Appendix #5: Intui/ve Surgical, “Da Vinci” (a) Appendix MIS capabili/es?: Does this technological wonder fall under the above interpreta6on of MIS? Well, yes <strong>and</strong> no – no doubt that this MIS technology has, a?er more than ten years in the <strong>market</strong>, finally found some true jus6fica6on. Based on surgeon interviews conducted by aquilo there seem to exist consensus among surgeons that beHer pa6ent outcomes are achieved for e.g. prostatectomy due to the possibility of more precise dissec6on, hence significantly reducing trauma to vital structures. But that is about it. From here there seem to be as many opinions about the technology as there are surgeons. Hence Intui6ve Surgical's claim that the Da Vinci Robot is also fantas6c for: Bariatric, colorectal, cardiac <strong>and</strong> many more procedures, could not be supported through the interviews carried out with different surgeons. Bariatric <strong>surgery</strong> (also known as obesity <strong>surgery</strong>) is at the top of Intui6ve Surgical's “General Surgery” list of interven6ons where the device offers significant benefits. This might be, if your surgeon has passed the learning curve <strong>and</strong> one is not among the pa6ents that are included in the learning curve. Well, the learning curve aspect is always present when implemen6ng a new technique, should technologies like the Da Vinci Robot not be allowed to have that learning curve? Indeed it should. However, through the below anecdotes we will illustrate the challenges of dis6nguishing between true MIS <strong>and</strong> marke6ng or perceived MIS: In the first anecdote a bariatric clinic was adver6sing for “the safest <strong>surgery</strong> in town” as the clinic was offering Robo6c Surgical Implanta6on of a gastric b<strong>and</strong> to obese pa6ents – so what? Is it wrong to adver6se for Da Vinci <strong>surgery</strong>? Well, in an experienced bariatric surgeon's h<strong>and</strong>s an implanted gastric b<strong>and</strong> by tradi6onal laparoscopy, also a MIS technique, will take on average 30 minutes (the really experienced o?en go as low as 20 minutes). Because of the complexity of opera6ng the Da Vinci robot <strong>and</strong> changing instrumenta6on during <strong>surgery</strong>, gastric b<strong>and</strong> implementa6on in this clinic averaged three (3) hours. Even an unexperienced bariatric surgeon will be able to implant a gastric b<strong>and</strong> laparoscopically in about one <strong>and</strong> half (1,5) hours. Another Da Vinci case related to the more <strong>invasive</strong> bariatric procedure, gastric bypass, paints a similar picture. In this case a clinic decided, for scien6fic <strong>and</strong> research purposes, to operate with the Da Vinci Robot. <strong>The</strong> average opera6ng 6me for this group of surgeons by tradi6onal laparoscopic technique was around two <strong>and</strong> a half hours. When first switching to perform the gastric bypass with Da Vinci, the opera6ng 6me exploded to around five to six hours. It was only a?er more than three years of experience <strong>and</strong> 300 Da Vinci gastric bypass procedures that this team managed to get the average opera6ng 6me down to a level that mirrored that of their tradi6onal laparoscopic gastric bypass procedures. And so what? Well, 6me is always a factor <strong>and</strong> especially in pa6ents undergoing bariatric <strong>surgery</strong>. One should consider that these pa6ents are high risk pa6ents, due to their complex disease paHern. Though bariatric pa6ents are operated for extreme overweight (one medical condi6on), many of these pa6ents also show up with a variety of co-‐morbidi6es (mul6ple medical condi6ons) further complica6ng <strong>surgery</strong>. To give the reader, who might not be familiar with the disease picture of bariatric pa6ents, a quick overview of what we are talking about one should note that apart from extreme overweight, bariatric pa6ents o?en suffer from hypertension, diabetes, damaged/warn down joints, sleep-‐apnoea <strong>and</strong> more. On top of this, one must add that during a tradi6onal laparoscopic or Da Vinci laparoscopic opera6on the pa6ent is on her/his back, anesthe6zed, ven6lated <strong>and</strong> “tossed around” from side to side – from extreme an6-‐trendenelburg to extreme trendenelburg posi6ons (from siang upright to having the upper-‐body in 35 degree ver6cally inversed angel). How do you think opera6ng 6me maHers to this kind of pa6ents? Well, some bariatric surgeons' rule of thumb is that if a laparoscopic procedure in bariatric pa6ents cannot be carried out in less than three hours conver6on to open technique should be st<strong>and</strong>ard opera6ng procedure, hence assuring that the opera6on is terminated within the 3,5-‐4,0 hour mark. Knowing this, how would you appreciate being among the first 300 pa6ents in the above anecdote? And we have not even discussed the monetary cost factor yet. <strong>The</strong> monetary part of the anecdote comes in two parts: First there is the extra 6me consump6on where the same team of surgeons, anesthesiologists, nurses etc. could have carried out more opera6ons, then there is the amor6za6on of the DKK 10-‐12 million Da Vinci Robot price-‐tag (instrumenta6on excluded). <strong>The</strong> authors of this brief hold conflic6ng views on technologies like Da Vinci in rela6on to MIS capabili6es. On one side it is inarguably a great piece of technology that in e.g. prostatectomy procedures offers MIS capabili6es beyond what is achieved by tradi6onal laparoscopy. However, considering the examples of gastric bypass or the horrendous example of gastric b<strong>and</strong>ing one must ques6on the true <strong>and</strong> broad level MIS capabili6es of this technology. Regardless of the authors cri6cal, yet, hopefully objec6ve assessment of Da Vinci as a true MIS technology across a broad range of procedures, it remains clear that with this technology <strong>surgery</strong> has taken a step towards a poten6al revolu6onizing future. It remains to be seen if it will be in the form of a robo6c console or whether some of these new features developed by Intui6ve Surgical, will be further enhanced <strong>and</strong> applied in the tradi6onal laparoscopic devices, <strong>and</strong> to which extend Intui6ve Surgical will be able to financially benefit longterm from the innova6ons it has become a first mover within. We hope that these two anecdotes <strong>and</strong> discussion around the Da Vinci Robot illustrates well the challenges in evalua6ng true MIS capabili6es <strong>and</strong>, thus, the challenges of developing true MIS devices. aquilo Ι www.aquilo.info 31
Appendix #5: Intui/ve Surgical, “Da Vinci” (b) Source: Intui-ve Surgical aquilo Ι www.aquilo.info 32