Image this scene in the OR: A surgeon who is performing a tedious laparoscopic procedure starts to experience hand-eye fatigue. The assistant holding the camera for the surgeon’s visualization experiences involuntary tremor. That in turn results in motion artifacts on the video resembling an earthquake. Other members of the surgical team aren’t spared, either: They are getting “seasick” as they watch the wavering image on the screen. Obviously, all of this is affecting the team’s concentration and performance of critical tasks.

Now a solution exists: robotic-assisted laparoscopy. The surgical team uses a robot with mechanical arms to perform complex surgery without the problem of human hand-eye fatigue — and with a high degree of precision. In fact, the movement possible with robotic “hands” and instrument tips is superior to that possible with the human hand.

As robotic-assisted laparoscopy grows more widespread, more nurses are likely to encounter patients scheduled for or recovering from such surgery — or be a member of a surgical team that uses robots. To fully appreciate the impact of robots in the OR during laparoscopy, the nurse must have a fundamental knowledge of endoscopy, the use of telescopes and long instruments to enter the body through a natural body orifice or a series of tiny incisions in the skin. The term endo means inside, and scopy means to look. Endoscopic procedures are usually named for the entry point location of the body, such as neuroendoscopy for the vetricles of the brain or hysteroscopy for procedures of the uterus. The use of endoscopes in abdominal surgery is termed laparoscopy.¹ (Laparo means loins or flank.)

Candles and torches

Endoscopy has a long history, with roots in ancient Greek medicine, as in Hippocrates’ use of tubular specula for examination of natural body orifices. This was a tenuous procedure since lighted candles and torches were used for illumination. Visualization of internal structures was poor, and procedural tissue manipulation was restricted to grasping instruments and metallic cauterization tips heated by fire.² Endoscopic techniques through natural orifices improved in the 19th century as the use of mirrors and other reflecting elements enhanced illumination. But reflected illumination generated uncontrolled heat in the patient’s tissues, causing burns. (Methane in the colon was a source of combustion.) Later, small electric bulbs were used with some success. However, the risk of electrocution was significant.¹

In the late 1800s, urologists and opticians made major strides in technique and safety by creating a telescope illuminated by an external light source for viewing inside a patient’s urinary bladder. This invention, the cystoscope, increased the field of vision by directing light through a lens to the interior of the working space, which was created by sterile water in the bladder. (Bladder endoscopy is called cystoscopy.)¹

In the early 20th century, surgeons developed a new method to create a working space: insufflation of air into a body cavity. Surgeons of the era experimented by using ambient air to expand the peritoneal cavity and look inside with the newly developed cystoscope. But problems included fires and explosions caused by electric sparks in an oxygen-enriched environment.

Surgeons later switched to carbon dioxide, which is readily absorbed by the peritoneal membrane of the abdomen and easily excreted from the body via the pulmonary system. Carbon dioxide is nonflammable and safe for use in endoscopy.¹

In the mid-20th century, surgeons refined endoscopy to incorporate the measurement of intra-abdominal pressure and the use of refined electrosurgical techniques for procedures including tubal coagulation for female sterilization. The introduction of fiberoptic technology permitted the surgeon to videotape and photograph internal structures, thus enabling more advanced procedures, such as cholecystectomy (removal of the gall bladder) and bariatric surgery. The next step was robotic control for precise movement within the working space.

The essentials

The integration of robotic technologies into laparoscopy involves a series of steps common to all endoscopic procedures. The eight essentials of endoscopy incorporate methods of entering the body, providing space for the surgeon to handle tissue under direct or indirect vision, removing specimens, and reestablishing the integrity of the entry point.¹ The eight essentials of endoscopy include the following:

1. An access portal. This is a natural body orifice or a set of one or more strategically placed percutaneous puncture sites. An access portal is required for the creation of the working space in all endoscopy.
2. Working space. This is the surgical area wherein the boundaries of the internal environment are expanded and maintained throughout the endoscopic procedure. Expansion media can be ambient air, fluid, carbon dioxide, or physiologic structural support. Laparoscopy requires carbon dioxide to expand and maintain a space within the peritoneal cavity.
3. Illumination. The internal environment is lighted by fiberoptics within the boundaries of the working space. The telescope delivers the light to the internal working space.
4. Vision. Members of the surgical team observe the internal anatomy through a lighted hollow tube or through a series of lenses. In laparoscopy, the surgeon observes the internal target regions within the working space with a telescope-camera assembly inserted through the primary endoscopic sheath. The team can see the internal images on a digital video monitor.
5. Manipulation. The surgeon examines or alters the target tissues using long, specialized instruments passed through a percutaneous sheath or working channel of the endoscope. All surgical techniques, such as dissection, grasping, debulking, probing, and excising, take place with the instrumentation passed through the secondary or accessory endoscopic sheaths.
6. Capture. Target or accessory tissues are isolated and removed as surgical specimens through the access portals and endoscopic sheaths. Small rolled-up plastic bags are passed through the secondary sheath to capture the specimen.
7. Evacuation. The expansion media, body fluids, irrigation, and plume are safely removed from the working space at the end of the surgical procedure to prevent biologic contamination of the surgical team.
8. Closure. Access portals are approximated with suture medium to reestablish the integrity of the body’s surface at the end of the procedure.^1-3

Enter the robots

Robotic-assisted technology has fine-tuned each of the eight essential steps. Advantages of robotic technology include the ability to perform more precise movements within the working space, stable visualization up to 12 times the magnification of standard laparoscopic approaches, and decreased human fatigue and tremor during prolonged surgical procedures.³ In addition, the precision of motion and the acute visualization possible with robotic-assisted technology permits the surgeon to avoid many blood vessels, thus reducing blood loss. Disadvantages include the high cost of starting a robotic-assisted laparoscopy program and the $1,000 additional per robotic-assisted procedure, the intensity of user training programs, surgeon and team learning curves, and loss of human tactile sense.⁴

Moving forward

Several advances have been key in the evolution to date of robotic-assisted laparoscopy. The invention of the mechanical camera holder in the early 1900s virtually eliminated the motion artifact caused by unsteady human hands.⁵ Decades later, this device was developed into an automated, voice-activated system. The Automated Endoscopic System for Optimal Positioning is known as the first endoscopic robot, approved by the FDA in 1994.¹ AESOP is an articulated arm, mounted on the operating bed, that takes directions that the surgeon transmits electronically via a headset and microphone. AESOP allows the physician to position the camera with voice commands, leaving his or her hands free to continue operating on the patient. At the surgeon’s voice command, the camera assumes a position and stabilizes the image without extraneous motion. Each surgeon has a voice card that individualizes AESOP’s responses to the spoken word and sorts out verbal patterns not intended as instructions.^1,5,6

Current robotic-assisted technology is led by a robotic surgical system that includes a console station a few feet from the sterile field and a remote-controlled robot with three to four mechanical arms positioned over the surgical field. The primary surgeon sits at the console to remotely manipulate the mechanical arms, which hold in place the surgical instruments. One of the arms is equipped with a camera; the others are fitted with surgical instruments that the surgeon controls to dissect and suture tissue during procedures. The surgeon does not touch the instruments directly during surgery.^5-7

The human touch

Whatever the advantages and disadvantage of robots in endoscopy and larparoscopy, the human surgical team is still very much on the scene. Procedural setup starts at the proposed sterile field with a sterile team of one or two surgical assistants and a scrub nurse, who remain in place throughout the procedure.

The sterile team drapes the patient and inserts three or four percutaneous access ports through the patient’s skin. These portals are positioned in a generalized triangular pattern in preparation for insertion of a camera-telescope assembly and endoscopic instrumentation. Carbon dioxide under pressure is insufflated through a Veress needle — a specialized surgical needle — to create and maintain the working space.⁵

The robot with its three or four mechanical arms is positioned over the sterile field and attached to instrumentation inserted into the percutaneous ports. Only instrumentation manufactured for the robotic arm assembly can be used. One mechanical arm is designated as the director of the camera-telescope assembly. The primary surgeon controls illumination and viewing by operating the arm from the console several feet from the field. The surgeon operates the other mechanical arms for tissue manipulation and capture during the procedure.⁶
To start operating the robot, the surgeon presses his or her forehead into a face-port viewer on the console. Failure to make full contact with the forehead rest causes the robot to go into standby mode as a safety feature. This prevents involuntary motion of the arms or instrumentation, which could injure nontarget tissue.¹

The surgeon creates the fine hand motions required for the procedure by manipulating joysticks — general control devices consisting of handheld levers — in response to real-time images the camera transmits to the viewfinder. The surgeon has an excellent view within the working space that enables precise directional motions of the robotic instrument tips. The range of motion is superior to that of the human wrist in surgery. The motions generated in response to the joysticks include the following:¹

• Roll: circular rotations of the tip; clockwise and counterclockwise
• Pitch: linear up and down motion
• Yaw: linear side-to-side motion
• Insertion: linear back and forth motion
• Grip: grasp and release

Always involved

Nurses on the surgical team are involved at all stages perioperatively. In transferring the patient from the transport cart to the operating bed, the circulating nurse positions the patient using the appropriate positioning devices and making sure enough staff are available to assist. The circulating nurse secures the patient in a supine position on the operating bed with a safety belt across the thighs. The nurse places a small pillow under the patient’s knees to reduce lumbar pressure. The nurse should slide one hand between the safety belt and the patient’s leg to ensure that the belt is not too tight.¹

The anesthesia provider, possibly a certified registered nurse anesthetist, indicates when the patient can be moved into the surgical position for the procedure. If the perineum is accessed, the patient’s legs are secured in stirrups. Some procedures require access to the rectum, such as robotic-assisted prostatectomy, for palpation of the prostate. After the patient is safely positioned, the nurse preps the skin with antiseptic and applies sterile drapes while leaving the surgical access points exposed. For laparoscopy, the abdomen is exposed.

The nonsterile components of the robot are draped at the same time the patient is draped. Some robotic arms clamp directly to the operating bed. Other devices are on wheels and are rolled up to the patient’s side and locked into position. Locking the mechanism is critical because any unintended movement of the robot during the procedure could cause misalignment of the robotic arms with the surgical planes of the patient. Tissue injury could result.
Care is taken not to contaminate the sterile-draped robotic arms as they are a attached to the sterile instrumentation used inside the patient’s body. The assistant surgeon makes the tiny incision in the infraumbilical margin required to insert the Veress needle to create the pneumoperitoneum. The carbon dioxide flows into the patient’s peritoneal cavity at pressures of 12 mmHg to 14 mmHg.¹ Patients with a large body mass having bariatric procedures may require pressures up to 18 mmHg to compensate for the weight of abdominal fat.¹ Some hospitals use a CO₂ warmer because the gas is cold in its gaseous state in the tank. CO₂ is not sterile, so the delivery tubing has an inline filter to collect particulate before the gas enters the patient.¹ After the working space is established, the assistant surgeon slightly enlarges the infraumbilical skin incision and percutaneously inserts a 10-mm to 12-mm primary trocar and sheath. The Veress needle is removed, but the sheath remains for placement of the high-resolution telescope-camera assembly secured in a robotic arm. The illuminated light cable is attached to the laparoscope. The CO₂ tubing is switched from the primary access sheath to a secondary port to minimize lens fogging caused by the cold gas.¹

Accessory 5-mm to 7-mm access portals are placed percutaneously in the patient’s abdomen in a triangular pattern under direct vision of the camera. Instrumentation attached to the robotic arms is inserted through the portals and positioned within the patient’s body.⁵ The primary surgeon manipulates the instruments and camera from the console several feet from the patient. The surgeon uses joysticks and foot pedals to perform the procedure while watching through the forehead-pressure viewfinder. Electrosurgical dissection and specialized powered instruments are used during the surgical procedure.

On the alert

The sterile team remains at the sterile field to change instrument tips during tissue manipulation and specimen capture. The entire team observes the patient for reactions to procedural manipulation and physiologic status. The anesthesia provider observes for blood pressure, pulse, respiration, oxygenation, and potential complications of air or gas in the abdominal cavity.¹ Changes in body temperature are monitored throughout the procedure because hypothermia could complicate the outcome.

At the end of the procedure, the CO₂ is evacuated through the suction tubing but is not released into the room air; the gas becomes a biologic contaminant and when aerosolized is hazardous for members of the surgical team. The skin access incisions are sutured or closed with other closure medium. Small bandages are applied.¹

Staying flexible

Possible complications of robotic-assisted laparoscopy include perforation of untoward structures and tears in tissue under tension. A stray electrical current or heat from electrosurgical tips can injure tissue, and injuries may not be manifested until several days after surgery. Hemorrhage can obscure the surgeon’s vision through the laparoscope and require the sterile team to convert from a laparoscopic procedure to an open laparotomy.⁵ The team must always be alert to this possibility. When it arises, instrumentation, sponges, and sharps from the laparoscopic procedure are accounted for and kept separate from the countable items used for open laparotomy.¹

Robotics has revolutionized surgical patient care. One day, surgeons may even be able to operate remotely on patients in distant locales. The field is relatively new, but robotic-assisted techniques are taking the surgeon, the nurse, and the patient into a realm of precision never before imagined.