Transendoscopic flexible parallel continuum robotic mechanism for bimanual endoscopic submucosal dissection

In endoscopic submucosal dissection (ESD), the gastrointestinal (GI) tract warrants the surgical instruments to navigate through a long, narrow and tortuous endoscope. This poses a great challenge in developing ESD instruments with small dimensions, flexibility, and high distal dexterity. In this work, we propose the first Transendoscopic Flexible Parallel Continuum Robotic mechanism to develop a miniature dexterous flexible-stiff-balanced Wrist (FPCW). Besides, it can steer multifunctional instruments of diameters 2.5 mm to 3.5 mm, including the electrosurgical knife, injection needle, and forceps. Our FPCW instruments are adaptable to commercially available dual-channel endoscopes (diameter: <12 mm, channel width: 2.8 mm and around 3.8 mm). Furthermore, we develop a surgical telerobotic system, called DREAMS (Dual-arm Robotic Endoscopic Assistant for Minimally Invasive Surgery), by using our smallest FPCW instruments for bimanual ESD procedures. First, we conduct a series of experiments to determine the FPCW's design and kinematics parameters and to verify the mechanical properties of the FPCW instruments' prototypes, including workspace, stiffness, strength, and teleoperation accuracy. Second, we validate the functionality of the FPCW instruments through ex-vivo tests by performing ESD steps on porcine stomachs. Finally, we perform an invivo test on a live porcine model and showcase that our developed DREAMS can be teleoperated intuitively to perform bimanual ESD efficiently with an average dissection speed of 108.95 mm(2)/min at the greater curvature in gastric body, which demonstrates that our DREAMS has satisfactory maneuverability as well as accuracy and is more competitive than counterpart robotic systems.