Maine Medical Center's First 

Robot-Assisted Open Prostatectomy

November, 2003

 
In November, 2003 the Department of Urology used the new DaVinci Surgical Robot in the first Robotically assisted Prostatectomy performed at MMC. Below are pictures and comments designed to assist those involved in subsequent procedures using this device.
November2003 (7).JPG (713526 bytes)

After induction, intubation, and placement of orogastric tube, with arms tucked at side, extensive padding is placed across shoulders and other pressure points in anticipation of restraints to allow steep Trendelenburg position (often at least 30 degree head-down).

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November2003 (9).JPG (501826 bytes) Wide velcro table restraints are placed in bandolier configuration. Legs are in padded stirrups.
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November2003 (11).JPG (447529 bytes) Bair Hugger Blanket is placed for warming, and Mayo stand moved allow to both protect patient and allow for assistant's armrest and instrument placement.
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November2003 (13).JPG (503022 bytes) After prep & drape, surgical portals are established. Note stereo camera.
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November2003 (16).JPG (568635 bytes) After five portal established (1 for camera, 2 for robot arms, two more for surgical assistants), robot is moved into position between legs.
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November2003 (17).JPG (519784 bytes) Robot arms are attached to instruments passed through portals.
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November2003 (18).JPG (572160 bytes) Final configuration, ready for definitive surgical procedure.
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November2003 (19).JPG (590810 bytes) Surgical assistant and OR team monitor procedure on one of two video monitors (2-Dimensional). Robot arms can move quickly, so assistant must be careful to avoid contact.

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November2003 (21).JPG (583718 bytes) Surgeon manipulates robot arms at console in corner of room. Viewing is binocular (3-D). Assistant(s) passes suture, retracts, and otherwise assists surgeon.

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Anesthesiologist Comments from 1st case:


A. Trendelenburg: about 30 degree angle, both arms tucked at side.
I had problems with pulse oximetry initially, as the regular slide-on finger probe was compressed by the weight of the patient's buttock(s), and the signal became progressively weaker, subsequently non-functional. So I tried a number of positions on the face, earlobe, nose, cheek, etc., but those too didn't work,  presumably from the venous congestion due to the steep T-Berg.  So I asked the circulator to slither under the drapes and try to free up the hand and restore circulation, which she did, and I had no further problems. I can see real problems in wide-body patients, though, and I wonder if the clear plastic toboggan(s) might be a good solution.

Also, these first cases are going to be LONNNGGGG. I started at 8:30 (Thurs) and was relieved at 3:30; the case was still going strong. That's a long time in the T-berg position, and facial/neck/airway edema could be a real problem. If so, it may be a good idea to leave the patient intubated, head-elevated, in PACU for a couple of hours to let the edema subside. As proficiency develops, these cases should last only 3- 3.5 hrs.

B. Estimating blood loss is almost impossible (just like other open prostates). Yes you can measure suction and subtract irrigation, but who knows how much blood is pooled up near the diaphragm until you eventually level the patient out? The good news is that blood loss seems substantially less, as there is meticulous attention to hemostasis during the dissection.

C. Surgeons asked me to limit fluid replacement to <1500 cc; the goal is to reduce urine output, as the bladder is open much of the time and profuse urine production makes for more difficult visualization. This request seemed reasonable for a 3-4 hr case; when the case stretched on and on however, and blood loss mounted, I had to
give more crystalloid. Excessive urine output was not a problem.

I did the Tegaderm trick to the eyelids; worked well I think. The reasoning here is that steep Trendelenburg may cause oral secretions to seep out onto the face, possibly dripping into unprotected eyes and setting up a real good conjunctivitis. Judiciously applied Tegaderm seals the lids and prevents this. Also Bair Hugger to the Torso (I used a pediatric "Bottom" drape; maybe there are models for adult torsos, but I couldn't find one)

Shoulder restraints: Surgeons don't want problems from these any more than we do. They are trying various forms of restraint. Today's method was lots of foam on the shoulders, held on by tape, and then two velcro table restraints criss-crossed like bandoliers across the chest. The patient was nice and thin, and I think this worked well.

Peak Airway Pressures: With the T-Berg and abdominal insufflation, I regularly ran Peak Airway Pressures  of 38-42, despite my best efforts to adjust flow rates, tidal volumes, etc.  The cost of doing business, I guess. Also, CO2 retention (EtCO2 in the 50-60 range) can be a problem.

Anesthesia: I used Forane/fentanyl/O2/air (no nitrous); Forane 1.5%-3.0% range (if running this for 6 hrs, good luck waking up!!) But once that robot is in place, you really don't want the patient moving around. I suppose I could have used a lot of NMBs, and I would have if the patient didn't tolerate the forane.

The robot itself is very cool. It offers significant advantages, especially in tight places like the pelvis, and we're going to see a lot more if it.