Da vinci robotic surgical system

Dr.Omar K. Ibrahimurosurgery

Background

The word robot, taken from the Czech word “robota,” meaning forced work

The first time a robot was used to assist a surgical intervention was in 1985 in the Memorial Hospital of Los Angeles brought the industrial Unimation PUMA 200 robot into the operative room to hold a laser for neurosurgical interventions.

Surgical robots fit into three categories: active; semi-active; and the so-called master−slave systems. The active system consists of a robot performing tasks autonomously under the supervision of the surgeon. Semiactive systems have an autonomic and a surgeon-driven component. Master−slave systems allow the surgeon to directly

telemanipulate the robot from a more or less remotely placed command center. In this situation, the surgeon’s movements are translated into robotic motion.In urology, robots have been tested in two areas: endourology and laparoscopic surgery.

Instrumentation

Robotic-Assisted Laparoscopic Prostatectomy

da Vinci S or Si Surgical System (Intuitive Surgical, Sunnyvale, CA)

Endowrist Maryland bipolar forceps or PK dissector (Intuitive Surgical, Sunnyvale, CA)

Endowrist curved monopolar scissors (Intuitive Surgical, Sunnyvale,CA)

Endowrist ProGrasp forceps (Intuitive Surgical, Sunnyvale, CA)

Endowrist needle drivers (2) (Intuitive Surgical, Sunnyvale, CA)

InSite Vision System with 0-degree and 30-degree lens (IntuitiveSurgical, Sunnyvale, CA)

12-mm trocars (2) 8-mm metal robotic trocars (3 if using a fourth

robotic arm) Small and medium-large Hem-o-Lok clips

(Teleflex Medical,Research Triangle Park, NC)

Patient Positioning

After induction of general endotracheal anesthesia, the patient is placed in a supine position in steep Trendelenburg with arms tucked and padded at the sides. Sequential compression stocking devices are placed on both legs and activated. The patient’s legs are spread apart and supported by spreader bars to allow for access to the rectum and perineum.

Alternatively, the patient’s legs may be placed in stirrups in the low lithotomy position. The patient is then secured to the table using tape and egg-crate padding. An orogastric tube and urethral catheter are placed to decompress the stomach and bladder, respectively.

Operating Room Personnel

LRP and RALP require that the surgical team including the scrub technician, circulating nurse, and surgical assistant(s) be fully trained and skilled in the instrumentation, operative setup, and technical steps of these minimally invasive techniques.

Steps of the transperitoneal access in

RALRP Trendelenburg up to30° Peri- or supraumbilical incision to insert

the trocar for the optics Insertion under vision control of five others trocars (three for the robot and two for the assistant if four-arm system)

Anterior peritoneum incision and primary lowering/extraperitonealizing of the bladder

Exposure of the anterior face of the prostate and internal face of the obturator fossa

A V starting at the root of the penis helps to locate the position of the two 8-mm trocars of the robot at 18 cm distance, with a space corresponding to a hand on both sides of the umbilical trocar. A 12-mm VerSastep trocar (Tyco, Norwalk, Conn.) is inserted two fingers inside and two fingers upward of the right anterior iliac crest

Through this trocar one can insert the camera and control the placement of the umbilical trocar and guide the insertion of a 5-mm trocar between the right arm and the optical instrument . On the left side, in the same way, a 5-mm/8-mm trocar (assistant tool or fourth arm of the robot) is inserted.

The robot is then connected and the position of the operating

table is locked. The umbilical trocar with

the camera exerts a discrete rise of the abdominal wall. The pressure of insufflation is decreased to 12 mmHg.

Access to the Pelvis and Incision of the Anterior

Peritoneum The optics 30° is directed to the top (up on

the console), and the surgeon at the console

handles a bipolar forceps on the left arm, and of the monopolar scissors on the right

arm, and a grasper on the third arm (if available). The electric current is regulated

between 20 and 40 W on the bipolar forceps and has 40 W on the monopolar scissors.

The assistants hold a Johan forceps and a suction device.

The sigmoid loop is released from possible adherences and the small intestine is pulled back upwards. The peritoneum is incised by dividing the umbilical arteries, and while going down to the deep inguinal ring, the vas deferens is retracted or divided to give more mobility to the bladder

The pneumoperitoneum facilitates the dissection of cellulo-fatty space, and the assistant using the suction device contributes to complete the lowering of the bladder exposing the pubic arc and the Cooper ligament, the internal face of the obturator fossa, and the anterior face of the prostate

All the fatty tissue covering the prostate, the endopelvic fascia, and the puboprostatic

ligaments is removed. The transperitoneal access is then accomplished and the

radical prostatectomy can start.