"The future of surgery is not about blood and guts; the future of surgery is about bits and bytes.”
/Dr. Richard Satava/

Friday, March 6, 2009

Da Vinci procedures III

No doubt about it, the da Vinci became a success story. According to Intuitive’s site, there have been 1,111 unit shipments (825 in the US, 194 in Europe and 92 in the rest of the world), as of December 2008. This large number of deployed robots also means an exponential rise in the amount of procedures performed. In total, it’s above 300,000 by now.
Despite the large number, the reported device failure and complication rate is still relatively low.
Patel (2007) reports 4.7% complication ratio (based on 900 cases). Bodnera (2005) observed 2% conversion to laparoscopy and 3% conversion to open surgery (128 cases). Olthof (2007) reports 2.27% conversion (400 cases). For Robot-Assisted Laparoscopic Radical Prostatectomy (RLRP) the numbers are even lower: Borden (2007) found 2.6% technical problems(350 RLRP), while Zorn 2007 observed 0.4% conversion to laparoscopy and 0.5% conversion to open surgery (850 RLRP). These are well under the average ratio in the case of classic laparoscopy. In addition, Koliakos (2008) reports 1% software failure and 1 case of broken EndoWrist from O.L.V. Clinic, Belgium (520 cases).
According to Borden (2007) the main mechanical issues with the da Vinci are:
  • Mechanic failure of wrist
  • Mechanic failure of arm
  • Power supply
  • Loss of 3D display
  • Camera error
  • Breakage of master device
  • Failure of slave device
  • Software errors
There has only been one serious case in 2002, in St. Joseph's Hospital Tampa, FL. During a robotic nephrectomy, two renal arteries have been cut accidentally, and the bleeding stayed unnoticed until the end of the procedure, when it was too late to save the patient. No technical failure of the robot was found.
In the past years, the da Vinci had received FDA approval for a dozen operations, but the system has been used with more than 100 procedures, out of which a couple showed significant clinical advantage over the classic methods.
Yet, prostatectomy stays the killer application of the da Vinci, and app. 70% of all radical prostate procedures were performed with the da Vinci robot last year in the US.
A new field of application for the da Vinci is the R-NOTES, the Robotic Natural Orifice Translumenal Endoscopic Surgery. There have been reported thoracic, transrectal and transumbilical procedures, mostly on animals. More interesting that da Vinci was demonstrated to be an effective help even in origami.

Image credit: Box et al (2008)

No comments: