Robots to assist surgery: the da Vinci system

The da Vinci system was created to perform efficient surgical procedures with minimal damage to the patient’s body. With its advanced technology, it assists surgeons by providing high-resolution images and reproducing their movements with greater precision.

Intuitive Surgical (ticker: ISRG US), founded in 1995, created the da Vinci Surgical System in response to a request from the US Army to operate soldiers remotely. The first da Vinci system was installed in late 1998 and, for more than 20 years, this innovation has transformed the field of minimally invasive surgery. Since 2000, more than 10 million surgical procedures have been performed worldwide using da Vinci systems, and Intuitive has become a leader in surgical robotics(1).

The minimally invasive surgery revolution

Surgery has three ideals that motivated minimally invasive procedures: detect any disease, remove all diseased tissue while sparing healthy tissue, and leave the body as if no surgery had taken place. The main obstacle is that diseased tissue is rarely close to the surface of the skin: it is often buried in the body’s structures, causing collateral damage as surgeons cut through healthy tissue to reach their target.

In the past, surgeons made large incisions in the skin and muscle so they could see and work directly on the area of concern: this is called open surgery. Today, they still perform many open surgeries, but sometimes have the option of performing two types of minimally invasive surgery: laparoscopic surgery and robot-assisted surgery. Both approaches require only one or a few incisions that the surgeon uses to insert surgical equipment and a camera to see inside the body(1).

In laparoscopic surgery, surgeons use special long-handled tools to perform the operation directly on the patient while watching enlarged images from the camera (laparoscope) on a monitor. In contrast, the da Vinci system is robot-assisted surgery based on teleoperation, a technology that has already been deployed for space exploration or handling hazardous material. It uses the same type of cameras and tools, but the operator is remote from the patient(2).

Compared to traditional open surgery, the small incisions created by minimally invasive surgery significantly reduce the time patients spend in the hospital and the risk of infection.

Exhibit 1: The da Vinci system in the operating room

The da Vinci system enables robotic-assisted surgery. It is based on teleoperation: in the operating room, surgeons sit away from the patient at a console where they operate handles that move the robotic arms remotely. Meanwhile, an assistant stays by the patient’s side to monitor their condition, help with the operation, and change the surgical instruments at the end of the arms. The assistant can see what the surgeon sees through the additional screens placed around the room. The da Vinci system takes up a lot of space, and therefore requires a large operating room. (Source: All About Women Obstetrics and Gynecology).

What is the da Vinci system(1,2)?

The da Vinci system is suitable for several types of surgery in cardiology, gynecology, urology, etc. It is composed of three parts.

The surgeon console is where the surgeon sits, away from the patient. It provides a high-resolution 3D view of the inside of the body, magnified ten times over what the human eye sees. From there, the surgeon controls the movements of the surgical instruments and the camera. The robot cannot operate alone and is not programmed to make decisions. All movements are initiated and controlled by the surgeon.

The patient cart is placed next to the patient on the operating table. It contains four manipulators, or arms, that can support a camera or a surgical instrument such as scissors, a needle driver, etc. The instruments respond in real time to the surgeon’s hand movements. Next to the patient, the assistant surgeon supervises the operation (threading, vessel closure, etc.) and the changing of da Vinci instruments.

The vision cart provides communication between the surgeon console and the patient cart; it transmits video images from the camera to the console and transmits the surgeon’s hand movements to the robotic manipulators. It also provides a screen for the care team to view the operation.

Because the link between the surgeon console and the robotic arms is electronic, the integrated software can filter the signals to remove the surgeon’s natural tremor or reduce the range of motion for greater accuracy. The software also includes modules for guidance (on-screen procedure notifications, visual cues), training (simulation technology for practice), guided setup to simplify preparation (and even automatic patient cart deployment in the latest versions), and user-adjustable settings (ergonomic preferences).

In the future, the goal is to enhance surgeons’ capabilities by integrating additional imaging technology to augment their view of the body (e.g., fluorescent particles that attach to a tumor and make it glow), or by providing tactile feedback to locate hidden structures such as vessels and nerves, which is a key element that surgeons are used to rely on during open surgery.

Exhibit 2: Components of the da Vinci system

The da Vinci xi is the fourth and latest generation of da Vinci systems. Innovation has not been focused on changing the structure of the system – the shape remains similar over the years – but on adding the latest technologies to make it more efficient.

One of the robotic arms is a camera that films the inside of the patient’s body. A magnified 3D version of the image is displayed on the console, so that surgeons can watch the operation while being away from the patient. They control the robotic tools using handles. The movement is filtered to remove natural tremor and transmitted to the robot that will replicate. (Source: Excelencia Robótica, Azizian, et al., Intuitive Surgical).

Why use a da Vinci system(3)?

The alternative to the da Vinci system for minimally invasive surgery is laparoscopic surgery, where all instruments are held by assistants. Laparoscopic surgery has major drawbacks that make surgery uncomfortable and difficult: it only offers a 2D view, which impairs depth perception; the camera is held by the assistant who must synchronize with the surgeon and not shake; and the instruments are straight and inflexible. In contrast, the da Vinci system offers 3D vision, the camera is controlled remotely by the surgeon, and the instruments have micro-wrists for greater flexibility. In addition, it is more comfortable for surgeons to sit in front of an adjustable console; this reduces the physical demands on them, making them less prone to errors.?

The main negative is low accessibility: the average cost of the da Vinci system is between $0.5 and $2.5 million; the price of instruments and accessories is $700 to $3,200 per procedure; and maintenance costs exceed $100,000 per year. Intuitive has a monopoly on the market, and therefore sets the prices, but other companies are trying to offer their own prototype and enter the market. In addition, the robotic equipment takes up a lot of space: the high cost combined with the space needed to install the system limits it to larger hospitals.

References:(1) Intuitive Surgical - (2) M. Azizian, et al., The da Vinci Surgical System, Handbook of Robotic and Image-Guided Surgery, Elsevier, ch. 3, pp. 39-55, 2020 - (3) L. Toumbas, et al., Recent Advances in Remote Assisted Medical Operations, Ambient Assisted Living and Enhanced Living Environment, Butterworth-Heinemann, ch. 6, pp. 123-145, 2017

The performance returns disclosed in this market review are those of representative stocks, indices and futures contracts. Such performances are provided for illustrative purposes only and are not meant to depict the performance of a specific investment. Past performance is no guarantee of future results.