Basic Equipment and Setup for Robot-Assisted Laparoscopic Surgery Using the Intuitive Da Vinci Si Robot
Tommaso Falcone
Henry F. Kraft
General Principles
There are several steps to efficient use of the robot:
Correct choice of equipment during surgery.
Correct placement of robotic ports for effective pelvic surgery.
Correct docking so as to maximize the full range of motion of the robotic arms.
This chapter will cover the use of a multi-port robot-assisted laparoscopic procedure.
Instruments and Equipment
Correct Choice of Equipment During Surgery
It is critical to choose the correct instruments required for a procedure. Surgery must be cost-effective, so it is inappropriate to simply keep changing instruments during the procedure until you find the one that works. The surgical approach should be carefully planned and appropriate instruments chosen to reduce exchange of instruments and be cost-effective. Each surgical procedure has some basic instruments required—a grasper appropriate for the case, an energy form for hemostasis, and a cutting instrument such as scissors.
Figure 2.1 shows some basic instruments.
Correct Port Placement
After the patient has been properly positioned in dorsal lithotomy, prepped, and draped, and a proper time-out has been done, incision is made, and the ports are placed.
There are different possibilities for placement of robotic ports based on pathology and type of procedure. The camera port can be placed at the umbilicus for most procedures. The assistant/accessory ports are placed in the left or right upper quadrant.
However, if the uterus is large, a supra umbilical port is necessary.
The camera port should be placed 2 to 4 cm higher than the umbilicus so as to maintain a 10 cm working distance between the tip of the endoscope and the fundus of the uterus.
Likewise, the 8-mm robotic instrument ports should also be moved higher in tandem with the movement of the camera port.
It is also noteworthy that all precautions should be taken to keep the tip of the endoscope from touching any of the surrounding tissue. It is hot and can cause thermal injury.
Scenario 1
It is a standard four-arm configuration, where the camera port is placed at the umbilicus and the 8-mm robotic ports are placed each at least 8 to 10 cm lateral to the camera port.
See Figure 2.2.
Scenario 2
It is a three-arm configuration, where the camera port is placed at the umbilicus and only two robotic instrument arms are used. Each robotic instrument arm should be placed 8 to 10 cm lateral to the camera port.
See Figure 2.3A.
Scenario 3
Another approach is a four-arm configuration where robotic port no. 2 is placed higher (closer to the costal margin). This is particularly advantageous with smaller patients.
See Figure 2.3B.
Scenario 4
There are exceptions to introducing the assistant/accessory port in the upper abdomen. For tubal reanastomosis, a three-arm configuration is used as in Figure 2.3A. However, in this scenario, a 12-mm assistant/accessory port is placed in the lower quadrant so that small needles can be introduced and extracted under direct vision.
Docking the Robot
After the ports are placed, and the patient is positioned in the proper amount of Trendelenburg, lower the operating room table to the lowest position possible.
Place the patient’s legs as close together as the yellowfin stirrups will allow—this will enable maximum access and visualization as the robotic patient cart approaches the OR table.
Align the patient cart base pointing toward the patient, with a starting point 2 to 3 ft beyond the yellowfin stirrups, and oriented so as to be able to come straight toward the patient’s umbilicus on a 45-degree angle to the patient’s longitudinal axis.
See Figure 2.4.
If maneuvering the patient cart is difficult due to the confines of a small OR, it can be helpful to preemptively angle the OR table 15 degrees to one side or the other in order to facilitate advancing the patient cart on a 45-degree angle to the patient’s umbilicus and longitudinal axis.
Figure 2.2. A: Robotic Vessel Sealer—energy form for hemostasis and cautery. B: ProGrasp Forceps—grasping forceps for manipulation of tissue. C: ProGrasp Forceps versus Cadiere Forceps—side-by-side comparison. Grasping forceps for manipulation of tissue. D: Maryland Bipolar Forceps—bipolar energy form for hemostasis. Grasping forceps for dissection and manipulation of tissue. E: Monopolar Scissors—monopolar energy form. Cutting and cauterization of tissue. F: Permanent Cautery Hook—monopolar energy form. Divides and cauterizes tissue. G: Mega Suturecut Needle Driver—dual function instrument. Both drives needle through tissue and cuts suture. H: Large Needle Driver—drives needle through tissue. Medium size jaws are more appropriate for smaller needles. I: Black Diamond Needle Driver—drives needle through tissue. Fine tip jaws needed for very small needles. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015 all rights reserved.)
Figure 2.2. Port placement for standard four-arm side docking of the Intuitive Da Vinci Si robot. Numbers 1, 2, and 3 are 8-mm robotic instrument arm ports. (Reprinted with permission, Cleveland Clinic Center for Medical Art & Photography © 2015 all rights reserved.)
Place the robotic endoscope arm, so the sterile adapter, clutch buttons, and patient cart center column are in alignment, as well as centered between the legs of the patient cart base.
The camera arm setup joint (which is the articulating joint on the robotic endoscope arm closest to the patient cart center column) should be articulated to the same side as robotic instrument arm no. 1. There is no consideration necessary for the “sweet spot” (blue band) found on the camera arm setup joint when side docking.
See Figure 2.5.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
