The year was 1999, and California-based Intuitive Surgical Inc. introduced its da Vinci® Surgical System for robotic-assisted minimally invasive surgery. The system revolutionized several procedures and holds promise today as a catalyst for further surgical advances. More than 900 academic and hospital sites own a da Vinci, and the company grows in excess of 25 percent annually.
That growth continues with the da Vinci Si HD, Intuitive’s latest iteration of the system, introduced last year. Already, surgeons in at least three Middle Tennessee hospitals are employing the da Vinci Si for procedures as varied as bariatric surgery, hysterectomies and prostatectomies.
Features of the new da Vinci Si system include:
- Enhanced high-definition, 3D vision with up to 10x magnification,
- An updated user interface for streamlined setup and operating-room turnover,
- Dual-console capability to support training and collaboration,
- EndoWrist® instrumentation (5 and 8 mm) with improved dexterity and range of motion superior to the human hand,
- Motion technology that preserves natural eye-hand-instrument alignment and control,
- An ergonomically designed surgeon console,
- A lightweight camera head with buttons for focus control, automated scope setup and illuminator control,
- An integrated surgeon touchpad that offers comprehensive control of video, audio and system settings,
- Fingertip and footswitch controls, and
- A motorized patient cart for quick and controlled docking of the system to the patient.
“The development of the optics of the machine is such now that we can see to do these difficult procedures better,” said Laura Williams, MD, a gynecologic oncologist on staff at Baptist Hospital. “The instruments have a greater range of motion, and they’re longer and can penetrate deeper into the abdominal cavity. So the technical capability of this machine is much greater than it used to be.” According to statistics from Intuitive, Baptist performs more gynecologic, robotic-assisted procedures than any other Tennessee hospital – 30 percent of the volume in the state. Eight surgeons use the robot for a variety of procedures there, and Williams estimated that she’s performed about 350 procedures robotically in the last three years.
“It allows us to do fairly extensive operative work through very small incisions. We’re ultimately able to remove organs on the inside through an incision for women that’s through the top of the vagina when we detach a uterus and a cervix,” Williams explained. Not only does she perform hysterectomies, Williams uses the da Vinci to remove lymph nodes in the pelvic and abdominal area and to treat uterine fibroids, endometriosis and complex ovarian cysts.
Williams teaches Vanderbilt obstetrics/gynecology residents, who rotate through Baptist and learn about the da Vinci applications for their specialty. Also, she has proctored and assisted other physicians learning the technology.
Williams acknowledged that the newest da Vinci version is “actually technically more challenging because there are more options on the machine.” She likened the first da Vinci to changing the channels of an analog television by turning the dial. “Compare that to a contemporary remote that has like 42 buttons. There are a lot more bells and whistles on the machine now, and then there are a lot more things I have to maneuver, manipulate and control,” she said. “The learning curve is pretty steep, but once you get beyond the learning curve, it’s so beneficial to patients that it just fuels itself really.”
Williams contended that “patients absolutely recover faster.” Most are in the hospital fewer than 24 hours and are back to work in two weeks. Use of the da Vinci also decreases the amount of pain medication needed, she noted.
Ram Dasari, MD, a urologist at Centennial Medical Center, has been using the da Vinci since 2003. In fact, he completed a specialized fellowship in robotic surgery at Henry Ford Hospital in Michigan, where the world’s first robotic prostate operation was performed. He concurred with Williams that “patients do better with this type of operation compared to the old one,” adding that there’s less blood loss using the da Vinci and therefore a need for fewer transfusions. “Also, functional results do tend to be better,” he said. For prostate procedures, that means preserved continence and potency.
Dasari said he probably does more robotic prostate procedures at Centennial than any other urologist – radical prostatectomies, pyeloplasties to treat kidney blockages and partial nephrectomies to treat kidney cancer. He said the da Vinci has done for prostate surgery what minimally invasive laparoscopic capability did for gall bladder surgery.
Dasari lauded the new da Vinci’s improved optics. “We can see things much more clearly,” he said. “There’s much better visualization of the movement of the instruments, and the robotic technology is much more superior than doing it just laparoscopically alone. It has changed the way we treat prostate cancer completely.” He added that the addition of a fourth arm on the Si version is “a big plus.”
For Wayne Westmoreland, MD, a general surgeon at Middle Tennessee Medical Center in Murfreesboro, the da Vinci’s promise is more valuable than its capabilities today. Westmoreland recently performed the first bariatric procedure using a da Vinci in Tennessee, yet the procedure actually takes a little longer robotically than the conventional method.
Nonetheless, he’s adopted the da Vinci’s use in his practice. “If it turns out there is an advantage to using the robot, then we’ll already have the experience and be used to it, and we can help train others like we helped train doctors to do lap choles (laparoscopic cholecystectomies) back in the early 1990s,” he said.
While the jury is still out for Westmoreland, some physicians believe gastric bypass using the da Vinci does offer an advance – the ability to hand-sew anastomoses rather than use staples. “Some people say that if you do an anastomosis with absorbable sutures as opposed to staples, then you don’t have a foreign body that will stay there forever to prompt some inflammatory response,” Westmoreland said. He noted that the da Vinci Si’s two cameras offer depth perception, “just like you have two eyes, and you can do finer details.” For sewing an anastomosis, the robot offers wrist and finger motion, which Westmoreland said allows for more precise movements. He predicted that the da Vinci’s features will prove to be an advantage for colon procedures deep in the pelvis, such as low anterior resections.
“When I add new procedures to my practice, it adds new life to my practice,” Westmoreland said. “Honestly, it’s adding time and effort to our procedure right now, but I hope that that will be time invested for benefit down the road. We want to be able to offer a full spectrum of minimally invasive surgery. If somebody’s doing it, we want to be doing it Murfreesboro.”