With more than 1000 machines in use in the US, Europe and Japan, Intuitive Surgical is, with its Da Vinci robots, the leading enterprise in the field of numerical surgery.
The system was approved in the US in July 2000 by the very demanding FDA for surgical operations including cutting and stitching. It is the first robotic surgical apparatus which gives it a lead position in relation to its competitors.
To achieve this result, Intuitive surgical had to overcome numerous obstacles to succeed in managing numerical surgery. The company is now expanding rapidly.
HOW DOES THIS DEVICE WORK?
Through a small incision, the surgeon carries out minimally invasive surgery thanks to this system. According to Ben Gong Financial Vice-President of Intuitive, thanks to Da Vinci system the 2-3% risk of nosocomial infection is close to zero.
The Da Vinci Robot comprises four principal components: the surgeon side console, the multi-armed patient side telemanipulator, the Endowrist surgical instruments and the high resolution 3D Insite endoscope linked to a numerical image analyser.
Da Vinci robot1. The Console
The surgeon sits at the console placed a few metres from the operating table on which the patient is lying. He is comfortably installed in an ergonomic position avoiding fatigue. His head is supported in direct view of the operating field and the fingers of his two hands control the instruments with ‘joysticks’.Through binoculars, the surgeon sees a 3D high definition magnified image of the operating field with real time progress of the instruments he commands. He can move about as he wishes in the operating field.
2. The telemanipulator
JoystickThis element of the system contains the robotic arm in direct contact with the patient. It is composed of two or three arms for the instruments and one arm for the optic of the endoscope.Current technology does not allow the surgeon to see the force applied by the instruments on the tissues or the suture thread. He must therefore rely almost exclusively on his visual impression when he is stitching or dissecting soft tissues.In 2003, Intuitive added to its latest robots a fourth arm which allows control of an extra instrument for complex surgery.
3. The surgical instruments (Endowrist and Intuitive Masters Instruments)The interchangeable Endowrist instruments manipulated by the robotic arms operate by simulating the movements of the human hand. Each instrument has its own functions, needle carrier for the sutures, graspers and forceps for holding tissues or for (Bipolar Coagulation) and scissors
Telemanipulator and instrumentfor dissection. They can be interchanged rapidly using the rapid liberation levers provided on each robotic arm.The mechanism memorises the position of each robotic arm before the first instrument is replaced so that the second can be repositioned in the same operating field and the same position as the first instrument.Articulation of these instruments is possible within 360 degrees so they offer a significant advantage with respect to non-robotised instruments used in conventional laparoscopy.The seven degrees of freedom, corresponding to the number of independent movements that each of the robotised instruments can carry out, offer a considerable choice of rotation and pivoting.Otherwise, the surgeon can control the force applied to the tissues which can vary from a fraction of a gram to several kilos.
The intuitive technology allows also trembling of the surgeon’s hand to be filtered out and removed and it reduces the scale of movement of the human hand. Thus, wide movements of the surgeon’s hand will be transmitted as movements of much more limited amplitude by the robotised mechanism.
4. The 3-D vision system (Insight Vision and Camera Control Navigator)The optic of the endoscope provides the surgeon with a high resolution image in real time, considerably magnified, in three dimensions, reproducing the perception of contours and is extremely stable. For the operator, it represents a considerable advantage compared to the vision he would have in traditional ‘open’ surgery.In traditional laparoscopy, vision is in two dimensions and the image is less stable due to small involuntary movements of the assistant controlling the optic. The Da Vinci system provides more than a thousand items of information per second to the computer on the position of the optic to eliminate any parasitic movement.The endoscope also has a function to regulate the temperature of its extremity automatically and avoid the condensation which is usually such a disturbance in laparoscopic operations.
The surgeon directs the positioning of the optic as he wishes by using a release pedal’
ADVANTAGES AND DISADVANTAGES
Compared to direct coelioscopy, the advantages of assisted coelioscopy with the da Vinci Robot are:
Rotation of instruments.
- 3D vision
- Accuracy of movements
- Rotation of the instruments on six axes
- Comfort of the operator.
The da Vinci Robot reduces the hospital stay by about half and thus the costs of surgery by about one third. The length of stay in the intensive care unit is also reduced as a result of the reduction in intensity of post-operative pain and a more rapid recovery of the patient.
The minimally invasive Da Vinci surgery leaves no surgical scar of significance. Furthermore, according to Intuitive Surgical, only 80 000 of the 230 000 new cases of prostate cancer diagnosed each year in the USA are treated with surgery because of the more invasive nature of conventional surgery.
The development of robotised technology offers the possibility of cure to a larger number of patients.
The principal disadvantages of this technology are the learning curve of the surgeon and the high cost of the apparatus. Although Intuitive Surgical provides a training programme for surgeons using its robots, each surgeon needs 12 to 18 cases before he feels confident in using the procedures.
One of the greatest challenges to surgeons training in the use of the apparatus is lack of ease as a result of losing direct tactile feeling.
The expansion of the telemanipulator limits the access of the surgeon’s assistant to the operating field.
Many surgeons cannot have access to the Da Vinci technology because of the high cost of the apparatus. In an article published by the American Journal of surgery, 75% of surgeons stated that they were limited by finance in their access to the system which costs $1.5m.
Which does not include costs of annual maintenance of the machine and especially the coast for each operation of the different consumable items, notably that of the instruments.
These expenditures are at present particularly inhibiting for health establishments which equip themselves with systems which are based on a system of refunds like the French system because there is then no specific rate for these robots which could take account the difference in costs with respect to traditional open surgery which is not expensive to execute.
At present, surgery with the Da Vinci robot can be carried out by a trained operator as quickly as traditional ‘open’ surgery.
FAIL SAFE SYSTEMS
Security considerations are at the heart of the preoccupations of Intuitive Surgical.
To initiate the procedure, the head of the surgeon must be placed in the field of the optical binoculars. If not, a locking device immobilises the system until it can again detect the presence of the surgeon’s head.
During the course of this procedure, a system of zero movement stops the robotic arm from pivoting and damaging the tissues at the point of entry of the laparoscopy trocars.
Included in the supply source, an emergency battery allows the system to function autonomously for twenty minutes during a general power cut, allowing the operation to continue as power is restored.
Each instrument contains an electronic chip which stops use of any instrument not manufactured by Intuitive Surgical. These chips also stock information on the use of each instrument and allow one to know exactly when they should be replaced.