**3.1 STRAS**

*Recent Advances in Laparoscopic Surgery*

**Figure 6.**

**3. Robotics for the flexible endoscopic surgery**

*Viky, reprinted by permission from Springer Nature: Springer Nature [16].*

Natural orifice transluminal endoscopic surgery (NOTES) was introduced in 2004 [19]. It is the surgery using flexible endoscope instead of rigid laparoscope. As access to the lesion is through the natural orifice (mouth and anus), no incision on the patient skin, but on the organ inside body such as gastrointestinal wall instead is required. Conventional flexible endoscopes and instruments were not enough effective to perform this surgical procedure. So, several companies developed multi-tasking platform [20–25] (**Figure 7**). They basically contain flexible endoscope, articulating instruments, and grasping and cutting devices. They were not motorized, but manually actuated using wire transmission. However, NOTES is still in the experimental phase because this procedure was still technically difficult even using those platforms. Most of those platforms are discontinued. However, if new, effective device were introduced in the future, NOTES could be clinically accepted. Endoscopic submucosal dissection (ESD) is another surgical procedure using flexible endoscope [28, 29]. ESD is applied only for gastrointestinal mucosal cancer. Therefore, it has limited coverage of organ compared with NOTES. ESD has been clinically accepted and prevailing especially in Asian countries. Although ESD

*Examples of manually driven multi-tasking platform. (A) ANUBISCOPE (IRCAD & Karl Storz Endoskope), reprinted by permission from Springer Nature: Springer Nature [26]. (B) EndoSAMURAI (Olympus, Japan),* 

*reprinted by permission from Springer Nature: Springer Nature [27].*

**98**

**Figure 7.**

ANUBISCOPE (IRCAD & Karl Storz Endoskope) [20, 21] was developed for NOTES and ESD procedure. The system composed of a custom made flexible endoscope with two articulating instruments. It was not motor driven but manually driven system. Strasburg University jointly developed motorized version, STRAS with Karl Storz and IRCAD [32–35]. By using vision computation technology, they applied automated target tracking [32] and position detection of the instruments [33]. This project is still in the phase of academic research. Some animal trials have been carried out [34, 35].
