Working With The da Vinci Robot
Minimally invasive surgery, or MIS, is becoming the preferred method of operating for a variety of procedures. Two of the biggest reason for this are better access to the targeted anatomy and better patient outcomes. Abdominal procedures can be performed with a laparoscope and laparoscopic instruments or with a robotic system, such as the da Vinci. I’ll focus on talking about the da Vinci robotic system today. I learned this system about 10 years ago on a previous model, the Si.
Procedures as simple as a cholecystectomy or hernia repair can be performed with the da Vinci, but complex procedures such as a low anterior colon resection (LAR) or an abdominal perineal resection (APR) can also be done robotically. You can have any amount of your colon removed and only have 4-5 small incisions. One of which will be slightly extended to remove your colon, but a much better option than an almost foot long midline incision, right??
There are a handful of surgical instruments that can be used with the da Vinci, and more are being introduced pretty regularly. Of course, you have your basics like Maryland scissors, needle drivers, clip appliers, and graspers. They also have created a robotic stapling system to perform the resection completely robotically. They have energy devices such as the vessel sealer to ligate tissue. There is also a suction irrigator, which in my experience is not frequently used and the assistant is usually the one using through the additional “assist port” or the air seal port. The air seal is another system that is used to maintain ideal pneumoperitoneum, it also has a function where it suctions out plume (surgical smoke) to ensure the field is clear.
As a nurse and a surgical tech, you must be very comfortable and knowledgeable with the robot. There is a lot to know about the da Vinci, but once you learn and repeat it, it should stick. I remember learning how to manipulate the robotic arms, I thought there is no way I will ever remember what all of these buttons do. I was terrified I was going to do something wrong, and that would result in the patient being harmed. I also learned that there are many safety features to prevent something like what was running through my brain from happening. Good work, Intuitive. I’ve came a long way from being intimidated by the robot to loving to teach others how to manipulate the robot.
The facility that I trained at had an excellent onboarding program and we partnered with the Intuitive reps for hands on training as well as online modules form Intuitive. The rep that was over our territory was phenomenal. She was extremely knowledgeable and shared everything she knew about the system with those she trained. Often times it seems like some of the reps do not truly have a good grasp on what they are representing, but she did! She was also present for a large percentage of the procedures, which was not always necessary, but always appreciated.
Learning how to ‘drive’ the robot up to the field was challenging, but again, once you learned the basics of how to move the robot to the field, it became a simple task- which is actually pretty fun to do! When you drive the robot to the field you are moving the robot from out of the sterile field up to the patient so it can be docked to the patient, this means that you have to line up a small laser light crosshair to the cannula that the camera will be introduced through. Usually, the surgeon will help guide you to the correct location, but sometimes the surgeons will not give much guidance. What can make this difficult at times is taking direction from the surgeon on how to manipulate the robot. When you drive in the robot there are many different ways you can maneuver it, some of which may achieve the same result, so it can become a little confusing if there is not clear communication from the surgeon.
If you ever find yourself in a position to be able to look through the surgeon console, do it. You will be amazed at the difference that you see displayed on the screen versus what the surgeon sees. When I first trained on robots, I was scrubbing two robotic prostatectomies twice a week, and that helped get me started on the right foot as a robotic prostatectomy usually requires a variety of instruments and techniques to be used.
There is at least one person scrubbed in at all times to attend to the robot. While the surgeon controls the articulations of the robot, the surgical tech will need to insert and remove the robotic instruments a necessary and use instruments as requested through the assist port. Usually, the only instruments used through the assist port is a suction irrigator and a grasper to hold tissue and retract as needed. A rule of thumb for assisting is to always announce to the surgeon if you are removing or adding an instrument, even if they requested you to do so.
It is very important to communicate when switching anything on the robot or when coming in with anything through the assist port.
Assisting robotically is a lot like assisting laparoscopically… except add having to dodge the robotic arms. During a laparoscopic case this is not typically an issue because you are standing right next to the surgeon and they know where you are, but in a robotic procedure the surgeon has their head in the console while they operate, and they do not know where you are. It might seem like they are intentionally hitting you with the arms, but they aren’t! There is a microphone that picks up what is being said at the field and the surgeon is able to hear it all, so make sure you do not say anything you would not want them to hear!
I remember during my training there would be a bleeder that I thought was “huge” and no one seemed concerned at all, in fact there were times when I was thinking “oh man, I need to get stuff ready to open this patient up”. I quickly learned that what looks like a “huge” bleeder on the screen during a robot is in fact only a small bleeder and no cause for concern (if taken care of, of course).
I’ve learned a lot working with robotics and they are some of my favorite procedures to scrub or circulate. They usually require a fairly large set up, unless it is a hernia repair or a cholecystectomy. But, if a bowel resection or APR then you generally have your robot set up in addition to an open set up to be ready just in case of an urgent need. Of course, you count all the instruments in your count so you don’t have to rush to do so at a not so great time, but if you do not end up opening then you won’t need to count them again!
If you are new to working with robots or haven’t worked with robots before, it’s normal to feel intimidated! Just get in there when the room is open and power it on and push all the buttons! See what they do! There is no better way to get more comfortable with the robot than to get your hands on it. Most facilities usually keep dropped drapes and old instruments for training, so check and see if any of those are laying around too. Once you get comfortable and confident with the robot, you could love it too!
