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All contents (c) 2008 John J. Otrompke, JD

Standard Da Vinci vs. the Da Vinci 'S' From a Nursing Standpoint

By Patricia Francois, RN, CNOR,
Surgical Robotics Coordinator at Advocate Lutheran General Hospital in Park Ridge, Illinois

At Advocate Lutheran General Hospital we currently own both robotic systems : the standard Da Vinci and the Da Vinci “S”. There are mechanical and technical differences between the two robotic systems, which makes it difficult to train new people. This article will detail the differences between the two robotic systems in five specific areas: narrow profile, patient side cart, range of motion, brake system, and the battery backup.

Narrow Profile and the Patient Side Cart

The Da Vinci “S” patient side cart has a narrow profile and is designed to have smaller arms with two inches longer instrumentation than the Standard system. The Da Vinci “S” patient side cart has a 4th robotic arm that can be counter-balanced or “homed” in its stowed position in the back of the system. This cannot occur with the Standard system; all arms must be properly positioned and “homed” before use is possible. The “S” system also has greater range of motion than the standard system with the robotic instrument arms. With the range of the instrument arms in addition to the longer instrumentation it is found easier to get into tight abdominal spaces as well as accomplishing better range of motion with suturing techniques such as a “figure eight” stitch.

Brake System

The brake is another mechanical difference between the two systems. The “S” system has a built-in auto-lock safety when docked to the surgical field. Therefore, when robotic arm cannulas on the patient side cart are attached to camera and metal trocars at the surgical field the cart has a safety lock and an alarm which will not allow the system to move when trocars are attached to it. The standard system does not have a safety lock alarm, furthermore, if you do not manually lock the wheel s upon docking the system it has the ability to move at the surgical field even if trocars are attached. Nevertheless, the standard Da Vinci side-cart weighs 1200 lbs which originally took two nurses to move the cart into the surgical field without hurting your back. An upgrade was made to the break pad system which made it 50% easier to move but can still be a nuisance especially to those with back problems. On the other hand, the Da Vinci “S” system has the ability to be moved manually or motorized by shifting the gears at the base of the cart from “D” drive to “N” neutral. The drive mode is controlled by your fingertips and a throttle mechanism built into the steering system. The system easily and slowly glides across the operating room in the drive mode which is the mode used for docking the system. The neutral option on the brake system allows faster free long distance movement of the cart. In addition, in the neutral mode this cart can be moved using one hand except when turning the cart around a corner or an object.

Battery Back-Up

Unlike the standard system, the “S” system has a backup battery for both the surgeon’s console as well as the patient side cart. The standard system only has a battery backup for the surgeon’s console because this is the primary source of power for the robot. Also, if the robot is stored incorrectly, i.e. if the robotic arms are sticking out and not protected you could change the position of the arms of the “S” system by pressing a button, which allows the robot to be powered on from the battery backup system and the arms can be moved at this time. But with the standard system, if you need to move an arm that is not stored correctly you have to connect all the heavy cables of the robot to the surgeon’s console, power on the entire system, and only then will the system allow you to move the arms into their correct stowed position.
The “S” system was created to be more technically user friendly than the standard system, starting with the button labels available on the surgeon’s console, to the LED lights available on each arm (which are color-coded for specific tasks that are done with that arm), to the built-in sterile adapters available on the drapes of the robot and the integrated touch screen monitor with telestration now available for the patient side cart (this can be utilized for teaching purposes). None of these options are available on the standard system, which makes things less user-friendly for everyone involved.

Relative Advantages and the Learning Curve

In conclusion, when I start the process of training new people, I have to decide which system to start with, and usually we start our training with the user-friendly system, which is the Da Vinci-S. Furthermore, there are numerous options available on the Da Vinci “S” which make it easier to learn how to operate the system safely and effectively. As a robotics team nurse the ability to learn quickly and efficiently is very important with moving forward in the training process of learning to use the robot.

Medical Robotics Popularity Leads to New Specialists, New Educational Necessities

The robotic surgery sensation is not only transforming care, but improving the jobs market and affecting intellectual property trends as well

By John J. Otrompke, JD

On a typical day at work, Patricia Francois, RN, begins the day by readying operating rooms at Advocate Lutheran General Hospital in Park Ridge, Illinois. “We have to get the room set up an hour and a half before the patient even comes into the room,” Francois said.

“Three nurses are involved in each case,” she continued. “One team member scrubs in to assist the surgeon at the sterile field, and the other two team members are circulating nurses which are very necessary to share the role of taking care of the patient , documenting the procedure , and troubleshooting any issues that occur during the operation. If there is a troubleshooting issue occurring in a room that I am not present in at that time, and the nurse in that room is capable of trouble-shooting, then I am called into the room to assist,” she said.

Nurses everywhere may be used to busy case loads, but Francois is extra dynamic, because her cases are not ordinary cases; she is the surgical robotics coordinator at Advocate Lutheran General, and when she is not busy in the operating room, she is occupied with putting together educational curricula for an entirely new field of specialty: the medical robotics nurse. [See attached article].

“I created a resource book, called “The Robotics Resource Manual,” which has pictures of the surgical room set-up. For each procedure (robotic prostrate surgery, for example), it will tell you where to put the patient side cart, because you have to put the robotic arms or the patient side cart in the right place during the procedure to make it easier for the surgeon. (For prostate cases, it is placed at the foot of the bed, whereas for liver resection, it has to go at the head of the bed). And I have some anatomical pictures with information explaining the robotic procedures, as well as a log of different types of trays, and a log of different types of Da Vinci trays and single instrumentation available, as well as doctor-specific preference cards for each case if the procedure gets converted to an ‘open.’ For example, I have in there how to access error log if you have a problem during a case,” Francois said.

The nursing manual is the first of its kind in existence, but Francois said it is for use for in-house use only so far. This manual is hospital-specific with professional robotic room set-up pictures created by robotic team nurses and media team services. The nursing manual is the first of its kind in existence, but Francois said it is for use only in-house so far. Not even Lutheran General’s sister hospitals use the manual.



“One of my goals for 2008 is to teach a robotics preceptorship for other Advocate hospitals, and once we offer that course I will have the opportunity to share those surgical illustrations with them,” she said.



A Booming Business

While Advocate Lutheran General already owns two da Vinci surgical robots, the hospital is considering purchasing a third, because the cases are coming in quickly. “We have the standard Da Vinci and the Da Vinci S, and two upgraded robot-specific operating rooms,” Francois said. The hospital is doing as many as 3 or 4 cases per day, and up to 6 robotic surgery cases per week. Last year, Advocate Lutheran General hospital handled over 200 robotic cases, she said. But with those cases, come technical difficulties, she said.

“Intuitive has provided representatives that have taught the robotic team nurses and myself how to trouble-shoot certain problems which occur during a procedure. “The robot will alarm if something occurs that the system doesn’t like, such as if the doctor is too rough with the instrumentation or uses jerky movements. It’ll let you know what the problem is. You just acknowledge the alarm by hitting a button, and it clears itself.

“But sometimes if you do something, such as repeated non-intuitive motion, the robot will sometimes give you a non-recoverable fault, and lock you out, and its not going to let you go forward until you fix the problem. Me being coordinator, if I can’t solve the problem, I have an 800 number, and it will take you right to Intuitive technical support, and talk to a live engineer, in about 30 seconds if you’re in the middle of a case. That’s if I don’t have an Intuitive representative in the room with me,” said Francois.

The robot creates a page of errors as they occur during a case, and these errors are translated as codes which are stored in what’s called an error log in the system. “I’m reciting line by line from a whole page of errors that’s on the monitor, and the engineer I’m speaking to has a book of codes, and helps me to identify and solve the problem,” she said.

At the beginning, the Intuitive representative was present for 98% of the cases, she continued. Now that the hospital has been doing robotic surgeries for several years, the original rep hasn’t been in all the time, “but we do have a new representative who has been here to help support a new surgeon beginning to use the robot,” she continued.

Another of Francois’ new duties as coordinator involves facilitating a semi-monthly meeting of the entire robotics team of 17 multi-service staff members, to discuss any updates, research topics, or problems which have occurred. “Communication and teamwork is the number one key to having a successful robotics program,” she said.

Still, notwithstanding the learning curve, Francois said, “overall, it is just fantastic what the surgeons are able to do robotically. We did a robotic inguinal hernia the other day, and it took an hour and a half total room time. And when you view the 3-D image, as opposed to a two-dimensional laparascopic image, you can see small, delicate vessels, and they are much more defined,” she said.

Robotic Surgery Developer Wins Microsoft Award

Early Surgical Robot Developer Behind Microsoft Award for Neonatal Technology

By John Otrompke
A system for improving health care delivery to premature babies and neonates which recently won a prestigious award issued by the Microsoft Healthcare Users Group (HUG) may have had part of its genesis in one of the first surgical robots ever developed.
The LacTrack System, designed by Neoteric Technology Ltd., won a first place award for Healthcare Innovation in the category of Delivery Transformation. The SafeLx solution was honored for preventing infant feeding errors at Sunnybrook Health Sciences Center’s Neonatal Intensive Care Unit (NICU) in Toronto.
“At Sunnybrook, our technology is being used to prevent misfeeds. They operate a very large fridge for storing the mothers’ milk (which they nickname the ‘Dairy Queen,’” said Geof Auchinleck, President of Neoteric.
“We’re a regional perinatal unit where babies are ventilated, and our expertise comes in looking after particularly small ones, such as babies born under 26 weeks, who weigh under a kilo. These babies are only a little over halfway through gestation,” said Dorothy Dougherty RN lactation consultant and developmental care team leader at the 42 bed clinic.

The collaboration between Sunnybrook and Neoteric was especially important, because due to mergers, the Sunnybrook is currently housed at Women’s College Hospital, while the new unit is being built at Sunnybrook, said Doughterty, who noted that Neoteric allowed Sunnybrook to help design the system. “We’re making darn sure when move that everything has to talk to each other,” said Dougherty, adding that the clinic is actually connected to Sunnybrook electronically.

“We have been following the problem of neonatal misfeeds now for a decade,” said Dougherty. “But somehow we could never seem to prevent the errors from happening
Data from Sunnybrook indicate that between August 27 and December 5, 2007, the technology captured and prevented 168 feeding errors out of 28,000 feeds given to 175 premature patients. Each baby received 161 feeds, for a total of more than 31,000 transactions including ordering, beginning and ending feeds.

Robotic History

Part of the idea for not only LacTrack, but many of the products Neoteric offers, may have come from Auchinleck’s pioneering work in the robotics field. In 1984, Auchinleck worked on a device called the Arthrobot, which was intended to position the patient’s limb for orthopaedic surgery. Together with Dr. Jim McEwen and Dr. Brian Day, who is this year’s president of the Canadian Medical Association, Auchinleck and colleagues performed over 200 procedures with the Arthrobot.

“While the Arthrobot project ultimately morphed into software which ultimately entered the market, the endeavor led me into the realization that there were major problems and opportunities in data management in the labs that started with poor quality patient identification,” said Auchinleck. In 1997, Neoteric was founded, and today offers a suite of process management tools.

“We began to press for adoption of electronic positive patient identification, which to us means barcodes or RFID id, then added blood transfusion, mothers’ milk administration and medication administration options,” he continued.



In addition to the neonatal unit, Neoteric’s technology is widely used in managing blood transfusions. “We manage the movement and transfusion of blood in more than 80 hospitals, most in the UK and Ireland. For example, our system controls every blood unit in the city of Glasgow, also the city of Leeds,” Auchinleck said.
Neoteric uses a range of Microsoft technologies in its products, including the operating systems, as well as development and database products. “As many of our products are PDA based, we use the Windows Mobile platform as well,” Auchinleck explained.

“Yet, we were given the award because by using these tools, we have come up with products that change the way health care is delivered.”

It has even said by at least one expert that “this is the most important advance in blood transfusion in decades.”

Reminder- Animal Testing Essay Contest!

Please Repost!

For the next year, Medical Robotics magazine will solicit proposals from essayists describing any one or more new ways to reduce or eliminate the deleterious effects of harmful animal testing. Some time prior to Spring of 2009, the essayist with the most beneficial submission will be awarded $1,000 US.

You may submit your essays to :

John J. Otrompke, JD
Medical Robotics Magazine
John_Otrompke@yahoo.com
312-217-3394

Thanks much!