Abdominal Access

Robotic Access

Based on Dr. Halsted's legacy, a surgeon should always protect tissues with exquisite care based on three principles: asepsis, hemostasis, and gentleness. None of the preoperative preparation is as essential as the manner in which details are executed. Gentleness is essential in the performance of any surgical procedure.

However, in recent decades a shift toward the search for less invasive procedures has seen the expansion of laparoscopy. Historically, Kelling was the first to examine the peritoneal cavity with an endoscope in 1901, although it was done in a dog. The first major series of laparoscopies in humans is attributed to Jacobaeus, who in 1911 reported examining both the abdominal and thoracic cavities with a “Lapaothorakoscopie.”

Most recently, the technological evolution has brought us computer-assisted remote mechanical devices in the form of robotic surgery. The term robot defines a device that has been programmed to perform specific tasks in place of those usually performed by people. In contrast to the use of robotics in industry, the robot does not work autonomously in most surgical applications but rather acts as an interface between the operating surgeon and the patient.

It was largely developed to overcome the limitations of conventional laparoscopy, which include two-dimensional visualization, incomplete articulation of instruments, and limited ergonomics. The robotic platform incorporates high-definition imaging systems, powerful computer processors, and advanced robotic technology surgery with the easier transmission of open surgical skills to laparoscopic surgery. This platform also provides precise and ergonomic control of “wristed” surgical instruments with 7 degrees of freedom in an ergonomically comfortable workstation, and with three-dimensional visualization of surgical anatomy, tremor elimination, and scaling of movement.

The robotic assist surgery (RAS) system is composed of three major hardware components:

• 1.

  Surgical (aka patient) cart: contains the mechanical arms (one camera arm, three to four surgical instrumentation arms) that interface with the patient directly at the operating table.

• 2.

  Vision cart: usually contains a video monitor (for bedside/assistant visualization), the video processor, a light source, insufflator for CO ₂ gas, etc.

• 3.

  Surgeon console: contains a “stereoscopic” or binocular visual display that provides high-definition, three-dimensional images with adjustable magnification and fine focus of the operative field and the master controllers.

The most recent iteration of the robotic platform features a second console slave enabling greater assisting and teaching opportunities. An assistant remains at the bedside and changes the instruments as needed, providing retraction as needed to facilitate the procedure.

All patients considered for RAS should undergo preparation for surgery in standard fashion and be carefully evaluated for perioperative risk factors. An emphasis on ample patient education prior to surgery will prepare the patient for a more satisfying surgical experience.

From the physiologic perspective, RAS is similar to standard laparoscopic surgery because the creation of a surgical “working field” will require the development and maintenance of a pneumoperitoneum throughout the procedure.

You must ensure that all three components of the RAS platform are functioning correctly. Once the patient is safely under anesthesia and properly positioned, gaining access to the target surgical anatomy is undertaken in a typical minimally invasive or nonrobotic, laparoscopic fashion. According to individual surgeon preference, a Veress needle, an optical view trocar, or an open, “cut-down” approach is undertaken to gain access to the abdomen and initiate the pneumoperitoneum. Robotic reusable trocars are available from 5- to 13-mm sizes. The robotic endoscopes can be used with standard 12-mm laparoscopic ports or can be used with their respected robotic reusable trocars. The robotic instruments must be used with the robotic reusable trocar cannulas.

Regardless of the initial access technique, upon establishing pneumoperitoneum, the intraabdominal contents are surveyed and carefully assessed for signs of injury due to the initial access maneuver. Once this has been confidently excluded, we can begin placement of additional cannulas under direct visualization. Specific locations and the number/size of the surgical cannulas will be determined by the demands of the surgical procedure and the characteristics of a patient's anatomy. As in laparoscopic surgery, triangulation of the surgical target with respect to the camera and the bilateral working arms is preferred in most situations.

Once all of the cannulas have been placed, the operating table is adjusted into optimal position for the anticipated procedure. In this position, the individual arms of the surgical cart may be prepared for surgical maneuvers in a process called “docking the robot.” Visualization is maximized when the center column of the surgical cart is positioned in a straight line behind the target tissue, and the camera is also lined up directly in front of the target tissue. The surgical arms will then be extended over the patient's body and ultimately docked to their designated cannulas.

This results in a final configuration with the camera and all instrument tips pointing directly toward the surgical target with the surgical cart standing directly beyond it. The use of a fourth robotic surgical arm and the placement of additional bedside assistant port(s) are up to the discretion of the operating surgeon. Once docked, the laparoscopic wristed instruments and endoscope can be inserted.

The lack of tactile resistance or feedback must be respected and overcome. The only feedback that the operating surgeon experiences at the surgeon's console is purely visual. Keeping all working instruments in direct and constant visualization is an absolute must for RAS. In addition, careful insertion and removal of surgical instruments by properly trained and knowledgeable assistants is critically important. Furthermore, the surgeon should make a conscious effort to reduce the number of instrument exchanges during the procedure to limit the risk of inadvertent injury and to maximize surgical efficiency.

As with laparoscopic surgery, there has always been an interest in further minimizing the invasiveness of surgery by converting RAS procedures using multiple incisions into a “single-site” operation, using only one small incision.

Single-site laparoscopic surgery required a disoriented “crisscrossing” of surgical instruments, limited surgical views, and poor ergonomics, whereas the RAS platform's capabilities, such as the ability to designate control of individual surgical arms, enhanced surgical visualization, and improved ergonomics, all help to overcome some of the challenges of single-site laparoscopic surgery. Proper patient selection and preoperative planning and optimal equipment setup are the fundamental keys to a successful RAS procedure.

Laparoscopic Access

Described adeptly as a disruptive innovation, laparoscopy has supplanted laparotomy to become the preferred option for many intraabdominal surgical procedures. Since the early 1990s, general surgeons have used laparoscopy in the treatment of intraabdominal and retroperitoneal pathology. The technique and equipment have greatly improved in the three decades since early adoption, making laparoscopy the most common approach for abdominal operations.

Laparoscopy is superior to laparotomy because it offers measurable advantages such as decreased postoperative pain, decreased incidence of wound complications (hematoma, seroma, fat necrosis, wound dehiscence, evisceration, and hernias), shorter duration of postoperative ileus, and ultimately decreased length of hospital stay. These benefits directly translate to lower cost of surgery, which offsets the initial costs of acquiring laparoscopic instruments. Patient satisfaction is boosted by the ability to largely preserve cosmesis using the smaller incisions afforded by this approach. The principles of laparoscopy are transferable and are now widely used in the fields of robotic and endoluminal surgery.