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The da Vinci Surgical System -- The Growing Use of the Robotic Tool for Minimally Invasive Surgery

Cover Story

Issue: October 2009

By: Stacy Schwan

Yesterday Dr. Albert Pisani performed four surgeries. One was a minor outpatient procedure and the other three—two hysterectomies and a pelvic prolapse repair—were done using the da Vinci Surgical System. A gynecological oncologist, Dr. Pisani is one of a growing number of surgeons who are using da Vinci Surgery as an alternative to both open surgery and conventional laparoscopy.

Used now for a decade in minimally invasive surgery, the da Vinci System consists of an ergonomically designed surgeon's console, a patient cart with four interactive robotic arms, a high-definition 3D camera, and miniaturized instruments. The camera and instruments are introduced into the patient through four 1-2 cm incisions. Seated several feet away at a computerized console, the surgeon’s movements are scaled, filtered and processed to reduce tremor and are translated in real-time into precise micro-movements of the da Vinci instruments. Surgery is performed with the help of an assistant, who stays at the patient’s side to assist with retraction, suction, and the passing of needles and sponges.

Dr. Pisani started using the da Vinci System after moving from San Diego to the Bay Area in 2007. By this time, he had already been performing conventional laparoscopy for more than a dozen years.

“When da Vinci first came out I was a little skeptical, because we were already doing advanced laparoscopy and I didn’t really see how this expensive technology would help us do any more than we were already doing,” he recalls. “But I have to say, when I took the course with the training, I realized the technical advantage of the da Vinci really is superior, particularly in what we do with gynecological oncology. It helps a lot, and it allows us to do more challenging cases than we would otherwise be able to do laparoscopically.”

Gynecologic oncology patients in particular are often elderly and have medical co-morbidities such as obesity, hypertension, diabetes and cardiovascular disease, which increase their surgical risk. Using the da Vinci System, Dr. Pisani can perform most endometrial cancer, uterine cancer and uterine prolapse surgeries as well as regular hysterectomies. “We can also do radical hysterectomy for cervical cancer with da Vinci laparoscopy as opposed to using regular open surgery techniques like before,” he adds.

As a member of Palo Alto Medical Foundation, Dr. Pisani has privileges at numerous Bay Area hospitals. However, he performs 80-90% of his surgeries at El Camino Hospital, one of only a dozen Bay Area hospitals (and one of about 750 hospitals nationwide) to own a da Vinci System.

The da Vinci legacy

The system is called da Vinci, in part, because Leonardo da Vinci is credited with inventing the first robot and also because he used precise anatomical accuracy and three-dimensional details in all of his renderings. The original prototype for the system was developed in the late 1980s at SRI International, an independent nonprofit research institute, then under contract to the U.S. Army. While initial work was funded in the interest of developing a system for performing battlefield surgery remotely, it soon became clear that the technology could be used to broaden the application of minimally invasive surgery to a wider range of procedures.

Intuitive Surgical, Inc. was founded in Sunnyvale in 1995 to further develop the technology for commercial use. In January 1999, Intuitive Surgical launched the da Vinci Surgical System, and in 2000, it became the first robotic surgical system cleared by the FDA for general laparoscopic surgery.

Since that time the FDA has cleared the da Vinci Surgical System for thoracoscopic surgery, for cardiac procedures performed with adjunctive incisions, and for urologic procedures. The system gained FDA approval for use in performing gynecologic procedures in April 2005.

Gynecologists get on board

In addition to Dr. Pisani, gynecologist Kirby Tran also uses the da Vinci System to perform surgery at El Camino Hospital. Dr. Tran became interested in the system while discussing it with her husband, Dr. Wen-Kai Weng, an oncology physician and clinical instructor at Stanford University, who had learned about its growing use in the treatment of prostate cancer.

“This technique has been available to gynecologists only in the last four to five years,” Dr. Tran says. “Not a lot of residency training programs have da Vinci, so only a few get trained on the system.” Although robotic residency programs are starting to be introduced into academic hospitals, experienced physicians like Dr. Tran must take it upon themselves to obtain the additional training needed.

Dr. Tran says that learning the system was a little like learning to fly an airplane, from a technical standpoint. “First I went to my own hospital [El Camino] to train with the robot, to play around with it and see how it felt,” she says. “Then I went to Intuitive’s main headquarters in Sunnyvale, and they set up a training lab for me.”

Once she completed formal training Dr. Tran booked her first few cases with her own patients. The surgeries were proctored until she felt completely comfortable using the system.

Dr. Tran says that patients undergoing both conventional and da Vinci robotic-assisted laparoscopy benefit in shorter hospital stays, less pain and blood loss, faster recovery times and better cosmetic outcomes than those undergoing open surgery. “The benefits for physicians doing da Vinci are that it is ergonomically better than conventional laparoscopy, and it offers a superior 3D view and superior hand and finger manipulations to achieve a ‘cleaner’ surgery for patients,” she says.

Dr. Tran says she continues to use open and traditional laparoscopic techniques as well as the da Vinci System, depending on the patient’s condition and the complexity of the case. “For myself as a surgeon, it makes me more versatile,” she concludes. “If I go to a hospital where they don’t have a robot, I still have my skills to do a regular conventional laparoscopy.”

New uses in cardiology

Seton Medical Center in Daly City has one of the newest da Vinci Surgery programs in the Bay Area, and is one of only a handful of hospitals in California using the system for cardiovascular surgery. That’s partly because Dr. Naoum Baladi, chief of the Cardiac Surgery Center at Seton, is one of the pioneers of cardiac robotic procedures in the Bay Area. Dr. Baladi explains that current uses of the da Vinci System for cardiology are limited to coronary bypass and mitral valve surgery, as well as minor procedures like atrial fibrillation treatment and atrial septal defect repairs.

“We’re limited in the number of coronary bypasses that we’re able to do with the robot at this time to either one or two bypasses on the left side. We can do the left anterior descending artery and an obtuse marginal using two internal mammary arteries. For mitral valve surgery we can do mitral valve repairs or mitral valve replacements, and we do that through the right chest,” he says.

Dr. Baladi stresses that surgeons using the da Vinci System are not performing “new” procedures. “It’s just a tool that allows us to do the procedure with less trauma to the body,” he says. “Until the robot was available, the incisions varied anywhere from a full sternotomy to partial sternotomy to minimally invasive incisions, but never just small port incisions. The robot allowed us to eliminate the incisions and instead have ‘peek holes.’”

“No doubt about it there is less trauma and the recovery is faster, and these are advantages for the patient,” he adds. “The advantage for the surgeon is that the visualization is so much better, because it’s magnified ten times and it’s three dimensional.”

Comparing conventional and da Vinci robotic-assisted laparoscopy

Dr. Douglas Rittenhouse is one of a half dozen gynecologists who make extensive use of Seton’s da Vinci System. Performing both open and laparoscopic surgeries since 1992, Dr. Rittenhouse began using the da Vinci System about 18 months ago.

Explaining the main differences between da Vinci Surgery and conventional laparoscopy—where surgical instruments are attached to long, straight tubes that are inserted into the body through tiny incisions—he says:

“The da Vinci gives you a step up against traditional laparoscopy because it takes those same instruments and makes them “wristed,” like the wrists on your hands. So now instead of a straight stick you’ve got something that can bend and twist and turn at its pit. It gives you much more flexibility and dexterity, for a wide range of different surgical instruments.

“Also, the visualization is binocular with HD capabilities, giving you a really good, microscopic binocular vision of your surgical field and the capability to move around the anatomy from different angles. So it adds a greater level of dexterity and control to what we were already doing previously.”

The downside to this improved technology is that it takes additional time to set up—and often perform—the surgeries.

“The cases themselves sometimes take longer than what you could do by making a big cut on someone’s stomach and opening it up and using big instruments,” he says. “But the benefit down the road is less time in the hospital and an easier and shorter recovery for the patient, which is an advantage for everybody.”

If the da Vinci System is such a great tool, then why hasn’t it replaced conventional laparoscopy altogether?

“Some cases are very simple and you don’t need the da Vinci device; you can just do straight laparoscopy and be done much quicker because there’s a setup time involved with the da Vinci machine,” Dr. Rittenhouse says. “It is just a tool to assist in difficult cases in a cavity. It’s like any other tool that we use—it’s not for everybody all the time, but in those cases where it can be helpful it’s a very powerful tool to use, and it’s nice to have that technology available.”

Dr. Rittenhouse says he anticipates the da Vinci System becoming a larger part of his practice in the future.

“For my field, a lot of surgery is elective,” he explains. “You have pain and discomfort and symptoms from some problem in your pelvis that you can choose, or not choose, to do something about.

“When it was a big surgery with a big cut and you had a long recovery, most people would choose not to do something unless they were really feeling bad. But now, when you know you can have surgery done and recover easier, and generally get it done with little cuts, more people will elect to have their condition made better. It’s nice for us to be able to help somebody and not have to worry about so many complications and difficulties recovering,” he adds.

Happy patients are the bottom line

‘I’ve been very fortunate,” says Dr. Rittenhouse. “Everybody I’ve taken care of has done great—out of hospital in less than 24 hours, less pain than even with laparoscopic cases, and just all around good outcomes.”

Dr. Pisani agrees that, particularly in the case of complex or difficult surgeries, da Vinci Surgery has proven to be a wonderful alternative for many patients.

“Patients are generally very pleased. Most of them get out of the hospital in one or two days and back to their normal activity in about three to four weeks. I’ve had several patients that haven’t required any additional pain medicine other than Tylenol or Advil when they get home. That is great for a major operation.”

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