Principles and Practice of Robotic Surgery, 1st Edition

General principles

1. Anesthesia for robotic surgery

• Physiology of pneumoperitoneum
• Complications

• Air embolism
• Arrest… etc

• Preoperative assessment and patient selection
• Patient positioning and prevention of injury

1. Draping robot

• (basic understanding in order to be able to deal with trouble shooting)
• Need all 4 arms to be draped even if not using

1. Port placement

• Establishing pneumoperitoneum

• Hasson
• Veress
• Optical
• Insufflation pressure

• Complications and trouble shooting
• Eg. Adhesions, Obesity, Narrow pelvis, Prior surgery or radiotherapy, Existing stoma

1. Docking the robot

• Modelled on Device teaching

• Targeting
• Ensuring adequate space between arms
• Burping

1. Safety

• e.g. height limitation
• Locking instruments to avoid drift
• Emergency undocking
• Trouble shooting errors and faults

1. Instruments

• Familiarity with commonly used laparoscopic instruments for the bedside assistant
• Inserting and exchanging instruments

1. Diathermy settings

Console

2. How does it all work?

• Basic rundown of buttons etc
• Controlling the camera

• Use of different lenses and changing view
• Understanding when/why to use different lens

• Swapping between instruments
• Fourth arm control
• Clutching
• Customising your setup
• Ergonomics
• Scaling ratio movement

• Adjusts movement speed to surgeon preference
• Default 3:1, 2:1, 1.5:1

• Available instruments
• Diathermy settings

1. Haptics

• Definition

1. Wrist movements
2. Understanding how the system works and how optimise use
3. Grasping objects
4. Passing items between hands
5. Cauterising

• Settings

1. Knot tying
2. Suturing

• Dissection and developing tissue planes

1. Emergency management

• Vascular emergency
• ??other essential crisis management

1. Trouble shooting

• Instrument out of view

• Use instrument out of view visual cues
• Only works if foot is on camera pedal

• Poor vision

• Switch dominant eye if smudge only on one side
• Can adjust zoom if tissue close and there is spatter/diathermy smoke issue

1. Fundamental laparoscopic skills

• Safe instrument handling
• Suctioning
• Clipping
• Stapling
• Cutting
• Specimen extraction

1. Trouble shooting

• Loss of pneumoperitoneum
• Port loss (inadvertent removal)

1. Port site closure
2. Undocking robot

• Emergency and routine

1. Haemostatic agents
2. Stapling
3. Fluorescence imaging
4. Tilepro

• E.g. USS

1. Communication and human factors

• Team based training
• Operating room communication

1. Virtual Reality Simulator Training
2. Procedural Training

• 3D printed synthetic human organ hydrogel models (this model may soon replace animal and cadaver training in robotics)
• updates could be included with scannable QR codes and searchable web links. These links will provide access to the latest instructional content for the major robotic surgery systems

1. Urology

Nephrectomy partial nephrectomy pyeloplasty, intrarenal stone surgery, in surgery, nephroureterectomy, cystectomy, cystoprostatectomy, radical prostatectomy, retroperitoneal node to section.

2. General surgery

Hernia surgery including incisional hernia and mesh hernia repair. Colorectal cancer surgery. Upper gastrointestinal surgery including obesity surgery antireflux surgery and gastric surgery. Pancreatic surgery. Appendicectomy and gallbladder surgery.

3. General gynaecology and gynaecology Oncology

Hysterectomy oophorectomy endometriosis surgery

Radical hysterectomy radical ovarian surgery and retroperitoneal node to section

Sacrocolpopexy /incontinence surgery

4. Cardiac surgery

Mitral valve repair/replacement

5. ENT surgery

Floor of mouth tonsillar vocal cord surgery

6. Thoracic surgery

Lobectomy, lung cancer surgery, thyroid surgery, diaphragmatic surgery, flexible endobronchial surgery

7. Endoscopic flex robotics for oesophageal and gastric surgery performed by gastroenterologists (a new market)