1. Tabor, Wendy RN, BSN


Joysticks meet scalpels in a new computer-enhanced surgery system.


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A NEW ROBOTIC SURGICAL system is taking laparoscopic surgery to new horizons. With the potential for greater surgical precision, shorter hospital stays, and better patient outcomes, this minimally invasive surgical technique offers an exciting new option for many patients undergoing various surgical procedures (see What kind of surgery can be done robotically?). Read on to learn more about robotic surgery, including your role in patient care.


New and improved laparoscopy

Introduced some 20 years ago, minimally invasive laparoscopic surgery was a revolutionary improvement over open surgery, which often required large, painful, slow-healing incisions. Guided by laparoscopic cameras and scopes with a three-dimensional view, a surgeon could perform many procedures through tiny incisions, minimizing surgical trauma and shortening recovery time. But traditional laparoscopy has shortcomings of its own, including limited dexterity for the surgeon, loss of visual depth perception, camera instability, and poor ergonomics for the surgeon. Featured here, the da Vinci Surgical System (Intuitive Surgical) overcomes many of these drawbacks.


Space-age technology

The computer-enhanced da Vinci Surgical System consists of a surgeon's console, robotic arms, and a video tower. Seated at the console, the surgeon controls movement of the robotic arms, which are attached to the video tower. One arm holds the camera and scope; the other two or three arms control robotic surgical instruments. These arms are attached to robotic trocars that are inserted into the patient through tiny incisions.


Let's look at how the da Vinci system improves on older laparoscopic techniques.


* Dexterity. The instruments are designed to mimic and improve upon the movements of the human wrist. The surgeon can grasp, reposition, retract, and suture with greater dexterity, precision, control, and range of motion than he'd have if operating by hand.


* Visual perception of depth. Traditional laparoscopes give a two-dimensional view that makes suturing difficult to view closely. The da Vinci system gives the surgeon a detailed three-dimensional view of the surgical field. This makes it easier for him to perform detailed suturing, suture an anastomosis, and see difficult tissue planes.


* Camera stability. One robotic arm holds the camera, providing a more stable picture than that afforded by traditional laparoscopic surgery, which requires a person to hold the laparoscopic camera.


* Surgeon ergonomics. Instead of standing bent over the operating table, the surgeon using the da Vinci system sits at a surgical console. This reduces fatigue, possible nerve palsies, finger numbness, and eye fatigue.



Learning the ropes

All members of the robotic surgical team-surgeon, nurses, surgical technicians, central processing personnel, anesthesia provider, and operating room assistants-must be trained for their roles before, during, and after surgery. As a nurse on the team, you'd need to be able to:


* identify the system's components and know how they're used


* prepare the system before surgery


* know emergency procedures if the system malfunctions or the power goes out


* know how to clean and sterilize the robotic instruments and clean the nonsterile equipment


* troubleshoot error messages


* position the patient and equipment safely.



A mock setup should be performed at least four times until everyone on the team is comfortable with the setup and knows the emergency procedures.


Preparing the system

The circulating nurse prepares the surgical system before surgery. This includes connecting the proper cords from the video tower to the surgeon's console and from the robotic arms to the surgeon's console. Make sure that the surgical system's cords aren't in the way of those walking around the operating suite, so they don't accidentally disconnect the system while it's in use. Inspect cords for any frayed areas or damage that could create an electrical hazard. Labeling the cords in advance will let you quickly identify and unplug (or plug in) a particular unit in an emergency.


Following your facility's electrical safety policy, ensure that the system is plugged into the proper electrical power outlets, then turn the system on and follow the instructions to home the system. This places the surgical arms in a neutral position, ready to be used.

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The scrub nurse covers the robotic arms with sterile drapes that house the sterile instrument and camera adapters. Working together, the circulating and scrub nurses prepare the unsterile camera and sterile scope for surgery, following the manufacturer's instructions.


Be sure to have a fully stocked robotic instrument cart. Inspect the instruments for damage and replace damaged instruments. Also, know the location of the emergency hex wrench that comes with the equipment; during a power outage or system failure, you and the surgeon would need this wrench to free the surgical arms from the trocars inserted into the patient.


When these preparations are complete, place the system in position for patient docking. Report any faults or system errors (for example, if the system won't let you complete the homing process or if it fails its self-check) to the surgeon immediately.


Your role

Before surgery, make sure the patient has given informed consent. For example, he should understand that in case of unforeseen circumstances, the surgeon may opt to switch to an open procedure.


In the operating room, if you're the circulating nurse, ensure patient safety when docking the surgical system to the patient by making sure that the robotic arms or cords aren't resting on any part of the patient's body. Consult with the anesthesia provider about safe patient positioning. For example, a patient having a robotic-assisted radical prostatectomy will have his arms tucked at his sides. To prevent nerve damage or loss of circulation, make sure his arms are appropriately padded and not underneath him. Be prepared to assist the anesthesia provider if the patient develops third-space fluid shift and extreme tracheal swelling during surgery, which would complicate extubation. This is a risk because of the steep Trendelenburg position used during surgery.


You'll also be responsible for keeping track of the number of times each robotic instrument is used and sterilizing new instruments as needed. (Robotic instruments have a limited number of uses before they need to be replaced.)


Protect the cords of the surgical system from damage. For example, don't let equipment or the patient's stretcher roll over them.


High-tech medicine

The use of technology in the operating room is advancing rapidly. By understanding how robotic surgery systems work, you can stay on the cutting edge of surgical care.


What kind of surgery can be done robotically?

The da Vinci system can be used for various procedures, including cardiac, gynecologic, urologic, and weight-loss surgeries. The minimally invasive approach means a shorter hospital stay, less blood loss and need for transfusions, less pain and scarring, a lower infection risk, and a quicker recovery time.


* Cardiac. Using the da Vinci system, a surgeon can perform internal mammary artery mobilization and harvest, pericardiotomy, target vessel identification, and mitral valve repair through a 3-to-5-cm thoracotomy. The system gives the surgeon more precise visualization for anastomosis suturing. The patient is spared the risk of a sternal wound infection and the complications associated with cardiopulmonary bypass.


* Gynecologic and urologic. Because it allows three-dimensional visualization, the da Vinci system can be used for robotic-assisted minimally invasive hysterectomy and robotic-assisted myomectomy, or removal of uterine fibroids. In myomectomy, the surgeon can perform a multilayer closure of the uterus that reduces the risk of uterine rupture during a later pregnancy.


* More precise visualization also means less risk of bleeding complications during robotic-assisted radical prostatectomy. Traditional open suprapubic prostatectomies can cause serious bleeding.


* Weight loss. Robotically sutured anastomoses in the Roux-en-Y gastric bypass reduce the risk of a leakage or stricture. This surgery is also technically more challenging with traditional laparoscopic instruments than with the robotic instrument arms.





da Vinci Surgical System Intuitive Surgical, Inc.


Francis P. The evolution of robotics in surgery and implementing a perioperative robotics nurse specialist role. AORN Journal. 83(3):629-650, March 2006.


Rose K, et al. Current status of robotic and laparoscopic pyeloplasty. International Journal of Clinical Practice. 60(1):6-8, January 2006.