Current Applications of Flexible Endoluminal Robotics for Colorectal Endoscopic Submucosal Dissection

Endoscopic submucosal dissection (ESD) is the current standard treatment for early intramucosal gastrointestinal neoplasia, as ESD achieved a higher rate of en bloc resection and lower rate of local recurrence, especially for neoplastic lesions greater than 20 mm, compared with endoscopic mucosal resection. However, colorectal ESD remains technically challenging, with a significant risk of complications, especially perforation during dissection. The higher risk of perforation is related to the intrinsic operational difficulties of using flexible endoscopy and dissection via the coaxial ESD device, as well as the unfavorable anatomical characteristics, including thin colonic wall and haustrations. The lack of bimanual tissue manipulation, mucosal traction, and poor visualization of dissection plane led to the challenges in colorectal ESD. The development of endoluminal flexible robotic systems aims to overcome these challenges with innovative flexible robotics to refine the endoscope and instrumentations, some of which have already been used in clinical trials. Preclinical studies demonstrated promising outcomes with using flexible robotics in improving the learning curve of colorectal ESD. This review will also explore future development of endoluminal flexible robotics and a training system, which are crucial to ensure an effective, efficient, and safe training program for novice endoscopists to perform robotic colorectal ESD.