Full Interviews With 2 European da Vinci Surgeons About The TransEnterix Senhance

11/11/2017 at 6:06 PM

Extensive Conversations With Two European Da Vinci Surgeons

The following are two extensive conversations Adam Gefvert, CFA, the head analyst for White Diamond Research, had with two European surgeons. We discussed both the da Vinci and the Senhance.

The first conversation was with Dr. Shahab Siddiqi. He’s a colorectal surgeon in the UK. He has extensively studied and experimented with the Senhance, and even met the creator. His hospital is going to buy the new Da Vinci Xi in a couple months. He had good and bad things to say about both the da Vinci and the Senhance.

The second conversation was with Dr. Joachim Thuroff. He’s a urologist, and does several da Vinci surgeries per day. He does surgery in Manheim University and also sees patients post surgery. He attends many industry conferences all around Europe.

The questions in both interviews are from Mr. Gefvert.

Dr. Shahab Siddiqi

Most people think the da Vinci is the only thing going. In the UK, a new robotics system to come in isn’t easy.

Does the da Vinci have better ergonomics?

Um, yes, but that might be a biased statement because I’ve done 170 operations with the da Vinci.

The sitting position is very comfortable in the Senhance. That thing about moving the camera back and forth with your head, that’s something that needs to be learned. Is it useful? It’s a tough one, once you get used to it, maybe it does become useful. Ergonomically, I don’t think there’s much in it.

Do you think the Senhance will sell in the US?

No prosthetic surgeon who uses a da Vinci for prostate cancer will move to the Senhance. They aren’t even contacting urologists, they are contacting general surgeons. Up and lower Gi is a place for an expansion, and it will be very hard for them to break that market. With the price structure as well. If they were half the price, that’s different. But to come in at the same price as the da Vinci and saying that your cheaper in the long run is a difficult statement to make to someone I think.

I was surprised at the price they were asking, and the level of development. The da Vinci XI is way beyond the S and the SI, yet it is the same price as the Senhance.

We were offered the same price, the XI for $1.5M. And the Senhance was the same price. Whether it’s the same cost in the long term, I don’t know.

Regarding the Senhance:

With standard laparoscopic equipment, the way you’d hold it in your hand, is the handle would go vertically upwards. Some people do at angles, but the ideal position is your hand is straight up, with your arms by your sides so you don’t get fatigued. Now if you held the Senhance that way, the handles and everything go into your knees while in the sitting position. So actually, the Senhance handles, you have to hold at 45 degrees, if not slightly more so you are immediately operating at an angle which isn’t natural for a laparoscopic surgeon. That can be learned and changed, that’s not an issue.

The lack of haptic feedback is actually an overblown thing in a robotic platform. As surgeons, we all learn surrogate markers to look for strength, distance, whatever we’re doing. Because on a 2D platform, we learned to do things in a 3D manner, for surrogate markers, by where you are, the darkness, reflection of light, wherever you are. Now on the Senhance, it isn’t a natural pull. They give you a slight tug a surrogate marker of tension. It’s not very useful, it’s not very necessary.

The vision because you can have someone else’s camera to make it 3D vision, we have a 3D setup in our non-robotic theaters already which gives you a better view than the Senhance 3D. But that’s OK, that’s not a big deal.

It feels to me, that the Senhance is a good option, but it’s still not there yet. It has potential, and one of the good things it does, is the pivot points.

The wristed instruments are further down.

You know the black line on the trocars of the da Vinci. There’s a big thick black line. That’s the line that the instrument will pivot around so therefore it creates minimum interference with the fascia so you don’t have a massive fascial defect when you close the fascia. If it’s too big, you’ll get incisional hernia, and more pain.

Now, the da Vinci you have to be very careful where you put it. But the Senhance has a very clever technique where your instrument pivot point is by itself. So it will pivot to the right place every time so that’s very very good. That’s well above the da Vinci.

The arms of the Senhance are massive, so you need a big theater to operate in, not huge, but a big theater, and the assistants have to dodge and weave around the big arms in order to be a good assistant to the surgeon. Is it any more or less fatiguing than the da Vinci? It’s no differnet. Is there a better ergonomic position with the Senhance? Maybe slightly but not with the way the arms are in a slightly pronated position. It’s not a natural laparoscopic thing, but it is an in between instrument, it isn’t a standard da Vinci on a robotic platform. It’s a laparoscopic platform where you can do laparoscopic work using a robotic equipment. You can used non-wristed or wristed equipment and the expense goes up accordingly. But it’s actually quite expensive, it’s $1.5M, and that’s not that far off from a Da Vinci XI. They’re suggesting you’ll save money by using your own equipment and your own stuff as necessary. And also the Senhance will replace the instruments for free as they get worn out, which is not that much cost savings. So it might be cheaper in the long run.

Dr. Joachim Theroff

I go to the national and international meetings, only the major meetings. I don’t search for industry contacts, because usually I get the information that people bring to me. So there was nothing from this robot.

I go to the Germna urological association. EGU. EAU. The European association for urology. The AAU. American association for urology. I didn’t go last year, but usually I go every year. I go to the pelvic surgeons. I go to the geo surgeons.

Just 3 weeks ago I was at the in Societe international d’urologie in Lisbon.

I’m a urologist, I sometimes go to gynacalogical societies when I’m invited as speaker, but not normally.

But for instance, the society of pelvic surgeons is primarily gynecological society, with 50% gynacologists, 25% gastrointestinal surgeons, and 25% urologists. That’s an exclusive society founded in the US, I’m going there, I’m a member there. They haven’t mentioned the Senhance there.

I was not aware that the new machine was on the market in Europe or Germany. There has been no advertisement.

I get quite around on medical meetings, and there has been no representative on the company or show on the company. I know that some companies are in the progress to come to market with new developments like Olympus and I know another Japanese company has a robot but they all did not present in Europe so far in Germany.

No I have not heard of Transenterix before. (they have been aggressively marketing this machine since 2015) – that is a surprise to me because I’m in 2 of the centers, prefiously in Mines, and we started in robotic surgery in 2007, and now I’m in Manheim, they started the robotic program in 2008 or 2009, and in these places this robot is not known. They have not gone to surgeons, at least not in urology.

I do surgery every day and 3 days of the week I work in the University of Manheim. Those 3 days I work with the robot.  I’m in Mines where I see outpatients, so I intensively work with the robot and I’m trusting the program. I do it openly, and in the program to get the knowledge and technical skills to do it robotically.

I do laparoscopic surgery with the da Vinci every day. Only use the da Vinci, don’t do it by hand.

I never was doing traditional laparoscopy. I’m basically an open surgeon. When I was the chair of the department in 2007, I didn’t intend to do the robotic surgery myself, but then it happened, I got involved and I do it quite a bit, I do prostate of course, kidney, hydroplasties, those are the main things I do.

I don’t do hernias. As a urologist, you don’t’ see too many hernias. Since I’m in the field of doing radical prostectomy, I see the laparoscopic surgery the surgeons do, I don’t like. They put in the mesh and sometimes they leave a mess behind and everything is concrete. For me a hernia is for open surgery and not laparoscopic surgery and putting in meshes. So I believe strongly that this is nonsense. And I’ve taken out so many meshes from patients who had meshes implanted from surgeons, and the pain and other problems. But the main reason is you see if you do pelvic surgery, you see from the mesh implantation all the complications and the problems.

Gynacological surgery I don’t do. But in the time I was working in Mines, a good friend of mine who was the chief in gynecology they did some cases with our robot, but for me it wasn’t so clear where the indications are because obviously you can do a hysterectomy in conventional laparoscopy techniques and don’t really need the robot, while in urology you have a reconstructive element in radical prostolectomy? and kidney tumor and hiroblasty? Where the suturing is a big advantage. Just taking an organ out, they also do kidney hysterectomy with the robot. But this can be done with conventional laparoscopy. I think the surgeries for prolapse? Coprosacropexia and so on, that’s a good indication for the robot. But I’m not sure hysterectomy is a good indication, but htat’s not my position, not my specialty.

We just have the new robot, 1.5 years ago. It’s an XI with new consoles, it’s the newest model. It’s much faster to set it up and put it in. The instruments are smaller, no so bulky, has less clutching, and have a longer way to go. It’s not so different, in Mines, the SI and now we have the XI, it’s not so different, it’s more practical the draping is much faster, easier, and also the alignment when u insert the instruments is faster, and you can do a little more with it than the old one. It was $2.3M Euro, with 2 consoles. It’s expensive. Our hospital gets a good price. In our hospital we get the same price doing the hysterectomy open or with the robot. With the cost of the robot and disposables, we make 3k Euro more expenses to the robot company and disposables as compared to doing open surgery. People are unhappy. In our system we don’t’ have extra reimbursement. If we do it robotically, it is simply more expensive than if we did it open. It’s an economic burden to the hospitals. Some indications like radical hysterectomy? You can hardly convince patietns to have it openly done. There has been development which has been much slower in Germany than in the US. We don’t have that in Germany. The Senhance is only $1.5M. Would that make a big difference with hosptials? Yes, price is important. With Intuitive, the robot is excellent, the service is excellent. No failures. So it works, but everyone is setup with the politics of the prices of the disposables, you can only reuse it 10 times, but everyone is convinced you can use it 20 times, and they say that for sales reasons, not safety reasons, but they say that’s for safety reasons, and so on. So they use their monopoly situation very well, that’s’ OK, but if there’s equally good machine available at a lower price, not only the purchase price, but disposables, because that is a big problem for our system. Then people would be willing to look into it.

“read what Helios said, negative on the Senhance”

I cannot judge on this, because I don’t have experience with the Senhance. I have only seen the video and it doesn’t give so many details. And even if it works, you have to put the hands on for the experience. If the needle drivers and so on are not wristed, then that would be a major disadvantage obviously, because this is one of the main advantages of the da Vinci, that you have working ergonomics that are very good and effective.

All of the instruments are wristed with da Vinci. Whether you have the needle driver, or forceps or scissors, they are all wristed. The advantage of being wristed is it’s very difficult to get the right angle without. The whole suturing with laparoscopy is a mess, because it takes forever, the needle is a certain angle in order to get the results you want, you work like conventional surgery with your hands. You take the angle which you need, the needle is in the needle holder with a right angle, nad you’re turning your wrist. It’s a big advantage and if you have a robot without wristed instruments, forget about it.