After completing this module, the learner should be able to:
Sarah P. Conley, MD
Fellow/Instructor Tulane University School of Medicine
Department of Urology
New Orleans, LA
Disclosures: Nothing to disclose
Steven Shichman, MD
Connecticut Surgical Group
Disclosures: Nothing to disclose
Benjamin R. Lee, MD
Professor of Urology
Department of Urology
New Orleans, LA
Disclosures: Cook Urological: Consultant or Advisor
UROLOGIC ROBOTIC SURGERY COURSE
Fundamentals of Robotic Surgery
This section will complement Intuitive Surgical's online system training.
Intuitive Surgical Online System Training
Prior to completing the AUA Urologic Robotic Surgery online course, please complete the Intuitive Surgical ® online system training course for the daVinci Robot. This will take approximately 90 minutes to complete including an assessment at the end of the course. Upon passing the assessment with 80% accuracy, print your certificate to provide documentation of your completion upon request.
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Robotic surgery has gained widespread acceptance and popularity among urologists over the past several years, allowing complex surgery to be performed through a minimally invasive approach. The daVinci Surgical System (Intuitive Surgical, Inc., Sunnyvale, CA) is the most commonly utilized clinical robotic system. It is classified as a master-slave surgical system with true 3-D visualization and EndoWrist®technology. The system was approved by the FDA in July 2000. In 2009, there are over 1,000 daVinci Surgical Systems being used to perform surgery throughout the United States.
A list of equipment necessary for laparoscopic and robotic renal surgery, as well as robotic pelvic surgery is included in Table 1. Additional equipment will be necessary for robotic renal and pelvic surgery and will be covered later in this handbook. An open tray should be either set up or immediately available in the room in the event rapid conversion to open surgery is necessary.
A minimum of three robotic ports are utilized during surgery, along with one or two assistant ports. The robotic camera fits through a 12 mm trocar. Instruments for the robotic system are available in 5 mm pediatric and 8 mm adult sizes, thus either two 5 mm or two 8 mm robotic ports are also placed (three when using a four arm system).
The instruments most commonly used in urologic robotic surgery include the monopolar scissors, bipolar Maryland grasper, ProGrasp, fenestrated bipolar electrocautery, and two needle drivers. Options for types of needle drivers include: Large, Mega, Large Suture Cut, Mega Suture Cut, the choice of which is at the user's discretion.
Similar to laparoscopic monopolar and bipolar cautery, there is less thermal spread with bipolar energy. Options for bipolar instruments include Maryland, Precise, and fenestrated bipolar instruments. The monopolar scissors have a replaceable insulating sheath which should be inspected at the beginning of the case to ensure there are no breaks in insulation. If there are breaks in the insulation sheath, it must be replaced immediately, since arching of electrocautery can occur (Figure 1). There are many other available instruments, such as the Hem-o-Lok ligation system (Teleflex Medical, Research Triangle Park, NC), Potts scissors, dissecting forceps, harmonic scalpel, bowel grasper, cautery hook tip, and deBakey forceps. The robotic instruments are disposable and the majority have a limited lifespan of ten uses before expiration, the exceptions which may be surgeon dependent for use, include the fine tissue forceps which are 15 uses, the harmonic curved scissors which are 20 uses, and the clip applier which has 100 closures.
Bedside Assistant Laparoscopic Instruments
The bedside assistant will require additional instruments including a laparoscopic needle driver, grasper, suction irrigator, scissors, Hem-o-Lok ligation system and Lapra-Ty ligation system (Ethicon). For robotic-assisted laparoscopic partial nephrectomy, the assistant will also need laparoscopic bulldogs with applicator and remover (can be used to both apply and remove bulldog clamps) or Satinsky clamps for hilar occlusion (Figure 2A, 2B, and 2C), as well as a laparoscopic ultrasound.
The surgeon console typically sits in a corner of the operating room, depending on the room configuration. In the newer generation system (Si), the optical viewer, arm rest and foot pedals can be easily adjusted for surgeon comfort and improved ergonomics. The surgeon should take time to establish comfortable, ergonomic settings on the chair and console in order to avoid neck, shoulder or back strain.
Robotic Patient Cart
The Robotic system is covered with sterile drapes by the scrub nurse, with white balance, calibration and setup completed prior to the patient entering the room. It is our practice once the robot is sterilely draped, to cover with a gown to prevent inadvertent contamination prior to docking.
The main laparoscopic tower is typically placed on the side opposite of the surgeon achieving pneumoperitoneum and placing trocars prior to docking the robot. The tower contains a video monitor, the light source, camera source and CO2 insufflators, as well as preferable the electrocautery generator. The CO2 insufflator is placed within the surgeon's view to allow for continuous monitoring of the intraperitoneal pressure. A second video monitor is placed in view of the second assistant and scrub nurse.
Operating room set up and patient positioning are crucial to the success of these procedures. Suboptimal positioning not only can lengthen operative times and lead to surgeon frustration, but lead to devastating complications.
Robotic Renal Surgery
Patient positioning for transperitoneal robotic surgery is similar to that of laparoscopic surgery. The patient is placed in a modified lateral or semilateral decubitus position (Figure 3A and Figure 3B ). The ipsilateral side of the patient is elevated 30-45 degrees using gel rolls. The bottom leg is flexed and the top leg is left straight or gently bent over pillows resting between the legs. When the four arm robot is being used additional working space can be obtained for insertion of the fourth arm trocar by flexing the table. In these cases the umbilical line should be placed over the flex point of the table and flexion of the table fifteen to twenty degrees will increase the space between the costal margin and iliac crest. The chest and hips and legs are secured to the table with three inch silk tape. The ipsilateral arm can either be padded and secured in a modified "sling" position, similar to the position used by orthopedics for clavicular fractures or placed on a neuro arm rest. The neuro arm rest allows added access for intravenous lines or blood pressure monitoring but if used the positioning of the arm should be kept low and cephalad to prevent potential collision with the most cephalad robotic arm (right arm for right sided cases and left arm for left sided cases). The contralateral arm should be secured to an arm board. Alternatively, the ipslateral arm of the patient can also be placed alongside the patient's chest and abdomen if is securely padded and taped, for renal surgery, to prevent collision with the robot's cephalad arm. All pressure points are padded with corrugated foam or gel pads. An axillary roll is not necessary in using the modified lateral or semi-lateral decubitus position. Prior to draping the patient, lateral and supine rotation of the patient should be performed to ensure patency of IV access and most importantly the security of the patient. The table can be rolled in a more supine position when obtaining initial access and insufflation of the peritoneum and then rotated to a more lateral position prior to docking the robot.
Positioning for retroperitoneal robotic renal surgery is similar to open nephrectomy. The patient is placed in full lateral position in the center of the table with the kidney rest elevated slightly and the table flexed. An axillary roll is placed to prevent brachial plexus injury. The docking of the robot with retroperitoneal approach is different in that the robot comes over the head, whereas with transperitoneal surgery the approach is angled from over the shoulder in alignment with the axis of the kidney hilum.
Robotic Pelvic Surgery
For robotic pelvic surgery the patient is ultimately placed in steep Trendelenburg position with the legs in low lithotomy position. (Figure 4) This position allows gravity to pull the abdominal viscera away from the operative field and allows the assistant to access the perineum and genitalia intraoperatively. The operating table is prepared with gel pads taped to the table and a folded sheet placed under the gel pads to facilitate securing the arms. The friction between the gel pad and the patient's skin will help prevent cephalad slippage or movement when the table is in full Trendelenburg position. The patient is placed in supine position with the buttocks at the end of the table break. Prior to induction of anesthesia, compression stockings and sequential compression devices are placed on the patient's lower extremities. The legs are placed in Allen Yellowfin stirrups (Allen Medical Systems, Acton, MA) with the knees flexed. The foot of the table is then lowered until it is perpendicular to the floor. Care should be taken to align the toe, knee and opposing shoulder, to ensure the heels are touching the heel of the boot, and to check that the calves have adequate space to avoid popliteal artery occlusion, peroneal nerve injury 2 or the devastating complication of lower extremity compartment syndrome.3,4 The anesthesiologist should evaluate the position of the patient's head before and after applying Trendelenburg position in order to monitor for slippage. The arms are tucked at the patient's side with the pre-placed sheet placed under the gel pad. The fingertips are positioned at the anterolateral thigh. The elbows and wrists are protected with gel padding, and small foam rolls are placed in the patient's hands. Care should be taken to ensure that vascular lines and the pulse oximeter are properly functioning. The arms should be secured low enough for the prepped field to include the area lateral to the anterior superior iliac crest. Obese patients may require an arm board on the side of the table to support the arms or three inch cloth tape across the chest to prevent cephalad slippage. According to surgeon preference, routine taping the shoulders in a harness fashion may lead to brachial plexus injury, and obese patients may require additional taping to prevent sliding on the table in Trendelberg position.5,6
After initial insufflation and port placement, the patient should be placed in steep Trendelenburg position. The robot is brought in for docking between the legs. The Allen Yellowfin stirrups should be low enough to accommodate the robot. Once the robot is docked, there should be no additional manipulation of the table position.
Stereoscopic (3D) Visualization
The daVinci Surgical System is an impressive improvement over conventional laparoscopy for complex renal and pelvic surgery. Stereoscopic (3D) visualization provides superior depth perception. In addition, the surgeon no longer relies on the assistant to move the camera as the robotic console allows for camera repositioning and focusing with simple hand movements when the foot pedal camera control is activated. A setup joint malfunction is a recoverable event. If one of the cables or the camera head malfunctions, the field of view will appear in 2 dimensions, or monocular appearance, which is a non recoverable system error.
Articulating Instrumentation Capability
The EndoWrist® instruments simulate the natural movement of human hands and wrists, thus enhancing dexterity. The system allows for six degrees of freedom, 90 degrees of articulation, fingertip control, motion scaling and tremor reduction.
The daVinci Robotic System has an ergonomic design that allows the surgeon to operate from a comfortable, seated position at the console. The eyes and hands are positioned in line with the instruments. The instruments are controlled by the surgeon with simple movements of the hands and by manipulating the foot pedals.
The 0 degree, 30-down, and 30-up camera lenses provide superior magnification. This permits the surgeon to perform complex dissection during minimally invasive surgery. Camera position in renal surgery will typically be a 30-down for medial camera positioning and 0 degree or 30-up for more lateral camera placement. For pelvic surgery, the zero degree lens is sufficient, and if the pubic symphysis causes difficulty in visualization of the apex of the prostate, one may switch to the 30 degrees up lens to improve visualization.
As with most highly technical pieces of equipment, the daVinci Surgical System may require intraoperative trouble shooting. The following is description of common challenges encountered during robotic surgery and possible solutions.
Laparoscopic lens fogging is a frustrating component of robotic surgery. The most common reason for laparoscope lens fogging is condensation of moisture from the peritoneal cavity as the carbon dioxide rapidly expands and cools as it enters the peritoneal cavity. The easiest way to help prevent fogging is to attach the insufflation tubing to a trocar not being used for the laparoscope. Fogging can also be prevented by keeping the laparoscope warmed in a thermos or water bath until it is ready for use. Antifog solution is not recommended for use on the robotic lens. The bedside assistant can apply suction with the aspiration-irrigation apparatus in front of the lens. The lens can be immersed in the warm water periodically throughout the case as necessary. Use of heated insufflation gas in preventing fogging is debatable, as it requires additional specialized tubing and added expense.
Docking of robot and seating of trocar to robotic arms. Docking of the patient side cart with the first generation device requires full placement of the robot arm base onto the robotic 8mm trocar, insertion of 2 screws which are then tightened to complete the procedure. With the S and Si system, docking of the robotic arm to the trocar has been simplified to compression of 2 side "wings" which close around the head of the trocar.
Instrument collision outside of the body can both damage the robotic system and injure the bedside assistant, cause malfunction of the robotic instruments or cause inadvertent internal injury to the patient. Moving the "shoulder" of the robotic arms as high as possible and laterally will help minimize any collisions. It is important for the surgeon to understand the position of the instruments outside of the body relative to the working field. Placing the assistant ports as far as possible from the robotic working ports allows the bedside assistant to have a safe working space.
Inadequate range of motion is usually due to poor initial trocar placement. Each trocar should be placed at least 8 cm from other trocars to maximize range of motion. During a guided tool change, the release handles are depressed, and the instrument withdrawn, the camera does not have to be moved when performing a guided tool change, as the depth of insertion will be identical to the previous position.
Restricted instrument reach during surgery can result from multiple factors, such as suboptimal alignment of the robotic arms, body habitus, operating at the extremes of the surgical field and from the trocar positioning outside of the intended level of the fulcrum at the skin level. There is a solid black ring midway on the shaft of the robotic trocar which should be positioned at the inner abdominal level. The bedside assistant can reposition the robotic arms or adjust trocar depth. It is important that the assistant always perform this adjustment while maintaining direct visualization of the instruments tips.
Please check for adequate insulation of robotic monopolar scissors and other laparoscopic instruments.
The robotic system may also provide the surgeon with various error messages. There are recoverable and non-recoverable faults that may lead to surgeon handicap, conversion to standard laparoscopic or open approach and/or case abortion. Intuitive Surgical Systems, Inc. provides a 24 hour a day customer service line for assistance with error messages as part of the service contract.
Additional information about daVinci Surgical Systems can be found at www.intuitivesurgical.com.
|List of Basic Equipment for Robotic Surgical Procedures|
|Mobile video cart with monitor|
|Secondary video monitor|
|C02 insufflator with C02 tank or wall supply|
|CO2 insufflation tubing|
|Camera, high-resolution and control box|
|0 degree and 30 degree robotic laparoscope|
|Aspiration-irrigation system with double canister suction apparatus|
|1 Veress needle|
|1 11 blade for trocar incisions|
|2 12 mm trocars for camera and assistant|
|2 5mm or 8 mm robotic trocars|
|1 5 mm trocar assistant trocar (optional)|
|2 Robotic needle drivers|
|1 Robotic Maryland bipolar|
|1 Robotic monopolar scissors|
|1 Robotic Prograsp|
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