Surgeon autonomy in da Vinci 5

Da Vinci 5 is the most advanced robotic surgery system we’ve ever created.

Through component integration and control at their fingertips, surgeons can manage all components needed for surgery—such as insufflation and energy—from their console.

“With the head-in menu, you can manage all your settings without taking your eyes off the patient,” said Jason Hart, vice president of US marketing. “And more importantly, not waste time by having to re-set your thinking, have a discussion, and then come back and zoom in on what you should’ve been focused on in the first place—the patient.

“The reality is that equipment in the operating room is often a disconnected environment from possibly a dozen or more vendors,” Hart said. “And all of that technology requires a staff, sometimes three or more to support it.”

All these different technologies require integration in order for the surgeon to do their job.

“They've got laparoscopic instruments from one company, maybe a laser from a different company, or a generator from another company,” said Dan Baker, vice president of Product Management, da Vinci multiport systems. “In that sort of disconnected environment, how does integration occur and whose job is it to actually execute that integration? It's the surgeon, right? So in addition to focusing on the patient and a procedure, you have to also focus on this complexity of all these other things. And the mix of equipment is going to be different from one operating room to the next, at one hospital to the next.”

In da Vinci 5, Intuitive has integrated more of the operating room into one platform—running on the same software.

“This can help reduce the staffing needs and more importantly, provide a more integrated experience with less technology and equipment to service and operate,” said Hart.

Streamlined and integrated

Intuitive’s second-generation da Vinci system, in 2006, was the da Vinci S. The “S” stood for streamlined.

Intuitive’s vision has been consistent: to create an increasingly streamlined and intelligent surgical platform—including the patient cart, vision tower, and surgeon console—that work seamlessly together, giving surgeons and care teams a solution to strive to provide the best surgery possible.

Mark Garibaldi manages the Human Performance Engineering team as part of Human Factors Research: they conduct experimental psychological, physiological, and biomechanical research that informs product development at Intuitive.

“It’s work that focuses on determining the potential value or impact of the user experience on the learning and performance of our customers,” Garibaldi said. “This helps the business determine whether, why, and how much there is an impact on the feasibility and desirability of our products.”

“Ultimately, my team is focused on generating evidence that helps determine whether or not the user experience of a product is the right thing to build,” he said.

Customers have expressed a desire for more autonomy in the user experience with our products— which looks like reduced dependency on care teams who vary in team size and experience level. This feedback informed early stages of product development with da Vinci 5, leading to the development of feature sets to facilitate greater surgeon autonomy.

“Compared with other value propositions associated with da Vinci 5—such as surgeon ergonomics or care team proficiency—I would say surgeon autonomy is probably the most complex, in part because it seems qualitatively linked to familiarity with the features, surgeon experience in robotic surgery, and care team experience.”

In 2022, Product Management and Human Factors Research experimentally studied whether and how much the user experience of da Vinci 5 could influence surgeon autonomy.

Control over variability

Surgeons in their study defined surgeon autonomy as not only having more control—but more control over variability in surgery.

“They want more control over procedures, and over the OR to reduce the variability and establish the standard of care being delivered with robotic systems,” Garibaldi said.

By introducing features that allow surgeons to monitor various aspects of the procedure and execute tasks from their console, surgeons may be able to achieve greater operational efficiency through surgeon autonomy and workflow.

“One feature that may have the biggest influence on surgeon autonomy is the head-in UI menu in the surgeon console,” Garibaldi said. “This feature provides a lot of access to new features and existing features at the fingertips of the surgeon, without having to come ‘head-out’ of the console.”

The head-in UI menu includes settings for features like insufflation and energy with the E-200 generator. Prior to da Vinci 5, surgeons would have to request that care teams monitor and adjust insufflation from a third-party insufflator.

There is also the issue of care team variability, and staffing challenges. Care teams may be spread too thinly; they may be stressed.

“Care teams have different levels of experience,” Garibaldi said. “They're coming in and out of the room, which may increase mental demands on surgeons while they attempt to control for care team member variability.”

“Da Vinci 5 may help with redirecting responsibility of certain tasks from the care team to the surgeon,” he said.

A state of flow

A flow state is achieved when a person is utterly engaged in a task, humming along, often unaware of time passing. It is a state of immense focus.

Greater immersion and autonomy could enhance flow: more experienced surgeons reported higher levels of “flow” from this study on the influence of da Vinci 5 on surgeon autonomy.

“Surgeons can get hyper-focused during surgery,” Garibaldi said. “Interruptions can disrupt that sense of flow. We've had a couple surgeons report in the study that there is a tendency to lose a sense of time; that is one of the variables associated with flow state.”

“There might be unique complexity associated with their surgical task in order to achieve a goal—and they want to keep going at it. ‘Okay, that didn’t work. Can we try a different way? That didn't work...’ And so they sort of get into a place where time has lapsed, just trying to solve this one problem.”

Surgeons often work against a clock. Efficiency is greatly incentivized in American healthcare, and in the OR specifically. Additionally, there are time limits associated with certain procedures, such as a partial nephrectomy.

The timer is a new feature in the da Vinci 5 head-in UI and can be selected while the surgeon is performing their surgical tasks, rather than relying on the care team to monitor time or provide updates for them.

Captain of the ship

Technology has complexity and variability—different UIs, different ways of working with each device—and varying levels of staff expertise. A dedicated, highly trained team would be ideal, but in the complex and challenged world of healthcare, this is not always possible—especially for emergent and acute cases that may arrive unplanned.

“So you've got variability in terms of the technology that the surgeon has to integrate,” Baker said. “And then you have different support staff, different individuals who may have less experience in a procedure or with that technology. And then you've got the surgeon who's responsible for all these things. The surgeon has to understand and integrate these components. And if you think of their role, they're kind of like a captain on a ship. They're responsible for the outcome of the procedure, but then they’ve got to bark orders, and they're completely reliant on others to get these things done.

“And now we’ve made their job easier as a surgeon, because they don't have to think about as many of those things—we’ve built it into the technology.”

Intuitive has decreased the surgeon’s cognitive load and barriers associated with understanding our da Vinci technology by making things more seamless.

“You take that surgeon and they’re now less of a captain on the ship; now they're more of a pilot in the cockpit,” he said. “You've given them more direct control over all of these things. So this is about autonomy. They can do things efficiently. They're less reliant on other people in the room.”

Great technology can be so intuitive, so well designed, and so additive that it feels like an extension of the user.

“Part of the elegance of the technology is that as you use it, it just disappears—it just gets out of your way,” Baker said. “And that's actually what you want. You want to experience the absence of feeling that it's there, because you just want to do your job. And I think that's what we're trying to get at.”

High performance, high stakes

There’s no doubt that surgeons are highly skilled individuals, working in a specialized job with exceedingly high stakes.

“Surgeons are high-performance individuals that are 100% results oriented, right? They want to perform, and their only measures are the objective measures at the end of the procedure,” Baker said.

“I think it fits with the psychology of the surgeon: the high-performance individual doing a high-stakes job,” he said. “And what do they want to do? They want to reduce variables and decrease uncertainty, so they can deliver optimum care and they can de-risk the likelihood that something out of their control is going to cause care to go sideways.”

Intuitive’s goal: to make the use of da Vinci 5 so intuitive that the surgeon integrates its functions into their performance—seamlessly.

“It's very appealing to them because it's a technology that is consistent with the type of control that they're inherently trying to get, so they can do their job to the best of their ability.”