da Vinci Surgical System

Da Vinci Surgical System

Manufacturer	Intuitive Surgical
Type	Robotic surgery
Units sold	1,032 units worldwide[1]

The Da Vinci Surgical System is a robotic surgical system made by Intuitive Surgical and designed to facilitate complex surgery using a minimally invasive approach. The system is controlled by a surgeon from a console. It is commonly used for prostatectomies and increasingly for cardiac valve repair and gynecologic surgical procedures.^[2][3]

Overview

The da Vinci System consists of a surgeon’s console that is typically in the same room as the patient and a patient-side cart with four interactive robotic arms controlled from the console. Three of the arms are for tools that hold objects, act as a scalpel, scissors, bovie, or unipolar or dipolar electrocautery instruments. The fourth arm is for an endoscopic camera with two lenses that gives the surgeon full stereoscopic vision from the console. The surgeon sits at the console and looks through two eye holes at a 3-D image of the procedure, meanwhile maneuvering the arms with two foot pedals and two hand controllers. The da Vinci System scales, filters and translates the surgeon's hand movements into more precise micro-movements of the instruments, which operate through small incisions in the body.

According to the manufacturer, the da Vinci System is called "da Vinci" in part "because Leonardo da Vinci invented the first robot", and also because he used anatomical accuracy and three-dimensional details to bring his works to life.^[4]

To perform a procedure, the surgeon uses the console’s master controls to maneuver the patient-side cart’s three or four robotic arms (depending on the model), which secures the instruments and a high-resolution endoscopic camera. The instruments’ jointed-wrist design exceeds the natural range of motion of the human hand; motion scaling and tremor reduction further interpret and refine the surgeon’s hand movements. The da Vinci System incorporates multiple, redundant safety features designed to minimize opportunities for human error when compared with traditional approaches. At no time is the surgical robot in control or autonomous; it operates on a "Master:Slave" relationship, the surgeon being the "Master" and the robot being the "Slave."

The da Vinci System has been designed to improve upon conventional laparoscopy, in which the surgeon operates while standing, using hand-held, long-shafted instruments, which have no wrists. With conventional laparoscopy, the surgeon must look up and away from the instruments, to a nearby 2D video monitor to see an image of the target anatomy. The surgeon must also rely on his/her patient-side assistant to position the camera correctly. In contrast, the da Vinci System’s ergonomic design allows the surgeon to operate from a seated position at the console, with eyes and hands positioned in line with the instruments. To move the instruments or to reposition the camera, the surgeon simply moves his/her hands.

By providing surgeons with superior visualization, enhanced dexterity, greater precision and ergonomic comfort, the da Vinci Surgical System makes it possible for more surgeons to perform minimally invasive procedures involving complex dissection or reconstruction. For the patient, a da Vinci procedure can offer all the potential benefits of a minimally invasive procedure, including less pain, less blood loss and less need for blood transfusions. Moreover, the da Vinci System can enable a shorter hospital stay, a quicker recovery and faster return to normal daily activities.^[5]

The robot costs on average $1.3 million in addition to several hundred thousand dollars of annual maintenance fees. Surgical procedures performed with the robot take longer than traditional ones. Critics have pointed out that hospitals have a hard time recovering the cost and that most clinical data does not support the claim of improved patient outcomes.^[3]

FDA approval

The Food and Drug Administration (FDA) has cleared the da Vinci Surgical System in 2000 for adult and pediatric use in urologic surgical procedures, general laparoscopic surgical procedures, gynecologic laparoscopic surgical procedures, general non-cardiovascular thoracoscopic surgical procedures and thoracoscopically assisted cardiotomy procedures. The da Vinci System may also be employed with adjunctive mediastinotomy to perform coronary anastomosis during cardiac revascularization.^[6]

Representative clinical uses

The da Vinci System has been successfully used in the following procedures^[6]:

• Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteral reimplantation;^[7]
• Hysterectomy, myomectomy and sacrocolpopexy;
• Cholecystectomy, Nissen fundoplication, Heller myotomy, gastric bypass, donor nephrectomy, adrenalectomy, splenectomy and bowel resection;
• Internal mammary artery a blood vessel mobilization and cardiac tissue ablation;
• Mitral valve repair, endoscopic atrial septal defect closure;
• Mammary to left anterior descending coronary artery anastomosis for cardiac revascularization with adjunctive mediastinotomy
• Transoral resection of tumors of the upper aerodigestive tract (tonsil, tongue base, larynx), transaxillary thyroidectomy

Future

Although the general term "robotic surgery" is often used to refer to the technology, this term can give the impression that the robot (the da Vinci System) is performing the surgery. In contrast, the current da Vinci Surgical System cannot—in any manner—run on its own. This is due to the fact it was not designed as an autonomous system and lacks a decision making software, instead it relies on a human operator for all input, however all the functionality—including vision and motor functions—are performed through remote human-computer interaction and thus with the appropriate weak AI software the system could in principle perform partially or completely autonomously. The difficulty with creating an autonomous system of this kind is not trivial, a major obstacle is that surgery per se is not readily formalizable—a requirement for weak AI. The current system is designed to merely seamlessly replicate the movement of the surgeon's hands with the tips of micro-instruments, not to make decisions or move without the surgeon’s direct input.

The da Vinci System could also potentially be used to perform truly remote operations. This was, in fact, what the Da Vinci system was originally designed for, though this was abandoned early.^[8] The possibility of long distance operations depend on the patient having access to a da Vinci System and someone to put in the ports, but technically the system could allow a doctor in the United States, for example, to do surgery on a patient in Antarctica. The da Vinci Surgical System can theoretically be used to operate over long distances. According to the manufacturer, this capability, however, is not the primary focus of the company and thus is not available with the current da Vinci Surgical System.^[9]

Criticism

While the use of robotic surgery has become an item in the advertisement of medical services, critics point out a lack of studies that indicate long-term results are superior to results following laparoscopic surgery.^[10] On the other hand, there is no question that some procedures that have traditionally been performed with large incisions can be converted to "minimally invasive" endoscopic procedures with the use of the Da Vinci, shortening length-of-stay in the hospital and reducing recovery times. But because of the hefty cost of the robotic system it is not clear that it is cost-effective for hospitals and physicians despite any benefits to patients since there is no additional reimbursement paid by the government or insurance companies when the system is used. Data are absent to show that these increased costs can be justified. Another problem is that in the medical literature very experienced surgeons tend to publish their results. These, however, may not be representative of surgeons with lesser experience.^[10] And there is a steep learning curve for surgeons who adopt use of the system.

Pediatric use of robotic technology

Researchers from Children's Hospital Boston developed and perfected the technique for performing robotically-assisted pediatric pyeloplasties, and have recently completed an 18-month study that showed that the same technique is effective for bladder augmentation procedures. Results from research conducted at Children's have also led to advances and refinements in the robotic equipment, making it more suitable for use in pediatric surgery.

The Center for Robotic Surgery's research program is focused on finding safe and innovative applications for robotic technology. Children's Hospital Boston is one of the only pediatric hospitals to perform clinical assessments and outcome analysis - measuring and analyzing the outcomes of robotic surgeries versus open surgeries to ensure the use of the surgical robot is always advantageous to the patient.

A second surgical robot is dedicated exclusively to training surgeons and developing and perfecting new robotic procedures and surgical techniques before they are applied to patients.

References

1. ^ http://www.intuitivesurgical.com/products/faq/index.aspx
2. ^ Robots as surgical enablers, MarketWatch, 3 February 2005
3. ^ ^{a b} Prepping Robots to Perform Surgery, The New York Times, 4 May 2008
4. ^ http://www.intuitivesurgical.com/products/faq/index.aspx#2
5. ^ J Minim Invasive Gynecol. 2008 May-Jun;15(3):286-91. Epub 2008 Mar 6. PMID 18439499
6. ^ ^{a b} http://www.intuitivesurgical.com/products/fdaclearance/index.aspx
7. ^ Dorian Block (June 25, 2006). "Robot Does Quick Fix on Prostate; interview with Dr. Michael Palese". New York Daily News. http://www.nydailynews.com/archives/news/2006/06/25/2006-06-25_robot_does_a_quick_fix_on_pr.html. Retrieved February 23, 2011. 
8. ^ The Slow Rise of the Robot Surgeon from Technology Review (MIT)
9. ^ Corporate FAQ page
10. ^ ^{a b} Gina Kolata (February 13, 2010). "Results Unproven, Robotic Surgery Wins Converts". The New York Times. http://www.nytimes.com/2010/02/14/health/14robot.html. Retrieved March 11, 2010. 

External links

• Official website