wristed instruments that can be deployed and used like a laparoscopic single port robot. This delivers direct drive from a console of two robotic arms that can apply the needed traction, counetrtraction, precision for dissection, suturing, grasping and transforming endoscopy into surgery. Each arm allows independent tissue manipulation - independent of the delivery system - and this is a major difference. For later - you must think about the precision this brings for accessing tissue layers.

This alone changes the dynamics of an ESD from a “Craft” to a “Procedure.”

It is a vast “unlock” by allowing most operators ( I chose this word carefully as it now opens up both endoscopists and surgeons to have the required skill sets) to perform these complex procedures with surgical precision and speed.

Western ESD volumes could increase dramatically by 3-5X just by eliminating this as being performed by an “exclusive club.”

Importantly - it also means that most physicians know the “right answer” for many EMRs is actually to perform ESD - and this unlocks the move from simple EMR to ESD for a majority of operators. This has vast societal implications, huge healthcare economic implications and improved patient outcomes. I do also want to imply that EMR rates could also go up. Why? It will allow all endoscopies at any stage of their career to do a precise, potentially faster, better EMR. So would could see more EMRs actually get done.

2. Time compression

The criticality of the ability to operate as if it was a surgical robot cannot be underestimated. Anyone that has sat in on a complex ESD knows the poor visualisation, scope fighting, parallel instruments all take time to achieve the ESD. With the use of the robot - all of these issues fade away - and that means that an ESD becomes a more predictable and shorter procedure. Scheduling ability is critical to make this happen on a routine basis.

The big unlock here is that an ESD can now enter into a predictable and shorter OR/endoscopy suite scheduling format. It allows higher throughput.

But more importantly the ESG gains from these advantages, and that now allows this procedure to become commercially viable at scale. Scale is an important concept as we move forwards here.

3. Risk reduction allows guidelines expansion

The robot delivers a level of surgical precision and control that will translate into few perforations, uncontrolled bleeding and ultimately deliver more consistent en-bloc resections.

This will allow early stage cancers to stay endoluminal and avoid downstream colorectal surgical cases. That fact will shift the guidelines for earlier detection and treatment via ESD. It will be a difficult political and economic shift - but this happened in cardiology with stenting; and will happen again here.

What robotics does to the TAM

EMR - 0.5 - 1 Million - Robot could have some impact here with more EMR done - but it may stay level as many of the EMRs move to ESDs instead. (It will be dynamic)

ESD moves from 100K cases per year to 300-500K cases per year

ESG moves from 10-15K cases per year to 100-250K cases per year.

The key change is that endoluminal robotics does not simply steal EMR cases - instead it creates a new untapped ESD and ESG volume that is significant. While bringing in even more EMR through efficiency.

The winners and the losers in this transformation

Without doubt endoscopists gain a new skill leverage. Surgeons that do endoscopy can do more advanced procedures.

Hospitals gain much more predictable throughput of cases and scheduling.

Ultimately the payers will see fewer patients advancing to more expensive surgeries; and for those that don’t, there will be fewer repeat procedures from recurrences. The future avoidance of surgery is massive for patients and healthcare. Funding of this will need to be a key focus of the healthcare community - pay now to gain later.

A big winner is the robotics manufacturers that provide bi-manual control systems. The company that delivers the platform owns access to the delivery mechanism for all future consumables - period. If you are a company that makes consumables - your future gateway for many of those consumables will be exclusively via the delivery platform - the robot. So get a robot !!!

But in life there are always winners and losers. In my opinion, the single biggest loser could be the manual scope manufacturers. (Notably dominated by Japanese companies like Olympus.) It is then no surprise that Olympus has seen that this is an inevitability that is arriving at them like an asteroid. The investment into Swann Endosurgical is the highest level acknowledgement that this will happen. It is not a future speculative market. It is coming. Companies like Medtronic, JNJ, and especially Intuitive all have plays in this area of robotics, and a natural next step is to GI robotics. I personally would not want to be in FUJI’s or Boston Scientific’s shoes in the coming years.

Surgical oncology for early stage GI will be massively affected as procedures move to curative with the assistance of the robot. Be prepared for some of the biggest changes in surgical oncology!

The big training programs that still rely on “Go to Japan for a year” will take a huge hit. This will no longer be a case of going to learn the craft in Japan. That entire time and money sink will evaporate - and this hurdle to many western physicians will simply go away. That alone will accelerate the shift to robotic ESD.

The bottom line for today’s procedures

Advanced endoluminal therapy is demand-unconstrained but skill-constrained; robotics unlocks a 3–5× volume expansion by turning expert-only procedures into scalable ones. It is an utter game changer for these disease areas downstream and upstream.

One possible revenue cut based just on the above

As a commercial person - I do like to speculate how big these mattes can be. Revenue models in robotics are complex and never certain. But in an emerging field like endoluminal surgery we must steer clear of looking at second followers to Intuitive - as that is a skewed revenue model.

Instead it is better to see a market leading “pioneer” model for revenues and see what is possible.  Let’s dip into a speculative, system level revenue model for an endoluminal robot.

Let’s first make some assumptions - and separate the revenue possibilities from some of the issue around reimbursement. It will keep the model a little cleaner - as reimbursement and funding changes will be important later but as we move to mass adoption. Much as happened with da Vinci over the years.

We can use some older da Vinci numbers simply as a surrogate for what hospitals are willing and capable to spend for robotics systems. It is a frame work they can work within as it is familiar. But we can’t let these robots become the same category.

Capital portion of the system is $1.5-$2.5M (not necessarily cash up front)

Annual service $100K to $175K

Per procedure instruments $700-$3,200 per case (complexity dependence)

EMR (For simplicity I’ll keep this flat) would be a baseline and hard to predict more in vs more out of the pool.

ESD higher as more instruments used

ESG even higher as we enter complex suturing etc.

Key is to investigate the ARR per installed system = (cases per year X $ per case) + Service costs

Conservative / Base / Aggressive (per system)

Assume service = $150k/yr and CAPEX portion  = $2.0M (midpoint analogue and early system deployment for pioneers)

Utilization	Attach $/case	Recurring / year	5-yr revenue (incl. capex)
250 cases/yr	$1,000	$0.40M	$4.00M
250 cases/yr	$2,000	$0.65M	$5.25M
500 cases/yr	$2,000	$1.15M	$7.75M
500 cases/yr	$3,000	$1.65M	$10.25M
1,000 cases/yr	$2,000	$2.15M	$12.75M
1,000 cases/yr	$3,000	$3.15M	$17.75M

Base-case “good site” (500 cases/yr, $2k attach) → ~$1.15M recurring per year per installed system.

If you can drive to 1,000 cases/yr, recurring revenues becomes the whole game. So volume is a major strategic incentive driver for any company. The capital could be deployed as a cash up front payment or a PPC (pay per case), lease plan or rental plan. This is critical in my thesis of why this cannot initially be a low volume surgical system. If it does it will not his the revenues and usage needed to prove the value of the systems. It will give a false narrative making the endoluminal robot a curiosity not a work horse. (THIS IS IMPORTANT! Especially if you are a surgical company looking to lean into your close surgeon base. Watch out !)

Scaling to market revenues based on limited installs

If we use the simplified maths of:

N=installed systems, U=cases/system/year, A= $attached/case, S= annual service then we can simply determine an ARR by

ARR= N X (S + U X A)

Year X total revenues = (new installs X ASP) + Recurring **New install ASP can be broken across 5 to 7 years (but for simplicity I’ll make it upfront.)

BUT we must look at the ramp in systems for a pioneering system and look at a 5 year model with a steady build in installs and case averages.

Year	Capital Installs	Cumm Installs	Capital portion of revenues	Total cases performed	Total ARR inc service	Total Recurring revenues
1	5	5	US$10,000,000	500	US$‎ 675,000	US$‎ 10,675,000
2	10	15	US$20,000,000	2250	US$‎ 2,425,000	US$‎ 22,425,000
3	40	55	US$80,000,000	11000	US$‎ 11,175,000	US$‎ 91,175,000
4	60	115	US$120,000,000	28750	US$‎ 28,925,000	US$‎ 148,925,000
5	85	200	US$170,000,000	70000	US$‎ 70,175,000	US$‎ 240,175,000

In this conservative model we can see a global total installed base of only 200 systems - which is conservative. Thinking that today over 1000 surgical robots are installed each and every year. That compares to our conservative 85 systems installed in year.It also conservatively estimates that cases on average do not go above 300 cases per site per year. (They will go higher.)

The capital portion could be accounted for as upfront - or spread across a PPC, or lease model. The revenues remain the same - it is an impact on cash flow.

Bottom line:

In the most conservative of cases we can see that within five years the ARR is approaching $250 Million.

And we must remember that this is only the base case that focuses on ESD and ESG transformation and TAM unlock. There could be upside if it is used in EMR as well. Below I will explain why this is potentially a vastly low estimate of the potential. And we must realise that today there are over 10,000 installed surgical robots with many doing 400-500 cases per annum as a comparator of what is possible.

Why do we need to reference surgery and surgical robots?

The nature of this topic is complex and has several unresolved questions. It also draws on patient flow, patient ownership, sites of care, willingness to perform procedures, willingness to pay and defence of therapy territory. Let me explain a little deeper.

We need to start by asking where most advanced GI endoscopy actually happens now - today.

A: Hospital endoscopy units are dominant today

EMR - majority done here today; ESD: almost all (outside of Japan); ESG split between here and OR but shifting to the hospital.

Why is this? Well we need to look at anaesthesia availability, back up for any bleeding / perforations that may occur, current pathology and oncology pathways… and very importantly credentialing and privileging to be allowed to carry out the procedures.

B: OR / Hybrid OR (Minority today but important)

Often used for complex ESD cases. Often a port of call for rescue cases, and frequently for ESG in very conservative hospitals.

Why is this? Well firstly understanding the OR or Hybrid OR is important and the size, infrastructure, anaesthesia, equipment etc. It is for higher acuity than you would find in most endoscopy suites.But there are three key factors; full anaesthesia vs light sedation is always available. In an OR there are always surgeons nearby should the abdomen need to be accessed or a rescue performed. And finally, there is a different culture around risk containment. These three all combine to it being a site of care for some advanced GI procedures. But it comes with major cost and logistical implications.

C: ASC’s today are very limited

They are confined to mainly simple EMR. ESG may be the reserve of some very select, high volume private centres that are well equipped. But it is a long way from most ASCs or small private clinics.

Why is this? There is absolutely zero tolerance for complications and complications management (complexity and costs.) Often there is no surgical bailout and that means patients would have to be blue lighted to an emergency centre. But one of the bigger issues is super tight room economics that just make long - variable cases unpalatable at and ASC.

What changes when we introduce a larger format endoluminal robot - and where - and who

When we discuss these systems we need to understand that these are not bedside - robotic assisted endoscopes. We are talking a real deal system of an operator console for bi-manual dexterity. A dedicated bedside cart that delivers a stable robotic delivery system - not a “half system.” And just by the nature they do have a larger format footprint than most endoscopy suite equipment today. But very common size of equipment for hospital ORs and hybrid ORs. So we need to think about the sites of care and the impact on sites of care. And especially where this may falsely take us in our thinking of where to deploy first. (Beware!)

Hospital endoscopy suites (The beach head)

Today this is the standard site of care and patient pathways referral pathway. The staff in the endo suite are very familiar with the types of procedures that would be performed, and they are used to endoluminal therapies, procedures, instrumentation and equipment. Importantly there is also a lower political resistance than the “OR” suddenly taking over the GI procedures. And this fact should never be underestimated in medicine - especially when there are patient gatekeepers.

The interventional cardiologists ultimately won over surgeons in the coronary wars because they controlled the patient and procedural decision making - and ultimately the site of care - the Interventional Cath labs.

But for this to occur at the endo suite there would be a subtle but marked change that would occur. The Endo suite would start to feel more like a mini OR with this complexity of equipment in it. In a well kitted out endo suite with an endoluminal robot, complex ESD + ESG could actually start to become routine in a place where surgeons don’t “own” the room - but the endoscopists (the gate keepers) do.

Hybrid ORs (early adopter route)

We could think of a transitional site of care. Remember hospitals feel very “safe” and there are always surgeons present "just in case.” And most importantly - in hospitals - robotics are already completely normalised. And this last fact should not be underestimated in terms of clinical practice, sterilisation services and budgeting.

However we must remember that OR time is relatively expensive vs GI suite time. And ultimately for large, wide, mass adoption; this route is not scalable for GI volumes. Trust me on this… What the future Endoluminal robot manufacturers want is not driven in the OR.

ASCs (could be part of the future but only after significant proof)

They are not first site of entry, or even second - and likely a low down third site of care when several key proof points are guaranteed. Firstly, for these complex cases complications rates must drop dramatically to almost zero. And as ASCs are all about efficiency, room turn over and utilisation - the procedures must show procedure time compression and be consistently time compressed. This can not happen early on in a program. It will take time to get to that rapid proficiency: and the ASC is not the place for that learning curve. The ultimate acid test that would fail for adoption would be the need for surgical conversation. There is zero appetite or tolerance of this at the ASC; so that must be proven out in other sites of care first and come to the ASC with an established track record. In fact, robots will be able to enable this - but only after hospital normalisation. Do not think of ASCs early on.

Let’s talk reality here and why we may assume “large format” robots favour surgeons (if people want to hear this or not)

Function wise - large format endoluminal robots actually function much like surgical robots. But also “equipment” wise they follow the same paths of surgical robots. They require complex capital approval committees, service contracts, coordinated block scheduling, formal privileging and robotically trained staff. In fact the entire ecosystem around it is much more akin to a da Vinci SP than an Olympus endoscope. And none of this should be taken lightly. Our minds will gravitate here.

Let’s consider that today surgeons have various forms of robotic credentialing, they already work under OR block control, they know how to influence a multimillion dollar robotics program through the complex capital minefield. They are already comfortable with complications (especially during the learning curve) and they already do have “billing leverage.” And many endoscopists would struggle with all of this.

We need to think about the mechanics and the control paradigms. If a surgeon has ever driven a surgical bi-manual robot - then these large format endoluminal robots will be so familiar to them. If they have driven a single port robot - it will feel an almost identical experience. And that means they are not on such a steep learning curve compared to a robotic naive endoscopists that is used to using a flexible endoscope paradigm controller.

It will be the same for the staff - and the same for the ecosystem around the robot. In surgery this is a natural extension of what they do today. So of course we feel this is where it “fits.”

But there may be a longer game that plays out and a hidden danger

I outline here one possible pathway that the clinicians and the patients follow on a long journey to the flexible endoscopic robots becoming mainstream.

Phase 1: The endoscopists lead : This is where GI drives adoption of the initial technology. They take their manual skills and port them across from manual ESD and ESG and show improvements in time, complications and outcomes. Here we see ESD and ESG volumes rise as a consequence of the greater efficiency. This is the gateway opening to a rebranding of “Endolumnial therapy.” And I cannot stress how much I encourage a rebranding of endoscopy when we add a robot.

Phase 2: A degree of co-management : Here we see the elite surgeons, and those surgeons that already do endoscopy start to move into more and more advanced endoluminal cases. This will be especially true where there is a lot of colorectal and bariatric overlap. Nascent today - this move starts the creation at a more formal level of the “Hybrid GI surgeons” and societies like NOSCAR can start to form more training pathways towards this new specialty. (Stay with me.)Phase 3: Surgical gravity wins (it’s subtle) : We need to acknowledge that clinical is the most important part of any system uptake and clinical practice change. But hospitals and hospital systems will ultimately decide on the consolidation of systems and treatment. They will dictate that one single robotic platform does Endoluminal GI, NOTES, Bariatric revisions and the procedures for early oncology. Here training shifts from the “specialist societies” to surgery residency/fellowships.At this point there is a key shift: Endoscopy becomes a modality - not a specialty boundary. And this is important if we let it go this way.

Why this really matters for the robotics opportunity

I believe that large format robotics platforms that give bi-manual dexterity win over hand held “robotic endoscopes.” And knowing that hospitals will ultimately want as few platforms as feasible to give the optimal clinical care…  they will think consolidation of platforms. In combination with the fact that today surgeons own robotic infrastructure then it all points to the fact that over time the “Real customer” is surgery using endoluminal robotic tools. (This is where our logic takes us if we look in the rear view mirror. This is the danger of the mental trap we can fall into. But the future is very different.) DO NOT LET THIS HAPPEN!GI remains the volume generator but surgery becomes the actual platform owner.

The path can be summarised as - “Large-format endoluminal robots will enter through GI, scale in hospitals, but ultimately be absorbed into the surgical robotics ecosystem — because capital, risk, and platform logic always follow surgery.”And for me - this is where we dramatically stunt procedure numbers of ESD and ESG - and kill the big prize of the future. Possibly lose this as a way for a platform to totally disrupt GI Endoscopy.

Considerations of today’s clinical pathway “control” structure

When we look back historically to cardiovascular and the change from surgery to cardiovascular interventional procedures we can remember that the gatekeeper of the patient was the cardiologist and they determined the path the patient should follow. And it was to drive their own agenda (and better patient care) by moving patient where possible to the interventional cardiology procedures. We saw CABG volumes collapse and stenting explode.

This is also true of many GI patients. The Endoscopists are gate keepers that control screening, diagnosis, initial therapy decisions and the follow up surveillance. Often said “In GI the first scope = the patient.” And in many cases the surgeon only sees what GI sends to them. So theoretically, the GI endoscopists should never lose that patient (if that’s what they want.) Much like was true in cardiology.

However, we must consider why patients will still “leak through” to surgery - despite that gate keeping.

Today much of this is about structural pressure that will drive patient flow.

Risk ownership shifts fast: The moment cases become long, technically hard (bordering surgery) and above all “potentially perforating” the entire risk perception flips and hospitals in 2026 will ask “Who’s holding the bag if this goes wrong?”

And today - that answer is most likely to point at surgery. There is a subtly different culture between interventional cardiologists and GI endoscopists. Here, endoscopists actually prefer to refer than to escalate personal risks. The world is very different than the early 1990’s in cardiology. And this is something that endoluminal robotics platforms will need to prove. That risk goes down, not up.

We must understand that platform control beats referral control.

Gatekeeping is not equivalent to that platform control - especially with larger format bi-manual “surgical like” endoscopic robots. It is clear that for this type of platform surgeons often control the robot, the room, the schedule and importantly, the capital committee narrative. If the robot is positioned into the OR.Logistics, dimensions, complexity will all point to the large format endoluminal robots being best suited to the OR or hybrid OR. “And let’s be real… the robot will most likely live in the OR” - and at that point the surgeons own the platform and do not need “permission” to use it. It will be natural consequence. This will be a very subtle but incredibly important “quiet power shift.” And once that happens we lose the real volume opportunity - and the entire big big market opportunity I will outline later. I cannot stress enough that is surgeons own this the opportunity dies.

Training will be a key influence.

It mustn’t be underestimated that in many countries robotics comes with formal credentialing of the systems and the procedures. Part of the training is often mandated to be carried out with proctorships (local or tele proctoring.) It also often requires, or is expected, to have deep simulation and data connectivity. And for many of the procedures there will absolutely be a case minimums threshold. And the closest parallels today for this currently side in the surgical domain. The natural flow for training would be for them to follow surgery - and it would take the GI endoscopists a “fight” to up end this and ask for a major change in practice. It would require setting up for parallel pathways in training - and that all causes friction. Easier for surgeons to integrate this than GIs to initiate it. (Right?)

All of this logic points us to the “path of least resistance being go to the surgeons first.”

Reality around complexity

It is just known that the more complex the tool the more likely it is for surgery to lay claim to it. It is, after all, what they are used to. And it is not just about the complexity of the actual “tool” but the entire complex ecosystem that surrounds the robot. A robotic “scope” would without doubt be of a level of complexity that would fit directly into the GI domain. But we are not taking about a robotic scope - we are talking about a large format, bi manual complex robotic platform. And the reality of that complexity is that it fits in the OR and the OR ecosystem - not in the GI suite.

Although some GI suites may “dabble”  if we are looking at adoption of complex procedures utilising complex robotic system - it is obvious that the surgeon and OR are the right users and site of care. Especially as the acuity of the procedures increases towards near surgical procedures.

But in my strong opinion, this is not the right path - and Endoluminal robot manufacturers will need to fight this logic. They need to pick a side. And I will say that for this to be a revolution it needs the GI’s to won it with the support of surgeons advocates. Not the other way around.

What would the GI need to win to actually keep the patient?

Let’s look a little deeper at the flip side and understand what the GI endoscopists would need to “win” to be able to own this future. It’s no small task - but I believe it is the right long term path.

Site of care ownership: For this to be a regular usage - the practicality of the robot would mean it would have to live in the Gi suite. And that for a large format robot would be challenging in many GI suites across the world. So the GI teams would need to fight for the location to be the GI suite - and that would also entail having the endoscopy staff up-skill to the use of a complex larger format robot.. Endoscopy suite scheduling would initially be turned upside down; and new ways of thinking about scheduling would have to be introduced. And the “leadership” would have to come from endoscopy. Why? Because the second this technology resides in the OR the battle and future is over.

Credentialing ownership: If GI is to retain control, then they would need to go from ground zero on robotic credentialing. They need to decide who gets trained? To what proficiency of the procedure and rescue? Who proctors? Because if surgery writes this book, then GI endoscopists become users and not owners of the platform. Pioneering surgeons can help them here.

Complication narrative control: Much of this was understood back in the days of interventional cardiology. If there was an issue - who did the rescue. And who decided that? For GIs to own the platform they must demonstrated that in their hands there is equal or lower complication rates vs surgery. They must set up clear rescue pathways that must be “better” than the idea of in the OR conversion to a surgical procedure. They’d need to show that emergency hustling from the GI suite to the OR would be “better…” and that is a very hard one to show. And they need to show that in complications there would be predictable economics. Because if complications trigger automatic surgical transfer… surgeons gain moral authority. Once that happens it is just “more logical” for the surgeons to do these procedures in the OR in the first place.

Let’s think why some endoscopists will willingly let surgeons own this

In 2026 economics and reality “Volume beats pride.” And the theoretical introduction of the robot should lead to shorter procedures, less fatigue, more cases per day and a broader indication set. That could lead some GI thought leaders to think “If surgeons help grow the bigger pie, I still get a small slice of a bigger pie.”

And although this may be a rational thought based on enlightened self interest… it ultimately accelerates the move to this platform and those procedures being owned by surgery. It is not in the long term best interests of the GI endoscopist. Surgeons must be involved but as followers and supporters not leaders and owners. (Surgeons follow my logic here.)

Let’s hypothesis what is likely to happen:

In top tier GI centres - GI endoscopists will fight and will win control.

Mid-tier hospitals - will almost certainly default to surgery as the owner if allowed.

Community sites will follow the gravitational pull of the capital and default to surgery if it is allowed.

So: Gatekeeping controls patient flow; platform ownership controls who ultimately treats the patient. And robotics shifts power to whoever owns the platform.

What are the real world and commercial implications for Endoluminal Robotic Platforms

All of the above leads to the decision points and gravitation of where these platforms and procedures eventually end up. Who treats them and owns the procedure. But Endoluminal robot manufacturers will (must) have a large say in how this new technology rolls out, and where the reality lands around endoluminal robotics and future procedures / therapies.

So despite all of the theory above - and the sentiment that the OR should become the final resting place of these large format Endoluminal system - by approaching GIs the right way - Endoluminal robot manufacturers could ensure GIs own this space. By aligning with what the GIs must do to own this above - Endoluminal robotic manufacturers could scale bigger and faster than if surgery leads this. In fact, I’ll stick my neck out and say that if surgery gets this and owns it, it becomes a niche product fr a few elite surgical endoscopists - and opportunity for all is lost.

The patient must never leave the GI suite: The avoidance of patients having to be emergency shuttled to the OR is critical. No incision must mean (for as much as possible) no incision. No rescue to an OR hand off to avoid the “Surgical escalation” rating. This will keep referral loops with the GI, follow up with the GI and all surveillance stays within GI. Surgeons would need to be framed as a last resort after failure - which must be extremely rare. They need to be framed this way - much as cardiac surgeons are today for ICs.

The robot must be positioned as an extension of the scope: This is a subtle positioning but super important. If an endoscopist believes in their heart this is a “smarter more competent scope platform” they will feel the moral right to own it. They will fight to keep it. If they see this as a long flexible surgical robot - they will feel obliged to let it go to surgery.Endoluminal robotic manufacturers must help to determine that psychology by their positioning - in every breath they make. If not, and they sit on the fence, then the market and “gravity” will pull this to surgery - which ultimately might be a way smaller market… (Read more. As I mean hundreds of times smaller.)

The non-negotiable for Endoluminal robotic manufacturers - if they really want this to be a massive scaling business - is to keep it in the GI suite; and not let it become a tool of the OR. For endoluminal GI robots to be a GI endoscopist first platform - all of the first installs must be into GI suites and not ORs. OR can come later and be secondary - but where 1st placements go determines the future trajectory and ownership of the platform.  The minute capital appropriation committees table it as an OR robot - I believe - it will be that forever. And that may not be the bigger market opportunity.

Like wise - if surgery own credentialing of this system - then they own the platform and ultimately the procedures - the patient selection - the proctoring etc. If this is to be a GI led system then GIs need to lead training through GI societies, GI case definitions, GI proctors. Even if this becomes “shared” between GIs and surgeons… that path leads to loss of ownership by the GIs and the surgeons gravity will pull it in.

Pioneering robots - Beware of overselling NOTES early on - NOTES is seductive - cutting edge - “cool” but ultimately seen as surgical. Early selling as a NOTES platform will immediately gravitate this platform to surgery. It will intimidate GI endoscopists and empower NOTES surgeons.

Procedures should be led by where the market is today ESD, Full thickness endoluminal resections, ESG and bariatric revisions. NOTES can absolutely come later - but after GI has established itself as the owners of the platform in the large volume areas.

Surgeons will be important - but as the “guest” that brings knowledge and wisdom. Not the owner that leaves the endoscopists behind.

In reality would surgeons even want the “Endoluminal robotic platform” patients?

Except for some super hard surgeon pioneers; most surgeons may not actually want these long and complex endoluminal cases. They also like “incisions” and like being in the abdomen - it is what they signed up for. Not for advanced endoscopy.They are also not into the GI style follow ups - and all of that (procedures and follow up) associated to a lower RVU per minute fee structure (initially.) Surgeons like predictable blocks, clear unambiguous ownership, and higher acuity reimbursement. So unless Endoluminal robotic manufacturers pick a side of the fence and decide to name it as a “Surgical robot” then most surgeons won’t automatically rush to claim it. I feel strongly that Endoluminal robot manufacturers must lean into this sentiment. In surgery it is for a niche of surgeons - but once it becomes a surgical robot hospitals will not get out of that mentality and they will make it a niche product.

We must also take into consideration the reality of the health systems globally today. And we must think about what adding hundreds of thousands of cases would do short term to OR infrastructure. ORs are already full with capped block time, low staff numbers: surgeon throughput limited (not demand limited). The reality is that adding hundreds of thousands of cases (yes that is the real opportunity) would be physically impossible TODAY for the surgical community to absorb. The idea that widespread surgeons would just absorb all those cases from the GIs is simply fantasy.

If it heads into surgery then there are realities that will automatically cap the market opportunity for Endoluminal Endo GI robots. It defect becomes an OR capacity capped procedure.

The danger is that if pioneer endoluminal robotics companies position their platforms as a surgical system - it runs into a brick wall of reality and it becomes a niche surgical robot in the hands of a few specialists… and never reaches potential.

Even if surgeons wanted it - there is nowhere to put it !!!

Endoscopists will not rush to go and fight for it back for the hands of the surgeons.

The Endoluminal robotic sweet spot - for now

GI keeps the patients - surgery helps the backup - much like Interventional cardiology and cardiac surgery.

The winning position that will maximise the long term utility of the platform, ensure mass adoption and ultimately benefit healthcare best is “Containment not exclusion” of surgery - where GI owns the platform and surgery owns the rescue.

This position should be acceptable to hospitals (they see it in cardiac already), acceptable to surgeons, and keep the patient with the GI endoscopists.

This allows for the optimal scale without endoluminal robotics becoming a niche surgical robot in the hands of the few. It turns ESD into a standard GI skill. ESG into a repeatable outpatient therapy. Turning full-thickness endoluminal work into a GI ownership.

That right there is 3-5X volume increase without treading on any hospital politics and without causing a war.

“Endoluminal robotic platforms are expanding what endoscopists can treat. They are not changing who treats the patient.”

This is a critical positioning for the short term introduction that establishes the platform as a GI enabling technology whilst tapping into the real market opportunity.We must be thinking of the delivery system and bi manual dexterity as a delivery platform for endoscopic therapies. This is an important understanding. And if done right, It could become the de-facto way that all consumables get delivered and used for complex endoscopic procedures.

What happens a decade out?

When endoluminal robotics works and patients are treated earlier on in the disease state we see a major change. We start to see fewer colectomies, fewer ostomies, fewer ICU days, shorter LOS and more day cases. And importantly, lower oncology spend. This over time shifts the thinking of surgery to a rescue specialty for difficult cases, not the default pathway for patients today. As a result surgeons don’t get busier (a problem we are heading towards and are ill equipped to deal with) - instead they get more selective. They end up with the right patients for the right procedure.

If we imagine ten years out - 3X ESD, 2X advanced EMR, earlier inception of dysplasia (better AI diagnosis and an ability to actually treat there and then.) It will result in a material reduction in colonic cancer resections; so surgical GI oncology volumes could flatten or even decline (which is desirable from a health system point of view.) It allows surgeons to focus on complex surgical cases, advanced diseases and multi visceral work.

It is the exact analogue of what happened in cardiac surgery after PCI, or what happened to open aneurism repair after stent grafting. It ultimately removes the wrong work from surgeons and preserves much needed capacity for the right work.

That is how endoluminal GI robotics avoid the surgical niche trap - and performs at scale. Prevention finally wins without breaking the hospital capacity. But endoluminal robotics platform manufacturers will need to drive this as a position - not hope the wind blows them that way.

If they sit on the fence - and surgeons take the console… this opportunity for patients and healthcare systems will be lost forever.

How does this translate from a strategy to tactics?

The first 3 commercial years must be survival and proof NOT territory wars. Endoluminal robotics platforms do not win by owning endoluminal surgery - it actually wins by making advanced GI endoscopy boringly routine.

Year 0-3: The expert GI power users. ESD power endoscopists Japan, Korea, EU centres of excellence, select US sites. Then placements into advanced EMR centres. ESG-heavy private & academic GI units. And importantly teaching hospitals with GI fellowships. This has to become part of the “norm.”

Why these are the right first customers? These current users already “feel the pain”; own the patients; fight surgical referrals; will be willing to accept friction if outcomes improve.

Why surgeons are not the right first customers: Most surgeons - except a few academics are already maxed out - so this is potentially relegated to a side gig. They actually have no real incentives (real world capacity) to add these long complex GI cases. In 2026 OR time is the scarcest asset in the hospital. Having management pressure to “avoid the cases” is not a good starting point for a new technology introduction. If surgeons need to ask “where does this fit into my week?” - the eventual answer is “it doesn’t.”

There is just a workflow mismatch - early cases will be slower, way more set up and more staff sensitive. Most surgeons will not have the volume - patience or motivation to tolerate it. GI specialist actually do.

There is an incentive mismatch - In the early installs the robot improves outcomes, increases volumes but doesn’t immediately maximise RVUs - so it mismatches in surgery. Instead GI endoscopists value volume, referrals and the longitudinal care it brings.

The GI endoscopist should actually fight for the endoluminal robot as it keeps the patients endoluminal, expands their treatable lesions, reduces referrals and importantly, raises GI prestige internally. It will create internal champions which would be very powerful for Endoluminal robotics manufacturers.

This is not to exclude the surgeons - but to frame this right and maximise the opportunity - surgeons should be the secondary users, seen as the rescue “partners”, co-authors on any outcomes papers (adds credibility) - but they must no be the platform owners. Colorectal surgeons with an endoscopy interest would be strong partners, bariatric surgeons with ESG practices, and academic innovators (not OR grinders.) By addressing the surgeons, but placing them in the right pecking order you get political cover, a strong safety narrative and better institutional buy ins (less resistance.) But they must be invited guests on the robot - not the owner of it. And any right minded surgeon must be able to see the long term opportunity for patients and healthcare by buying into this.

Geography matters a lot year 0-3: Japan & Korea must be top of the list with GI masters of ESD - to get rapid credibility of the system, and excellent outcomes “faster.”. EU academic centres give hybrid comfort. US centres of excellence - GI led with surgical back up.

Initially we should avoid community hospitals or any institution that wishes to be an OR led program. And subtly we must avoid (initially) capital committees that are all about OR led robotics (ie heavyweight surgeons that sit on those committees that are OR robotics biased.) A balanced capital committee should be sought - not the surgical Robotic Users Group capital committee.

By going this route first - you avoid the traps of: The robot lives in the OR, surgery cherry picks selective cases, GI feels unwelcome and disengages, the platform stalls and you end up with low usage. That will literally be the death sentence of the endoluminal program. In my opinion, it is also where Intuitive could most likely lead, and JNJ could follow. They know this space and the surgeons are their customers today. Medtronic has a foot in both camps so they could go either way. Early endoluminal robotics manufacturers must set the direction first and let the others follow. Companies like Endoquest and Swann Endosurgical must focus on the GI endoscopists in my humble opinion. If this is surgical company owned - it’s a niche and misses the very big picture. (Although some patents by Intuitive give me hope they are thinking beyond surgery.)

Think like this “In the first three years the endoluminal robot company’s mission is to make expert GI endoscopists faster, safer and less tired. It should no try to redefine surgery.” This ensures that volumes grow, GI suites learn to adapt and show the best practices, and surgeons can come later but on the endoluminal robotic company’s terms.Select surgeons can be part of the journey but in the copilot’s seat - bringing experience and insights but not driving it to surgery.

Let me jump off my soap box for a minute on who and get back into what.

Deeper dive on ESG - as an example

If we strip out the “user” for a moment - we can see that ESG needs several things to succeed as a procedure. Reliable full thickness tissue bites, consisted plication geometry, repeatability over 6-12 sutures, low fatigue over a long case (45-90 mins today.) But you don’t need open surgery access, you don’t need a whole OR infrastructure; and it is certainly not surgeon only skills. The biggest issue today is all that manual suturing through a flexible scope with today’s instruments.

Apollo Overstitch (Boston Scientific) has moved some way to answering the question but, in my mind, it is still a long way from what is really needed for mass adoption. It is still single handed with awkward dual control. The user still deals with scope instability and constantly fighting all of the stomach. It’s still tiring to perform and by many is considered to have a long learning curve. This all results in a small subset of GI endoscopists doing high quality ESG. Wildly variable procedure times and massive outcomes variance dependent on operator skill and experience.

The new generation of endoluminal robots with bi-manual control inside the stomach change the game. One arm can grasp, create tension and present tissue whilst the other drives the needle at a controlled depth and gives close plication. The platform stops scope torque, having to go fish for tissue and the dreaded inconsistent bites. Just that reduces fatigue.

But importantly the stable platform gives another big advantage. It stabilises the distance from the scope to the wall, sets reproducible angles of attack and allows much more consistent suture spacing. Sleeves become more consistent, the plication starts to look “boringly” the same and that means outcomes should normalise. All combined with a more predictable procedure time.

The fact the user is now seated at a console to do all this, instead of bedside, means greater comfort, lower physical stress and fatigue and better comfort over a fairly long procedure. This brings a whole new level of thinking to the GI endoscopy suite for these procedures. In many GI suites this can be done today with the same level of anaesthesia as they use today, standard GI staff - as long as the facility has surgical backup on call if needed. It does not need to be done in the OR and should not be done in an ASC (yet.) The flow is… roll in the endoluminal platform - dock it in - and go. With the criticality of choosing only GI Suites where the robot fits today - because if there is any renovation or special building of a special room - ESG on large format endoluminal robots will not happen.

This then pans out like this: Year 1 still long(ish) cases and superusers in Academic and Private GI centres. By Year 2 the time for procedures drop and indications expand, and with the experience gained training becomes standardised. By Year 3 ESG becomes a routine advanced endoscopy block, no longer a “special event.” - At that point volumes can go up massively.

Why surgeons are not needed to do ESG (but must be onboarded politically.)

The surgeons are useful and needed for bariatric alignment, complication rescue and overall institutional comfort (as they will be consulted as part of the process.) But they are not needed for “suturing inside the stomach” - now we have a robot. There is no need for their expertise for long endoluminal cases; and they are not needed for longitudinal obesity care. GI can totally own ESG if the robot makes it repeatable, predictable and efficient. And the hidden upsides this brings are that you unlock redo/ revision ESG, Sleeve tightening, post surgical revision endoluminally… and the big long term unlock - Combination metabolic procedures. (Later my friends - you will like where this goes.)

It’s not that the robot makes the ESG possible - the mentality is that the robot makes ESG scalable. And that is the key.

Deeper dive into ESD - as an example

If we break it down ESD is clinically the right thing to do but is systemically broken because it is too hard to do by current manual means. The learning curve is estimated at 50-100+ cases, depending on user skill. And that skill is centred about a fairly rare manual dexterity, and a skill that is shown to decay without continued volumes. Based on this most GI endoscopists never attempt it - and few go through the rigorous training, often in Asia.

Block time doesn’t help, as a good ESD can be 2-4X longer than an EMR. (and note that 2-4X means very unpredictable case length.) The issue with long cases in the endo suite is that it kills room utilisation… which is a red line for most working GI endoscopy suites.

You then throw on top of all this the high risks of perforation and bleeding (and difficulty in controlling bleeding) and it becomes a scary area for most. Especially in a highly litigious western system like the USA. Go less risk with EMR - right?

Add to this, that even if GI endoscopists want to do it - the current western economics around this procedure make it hard to justify with weak and unclear reimbursement, long cases and often flat fees which discourage doing the right thing. Any rational hospital in the west would clearly avoid it today.

And to get there requires training in a training system that does not scale today. It’s based on an apprenticeship model that often requires extensive travel and stay in Asia with long proctorships which inherently stunt volume growth. (Not exclusively correct but in many cases.)

And if you get through all of that, there is significant physical and mental fatigue that in itself limits how many cases can be done daily. Even the best experts set limits to the number of cases.

Here’s the big irony… ESD prevents surgery, but then the surgery that gets done is easier to staff, easier to schedule and ultimately easier to defend: Making the worst therapy the one that’s easier to run. So this means that ESD isn’t failing clinically - or isn’t the right thing clinically - it’s failing operationally. It is this that gives endoluminal robotics an obvious gap to close.

But the gap it closes in upper GI ESD is actually a little different to lower GI tract ESD. Upper ESD in the stomach is the dominant use (with also the oesophagus for early SCC/Barrett’s neoplasia.) It is where ESD started, and today has the highest volumes and maturity. Of note is that it also has a lower perforation risk due to to tissue thickness.

Lower (colon and rectum) ESD is growing but is deemed way harder. The endoscopist has to deal with thinner walls, way more looping, a higher and worse perforation risk; and ultimately a longer learning curve. This is shown by significantly slower adoption, especially in the west.Why this is important to distinguish is because the real “prize” is lower GI ESD for the robot. It could replace EMR with the “right procedure” ESD, replace unnecessary surgery  and give massive volume upside in these procedures. The real opportunity of the robot early on is unlocking all that potential in the lower GI ESD market.

ESD and full thickness resections - a deeper dive

We have to discuss a little more on where truly endoluminal procedures go beyond the lumen and end up in full thickness resections. This is important as it is at the limits of what an endoluminal procedure can do. And an area where the robot could be the absolute game changer.

To be genuine “full thickness” the endoscopist is removing all layers of the GI wall. This is so different to an EMR. The operator will take mucosa, submucosa, muscular propria and (importantly) the serosa; which often is part of the peritoneal cavity. It is basically the GI endoscopists worst nightmare of perforation - BUT intentional; followed by a controlled closure of the defect. This is why it becomes such a big deal.

Today there is lesion identification and marking using advanced imaging, margin marking and confirmation of suitability for the procedure (no lymph risk.) All of this is firmly in the realms of the GI endoscopist. But then at the site of the lesion the endoscopist needs to perform a full thickness capture.

The tools of choice today are a Cap based full thickness resection or a “freehand” full thickness resection (where bi-manual endoluminal robots would shine.)

The cap based FTR is basically a plastic cap that sits over the end of the scope. The lesion is literally dragged into the cap and a small over the scope clip - like a mini bear trap is deployed that grabs the full thickness from serosa to mucosa in a bunch. And then the tissue above the clip (lumen side) is trimmed off. Pretty simple - pretty safe but has size limitations and is very geometry limited.

The free hand resection is where the tissue is grabbed and traction is applied as best as possible and then the endoscopist cuts through the muscularis as they control bleeding as they go. Today it’s a complex parallel twin handed operation; with the skill and dexterity of the operator being the most critical factor. The image is not great - counter retraction is near impossible, and it is slow, long and painful for the operator.

Controlled perforation is where you continue deeper until you pass the serosa and enter the peritoneal cavity. Ideally you need stable visualisation, a good degree of ability to apply haemostats and nerves of steel. And at that point - if you can’t close the defect reliably you probably shouldn’t be here. Today the weapons of choice are over the scope clips or endoscopic suturing which is not easy. It is often quoted that the procedure legitimacy is down to the quality of that closure. And it should be starting to be pretty obvious why a robot with bi-manual dexterity - cobra like scopes (that give wider fields of view) and articulated wristed instruments are the game changer here.

Finally there is a leak check and recovery. Often done by visual confirmation, CO2 management, and of course post procedure observation for leaks. By improving the ability to close - operators will have better results here and greater, reproducibility of a leak proof closure. Ultimately it is that leak free closure that determines the avoidance of surgery, short stay and faster recovery. It is why it is so critical.

This is often done for non-lifting lesions, fibrotic recurrences, subepthelial tumours, early cancer unsuitable for ESD and for rare but critical surgical avoidance cases. All of this is colectomy avoidance procedures. And these complex procedures are done in hospital endoscopy suites, sometimes in a hybrid OR and there is always surgical back up.

Why full thickness matters strategically

In the long run, full thickness endoluminal surgery is a critical bridge between GI endoscopy and surgery; between ESD and NOTES. And it is the gap between endoscopy and intervention. If GI endoscopy can own this space… then surgery loses cases, the OR load drops for the wrong procedures; and above all patient outcomes improve. And that is the long term game here.

And it is the robot that will truly open up all off the above and make it more mainstream - make it more predictable - more precise and widen indications. If the GI teams can get on board, get trained and make this part of the GI platform of procedures - the game changes.

We’ve discussed full thickness - now let’s take the logical next step and go transluminal

Before we even go here - remember that just through ESG and ESD expansion - Endoluminal robotics pioneers have a vast business opportunity. And that work is foundational for the newer procedures discussed above… and the whole aspect of NOTES. No company will need to rely on any of this future looking space - but as it enables it - it opens up a vast new horizon of therapies. And this opens up the “Platform” owning the space for the future. The foundational work with the GI endoscopists with surgeon back up support is the gateway to more advanced procedures and moving from procedures to therapy development.

I cannot stress enough that whoever owns the repeatable, stable, Bi-manual delivery PLATFORM - own the data, the access route for all the consumables and ultimately the future of therapeutic endoscopy. This is why this form of robotics 2.0 is so big and important.

In NOTES today (although limited) we start with controlled access. A small deliberate incision (stomach or rectum most common), delivering clean edges with minimal tissue trauma. People often ask about the infection - so bowel prep for colorectal is an absolute must with aggressive mechanical prep and broad spectrum antibiotic coverage. This actually only reduces the bio burden and does not create sterility. That is important when we think about the system and the procedure.

CO2 - much like laparoscopy must be used - to allow all the benefits we see in laparoscopy - such as rapid absorption, lower peritoneal irritation and interestingly, less bacterial spread. In another set of posts I will cover the particular issues around insufflation and other peripherals needed to advance this type of procedure.

A key to reducing infection risk is in the containment. Entry > do the procedure > controlled closure. That means no wandering around the abdomen, as the more time in the abdomen the higher the risk of infection. Technically it is the closure technique that matters more than the entry technique; and quality closure can be achieved by over the scope clips, but even better by suturing. With the holy grail being multiple layered closures. It’s known that if the closure is airtight then infection risk drops dramatically, and outcomes start to resemble laparoscopy.

It is counter intuitive that infection rates would be lower than intuition suggests. But we must remember that the peritoneum in real life is not the totally sterile space we believe. It actually handles quite well microleaks, bacterial exposure and inflammation. It’s actually less fragile than most people think.

We also need to ensure we don’t confuse GI flora with faecal contamination; as the upper GI tract of the stomach and proximal small bowel actually have low bacterial load and the acidic environment is contra bacteria. It still remains a reason why transgastric is always a good place to start.

If we assess where infections do happen today we can see that if closure failed, or the procedure ran too long, if the preferred route was the colon or if the teams doing the procedure were inexperienced. It’s actually for this reason that NOTES stalled and surgeons pulled back. But much of the cause was likely the fact there was no robotic platform to eliminate many of these pitfalls.

Here we can think that endoluminal robotics can be a key to unlocking NOTES by addressing many of the issues that we have. Of course it goes without saying that we gain precision of entry with controlled multilayer entry. Importantly from an infection and fatigue point of view is speed of execution. Once the procedure is performed we have the all important reliability of closure that a bi-manual robot with a stable locked platform and superior imaging brings. All of this reduces tissue trauma which counts towards the lower leak rates. This is not about allowing endoscopists to become more brave in attempting these procedures, but bringing less open time with better closure that lowers the infection risk. NOTES to date has not failed because of “infection” it has failed to date because the humans with hand held devices couldn’t execute the right way to lower the infection risk.

Let’s focus on transgastric approaches

In essence this gives you a very controlled opening through the stomach wall, giving access to the peritoneal cavity whilst avoiding any form of abdominal incision - even minimal invasive. It allows access to bariatric anatomy “from the inside” and you can act on organs involved in metabolism and not just reduce stomach volume. This in itself is a major mental shift vs abdominal surgery. It allows procedures like tightening a dilated sleeve, revising a stretched pouch, fixing gastric-gastric fistula and managing post surgical weight gain. All of which today are surgical problems that now become endoluminal therapies. This in itself is a massive and addressable market that the robot unlocks.

It also allows us to now think beyond the classic ESG by allowing combined internal plication along side external gastric shaping; which should lead to better geometry, more durable restriction and eliminates the need for trocars, which all starts to challenge the outcomes of laparoscopic sleeves.

Next we can think of targeted fundus exclusion, where by instead of removing the fundus you simply functionally isolate it, reduce Gherlin secretion yet preserve anatomy. You can aim for metabolic effects without the need for resection.

We can also enter into the realm of endoluminal bypass analogues - not a classic Roux-en-Y but some metabolic shortcuts such as partial jejunal exclusion, controlled duodenal access and temporary or adjustable bypass constructs that are simply impossible without transluminal access. We can even now step into metabolic surgery “Without surgery” by delivering highly controlled local ablation, nerve modulation and even tissue remodelling (I won’t go too deep here but repeat later.) But these target things like Gherlin pathway, vagal branches and critical gastric pacing regions.

This then can lead to combination metabolic therapy where we could see highly targeted ESG + neuromodilation, plication and direct drug depot, and combination restriction with hormonal control.

But of course none of this replaces complex malabsorption bypass, advanced super obese cases or acute surgical complications - however it would have already massively shrunk the current surgical pool. And in a ten year horizon we could see bariatric care split into two fields. High volume endoluminal metabolic therapy and surgical bariatrics reserved for complex cases and rescue cases.

We should think of it like this - transgastric access turns bariatric surgery from a single irreversible operation into a programable metabolic intervention.

Now let’s turn to transcolonic approaches

Transcolonic access can treat a number of diseases that are treated often with surgery today - but would make more sense with a more conservative GI transluminal approach. The focus should be on colon preservation as opposed to resection and anastomosis. This could be used for pericolonic tumour excision, types of mesenteric involvement and even locally advanced but contained disease. By approaching this way you can make a more conservative approach and treatment plan and intervene earlier where possible.

It also allows for sentinel lymph node access which is massively under-appreciated, but having localise transcolonic access could permit (with a robotic platform) targeted pericolonic lymph node sampling, local nodal ablation and staging without colectomy. And if the robot allows this to work as predicted it radically redefines early colon cancer management.

We can’t be blind to the fact that there may be complications attributed to the endoluminal therapies. The ability to go trans colonic could be well used in treating contained perforations, or draining localised abscesses, and importantly, trans colonically managing leaks from ESD and Full Thickness Resections. The robot becomes a rescue platform that does not require surgery.

Benign conditions can also be resolved with a robotic transcolonic system such as adhesiolysis and local release for post surgical adhesions or for localised obstructions. It would not be wide spread, but it is a very good use of a transcolonic robotic platform if it is already in the department.

Of more scale is probably palliative interventions. With a bi-manual stable robotic system trans colonic you can enter into the realms of tumour debulking, local nerve ablations and delivering symptom control without resection. This may not be the most glamorous use case - but it certainly brings high clinical value.

All of this needs to be put into perspective and describe what it is probably not good for, and smash some of the fanciful myths early on. It will not be part of large free intraperitoneal exploration - that will fall into the realm of a single port application of current technology - or an evolution of Endoluminal platform technology. It will also not displace robotic systems in complex multi quadrant surgery - so it is not replacing major colorectal cases by the surgeon. Speed is of the essence with trans colonic, so it will be contained to shorter procedures - leaving longer more complex procedures to laparoscopy. And the idea of transcolonic approaches to bariatric surgery are just the wrong risk on the wrong anatomy. Basically if you think the transluminal robot I doing laparoscopy then you are not seeing this the right way.

And to put transcolonic in context with transgastric - the infection risk is manageable but only just. All of the good things we talked about - mechanical bowel prep, antibiotics, CO2, small controlled openings and immediate closure go some way… but… transcolonic will always have higher risk than transgastric: resulting in the reality of fewer transcolonic cases, with a higher skill bar and stronger clinical justifications needed. It will not be high volume but it will be high impact.

When looking at the transcolonic space we must agree it is not the growth engine of the endoluminal robot… but the capability edge for when it it used. Hospitals will NOT be buying the robot just for this - but when it is in, and it is capable to do these cases, they will have high respect for it. And all of this helps to point us to the right positioning of the right patients with the right users in the right site of care.

We should talk about the halfway house and Rendezvous procedures

This moves up complexity mountain quite significantly, but it does have an honourable mention here. We are talking about two access routes via two operators (or potentially one depending on system architecture) but ultimately one target they go after.

You intentionally come together at the same anatomy from inside the lumen and  outside the lumen (or another lumen) to solve problems that neither side could simply solve alone.

Even today there are many examples of rendezvous procedures done without an endoluminal robot. ERCP rendezvous is a percutaneous biliary access where a guide wire is passed and an endoscope grabs it. Laparo-endoscopic rendezvous where for cases a surgeon exposes or stabilises anatomy while the endoscopist completes a therapy. We even have some hybrid-NOTES case where there is transgastic endoscopy combined with laparoscopy for safety.

They work - but they are clunky today, very OR dependent and personnel heavy. Non of which makes tis particularly main stream.

This is a classic area where the robot changes things and potentially unlocks these procedures. The combination of precision alignment, stable tissue presentation, predictable timing and… shared visual reference are the ingredients that turn rendezvous from coordination headache into a well planned workflow.

They unlock:

Endoluminal - laparoscopic rendezvous for cases such as full thickness resection with external confirmation. You can have secure closure under direct vision from above. In combination which can lead to avoidance of colectomy for early cancers. It will be a more logical starting point as surgeons feel safe, the GI endoscopist keeps the patient, and OR time is minimised by the robot. These are safe procedures as training cases for transluminal GI cases later.

Endoluminal - endoluminal dual scope rendezvous for trans gastric & trans colonic access or oesophagus and stomach with two scopes triangulating the same target tissue. Here the robot makes this synchronised, removes some of the chaos and can make such procedures repeatable.

Endoluminal - percutaneous rendezvous is probably the quiet, powerful form of rendezvous for things like biliary access, abscess drainage, and more so in the future, targeted delivery of drugs, biologics and next gen therapies. Robots will improve needle accuracy, docking and exchange reliability in these procedures. We are already here for Monarch with PCNL for JNJ in the urology realm.

Transluminal - transluminal rendezvous is a future facing option but one worthy of a mention. There is talk of trans gastric and trans colonic meeting in the abdomen to allow the thought of larger multi quadrant, multi traction surgery by basically replacing the extra hand needed with geometry. There is strangely a strategic safety message in it - if people can get their heads around it. The GI keeps patient ownership and surgery provides the back up without taking over. Hospitals should love this risk profile. The step wise plan to comfort is management of perforation. Then advanced closure, and then full transluminal work. This allows training in shared cases with shared outcomes.. and actually it drives less politics.

But let me be clear - as the use and skill sets of the robot matures, the actual rendezvous cases vanish. They are a halfway building house to getting to to a final single robotic capability. They are a way of doing training wheels, but not the volume engine for endoluminal GI robotics. These are more reasons to have the robot - or multiple robots - as they are not just seen as only ESD and ESG workhorses - but can be seen to be gateways to transformative endoluminal therapies.

Let’s look even more to the future

So far we have really focused on where the robot can become the enabler for the GI community within three key existing procedures; plus a voyage into NOTES and rendezvous. I want to stress that the ESD and ESG is the foundational area and the massive base case for Endoluminal robotics platforms. However, in my mind, the transformative clinical care and market opportunity lies beyond these procedures.

The endoluminal robot opens up an entirely new way of thinking. Of course we must crawl - walk - run. But a robotic platform becomes a game changer in so many other ways. I want to dig deeper into where this could be an explosive market comparable to interventional cardiology.

True endoluminal ablation. By introducing a highly controllable delivery system and bi-manual arms we can change the game in ablation within the GI tract. We now have control over the fixed distance to the tissue, controlled contact pressure and importantly - stable dwelling times. We can bring surgical grade ablation to within the endoluminal cavity. This opens up some new procedures en-mass such as Focal Cancer Ablation (early GI neoplasia), submucosal tumour ablation, Barrett’s focal eradication (well beyond RFA) and RF ablation for recurrence without resection. This is about tumour control and not only resection.

Layer specific therapy (a new frontier). Manual scopes can treat the surface - where as bi-manual stable robotic systems enable depth selective interventions that are beyond the skills of most individuals. The capabilities it brings are to treat the submucosa only, preserve the mucosa or treat the muscularis selectively. This capability opens up new procedures such as submucosal fibrosis remodelling, motility disorder interventions, local nerve modulation and early neuromuscular GI disease treatment. This passes us from the realm of GI endoscopy into Interventional GI therapy.

Endoluminal tumour debulking. We are not talking removal here we are talking about control of the tumours as we now have traction, counter traction, repeated passes and haemostats on demand. Think palliative tumour reduction, removal of obstructing lesions, pre-definitive therapy downsizing which are today mostly surgical or radiological territory.

Endoluminal reconstruction: Without shouting this too loud, this is where endoluminal robotics quietly beats surgery (sorry my surgical friends). Think robotic gastroplasty variants that are way beyond ESG, endoluminal anti-reflux reconstruction, anastomosis revisions, stricture remodelling by using sutured geometry. Manual tools just can’t do geometry easily today, but a bi-manual robot can. And quite easily.

Targeted drug delivery which is massively underplayed. But one ability of the robot is to deliver precise injection depth control, multiple controlled deposits and consistency of spacing. The operator now has that level of control, and as software navigation improves we get AI assistance here. This opens up local chemo delivery, immunotherapy seeding, fibrosis modulation and biological delivery to the GI wall. All along the lines of oncology, IBD, Motility. (Did I mention Intuitive ventures was placing bets in the CAR-T space?)

Endoluminal neuromodulation.  With the degree of control and bi-manual instruments GI endoscopists gain access to nerve rich layers within the GI tract delivering controlled ablation or stimulation. Think obesity neuromodulation, gastroparesis treatment or functional bowel disorder therapy. New frontiers that can be brought to the masses because of a stable robotic delivery platform.

Hybrid resection & therapy: We have to think more widely and understand that robots enable combinations that are simply impossible with manual scopes. Think of partial resection and ablation margin control, resection and immediate reconstruction, full thickness excision and surgical grade sutured repair. One single session, one lumen and zero OR.

Longitudinal care procedures: We now have repeatable, precise access with low fatigue and delivering consistent technique. This opens up new ways of approaching longitudinal care by enabling scheduled tumour control, metabolic tuning and disease maintenance procedures - more of a parallel to GI dialysis - not one off surgery.

Let’s go further with procedures that don’t exist yet: That stability, bi-manual dexterity and depth control can open up endoluminal lymphatic interventions, microvascular GI procedures and local immune microenvironment shaping. Yes this is a 10 year horizon - but as a physiologist I see the potential that the robotic platform finally unlocks. Let’s not think of it as a “new procedure” but rather think of the robot as a platform that enables controlled, layered, repeatable therapy inside the GI tract. It’s a tool that unlocks new ways of thinking. And… it owns the tools it delivers.

We are not talking about the above where endoluminal robotics is just substituting / replacing surgery.  Instead, with the right vision, messaging, societal support -  it creates an entirely new interventional layer between medicine and surgery.

Metabolic endoluminal therapy - a platform change

As medicine and surgery passes into the future - there are very different ways of thinking about treatment. And convergence of enabling technologies finally allow some of the more outlandish ideas to start to become an everyday reality. ( I like to dream.)

Metabolic endoluminal therapy is not about restriction or bypass. It is all about resetting the signalling: Enteroendocrine cells, Incretin pathways (GLP-1, GIP), insulin resistance drivers in the duodenum/jejunum and vagal neural signalling. Already today companies are manually delivering therapies inside the lumen. Endogenex being one new example which is using energy based mucosal therapy to induce metabolic changes.

I am a firm believer that robots in combination with emerging therapies will be the right delivery platform. Bi-manual dextrous robots will be needed to make specific treatments and delivery into specific, precision layers. Today the tools are linear, sort of blind by surgical standards, a bit too “one size fits all.” Whereas when you have an endoluminal, bi-manual, stable robotics platform, you flip this to being a precision metabolic intervention. (I’m not alone - just go look at Intuitive’s endoluminal GI energy mapping and delivery patents.)

Depth controlled ablation is one of the critical differences that will determine if patients get better outcomes. This allows a constant contact pressure (which will be seen to be critical), controlled dwell time and layer specific energy delivery. All of this avoids over/under treatment, reduces complications and critically when we think longitudinally - repeatability. This is why it moves things from procedures to controlled therapies.

With such dextrous control we can also  move from blanket therapy to patterned therapy. This can avoid circumferential ablation - which can induce risks of stricture, or treating areas you do not want to treat with adjacent structures. Instead the robot can allow segmental treatments, zonal targeting and even as we advance, patient specific patterns prescribed via AI. You could treat the duodenal bulb differently to the distal duodenum. You could adjust the ablation based on insulin resistance phenotypes, opening the concepts of precision metabolic therapy.

You can expand to multimodality delivery in one session because the robot brings an unparalleled level of stability for exact tool exchange. This opens up the ability to perform ablation, injections (peptides, biologics), neuro-modulation and even mechanical remodelling. This is practically impossible without an endoluminal robotic delivery platform.

We must remember that metabolic disease is chronic - and the robot allows low-fatigue procedures, standardised re-entry and scheduled “Metabolic tuning.” It changes from a “procedural system” to a chronic disease management platform.

Neuromodulation just becomes inevitable. Endogenex is hinting at this direction, but the robot will open up new ways of thinking where a clinician can target nerve-rich regions precisely, delivering controlled ablation and / or stimulation. And this can be done repeatably without surgery. This has possible applications in obesity treatment, Type 2 diabetes modulation, gastroparesis and other functional disorders: all with no incisions and no implants.

If the above starts to get in combination with drugs then there could be massive financial interest. Imagine delivering hyper precise localised drug depots to the right target layer. Or precise depth injections - both of which greatly reduce systemic exposure. Just look at Mirena within gynaecology as a great example. A bi-manual dextrous robot could allow these hyper precision drug delivery routes. Imagine GLP-1 locally potentiated with lower doses and few side effects along side higher durability. If pharma starts to pay attention the therapies explode (note JNJ is a pharmacist company by the way.) The company that own this data driven delivery platform owns the access route.

But all of this is only possible at scale with the robot. It brings consistency, safety, repeatability across a broad operator base. Manual tools create too much fatigue, variability and require way too much learning curve for this to hit scale. This is exactly what the robot solves.

And all of this is led by the GI physician, is endoscopy suite based and results in longitudinal care.

Positioning wise; surgeons don’t generally want chronic metabolic management; but the GI physician already does.

I come back to the fact this only ever gets unlocked fully if the GIs own the platform and not surgeons. If this stays as a niche surgical tool… none of this becomes real.

This drives my reasoning as to why Endoluminal platform manufacturers must not let this drift in to the hands of surgeons. They can use it - but only after it has been strategically established as a GI platform for longitudinal therapies.

Positioning though must be carefully done - not as a robot for obesity (we have those) - but as an Endoluminal Metabolic Modulation Platform. It survives the reimbursement evolution, dramatically scales beyond a single indication… and supports multiple partners such as Endogenex, other tool companies, and pharmaceutical companies etc. It is the robot that turns metabolic endoscopy from a single blunt intervention into a programable repeatable metabolic therapy - and this is a potential game changer.

Once you can place energy precisely, repeatedly and safely inside the GI wall, endoscopy changes into intervention in a dramatic way.

We need to think more broadly on energy that can be delivered - RF is known today but microwave and conductive heating become plausible via the robotic unlock. Again it comes down to that fixed contact force, controlled dwell and the layered targeting offered by bi-manual capabilities. And who owns all that critical procedure data and “what is needed to work?” - the platform owner. The endoluminal robot manufacturer. You get it?

For thermal energy delivery: We can start to imagine that we can deliver focal cancer ablation beyond just RF. Then submucosal fibrosis remodelling, Barrett’s precision eradication and motility disorder modulation.

For electroporation (IRE/PEF) the robot allows better and precise electrode spacing which leads to geometry control and that allows a reproducibility not possible with manual tools. This opens up non-thermal tumour ablation, nerve sparing metabolic modulation, pancreatic / peri-pancreatic targets (via Duodenum) which catheters cannot do reliably today.

Cryo - precise cryogenic- can be delivered. Treated freezing with a focus on minimal collateral damage could be used for better submucosal tumour control, refractory Barrett’s and repeatable longitudinal lesion treatment. If we imagine better navigation tools and smart software we can solve the problem of “where di I treat?”

Photodynamic / Light based therapy where we can now deliver very precisely local photosensitised activation with controlled illumination geometry. This could be used for early cancer treatment, field “cancerization” control, and very repeatable margin therapy. It is this combination of geometry and repeatability for a broad user base that makes the therapy become viable and scalable.

Magnetic / focused fields: This is very early but coming fast. This is a type of particle mediated energy that causes targeted heating or stimulation… and robotics allows the positing accuracy needed for it to work consistently.

The idea is to have these focal therapies ultimately replace resections allowing smaller interventions, repeatable re-interventions and this will ultimately lower the risk for the patients. It can be thought of how prostate cancer treatment is evolving - from surgery to focal therapies. By being able to use bi-manual dexterity you can selectively treat the mucosa or the submuscosa or the muscle or the nerves - targeting different treatments to different disease states. It is this ability from a stable platform with improved visibility and bimanual, triangulated instruments that you can treat the layers repeatably. Something manual scopes or simple robotic scopes cannot do.

Research is showing that the combination of energy, shape of application and layer do matter a lot. If this is combined with biologics, initial research is showing that energy primes the tissue but the biologics finish the job. We see this in ablation and immune activation, neuromodulation and drug depot, fibrosis release and then stem cell delivery. If the robot can enable this - it is where the pharma industry will support the push of this technology. The pioneer that owns this - owns this for the long term.

I know I have pushed the emerging combination therapies quite hard. Because the robot is so much more than a procedure platform, and must be positioned beyond that. It is the only way to unlock GI as a repeatable, therapy platform. And that is amazing for patients, healthcare systems… but will be transformative for the robotic company that gets to this first.

Plus we must also see that today we look at one lesion - one intervention - one outcome - one revenue point. Instead we now move to a temporal model where we do treat  - observe - re-treat. We get dose response curves for things like energy, and progressive remodelling instead of single trauma.  We build programs not procedures; and that is an entirely new market. It is about treating the stomach - the duodenum - the colon very differently with different target layers and targeted signalling zones. We start to treat regions of the GI tract not individual lesions.

It opens up a vast market akin to how cardiology thinks… and GI rarely does today.

And layered on top of this, these endo GI robots will throw off proprietary data - force, geometry, energy dosing, time in contact, tissue response - all things that manual GI scopes cannot do. All things that build a big defensible moat around the product. The platform will have unique propriety data. Pioneer endoluminal robotics companies will own the procedure standardisation, outcome prediction, AI guided therapy planning: and that will build a huge regulatory defensibility. The propriety measurability is what Intuitive has today in surgery. This is what these new endoluminal robots will have in GI tomorrow.

From a regulatory point of view it is all important. It most likely sits in a new regulatory sweet spot - where it is less invasive than surgery - yet more controlled than endoscopy; and opens up faster pathways for adjunctive therapies. Regulatory wise it will allow stepwise indication expansion and way faster clinical iteration - keeping a strong first mover advantage.

Summary for Endoluminal Robotic Platforms

I want to come back to say that most of the latter part of this document is where the huge future value creation is. But it is a stepwise and credible approach to get there. I have to discuss all of this at the latter part of the document to drive home why this cannot be a tool put into the hands of surgeons at the start (sorry my surgeon friends but I’m thinking patient first here.) It MUST be strategically shown as a long term GI platform for allowing future interventional programs. The GIs must own that. The opportunity for patients, healthcare systems and users deserves it.

Today we already have a massive opportunity - ESD, ESG and FTR. This alone makes endoluminal GI robotics a vastly valuable opportunity. Massive. And that is why I think it rapidly becomes bigger than the current surgical robotics market.

But imagine if next we get to robotic enabled metabolic modulation, directed energy and neuromodulation. This becomes a vast new opportunity that cannot be done with manual systems. It opens up white space therapies. Vast.

Later comes combination therapies, pharmacy partnerships and the establishment of chronic disease programs. That is transformational.

This is foundational knowledge to understand why endoluminal robotics manufacturers must strategically drive this through the GI endoscopists - and ensure that they “own” the platform. If it escapes to the surgeons - I fear they will be less aggressive - more robotic procedure focused and miss all the next and (importantly) later opportunity, because it’s not their field. Of course some surgeons will and must use the system; but I feel it is later, and at the coordination of the GI endoscopists. If the surgeons OWN this today - I believe the result will be smaller numbers of procedures, less uptake, conservative use, and a totally missed long term opportunity. The big opportunity for patients.

I’m not saying enthusiastic surgeons should be excluded. The opposite. They should be development partners bringing their knowledge to the GIs and helping with education, credentialing and setting the frame fro any surgical bailout. But they must keep front and centre this is a GI platform, for GI endoscopists. Only then will it reach its potential.

In my humble opinion, endoluminal robotics should focus on the GI endosuites and allow a wider group of surgeons into the platform once it is established as a GI platform. We all need to focus today tactically on the 3 year introduction… and then aim for a 10 years expansion to the big and game changing play.

For me… If we get this right… the future could be exciting. If we get it wrong… we waste a golden opportunity. These are speculations and future looking assumptions by the author and are for educational purposes only.