Original article S W I S S M E D W K LY 2 0 0 5 ; 1 3 5 : 6 7 4 6 7 8 w w w . s m w .

c h 674
Peer reviewed article

The da Vinci robotic system for general

surgical applications: a critical interim appraisal
Johannes Bodnera, Florian Augustina, Heinz Wykypiela, John Fisha, Gilbert Muehlmanna, Gerold Wetscherb,
Thomas Schmida,
a
Department of General and Transplant Surgery, Innsbruck Medical University, Austria
b
Schnaz County Hospital, Austria

Summary
Principles: The recently introduced robotic due to surgical problems, and two other pro-
surgical systems were developed to overcome the cedures were completed by conventional lapa-
limitations of conventional minimally invasive roscopy due to robot system technical errors.
surgery. We analyse the impact of the da Vinci 30-day mortality was 0%, one redo-operation was
robotic system on general surgery. necessary and two lower complications not requir-
Methods: The da Vinci operating robot is a ing surgical re-intervention occurred. The resec-
telemanipulation system consisting of a surgical tion margins of all tumour specimens were histo-
arm cart, a master console and a conventional logically tumour free.
monitor cart. Since its purchase in June 2001, 128 Conclusions: Various general surgical proce-
patients have undergone surgery using the da dures have proved feasible and safe when per-
Vinci robot in our department. The mean age of formed with the da Vinci robot. The advantage
the 78 female and 50 male patients was 52 (range of the system is best seen in tiny areas difficult of
1878) years. access and when dissecting delicate, vulnerable
Results: The procedures included 29 cholecys- anatomical structures. However, in view of longer
tectomies, 16 partial fundoplications, 16 extended operating times, higher costs and the lack of ade-
thymectomies, 14 colonic interventions, 10 quate instruments, robotic surgery does not at the
splenectomies, 10 bariatric procedures, 7 hernio- moment represent a general alternative to conven-
plasties, 6 oesophageal interventions, 5 adrenalec- tional minimally invasive surgery.
tomies, 5 lower lobectomies, 4 neurinomectomies
and 6 others. 122 of 128 procedures (95%) were Key words: robotics; da Vinci; laparoscopy; thora-
completed successfully with the da Vinci robot. coscopy; general surgery
Open conversion proved necessary in 4 patients

Introduction
The introduction of minimally invasive sur- Further developments in the fields of com-
gery some 20 years ago marked a milestone in the puter technology, micromechanics and data trans-
field of operative medicine [1]. It has resulted in fer have recently led to the implementation of
reduced tissue trauma and allows quicker recovery, robotic surgical systems [1113]. This has raised
with early reintegration into the patients normal hopes of overcoming the limitations of conven-
social and working processes. Minimally invasive tional minimally invasive surgery and thus throw-
surgery represents a basic advance in surgery and ing it open to more surgeons and procedures. At
new horizons have been opened [25]. Innsbruck University Hospital a da Vinci oper-
Although today minimally invasive surgery is ating robot (Surgical Intuitive, Inc., Mountain
well established in general surgery, its routine ap- View, CA, now occupying a monoply position in
plication is still restricted to technically relatively surgical robotic systems) was purchased in June
simple surgical procedures: for cholecystectomies, 2001. To maximise utilisation and reduce mainte-
fundoplications, pulmonary wedge resections and nance costs it is jointly used by the departments of
all kinds of hernia repairs it has achieved gold stan- General and Transplant Surgery, Cardiac Surgery,
dard status and is used all over the world. A multi- Urology and Gynaecology/Obstetrics.
tude of other, more complex minimally invasive
procedures are being carried out successfully in
No financial
support declared. some centres but have not yet achieved general ac-
ceptance [610].
 S W I S S M E D W K LY 2 0 0 5 ; 1 3 5 : 6 7 4 6 7 8 w w w . s m w . c h 675

Observation material and methods

The da Vinci operating robot is a telemanip- The patient side-placed surgical arm cart is a
ulation system composed of a surgical arm cart, a manipulator unit with two instrument arms and a
master console and a conventional monitor cart central arm to guide a two-channel endoscope. At
[14]. the master console the surgeon handles telemanip-
ulators and optical controls using three-dimen-
Figure 1 sional vision. His intuitive hand movements are
The three compo- transmitted from the handles to the tips of the la-
nents of the da paroscopic instruments on the surgical arm cart.
Vinci robotic
system.
The range of robotic instruments is limited. A
cautery hook, different forceps, scissors, needle
holder, clip applicator and an ultrasound coagu-
lation device (Endosurg) are available. Stapler
devices are not yet available. The instruments are
reusable, most of them up to ten times.
The main technological advantages of this
system are realistic 3-D imaging, motion-scaling
and tremor filtration. Thus, it facilitates more pre-
cise and accurate endoscopic surgery.
Since its purchase and approval by the local
Figure 2a + b ethics committee, 128 patients have been operated
The surgeon sits at on with the da Vinci robotic system in our
the console in an er- department. The mean age of the 78 female and
gonomic, comfort-
able position and 50 male patients was 52 (range 1878) years.
handles the robotic Informed consent was given by all patients. The
instruments on the
surgical arm cart via
different robotic procedures are classified into
telemanipulation. 12 operating groups (table 1). The following pro-
cedural steps were performed robotically:
cholecystectomy: dissection and controlling of
the cystic artery and the cystic duct extirpa-
tion of the gallbladder from its hepatic bed
partial posterior fundoplication: mobilisation
of the right and left diaphragmatic crura mo-
a
bilisation of the distal oesophagus closure of
the hiatal crura creation and fixation of the
partial posterior fundic wrap (the entire pro-
cedure)
procedures on the left hemicolon: central clip-
ping and dissection of the colonic arteries
and veins total mobilisation of the affected
colonic segments (if necessary including a total
mesorectal rectal resection) mobilisation of
the left colonic flexure
extended thymectomy: resection of the thy-
mus en bloc with the precordial fatty tissue
laterally to both phrenic nerves, caudally to
the diaphragm and cranially along the upper
b
thymic horns up to far cervically dissection
Figure 3 and controlling of the thymic veins at the
The multiarticulated innominate vein with clips (the entire proce-
robotic instruments dure)
allow for precise
manoeuvring within splenectomy: division of the peritoneal attach-
tiny areas of difficult ments and the splenic ligaments controlling
access.
of the short gastric vessels dissection of the
splenic hilum
bariatric procedures: installation of an ad-
justable gastric banding installation of a gas-
tric pacing (the entire procedures)
extraperitoneal inguinal hernioplasty: retrac-
tion of the hernial sack dissection of the sper-
matic cord and vessels / of the rotundum liga-
The da Vinci robot in general surgery 676

Table 1 Procedure n Indication (n) section for oesophageal cancer; oesophago-

Robotic procedures: Cholecystectomy 29 Cholelithiasis myotomy resection of a submucosal tumor
numbers and indica- suture of the oesophagomyotomy
tions. Partial fundoplication 16 Gastrooesophageal reflux disease
adrenalectomy: dissection of the adrenal gland
Colonic intervention 14 Diverticulosis (11)
controlling of the adrenal veins with clips
Sigmoid / rectal carcinoma (3) (the entire procedure)
Extended thymectomy 16 Thymoma (6) lower pulmonary lobectomy: dissection of the
Myasthenia gravis (7) pulmonary ligament dissection of the lower
Others (3) pulmonary vein dissection, ligation and divi-
Splenectomy 10 Idiopathic thrombopenic purpura (5)
sion of the lower apical and lower mainstem
arteries dissection of the lower lobe bronchus
Lymphoproliferative disorder (3)
lymph node dissection
Others (2)
resection of a thoracic paravertebral neuri-
Bariatric procedures 10 Morbid obesity noma: incision of the parietal pleura resec-
Hernioplasty 7 Inguinal hernia tion of the tumour, controlling of its vessels
Oesophageal 6 Oesophageal cancer (4) (the entire procedure)
intervention
Benign oesophageal tumour (2)
others: resection of an ectopic parathyroid
from the aortopulmonary window (the entire
Adrenalectomy 5 Adenoma (3)
procedure); resection of a mediastinal goitre
Phaeochromocytoma (1)
(the entire procedure)
Metastasis (1)
Lower lobectomy 5 Non small cell lung cancer (T1N0) The interventions were performed by six dif-
Neurinomectomy 4 Thoracic, paravertebral neurinoma ferent surgeons who were experienced laparo-
Others 6 Various benign tumors scopists. Before starting the institutional robotic
programme, three surgeons received prior train-
ing on the robot at the companys laboratory in
ment positioning of the mesh (the entire pro- Utrecht, Netherlands. The other three surgeons
cedure) completed special training at the department with
oesophageal procedures: thoracoscopic dis- defined manoeuvres (knot tying, grasping of vari-
section of the oesophagus and lymph node dis- ous objects etc).

Results
122 of 128 procedures (95%) were successfully tebral thoracic neurinoma. Conversion to the
completed with the da Vinci robot. Open con- conventional laparoscopic approach was necessary
version was necessary in four cases posing surgical in two cases due to technical robotic problems
problems: in the very first pulmonary lobectomy which, however, did not compromise patient safety
procedure dissection of the lower stem pulmonary (sudden total breakdowns of the system which
artery led to major bleeding, and in another lobec- could not be booted up again). Besides the above
tomy procedure problems arose due to an anatom- mentioned two bleedings with a blood loss of
ical anomaly of the pulmonary artery. In one 300 ml and 90 ml in the pulmonary lobectomy and
thymectomy procedure a lesion of the mammary thymectomy procedures respectively, there was no
artery occurred due to collateral tissue damage by relevant (>50 ml) blood loss in any other proce-
a robotic instrument. The fourth open conversion dure. 30-day mortality in all 128 patients was 0%.
concerned a patient with a 178 cm large paraver- One redo-operation was necessary in a patient
after oesophageal dissection (a persistent lymph
Table 2 Procedure Set-up Console Total fistula was clipped thoracoscopically). Lower com-
Times for each Cholecystectomy 35 52 98 plications without surgical re-intervention (n = 2,
procedure (median
in minutes). Partial fundoplication 35 154 198 2%) included transient recurrent nerve palsy after
Colonic intervention 45 178 310 resection of an ectopic parathyroid from the
aortopulmonary window and a haematoma after
Extended thymectomy 40 130 150
splenectomy. A wound infection of a port side was
Splenectomy 35 107 147
observed in four patients (3%). The resection mar-
Bariatric procedures 45 137 167 gins of all tumour specimens were histologically
Hernioplasty 40 67 118 tumour free.
Oesophageal intervention 40 117 147 The operating times for the different proce-
Adrenalectomy 40 128 181 dural groups are shown in table 2. Times for ro-
botic procedures are divided into set-up time, con-
Lower lobectomy 70 270 318
sole time and total operating time. The set-up time
Neurinomectomy 30 51 65
includes connection of the components, booting
 S W I S S M E D W K LY 2 0 0 5 ; 1 3 5 : 6 7 4 6 7 8 w w w . s m w . c h 677

Figure 4 robotic
conventional
Procedural costs 7.000.00
(median per patient,
in H): robotic versus 6.000.00
conventional mini-
mally invasive sur- 5.000.00
gery.
4.000.00

3.000.00

2.000.00

1.000.00

0.00

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Table 3 Procedure Material Personnel to Overall
the cost of maintenance per year is approx.
Procedural costs per Cholecystectomy 2308 518 2826
patient (median in D).
B 100,000. The robotic approach is significantly
Partial fundoplication 3732 990 4722 more expensive than conventional minimally in-
Extended thymectomy 2857 704 3561 vasive surgery. Figure 4 shows the institutional
Splenectomy 4815 747 5562 procedural costs for the various procedures in
comparison with the corresponding laparoscopic
(thoracoscopic) costs. This extra cost is due to
up of the robotic system, and sterile draping of the longer operating times, as well as the high per-
surgical arm cart. The console time is that part of minute cost of the robot itself and higher costs for
the total operating time (first cut to skin closure) the robotic instruments, which are re-usable ten
during which the surgeon operates on the console, times only. Table 3 gives the material costs, per-
the time of the effective robotic act. sonnel costs and overall costs for the robotic pro-
In 2001 the purchase cost for the da Vinci cedures cholecystectomy, fundoplication, the gas-
robotic system accounted for B 1,000,000, while tric banding procedure and splenectomy.

Discussion
Robotic surgery was originally developed to interventions evaluated the robot either does not
render possible a kind of telesurgery bridging offer relevant advantages over conventional lapa-
thousands of kilometers or even continents. Al- roscopy to justify its extra cost (cholecystectomy,
though the feasibility of this aspect was proven and fundoplication, bariatric procedures, extraperi-
gained some media attention, it is not the future of toneal inguinal hernioplasty) or the robots current
robotic surgery. More probable opportunities for level of development is inadequate (colonic proce-
robots in general surgery are those interventions dures, splenectomy). In our department the pro-
for which only the robot renders possible or no- gramme has been momentarily confined to
ticeably simplifies a minimally invasive approach, adrenalectomies and thoracic and oesophageal
i.e. procedures in which precise dissection and procedures.
reconstruction of delicate, vulnerable anatomic The patients satisfaction following a robotic
structures take place in tiny areas difficult of access approach is high. In a recent follow-up study 33
[1517]. In the light of our present experience, (3035) months after robotic cholecystectomy the
we regard extended thymectomies and other me- robotic approach was favourably viewed by all 23
diastinal interventions, adrenalectomies, oeso- patients and 22 (96%) reported that they would opt
phageal procedures and total mesorectal exci- for a robot-assisted procedure again if offered [18].
sion deep in the pelvis minor as appropriate for a This ready acceptance of the robotic approach may
robotic approach. The steric vision and the ma- result from the satisfactory cosmetic and sympto-
noeuvrability of the instruments are of great assis- matic results, but also from the patients impres-
tance in pulmonary lobectomies, although the lack sion that they had taken part in the dawn of a new
of robotic stapler devices and flexible instruments surgical era.
hampers full robotic performance. For the other On the other hand, robotic surgery is signifi-
The da Vinci robot in general surgery 678

cantly more expensive than conventional mini- and robotic virtual-reality training programmes.
mally invasive procedures (figure 4). This differ- Thus, similar to a pilot on a flight simulator,
ence results from the use of specific robotic instru- surgeons in training will perform new operations
ments, higher costs for disposables and the longer only after performing them successfully in virtual
total operating time [19]. The time delay may be reality.
explained by the learning curve. However, with in-
creasing experience on the part of the entire team Conclusion
(surgeons, scrub nurse, theatre attendant), the set- With the da Vinci surgical robot surgery re-
up time has been markedly reduced in our depart- gains everything it lost with the introduction of the
ment from approx. 90 minutes in the first robotic minimally invasive technique: intuitive control
cases to the present 3540 minutes, and no longer over the surgical instruments and steric perception
involves any time loss. of the operative field. However, the disadvantages
are still great and a series of unsolved problems
Future perspectives continue to hamper its broader and routine appli-
Hybrid operations could offer a future field cation: the lack of haptics is only partially compen-
for robotic applications: most parts of a surgical sated by the three-dimensional view, the system is
procedure would be done as conventional mini- cumbersome and its dimensions and rigidity ham-
mally invasive surgery, and the robot would be per rapid change of the patients position, as well
used only for the technically most challenging as direct access for the patient-side assistant. A
parts of the operation, such as vascular or intestinal breakthrough for the da Vinci system in the field
anastomoses. of general surgery presupposes further system de-
Image fusion is another future domain for the velopment as well as a drastic reduction of costs.
robot. At this stage the superposition of different The challenge for todays robotic surgeons is to ad-
radiologic imaging systems permits more precise vance the system through clinical research in such
and detailed surgical planning. The da Vinci sys- a way that it becomes suitable and indispensable
tem will implement this technique in the operat- for routine general surgery.
ing room itself by flashing a patients scan images
into the virtual three-dimensional view on the con-
sole. This will enable the surgeon to more easily
detect and identify hidden anatomical structures, Correspondence:
and in this way robotic surgery will help to make Johannes Bodner, MD
minimally invasive surgery safer. Department of General and Transplant Surgery
The greatest potential for the da Vinci robot Innsbruck University Hospital
probably lies in its impact on surgical training. It Anichstrasse 35
will be possible to carry out a particular patients A-6020 Innsbruck
complete surgical procedure using his CT scans johannes.bodner@uibk.ac.at

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