My friend and co-worker, Alice Dungen, CSFA, has written a great article about working with the DaVinci for surgical procedures. She has agreed to let me share it as to assist Surgical Technologists and Surgical Assistants alike. Alice offers great advice and perspective, not just in this article but also in my personal growth as a surgical tech. Thank you Alice for all the advice you have given to me and so many others!
Robotic Surgery: The DaVinci
Maybe you’ve been working with the daVinci for a period of time or maybe you’re just beginning. I started working with robotics about 5 years ago and still remember the first case I did. Didn’t like it at all. Didn’t see myself continuing covering these cases. Felt very uncomfortable with the surgeon not being scrubbed in and sitting at the console with his/her shoes off on the other side of the room!
Fast forward to five years later and I have truly learned to enjoy assisting on daVinci cases and even look forward to them. They can be very challenging at times, but rewarding when everything goes as it should. In a perfect world that would happen. Since that “perfect world” doesn’t exist, here are a few troubleshooting and procedural tips that may make your transition smoother or help you out of a sudden difficulty. This is by no means everything that “could” go wrong with a case, but represents some of the more common issues that you may be faced with.
- It’s a great idea to familiarize yourself with port placements for various procedures. Unless you work with the same surgeon every time, you never know if you’ll be across the table from a surgeon who is new to daVinci and may ask your input. If you can suggest some positioning tips and measurements for the trocar placements you will be invaluable right off the bat.
- Keep the suction tip out of the way of the camera. This may sound obvious, but when you first start to assist on these cases, sometimes the tip will appear in front of the camera (yeah…you did it) at an inopportune time. This is a good way to drive your surgeon crazy. Also, resist the urge to suction all areas you can see that need it; primarily focus on the area where the surgeon is working. A quick “in and out” will usually suffice.
- Venting during high cautery. Sometimes, there will be a great deal of “smoke” which can inhibit visibility. You can open a port slightly so there is a constant venting and/or vent with the suction. Mention to your surgeon that you are doing so as they can hear escaping gas from the next room. Keep an eye on the insufflation/pressure monitor to be sure the pressure doesn’t drop too low and you loose insufflation, which means you’ll also quickly loose visibility as the abdominal cavity closes down. Not to mention the fact that the patient would almost literally be suspended by the daVinci arms if this occurred.
- When the surgeon places the dorsal venous stitch in a Prostatectomy, he or she will probably ask you to move the catheter to ascertain if the needle caught it. After a little practice, you will be able to tell if this has happened. Be sure to let your surgeon know right away as this can be rectified pretty easily before the knot is tied down. Oftentimes, the catheter may be exchanged just before the urethral reanastomosis and if a stitch is caught in it, you won’t be able to remove it. Worst case scenario would be the catheter would have to be left in until the stitch dissolved; anywhere from 6-8 weeks. Not an ideal situation for sure, but not the end of the world.
- You have two hands: use both of them! You’ll no doubt need to have the suction tip in one hand and a clip applier, grasper or scissor in the other. Trying several different methods for reloading clips, I have found that for me it’s easier when reloading a clip applier to hold the suction and the clip rack in your left hand and that will provide a solid base for you to reload the applier. Experiment on your own to see what works best for you. It might be easier for you to stick the clip rack to the drape or a mayo stand. Whatever method you use, ALWAYS keep your clip applier loaded! If you don’t have time to reload, ask your scrub tech to do it for you.
- If a drain is required, the size and type should be noted on the preference card. The drains are normally inserted into one of the lateral 8mm ports after closing the top cap so insufflation is not lost. You’ll have to carefully remove the trocar around the drain, ensuring that you don’t pull the drain out at the same time.
- Let’s say you are assisting on a daVinci Sacral Colpopexy, which may call for a number of Vicryl sutures cut to a certain length. As the surgeon is throwing the last knot from the first stitch, have your needle holder loaded with the next stitch. Pass the stitch to him/her and before removing your needle holder, grab the used suture and remove it. This will save you from removing the used suture first, taking out your needle holder and then reinserting with a new suture. Economy of motion! And, the bonus here is that your surgeon won’t have to wait for you to pass another stitch.
Sometimes, you’ll be working along when suddenly you notice that your insufflation has left the building! Don’t panic. Here are a couple of things you can check, but be sure to advise your surgeon what is happening and that you are on it.
- Check that the clips holding the trocars on the arms are both tight and in place. Sometimes one of the two clips may spring open. This could cause a gas leak. In addition, the daVinci arm holding the robotic instrument will not operate properly and will undoubtedly alarm.
- This may seem obvious, but sometimes it’s as simple as the insufflation tubing simply disconnecting from the trocar. This is a quick fix. Take a quick scan of all of your tracers with luer locks to see if you’re experiencing a loss of insufflation.
- What if the daVinci doesn’t recognize an instrument and flashes yellow? Check to make sure that it has not expired, or is not close to expiration. You’ll need to replace it with a new instrument if it has.
- Is the C02 tank “out of gas?” Stranger things have happened!
- Sometimes, a trocar may back out of the fascia and this will not allow the C02 to keep the abdominal cavity insufflated. You will need to remove the robotic instrument, disconnect the robotic arm from the trocar, obtain the obturator from the scrub tech and reinsert the trocar. Reattach the robotic arm and insert the instrument. Remember that since you have moved the arm the robot will not remember where the instrument was so you will have to reinsert the instrument under direct vision.
- This is very important! NEVER remove ANY instrument from the arms until you are sure that the surgeon has not placed the jaws on anything. This could be disastrous if the instrument is holding a portion of bowel out of the way, for instance, and you remove it and tear the bowel.
- You will undoubtedly encounter different surgeons who will request you to stand on either the right or the left side of the patient. You will need to be flexible and be able to work from either side. I personally did my first 4 years of prostatectomies on the right side of the patient. My surgeon gained a partner who asked that I stand on the other side. I think I dropped the suction tip 3 times during that first case! Believe me, it feels different!
- As you are removing obturator lymph nodes, for instance, be sure to draw the specimen out of the trocar slowly while keeping it centered. This will make it easier to remove the whole specimen on the first pass. Remove your grasper slowly and steadily. Sometimes you may need to use a hemostat to gather any remaining bits of specimen from the top of the trocar.
- Here’s my analogy to working with the daVinci; I use the “Red Riding Hood theory” of “not too much and not too little, but just right!” With a little practice and attention to detail, you’ll soon be a whiz at daVinci assisting.
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