Intuitive DaVinci 5 turning up the Gas on insufflation
- Steve Bell
- Oct 3, 2024
- 19 min read
Updated: Jul 30
A few months ago I indicated that the battle ground for the next few years will be down to the “Power of the tower.” DV5 took a strategic step forwards by launching with a fully capable and integrated laparoscopic tower at the heart of its new daVinci surgical 5th Gen robot.
Two big features jumped out to me on that system. The first (and I will come back to this in another post) was the significant upgrade of the integrated NIR (ICG - Fluorescence capable) hand held scope. And no, it is not just for first entry. That allows any DV5 tower to be used as a stand alone laparoscopic, fully capable, and data scooping tower. And that is a huge threat to companies like Stryker, Storz and Olympus. (See my other posts here.)
But the second - and potentially most critical component on that tower is the advanced and integrated insufflation system. I have mentioned this before, but due to the many questions I get, it maybe hasn’t landed with everyone what this means - and especially for robotics.
So today, let me do a deep dive into the world of insufflation, explain what it is, what the strategic significance of the Intuitive insufflator is, and the reaction of the other companies. And finally give you a line of site of what’s next in insufflation. Because it’s about to get very interesting.
What is insufflation?
Let me start with a basic refresher on what and why insufflation.
To be able to do laparoscopic or robotic surgery through “keyholes” trocars… technically the cannulae, you need to create a real working space inside the abdomen. Normally the abdominal muscles lie flat (ish) and the organs inside are more or less all touching each other and the underside of the abdominal wall. There’s very little space in there. Think of it like the inside of a deflated balloon.
Now to be able to put a scope in there, and then instruments - you need to blow that balloon up so that you create a cavity to work in. In some fields of surgery that is done with fluids (hysteroscopy) but with the abdomen being so big - you need to use gas.
The choice of gas was made many years ago by pioneers like Kurt Semm - it needed to be safe to put in the abdomen, relatively inert, cheap, non flammable, and if absorbed into the blood hyper soluble so you didn’t end up with embolism in the blood. The natural choice was to use CO2. Any CO2 absorbed into the blood would just be expelled via respiration. It is cheap, easy to make, inert and well… just the right choice.
So what is done is often (more so historically) a Veress needle was inserted into the abdomen via the umbilicus (more so now Palmer’s point) and gas was run from a cylinder, through a set of control valves, tubes, and into the abdomen. The abdomen would blow up like a balloon and create a working space. Trocars would be inserted though the abdominal wall and the valves in the cannulae would keep the gas in (sort of) so that the surgeon could operate in that nice big space (inside the inflated balloon.)
The general pressure used was 15mm/hg (15 millimetres of mercury) - that was used to have enough pressure to keep the abdomen nice and tight and maximise the space inside.
However - as procedures got more complex - some gas would escape through valves - or just with time around the ports, or through incisions made for organ removal, or when something was inserted or pulled out of the valves of the trocars, or other small incisions were made in the abdominal wall.
This caused an issue. You see how fast the you lose gas from these “leaks” and how fast you pump gas back in will determine if the pressure stays up or the pressure goes down. If the pressure goes too low the abdomen collapses and the space reduces.
NOTE: For robotics this is a big problem (bigger than manual lap) because the robot has fixed pivot points that are set when the abdomen is fully inflated. If the abdomen deflates and the abdominal wall shifts relative to the pivot points - you can cause damage and pain. Some systems that use a remote centre, like daVinci would literately keep the pivot points relative to robot arm and not the abdomen - (remote centre). So high forces could be translated into the abdominal wall. Other systems that use software pivot points could actually alarm. So leaks - loss of air and collapsing abdomens is a major issue in robotics.
For all types of laparoscopic surgery (manual / robotic) gas leak is not great - as it removes the working space - and if the insufflator does not have enough flow rate (high flow) it can be an issue that delays surgery.
But that is not all. That is not the only issue that flowing huge amounts of gas in to the abdomen causes.
I’ll try not to get too technical on this post. But think about when you’ve sprayed an aerosol can for a long time - the gas is stored under pressure and often in a liquid form inside the can or cylinder. When the liquid escapes from the cylinder (can) it rapidly expands from liquid to gas. That expansion takes energy - and what happens is that ambient heat is “absorbed” by the gas to allow it to expand. That mean that the air around the gas, the cylinder, the tubing and everything that expanding gas touches gets cold. You felt how the can gets cold if you spray long enough right?
So one of the issues with leaking CO2 from the abdomen is that as it is replaced it is replaced with expanding gas that is cold. So you effectively have lots of cold - dry gas going into the abdomen. And if the surgeon has put the gas inlet onto the main laparoscope port (often there as it’s the biggest in most cases) then cold gas flows across a metal laparoscope and chills it - and the lenses get cold - and then hot moist air from inside the abdomen condenses on the lenses and you get a “foggy lens”. A constant battle in laparoscopy and robotics in the past.
Now that cold dry gas going in is also not that great for the patient, as it starts to dry out the delicate organs and chill them. The more you crank up the flow of the insufflator and get more flow and gas - the worse this can be. Patients get cold, patients get dry - and dry cold organs are not great for post operative recovery.
I want to also talk about another issue of the “sealed” gas filled abdomen - to hit some context for later. Every time you apply electrosurgery - you “burn” the tissues and release smoke which contains volatile gasses, chemicals and carbon particulate matter. That “greyish” smoke in open surgery drifts up into the operators face - but goes away from the abdomen. Instead in laparoscopy (manual or robotic) it gets trapped in the “sealed” abdomen - and you can end up like you’re looking through London smog. One way historically (okay still happening in most places) to get the smog out of that abdomen is to open a valve on one of the side trocars and let the smog vent to the atmosphere. (If you’re an assistant do not breath that shit in!!)
That clears the smog - but at the same time releases gas - making the insufflator pump in more clean gas to maintain pressure. If the input flow rate is lower than the venting gas - pressure drops and the abdomen collapses down. (As per above). Then cold gas pumps in - the lenses get condensate - the operator cleans the laparoscope - and poor vision can result. And the scope is removed… losing gas etc etc…
So… low flow leads to collapse of the abdomen when there’s a leak. Cold gas coming in is an issue. Dry gas coming in is an issue. Smoke and venting it is an issue. And that becomes massively problematic for robotic surgery - especially if the position of the pivot points shifts.
Good summary here as well - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6444464/
Enter the world of modern insufflation
The best inventions comes from needs. So give me a high flow insufflator that will always pump in more gas than is being lost (40 litres per minute or even 50 litres per minute.) Wow - that is a lot of chilly gas running in… so let’s heat that gas up to body temperature. Oh and while we’re at it add a bit of moisture.
That way - even if we lose gas - we maintain the 15mm/hg and full abdominal volume without chilling the patient and drying them out.
And how about instead of venting that “smog” to atmosphere when we use electrosurgery - why now stick an outflow pipe one that side trocar and suck that gas back to the insufflator - pop a filter on it (I’m gonna cover this later) and recirculate that clean (ahem) CO2 back into the patient via the inlet tubing. That way we filter the air and reduce the smog way more efficiently than venting and without losing pressure and volume.
Hey hang on… why did we use 15mm/Hg? What was Kurt Semm thinking? That is way more pressure than you need to expand the abdomen. Ahh you see if you start to go under that - at about 8mm/Hg and less the abdomen potentially collapses. So if we ran at 8mm/Hg historically (1990s insufflators) - the slightest leak would collapse the working space - so we used 15mm/hg to give us some wiggle room to avoid collapses even if pressure dropped.
So what? Well at 15mm/Hg you have a lot more CO2 at high pressure and you end up with the same abdominal volume (working space) as 8mm/Hg, but the abdomen gets over pressured and stretched tight like a drum. That causes pain through stretching the muscles and the nerves. It also drives more CO2 into he microvasculature and causes a few physiological problems - plus more pain in and around the shoulders (go read it as it’s an interesting side effect of laparoscopy.)
But with the advent of high flow insufflation we can drop the pressure to 8mm/hg and even if we lose some gas - the “top up” is so fast that the volume doesn’t collapse. In fact as an operator you won’t even notice in most cases. Bingo - better for the patient. But also has no impact on the robotic pivot points.
Let me add a final one in here - about those valves in trocars. Inside a trocar (the tube the cannula) is a small valve that stops CO2 leaking out when the cannula is empty. The gas pressure auto closes the valve (bit more technical depending on types of valve but let me keep it simple today.) That’s great - but it causes drag on instruments - and a sort of juddering on instruments - and if you want to pop needles in and out - it’s a pain. If the valve gets dirty on the camera port… it can keep dirtying the lens as the scope passes the valve. In effect it would be way better if we eliminate those valves.
Well Conmed has Airseal - a high flow insufflator that on the 12mm ports has eliminated the valves with a clever airflow system that makes a virtual “air seal”.
So high flow insufflation has come a very long way.
Many companies make various versions of high flow insufflators - with different heating elements, moisture elements, smoke circuits with filters, algorithms to get maximal volume for minimal pressure etc etc. I’m not going to list them all out here.
But modern high flow - smart insufflators are becoming a must have in laparoscopy and more so in robotics - as it allows that all important low pressure laparoscopy (manual or robotic) without compromising working volume and not having the abdominal wall bounce around.
It also allows low smog, smoke extraction and filtering and patient warming. All of this makes operating “smoother” and patient comfort better. And if you’re doing a robotic case - then it makes the robot feel way way way better. And having a stable abdomen without effort during that all important learning curve of a robot is one less thing to add to cognitive load. So…
Intuitive and insufflation
If you looked at a daVinci Xi - it had a robotic camera system - an optional hand held “first entry” camera system. Electro surgery unit. All from Intuitive. But it didn’t have its own insufflator. It relied on what was there on an ancillary tower next to the system.
So first point. Often if the Intuitive “stack/ tower” did not have the optional hand held entry camera and the insufflator - a second stack / tower was wheeled in - the hand held camera used for trocar entry, and the insufflator used for the entire case. And that insufflator did not talk to the daVinci system in any way shape or form. Keep that in mind for later.
Each surgeon would manually enter their setting into the insufflator for each type of case and it would be set and leave. Sometimes during the case to ask the assisting OR team “Turn up the flow, turn down the pressure, turn down the flow.” Not great workflow.
But most importantly - OR space is a premium and this setup has / had the daVinci system (boom, console and DV tower) plus often a secondary tower taking up space for the primary entry camera and the all important insufflator.
Let’s dive into the insufflator a little. As said earlier - a really “Nice to have” for a surgical robot - to get the maximal experience - is to have a modern model, high flow insulator with air warming and smoke extraction.
Many cases I attended - I saw that the Conmed Airseal insufflator was often used along side the daVinci system. This gave them all the punch they needed for low pressure, high flow insufflation.
I’m not saying other companies with their stand alone high flow insufflators were never used - they were. In fact some surgeons preferred other models for different reasons I won’t go into now. But the perceived risks of dragging ambient “air” in through the seals with some systems was often quoted as a reason. Others said they preferred other insufflators because of the way they handled the flow and pressure etc etc. Others just because they had them in the room on the tower they used for manual lap.
But - what was clear is that with a high flow, low pressure insufflator the cases were “better” in many ways. But a second tower was nearly always needed. It was apparent to Intuitive that if they wanted to reduce footprint, and get more control over insufflation then they needed their own insufflator. But not just that - the data from, and the control of it into their tower system would allow a few exciting things. Step in DV5.
DaVinci 5 Insufflation integration
If you look at the tower for the DV5 you need to look at it through two lenses. The first is as a companion tower for the DV5 and the second is that once you get a hand held full capable ICG ready imaging system and a fully integrated high flow insufflator - you now have a super capable stand alone lap tower.
I’ve opined on this adnauseum about how this is a trojan horse into ASCs, and to take on the lap procedures - scoop up the data and get 1/3 of a system (DV5) in the room for the future. It’s cunning and elegant at the same time. And Intuitive now have all your laparoscopic data to start to make comparisons to robotic cases…. Hmmmmm….
But let me just focus on the integration of their own highly capable insufflator and what that does when full integration hits home on a robot.
So first all the flow and volume data gets scooped up - and pumps more valuable data into the data lake that Its behind My Intuitive… and that ultimately helps with better insights.
Secondly it adds in a highly capable high flow insufflator - the parameters of which Intuitive now control - and do not rely any more on third party insufflators - so they can tune that (and they will) over the coming years to give the optimal insufflation for the best DV5 case. And those settings can be set by the surgeon from the console - no more shouting across to have a nurse tweak it.
The integrated experience and control for workflow is an essential part of the DV5 experience - and appeal to get workflow suitable for ASCs.
Next it sets up a nice revenue stream of consumables - very nice. The inlet / outlet tubing cassette with filters is another revenue bump they get on every robotic case - go and every lap case it is used in.
And, it starts now to allow smart features like smart smoke extraction. Remember before I said you burn - you create smog - you see the smog… you smoke evacuate. Well some systems have sensing that senses the smog and then sets off an evacuation cycle to clear the view - BUT it’s sort of activated once there is significant smog and visualisation has become sub optimal.
Instead - in the DV5 tower as you press the burn button on the electrosurgery - the anti smog action of the insufflator starts - so has anticipatory smoke evacuation - to minimise smog disruption. Very slick.
It’s this deep level of integration that creates a better user experience. And as Intuitive controls all the parts of the chain - they can start to fine tune (as data pours in) the characteristics of the system and make it better and better through software upgrades. They own it all.
That not only gives a better robotic experience - but a smart tower like this will also give the lap hand held users a better experience and lock them into Intuitive’s ecosystem - and make them think - “if it’s this good by hand - what will it be like on the DV5?”
It’s all linked.
So as I’ve said - if I was Stryker, or Storz or Olympus - I’d be terrified of how this could all impact their tower businesses. And their tower commercial models. DV5 tower for free - will get serviced with the DV5 - and just pay the consumables vs “buy a tower, pay a tower, pay servicing” - no brainer.
And you no longer need that ancillary tower in the room for the DV case. So the tower needs just dropped 15% or more across the US.
What about other companies?
I’m first going toto talk about Medtronic and the worst kept “possible” secret in the medtech industry. Rumours abound that for HUGO they need their own smart - high flow insufflator. Pundits keep saying they will buy Palliare. They have a very small compact and capable high flow insufflator with smoke extraction and multi flown modes.
I won’t go deep in this post about how thew insufflators deliver the pressure / flow are part of the sauce that people like. In fact some people using the Intuitive DV5 insufflator have returned to their trusted Airseal - as “they prefer the way it delivers the constant pressure.”
For Medtronic - they need their own solution - and cannot just OEM or “Off the shelf” attach an insufflator. Why?
Well firstly we need to look at the Storz factor. So far Medtronic’s strategy was to abandon their own tower and go for off the shelf imaging and insufflation by Storz. With the Storz acquisition of Asensus all cards are potentially off the table. Storz has different high flow / warming / integrated solutions such as the Endoflator 50 - but will they now make it available to Medtronic?
Will they allow it to talk to Medtronic’s Valleylab electrosurgery units?
No, not in my opinion. So instead Medtronic (Hugo being now a competitor) will need to start to construct their own tower of power to compete with Intuitive (and Storz). If they want to customise the interfaces to work with HUGO and integrate Valleylab controls and make a more complete solution - then they need to start buying the components they can own… and Palliare is an obvious first choice for them.
** UPDATE ** Look carefully at Palliare - any keen eyes is going to see three tubes. So that's CO2 in - evacuation out and what? Well it's a third tube for constant pressure monitoring. Different systems have different ways of measuring the CO2 pressure in the abdomen. If you use the same tube (as appears with the case in Intuitive) as the inlet of CO2 - then to get a measurement you need to halt inflow - measure the pressure and then adjust and continue. So that can happen say about every second or so. And that can make a system feel less responsive. Instead if you have a continuous dedicated measuring tube then you can actually have up to 100 samples per second.
That is important as you not only have continuous flow - you have continuous measurements so get faster response times. One pundit has suggested the lack of this in the Intuitive insufflator may be why some surgeons are going back to the Airseal devices. Thoughts?
As I’ve said - Storz come at this backwards to the robot companies. They have very very capable and integrated towers - they now bought the robot to back into their tower architecture. But make no mistakes they have a world class imaging - and insufflation know how. They did have a fairly basic electrosurgery unit with the AUTOCON III - but this and the Endoflator both give automatic and coordinated smoke evacuation with a smart link to the S-Pilot system.
So Storz will have a very capable tower that again could - in conjunction with the robot - offer a full spectrum of robotic and manual laparoscopic capabilities. A place this market is storming towards at high speed. Take note all companies without towers,.
JNJ - Ethicon. Let’s wait and see what their tower solution finally looks like with Ottava - but they do have the rudimentary components in there - with Megadyne electrosurgery generator - they will have Ottava imaging and we know they are working hard on this - but Insufflation? They have a Megadyne smoke evacuator - so starts to make sense that they are looking at gas management.
I would not be surprised if they have quite a capable tower on Ottava with a decent imaging system, bespoke insufflator, smoke extractor, multimodal energy (electrosurgery, ultrasonic, nuWave - Microwave.) And to be “coherent” and with their strategy of more advanced imaging - I would imagine all these components will talk to each other.
Now let’s talk (as I have done ) about the elephant in the room. Stryker. They are the company with the most at risk from Intuitive, Medtronic and Storz today. And if and when Ottava comes - it will be under threat by Ottava. Every integrated tower that drops with a robot is one less tower that Stryker can sell. Okay and Olympus otiose of the USA). Their lack of robot is an issue for them - and it will get bigger faster - so they need to drop into Moon Surgical or Distal Motion and soon.
This will be a Storz like protection move for their gorgeous 1788 Tower system. They already have a very decent and smart insufflation system that runs up to 50 l/min with their PneumoClear.
It brings smart - connected (through their hub) smoke evacuation and constant in and out management via software. The one thing they seem to miss is an electrosurgery unit… hmm bit odd. So they will need to get one to stay in the game with a fully functioning tower. I see Stryker as one of the biggest casualties of “The Tower is power” game that is unfolding. And I hope they make a play very soon to protect their ASC business above all.
Where does insufflation go next?
Firstly no one seems to have the absolutely perfect system with full integration where each component delights everyone…. Yet, one of the big benefits of a lot of these systems is that much of the functionality (as long as the base hardware is right) will be about tweaking the software algorithms for the control of flow and pressure to tune the insufflators into the best settings for the robotic system or manual laparoscopy. It will be about refining the communication between electrosurgery units - imaging systems and insufflators to get a synchronised and combined effort to get the optimal space, minimal pain, optimal smoke clearance, optimal imaging and most importantly patient benefits.
In fact - I’m predicting that that Insufflation will play a bigger part in the robotic user experience and patient outcomes than many people may appreciate today.
But what is exciting is what is on the horizon for insufflation and “what’s next?”
One of the biggest problems that still remains in surgery is anastomotic leaks. 5% -19% of colorectal cases have some degree of anastomotic leak. Now ICG imaging and advanced imaging is being deployed to ensure better blood supply, and advanced stapling technologies with “smart” staplers are being advanced to help with staple formation. But leaks are so multifactorial that knowing intraoperatively there is a potential leak is critical. Many surgeons still use the rather ancient technique of the “Bicycle tyre like” air bubble leak test. And some just hope it worked and find out in the post operative course - with many explain away fistulae etc as nothing to do with anastomotic leaks.
Now here’s the interesting thing - we have a closed gas environment of CO2 in the abdomen. So why can’t we monitor that environment and look for gas and pressure changes. If CO2 % drops - we might have some kind of leak. If we stress test the anastomosis and really look at the gas composition and pressure in the abdomen - could we see potential leaks?
During LSI I saw something quite interesting. A small, innovative company called Qaelon Medical demonstrated just that. They are developing a next generation laparoscopic insulator that will use algorithms to detect anastamotic leaks.
Qaelon Medical’s CEO, Liam Burns, said: “In less than a minute, our platform can detect tiny leaks, enabling surgeons to take immediate correction action before the patient leaves the operating room. We believe this creates a new standard for insufflation helping surgeons avoid devastating and costly post-surgical complications.”So this opens up a whole new frontier in insufflation - especially as we start to think about not only measuring constant gas pressure and flow - but also gaseous composition in the intra abdominal atmosphere. Not only can that detect leaks (as Qaelon is doing) but what about laparoscopic atmospheric analysis for smoke - volatiles and even tumour cell detection.
Several groups have been using Raman spectroscopy to analyse the intraoperative real time gas compositions - to look for dangerous levels of O2 and Nitrogen that could be potentially harmful in the case of vascular injury.
Many studies have been done to analyse the laparoscopic gas for malignant aerosolised cells. This was to look for risks of cells being deposited in port sites. But some groups are looking at using the concentrations of these cells to either create risk profiles for tumour seeding - adapt surgical manoeuvres to reduce concentrations intraoperatively - allow rapid gas evacuation (like smoke) if concentrations of say aerosolised malignant cells rise. And there is some research looking at constant monitoring in all cases to see if malignant cells appear in the gas, as a form of first line detection in benign cases that may not yet have diagnosed cancer. A sort of early warning system.
One final area where improvements will come is the smoke and noxious gasses extraction and filtering. I’m not going to point to this too hard - but look at the filters in these systems and ask deep questions - how much of the noxious gases are actually removed - vs just the particulate matter. I think there is room in these systems for more than just passive smoke removal - but to bring in active systems that eliminate particulate material and actually scrub the noxious gases. One to watch, especially as impacts of OR smoke on staff gains more and more visibility (you see what I did there…)
There are lots of exciting new applications of this often underrated component in the laparoscopic and robotic tower. The one thing that is here and now is the certainty that companies must have a strategy for comprehensive towers that they control and insufflation will be a key central component.
Intuitive are not stupid by any means. And if they have out this at the heart of their gen 5 product - then maybe you should too.
The opinions of the author are for educational purposes only. All trademarks are owned by their respective companies.
