da Vinci Robotic Surgery System

The da Vinci® Robotic Surgery System is an advanced apparatus used to perform open or laparoscopic surgeries through assisted devices that lead to a procedure with minimal incisions, greater precision, less scarring, reduced damage to the surrounding tissue, and a shorter recovery time. The da Vinci robotic surgery system gives a surgeon greater control of the operating instruments with higher levels of precision.

Developed and manufactured by Intuitive Surgical Inc., the da Vinci robotic surgery system amasses its love by being minimally invasive than conventional surgical apparatus. There are more than 7500 da Vinci systems installed worldwide1. da Vinci robotic system has been used in over twelve million surgeries worldwide1.

History of da Vinci Robotic Surgery

In 1985, Dr. Patrick Walsh of John Hopkins University performed the first nerve-sparing radical prostatectomy2. For the first time, it was possible to preserve sexual function and urinary continence in this procedure. Intuitive, the company responsible for the manufacturing of da Vinci Robotic Surgery system was founded by surgeon Frederic Moll, engineer Robert Younge, and venture capitalist John Freund3. The first da Vinci system was sold to the Leipzig Heart Center in Germany in 19983. da Vinci robotic surgery system gained FDA approval in the year 2000 and was first used in surgery by a US-based healthcare facility in the year 20013. A decade later, da Vinci robotic surgeries were a major part of the US healthcare system.

Advantages of da Vinci® Robotic Surgery

Da Vinci robotic surgery has many advantages including:

  • Smaller incisions (less than or equal to one centimeter)
  • Reduced collateral damage
  • Less pain
  • Reduced recovery times leading to shorter hospital stays
  • Less postoperative scarring
  • Better postoperative outcomes
  • Reduced risk of infections
  • A decrease in the potential risk of complications
  • Enhanced patient satisfaction

Some of the procedures performed with da Vinci robotic Surgery

  • Urological Procedures like resection of prostatic hyperplasia or cancer
  • Abdominal procedures like resection of liver cancer or pancreatic CA
  • Gastrointestinal surgeries like colorectal cancer removal
  • Thoracic surgeries like pulmonary lobe resection
  • Cardiovascular surgeries like mitral valve repairs
  • Resection of ovarian and ovarian growths and tumors
  • Removal of head and neck cancers

Though this system is used in many other surgeries, the most commonly performed procedure with this system is Robot-assisted Radical Prostactomies (RARP). By 2013, over 80 percent of radical prostatectomies were performed by this system in the US4. According to Benjamin Davies, surgeon and professor of Urology at the University of Pittsburgh, when it comes to prostatic cancer surgery, “the die is cast; there is only robotic surgery5.”

da Vinci robotic surgery system arms
Image Source: Intuitive Surgical. https://www.intuitive.com

Workings of da Vinci robotic surgery

da Vinci robotic surgery system works by combining multiple surgical apparatus into a system to give the surgeon greater control over the procedure with enhanced precision.

The system consists of,

  • a tower containing three arms to hold the surgical instruments and a fourth equipped with a 15x zoom camera with the ability to provide high-definition real-time video feed to the surgeon.
  • A console that hosts the surgeon’s seat and provides him the control of the system
  • A cart that contains the processing equipment responsible for image generation and instruments control
  • And an operating table for the patient
da vinci surgical system visioncart
Image Source: Intuitive Surgical. https://www.intuitive.com

The two unique selling points of the da Vinci robotic surgery system are Endowrist Instruments and the Vision System. The endowrist instruments allow wrist-like movements of the surgical instruments while offering even more flexibility in the range of motion. The vision system provides high-definition imagery with zoom capability as mentioned earlier.

davinci system surgeon console
Image Source: Intuitive Surgical. https://www.intuitive.com

During a procedure, a few small incisions are made, rather than a large one as in the case of open surgery, and thin instruments are entered into the body cavity along with a camera. The cavity is filled with gas to make way for the instruments and the camera and for the surgeon to view the tissues. A light source is also attached to the camera for better visibility. The surgeon then controls the arms to use the instruments while watching the video feed through the camera in the line of instruments. Surgeons who use the da Vinci robotic surgery system are trained properly in the use of the system.

Utilizing all these instruments and techniques helps the surgeon perform complex surgical procedures with greater surgical precision, improved dexterity, ability to reach hard areas, and increased range of motion while minimizing damage to adjacent tissues. The system allows the surgeon to sit for the duration of the surgery, rather than standing in case of conventional surgeries while the system mimics the actions of the surgeon’s hands along with providing a view of the surgical site. According to Freddie Hamdy, Nuffield professor of surgery and urology at the University of Oxford, UK, “We can see the anatomy of the prostate like we have never seen it before.”

The system is designed to assist the surgeon at all times and perform exactly according to the intentions of the surgeon. The surgeon has complete control over the system which is why it is called a “master-slave system.”

What to expect as a patient?

If you are undergoing a procedure that will be performed using da Vinci robotic surgery system, you need to be prepared to have surgery just like you would have in case of other surgeries. Your hospital stay can be overnight; or longer if you have other conditions affecting the course of your treatment. Your care provider will instruct you on the preparative steps for the surgery as is the case in all other surgeries. Be sure to have your questions answered before you prepare for the surgery.

Complications of da Vinci Robotic Surgery

However advanced the system may be, one still needs to know about the potential risks and complications of the procedure being performed. The potential side effects or complications depend on the type of procedure you are undergoing and any other medical conditions that you are suffering from.

Da Vinci robotic surgery has similar other potential complications associated with it as other open or laparoscopic surgeries such as perioperative and postoperative bleeding, infection, surgical hernia, and iatrogenic injuries. Moreover, there are certain complications associated with robot-assisted surgeries. These complications include,

  • Equipment malfunction
  • Longer anesthesia time (da Vinci robotic surgery lasts, on average, an hour longer than open surgery.)
  • Gas trapped in the body cavity
  • Conversion to open surgery leading to an even bigger incision
  • A 2022 report in the journal Digital Medicine also pointed to the risk of cyberattacks against surgical robots6.

These complications can lead to an even longer hospital stay in some cases than conventional surgical procedures. However, the safety and efficacy of the system have been established in many healthcare studies. In case the patients experience side effects or complications, contact with their care provider should be made immediately. Any complication arising from the use of da Vinci robotic system has to be reported to the FDA.

Impact of da Vinci Robotic Surgery System on the medical economy

A single da Vinci robotic surgery system can cost a hospital around 2.5 million USD7. Regular maintenance of the system can approach $100, 000 annually, and many of the disposable equipment and items used, need to be replaced for each procedure.

The use of a robotic system adds a cost of $3000 to $6000 to the surgery which is translated to the patient resulting in an 80 percent increase in the medical bill8. In the US healthcare system where universal coverage is not the situation, these costs can be detrimental to the financial well-being of the patients.

Moreover, some believe that the additional costs associated with robotic surgery are not justified. Medical director at Consumer Reports Health, Dr. John Santa, said, “fancier way of doing what surgeons have always been able to do9.” He said it’s not the miracle it has been marketed to be.

To learn more about the US healthcare system and the associated economics, please read our article, Understanding the US Healthcare System.

Controversies surrounding da Vinci system

When it comes to da Vinci robotic surgery system, it is neither all good nor all bad. Here, we have summarized key points to make an account of the efficiency of this system.

The marketing race leading to disparity

The use of advanced medical technology in marketing has resulted in creating an accessibility gap among healthcare setups. A hospital advertising fancy new technology that it can afford can further capture more market share from others that cannot afford the technology in the first place. This leads to a monopoly that shifts the incentive from broader healthcare delivery to focusing on the development and implementation of strategies that may or may not benefit the population.

This accessibility gap also exists between the First World nations and those of less developed countries. Surgeons trained in more developed countries like US and UK have only had the experience of performing surgeries with da Vinci robotic surgery systems. If those surgeons were to practice surgery in third-world countries, they would have to face serious problems due to a lack of such technology in those countries.

Lack of Proven Benefit to Disease Outcome

Many healthcare professionals have expressed their views that using robotic systems in surgical procedures provides little to no benefit in terms of outcome. Though da Vinci robotic surgery does help in reducing perioperative complications, such as blood loss, and shortening the recovery time; the longer-term outcomes are equivalent to those of open surgery.

For instance, in the case of prostatectomies, the recovery of continence is earlier in the patients who underwent robotic surgeries than in those with open surgery. But this benefit diminishes after twelve months5. In the case of cancer, the effect is similar and the outcomes remain the same regardless of the mode of the surgery. According to Thanigasalam, the overall outcome of the surgery depend on the skills of the surgeon than on the technology5.

Many studies conducted worldwide have reported that there is no difference in the outcomes between open and robotic surgeries. Even da Vinci’s proponents acknowledge the temptation to overplay its ability. “We all love a good robot,” says Richard Sullivan, professor of cancer and global health at King’s College London and director of the Institute of Cancer Policy in the United Kingdom5. “Human beings, particularly surgeons, are incredibly neophilic. We love this sort of thing; it gives us authority. And the patient will think that, because you’ve got all of this fancy kit, you must have better outcomes. But that’s not true, the robot is not an indicator of quality5.

In 2014, a study published in the Obstetrics & Gynecology journal states that resection of ovaries or ovarian cysts with robotic surgeries was likely to result in more complications than traditional minimally invasive surgeries. There was also a 2013 Journal of the American Medical Association study of more than 250,000 procedures that showed hysterectomies performed robotically resulted in similar outcomes as those done by traditional laparoscopic surgeries. Many other research articles state similar outcomes in other surgeries.

The Financial Burden

Moreover, the use of da Vinci robotic surgery system inflates the cost of the procedure and puts a burden on the economy. In the eyes of some, this burden is unjustified as it does not translate into better outcomes for the population overall. Their view dictates that medical technology should not only benefit the surgeon and the patient during the surgery but should also have positive effects on the outcomes.

Reliability

The other thing is reliability. Though the surgeon is in charge of the operation at all times, equipment malfunction can still complicate the procedure and end up doing more harm than good. Intuitive has issued multiple recalls over the years for a series of issues with the robotic device, including reports of friction within certain instrument arms resulting in interruption of smooth instrument movement. All recalls were classified by the FDA as Class II recalls, meaning the device was capable of causing temporary or medically reversible health problems, with the potential for serious complications being a more remote possibility10.

The 4 areas subject to Class II recall included10:

  • Recommendations for the proper use of the Tip Cover Accessory and the correct generators that should be used with monopolar (single-poled) instruments
  • Use of the da Vinci Surgical System for thyroidectomy (removal of part or all of the thyroid gland) indications, which the device was not cleared for
  • Information for inspecting instrument cannulas (a thin tube inserted into a vein or body cavity), proper flushing of the instruments, and proper transport of the system between buildings
  • Replacement user manual addendum that included changes to the types of patients and conditions for which da Vinci TORS is indicated, including use in pediatric patients

Increase in Medical Device Reporting

FDA posted an article in 2015 that mentioned an increase in Medical Device Reporting (MDR) about the da Vinci robotic surgery system10. Most of these reports indicated a malfunction in the system or the associated instruments. However, it is necessary to note that FDA also suggested a lack of proper reporting alongside it.

The FDA listed various possible reasons for the increase in reports, including10:

  • Increase in the number of devices being used or surgeries being conducted
  • Better awareness of how to report device issues to the FDA
  • Increased publicity resulting from product recalls
  • Media coverage
  • Litigation

The federal agency further stated that because submissions can potentially contain incomplete, inaccurate, duplicative, and unverified information, it is impossible to confirm whether the device caused a specific negative event based solely on the information provided in the report.

Intuitive submitted an earlier response to the already apparent issue on March 13, 2013, stating that “the noted rise does not reflect a change in product performance but rather a change in MDR reporting practices11.” Intuitive explained that it revised its MDR practices in September 2012, which resulted in increased reports of device malfunctions11. It pointed out that the majority of the reports were related to the instruments and not the system itself. Intuitive further stated, “None of these device malfunction MDRs involved reportable injuries or deaths11.”

Summary

Whatever the case may be, the use of da Vinci robotic surgery system is not all bad. The device does improve the quality of the treatment and helps the patient in the short term. These short-term advantages may not affect the outcome of the disease itself, but they do help in the longer term by decreasing the risk of complications caused due to infections, bleeding, collateral damage, and scarring. The system has its value in cases where the surgery would otherwise be open.

The issues with recalls and MDRs exist, yet most of the time, the malfunctions reported in the MDRs were not caused by the da Vinci system itself, but rather by the instruments which would have been used otherwise too. Any new technology is prone to some flaws and Intuitive has done its part by fixing the problems experienced, as is demonstrated by the huge increase in the stock price of the company.

The continuously growing competition in the medical technology space can help bring down the cost of such robotic systems. A UK-based company, CMR Surgical, which has raised $240 million since 2016 for its Versius robot12, and Verb Surgical, a partnership between Johnson & Johnson and Alphabet is expected to give da Vinci robotic surgery system a run for its money. Latest technologies are being developed every day and can improve the overall standard of surgical care, reduce the accessibility gap and promote the standardization of medical care.

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Sources

  1. About Us. Intuitive.com. Minimally Invasive Care | About Us | Intuitive
  2. 40th Anniversary of a Lifesaving Discovery. John Hopkins Medicine. Feb 11, 2020. 40th Anniversary of a Lifesaving Discovery (hopkinsmedicine.org)
  3. George, Evalyn. et al. Origins of Robotic Surgery: From Skepticism to Standard of Care. National Library of Medicine. Oct-Dec, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6261744/
  4. Hale, Graham. et al. Measuring Quality of Life Following Robot-Assisted Radical Prostatectomy. National Library of Medicine. Jun 23, 2021. Measuring Quality of Life Following Robot-Assisted Radical Prostatectomy – PMC (nih.gov)
  5. Bec Crew. A closer look at a revered robot. Nature Journal. April 23, 2020 .d41586-020-01037-w.pdf (nature.com)
  6. Gordon J. William. Et al. Protecting procedural care—cybersecurity considerations for robotic surgery. NPJ Digital Medicine. Sep 20, 2022. Protecting procedural care—cybersecurity considerations for robotic surgery | npj Digital Medicine (nature.com)
  7. Emily Singer. The Slow Rise of the Robot Surgeon. MIT Technology Review. March 24, 2010. The Slow Rise of the Robot Surgeon | MIT Technology Review
  8. Wilensky Gail. Robotic Surgery: An Example of When Newer Is Not Always Better but Clearly More Expensive. PubMed Journal. Mar 14, 2016. Robotic Surgery: An Example of When Newer Is Not Always Better but Clearly More Expensive – PMC (nih.gov)
  9. Cameron Scott. Is da Vinci Robotic Surgery a Revolution or a Rip-off?. Healthline. Aug 10, 2016. https://www.healthline.com/health-news/is-da-vinci-robotic-surgery-revolution-or-ripoff-021215
  10. Kristin Compton. Da Vinci Surgical System. Drugwatch. Nov 08, 2022. https://www.drugwatch.com/davinci-surgery/
  11. Intuitive Surgical Comments on Medical Device Reporting Practices. (GLOBE NEWSWIRE) — Intuitive Surgical, Inc. Mar 13, 2013. https://isrg.intuitive.com/news-releases/news-release-details/intuitive-surgical-comments-medical-device-reporting-practices
  12. Steve Crowe. CMR Surgical raises $240M for Versius surgical robot. The Robot Report. Sep 17, 2019. https://www.therobotreport.com/cmr-surgical-243-million-versius-surgical-robot/
Dr. Muhammad Hussain
Dr. Muhammad Hussain

MD, Entrepeneur & Administrator. Six years of experience, working in the field of clinical care, medical administration, and healthcare business.

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