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5 mm
5 mm
Short stitch Long stitch
15 Fundamentals ofLaparotomy Closure
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211
site infection rates [32] compared with the traditional closure (Figs.15.9 and 15.10).
Recommendations vary regarding which structures should be included in abdominal closure.
Traditionally, a mass closure technique of suturing fascia and muscle was recommended; however, some experimental and clinical studies
recommend closure of the aponeurosis only [16],
although no rm conclusions can be drawn, since
there has been no clear denition of closure methods. Due to this, the European Hernia Society
guidelines proposed dening mass closure as a
Fig. 15.9 Fascial closure using the small bites technique
of 5mm fascial bites and 5mm advances
10 mm
Fig. 15.10 Schematic showing two different types of
laparotomy closure. Recent literature has supported the
short stitch technique using 5mm fascial bites and 5mm
advances compared with the traditional 1cm fascial bites
and 1cm advances
10 mm
suture bite including all layers of the abdominal
wall except the skin, dening layered closure as
an incision closed with more than one separate
layer of fascial closure, and dening single-layer
aponeurotic closure as suturing the abdominal
wall fascia in one layer [15]. Whether to close the
peritoneal layer separately during laparotomy closure is debated; however, no short- or long-term
benets from this technique have been reported
[33], so this has not been recommended [15].
15.4 Current Controversies/
Future Directions
Current laparotomy closure controversies relate
to the lack of strong evidence for closure in
patient groups that have not been well studied in
current literature. While the evidence is convincing for the short stitch technique for laparotomy
closure, one major criticism is that the data are
from European studies, which include patients
with a lower body mass index (BMI) compared
with the United States population. Another
unknown is the ideal laparotomy closure methods for patients undergoing emergency surgery. It
is unknown whether the short stitch concept
applies to the higher BMI patients or to patients
that undergo emergency surgery. However, if you
believe in the concepts related to this closure
method, it makes sense that this technique would
apply, although further research is needed.
One major factor related to laparotomy closure that has not been well studied is fascial tension. The amount of tension placed on the fascia
during laparotomy closure may effect incisional
hernia formation and ischemia development. An
old adage related to the closure of fascia (or other
suture closure techniques) is “approximate, don’t
strangulate.” While many surgeons subscribe to
this with regard to laparotomy closure, it is a difcult factor to measure and can be very subjective and surgeon dependent.
The future direction of laparotomy closure
includes creating accurate predictive models of
risk factors for incisional hernia development.
Undoubtedly, some patient groups are at risk
even when applying appropriate laparotomy
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W. W. Hope and M. J. Rosen
closure principles. For these patients (such as
patients with abdominal aortic aneurysms), the
use of prophylactic mesh augmentation has
been proposed and has shown efcacy [34].
Education will be critical, since some surgeons
are still not using the short stitch technique or
adhering to other principles related to laparotomy closure. Future technological advances
will also have a major impact on laparotomy
with the potential development of devices such
as automated sewing machines to help minimize
variability and improve efciency of fascial closure techniques.
With continued advances in minimally invasive surgery, improvements in surgical techniques
and education related to laparotomy closure, and
the potential use of prophylactic mesh in highrisk patients, there may be a day when incisional
hernias no longer exist.
Take-Home Points
• Surgeons performing laparotomies
should have a basic understanding of
wound healing principles and abdominal wall anatomy.
• Laparotomy closure should not be a
neglected part of abdominal surgery,
and evidence-based closure techniques
should be taught.
• A slowly absorbable monolament suture
should be used for laparotomy closure.
• Laparotomy closure should be achieved
using a 4:1 suture to wound length ratio
and using a small stitch technique in
appropriate patients.
• Suture to wound length ratio should be
calculated following laparotomy closure
to ensure an adequate 4:1 ratio is obtained.
Suggested Readings
Muysoms FE, Antoniou SA, Bury K, Campanelli G, Conze
J, Cuccurullo D, de Beaux AC, Deerenberg EB, East B,
Fortelny RH, Gillion JF, Henriksen NA, Israelsson L,
Jairam A, Janes A, Jeekel J, Lopez- Cano M, Miserez M,
Morales-Conde S, Sanders DL, Simons MP, Smietanski
M, Venclauskas L, Berrevoet F, European Hernia
S.European Hernia Society guidelines on the closure
of abdominal wall incisions. Hernia. 2015;19:1–24.
https://doi.org/10.1007/s10029-014-1342-5.
Israelsson LA, Millbourn D.Prevention of incisional her-
nias: how to close a midline incision. Surg Clin North
Am. 2013;93:1027–40.
suc.2013.06.009
Hope W. Prevention of incisional hernia development.
Minerva Chir. 2011;66:145–52.
Deerenberg EB, Harlaar JJ, Steyerberg EW, Lont HE,
van Doorn HC, Heisterkamp J, Wijnhoven BP,
Schouten WR, Cense HA, Stockmann HB, Berends
FJ, Dijkhuizen FP, Dwarkasing RS, Jairam AP, van
Ramshorst GH, Kleinrensink GJ, Jeekel J, Lange
JF. Small bites versus large bites for closure of
abdominal midline incisions (STITCH): a doubleblind, multicentre, randomised controlled trial.
Lancet. 2015;386:1254–60. https://doi.org/10.1016/
S0140-6736(15)60459-7.
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Fundamentals ofRobotic Surgery
https://t.me/med1917
TomokoMizota, VictoriaG.Dodge,
andDimitriosStefanidis
16
16.1 Introduction
16.1.1 The Advent of
Robotic Surgery
Advancements in technology have revolutionized
surgery, rst with the introduction of laparoscopic
surgery and more recently with the advent of robotic
surgery. The original idea of the current robotic
surgery system began with the concept of “telepresence” at the National Aeronautics and Space
Administration (NASA) [1]. NASA researchers created a virtual reality system that could be
remotely controlled to operate in space. This system
displayed a three-dimensional (3D) graphic image,
which seemed to surround the viewer in an imaginary environment [2]. This idea was introduced to
surgery in the 1980s allowing surgery to be performed remotely by an expert surgeon transferring
his/her skill techniques to the patient site. In 1997,
the rst telepresence surgery cholecystectomy was
performed in Belgium [3]. After being approved
for clinical use in the USA in 2000, robotic surgery
has been applied to diverse surgical procedures in
a variety of disciplines, such as urology, general
surgery, gynecology, neurosurgery, orthopedics,
and cardiac surgery [4]. The number of procedures
performed by robotic surgery has been constantly
increasing since its introduction. According to the
annual report of Intuitive Surgical Inc. (Sunnyvale,
CA), which has developed the da Vinci® Surgical
System, approximately 563,000 procedures were
performed across specialties in the USA in 2016
[5] up from just under 300,000 procedures in 2011
for an approximate 190% increase in case volume
over the past 5years [5].
16.2 Features ofRobotic Surgery
16.2.1 Advantages ofRobotic
Surgical Systems Over
Laparoscopic Surgery
Several technological limitations in laparoscopic
surgery have made the learning curve long and
difcult. A robotic surgical system has been
developed to address constraints of laparoscopy
in addition to enabling telepresence surgery
[6, 7]. Table16.1 lists specic features of robotic
surgery, which address limitations of laparoscopy
and make difcult tasks easier, resulting in
improved operator workload.
T. Mizota · V. G. Dodge · D. Stefanidis (*)
Department of Surgery, Indiana University School
of Medicine, Indianapolis, IN, USA
e-mail: dimstefa@iu.edu
© Springer International Publishing AG, part of Springer Nature 2018
F. Palazzo (ed.), Fundamentals of General Surgery, https://doi.org/10.1007/978-3-319-75656-1_16
16.2.2 Three-Dimensional Imaging
Traditional laparoscopes show surgeons the operating eld in two-dimensional (2D) images on a
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Table 16.1 Advantages of robotic surgical systems over
laparoscopic surgery
Laparoscopic
surgery Robotic surgery
Image quality Two-
Movements Reversal/
Motion scaling Amplied Favorable
Tremor Amplied Eliminated
Degrees of
freedom (DOF)
Camera
platform
Ergonomics Restricted Improved
dimensional
fulcrum effect
5 DOF 7 DOF
Unstable, held
by assistant
Threedimensional
Natural intuition
Stable,
controlled by
operator
screen. Surgeons are required to recognize 3D
anatomy from 2D images, which makes laparoscopic surgery challenging and highly demanding. In contrast, the camera system in robotic
surgery is stereoscopic, allowing surgeons to perform procedures watching 3D images. The binocular imaging system reduces surgeon workload
and improves depth perception and precision during surgery [8].
Robotic systems have several levels of motion
scaling for both instruments and the visual eld,
so that surgeons can select a preferable scaling.
For instance, when a 3:1 ratio scale is selected,
the motion of the instrument tip is reduced by one
third of the surgeon’s hand motion.
In addition to motion scaling, a highperformance computer eliminates the effect of
tremors in a surgeon’s hands. It also enables more
precise and delicate movement of the robotic
instruments.
16.2.5 Increased Degrees ofFreedom
Since laparoscopic instruments are straight, the
degrees of freedom (DOF) are limited to ve:
pitch, jaw, rotation, insertion/extraction, and
actuation of the instrument. The 5 DOF restricts
the mobility of a surgeon’s technical performance
and makes laparoscopic procedures difcult. The
robotic system has a joint at the end of the
end-effector, which moves like a human wrist
(7 DOF) [7]. This then reects a surgeon’s complex performance in the tips of the instruments.
16.2.3 Elimination of
Motion Reversal
Due to leverage around a trocar site (fulcrum),
laparoscopic instrument tips move opposite of
the surgeon’s hand motions. This juxtaposition
can interfere with a surgeon’s performance during laparoscopy. Conversely, robotic instruments
translate surgeon’s hand motions into identical
instrument tip movements. This simplies operating tasks and improves surgeon’s performance
by mimicking natural hand motions.
16.2.4 Favorable Motion Scaling
andTremor Elimination
The fulcrum effect has another inuence on
instrument handling. The motions of instrument
tips are amplied greater than surgeon’s hand
motions, which complicates the learning curve of
laparoscopic surgery. Robotic surgery overcomes
this issue with motion amplication adjustments.
16.2.6 Stable Camera Platform
During laparoscopic surgery, an assistant handles
a camera and is required to manually adjust the
camera position and orientation frequently. Since
an operating view of laparoscopic surgery completely depends on images captured by a camera,
the assistant’s skill in camera handling and communication with the primary surgeon has a large
impact on procedure performance. On the other
hand, a robotic surgery camera system can be
handled by a primary surgeon, which aids in
tremor elimination. This enables operating view
stability and comfort for a surgeon.
16.2.7 Ergonomic Positioning
Ergonomic equipment for surgeons is essential to
maximize surgeon performance. Laparoscopy
has been demonstrated to lead to surgeon fatigue
and pain in the neck, back, shoulders, elbows and
hips, because surgeons are required to stand
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throughout a laparoscopic procedure, sometimes
in contorted positions [9]. To overcome these
issues, the robotic system is equipped with an
adjustable console. Thus, a surgeon can adjust
his/her visualization system and padded forearm
rest to the most favorable height. This may
facilitate improved surgeon performance in his/
her most comfortable position [10].
16.2.8 Safety Mechanisms
Equipment problems can cause critical injury
to patients. Unlike laparoscopic equipment, the
robotic surgery system has multiple sensing mechanisms to prevent patient injury. When the system
senses an error during a procedure, the surgeon is
alerted in order to avoid a patient injury. In addition, when a malfunction occurs in one component,
other backup components work to maintain the
operation safely. If the system still needs to be shut
down, it occurs stepwise, but not immediately.
16.3 Eective andSafe Use
oftheRobotic System
This section describes a stepwise practical usage
guide of the robotic surgery system. Although
robotic systems have built-in safety mechanisms
for the automatic detection of errors, they introduce new challenges for the operating room (OR)
team that need to be addressed. For example, the
remote position of the operating surgeon to the
patient bed introduces team communication issues
that need to be addressed. In the following paragraphs, we will provide some practical tips for
trainees new to robotic surgery that can help them
master this promising technique faster.
16.3.1 Preoperative Phase
• Setting up the robotic system
• While the robotic system is typically set up by
OR personnel prior to case start, it is still
important for surgeons to understand the basic
steps of its setup; this may prove valuable in
some occasions where personnel experience
may be lacking. The camera, for example,
needs to be calibrated appropriately prior to
case start. Inappropriate calibration will cause
problems with visualization at the surgeon
console; therefore, if problems are encountered with the image quality, camera recalibration should be considered. Attention to system
maintenance is also required to keep the system working efciently.
The robotic arms should be draped before the
•
case starts.
• Setting up the robotic room for best efciency (positioning of the patient and operating table)
•
Utilizing gravity is essential not only in lapa-
roscopic surgery, but in robotic surgery as
well. To maximize its advantage, surgeons
should be familiar with how to use gravity
while maintaining patient safety. A patient can
easily slide or move during the procedure if
he/she is poorly positioned. To prevent
improper patient positioning, surgeons need to
secure the patient well on the operating table,
and test table manipulations before draping
the patient to ensure that the patient does not
slide or move. Additionally, surgeons need to
make sure the operating table is locked to prevent movement during the procedure. This is
particularly important with the older generation of existing systems (da Vinci® Si) as
motion of the patient during the procedure can
lead to injuries. The newer generation of
robotic systems (da Vinci® Xi), however, has
addressed this issue by allowing the robot to
move with the operating table.
16.3.2 Intraoperative Phase
• Trocar placement
• Trocar placement is one of the signicant differences between robotic and laparoscopic systems, primarily with regard to distance between
trocars and the target. Surgeons should be thoroughly knowledgeable and plan where to place
trocars safely. A common error is to place trocars too close to each other, thus allowing
robotic arms to collide during the procedure.
Additionally, trocars should typically be placed
a bit further away from the target than is necessary for laparoscopy.
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• A robotic trocar has a thick black line near the
tip (Fig.16.1). This line should be positioned
at the internal surface level of the cavity (i.e.,
peritoneum, pleura, etc.). This minimizes friction between the trocars and the cavity wall
(i.e., abdomen, chest wall, etc.) during motion
of the arms.
• Docking of robot cart and arms
• The orientation of the surgical cart depends on
the type of procedure performed (Fig. 16.2,
16.3, and 16.4). Generally, the robotic cart is
positioned near the target side, so that its robotic
arms can more easily reach the target, i.e., at the
feet for pelvic procedures (Fig. 16.2) or over
the head for upper abdominal procedures
(Fig.16.3). Robotic arm docking sequence varies from case to case, but either starts from one
side and goes to the other or starts with the
T. Mizota et al.
Fig. 16.1 Robotic trocars
Fig. 16.2 Pelvis—at the feet, between the legs, or side-docked (i.e., prostate, colon, and rectum)
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Fig. 16.3 Upper abdomen—over the shoulder (i.e., foregut)
Fig. 16.4 Flanks—beside patient (i.e., kidney)
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T. Mizota et al.
camera arm and continues to the rest of the
arms. Once all arms are docked, surgeons
should conrm that the arms can move without
collisions. If not given proper attention, this
may limit instrument motion during the procedure. The newer generation da Vinci® Si has
automated this process as it aligns the arms
automatically in reference to the target tissue so
that collisions are minimized.
• Most novices nd it very challenging to attach
the robotic arms to the trocars (this is mostly
true for the Si system and easier for the Xi).
To facilitate docking, align the axis of the trocar with the axis of the arm. Once the trocars
have been attached to the arms, the arm can be
elevated to some degree using the clutch button, so that the abdominal wall can be pulled
further away from the intra-abdominal organs.
This may be particularly useful in cases where
working space is limited due to patient anatomy. This maneuver may enhance the ability
to dissect.
• Instrument insertion
• Upon the rst instrument insertion, the clutch
button needs to be depressed to slide the instrument in and place it in the desired position.
Clutch button depression should be quick and
temporary. A common mistake made by unfamiliar users is to keep their nger on the clutch
button too long, which causes inadvertent repeat
depression and locking of the arm, preventing
further movement. Similar to laparoscopic surgery, any further instruments need to be visualized when inserted into a cavity to avoid
preventable injuries. Further, the camera should
be set at a wide-angle view to improve visualization of any structures in the cavity as well as
the instrument tip. Additionally, when an instrument is removed, the surgeon and the bedside
assistant should conrm that the instrument is
not attached to tissue. Communication between
the surgeon and the bedside assistant is therefore vital during this step.
• Importantly, during an instrument exchange
(i.e., after the instrument has been placed
and used), the clutch button should not be
depressed; the instrument should just be
pulled out and the desired instrument inserted
in its place. The arm light will turn green, and
the instrument can be safely reintroduced to
its prior position by pushing the instrument
in. This is a safety mechanism of the robotic
system, which allows efcient instrument
exchange without the need for visual monitoring of the insertion process. If, however, the
robotic arm is clutched during an instrument
exchange, this safety mechanism is canceled,
and instrument insertion needs to be visually
monitored.
• Setting up the surgeon console
• The surgeon console can be adjusted to an
ergonomically comfortable position which will
minimize surgeon stress and fatigue during the
procedure. A surgeon can adjust the height of
the viewer, the level of the handrest, and the
position of foot controls.
Next, the visual field should be set up. For
safety, the instruments should always be kept
within the visual field as instrument movements in the absence of visualization can
lead to injuries. The placement of a surgeon’s
head inside the forehead rest of the console
is required to activate the robotic instruments.
The surgeon can control instruments when
his/her fingers are placed in the controllers.
If too much pressure is applied on the controllers, the instrument will be temporarily
locked. In this case, the surgeon needs to
release the pressure and move the controllers gently again. If the surgeon takes his/
her fingers off the controllers after activation,
uncontrollable movement may occur which
can lead to injury and must be avoided. If this
occurs inadvertently, the best approach is for
the surgeon to immediately remove his/her
head from the viewer (which will immobilize
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the instruments). If he/she attempts to reinsert the fingers into the controllers, this may
likely lead to further movement and additive
risk since it is done blindly (as the surgeon
cannot directly visualize his/her fingers with
his/her head inside the viewer).
16.3.3 Postoperative Phase
• Undocking the robot
• After conrming that the instruments are not
attached to any organs of the patient, they can
be removed, the arms can be detached from
the trocars, and the robot can be safely
undocked. After this process, the robotic
patient-side cart should be moved away from
the patient. The surgeon should always pay
attention to both the patient and the robot so
that no injury occurs. In emergency situations,
the arms can be removed quickly with the trocars attached.
16.4 Robotic Skill Acquisition
16.4.1 Issues withRobotic Surgery
withFocus onSurgeon
Competency
While new technology has revolutionized patient
care in many instances, its introduction is often
associated with poorer patient outcomes. This
issue became evident during the introduction
of laparoscopic techniques in surgery. Despite
multiple benets of laparoscopy over laparotomy on patient outcomes, an increased incidence of technical complications was observed
related to inadequate training of surgeons on
this new technique [11]. To overcome this
issue, the Society of American Gastrointestinal
and Endoscopic Surgeons (SAGES) and the
American College of Surgeons (ACS) devel-
oped the Fundamentals of Laparoscopic Surgery
(FLS), a simulation-based curriculum for the
acquisition of basic laparoscopic skills outside
the OR [12]. Training on FLS has been demonstrated to improve surgeon prociency in laparoscopy [13], and currently FLS certication is
a requirement for residents to obtain board certication in general surgery.
Similar to the experience with laparoscopy,
robotic surgery has come under scrutiny due to a
number of reported adverse events resulting in
lawsuits against the manufacturer. One of the
main plaintiffs’ allegations has been inadequate
training of surgeons [14–16]. Several authors
have therefore recommended that standardized
curricula for the training and assessment of
robotic surgery skills should be developed
[17–19]. Accordingly, surgeons should be
required to possess an appropriate skill level utilizing the robotic system prior to performing an
operation on a patient.
To address this need, the Fundamentals of
Robotic Surgery (FRS) [20] was developed as a
simulation-based curriculum to help surgeons
acquire basic knowledge and skills crucial to performing robotic surgery.
16.4.2 Fundamentals ofRobotic
Surgery (FRS)
FRS is a prociency-based progression curriculum (course) of basic robotic surgery skills which
was developed using a full life-cycle curriculum
development method by over 80 robotic surgery
experts, behavioral psychologists, medical educators, statisticians, and psychometricians from
around the world. The Department of Defense
and Intuitive Surgical, Inc. funded its development. The main aim was to develop a standardized curriculum that would help ensure that
surgeons safely and efciently perform robotic
surgery [21].
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