So who will drive Endoluminal Robotic Surgery?

Steve Bell asks who will drive endoluminal surgery

In the recent wake of big announcements in the MedTech industry from Swan EndoSurgical Inc. Olympus Corporation Revival Healthcare Capital EndoQuest Robotics - it is clear the next frontier in surgery is to move endoluminal.

Lots of exciting new surgical and non surgical procedures are emerging in Endo GI surgery that today are only really done by the most elite endoscopists. The tools that we have today such as Overstitch by Boston Scientific are great advances - but honestly they are not able to deliver the full capabilities of "surgery" (such as traction, counter-traction, triangulation, suturing like surgery etc etc)

The next wave of robots coming are about to upset that applecart and bring the full power of precision, stability, navigation and "surgery" to inside the GI tract. And that means things change. And change big time. Especially as you don't need to be the most skilled endoscopist to do these complex manoeuvres - no the robot is there to level that playing field.

I won't dwell here today on the vast number of procedures that can benefit such as ESD (Endoscopic Submucosal Dissection) or other procedures. But, be assured, it will make them easier and allow a much more aggressive treatment (who cares if you puncture the bowel wall?) It will also allow new therapies to be delivered by everyone - such as metabolic therapies via energy. And then we will get to Rendezvous procedures - where we will come from the abdomen and the bowel in a concomitant approach. And finally - we would see transmural "NOTES" procedures finally become a reality. It's happening.

Here the issues

All sounds fine n dandy. But if you look across many of these procedures - we see that most of the advanced endoluminal flexible endoscopy is performed by the elite endoscopist today. And Surgery is performed by surgeons. And as we move to more advanced procedures in or across the lumen - who's turf is this? And who's paying? Who decides?

Cardiac surgeons used to rule the carpark with the most expensive cars. But as Interventional cardiologist came in with endovascular procedures in cardiac - that all shifted. They are the gate keeper and decide "A stent is better than a CABG." Over the years, as technology has improved, they have taken more and more of the cardiac surgeons business. It is a lesson that should be watched by all surgical speciaties.

So are we about to see this in GI Endoscopy?

Will the skilled endoscopists start to eliminate surgical procedures? A good ESD can mean no later colorectal cancer surgery. etc. But also - can they start to make precision tumour resections - full thickness? Will the general surgeons learn from their cardiac colleagues? Or will they ridicule them as their procedure numbers dwindle?

Who is better equipped skill wise (dissection, retraction, margins, haemostasis etc) to tackle the bigger cases, or deal with the problems? Surely that is all surgical knowledge? Right? I mean... come on... right....

Reimbursement? Who is going to pay and how much. It most likely won't support both physicians in the room. And which room? Will the big robots even fit into the EndoSuites? (not a lot.) So are these systems destined for the OR? For ASCs? where and how?

And who controls the patients? This is a critical part of the puzzle. I saw it in cardiac. I've seen it in other specialties - that the first physician the patient sees often dictates the treatment pathway (not always) but often. But if economics lines up, patient marketing gets a grip, payers see the benefits... do we see shifts?

And then there is "who will industry choose?"

So I ran a poll on linked in - not a massive sample size - but here's the result

Now, this is a mix of physicians and industry votes. And well industry will have a massive (self interested) say in who does this. So if you are say Pentax - with no surgical customers - no surgeon reach - no OR teams... surely you want this all to be done by the endoscopist. But if you are Intuitive with no endoscopy reach (Okay they have bronchoscopy with ION) then they may very well want to leverage their surgeon user base. Give them an endolumonal robot that drives like and Xi. Easy training - learning. And they "own" those customer relationships.

So Industry will drive a lot of the messaging - the promo - the training - the site selection - the support - the con dress support - the clinical etc etc. They will have a massive voice in this.

But more than that - they will decide how the robot "works" and if it is more of a surgical tool or an endoscopist tool. It will all depend on who is their target audience. And they will dictate those design inputs. My guess... the big companies will all drive to a surgical robot like interface - I mean just look at EndoQuest.

Now the poll above is interesting with a 50/50 split between Endoscopists and Surgeons. And the majority saying "Both." And what this indicated to me is that both might be capable to cross learn the skills of the other - and the robot can be the catalyst that allows that levelling of the playing field. Especially in the types of procedures this will open up. And for a concomitant procedures - for sure the surgeons will do the abdominal part - and will be capable to do the endoluminal part. But will endoscopists upskill? Will it even become a new subspecialty?

My early (and take it for what it is) feeling is that we will see the forward looking surgeons - and forward looking endoscopists start to "come together" and work towards Interventional Surgeons for a number of procedures. I think most of this will be done in the ASC or OR suite with some large endosuites perhaps taking on robots. But we might also see a new form of hybrid interventional OR come into play. Well it's already starting. Not endosuite - not full OR. Much like the early ideas of Dr Eric Fosse on hybrid cardiac interventional suites.

These new therapy spaces could have navigation - imaging - and bedesigned for only minimal access surgery - not really equipped for major open surgery. (sorry that won;'t make total sense.) Smaller than an OR, bigger than and endosuite room. Tables more capable than a standard endosuite table, stacks more capable than and endo suit stack - but not as powerful as full OR stack - there won't be a need. Overhead OR lights... nahh. I think this type of room will come. I think these hybrid surgical endoscopits will grow. I think that the "pioneers" like the folks that get together at NOSCAR by SAGES will eventually haver their day. They have been working on this stuff since 2005 when NOTES and NOS first emerged but technology was not ready. But the time is now.

I predict we will still get the laggards - and lots of them. The "This is stupid... bigger the cut... better the surgeon." The "Endoscopists have no capability to do any form of surgery" The "Surgeons don't have the skills to do advanced endoscopy" The "Not in my lifetime." crowd.

But I think they will rapidly, and I mean rapidly see the sand shift from under their feet. Just like Society of Robotic surgery was thought of as a fringe meeting in 2019 - with odd ball robotic urologists. ERUS was the curios stepchild to EAU - and same for colorectal surgery - thoracic RATS vs VATS meetings etc etc etc. Today this robotic meetings are the zeitgeist of the industry. And so will come the combined NOSCAR style meeting growth. Advanced surgical endoscopists and next generation procedures will take over. More and more Endoscopists will attend SRS. New specialisations will emerge. Training for surgery and advanced endoscopy. And it will be fast beacsue it is not 1998 - it is 2025 and robots are accepted, massive industry is behind this. It's coming.

The laggards will fade - as they did on open to lap, lap to robotic and now surgery to endoluminal. Technology will drive the change - but it will be 10X faster than we have seen before. AI and autonomy will pile on and procedures will come AI assisted... way faster than you think. New treatment modalities will be delivered via this stable, precise, guided platforms.

I do think that many surgeons have learned the lessons from other specialties... well some of them. Others will go the way of the dinosaurs - and there are lots of examples of this.

But the primary and most important thing.... is that will be amazing for patients if we can move from amputative - larger resection surgeries to precision resections - no incisions - targeted and personalised endoluminal surgical procedures. I'm excited.

These are just musings and specultaions by the author for educational purposes only