da Vinci Surgical System

• The da Vinci Surgical System is a platform for robot-assisted minimally invasive surgery (RAMIS).
• The chapter offers an overview of the da Vinci System's design, key subsystems for vision, tissue manipulation, anatomical access, operator technology training, and clinical adoption.
• It also provides insights into the invention and development process impacting technology and medicine.

Introduction

• As of the writing of the chapter, there are over 4,400 da Vinci Systems installed in over 60 countries, with approximately 875,000 procedures performed in 2017, and over 5 million procedures completed overall.

Goals of Surgery

• The fundamental ideals of surgery include perfect visualization, complete diseased tissue removal, precise reconstruction, and leaving the body as if no intervention occurred.
• One of the greatest obstacles in surgery is that diseased tissue is often buried deep within the body, making it difficult to access without causing collateral damage to healthy tissues.
• Minimally invasive surgical techniques, like laparoscopic surgery, have been developed to address this challenge.
• Laparoscopic surgery involves remote visualization and manipulation using mechanical instrumentation to transmit the surgeon's motions from outside the patient's body to the surgical field inside.
• The da Vinci system enhances this approach with teleoperation technologies, placing a computerized control system between the surgeon and the surgical field to enable complex tissue manipulations while minimizing invasiveness.
• The purpose is to make visualization and manipulation of tissue structures as transparent and natural as possible for the surgeon.
• Teleoperation enhances the surgeon's capabilities by stabilizing motions, scaling motions, augmenting senses, providing navigation, anticipating critical events, and potentially automating tasks.
• Present day technologies are just at the start of being able to do these tasks, but are evolving over time.
• The remainder of the chapter includes the da Vinci Surgical System architecture, key design features, product ecosystem, themes for future innovation, history of Intuitive Surgical, anatomy of the da Vinci Surgical System, visualization, tissue manipulation, surgical access, training, clinical adoption, concluding thoughts, and future directions.

The Intuitive Surgical Timeline

• Intuitive Surgical was founded in 1995 by Dr. Frederick Moll, Rob Younge, and John Freund.
• The company licensed telepresence surgical technology from SRI (Menlo Park, CA) and developed the da Vinci Surgical System, with the first installation in late 1998.
• Initial marketing focused outside the U.S. until FDA clearance was received in mid-2000 for general surgery applications.
• Additional FDA clearances followed for thoracoscopic and radical prostatectomy procedures.
• During its early days, Intuitive Surgical competed with Computer Motion, Inc., makers of the Zeus Surgical System, that launched in 1997.
• In 2003, Intuitive Surgical and Computer Motion merged.
• The Zeus system was phased out in favor of the da Vinci System due to its additional capabilities.
• After the merger, Intuitive Surgical developed and launched a series of products to extend and evolve the da Vinci platform and added clinical indications.
• To date, five models of the system have been launched globally.

Basic Principles and Design of the da Vinci Surgical System

• The da Vinci System comprises three distinct subsystems: the patient-side cart, the surgeon console, and the vision cart.
• The surgeon sits at the surgeon console, controlling the motion of surgical instruments at the patient side and observing video images from inside the patient.
• Unlike traditional laparoscopic approaches, the da Vinci operates using teleoperation.
• The da Vinci System uses a master-slave teleoperation architecture, where the surgeon console controls slave manipulators on the patient side cart.
• The concept of "teleoperation" dates back to science fiction writing in the 1940s.
• In the da Vinci System, the surgeon's "master interface" is electronically connected to the surgical instruments driven by "slave manipulators" via a computerized control system.
• The patient-side manipulators are mounted to the patient-side cart and can support a stereo endoscopic camera or surgical instruments such as graspers, scissors, or needle drivers.
• Instruments work within the sterile field, while the surgeon and console remain outside.
• The control system extends the surgeon's "presence" by transmitting video images and hand motions, filtering tremors, and scaling motions for enhanced precision.
• The control system may also augment the surgeon's view of the anatomy and anticipate task steps.
• When Intuitive Surgical began its development work in late 1995 the product vision included four key specifications, known as, "product pillars:
• The first was that the system had to be reliable and failsafe to be a surgical device
• The second that the system had to include user with intuitive control.
• The third was that the instrument tips were to have six-degree-of-freedom (6-DoF) dexterity as well as a functional gripper.
• The fourth was that the visualization would be 3D visualization of the anatomy.
• Subsequent generations of the da Vinci System have extended these product pillars to improve ease of use.
• A coordinated team interacts with the da Vinci System during multiple surgical phases, including preparation, draping, roll-up, deployment, docking, instrument insertion/removal, undocking, undraping, cleaning, and stowing.
• The da Vinci Xi System was developed to improve operative workflow.
• The da Vinci Xi System uses a gantry system to position instrument manipulators directly over the operating table, that is independent of surgical workspace orientation.
• Intuitive Surgical released the da Vinci X Surgical System in 2017 as a lower-cost solution with key innovations from the da Vinci Xi System.
• The da Vinci X System uses the same vision cart and surgeon consoles as the da Vinci Xi System.
• Building a robot-assisted surgery program requires an ecosystem of products and services, including a range of robotic systems, instruments, and accessories.
• This includes advanced instruments such as staplers and vessel sealers, and endoscopic stereo-imaging systems such as Firefly near-infrared imaging technology.
• The systems are connected to a network for predictive maintenance, downtime minimization, and analytic insights.
• Intuitive Surgical provides round-the-clock support, advanced courses for surgeons, and da Vinci Skills Simulators for training.

Visualization

• The da Vinci Surgical System was among the first commercial products to use stereoscopic endoscopes for soft tissue surgery.
• These endoscopes capture and display white-light images, until more recently.
• The chapter introduces advanced imaging technologies, offering more information than is visible in white light.

Fluorescence Imaging

• Robot-assisted surgery employs near infrared fluorescence imaging with a fluorescent agent, excitation light source, and detector.
• Surgical applications require regulatory clearance for agents with demonstrated clinical utility and safety.
• Indocyanine green (ICG) is widely used intraoperatively.
• The near infrared signal detected highlights the white light image with false color, providing surgeons with an augmented view of tissue.
• ICG is removed from the blood by the liver and secreted into bile, enabling surgeons to image bile duct structures.
• ICG excitation and emission wavelengths are in the near infrared region, allowing visualization through a modest thickness of intervening tissue.
• Research includes using ICG to image the lymphatic system and localize lymph nodes.

Other Optical Imaging Techniques

• Robot-assisted surgery offers the opportunity to use optical signals to improve tumor identification and reduce adverse events.
• Multi-spectral imaging can be used to acquire and analyze data across the electromagnetic spectrum.
• Narrow Band Imaging (NBI) uses selective bands of red, blue and green illumination to better visualize topical tissue features.
• Inherent surface-based technology, NBI shows promise to help evaluate suspicious superficial lesions in the head and neck, as well as bladder cancers.
• Robotics can facilitate the acquisition of image mosaics, allowing for easier image stitching (mosaicking).
• The challenge also exists for optical coherence tomography (OCT).

Tomographic Imaging

• Tomography refers to imaging cross-sections of an object using penetrating waves like X-rays (CT), gamma-rays (SPECT), radio-frequency waves (MRI), and mechanical waves (ultrasound).
• Tomographic imaging provides sectional images, offering information beyond the surface of tissue.
• Robot-assisted surgery for soft tissue has mostly focused on reflective imaging that allows the user to see only the visible surface of organs.
• Fluorescence imaging has been used to provide subsurface information
• Currently, although it is not intergral, tomographic imaging is used to visualize deep tissue structures, such as solid tumors, prior to surgery.
• Use of tomographic images during robot-assisted surgery may result in increased accuracy and speed, and reduced chance of cancer recurrence by more accurate tumor resection and better lymphadenectomy under image guidance.
• Tomographic images are often acquired pre-operatively and need to be aligned to intraoperative patient coordinates.
• The da Vinci System supports live images and video by feeding them from auxiliary video streams into the surgical display (TilePro).
• There is the lack of automated alignment between endoscopic view and tomographic view makes it counterintuitive to use tomographic images to guide the surgical procedure, but there are efforts to make effective use of tomographic imaging modalities with the da Vinci System.