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 February 9, 2024

78 Year Old Woman Dies After Surgical Robot Burns Hole In Intestine

A life lost to modern medicine's edge.

A Florida woman's journey to combat colon cancer ended tragically after a surgery involving a robotic system led to fatal complications.

Sandra Sultzer, a 78-year-old resident of Boca Raton, succumbed to her ailments in 2022, not long after what was supposed to be a life-saving operation for her colon cancer. Utilizing the da Vinci robotic surgery system, her procedure in September 2021 at the Baptist Health Boca Raton Regional Hospital took an unfortunate turn.

The root of the tragedy was traced back to what the lawsuit alleges was a failure in the equipment's design—specifically, cracks in the rubber sleeves of the robotic arms. These imperfections permitted the escape of electrical energy, unnoticed by the operating team, which resulted in the burning of a hole in Sultzer’s small intestine. This incident illuminates the grim truth of technological advancements: that with great innovation comes great responsibility.

An issue within the da Vinci system

An analysis by NBC News, uncovering over 20,000 adverse events linked to the da Vinci system between 2008 and 2018, casts a long shadow over its success. The narrative of progress is tainted by stories of injuries and fatalities, including instances where the device malfunctions went unreported.

The FDA's 2013 investigation into Intuitive Surgical, the company behind the da Vinci system, revealed a worrying pattern of negligence. Information about known injuries was not adequately disclosed, painting a picture of a medical innovation marred by secrecy.

This isn't an isolated incident. The lawsuit pinpoints recurring issues with the robotic system, highlighting previous reports about the faulty rubber sleeves that went unaddressed. The case brings to light the ongoing struggle between advancing medical technology and ensuring patient safety. As with any significant technological adoption in medicine, rigorous testing and oversight become indispensable.

One of the lawsuit's poignant criticisms concerns the training of surgeons operating the da Vinci system. It suggests a critical mismatch between the technology's sophistication and the medical professionals' preparedness. While defending its commitment to safety, Intuitive Surgical emphasizes the importance of continuous training. However, the question remains whether these efforts suffice in mitigating the risks associated with such complex devices.

FDA scrutiny and community response

In the wake of these revelations, commitments to patient safety and rigorous training protocols have been questioned. Intuitive Surgical's statement highlights their dedication, yet the sheer number of adverse event reports suggests a disconnect between ideal practices and real-world outcomes.

According to the lawsuit:

Had ISI safely designed its product so that stray electrical energy would not burn the insides of patients without the knowledge or control of the operating surgeons, the small intestine injury to Mrs. Sultzer would not have happened, and she would not have died.

The company also insists on the importance of ongoing training for surgeons, stating, "Our training, systems, and technologies reflect, and are informed by, our commitment to patient safety, so we offer a comprehensive, intensive training program on our technology." Yet, this assertion does little to console a grieving family and a community troubled by the potential hazards of modern surgical procedures.

The broader implications of medical technology

Moreover, the UK coroner's investigation into a patient's death highlighted similar concerns regarding the da Vinci robot and inadequate surgeon training. The issue transcends national boundaries, affecting global medical practices. The da Vinci robots, according to Intuitive Surgical, have been used in approximately 12 million procedures, which implies a vast potential for either benefit or harm. The volume of procedures underscores the importance of ensuring every aspect of the technology is as safe as possible.

Fatalities and device malfunctions raise essential questions about the balance between innovation and safety. As technology becomes inherently embedded in medical practices, the oversight mechanisms must evolve correspondingly. For all its potential, the da Vinci system has become a focal point for broader discussions about how medical devices are integrated into healthcare systems.

The call for improved design and training is loud and clear. As Intuitive Surgical points to its assertions of commitment and recommended practices, the medical community and regulatory bodies face the challenge of implementing more rigorous standards to prevent another tragedy. Sandra Sultzer's story reminds us that there is a human story behind every medical device statistic.

Why this story matters

The ordeal of Sandra Sultzer sheds light on the ethical and safety responsibilities incumbent upon medical technology companies. It highlights a pressing issue in healthcare: ensuring the safety of patients as they undergo treatments involving advanced technologies. This tragedy is a stark reminder of the risks involved and the utmost importance of oversight in medical innovations. Understanding and addressing these challenges is crucial for the community at large to trust and embrace the benefits of modern medical procedures without fearing for their lives.

Lessons to learn from this tragedy

1. Always inquire about the risks associated with any medical procedure, especially those involving advanced technologies. Understanding its potential side effects is crucial, no matter how promising a technological solution may seem.

2. It is essential for healthcare providers to undergo continuous and comprehensive training. This training should not just be at the start of using a new system but throughout their careers to ensure they remain adept at handling the technology safely.

3. Regulatory oversight needs to be stringent and transparent. Reports of adverse events should prompt immediate reviews and actions to prevent future occurrences. Remember, though these steps are vital, crime or accidents can happen to anyone, and victims are never to blame for their suffering.


  • A tragic fault in medical technology led to Sandra Sultzer's death.
  • Lawsuit against Intuitive Surgical raises questions about device safety and surgeon training.
  • Over 20,000 adverse events related to the da Vinci system were reported to the FDA between 2008 and 2018.
  • The need for improved design, training, and regulatory oversight is evident.
  • This story underscores the importance of balancing innovation with patient safety in medical technology.

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Written By: Rampart Stonebridge

I'm Rampart Stonebridge, a curious and passionate writer who can't get enough of true crime. As a criminal investigative journalist, I put on my detective hat, delving deep into each case to reveal the hidden truths. My mission? To share engaging stories and shed light on the complexities of our mysterious world, all while satisfying your curiosity about the intriguing realm of true crime.
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