1. Enabling Technologies for Natural Orifice Transluminal Endoscopic Surgery (N.O.T.E.S) using Robotically Guided Elasticity Imaging N.O.T.E.S Natural orifice transluminal endoscopic surgery (N.O.T.E.S) is a minimally invasive surgical technique that could benefit greatly from additional methods for intraoperative detection of tissue malignancies (using elastography) along with more precise control of surgical tools. As a first step toward performing N.O.T.E.S in-vivo, we integrated a phased ultrasonic micro-array with a flexible snake-like robot. The integrated system is used to create elastography images of a spherical isoechoic lesion (approximately 5mm in cross-section) in a tissue-mimicking phantom. Images are obtained by performing robotic palpation of the phantom at the location of the lesion. 6 DOF Snake-like Continuum Robot Advantages Elimination of abdominal wall incisions Subsequent reduction in postoperative pain Limitations Elasticity images typically suffer from low contrast Palpation motions require precise axial displacements along the imaging plane The extended tortuous route to the surgical site Closure of a trans-lumenal port Limitations of visualization !! B-mode image of the tissue-mimicking phantom lesion using the custom-made phased array (left), strain image highlighting the hard lesion embedded in the phantom (right). Results The proposed system could potentially increase the accuracy and reliability with which cancer is treated while reducing the invasiveness of surgical procedures. To the best of our knowledge, the presented prototype is the first integrated microarray ultrasound imager with snake-like miniature robot; it is also the first elasticity images generated by microarray. Conclusion Introduction H.Tutkun Şen, Nishikant Deshmukh, Roger Goldman, Peter Kazanzides, Russell H Taylor, Emad Boctor, Nabil Simaan  Access to surgical sites by initially passing the surgical apparatus through a natural orifice  Elastography can be used for intraoperative detection of tissue malignancies  For identifying clinically significant changes in tissue properties, palpation motions are needed to generate elastography images First System  Three serial segments  Tissue mimicking phantom  US Probe Connected 3D Reconstruction of Prostate 4 DOF Snake-like Robot  Each segment has 2 DOF which is achieved through simultaneous linear actuation of the three secondary backbones.  Palpation directions should be in the imaging plane.  US micro-array probe Second System  Amplitudes around 1 mm at 0.7 Hz are generated.  The probe consisted of 64 elements with a pitch of approximately 0.2 mm.  After identification of the lesion of interest was completed, several palpation motions were induced and a sequence of RF data frames was collected to generate strain images. Acknowledgements Funding: Department of Radiology discretionary funds, Michael J. Zinner Fellowship, National Science Foundation (NSF) grant ISS 1063750, Johns Hopkins University internal funds  The surface of the prostate phantom was swept with the ultrasonic phased array.  At fixed robot angle intervals, B-mode images of the prostate were collected.  Using the position information supplied from the robot unit, the images were reconstructed to form the B-mode 3D volume image of the prostate. Assistance: Paul Thienphrapa for assistance with the snake robot interfaces