What robot for tomorrow and what improvement can we expect?

PURPOSE OF REVIEW: The purpose of this review is to summarize the status of robotic surgery currently, contextualizing the advances and improvements we can expect in the immediate future. Robotics continues to demonstrate increased utility and expansion in medicine, particularly surgery. When coupled with the imminent expiry of Intuitive patents in the next few years, it is timely to consider what we can expect to see from new platforms; what new features might we anticipate and what technology will be available to enhance and improve patient care. RECENT FINDINGS: There really are no limits with the anticipated developments in the field of medical robotics. Multiple large companies and academic institutions continue to invest in design and production with the release of a number of platforms already having occurred, whereas others are to come in the near future. The main anticipated advances will be haptic feedback, decreased cost, improved theatre assimilation with open consoles permitting free communication and lower theatre footprint. The robot patient interface is to be enhanced with single port platforms in production with a better interface including haptic feedback. The addition of NOTES and smarter flexible robotics is the next key area of interest, whereas the introduction of technology with image guidance and networking where large data sets or connectivity permit increased clinical acumen to enhance decision making. SUMMARY: We are at the cusp of a tipping point as the intellectual property for the first major robotic system in surgery comes to an end. It is likely to be a period of great opportunity with enhanced surgery and patient outcomes through significant innovation, multiple platforms nearing dissemination, with various technological advances. We anticipate this will yield a great period of innovation and diversity. Will we see a truly automated robot soon; the Smart Tissue Autonomous Robots are the limit.

Management of early colonic neoplasia: where are we now and where are we heading?

INTRODUCTION: There have been considerable advances in the endoscopic treatment of colorectal neoplasia. The development of endoscopic submucosal dissection and full thickness resection techniques is changing the way benign disease and early cancers are managed. This article reviews the evidence behind these new techniques and discusses where this field is likely to move in the future. Areas covered: A PubMed literature review of resection techniques for colonic neoplasia was performed. The clinical and cost effectiveness of endoscopic mucosal resection (EMR) is examined. The development of endoscopic submucosal dissection (ESD) and knife assisted resection is described and issues around training reviewed. Efficacy is compared to both EMR and transanal endoscopic microsurgery. The future is considered, including full thickness resection techniques and robotic endoscopy. Expert commentary: The perceived barriers to ESD are falling, and views that such techniques are only possible in Japan are disappearing. The key barriers to uptake will be training, and the development of educational programmes should be seen as a priority. The debate between TEMS and ESD will continue, but ESD is more flexible and cheaper. This will become less significant as the number of endoscopists trained in ESD grows and some TEMS surgeons may shift across towards ESD.

Emerging Techniques in Minimally Invasive Surgery. Pros and Cons.

New trends have emerged regarding the best minimally invasive access approaches to perform gastrointestinal surgery. However, these newer approaches are seen critically by those who demand a more strict assessment of outcomes and safety. An international panel of expert gathered at the 2014 American College of Surgeons Meeting with the goal of providing an evidence-based understanding of the real value of these approaches in gastrointestinal surgery. The panel has compared the efficacy and safety of most established approaches to gastrointestinal diseases to those of new treatment modalities: peroral esophageal myotomy vs. laparoscopic myotomy for achalasia, transgastric vs. transvaginal approach, and single-incision vs. multi-port access minimally invasive surgery. The panel found that (1) the outcome of these new approaches was not superior to that of established surgical procedures; (2) the new approaches are generally performed in few highly specialized centers; and (3) transgastric and transvaginal approaches might be safe and feasible in very experienced hands, but cost, training, operative time, and tools seem to limit their application for the treatment of common procedures such as cholecystectomy and appendectomy. Because the expected advantages of new approaches have yet to be proven in controlled trials, new approaches should be considered for adoption into practice only after thorough analyses of their efficacy and effectiveness and appropriate training.

Natural orifice transluminal endoscopic surgery (NOTES): where are we going? A bibliometric assessment.

The aim of this study was to analyse natural orifice transluminal endoscopic surgery (NOTES)-related publications over the last 5 years. A systematic literature search was done to retrieve publications related to NOTES from 2006 to 2011. The following variables were recorded: year of publication; article type; study design; setting; Journal Citation Reports® journal category; authors area of surgical speciality; geographic area of origin; surgical procedure; NOTES technique; NOTES access route; number of clinical cases. A time-trend analysis was performed by comparing early (2006-2008) and late (2009-2011) study periods. Overall, 644 publications were included in the analysis and most papers were found in general surgery journals (50.9%). Studies were most frequently clinical series (43.9%) and animal experimental (48%), with the articles focusing primarily on cholecystectomy, access creation and closure, and peritoneoscopy. Pure NOTES techniques were performed in most of the published reports (85%) with the remaining cases being hybrid NOTES (7.4%) and NOTES-assisted procedures (6.1%). The access routes included transgastric (52.5%), transcolonic (12.3%), transvesical (12.5%), transvaginal (10.5%), and combined (12.3%). From the early to the late period, there was a significant increase in the number of randomised controlled trials (5.6% vs 7.2%) or non-randomised but comparative studies (5.6% vs 22.9%) (P < 0.001) and there was also a significant increase in the number of colorectal procedures and nephrectomies (P = 0.002). Pure NOTES remained the most studied approach over the years but with increased investigation in the field of NOTES-assisted techniques (P = 0.001). There was also a significant increase in the adoption of transvesical access (7% vs 15.6%) (P = 0.007). NOTES is in a developmental stage and much work is still needed to refine techniques, verify safety and document efficacy. Since the first description of the concept of NOTES, >2000 clinical cases, irrespective of specialty, have been reported. NOTES remains a field of intense clinical and experimental research in various surgical specialities.