The da Vinci X is part of the 4th generation of the da Vinci surgical system. Released after the da Vinci Xi and before the SP, it was developed as a cost-effective alternative within the newer generation. The X is a hybrid design that combines elements from both the Si (3rd generation) and the Xi. Specifically, it features the Si’s patient-side cart platform and the Xi’s distal robotic arms.
The cost savings primarily come from the platform architecture. Like the earlier da Vinci models, the X’s cart is built as a central column, with one robotic arm attached to each of its four sides. This configuration closely resembles the Si, but with a significant upgrade: it supports Xi-compatible instruments at the distal end. This allows for longer-term support, interchangeability with Xi instruments, and greater flexibility in arm use.
In the Standard, S, and Si systems, the endoscope was mounted on a specific, uniquely designed arm, different from the others due to the weight of the camera head, and the need for a counterbalance. In these older systems, instrument arms were color-coded in the Standard (yellow, green, red), and later numbered in the 2nd (S) and 3rd (Si) generations (1, 2, 3). The endoscope arm was not numbered.
With the Xi and X systems, all arms are now numbered 1 through 4 and are structurally identical in the distal part, allowing any arm to be used for the endoscope. This is a key evolution.
TORS and the da Vinci X
Transoral Robotic Surgery (TORS) was originally developed using the da Vinci Standard system, typically using only two instrument arms and the endoscope. The third arm (located at the back of the cart) was unused. However, to allow access to the mouth, the cart needed to be very close to the patient, angled approximately 30° relative to the surgical table, and often partially tucked under the table.
The Xi platform improved this by allowing a more distant and flexible positioning of the patient-side cart. Interestingly, although the X shares the older Si platform design, it does not require the same restrictive setup. The key lies in the flexibility of the arms.
The Trick: Using Arm 4
The breakthrough setup technique involves using the rear arm (Arm 4) for instruments. Here’s how it works:
- If approaching from the left side of the patient:
- Fold Arm 1.
- Mount the endoscope on Arm 3.
- If approaching from the right side:
- Fold Arm 3.
- Mount the endoscope on Arm 1.
This configuration is not possible with the older systems, where the endoscope was limited to a specific arm (it would be arm 2 in the current numbering). With the da Vinci X, this new approach allows the patient-side cart to remain parallel to the surgical table, significantly simplifying the setup for TORS—even more so than with the Xi.
I’m not sure who first described this set-up, but I must say: it’s a brilliant idea.
J Granell. May 26, 2025
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