Surgical robotics is moving beyond the abdominal cavity and into much narrower, more complex anatomical spaces.

One market trend is particularly noteworthy. The global robotic endoscopy market was valued at approximately USD 3.86 billion in 2024 and is projected to reach USD 10 billion by 2035, representing a CAGR of around 9.05%. In China, the flexible endoscopic surgical robotics market is growing even faster, reaching approximately RMB 4.32 billion in 2025, up 38.6% year on year.

Compared with the roughly 22.1% average growth rate of the broader surgical robotics market, flexible endoscopic robotics is advancing at a particularly rapid pace.Why?

Historically, surgical robots have focused primarily on minimally invasive procedures in the abdominal and thoracic cavities. The next frontier is the body’s narrower and more complex natural orifices—and the gastrointestinal tract is one of the most important.

Within interventional endoscopy, Endoscopic Submucosal Dissection, or ESD, represents one of the most technically demanding procedures and one of the clearest opportunities for robotic assistance.

China currently performs approximately 400,000 ESD procedures annually, and the volume continues to grow at around 20% per year, with an estimated 600,000 procedures expected by 2028.

ESD has become an important minimally invasive treatment for early gastrointestinal neoplasia. At the same time, it remains a highly demanding procedure with a long learning curve.

That creates a clear contradiction:

Clinical demand continues to rise, while successful execution still depends heavily on operator skill.

Conventional ESD is, in many respects, a “single-handed” procedure. Through the working channel of an endoscope, the physician must perform injection, incision, submucosal dissection, hemostasis and other highly precise maneuvers inside a narrow, curved and constantly moving gastrointestinal tract.

When lesion access is difficult, traction is insufficient or the approach angle is suboptimal, procedural complexity can increase significantly, along with the risk of bleeding or perforation.

High procedure volume, rapid growth and a high technical barrier create exactly the type of clinical environment in which robotics may add value.

The basic objective of a flexible endoscopic surgical robot is straightforward:to give a conventional endoscope an independently controllable “hand.”

Rather than simply helping the physician see the lesion, the robotic system aims to provide additional degrees of freedom inside the gastrointestinal tract—enabling more stable traction, exposure, cutting and dissection.

From ECO’s perspective as a medical tubing manufacturer, however, once this “robotic hand” is broken down into its underlying components, another challenge becomes apparent.The difficulty is no longer limited to algorithms, motors and control systems.

Within only a few millimeters of diameter, the system also requires a composite tube that can steer precisely in four directions, accommodate multiple functional lumens, and maintain consistent mechanical performance through repeated articulation.

A component that may appear to be “just another tube” is therefore evolving from a passive instrument channel into the flexible wrist of the robot.

What Problem Is ESD Robotics Really Trying to Solve?

An ESD robot is not intended to replace the gastrointestinal endoscope itself.

A more useful way to think about it is as an additional flexible manipulator attached to or working alongside the endoscope, providing the physician with more directions of movement, more favorable approach angles and greater freedom during therapeutic procedures.Its potential value can be understood in three areas.

1. Reducing procedural blind spots

The gastrointestinal tract is not a straight tube. It contains curves, folds and continuously moving tissue.

Conventional instruments are constrained by the orientation of the endoscope and the direction of its working channel. In certain anatomical positions, this can create unfavorable approach angles or even operational blind spots.

A steerable instrument can introduce an additional independent angle beyond the endoscope itself, allowing the physician to approach the lesion from a more appropriate direction.

2. Improving traction and tissue exposure

One of the key requirements in ESD is maintaining a clear and stable submucosal dissection plane.

Conventional endoscopic instruments do not naturally reproduce the familiar surgical sequence of:traction → exposure → dissection

A steerable system can help position an instrument at a more favorable angle, improving exposure of the lesion margin and increasing procedural stability.

3. Reducing dependence on individual operator experience

ESD has a long learning curve.

Highly experienced endoscopists can compensate for anatomical and technical limitations through patient positioning, transparent caps, traction techniques and years of accumulated procedural experience.

However, if the instrument itself can provide more intuitive and reproducible angular control, some of these complex maneuvers may become easier to standardize.That could ultimately help more physicians perform high-quality ESD procedures with greater consistency.

Why Is the Four-Way Steerable Tube So Important?

The technical challenge in an ESD robotic system does not reside only in the console, handle or control mechanism.It also lies in the flexible structure that actually enters the patient.

This component must perform one critical function:translate the physician’s proximal control input into stable and predictable distal movement.A four-way steerable tube is one of the key structures that makes this possible.

In simple terms, its distal section can actively deflect in four directions:up, down, left and right.This is typically achieved through multiple tendon or pull-wire channels integrated into the tube structure. Applying tension to a particular wire produces bending in the corresponding direction, while coordinated actuation enables more complex distal positioning.

Although it may appear to be a relatively simple tubular component, it simultaneously performs several functions:

・distal articulation;

・angular control;

・mechanical force transmission;

・support for instrument channels;

・coordination with the endoscope and therapeutic accessories;

・structural stability during bending.

For an ESD robotic system, therefore, the four-way steerable tube is not a conventional disposable tube.

It is one of the fundamental components determining whether the system can move accurately, remain controllable and reliably return to its neutral position.

Why Is It So Difficult to Manufacture?

The challenge is not simply making a tube that bends.The real requirement is much more demanding:It must achieve the required bending angle, provide smooth and predictable control, recover reliably after deflection, resist kinking and twisting, and maintain instrument-channel patency throughout articulation.Several engineering challenges are involved.

Precise pull-wire lumen geometry

Four-way steering relies on multiple pull wires.

If the pull-wire lumens are not positioned accurately, the distal bending direction may deviate from the intended trajectory.

If friction is excessive, actuation can feel sluggish or inconsistent.

If the relationship between the pull wires and the tube structure is unstable, repeated operation may eventually result in incomplete return-to-neutral or control hysteresis.

Carefully engineered stiffness transitions

The proximal section requires sufficient structural support for pushability and control, while the distal section must remain sufficiently flexible for articulation and atraumatic interaction with tissue.A single material is often unable to provide both properties effectively.Composite structures, segmented constructions or graduated-durometer designs may therefore be required to achieve the appropriate balance.

Extremely limited space

Endoscopic robotic instruments must work alongside existing endoscopic systems, meaning that the outer diameter cannot simply be increased to accommodate additional functions.At the same time, the tube may need to contain pull-wire lumens, one or more working channels and other functional pathways.This places substantial demands on multi-lumen design and precision extrusion.

Reliable return-to-neutral performance

A steerable tube must not only bend—it must also return predictably to its neutral position.Incomplete recovery after articulation can affect subsequent movements and reduce the physician’s confidence in distal control.Material elasticity, pull-wire geometry, wall-thickness consistency and distal structural design all contribute to this behavior.

ECO’s Perspective: ESD May Be Only the First Application

Based on 17 years of experience in medical polymer tubing, together with our ongoing market research and recent involvement in disposable endoscopy, gastrointestinal intervention and flexible surgical robotics projects, ECO has observed a clear shift in customer requirements.

The role of the tube is evolving from a simple functional channel toward a flexible operating platform integrating multiple lumens, active articulation and instrument compatibility.

This is where we believe the real significance of ESD robotics lies.Many current ESD robotic concepts address one fundamental problem: giving a conventional endoscope an independently controllable “hand.”But in the longer term, if that robotic hand can perform only a single ESD function, its clinical and commercial potential may remain limited.The more promising direction, in our view, is to turn the four-way steerable structure into a versatile flexible surgical platform.

With the same steerable architecture and control mechanism, different therapeutic accessories could potentially support different procedures and tasks:

・an ESD knife for incision and submucosal dissection;

・grasping or scissor-type instruments for traction, exposure and cutting;

・a snare for EMR procedures;

・future accessories for grasping, hemostasis or assisted positioning.

In other words, the more valuable proposition may ultimately be not an “ESD robot”, but a flexible endoscopic surgical platform capable of supporting multiple therapeutic instruments and procedures.

This changes how we view the four-way steerable tube itself.It is no longer simply a tube that bends in four directions.It increasingly functions as both the robot’s flexible wrist and its instrument carrier—responsible for distal motion while simultaneously providing stable pathways for therapeutic devices.

That creates a very different set of engineering requirements.The outer diameter must remain small, while internal functionality continues to increase.The distal section must be flexible, while pull-wire control must remain precise.

The working channel must remain patent even during four-way articulation.And after repeated movements, the tube must still demonstrate reliable recovery and return-to-neutral performance.For this reason, we believe the next technical threshold is no longer simply:“Can we make a four-way steerable tube?”

The more important question is:Can multi-lumen integration, articulation, force transmission, working channels and compatibility with different therapeutic instruments all be engineered into one compact composite tube—and then manufactured consistently at scale?

This is already an area in which ECO is actively participating.In overseas flexible endoscopic robotics projects, ECO has been involved in the design and development of composite and four-way steerable tubing, including complex structures with up to ten lumens.

These lumens may need to accommodate not only therapeutic instruments but also pull wires and other functional components within an extremely limited cross-sectional area.

These projects have also changed the way we evaluate advanced medical tubing.Traditionally, multi-lumen tubing has been judged primarily by parameters such as:lumen count, dimensional accuracy and extrusion consistency.

In robotic applications, additional performance indicators become increasingly important:steering angle, actuation efficiency, four-direction consistency, elastic recovery, kink resistance, working-channel stability and fatigue resistance under repeated articulation.

This represents a fundamental change in the role of advanced medical tubing:In the past, the tube was a channel. In robotic systems, the tube is becoming part of the motion mechanism itself.

Our view of the market is therefore clear:The real opportunity in flexible endoscopic robotics is not simply to make the robot smaller, but to integrate more degrees of freedom and more therapeutic functionality into an increasingly compact structure.Four-way steering is only the beginning.The next stage of competition is likely to center on:multi-lumen integration + precise articulation + compatibility with multiple therapeutic instruments.

For ECO, this also means moving beyond the role of a supplier that simply extrudes tubing to a customer drawing.With 17 years of experience in medical polymer tubing development and manufacturing, we aim to engage earlier in the development process—supporting customers with lumen architecture, material selection, durometer transitions, pull-wire design, working-channel configuration and design-for-manufacturability evaluation.

The objective is to help transform a robotic concept into a tubing solution that can be validated, manufactured consistently and ultimately scaled for commercial production.

When a Tube Becomes Part of the RobotThe fundamental question ESD robotics is trying to answer is not whether we already have an endoscope.It is whether endoscopic therapy can become more flexible, more stable and more controllable.

As gastrointestinal endoscopy evolves from diagnosis toward therapy, from single-instrument procedures toward multifunctional platforms, and from operator-dependent techniques toward more standardized robotic assistance, components such as four-way steerable tubing will become increasingly important.It may look like just a tube.

But inside a flexible robotic system, it can be responsible for distal articulation, angular control, tendon-force transmission and instrument coordination.

For ECO, this represents an important evolution of precision polymer tubing—from a basic medical component into a functional element of the robotic system itself.

Whether next-generation ESD robotics can ultimately achieve broad clinical adoption will depend not only on the control console, software and actuation system.It will also depend on something far less visible:a compact steerable tube capable of turning precisely, returning reliably and working seamlessly with the therapeutic instrument at its distal end.