111 Surgical Innovation Volume 16 Number 2 June 2009 111-116 © 2009 The Author(s) 10.1177/1553350609338181 http://sri.sagepub.com Joystick Interfaces Are Not Suitable for Robotized Endoscope Applied to NOTES Pierre Allemann, MD, Laurent Ott, MSc, Mitsuhiro Asakuma, MD, Norbert Masson, MSc, Silvana Perretta, MD, Bernard Dallemagne, MD, Dimitri Coumaros, MD, Michel De Mathelin, PhD, Luc Soler, PhD, and Jacques Marescaux, MD, FACS, FRCS Background NOTES has changed the working environ- ment of endoscopy, leading to new difficulties. The limita- tions of conventional endoscopes call for the development of new platforms. Robotics may be the answer. Materials and methods The authors compared human to robot- ized manipulation of a flexible endoscope into the abdom- inal cavity, in an animal model. Thirty-two participants were enrolled. Results were analyzed according to the clinical background of the participants: experienced endoscopists, experienced laparoscopists, and medical students. Two single-channel gastroscopes were used. Whereas one was not modified, the other had the han- dling wheels replaced by motors controlled through a computer and a joystick. A NOTES transgastric approach was used to access the peritoneal cavity. The time to touch previously positioned intra-abdominal numbered plastic targets was recorded 3 times with each endo- scope. Results Mean time to complete the tasks was significantly shorter using the conventional endoscope (2.71 vs 6.96 minutes, P < .001). When the robotized endoscope was used, the mean times of endoscopists (7.42 minutes), laparoscopists (6.84 minutes), and stu- dents (6.77 minutes) were statistically identical. No dif- ferences were found between laparoscopists and students in both techniques. Discussion Applying robotics to a flexible endoscope fails to enhance ability to move into the abdominal cavity, partly because of the interface. To overcome the limitations of endoscope when performing complex NOTES tasks, robotics may be useful, especially to control the instruments and to stabilize the endoscope itself. Conclusion Robotized endoscope with joystick interface is not sufficient to enhance immediate intuitive- ness of flexible endoscopy applied to NOTES. Keywords: natural orifices; NOTES; robotic; flexible endoscopy N atural orifice transluminal endoscopic sur- gery (NOTES) is currently under investiga- tion. Since the first report by Kalloo et al 1 in 2004, numerous NOTES procedures have been per- formed in animals demonstrating the feasibility of basic and complex procedures such as cholecystec- tomy, 2,3 pancreatectomy, 4 and nephrectomy. 5,6 The animal model carries its own limitations, and it is difficult, today, to assess the potential advantages of NOTES in terms of safety, postoperative trauma, pain, and physiologic stress. Human studies have started and will provide answers. 7-10 What we know from the animal model is that scarless surgery is feasible but it raises numerous challenges, which were clearly delineated in the white paper published by the NOSCAR group in 2005. 11 One of these chal- lenges is the technical aspect of tools and endoscopes, because usual instrumentation presents several lim- its. These tools were not designed to work outside of the hollow organs, and the operative endoscopes are equipped with 2 parallel working channels allowing for the passage of small-sized flexible instruments. From IRCAD-EITS Institute, Strasbourg (PA, MA, SP, BD, LS, JM); LSIIT (UMR CNRS 7005), University of Strasbourg, Illkirch (LO, NM, MDM); Department of Gastroenterology, University Hospital, Strasbourg (DC), France. Address correspondence to: Jacques Marescaux, MD, FACS, FRCS, IRCAD-EITS Institute, 1, place de l’hôpital, 67091 Strasbourg, France; e-mail: Jacques.Marescaux@ircad.fr.