[Downloaded free from http://www.indianjurol.com on Friday, February 10, 2023, IP: 202.186.48.

99]

Review Article
Instrumentation, sterilization, and preparation of robot

A. Bhandari, A. Hemal, M. Menon

Vattikuti Urology Institute, Henry Ford Health Systems, Detroit, MI, USA

ABSTRACT
The da Vinci surgical system is being used for a wide range of surgical tasks. As the applications of this robot increase, more
and more surgeons would like to acquire this piece of equipment. There are a wide range of expensive and sophisticated
accessories and instruments that come along with this machine, that need special care and attention. The aim of this chapter
is the make the user familiar with the various parts of the robot and to provide guidelines for the safe usage of this
equipment.

Key words: Robot, Sterilization, Preparation, Da Vinci

The da Vinci™ surgical system is a sophisticated piece Surgeon console

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.
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
For correspondence: A Bhandari,
scaling, enhances precision by reducing hand movements to
2799, West Grand Boulevard, Vattikuti Urology Institute
K9, Henry Ford Health Systems,
correspondingly smaller instrument tip movements in the
Detroit, MI – 48202, USA surgical field. Moreover, the natural tremor of the surgeon’s
E-mail: abhandari1@hfhs.org, hand is reduced (tremor filtering) which helps ensure stable
bhandariakshay@hotmail.com and predictable instrument control.

83 Indian Journal of Urology | December 2005 |

CMYK83
[Downloaded free from http://www.indianjurol.com on Friday, February 10, 2023, IP: 202.186.48.99]
Bhandari et al.: Instrumentation, sterilization, and preparation of robot
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:
1 . 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.
2 . Camera arm: The camera arm is fixed to the patient
with help of a cannula, which attaches to the cannula
| December 2005 | Indian Journal of Urology
84 CMYK
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.
3 . 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.
1. Move one instrument arm and the camera arm aside.
2. Drape the remaining instrument arm and then move it
away from the undraped arms.
3. Then drape the camera arm and move it away from the
undraped instrument arm.
4. 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.
84
[Downloaded free from http://www.indianjurol.com on Friday, February 10, 2023, IP: 202.186.48.99]
Bhandari et al.: Instrumentation, sterilization, and preparation of robot
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.
1. Unfold the instrument arm drapes according to the arrows
marked on them. Continue unfolding to expose the sterile
adaptor reinforcement (Figure 2A).
2. Then insert one hand into the center of the drape, such
that the sterile adaptor reinforcement is fully exposed
(adhesive backing forces out).
3. 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.
4. Hold open the drape and the slide it over the top of the
arm until the sterile adaptor is near the carriage.
5. Align the slots at the bottom of the sterile adaptor with the
pins on the instrument arm (Figure 2B).
6. Tilt the sterile adaptor toward the instrument arm until it
snaps into place.
7. 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.
8. Next, open the drape to expose the Cannula mount
reinforcement and align it with the Cannula mount on the
instrument arm (Figure 2C).
9. 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).
10. Attach the drape straps in the appropriate locations.
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.
1. Unfold the camera arm drape according to the arrows
marked on it.
2. Insert one hand into the center of the drape.
3. Then, extend the closed end of the drape until the adhesive
strip and reinforcement section are exposed such that the
adhesive side faces out.
4. Remove the liner of the adhesive strip and stick it to the
sterile adaptor camera arm (Figure 3A).
5. Hold open the drape and slide it over the top of the camera
arm until the sterile adaptor is near the carriage.
85 Indian Journal of Urology
6. 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.
7. 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).
8. Attach the drape straps in the appropriate locations.
9. Finally, move the draped camera arm close to the first
draped instrument 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:
1. Open the camera drape package and unfold according to
the marked arrows.
2. Attach the recessed end of camera sterile adaptor to the
sterile endoscope (Figure 4A).
3. Then insert the endoscope into the drape, sterile adaptor
end first (Figure 4B).
4. Push the camera sterile adaptor through the elastic end of
the drape until it fits around the sterile adaptor.
5. Fix the drape to the endoscope with the supplied adhesive
tape (Figure 4C).
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
| December 2005 |
CMYK85
[Downloaded free from http://www.indianjurol.com on Friday, February 10, 2023, IP: 202.186.48.99]
Bhandari et al.: Instrumentation, sterilization, and preparation of robot

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

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.
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.

A B C D

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

A
A B C
C

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

| December 2005 | Indian Journal of Urology 86

86 CMYK
[Downloaded free from http://www.indianjurol.com on Friday, February 10, 2023, IP: 202.186.48.99]
Bhandari et al.: Instrumentation, sterilization, and preparation of robot

A B C

D E

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

Cleaning Sterrad® sterilization. It recommended not to autoclave the

The instrument can be cleaned by using a syringe to inject endoscopes. The details of EtO sterilization and Sterrad® 100
enzymatic cleaning solution into all flush ports. The sterilization are as follows:
instruments are then immersed in an ultrasonic bath filled EtO sterilization
with an enzymatic cleaning solution for at least 15 min. The Temperature: 55 ± 2°C
enzymatic solution should not reach a temperature above Relative humidity: 70 ± 5%
98°F (37°C). The outside of the instrument should be scrubbed Pressure set point: 25.4 PSIA
with a soft, nylon bristled brush, and the instrument should Ethylene oxide concentration: 600 ± 30 mg/l
then be thoroughly rinsed to remove any residual debris or Gas exposure time: 2 h
cleaning agents. While scrubbing, move the instrument wrist Detoxification time: 0 h
joint through the full range of motion. The instruments should Drying time: 0 h
be dry before proceeding to sterilize them. Aeration: 12 h at 55 ± 2°C
Sterrad® 100 sterilization system
Sterilization Vacuum phase: 5–20 min
The instruments should be steam sterilized, following which Injection phase: 6 min
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 Figure 5: Diagram of a typical EndoWrist™ instrument showing its
The endoscopes (0–30°) can be sterilized using either EtO or major parts

87 Indian Journal of Urology | December 2005 |

CMYK87
[Downloaded free from http://www.indianjurol.com on Friday, February 10, 2023, IP: 202.186.48.99]
Bhandari et al.: Instrumentation, sterilization, and preparation of robot

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.
ACKNOWLEDGMENTS
Parts of this manuscript including the figures have been
recreated with permission from the intuitive surgical® user’s
manual.
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.
How to cite this article: Bhandari A, Hemal A, Menon M. Instrumentation,
sterilization, and preparation of robot. Indian J Urol 2005;21:83-8.

| December 2005 | Indian Journal of Urology 88

88 CMYK