Evolution of Robotic Surgery: da Vinci Xİ

Robotic-assisted surgery is currently used in all surgical disciplines. Technology seeking smaller size of instruments and carts, easier and faster docking, automatic instrument exchanges; tissue-feedback technology, integration with radiological images and artificial intelligence are in perspective. 

The most capable system created by Intuitive Surgical until is now the da Vinci Xi platform. Its release occurred in 2014, entering the market as the most advanced instrumentation, vision, cart design, as well as table motion and setup automation. Looking at a different perspective, the Xi latest model reinvented the concept of the patient cart design and its versatility and flexibility. The most advanced multi-port da Vinci Xi model has overcome the majority of the patient cart and arm limitations in the previous prototype as well as has come up with new technology, upgrading even more the robotic surgery.

The Intuitive Surgical fourth generation robot, da Vinci Xi System, has a brand-new designed patient cart to assure maximum mobility and flexibility during surgery. Its boom-mounted architecture provides docking from any angle and improves access around the patient at any quadrant. By targeting the surgical field and positioning the endoscope in the desired area, the robotic arms are disposed in the optimal setup. The redesigned arms provide greater internal range of motion while improving patient access and minimizing external collisions. Its flex joints are compacted, leaving one-fist-width spacing between each arm, and it can be optimized by adjustments that can be made to the patient clearance joints of each robot arm. The new patient cart disposes of a single-fin attachment system making the docking easier and faster. Multiple ergonomic adjustments provide comfort and reduce fatigue during surgical procedures and the surgeon’s hand movements are scaled, filtered, and seamlessly translated to the instrument tips for precise instrument control.

Visualization technology represented a major step in the new platform, assuring a stable, immersive, highly magnified 3D-HD view of the surgical field while providing the surgeon autonomous, independent control of an 8-mm endoscope. Compared to the bulky scope of the earlier systems, the new designed 8-mm camera offers the surgeon a clearer view of the surgical field with a brighter image, higher resolution and longer scope. The Xi 30° endoscope can be inverted from the surgeon console without the assistant having to remove and reinstall it. Also, there is no longer a need for draping, focusing, white balancing, or calibration during surgery. By having four independent and identical robotic arms, a multiport surgery is achieved allowing instruments and endoscope to be versatile and repositioned at any time or port, if needed.

Moreover, the FireFly® fluorescence imaging technology is integrated to improve specific real time decision-making steps during surgery, such as tissue perfusion or bile duct visualization. Regarding patients positioning, and patients cart mobility, the integrated table motion (ITM) feature is also a new available technology, which allows the patient to be dynamically positioned while surgery is in progress.

Another important upgrade in the new Xi system is related to its instruments, energy and stapling. First entry accessories such as robotic ports were redesigned in a fully reusable stainless steel canulae with bladeless or blunt tip, having Hasson cone and bladeless optical obturator available. Endowrist technology instruments were also enhanced, allowing robotic suction and irrigation or clip applying. Da Vinci energy devices have amplified performance, increased efficiency without sacrificing results with the speed, precision, and versatility. Robotic stapling has been improved with complete control, full articulation, and intelligent feedback of the tissue depth, providing constant monitoring and real-time feedback. Also, a wristed needle driver allows surgeons additional dexterity while suturing in the scenario, which was not available in the previous prototype.

The current Robotic Era has already shown huge impact on the surgical field, and it is part of a natural and logical evolution of minimally invasive surgery. Robotic-assisted surgery is spreading quickly and has been shown to overcome the intrinsic limitations of laparoscopy. High definition, three-dimensional stereoscopic vision and magnification, a stable and surgeon guided camera, improved ergonomics, superior range of motion and motion scaling are remarkable advantages. The latest data have related its benefits to visceral surgery, urology and colorectal fields. Concerning ventral hernia repairs, encouraging outcomes have been described allowing even more complex abdominal wall reconstructions in a minimally invasive approach by the robotic platform. The gynecological field has also seen benefits from robotic assisted surgery, which appears to facilitate the surgical approach for technically challenging operations to treat selected cases of cervical, endometrial, ovarian cancer or endometriosis.