Robotic Surgery: Basic Instrumentation and Troubleshooting

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Robotic Surgery: Basic Instrumentation and Troubleshooting

Wooju Jeong, Mouafak Tourojman, & Craig G. Rogers

Vattikuti Urology Institute, Department of Urology, Henry Ford Health System, Detroit, MI, USA

The da Vinci® System

The da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, CA, USA) consists of three core components: a surgeon console, a vision tower, and a patient cart with four robotic arms (Figure 81.1). One arm controls the camera and the remaining arms manipulate surgical instruments. On the da Vinci Xi Surgical System the camera can be placed on any of the four robotic arms, allowing for port hopping during a procedure. The instruments have seven degrees of freedom, including external pitch, external yaw, insertion, grip, roll, internal pitch, and internal yaw, allowing for wristed, articulated movement. The surgeon sits at the console and is presented with a high‐resolution three‐dimensional view of the surgical field.

Image described by caption and surrounding text. — **Figure 81.1** The Surgeon Console, Patient‐side Cart, and Vision System of the da Vinci Surgical System. (a) da Vinci Si Surgical System; (b) da Vinci Xi Surgical System.

Surgeon console

The console includes a stereo viewer with sensors as a safety mechanism. If the surgeon’s head is not positioned in the console, the system will be deactivated and the robotic arms will be locked in place. By using the two master controllers, the surgeon’s hand movements are processed by a computer and sent to the patient cart, which controls the robotic instruments inside the patient’s body in real time. Motion scaling can be performed to filter out physiologic tremor, allowing for finer movements [1]. Computer processing also facilitates intuitive motion, whereby movement of the surgeon’s hands is translated to the movement of instruments. This differs from laparoscopic surgery, in which, to move the instrument tips left, right, up, or down, the surgeon must actually move his or her hand in the opposite direction.

Adjustments to the system, such as camera control, scope setup, audio volume, and console ergonomics, can be made while the surgeon is seated at the console. The console surgeon can also toggle between robotic arms. These tasks can be accomplished using the console’s hand and foot pedal controls. The console is connected to the vision cart and patient cart components via cables.

Optical system

The da Vinci system offers three‐dimensional magnified vision. On the da Vinci Si Surgical System, a binocular telescopic camera lens system (0 or 30°) is attached to a high‐resolution 3DHD camera, and together they are held on the main robotic manipulator arm. The da Vinci Xi Surgical System endoscope has “chip‐on‐tip” technology, where the digital image sensors are placed at the tip of the scope. The digital image information is then transmitted directly to the image processor. The binocular images are translated by the computer into a magnified 3D image when viewed at the surgeon console [2]. The robotic scope is either 12 mm (Si) or 8 mm (Xi) in diameter. On the Xi system, the 8 mm robotic endoscope fits through the standard robotic trocar, allowing for port hopping between trocars, giving surgeons the ability to have multiple vantage points in a single procedure.

Patient cart (robotic arms and instruments)

The patient cart, consisting of the robotic arms and instruments, is draped and positioned alongside the patient table [3]. The patient cart has four arms. Robotic instruments have articulating joints (EndoWrist) near the tip that allow for wristed movement, providing seven degrees of freedom of movement for surgical tasks such as suturing and dissection. Robotic instruments are available with a variety of instrument tips in 5 or 8 mm diameter sizes.

The new da Vinci Xi™ Surgical System has four robotic arms attached to the mount of the patient cart, called the “boom.” The Xi Surgical System has narrower arms and improved reach to minimize collisions between robotic arms. The endoscope can attach to any robotic arm through a robotic trocar, allowing flexibility in optimizing visualization of the surgical site. The “chip‐on‐tip” endoscope has a longer focal length and wider field of view. The rotating overhead boom allows for laser targeting and improved anatomical access from almost any position, which can help avoid the need for redocking and repositioning during surgeries such as nephroureterectomy.

EndoWrist robotic instruments

The EndoWrist instruments are controlled by the surgeon at the console. The surgeon’s finger movements are translated into movements of the instrument tips. The foot pedals can be used to toggle between instrument and camera movements, reset instrument movements (clutching) or initiate electrocautery [2]. Toggling between instruments allows a surgeon to control his or her own passive retraction using the third instrument arm. Clutching can also be performed using the finger clutch mechanism. If the robotic nondominant instrument is attached to cautery, care must be taken to avoid hitting the wrong foot pedal and causing thermal injury to the bowel or other structures [4].

Different EndoWrist robotic instruments offer different relative advantages for different procedures (Figures 81.2–81.5). Note: Some instruments may only be available on the Si or Xi system.