Updated: 26/3/24 Intuitive Da Vinci 5 vs Xi an early review - but it’s more what they’re not telling you that you need to know
- Steve Bell
- Mar 15, 2024
- 21 min read
Updated: Jul 30
Included in this blog:
New haptics, insufflation system, new console with new control arms, helm, new control panel, energy systems, information system, vision system and more below:
So the rumours of modular systems and open consoles can be put to bed (for now.)
What is clear is a very clever strategy that we are seeing unfold here. These two statements brings everything into clear sense:
Statement1: “Force Feedback instruments, which are optional for use with da Vinci 5, are cleared for use in the same procedures as da Vinci Xi, except pediatric and cardiac procedures, and a specific contraindication for the Force Feedback needle driver for use in suturing during hysterectomy and myomectomy procedures.”
Statement 2: “We design our systems so we can integrate new functions, capabilities, indications, and instrumentation over time,” said Curet. “Our careful attention to customers’ long-term needs and goals has led our systems to become the hospital standard, and we expect to continue developing and innovating da Vinci 5 and da Vinci Xi over the coming years.”
Statement 1 indicated that da Vinci 5 has gained broad clearance to be used in almost all the same procedures as the Xi. That is a killer for all competitors.
This is why a smart strategy to make the system as “close” to the Xi as possible in architecture has been the chosen path. This leapfrogs the DV5 above all other systems that will come to the USA in the next years. Broad procedures is the critical tick box they needed so that any hospital could convert from an Xi to DV5 and not be penalised by not having most procedures covered. No other system will gain clearance with that ability.
This is massive !!!
But the down side of that is it similar in many ways TODAY to the Xi. They wanted to get the base technology through the clearance process with as broad procedure coverage as possible.
So Statement 2 is what is critical - and it discusses the future add on of “functions, capabilities, indications and instrumentation” over time.
I predicted that this decade cycle would move robots to have a core chassis that can be upgraded - and I’m going to dive deep into that below. It is clear how they have engineered this system for upgrades over the next years. It’s smart.
Watch now over the next 2 or 3 years for several 510Ks as dormant functionality is switched on, components are upgraded and features added. This has not been a technological choice but a regulatory step process choice to lower the barrier to get the main system cleared. Smart.
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Bedside Boom Design of the da Vinci 5:
The DV5 boom architecture is exactly the same as the Xi architecture on the outside. It uses 4 arms from a central tower. It is clear however that what is under the skin is very different. The tried and tested Xi architecture will has allowed Intuitive to convince FDA that historic data on millions of procedures is applicable - especially if some of the new functionality is dormant. But I will double down on the fact that there are a lot of smarts under the arm’s skin that we won’t see for a while yet. Such as collision avoidance.
Clearly we can see that the arms are externally similar - but in the DV 5 image we can see a force feedback instrument. I will talk a lot more about force feedback - I did discuss this in great depth in my other DV speculation report and am pleased to say I was right. They are releasing a range of high end force feedback (haptic) instruments. I gather they used the words force feedback because it is one aspect of Haptics - and is technically correct if they are delivering back to the user force sensations in the instruments.
Statement 3: “First-of-its-kind force-sensing technology: Da Vinci 5 introduces Force Feedback technology and optional instruments that enable the system to measure, and surgeons to feel, subtle forces exerted on tissue during surgery —something no other surgical technology in any modality offers. In preclinical trials with surgeons at all experience levels, Force Feedback demonstrated up to 43 percent less force exerted on tissue, which may translate to less trauma on tissue. The ability to measure this force adds an important new data stream to surgical data science.”
It is interesting they use force sensing in the statement which to me implies that they can not only feel gross forces but also very fine tissue “palpation forces.” They say this translates into 43% less tissue force applied - which is the start of them moving feature - to actual surgical benefit..
As I speculated in my last deep dive - I feel that force feedback will be a critical part of bringing a group of laparoscopists over the fence to the robot - and will make adoption of the robot easier and faster. That ability to not require a full visual haptics learning curve will be critical for junior surgeons, and less skilled laparoscopists. And it now sets the bar for all other robots. “Once you go haptic there’s no going backtic.”
Other companies - get your force feedback game going.
If there is one feature of this system that the market should pay attention to - it is this. Other companies will say “It’s a gimmick”. It ain’t. This is a defining moment where da Vinci 5 will step ahead. Because not only did they introduce force feedback - they have broad indications for it. Let that sink in regarding the competition. Not only does the competition have to get broad indications on their current systems - they would then have to develop haptics (force feedback) and then get clearances for broad indications. That is a very big mountain to climb. It will take a decade.
In the above image I’ve noted a force feedback instrument loaded (note the different circular release button) and I’ve also noted a potentially modified gas (insufflation port). I’m speculating here as images are not so clear - but as they have introduced the insufflation feature (see below) I am thinking there is a significant modification to the ports gas management system. Think “Airseal” because what I’ll describe below would start to make sense with their own control over insufflation.
So now we start getting into my theory of building “soft” controls as opposed to “hard controls” into all aspects of the system.
What do I mean. Think Tesla. When you put a hard physical button or switch in - you are stuck with that function directed by that switch. If instead you can bring in touch screens (like many new devices) you can make a software button - and have it control something - but you can rapidly change it (no hardware change) and get new functionality through software and user interface changes. (It also helps with language and translations by the way etc.)
So one simple indication of how DV5 has caught up to modern thinking ( a decade after the Xi which was designed before the iPhone existed) is that at the back of the boom - the controls have moved from a hard physical format of buttons to a bigger touch screen format. Take that as a massive cue to how the hardware in DV5 can be upgraded continuously over the next decade. Imagine that we we want to add in way more automated OR or procedure set up (Think work flow) - well now that touchscreen can be updated - reprogrammed - and you can add tons of new features without having to add any new physical buttons. This is what I was saying when I predicted upgradeable hardware.
I still predict that under the skin of this beast are a lot of dormant features that will help with automated set up - automated tear down - and the surgeon will be able to control a lot of that directly from the console. This will include table positioning from the console (and integrated table motion from the console - sorry Ottava.). But arm angles - set up - separation and so much more will be user controllable by the OR staff using the tower or the surgeon direct at console. An a lot of this will be customisable and be able to be stored in system settings.
So what?
One word - Workflow.
In any set up - procure - tear down - time is lost because users have to give instructions to team members and it wastes valuable minutes. Instead if most things can be done by any team member from boom - tower - or console - work flow will be massively enhanced.
And if much of this can be pre wired into settings that can be stored on the My Intuitive app - that can be done before the surgeon hits the OR.
I want you as the reader to not be lulled into a “Well it looks the same as the Xi boom”
Statement 4: “Improved accuracy and precision: Da Vinci 5’s design and engineering enhancements, including new surgeon controllers and powerful vibration and tremor controls, make it the smoothest and most precise system Intuitive has developed to date.”
You get a lot of this in software of course. But most of these gains come from motors - gear boxes - sensors etc. It is 10 to 15 years since the Xi was designed and the world has moved on in leaps and bounds. Encoders are way more advanced and accuracy way more improved.
I imagine that the new under-the-skin enhancements will make the DV5 run like butter. And that is what they are claiming in precision and accuracy.
Why are they focused on this? Because most other competing systems have this as a major problem. They have vibration - bounce - movement - and a host of things that just make it feel “less polished.” Intuitive are doubling down and bringing a combination of less tremor - vibration - and accuracy.” This could set the bar higher in FDA? (Maybe), but for sure it sets the bar higher for users. If you’ve driven in a Mercedes S-class with air suspension and then in a Kia over the same road - you know what it means. So if you can get the S-class at more or less the same cost as a Kia — sorry I know what you’re choosing. And this is what this means. The DV 5 will feel like a rolls Royce compared to all other systems. And that will be important when people come to buying decisions - especially as capital cost will no longer count (see my post on the industry changing to service models.)
Surgeon console or cockpit of the Intuitive da Vinci 5 (DV5)
This his potentially one of the bigger visual changes. As I predicted in my deep dive report - they have moved to a smaller periscope which has allowed a lighter and less bulky console.
Statement 5: “Next-generation 3D display and image processing: Da Vinci 5 is equipped with Intuitive’s highest quality and most natural 3D imaging system, enabling surgeons to see more today, and supporting future generations of surgical endoscopes and vision software as those technologies evolve.”
Next gen 3D display - read that as the technology inside the actual screen but also (they didn’t say yet) 4K screen. I suspect they didn’t mention it because to get through FDA they may have used their current imaging system (more to come later) which is actually a 3D HD chip in tip system. But everyone is moving to 4K - so this screen system (headset) will for sure be 4K ready. It will use new modern LCD / or LED / or OLED screen technology (probably by Sony?) which will give better clarity - luminosity - colour rendition - (Natural) and black points.
All of this will make you feel you are looking at a modern display. It will give an amazing immersive and real image.
Statement 6: “Greater surgeon comfort: The system features a redesigned console capable of customizable positioning, allowing surgeons to find their best fit for surgical viewing and comfort, including the ability to sit completely upright. The surgeon can make any necessary adjustments while their head is in the console, with options designed to fit different body types, including surgeons who are pregnant.”
So this is a big leap from customer feedback - and what a smaller lighter periscope allows.
One criticism of the da Vinci system is the way heads are thrust forwards into the periscope and neck pain is a problem. Now they have allowed up / down - back /forwards and pivot of the periscope - so that the user can bring the periscope to them. This allows the user to sit upright and keep the weight of their head above their neck - which increases comfort. But my prediction of a potential future optional open screen is still on. The design this console would potentially allow that periscope to be substituted by a screen. I think it would be a modified console design myself - but the acknowledgement that upright sitting is preferred is a slight nod to laparoscopists. I still hold that 25% of laparoscopists will never come across unless they get an open console with flat screen.
If you look closely inside the periscope - it has detectors to make sure the system is only active when the head is in - it has speakers and looks to have a microphone. Complaints about communication between the team has been listened to. And even on the tower that have added a speaker and microphone system - which I suspect is to allow easy two way communication between OR team and surgeon. The “Comms” system is built in to both the headset and the tower - allowing that better team communication. Most likely to compete with open systems.
I imagine some form of better arm awareness will also be piped into the periscope at some point. This will ow better situational awareness by the user off what is happening bedside.
Of note:
They talk about more and more control “While the head is in the console.”. Many of the controls a surgeon needs will now be directly in the headset.
So ergonomics, electrosurgery, insufflation, table control, arm set up, integrated OR functions, Intuitive Hub - etc etc will all be able to be controlled without taking the head out of the console. (And eventually the AI driven assistance).
It looks like quiote a rich heads up display has been integrated right into the surgeon vision system. Allowing lots of information and status updates. And importantly ability to control most functions while staying focused in the operative field.
This again will be about giving the surgeon ultimate control from the console side.
This matters - it matters in places with limited staff - with staff turnover (so they have to learn less) - or with less capable teams - because now the surgeon is in control of the entire environment. Think ASC folks.
Small detail - but thinking of the user. The arm rest now comes with an inbuilt wireless phone charger so you can keep topped up with the MyIntuitive app on the go throughout the case. Nice touch.
It makes things faster and workflow faster. Switching between electrosurgery settings - repositioning the patient - changing insufflation settings - lighting - imaging - and recording etc.
It all shaves seconds and minutes off procedures which improves workflow - which improves turn over - which makes lower acuity procedures close to manual lap procedures in terms of time.
Intuitive need to get there to really break the low acuity procedures.
The next upgrade is to the hand controllers. To be a bit brutal - the old Xi controllers are pig ugly (sorry) but they are old technology. Instead the new controllers of the DV5 look gorgeous. The haptic arms are curved and designed well and just look 2024 plus. But don’t be fooled by thinking they are just cosmetic. Those haptic arms are thicker and have a lot more volume inside for motors, and electronics. This is the other part of better tremor and vibration - by improving the input side.
But beyond that - this is how they are getting that force feedback back to the user. You need a little more power in the gravity compensation motors and you will need drive in the finger grips if you are to have force feedback palpation as well as instrument gross force feedback.
The finger grips have had one upgrade that a lot of surgeons will like. Those grotty white Velcro straps have gone (hurray) and they are replaced with what look like silicone finger rings. They probably worked our that no one ever tightens them up so they could move to fixed rings.
(Don’t be surprised if they are removable and interchangeable for different size fingers!)
In summary the entire console looks modern - is highly adjustable (even for pregnant users) - looks lighter. And because again the buttons are going away and software driven menus are built in the headset / periscope - (including adjustments of the actual console set up) you get a lot of future proofing in this console.
Big changes in the Intutive da Vinci 5 tower
Often a part of the system that is overlooked - because it never feels that exciting. Well that is about to change. This is becoming the heart of the system.
This is a significant upgrade on a few fronts so let’s break it down.
The biggest addition to the tower is the Insufflation system. This is a massive signal (so watch closely). If you have this tower in an OR - and the hand held camera - you could now do an entire laparoscopic hand held procedure without needing any other tower components.
The insufflator adds the final piece of a tower. So you could effectively leave this in an ASC and replace the need for another tower - secondary tower for your lap cases… hmmmmm. (Mobility… hmmmm no more towers need to be bight from olympus and Storz… hmmmm)
It also means integration. The user of the DV5 can now control everything - including insufflation and smoke evacuation. (Insufflation is blowing in the CO2 to make the belly extend. Smoke extraction is to remove electrosurgery smoke to clear the visual field.)
The system is geared up with two inflow and two outflow ports - so it can do smoke evacuation - but that screams too me high flow - low pressure modes. That means that you would be able to do an Airseal style insufflation and drop abdominal pressures for low pressure robotic laparoscopy (highly desired). But now you can do that with no need to buy a secondary expensive Airseal insufflator. (I think that is why the trocarcaps are slightly modified so that in and out can be added.)
Interestingly for the keen eyes - you can see smoke extraction has a toggle for auto - manual and off. Auto smoke extraction could be very interesting - again improving workflow by not having to have someone vent - wait for it to clear etc. And all user controlled from inside the periscope. The surgeon has full control of the environment and is heading to “solo surgery” in a way for some low acuity procedures.
And this now all comes as standard ! (And in an EU tender it stops competition.) One more tender barrier.)
These again are all tiny - well studied points that are small on their own - but start to stack up to the promise of better workflow. Think ASCs and low acuity procedures folks.
Think about bringing more users across from lap - because its a “modern way” of operating. Surgeon control !
So this is yet more of taking “hard buttons” and putting them into a large software driven control panel. The left hand side of the tower is a gorgeous and massive touch screen that controls the gas flow (insufflation) - Electrosurgery controls - and Vision system - all in one panel.
This is a massive change and all should take heed. Not only does it make it all super upgradeable for the next decade - it makes it super controllable by ANYONE in the OR. Especially the surgeon - from the console - because all the smarts talk to each other.
But this image gives a lot of things away - including it looks like some new electrosurgery modes and importantly vision control. Soft controls means as soon as they 510K the 4K White light ICG - or even future hyper spectral imaging - it can all be controlled easily trough a software driven interface. Mirrored in the heads up display. You see how smart that is.
It is future proof by design. I have said in the past and will say again - technology is never the issue - regulatory is. So as they get 510k after 510k watch how these interfaces change and grow.
On the left side of the tower are the connection ports. There;’s a nice big speaker for two way comms. There is the new insufflation port, Electrosurgery connectors 2 monopolar and 2 bipolar plus patient pad return.
This is another potential poke for Medtronic and their Valleylab unit. If these towers start to get into more ORs - and become used for manual lap - kiss goodbye to ORs buying more electrosurgery generators. They will simply use the DV5 tower with a world class electrosurgery system.
(Not for today but I predict hand held DV instruments may come one day.) It’s a message to Medtronic. “You step into my world — we come after yours.”
Okay so here I could be going off ranch as I only have a blurred image to go by. But unless I’m mistaken it looks like they have added a laser to the system. (No sure not)
This could make sense as it is a much requested modality in a lot of specialties - and supplying it within the DV5 would be a genius move for Tenders - for procedures and for user control.
Would love to know iff that is what I think it is.
I’m probably 100% wrong and this is the front port for the independent power adaptor for the electrosurgery system (Which makes more sense). I just kind read the yellow warning label.
(update) I'm Saying more strongly this is probably the power inlet for the Electrosurgery system -
Okay so let’s talk about the elephant in the room. The vision system boxes that you might think have just been stacked on top of this beautiful design. Okay - this is all about getting regulatory and then adding features and hardware in the simplest way possible later.
So on top of the system is a light box and a standard 3D HD camera system - and this one looks like the ICG light source. I think Intuitive went with their standard system as that is what is cleared today - and it makes it just easier for clearance of the DV5 (break clearances down into smaller bites.)
But. It is clear new vision systems are close behind following 510Ks - so it makes sense to have the camera system out of the “main box” and sitting on top. That way it can be user swapped by simply swapping it for a new 4K camera unit, or a 4K ICG unit, or a hypersectral unit, or a structured light unit.
By having the electronics out of the box. It makes things a lot easier as imaging systems upgrade. You don’t need engineers to come in and swap them. And it allows potentially users to choose their weapon that day. So watch this space for new 4K cameras and different functionalities.
So if we now zoom into the tower screen - there are some very interesting tell tales about this.
Firstly it is on a very nice extension boom arm. This allows it to come better into the field of the bedside team’s view. It means it can be put over the patient the help with ergonomics for visualisation. (Be nice for stander lap.. ahem….)
There is a lot of info given out on this screen. Table positing, insufflation, entry settings and instruments per arm. It has vision chain selection and surgeon / user details.
It’s also very clear that is has a lot of real estate for much more information - and maybe PiP functionality. You might want to note they did have a Force Feedback instrument shown which shows that capability and how it flags it to the team and especially the surgeon through the Ux. (user interface).
What is unclear is if this has 3D capability - but by looking at some of the user interfaces where eye channel selection can be streamed to the screen - I imagine that if you select both L&R you might get 3D. The form factor seems to be a 3D monitor - but this is speculation and I’ll update as I get info. However the DV systems have had output capability to 3D for a while, so it is possible.
Intuitive Hub and smart computing
So we’ve talked a lot about he hardware and the control software. But a huge amount of focus has been thrown into the compute power of the system:
Statement 6: “Expanded computing power and advanced data capabilities: Da Vinci 5 has more than 10,000 times the computing power of da Vinci Xi. This enables innovative new system capabilities and advanced digital experiences, now and in the future, including integration with Intuitive’s My Intuitive app, SimNow (virtual reality simulator), Case Insights (computational observer), and Intuitive Hub (edge computing system).”
Let’s not all be too bamboozled by 10,000X computer power. We are over a decade on from when the Xi was designed. My laptop has 10,000X more compute power in that time. But as I said in my deeper dive report (go buy it) - what can that compute power do is what is interesting. (You’ll need to get that report to get all of the details). Plus read what AI can do for robotics in my other blog.)
But what this tells us is that there is a huge amount of compute capability ready to be unleashed. Again the smart thing they have done is get it on the market as the “basic” model close to the Xi to get over the barrier. Then start to bring out all the dormant fictionality over time as regulatory allows.
Now note why this is even more super smart ! Because as they get regulatory clearances around the world that “Don’t allow that functionality” - they will just keep it turned off until they get clearances… say under MDR etc.
This clever software driven buttons, function and dormant add ons allows roll out globally with just one production model - where features get added and upgraded as regulatory allows. You don’t need to build five different regional models. Clever. That helps supply chain an manufacturing so much! Ands will help field servicing even more. Less versions are always better.
All that compute power can be put to use (see my other blogs and reports) for “AI” and “ML” good buzz words. So that translates into help: scene recognition, no fly zones, surgeon assist, procedure assist and way more. This just scratches the surface. But it is clear that there is a lot of horsepower to do some very clever “on console” computing which will help users be faster - get better results and improve work flow (There it is again.)
Lap surgeons will now be tempted across by the smarts - as that is not a direct attack on their manual skills - but now a combination attraction. Their skills combined with robotics - with imaging - with surgeon control - with compute power. It now makes sense to drop old laparoscopy and hop on the robotics train.
A nifty little upgrade is the addition of the new Intuitive Hub. Hard to see from this image - but it’s ability to record case data and other information and parse it up to the cloud and back to the app is a very strong feature. It looks like the system has had a significant upgrade - design and functionality. And by the statements of Intuitive, I reckon it talks even better to this DV5 system, gaining more data (including force feedback) that can all start to be mashed together as inputs (video, movements, forces, outcomes etc etc) and a very interesting data science driven picture can be formed. This can be fed back on the fly (to there smart periscope) - or later (To the My intuitive app) to give insights and help. Again all of this aimed at better patient outcomes - and improved efficiency.
So what does Intuitive DV5 do for the market?
Firstly this massively feature laden system is just screaming to the market place “You need to be on a robot if you want to be a surgeon in control in modern surgery.” It starts to add in enough features that even the most die hard laggard of a laparoscopic surgeon must say “Okay this is absolutely no longer about a robotic manoeuvre that mimics manual lap surgery.”
I think the DV 5 will be the tipping point for many “hold out” lap surgeons to come across to robotics. T will certainly be the most attractive toy for new young surgeons. How could they think of not using such a powerful system?
I think secondly with the help - improved workflow - control from the console and other features above. It will for some ASCs now be a possibility (as long as cost stays controlled) to integrate this into their workflow. But it has to be seen if all these additions and time savings stack up.
The boom is still big. But the console is more compact and … and the footprint of the tower is no longer and issue - because it replaces any lap tower 100%. It’s a 1:1 swap for any lap tower. So we have technically a 30% reduction of footprint of the robots entire footprint.
In ORs with space issue - you can have an Intuitive tower that could do lap procedures all day long - just use their hand held camera. Now that “footprint” is less of an issue as it’s an actual part of the OR. And it is a potential cost saving if people need to upgrade their current towers. (Watch out Olympus and Storz.)
As said in my deep dive report, this system could allow more surgeons to do more complex procedures with advanced energy - advanced imaging - advanced computing - advanced instruments - all with guidance (when all this comes). The ultimate impact will be to have more procedures come to the robot.
So more surgeons will come across and more surgeons will do a wider range of low acuity (because of workflow) procedures and high acuity (because of of technology help).
The haptics / force feedback will help a lot more surgeons get to grips (pun intended) with the robot - faster.
This is also something that some miss - because the image system, electrosurgery system, insufflation system, instruments, camera - screen etc. They are all the same no matter what OR you go into - no matter what Hopsital you are at. If you use a DV5 anywhere - you will get the best - most modern and reproducible equipment. That is a massive benefit to teams and surgeons. And makes a barrier to new robots (which are not the same.) familiarity and consistent performance becomes a leveller.
For the competition - the broad clearances just made life very very tough for them. It means that even the new DV5 system can be acquired by any hospital and replace any Xi across all procedures.
That is devastating for new competitors as DV5 is a new system two or three generations ahead that can do more proceeders than the competitor will be allowed to do on their Gen 1 product (if and when they get cleared). Why would anyone buy a two generations back system - with half the functionality - with half the instruments - no staplers - no advanced energy - that can only do a few select procedures. Ouch!
Broad clearance by keeping it close to the Xi - Genius.
In the USA for sure - intuitive is set to remain the market leader for years to come.
All of the above is from analysis of public information sources, personal knowledge of the market and guesswork. You should not be making in vestment decisions based on my guesswork.
It is author opinion for education purposes only. All trademarks and images are owned by their respective owners.
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