J Robotic Surg
DOI 10.1007/s11701-016-0662-0
ORIGINAL ARTICLE
Early clinical experience with the da Vinci Xi Surgical System
in general surgery
Monika E. Hagen1 • Minoa K. Jung1 • Frederic Ris1 • Jassim Fakhro1
Nicolas C. Buchs1 • Leo Buehler1 • Philippe Morel1
Received: 19 August 2016 / Accepted: 4 December 2016
 Springer-Verlag London 2016
Abstract The da Vinci Xi Surgical System (Intuitive
Surgical Inc., Sunnyvale, CA, USA) has been released in
2014 to facilitate minimally invasive surgery. Novel fea-
tures are targeted towards facilitating complex multi-
quadrant procedures, but data is scarce so far. Perioperative
data of patients who underwent robotic general surgery
with the da Vinci Xi system within the first 6 month after
installation were collected and analyzed. The gastric
bypass procedures performed with the da Vinci Xi Surgical
System were compared to an equal amount of the last
procedures with the da Vinci Si Surgical System. Thirty-
one foregut (28 Roux-en-Y gastric bypasses), 6 colorectal
procedures and 1 revisional biliary procedure were per-
formed. The mean operating room (OR) time was 221.8
(±69.0) minutes for gastric bypasses and 306.5 (±48.8) for
colorectal procedures with mean docking time of 9.4
(±3.8) minutes. The gastric bypass procedure was transi-
tioned from a hybrid to a fully robotic approach. In com-
parison to the last 28 gastric bypass procedures performed
with the da Vinci Si Surgical System, the OR time was
comparable (226.9 versus 230.6 min, p = 0.8094), but the
docking time significantly longer with the da Vinci Xi
Surgical System (8.5 versus 6.1 min, p = 0.0415). All
colorectal procedures were performed with a single robotic
This work was presented at the 7th worldwide meeting of the Clinical
Robotic Surgery Association on October 3rd 2015.
M. E. Hagen and M. K. Jung contributed equally.
& Monika E. Hagen
monikahagen@aol.com
1
Division of Digestive and Transplant Surgery, Department of
Surgery, University Hospital Geneva, 4 Rue Gabrielle-Perret-
Gentil, 1211 Geneva, Switzerland
•
docking. No intraoperative and two postoperative compli-
cations occurred. The da Vinci Xi might facilitate single-
setups of totally robotic gastric bypass and colorectal
surgeries. However, further comparable research is needed
to clearly determine the significance of this latest version of
the da Vinci Surgical System.
Keywords Robotic
Robotic surgery
Da Vinci
Xi

Minimally invasive surgery
Digestive surgery
Introduction
With improved vision and dexterity, robotic technology for
minimally invasive surgery has been developed to over-
come technical limitations of conventional laparoscopy
[1–3]. Since its introduction to the market, the da Vinci
Surgical System (Intuitive Surgical, Sunnyvale, CA, USA)
remains the most widely used system for robotic-assisted
laparoscopic surgery and is currently available in its 4th
generation with the da Vinci Xi Surgical System [4].
All da Vinci generations that include the da Vinci
Standard (sales and support discontinued by Intuitive), the
da Vinci S, the da Vinci Si and the da Vinci Xi Surgical
System share common core technical features that differ-
entiate them from conventional laparoscopy. All systems
contain three components with a surgical console, a sur-
gical cart and a vision tower with the following specifica-
tions [4]:
• Surgical console allowing comfortable seating position
of the surgeon with physical separation from the
patient, tools to interact with environment, and a
natural hand-eye alignment
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• 3D HD Vision with up to tenfold magnification and an
immersive surgical field-of-view
• Wristed instrumentation with 7 degrees of freedom
• Software features including motion scaling and tremor
filtration.
In addition to more gradual enhancements of the Stan-
dard over the S to the Si Surgical System, the latest version
(da Vinci Xi Surgical System; released to the market in
2014) has more fundamental design changes including
changes to the surgical cart including [4]:
• Torpedo-shaped robotic arms that are mounted on a
rotating beam (Fig. 1)
• Universal arms where camera can be docked onto any
arm
• Longer instruments, but currently only available at a
reduced variety
• A new vision architecture with chip-at-the tip technol-
ogy and camera, endoscope and cable integrated into
one handheld design
• Adapted user interface offering more assistance with
robotic setup and installation
• Integrated energy with a single device for mono- and
bipolar energy
• Standard integration of Firefly Fluorescence Imaging.
These design changes are targeted towards a facilitated
robotic setup and more streamlined user experience with
the possibility to access a greater field of surgery without
the need to re-install the robotic system. As such, the
system appears to be specifically capable of abdominal
procedures that take place in several quadrants of the
abdominal cavity such as colorectal and gastric bypass
procedures and thus appeared very appealing to us for our
robotic digestive surgery program.
Fig. 1 The da Vinci Xi arms mounted onto the rotating beam
(Provided by courtesy of Intuitive Surgical Inc.)
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After 8 years of clinical experience with all other da
Vinci models (Standard, S and Si) mainly for gastric
bypass surgery (Over 650 cases performed) but also many
other procedures of digestive surgery [5–9], we have
installed two da Vinci Xi Surgical Systems in late March
2015. One of the systems offers a dual console and the
other one has a single console setup.
Prior to the installation of the Xi Surgical Systems, we
have performed a hybrid procedure for Roux-en-Y gastric
bypass (RYGB) with laparoscopic cholecystectomy for
most patients, laparoscopic formation of gastric pouch and
laparoscopic measurement of the biliary loop [6]. Both
gastro-jejunal, as well as jejuno-jejunal anastomoses and
the measurement of the alimentary loop were performed
robotically. The gastro-jejunal, as well as the jejuno-jejunal
anastomoses were fully ‘‘hand-sutured’’. The left-sided
colorectal procedures were performed with either a hybrid
approach (laparoscopic mobilization of splenic flexure) or
with a re-arrangement of robotic arms with or without
repositioning of the surgical cart. This manuscript reports
our initial (first six month) experience with the novel da
Vinci Xi Surgical System in digestive surgery.
Materials and methods
Data on all patients undergoing robotic surgery had been
entered into a prospective database since 2006. All rel-
evant technical aspects during the procedure were col-
lected including operating room time, docking time,
intraoperative complications and other various other data
points.
A basic dataset of all patients who underwent robotic
digestive surgery in the first months after the Xi imple-
mentation was derived. Patients who underwent gastric
bypass surgery were compared to the equal amount of
gastric bypass patients who were operated with the da
Vinci Si Surgical System just before transitioning to the Xi
Surgical System. Data was presented using descriptive
statistics, and cohorts were compared. A p value of B0.05
was considered as statistically significant.
All members of the team were trained before the 1st Xi
procedure including online and live training with mock-up
of docking procedure according to Intuitive’s training
pathway. All team members involved in the early cases had
significant experience with the former versions of the da
Vinci Surgical System.
Robotic docking and port positioning was performed
after careful review of the targeted procedures and Intu-
itive’s recommendations according to their informational
product brochure. An Intuitive representative was present
during the initial cases and continuous support was pro-
vided as needed by Intuitive.
J Robotic Surg
Results
Thirty-eight patients underwent Xi surgery from the end of
March to July 2015. The procedures included 28 RYGB, 3
low anterior resections, 2 right colectomies, 1 revisional
bariatric procedure, 1 sigmoid resection, 1 Nissen fundo-
plication, 1 atypical gastrectomy and 1 revisional biliary
procedure.
The overall docking time was 9.4 (±3.8) minutes and
overall operating room (OR) time was 229.5 (±70.4)
minutes. No conversions to open, laparoscopic or da Vinci
Si surgery occurred.
The gastric bypass procedures using the da Vinci Xi
Surgical System were either performed as hybrid, near-
total robotic single console or dual console near-total
robotic with laparoscopic stapling procedures. The near-
total robotic procedure resulted in very similar docking
times (11.1 versus 8.7 min, p = 0.) and OR times (218.2
versus 223.7 min, p = 0.9616) when compared to the
hybrid procedure. Besides a higher percentage of male
patients, demographic parameters including rate of con-
comitant cholecystectomy was similar when comparing
the last 28 Si gastric bypass patients to the first 28 Xi
cases. Significantly more Xi patients underwent a total
robotic procedure (p = 0.007). With similar OR times
(230.6 ± 38.5 min for Si and 226.9 ± 71.0 for Xi,
p = 0.8094) and no intraoperative complication due to
the robotic system occurred in both groups. Docking
times were significantly longer for the da Vinci Xi Sur-
gical System (6.1 ± 4.3 versus 8.5 ± 4.3 min,
p = 0.0415). Costs of a basic set of robotic instruments
including one harmonic instrument and accessories (Si) or
vessel sealer (Xi), one needles driver, one long tip for-
ceps, two Cadiere forceps, one cautery hook, one fenes-
trated bipolar forceps, necessary accessories (drapes,
cannula seals, etc.) was 25527.7 United States Dollars
(USD) for the da Vinci Si Surgical System and USD
2296.4 for the Xi da Vinci System. Details in regards to
the comparison of Si and Xi gastric bypasses are listed in
Table 1.
All colorectal procedures were performed as total
robotic single docking procedures without re-arrangement
of robotic arms. The OR time was 283.3 (±9.5) minutes for
low anterior resections and 285 (7.1) minutes for right
colectomies.
Two patients required re-intervention due to a surgical
complication: One gastric bypass patient was diagnosed
with a biliary leak due to an insufficiently sealed cystic
duct (One of two intraoperatively placed Hem-o-lock clips
(Teleflex, Morrisville, NC, USA) in insufficient location at
revision, second clip was not found in place). One patient
with a hand-sutures extra-corporeal anastomosis during a
right colectomy developed anastomotical leakage with
required surgical treatment.
For detailed general results, please refer to Table 2.
Discussion
While robotic radical prostatectomy is an established pro-
cedure confirmed by large clinical data analyses [10, 11],
systematic meta-analyses and reviews [12–14], clinical
guidelines [15] and several Health Technology Assess-
ments (Ireland: HIQA HITA 2012; UK: NHS NIHR HTA
2012), quality data with high level of evidence is still
missing for the field of digestive surgery [16]. Besides this
currently limited availability of high quality data, technical
specifications of the former versions of the da Vinci Sys-
tem pose several challenges to abdominal procedures that
might be a contributing factor for a limited use in this
surgical field. In that regards, robotic surgery has repeat-
edly been criticized for a complicated setup, a limited
ability to reach multiple abdominal quadrants without re-
arrangement of robotic arms, and re-docking and/or repo-
sitioning of the surgical cart resulting in longer OR times
and less (cost-) efficient procedures versus alternative
methods [16]. However, numerous design changes to the da
Vinci family leading to the market release of the da Vinci
Xi Surgical System in 2014 address some of the major
challenges of robotic digestive surgery: Longer instruments
allow to retract the trocar location from the targeted anat-
omy, torpedo-shaped robotic arms result in a greater range
of motion without outside collision, and changeability of
camera position offers a more versatile view of the surgical
field. These qualities in combination allow access to a
greater surgical field without re-docking, re-arranging arms
and/or surgical cart—at least in theory.
In our early clinical experience with the Xi Surgical
System, we were able to use the above-described technical
advances to shift all of our low anterior resections and our
gastric bypasses from hybrid approaches or procedures
with re-arrangement of robotic arms to total robotic pro-
cedures within the first cases after clinical implementation
of the new system. As for all other procedures including
atypical gastric resection, Nissen fundoplication, hepatic
and revisional biliary surgery, we have not achieved a
change in surgical approach with the introduction of the
novel system and no distinct advantages of the Xi Surgical
System were observed. Perhaps streamlined docking and
setup might have a positive impact on these procedures
mid- and long-term, but other significant advantages over
previous da Vinci models are not obvious at this point.
As mentioned, all Xi low anterior resections were per-
formed with a single docking approach without re-
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Table 1 Comparative data da Vinci Si versus da Vinci Xi surgical system for gastric bypass surgery
Cases da Vinci Si surgical system da Vinci Xi surgical system p value
(n = 28) (n = 28)

Age, years
Mean (standard deviation) 44.0 (11.8) 46.1 (8.1) 0.4409
Gender, n (%)
Female 16 24 0.0366
Male 12 4
Body mass index, kg/m2
Mean (standard deviation) 43.3 (6.6) 42.2 (5.8) 0.5105
Rate of cholecystectomy, n (%) 21 (75.0) 17 (60.7) 0.5544
Surgical procedure methods, n (%)
Hybrid procedure 28 18 0.0007
Near total robotic 0 10
Operating room time, minutes
Mean (standard deviation) 230.6 (38.5) 226.9 (71.0) 0.8094
Docking time, minutes
Mean (standard deviation) 6.1 (4.3) 8.5 (4.3) 0.0415
Intraoperative complications due to surgical system, n (%) 0 (0) 0 (0) 1
Material costs of standard set of robotic instruments* in 2552.7 2296.4 NA
USD
* Set includes: One da Vinci Harmonic ACE (Si) or vessel sealer instrument (Xi–Harmonic Ace not available at that point) instrument and
accessories, one needles driver, one long tip forceps, two Cadiere forceps, one cautery hook, one fenestrated bipolar forceps, necessary
accessories (drapes, cannula seals, etc.)—All by Intuitive Surgical Inc., Sunnyvale, CA, USA

arrangement of robotic arms (Fig. 2). Surprisingly, all
anatomical areas of a classical LAR (splenic flexure to pelvic
floor) were accessible with the recommended docking strat-
egy by the manufacturer. Even though the upper left
hypochondrial robotic arm is very cranial and is arranged in a
very flat angle to the pelvis, we were sufficiently satisfied with
the range of motion during the pelvic dissection and all other
parts of the procedure. While there was no fundamental shift in
technique for the right colectomy cases, the retracted trocar
position (again allowed by the new design of the Xi arms and
the additional length of the robotic instruments) led to a larger
surgical field with improved macro-view of the anatomy.
Generally, this should help with orientation and handling of
tissue particularly in large and obese patients. Remarkably, the
Xi trocar setups for left- and right-sided colorectal procedures
are extremely similar (only mirrored—Fig. 3). This reduces
the complexity of the robotic docking for colorectal teams that
should result in improved OR workflow. Again, this early
colorectal experience is biased by the limited number of
patients included in the analysis with a limited variability in
body sizes and shapes. We will further drive our colorectal Xi
experience with addition of robotic staplers and report larger
and more systematic data sets in the future.
Since the introduction of the da Vinci Xi Surgical System,
we significantly shifted our robotic gastric bypass
procedures to a more robotically involved approach. How-
ever, this transition has not been ‘‘enabled’’ but rather ‘‘in-
spired’’ by the da Vinci Xi Surgical System. As a matter of
fact, several other groups routinely perform total or ‘‘near
total’’ robotic gastric bypasses using the da Vinci Si Surgical
System and as such the Xi features are not necessary for the
implementation of this technique. Still, the transition to a
new version of the da Vinci has been an occasion to revise the
robotic use for our dominant robotic procedure. Most of the
initial Xi gastric bypass cases were performed as ‘‘near total
robotic’’ cases using laparoscopic staplers as the Xi staplers
were not available during this early Xi experience.
When analyzing the comparative data of our last twenty-
eight da Vinci Si patients to the first twenty-eight da Vinci
Xi cases, two items are most noteworthy: docking times
were 2.4 min longer when compared to our Si dockings.
While this number reached statistical significance, the
clinical impact might be of less importance considering the
overall OR times of these procedures. However, the da
Vinci Xi Surgical System with an adapted user interface
offering more assistance with robotic setup and installation
as a distinct feature-has specifically been designed to
facilitate this part of the procedure. Indeed, the system
offers a variety of anatomical setups that are chosen before
docking, has a laser targeting system (Fig. 4), which helps

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Table 2 Patient data

Cases N Technique Innovation Mean docking Mean OR-time
time (standard (standard
deviation), deviation),
minutes minutes

Roux-en-Y 28 All RYGB – 9.6 (3.8) 221.8 (69.0)

gastric bypass 18 Hybrid procedure None 8.7 (3.5) 223.7 (79.7)
10 Near total robotic, dual console Shift from hybrid procedure to the 11.1 (3.9) 218.2 (46.7)
procedure with laparoscopic maximum amount of robotic use at time
stapling (robotic stapler not yet available at site)
Revisional 1 Hybrid procedure None, but if conversion to gastric bypass all 7 (NA) 217 (NA)
bariatric of the above innovations possible
surgery
Nissen 1 4-arm total robotic procedure None 9 (NA) 131 (NA)
fundoplication
Atypical 1 4-arm total robotic procedure None 4 (NA) 175 (NA)
gastrectomy
Revisional 1 4-arm total robotic procedure None 17 (NA) 225 (NA)
biliary
surgery
Sigmoid 1 4-arm total robotic (transanal Shift from either hybrid or multiple robotic 5 (NA) 379 (NA)
resection circularly stapled anastomosis) arm position procedure
single docking procedure
Low anterior 3 4-arm total robotic (transanal Shift from either hybrid or multiple robotic 10.3 (2.5) 283.3 (9.5)
resection circularly stapled anastomosis) arm position procedure
single docking procedure
Right 2 4-arm total robotic single None 6 (1.4) 285 (7.1)
colectomy docking procedure
Overall 38 9.4 (3.8) 229.5 (70.4)

Fig. 2 Xi trocar positioning for low anterior resection Fig. 3 Xi trocar positioning for right colectomy

to position the arm beam in the optimal location and allows
to automatically arranging the robotic arms in relation to
the targeted anatomy. While all this should facilitate a
robotic setup and faster system docking, we have observed
the contrary when compared to the last Si procedures, as
well as reported times for the da Vinci Standard System
and the da Vinci Si Single Site platform [17, 18]. Despite
the technology-enhanced user interface, the larger dimen-
sions of the Xi surgical cart pose a challenge in our ORs.
Because, we have firmly installed frames for airflow
(Fig. 5), we have limited space for the robotic system in
close proximity to the patient. As such, we have to position

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Fig. 4 Xi laser targeting system
the Xi system within the frame before we can deploy the
arms. The system is too high to enter with deployed arms.
The deployment of the arms and final positioning is then
complicated due to space restrictions within the frame.
This complexity of our specific setup results in a certain
variety of docking times and has so far not yet reached the
Fig. 5 OR installation with airflow frame off ceiling
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efficiency of the docking with the previous da Vinci
models. Although these prolonged docking times might
also be a result of learning curve effects, we are certain that
challenges to docking increased with the implementation of
the Xi Surgical System in our setting. Still, we believe that
the innovations of the da Vinci Xi facilitate robotic setup
and docking for robotically inexperienced teams with ORs
without space constraints.
Another interesting finding is a cost difference in favor
of the da Vinci Xi Surgical System for a basic set of robotic
instruments that are necessary to perform a gastric bypass
in our setting. Certainly, a per-procedure advantage of
USD 256.3 is meaningful. Still, the increased capital
investment and yearly maintenance for the Xi in compar-
ison to the Si System impact the overall per procedure
costs. As such, the da Vinci Xi Surgical System appears
financially most attractive at high volume site where the
positive impact of lower instrument costs and wide distri-
bution of other posts potentially have a meaningful impact.
Besides some positive developments of the da Vinci
family, the current version of the Xi system also poses
challenges particularly in regards to yet missing instru-
ments and equipment that forces us to adapt our surgical
technique: Currently, a variety of instruments are not yet
available for the Xi system including the Harmonic scalpel.
We routinely used this instrument during gastric bypasses
as well as colorectal procedures. Thus far, we were able to
compensate by replacing with mono-polar energy devices
J Robotic Surg
or the da Vinci vessel sealer. In addition, as no other trocar
is needed for the camera (robotic 8 mm trocar used as all
arms are able to host instruments and camera), we miss the
option to introduce the first trocar under direct camera
control within the trocar (Optiview). This option is par-
ticularly useful during our bariatric cases because an open
incision would need to be relatively large. To this point, we
gain initial access with a 12 mm Optiview trocar that is
later replaced by an 8 mm robotic trocar. While we are
very confident with the quality of the access, we are
leaving a larger than necessary skin and fascial incision
with the patients. As such we are hoping for more useful
equipment to come with the latest version of the da Vinci
System in the near future.
Besides the above mentioned systematically analyzed data
points, we observed a certain rate of technical ‘‘challenges’’
with the da Vinci Xi Surgical System that we did not
encounter with previous models. While we have missed to
quantify technical errors prospectively, we feel that the latest
version of the da Vinci family reacts more sensitively to minor
deviations from the optimal handling by signaling errors.
Mostly, these errors can be overwritten or overcome by re-
booting the system. Furthermore, it appears challenging to
adjust the image to the most preferable quality to the console
surgeon. While previous models allow arranging the distance
between camera and targeted anatomy followed by a manual
focus of the image, the Xi Surgical System offers a more
complicated setup with different levels of zoom and auto-
mated focus. In addition, the image on the current version of
the da Vinci Xi Surgical System appears to offer a different
color scheme than previous models with a higher saturation
particularly in darker environments (bleeding).
Despite all our enthusiasm around the installation of the
novel da Vinci Xi Surgical System at our site a few month
ago mainly due to the advancement of several procedures,
we have to emphasize that this is very early data in a
limited set of patients. So far, data is prone to bias and
should not be directly compared to mature outcomes data
of patients who underwent da Vinci surgery with previous
models. A such, more systematic research in larger num-
bers needs to be performed to confirm our initial findings
and to precisely determine the value of the da Vinci Xi
Surgical System for digestive surgery.
Acknowledgements We thank Francoise Bernardi for the data col-
lection and Jona Misasa Mendoza for the assistance with the data
analysis.
Compliance with ethical standards
Conflict of interest Dr. Hagen received personal fees by Intuitive
Surgical Inc. outside this project. Dr. Jung, Dr. Ris, DR. Buchs, Dr.
Fakhro, Prof. Buehler and Prof. Morel have nothing to disclose.
Ethical approval All procedures performed in studies involving
human participants were in accordance with the ethical standards of
the institutional and/or national research committee and with the 1964
Helsinki declaration and its later amendments or comparable ethical
standards.
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