Robotics and ESD: A 2026 Field Guide to Platforms, Evidence, and Roadmap

Overview

ESD is technically demanding — adoption is limited by long learning curves (50 to 1,000 cases depending on who you ask), by the ergonomic burden on the endoscopist, and by the absence of a systematic, structured way to apply counter-traction during dissection. This 24-minute lecture asks whether robotic platforms can finally close those gaps, surveys every credible candidate, and lays out a pragmatic clinical roadmap.

Why ESD Needs Robotics

A conventional endoscope has four degrees of freedom: push-pull, up-down, left-right, and rotation around its axis. Anything moving freely in 3D has six. A single robotic arm can add another seven to ten, and dual-arm robotic platforms inherit the endoscope's four and then layer joints on top — giving the operator something closer to two hands in the game instead of one. That extra dexterity, combined with structured traction and improved ergonomics, is what robotics promises to bring to ESD.

The Three Platform Families

1. Multi-tasking Dual-Arm Platforms

• EndoMASTER MASTER — The original, developed by Professor V. Ho in Singapore. First-in-human in 2011, five cases, zero complications. Bi-manual control, custom endoscope.
• EndoMASTER EASE — Professor Philip Chiu's Hong Kong successor platform, published metrics in Endoscopy comparable to expert human ESD.
• STRAS — European sibling from a different group. No human studies, never reached market.
• K-FLEX and the Medrobotics Flex Robotic System — the Flex Robotic is the cautionary tale: FDA-approved in 2017, then the company went bust. A reminder that the financial ground under robotic endoscopy is not solid.

2. Add-on Traction Robots

• Endomina (Endo Tools Therapeutics, Belgium) — a hybrid scope-mounted triangulation system already approved for bariatric procedures.
• EndoFaster — Chinese RCT data showing speed benefits and reduced muscular injury versus conventional ESD.
• GIFTS ecosystem from a South Korean company, including a realistic ESD box simulator that reproduces patient breathing and tissue mechanics.
• EndoRobotics ROBOPERA — a detachable robotic gripper on the scope tip. FDA-approved, corporately backed, likely to reach market soon.

3. Rigid Surgical Robots Adapted for Endoscopy

• Da Vinci SP — a single-arm variant adapted for transanal resection (robotic TAMIS). Already in clinical use at multiple US centres for the rectum.
• EndoQuest ELS — backed by the founder of Da Vinci, a novel rigid platform focused on endoscopy. Also rectum-only for now.

What Does the Evidence Say?

The Genidy 2026 meta-analysis pooled 115 patients across robotic ESD series. Heterogeneity is maximal and the numbers are small, but in the hands of expert interventional endoscopists — mostly at university centres — complete resection, R0 resection, and intraoperative metrics are solid. A separate randomised trial of five ESD-naïve endoscopists comparing conventional to robotic ESD found shorter procedure times, lower perforation rates, and better ergonomics in the robot arm. The study is small and platform-specific, but the signal is real: robotic platforms may flatten the ESD learning curve and standardise practice.

The AI-Integrated Future

Looking forward, combine a robotic platform with current AI capabilities and you can imagine real-time vessel avoidance, highlighted safety planes, automatic KPI reporting, and in-procedure performance feedback. Most of these individual capabilities already exist; integrating them into one workflow is the next obvious step.

Drawbacks and Implementation Barriers

• Cost. Robotic surgery consumables add €3,000+ per case. ESD is not a profitable procedure line in most hospitals — adding a robot makes the economics worse before they get better.
• Regulation. Europe's medical device regulation is too slow; innovations are coming out of China and not out of Europe. None of the European platforms have made it to market.
• Training gap. Nobody yet knows what it takes to train an endoscopist on these platforms, because nobody's had them in their hands.
• Physical space. Endoscopy rooms are already crowded. There is, in the speaker's words, "no room for a robot — there's hardly room for me."

Realistic Roadmap

First FDA-approved robotic ESD device likely 2027. Specialist-centre uptake in the years that follow. Meaningful democratisation to community practice: 5-to-10 years. Near-term, the most actionable gain is not a robot at all — it's adopting a reliable traction device and figuring out how it integrates into standard ESD practice. The evidence base is small and needs real-world data from outside the university setting.

Who Should Watch

Interventional endoscopists, ESD trainees, and anyone on a hospital's endoscopy equipment committee who needs a grounded, 24-minute map of the robotic ESD landscape — what's real, what's vaporware, and where the field is actually going over the next decade.