Robotic Surgery in Benign Gynecologic Indications Periprocedural Care

Updated: Mar 05, 2015
  • Author: Kimberly S Gecsi, MD, FACOG; Chief Editor: Michel E Rivlin, MD  more...
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Periprocedural Care

Patient Education & Consent

Elements of Informed Consent

Appropriate informed consent for robotic surgery includes a discussion regarding the risks, benefits, and alternatives.

Risks include bleeding, infection, and damage to surrounding structures such as bowel, bladder, ureters, blood vessels, and nerves. Additionally, the patient must be aware and counseled regarding the risk of conversion to laparotomy.

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Pre-Procedure Planning

A thorough history and physical examination should be performed prior to surgery.

A pregnancy test should be obtained in any female of reproductive age.

A review of relevant imaging and laboratory tests should be performed.

Based on the patient's risk factors and medical comorbidities, appropriate preoperative testing and consultations should be done.

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Equipment

The EndoWrist instruments include 3 different bipolar forceps—the PK dissecting forceps, the Maryland bipolar forceps, and the fenestrated bipolar forceps.

The monopolar devices include the Hot Shears (monopolar curved scissors) and the permanent cautery spatula.

Needle drivers available include the SutureCut, Mega, and large needle driver.

For retraction, instrument options include the Tenaculum forceps, ProGrasp forceps, and the Graptor.

Other instruments include Cadiere forceps and the double-fenestrated grasper. [19]

See the images below.

The daVinci Instruments. ©2011 Intuitive Surgical, The daVinci Instruments. ©2011 Intuitive Surgical, Inc
The daVinci Surgical System set up. ©2011 Intuitiv The daVinci Surgical System set up. ©2011 Intuitive Surgical, Inc

da Vinci Robotic System

The da Vinci Robotic System, which is the only device that is FDA-approved for surgical robotics, consists of 3 components: a surgeon console, the InSite vision system (which provides 3-dimensional stereoscopic imaging), a patient-side cart with EndoWrist instruments, and either 3 or 4 robotic arms (see image below).

The daVinci Surgical System. ©2011 Intuitive Surgi The daVinci Surgical System. ©2011 Intuitive Surgical, Inc

The console includes a stereoscopic viewer with an infrared sensor and hand and foot controls that allow the surgeon to control positioning and focus of the camera and activation of monopolar or bipolar energy sources.

The vision system creates a 3-dimensional image, as the endoscope is composed of 2 parallel 5-mm telescopes with 0° or 30° lenses. The image is magnified 10-15 times.

The laparoscopic surgical instruments articulate in 7° of freedom and 90° of articulation, allowing movements that mimic the surgeon’s hand, thus overcoming the fulcrum effect of conventional laparoscopy. They also decrease tremors and motion artifact. Laparoscopic instruments include energy sources such as monopolar and bipolar cautery, the Harmonic ACE, the PK dissecting forceps, and laser. Graspers, needle drivers, retractors, and specialized instruments (eg, clip appliers) are other tools designed for the robotic arms. [13, 31] See the images below.

The daVinci Instruments. ©2011 Intuitive Surgical, The daVinci Instruments. ©2011 Intuitive Surgical, Inc
Wristed Articulation ©2011 Intuitive Surgical, Inc Wristed Articulation ©2011 Intuitive Surgical, Inc
The daVinci hand control. ©2011 Intuitive Surgical The daVinci hand control. ©2011 Intuitive Surgical, Inc

The da Vinci standard system is no longer being commercialized after the creation of two additional updated models. The da Vinci S has a fourth surgical arm, longer instruments, increased variety in 5- or 8-mm instruments, interactive video display, motorized side cart, high definition, and a streamlined design.

The newest da Vinci Si System (see image below), launched in April 2009, has dual-console capability to support training in addition to enhanced high-definition 3-dimensional vision and updated user interface.

The daVinci Si HD Surgical System ©2011 Intuitive The daVinci Si HD Surgical System ©2011 Intuitive Surgical, Inc
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Patient Preparation

In the operating room prior to surgery, the following steps should be performed:

  • Mechanical deep venous thrombosis prophylaxis should be placed
  • Place the patient in dorsal lithotomy position with legs abducted, knees flexed, and thighs at table level
  • Perform a bimanual examination under anesthesia to aid in port placement planning
  • Pad arms and tuck in sides
  • Add additional support devices such as bean bags, foam, or gel pads to cushion pressure points
  • Insert a nasogastric or orogastric tube to decompress the stomach
  • Insert a Foley catheter to decompress the bladder
  • Prepare and shave the patient in the usual sterile fashion

A uterine manipulator can then be placed. Various uterine manipulators and colpotomy rings are available, and they aid in identification of the interface of the cervix and vagina during colpotomy if this is to be performed (see video below). [31]

Robotic hysterectomy

Positioning

For gynecologic cases, the patient must be placed into a steep Trendelenburg position for optimal visualization and mobilization of the small and large intestines out of the surgical field. The patient’s arms must also be tucked at the sides, similar to positioning for conventional laparoscopy.

The anesthesia-related implications of these positioning requirements must be carefully considered. With Trendelenburg positioning, ocular, neurological, hemodynamic, and respiratory effects must be monitored. Additionally, the pneumoperitoneum created by gas insufflation can cause respiratory complications. [32]

Patients should be warned about the possibility of significant facial edema after robotic surgery.

Limited access to the arms may require extra intravenous lines or an arterial line for blood pressure monitoring in certain patients.

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