The da Vinci™ surgical system is a sophisticated piece of equipment intended for control of endoscopic instruments during laparoscopic surgical procedures. It has various components, each of which requires special care, and attention. Before use in the operating room, the system needs to be properly draped and the instruments and accessories sterilized. To a new user, the entire process of draping and set up can be very tedious and time consuming. The aim of this article is to give an overview of the components of the da Vinci™ surgical system and walk you through the various steps involved in draping and setting up the system. We have also included a section on how to sterilize the instruments and accessories. For more detailed instructions, please refer to the user's manual provided along with the system and the instruments.
Components
The da Vinci™ surgical system is comprised of the following: (1) surgeon console with an integrated 3-D display stereo viewer, (2) the insite™ vision system, and (3) surgical cart with one camera arm, and two instrument arms.
Surgeon console
The surgeon sits at the console and operates using two masters positioned directly under a magnified 3-D display of the operative field. The surgeon rests his/her head on the view port in order to see the 3-D display in the stereo viewer. Two independent optical channels displayed on cathode ray tube (CRT) monitors are fused together to form the 3-D image of the surgical field. The da Vinci™ surgical system delivers status message screens through text and icons. On either side of the view port are head sensors that detect the presence of the surgeon's head. When these sensors are interrupted, the masters are immediately activated if the da Vinci™ surgical system is in ready mode.
The instrument tips viewed in the display are aligned with the masters to ensure natural and predictable instrument movements. The da Vinci™ surgical system places the instrument movements under direct, real time, control of the surgeon. The system also employs a joint movement (or kinematical) structure that allows the surgeon to use open surgery techniques at the console. These open surgery techniques are instantly converted to minimally invasive surgery movements at the surgical site.
The electronics of the da Vinci™ surgical system allow the use of motion scaling of the surgeon hand movements. Motion scaling, enhances precision by reducing hand movements to correspondingly smaller instrument tip movements in the surgical field. Moreover, the natural tremor of the surgeon's hand is reduced (tremor filtering) which helps ensure stable and predictable instrument control.
The surgeon operates critical da Vinci™ surgical system functions though buttons and foot switches. The functions that are used during a procedure but not while actually operating are located on the armrest, while those that the surgeon needs to access while operating are located on console foot switches. The foot switches are for the clutch, camera control, focus, and cautery. The console is outside the sterile field.
Insite™ vision system
The Insite™ vision system consists of a camera head and a vision cart. The camera head attaches to the endoscope and left and right images acquired through separate optical channels of the endoscope are directed to the camera head and processed independently.
The vision cart consists of two camera control units (CCUs), one each for the left and right optical paths, two synchronizers, a focus controller, the two light sources, and an assistant monitor.
The synchronizers process the image to maximize the clarity and edge definition of the operative image. The focus controller is operated via the foot switch on the surgeon console or two push buttons on the front panel of the focus controller. The light sources provide the desired illumination during the operation and also offer heating for the tip of the endoscope to minimize lens fogging during the operation. The distal tip of the endoscope may exceed 41°C during use, thus contact with skin, and tissue may cause tissue damage. The assistant monitor is used by the assistant and operating room staff to view the endoscopic images and the da Vinci™ surgical system text and icons during the operation.
All the components of the insite vision system are outside the sterile field. However, the two light guide cables that provide illumination and the cords from the camera head that relay the image to the CCUs enter the sterile field. While the light guide cables can be sterilized along with the other accessories, the cords from the camera head have to be draped in custom made drapes, before the beginning of the procedure.
Surgical cart
The surgical cart is the component of the da Vinci™ surgical system that is positioned next to the surgical table. Thus it is partially within the sterile field. The surgical cart has the following components:
- Instrument arms: Each instrument arm is fixed to the patient with the help of a cannula, which attaches to the cannula mount instrument arm with the help of cannula mount pins. The instrument arms position and move the instruments appropriately to permit precise instrument tip movements. The surgeon's hand movements at the masters are precisely replicated at the instrument tips.
- Camera arm: The camera arm is fixed to the patient with help of a cannula, which attaches to the cannula mount camera with the help of cannula mount camera clamp. The camera arm controls the position and movement of the 3-D camera from outside the patient's body.
- Set-up joints: The set-up joints hold the instruments arms and the camera arm and are used to position the surgical cart arms for the optimal approach to patient anatomy.
Instruments
EndoWrist™ instruments work with the da Vinci™ surgical system. The instruments have a total of seven degrees of motion (six degrees of freedom and grip), which is two more than the traditional laparoscopic instruments. Tip articulations mimic the up/down and side-to-side flexibility of the human wrist. The instruments attach to the instrument arms and are interchangeable during the procedure.
The EndoWrist™ instruments are valid for a predetermined usage amount. When instruments expire, they can no longer be used and should be discarded. At the end of the case, when both the instrument sterile adaptors have been removed, the system will display a summary table on the surgeon console, and the assistant monitor. The summary table lists the name of the instruments used during the procedure and the number of uses remaining on each of the instruments used.
Draping the da Vinci™ surgical system
Draping the surgical cart
Each arm on the surgical cart has its own drape. It is recommended that two people, one sterile, and the other nonsterile do the draping to complete proper placement of the sterile drapes.
Set-up for draping
The system should be powered on prior to draping. For this, press the system button, and wait for the da Vinci™ surgical system self-test to complete. Then press ready to initiate homing of the system.
Sequence of draping
We recommend draping the arms in the following fashion in order to maintain sterility.
- Move one instrument arm and the camera arm aside.
- Drape the remaining instrument arm and then move it away from the undraped arms.
- Then drape the camera arm and move it away from the undraped instrument arm.
- Last, drape the other instrument arm.
For convenience the arms should be fully extended while draping, so that the drapes can easily slide over. The sterile person stands in front of the arms and throws the drapes over. Meanwhile the unsterile person pulls the drapes through to the unsterile portion.
Instrument arm draping instructions
(Figure 1) shows all the sterile accessories and disposables required for setting up the surgical cart and camera. The sterile person should make sure that all the accessories and disposables are ready before beginning the draping process. The following steps are to be executed by the sterile person while draping the instrument arms.
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Figure 1: Sterile accessories and disposables required for setting up the surgical cart and camera. (A) Light guide cables, (B) sterile adaptors instrument arm, (C) cannula mounts instrument arm, (D) wrench (emergency grip release), (E) wrench (cannula mount), (F) cannulae instrument arm, (G) latching obturators (blunt and sharp), (H) drape (camera), (I) drape (camera arm), (J) alignment targets, endoscope (0° and 30°), (K) drape (instrument arm), (L) sterile adaptor camera arm, (M) sterile adaptor camera, (N) cannula mount camera, and (O) endoscope
- Unfold the instrument arm drapes according to the arrows marked on them. Continue unfolding to expose the sterile adaptor reinforcement (Figure 2A).
- Then insert one hand into the center of the drape, such that the sterile adaptor reinforcement is fully exposed (adhesive backing forces out).
- Slide the sterile adaptor through the grooves on the sterile adaptor reinforcement and the snap the lower end so that the adaptor is locked in the drape.
- Hold open the drape and the slide it over the top of the arm until the sterile adaptor is near the carriage.
- Align the slots at the bottom of the sterile adaptor with the pins on the instrument arm (Figure 2B).
- Tilt the sterile adaptor toward the instrument arm until it snaps into place.
- There are four discs on the sterile adaptor that move in synchronization upon successful engagement to the instrument arm. Listen for this disc synchronization before proceeding.
- Next, open the drape to expose the Cannula mount reinforcement and align it with the Cannula mount on the instrument arm (Figure 2C).
- Align the pins on the Cannula mount with the holes in the drape's Cannula mount reinforcement. Now place the Cannula mount on the instrument arm and tighten the screws using the Wrench (Figure 2D).
- Attach the drape straps in the appropriate locations.
Figure 2: Draping of the instrument arm. (A) Exposure of the sterile adaptor reinforcement (arrow head) on the instrument arm drape, (B) alignment of the sterile adaptor with the pins on the instrument arm, (C) alignment of the cannula mount, and (D) tightening of the screws of the cannula mount with a wrench
In the mean while, the nonsterile person opens the inside edge of the drapes and pulls them over the remainder of the instrument arm and set-up joints. At this point, ensure that there is adequate drape material for the instrument arm to function though the full range of motion.
Camera arm draping instructions
The following steps are to be executed by the sterile person while draping the camera arm.
- Unfold the camera arm drape according to the arrows marked on it.
- Insert one hand into the center of the drape.
- Then, extend the closed end of the drape until the adhesive strip and reinforcement section are exposed such that the adhesive side faces out.
- Remove the liner of the adhesive strip and stick it to the sterile adaptor camera arm (Figure 3A).
- Hold open the drape and slide it over the top of the camera arm until the sterile adaptor is near the carriage.
- Align the pins on the Cannula mount camera with the reinforcement and the hole in the drape and snap the Cannula mount camera into place (Figure 3B). At this point make sure that there are no folds of drape material behind the camera Cannula mount before installing.
- Then align the camera arm sterile adaptor with the carriage on the camera arm such as to create a trough for the endoscope, and push it firmly into place (Figure 3C).
- Attach the drape straps in the appropriate locations.
- Finally, move the draped camera arm close to the first draped instrument arm.
Figure 3: Draping of the camera arm. (A) Placement of sterile adaptor camera arm on the adhesive of the camera arm drape, (B) snapping of the cannula mount camera onto the camera arm, and (C) alignment of the camera arm sterile adaptor with the carriage on the camera arm
In the mean while, the nonsterile person opens the inside edge of the drape and pulls it over the remainder of the camera arm and set-up joints. Also ensure that there is adequate drape material for the camera arm to function through the full range of motion.
Once the draping of the three arms is complete, they should be hugged together and raised so that they remain sterile till the robot is finally docked.
Draping instructions for stereo 3-D camera
The following steps are to be executed by the sterile person while draping the stereo 3-D camera:
- Open the camera drape package and unfold according to the marked arrows.
- Attach the recessed end of camera sterile adaptor to the sterile endoscope (Figure 4A).
- Then insert the endoscope into the drape, sterile adaptor end first (Figure 4B).
- Push the camera sterile adaptor through the elastic end of the drape until it fits around the sterile adaptor.
- Fix the drape to the endoscope with the supplied adhesive tape (Figure 4C).
Figure 4: Draping of the stereo 3-D camera. (A) Exposure of the recessed end of camera sterile adaptor (arrow head), (B) insert the endoscope into the drape, sterile adaptor end first, (C) securing the drape to the endoscope with the supplied adhesive tape (arrow), (D) connection of the camera head to the camera sterile adaptor, and(E) inversion of the drape over the camera head by the unsterile person to cover the cables
The unsterile person then holds the camera head and connects it to the camera sterile adaptor (Figure 4D). While still holding the camera head the nonsterile person inverts the drape over the camera head and pulls in along the cables (Figure 4E). The Endoscope, the sterile person lays the draped camera head along with the cables and the light guide cables on a sterile mayo stand. At this point, the rear ends of the light guide cables are passed over to the unsterile person so that they can be plugged into the light source. The other ends of the light guide cables are plugged into the sockets on the endoscopes.
Cleaning and sterilization
Cleaning and sterilization of instruments
The specially designed EndoWrist™ instruments are multiple use endoscopic instruments. As shown in (Figure 5), a typical EndoWrist™ instrument consists of release levers that are used to remove the instrument from the sterile adaptor of the da Vinci surgical system™, the instrument shaft, a wrist and the end effector. Prior to use, all the instruments should be inspected for damage or irregularities.
Figure 5: Diagram of a typical EndoWrist™ instrument showing its major parts
Disassembly and precleaning
All instruments should be examined thoroughly after each use and if there are any abnormalities detected, they should not be used. During the cleaning process, all flush ports must be rinsed with pressurized water. After cleaning, clear water should be seen exiting the instrument. Proper care and handling is essential for satisfactory performance of surgical instruments.
Cleaning
The instrument can be cleaned by using a syringe to inject enzymatic cleaning solution into all flush ports. The instruments are then immersed in an ultrasonic bath filled with an enzymatic cleaning solution for at least 15 min. The enzymatic solution should not reach a temperature above 98°F (37°C). The outside of the instrument should be scrubbed with a soft, nylon bristled brush, and the instrument should then be thoroughly rinsed to remove any residual debris or cleaning agents. While scrubbing, move the instrument wrist joint through the full range of motion. The instruments should be dry before proceeding to sterilize them.
Sterilization
The instruments should be steam sterilized, following which all the components should be allowed to cool to room temperature. It is okay to sterilize the instruments using prevacuum steam autoclaving. The sterilization parameters that have been recommended are shown in the table. The use of flash sterilization is not recommended. It is also not recommended to sterilize the instruments at temperatures over 285°F (or 140°C). Moreover, these instruments have not been validated for Sterrad ®, EtO, Steris ® or other sterilization methods.
Cycle Prevacuum
Temperature 270-272°F (132-134°C)
Minimum exposure time 4 min
Average dry time 20 min
Cleaning and sterilization of endoscopes
The endoscopes (0-30°) can be sterilized using either EtO or Sterrad® sterilization. It recommended not to autoclave the endoscopes. The details of EtO sterilization and Sterrad® 100 sterilization are as follows:
EtO sterilization
Temperature: 55 ± 2°C
Relative humidity: 70 ± 5%
Pressure set point: 25.4 PSIA
Ethylene oxide concentration: 600 ± 30 mg/l
Gas exposure time: 2 h
Detoxification time: 0 h
Drying time: 0 h
Aeration: 12 h at 55 ± 2°C
Sterrad® 100 sterilization system
Vacuum phase: 5-20 min
Injection phase: 6 min
Diffusion phase: 44 min
Plasma phase: 15 min
Vent phase: 5 min
Total cycle time: approximately 75 min
Cleaning and sterilization of accessories
The accessories like the sterile adaptor camera arm, sterile adaptor amera, sterile adaptor instrument arm, scope alignment targets, cannula mount camera, cannula mount instrument arm, and instrument arm cannula can be cleaned with enzymatic cleaner and immersed in an ultrasonic bath. They can then be sterilized in an autoclave (prevacuum). The light guide cables can be cleaned with enzymatic cleaner and sterilized by either autoclaving them with the rest of the accessories or by EtO sterilization. The use of'Flash'sterilization is not recommended for any instruments or accessories.
Care of the surgeon console and surgical cart
The surgeon console can be wiped down with a soft, lint-free cloth, which has been wetted with a mild antibacterial soap and water solution. Particular attention should be paid to the master grips, the view port, the stereo viewer, and the armrest. As necessary, with the drapes removed, wipe down the surgical cart with a soft, lint-free cloth wetted with antibacterial soap, and water solution. Do not wipe down the vertical side rails on the surgical cart.
NOTE
This manuscript has been prepared based on the experience from Vattikuti Urology Institute, Henry Ford Hospital, Detroit, USA and substantial parts of the manuscript including the figures have been recreated with permission from the Intuitive Surgical ® User's Manual.
ACKNOWLEDGMENTS
Parts of this manuscript including the figures have been recreated with permission from the intuitive surgical ® user's manual.
