This study has shown that a dexterous miniature in vivo robot can apply significant forces in arbitrary directions and improve visualization to overcome many of the limitations of current endoscopic tools for performing NOTES procedures.

This study demonstrates the feasibility of using a miniature robot to perform complex, single-incision, minimal access surgery. Instrument positioning and lack of triangulation complicate single-incision laparoscopic surgery, and open surgical procedures are highly invasive. Using minimally invasive techniques with miniature robotic platforms potentially offers significant clinical benefits. A miniature robot platform has been designed to perform advanced laparoscopic surgery with speed, dexterity, and tissue-handling capabilities comparable to standard laparoscopic instruments working through trocars. The robotic platform includes a dexterous in vivo robot and a remote surgeon interface console. For this study, a standard laparoscope was mounted to the robot to provide vision and lighting capabilities. In addition, multiple robots could be inserted through a single incision rather than the traditional use of four or five different ports. These additional robots could provide capabilities such as tissue retraction and supplementary visualization or lighting. The efficacy of this robot has been demonstrated in a nonsurvival cholecystectomy in a porcine model. The procedure was performed through a single large transabdominal incision, with supplementary retraction being provided by standard laparoscopic tools. This study demonstrates the feasibility of using a dexterous robot platform for performing single-incision, advanced laparoscopic surgery.

Advances in endoscopic techniques for abdominal procedures continue to reduce the invasiveness of surgery. Gaining access to the peritoneal cavity through small incisions prompted the first significant shift in general surgery. The complete elimination of external incisions through natural orifice access is potentially the next step in reducing patient trauma. While minimally invasive techniques offer significant patient advantages, the procedures are surgically challenging. Robotic surgical systems are being developed that address the visualization and manipulation limitations, but many of these systems remain constrained by the entry incisions. Alternatively, miniature in vivo robots are being developed that are completely inserted into the peritoneal cavity for laparoscopic and natural orifice procedures. These robots can provide vision and task assistance without the constraints of the entry incision, and can reduce the number of incisions required for laparoscopic procedures. In this study, a series of minimally invasive animal-model surgeries were performed using multiple miniature in vivo robots in cooperation with existing laparoscopy and endoscopy tools as well as the da Vinci Surgical System. These procedures demonstrate that miniature in vivo robots can address the visualization constraints of minimally invasive surgery by providing video feedback and task assistance from arbitrary orientations within the peritoneal cavity.

Natural orifice translumenal endoscopic surgery (NOTES) bridges the gap between standard endoluminal and extraluminal surgery and, as such, presents unique instrumentation challenges, including lack of stable platforms, loss of spatial orientation, and limited instrument tip maneuverability. The proper instrumentation remains to be established, and the incorporation of robotic technology will be essential moving forward. Flexible robotics has been applied to ureteroscopy and holds promise for NOTES. Miniature in vivo robots will potentially play a role. The current status and future implications of these technologies are reviewed.

This study demonstrates the effectiveness of using a multi-functional miniature in vivo robot platform to perform LESS.