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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1170_Библиотеки_им_академика_М_И_Перельмана.pdf
25
O. Bardakcioglu (ed.), Advanced Techniques in Minimally Invasive and Robotic Colorectal Surgery,
DOI 10.1007/978-1-4899-7531-7_4, © Springer Science+Business Media New York 2015
Introduction
In this chapter, we will review equipment, setup, and general
techniques in robotic surgery. Robotic techniques are increasingly being applied to colorectal surgery. To date, the most
common indication for the use of robotics in colorectal surgery is in the pelvis for rectal dissection. More recently, however, robotic colectomy is gaining momentum. Before
incorporating robotic technology into practice, a fundamental knowledge of the system and proper use of the equipment
and basic procedure setup are critical to patient safety and
optimal outcomes.
Preparation for Robotic Surgery
Proper training in robotic surgery is critical for initial success and to optimize patient outcomes [ 1 ]. Training can be
obtained from industry, society, or local institutions.
Following training, case observations and proctoring are
highly recommended prior to initiation of procedures.
Utilization of robotic-trained bedside assistants, scrub technicians, scrubs nurses, and circulators are highly recommended for robotic-assisted cases. At the end of the chapter,
a robotic checklist is offered to enhance patient safety and
smooth operations during robotic cases.
Equipment
A typical robotic surgical system consists of the following
four components. The surgeon ’ s console is the place where
the surgeon sits and controls the instrument at the operative
fi eld using master manipulator while looking through the
viewer (Figs. 4.1 , 4.2 , and 4.3 ). The console plays a role in
adjusting the whole system and provides the capability to
communicate with the other persons in the operating room.
More recent robotic systems are equipped with secondary
(assistant) consoles, it allows for training, assistance, remote
surgery, and surgeon collaboration (Fig. 4.4 ).
The patient side cart equipped with remote manipulator
arms is controlled from the console by a surgeon. The remote
Operating Room Setup and General Techniques for Robotic Surgery
Seung Yeop Oh , Cristina R. Harnsberger ,
and Sonia L. Ramamoorthy
4
S . Y. O h , M D ( *)
Department of Surgery , Ajou University School of Medicine ,
Suwon , South Korea
e-mail:
kgsosy@ajou.ac.kr
C. R. Harnsberger , MD
Department of General Surgery , University of California,
San Diego , San Diego , CA , USA
S. L. Ramamoorthy , MD, FACS, FASCRS
UC San Diego Health System , Rebecca and John Moores
Cancer Center , San Diego , CA , USA
Electronic supplementary material Supplementary material is avail-
able in the online version of this chapter at
10.1007/978-1-4899-7531-
7_4
. Videos can also be accessed at http://www.springerimages.com/
videos/978-1-4899-7530-0
.
Fig. 4.1 Robotic surgeons console and hand console. For Fig. 4.1 : pro-
vided here exclusively for promotion and/or media coverage of Intuitive
Surgical and its products. This notifi cation serves as an authorization
for publications to make duplicate copies of the available highresolution scans for editorial use only (© 2014 Intuitive Surgical, Inc.
All people depicted unless otherwise noted are models)
26
manipulator arm is designed to move at the same time just
like the surgeon is manipulating hand switches. Surgeons
can perform a wide range of procedure, such as cutting,
suturing, and electrocoagulation through the manipulator
(Figs.
4.5 and 4.6 ).
The visualization system provides a panoramic view of
the surgical fi eld with high-resolution 3D images. The input
to the surgeon’s monitor is generated by a stereo-endoscopic
vision system that includes the camera, electronics, and a
separate monitor for the operating team and assistants
(Figs. 4.7a, b and 4.8 ).
Instruments are operated through small incisions in the
body through which a robotic trocar is placed. There are various types of instruments designed to provide surgeons with
natural dexterity and full range of motion for precise operation. The full range of motion and rapid responsiveness facilitate procedures such as suturing, knotting, dissection, and
tissue manipulation. Many of the instruments used for
robotic surgery mimic those that are available for laparoscopy (Figs. 4.8 and 4.9 ).
General OR Setup for Robotic Surgery
Setup of the robot is perhaps one of the most challenging
aspects of robotic surgery. Early data has cited length of
time to setup as a drawback of robotic surgery; however,
once the team is efficient at this part of the procedure, the
literature suggests that the operating times for laparoscopic and robotic colorectal procedures are similar [ 2 ].
Setup proceeds through various processes, according to
the procedure and surgeon preference. First, after turning
on the robot, calibration is essential for successful operation without delay or conversion. Often this setup is done
prior to the surgeon or patient entering the room. It is
necessary to calibrate the camera, patient side manipulators, and the master manipulators. If preparation for
operation is finished, trocar locations need to be placed
properly without “fighting” each other during operation,
which results in collisions. The trocars should not be
placed too close to each other. It is recommended by the
manufacturer that each trocar site should be 8–10 cm
apart to avoid collision and maximize arm excursion
(Fig. 4.10 ) (Box 4.1 ) [ 3 ]. In addition, approximately
10–20 cm is the ideal distance between the trocar and target anatomy. Robotic trocars need to be inserted up until
the thick black line can be visualized at the level internal
surface of the cavity, which is the axis of rotation called
the remote sensor (Fig. 4.11a, b ).
Fig. 4.2 Robotic surgeons console and hand console. For Fig. 4.2 : pro-
vided here exclusively for promotion and/or media coverage of Intuitive
Surgical and its products. This notifi cation serves as an authorization
for publications to make duplicate copies of the available highresolution scans for editorial use only (© 2014 Intuitive Surgical, Inc.
All people depicted unless otherwise noted are models)
Fig. 4.3 Robotic surgeons console and hand console. For Fig. 4.3 : pro-
vided here exclusively for promotion and/or media coverage of Intuitive
Surgical and its products. This notifi cation serves as an authorization
for publications to make duplicate copies of the available highresolution scans for editorial use only (© 2014 Intuitive Surgical, Inc.
All people depicted unless otherwise noted are models)
Box 4.1 Tip
Laparoscopic assistant ports can be placed 5 cm away
from the robotic trocars. Occasionally, a patient’s
smaller torso will prevent placing the third robotic tro-
car and arm at the minimum distance necessary and
should then not be utilized.
S.Y. Oh et al.
27
Fig. 4.4 Dual robotic surgeon’s console. Provided here exclusively for
promotion and/or media coverage of Intuitive Surgical and its products.
This notifi cation serves as an authorization for publications to make
duplicate copies of the available high-resolution scans for editorial use
only (© 2014 Intuitive Surgical, Inc. All people depicted unless otherwise noted are models)
Fig. 4.5 Patient side cart. For Fig. 4.5 : provided here
exclusively for promotion and/or media coverage of Intuitive
Surgical and its products. This notifi cation serves as an
authorization for publications to make duplicate copies of the
available high-resolution scans for editorial use only (© 2014
Intuitive Surgical, Inc. All people depicted unless otherwise
noted are models)
4 Operating Room Setup and General Techniques for Robotic Surgery
28
Patient Positioning
Obtaining the proper patient position and position in relation
to the robot is very important because it is not possible to
reposition the patient during the procedure without undocking. Positioning of the patient’s side cart according to the
procedure follows patient positioning (Fig. 4.12 ). Docking
of the robotic arms should be performed to minimize the arm
collisions during operation. To avoid bruising on the skin,
each port should be adjusted to slightly evert the skin as
opposed to depressing the skin.
Docking
The robot is placed close to the patient such that the arms can
be ranged within and reached to the operative fi eld. Robotic
arms should be docked to the ports defi nitely. Collisions can
be reduced by robotic arm positioning at the beginning of the
procedure. Care must be taken not to contaminate the arms as
the robot is brought closer to the sterile surgical fi eld and the
ab
Fig. 4.7 Robotic camera and camera arm. ( a ) Robotic camera, ( b ) robotic arm
Fig. 4.6 Patient side cart. For Fig. 4.6 : provided here exclusively for
promotion and/or media coverage of Intuitive Surgical and its products.
This notifi cation serves as an authorization for publications to make
duplicate copies of the available high-resolution scans for editorial use
only (© 2014 Intuitive Surgical, Inc. All people depicted unless otherwise noted are models)
S.Y. Oh et al.
29
same is true for de-docking. The robot must be brought in
with careful attention to its proximity to the patient’s anatomy
such as the face, legs if in stirrups, and arms if not tucked
(Box 4.2 ). If there is a chance that the robot arm may injure
the patient during the case, the robot position must be reevaluated and or the patients “at risk” anatomy must be proactively protected. For proper positioning of the camera arm in
relation to the patient, the blue indicator tab on the robot identifi es the “ sweet spot ” as a guide (Figs.
4.13 and 4.14 ). Instrument Insertion
Instruments should be inserted carefully under direct vision
and the memory clutch pressed to prevent injury to the tissues.
Instruments should be inserted with end effectors straightened
to avoid puncture of trocar seals and under direct vision to prevent tissue injuries. It is advisable to back the camera to widen
the view fi eld when instruments are exchanged. If the insertion
is the fi rst one of the case, the clutch button will need to be
depressed to slide the instrument in and position the arm. If the
insertion is a tool change, the clutch button does not need to be
depressed to insert the new tool to the existing position. The
surgeon goes to the console after fi nal review of the setting up
and checks the visual fi eld and operative fi eld.
Undocking
The fi nal step in a robotic procedure is to undock. This too
must be carried out carefully. First the instruments must be
removed from the patient’s abdomen; this should be done
under direct visualization. The robot arms then can be
undocked from the trocars and carefully retracted away from
the patient. The robot can then be withdrawn from the patient
OR bed. As the robot is withdrawn, care must be taken to
avoid injuring the patient and/or damaging the robot arms.
Care must be taken not to break the robot down from sterility
until the surgeon is clear there will be no need to re-dock.
Fig. 4.8 Wristed motion of robotic instruments. Provided here exclusively for promotion and/or media coverage of Intuitive Surgical and its
products. This notifi cation serves as an authorization for publications to
make duplicate copies of the available high-resolution scans for editorial use only (© 2014 Intuitive Surgical, Inc. All people depicted unless
otherwise noted are models)
Fig. 4.9 Laparoscopic
instruments ( left ) and robotic
instruments ( right ) used for bowel
surgery
Box 4.2 Tip
The base of the robotic cart should be lined up parallel
to a virtual line between the outer instrument trocars
(usually robotic arm 1 and 3).
4 Operating Room Setup and General Techniques for Robotic Surgery
30
General Techniques
Navigating the Camera and the Surgical Instruments
The surgeon must press the foot pedal while moving both hands
in order to properly move and position the camera. Due to the
motion scaling capacity of the robotic system and changes in the
fi eld of view, operator hand controls may need to be periodically
repositioned to the optimal operating position. Clutching is used
when the master controllers reach their limits of movement or the
surgeon’s operating position becomes uncomfortable. The surgeon can move the tip of the instrument up to 90° perpendicular
to the shaft of the instrument, which is helpful in complex
motions such as reaching behind a structure or suturing (Box
4.3 ).
Energy instruments can be used for coagulation, cutting,
and dissection of tissues. These include monopolar and bipolar cautery instruments (electrical energy) and the
Harmonic™ ACE (mechanical energy). Graspers can be
used to manipulate various types of tissues such as the peritoneum or uterus. Retracting instruments are used to allow
the surgeon to effi ciently provide exposure of the surgical
fi eld. This can provide the robotic surgeon to fully control
the operation fi eld. Clip appliers are available to allow the
robotic surgeon to perform vessel clipping. Needle drivers
ab
Fig. 4.11 Robotic trocar. Black line indicates remote sensor. For
Fig. 4.11( a ) (With permission from World Laparoscopy Hospital,
Institute of Laparoscopic and Robotic Surgery © 2014). For Fig. 4.11( b )
Provided here exclusively for promotion and/or media coverage of
Intuitive Surgical and its products. This notifi cation serves as an authorization for publications to make duplicate copies of the available highresolution scans for editorial use only (© 2014 Intuitive Surgical, Inc.
All people depicted unless otherwise noted are models)
Box 4.3 Tip
Mastering the frequent switch between the second
and third robotic arm for the left hand and actively
using both for variable tissue retraction and counter-
traction allows the surgeon to operate with “three”
hands.
Port placement (Hybrid)
5 mm assistant port
8 mm robot port
12 mm robot camera port
Arm 1 Arm 2
Arm 3
Fig. 4.10 Robotic port placement hybrid technique for rectal
dissection
S.Y. Oh et al.
31
can be used to suture with various types of needles such as
those used in cardiovascular surgery or in repair of uterine
defects. SutureCut™ needle drivers include an integral cutting blade for effi cient cutting of suture after knot typing.
Needle Holding, Suturing, and Knot Tying
Precision is one of the major advantages of robotic surgery.
Due to the lack of haptic feedback and the power of the
ab
Fig. 4.12 Pictures showing pelvic and side docking. ( a ) Pelvic docking, ( b ) side docking
Poor robot arm positioning Better robot arm positioning
Fig. 4.13 Arm collision left vs. maximizing arm spacing right
Fig. 4.14 Sweet spot below left
not ideal vs. right within the blue
4 Operating Room Setup and General Techniques for Robotic Surgery
32
instrument arms, it is possible to bend or even break a needle
when grabbing it at the wrong position [
4 , 5 ].
The surgeon must create the loop totally based on the visual
feedback and experience to handle the suture carefully without
break or tearing of the suture. Hold the needle between the
needle holder and make a single stitch near the wound. Pull
out the suture to leave a small suture tail. Move the needle
holder around the bent grasper tip to create a loop. Move the
two instruments together so that the bent grasper grabs the tail
of the suture while maintaining the loop wrapping around the
bent stem. Retract the grasper to tighten the simple knot. In
other methods, the surgeon begins by grasping the right end of
the suture without touching the left end. The right end of
suture is crossed over the left end to create a loop. The right
instrument is next passed under the loop, created by the crossing right end of suture, and grasps the crossed over right end.
The right end is then pulled by the right instrument underneath
the left suture, which is still untouched. The left instrument
grasps the left suture and the two ends are pulled apart to form
the knot [ 6 ]. Another knot can be placed over it in an alternat-
ing but similar fashion without swapping arms (see Video 4.1 ).
Control of Electrocoagulation/Energy
The activation for electrocoagulation in robotic surgery is
performed by the use of the foot pedals. If the incorrect pedal
is pressed for electrocoagulation of a vessel, serious hemorrhage or damage to surrounding tissue could occur. Visual
prompts are seen within the master console.
Advanced Tools for Colorectal Surgery
Robotic Bipolar Vessel Sealer
The EndoWrist One™ vessel sealer is a wristed, singleuse instrument, which uses bipolar coagulation. It is
designed to seal vessels up to 7 mm in diameter and tissue with a thickness that fits into the jaws of the device.
Following coagulation, the instrument can then mechanically transect tissue. This instrument employs the same
principles of bipolar coagulation devices designed for
laparoscopic surgery, but adds the precision, mobility,
control, and stability common to other robotic wristed
instruments (see Video 4.2 ).
Robotic Stapler
The EndoWrist ™ stapler is a fully wristed stapler 45 mm in
length and was modeled after the human hand such that it
affords dexterity and full range of motion. Using the robotic
stapler, the surgeon can access narrow areas such as the pelvis, which would be extremely hard to reach with conventional staplers used in laparoscopic surgery (see Video
4.3 ).
Firefl y Fluorescence Imaging
Firefl y technology uses near-infrared imaging to detect the
presence of injected indocyanine green in the blood. The
robotic camera is equipped with an 803 nm excitatory laser
source, which illuminates the surgical fi eld and causes
excitation of the indocyanine green, which reveals a green
glow, thereby allowing identifi cation of perfused tissue. In
colorectal surgery, this technology is used to assess the
perfusion of the bowel prior to transection and anastomosis, allowing the surgeon to revise the intended transection
point to a region that is better perfused if necessary
(see Video 4.4 ).
Avoiding Equipment Malfunction
The surgeon must keep ports at least 8–10 cm away from
each other to allow for maximal excursion of the robot arms
and avoid external collisions. The surgeon also has to adjust
the arms externally so that they do not collide with each
other. The robotic arms must be positioned ahead of time
with proper joint adjustment, making note of the “sweet
spot,” to minimize external collisions (limiting range of
motion) and avoid hitting the instruments internally. When
collisions occur, the surgeon must be updated and repositioning of the joints and arms should be attempted if
possible.
Ideally one does not lose sight of their robotic instruments
during the case to minimize the chances of inadvertent injury
to intra-abdominal structures. The surgeon must look for
their instrument as they are passed in an out of view whenever possible. Failure to do so, and with an inexperienced
bedside assistant, one may increase the risk of bowel wall
tears or, more commonly, puncture injuries to mesentery,
vessels, or hollow organs [ 7 ].
Robotic Preoperative Checklist
Procedure to be performed
• Total robotic versus hybrid with addition of laparoscopic component
• Addition of another procedure (e.g., robotic
hysterectomy)
Patient position (expected robot dock time)
• Steep Trendelenburg positioning not recommended for
>4 h continuously
S.Y. Oh et al.
33
Docking location (side, pelvic, etc.)
Equipment on fi eld: trocars, end effectors, 12 mm versus
8 mm camera, and Firefl y
Equipment on demand (in room): energy, clips, suction,
stapler, etc.
Extraction port/plan
Medications: ICG, Marcaine, etc.
Monitors/locations of slave
Robotic console settings
Post docking plan other than closure
References
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consensus conference on curriculum. 2012. NextMed/MMVR 20,
San Diego, CA, 2013.
2. D’Annibale A, Morpurgo E, Fiscon V, et al. Robotic and laparoscopic surgery for treatment of colorectal diseases. Dis Colon
Rectum. 2004;47(12):2162–8.
3. Ramamoorthy S, Obias V. Unique complications of robotic colorectal surgery. Surg Clin North Am. 2013;93:273–86.
4. Kenngott HG, Muller-Stich BP, Reiter MA, Rassweiler J, Gutt
CN. Robotic suturing: technique and benefi t in advanced laparoscopic surgery. Minim Invasive Ther Allied Technol.
2008;17:160–7.
5. van der Meijden OA, Schijven MP. The value of haptic feedback in
conventional and robot-assisted minimal invasive surgery and virtual reality training: a current review. Surg Endosc. 2009;23:
1180–90.
6. Guru KA, Sheikh MR, Raza SJ, Stegemann AP, Nyquist J. Novel
knot tying technique for robot-assisted surgery. Can J Urol. 2012;
19:6401–3.
7. Agcaoglu O, Aliyev S, Taskin HE, Chalikonda S, Walsh M, Costedio
MM, Kroh M, Rogula T, Chand B, Gorgun E, Siperstein A, Berber
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4 Operating Room Setup and General Techniques for Robotic Surgery
Part II
Right Hemicolectomy and Ileocecectomy