1. 2010 NOTES ® Summit Working Group Report Robotics July 8-10, 2010 Chicago, IL

2. A Opportunity of Robotics Need addressed: Decreased Surgical accuracy and Precision Poor ergonomics and increased mental workloads involved with traditional notes. Long operative times Difficult visualization Current need for multiple surgeons Poor adoption of natural orifice techniques

3. Benefits and Risks Benefits Robotics can allow for increasing precision of over current endoscopes Robotics may allow for more flexible and stable platforms with restoration of triangulation Automation of complex tasks with potential for increased efficiency and decreasing operative times Advanced imaging processing Risks Loss of direct control of instruments Potential for failure with increasing complexity Notes may fail if we wait for the technology to move forward Reliance of technology may lead to loss of surgical judgement

4. Operator Surgeons and Gastroenterologist

5. Timeline Expect robotic devices which would address one or more of these advances in 24 months, with a complete function system in 5 years.

6. Obstacles to adoption Cost and payer acceptance Training of the surgical taskforce and credentialing Health care reform

7. Applications of technology/device Real adoption of NOTES by the masses

8. Global obstacle 1 to adoption: The cost of development of a whole or partial robotic platform

9. Robotics as defined by the introduction of computer assisted control of surgical instrumentation or platforms may be advantageous in many ways. As the natural orifice surgery experience has evolved on an international scale several needs have been recognized that are not addressed by current endoscopic platforms. Specifically the currently available platforms have decreased accuracy and precision relative to laparoscopic surgical techniques. Current platforms do not incorporate sound ergonomics and mental and physical workloads are increased in NOTES cases. In addition operative times are longer. Visualization is also difficult during a NOTES case and there is no current platform which will automatically correct for changes in horizon and mirroring. Current endoscopes and platforms employed often require two or more surgeons to complete the surgical task, which obviously increases cause and decreases the widespread adoption of NOTES.

10. Robotic technology has the potential to solve many of these problems. Certainly robotics can increase both precision and accuracy in relation to standard notes techniques. Adding computer control may also allow for platforms which are both more flexible and stable at the same time. In addition robotics will allow for the restoration of triangulation, and has the potential for automation of complex tasks such as suturing. In addition to introducing computer control to aid in maneuverability of the platform and manipulation of tissues, real time image processing will allow better visualization of target tissues. All of these potential advantages will lead to decreased operative times.

11. The risks of introducing robotics into natural orifice surgery involve some of the same risks involved in surgical robotics. These include a removal of the surgeon from direct control of the instrumentation, and an increasing risk of equipment failure with increasing complexity. There is a risk in general that NOTES may fail of we wait for this promised technology to develop.

12. There are certain obstacles to the adoption of this technology. First and foremost will be the cost of developing such a system, as well as the cost of deploying the technology. A second problem will involve the training of the surgical workforce and credentialing them in the utilization of this technology. However, once created the technology will certainly allow for more widespread application of natural orifice techniques.