For surgery of the pelvis and anterior transabdominal surgery , patients are moved directly onto an operating room table with a gel pad (Fig. 3.2) [5, 6]. The gel pad increases friction and prevents patients from sliding during the procedure. The patient is positioned in a modified lithotomy position using yellow fin stirrups (Fig. 3.3a, b) with thromboembolic stockings and sequential compression devices. Both arms are padded and positioned along side of the patient on arm boards. A safety strap or tape can be used to secure the patient to the table, and it is recommended that it not be placed across the shoulder to prevent postoperative neuropathy. An upper body Bair Hugger^® (Arizant Inc., Eden Prairie, MN) is then placed above the xiphoid and insulated with a blanket. Once the patient is positioned, we secure a face shield plate (Fig. 3.4) to protect the patient’s face and endotracheal tube from inadvertent damage or dislodgement during movement of the robotic endoscope . The patient is then prepped from the xiphoid to perineum to midaxillary lines and draped.

For surgery of the kidney or ureters, the patient is moved onto the surgical table with a beanbag immobilizer and positioned in a 45° modified flank position for transperitoneal access or a full flank position for transperitoneal or retroperitoneal access with the surgical side up (Fig. 3.3b) [7]. The patient is positioned with the space between the costal margin and anterior superior iliac spine over the kidney rest. However, the kidney rest is not typically used for these cases. Thromboembolic stockings and sequential compression devices are placed and a urethral catheter is inserted. The surgical side leg is bent slightly and padded with pillows or towels. An axillary roll is placed to prevent postoperative neuropathy, and the arm is padded and secured. The upper arm is padded and secured to an arm board and the table can then be flexed. When flexing the table, the anesthesiologist should be alerted to support the head and place several pillows or towels to avoid hyperextension of the cervical spine. Safety straps or tape can be used over the hip, lower extremity, and thorax to secure the patient to the bed. An upper body Bair Hugger^® is placed and insulated with a blanket. The patient is prepped from the nipples to anterior superior iliac spine and midline to erector spinae .

Robotic-assisted surgery begins with abdominal access and trocar placement. Pneumoperitoneum may be established using a Veress needle or with open trocar placement by the Hasson technique [5]. The initial trocar can be placed via a direct vision bladed or non-bladed trocar, or a step system without direct vision can be used. For the standard and S systems , we typically gain abdominal access by making a small incision and carrying the dissection down to the level of the fascia. The fascia is then elevated with tracheal hooks and the Veress needle is inserted [8]. Placement is verified with the hanging drop test and the abdomen is insufflated to 15 mmHg. A 12 mm trocar is then placed with a Visiport™ device (Covidien, Inc., Dublin, Ireland). This will serve as the trocar for the da Vinci^® endoscope , and the robotic camera arm is compatible with most 12 mm laparoscopic trocars. The camera trocar should be placed 15–18 cm from the target anatomy to allow optimal visualization of the surgical field. For obese patients, the camera trocar may need to be placed closer to target anatomy to adjust for abdominal girth. This is especially important when using the da Vinci^® standard system [6].

After visual access is obtained, secondary trocars can be placed under laparoscopic vision. The robotic instrument arms are compatible with specific da Vinci^® 5 or 8 mm metal trocars that can be placed using blunt or sharp obturators (Fig. 3.5). The da Vinci^® system utilizes “remote center technology ” to maximize efficiency and minimize trauma to the patient tissues surrounding the robotic trocars. Trocars have three black lines to assist with correct trocar placement. The thick black line located between two thin lines is known as the “cannula remote center .” Correct trocar placement can be verified by directly visualizing the trocar during placement. Only the first thin black line should be seen within the abdominal cavity. This allows the thick black line, or remote center, to sit at the level of the abdominal fascia within the boundaries of the abdominal wall, thus minimizing pressure exerted on surrounding tissues. It is recommended that the robotic trocars be placed at least 8–10 cm away from the camera to avoid instrument arm collision and facilitate intracorporeal suturing. In addition, the angle created by the robotic and camera trocars should be greater than 90° to increase instrument arm maneuverability [1, 4]. Other laparoscopic instruments may need to be available for lysis of adhesions prior to robot docking and for the first assistant to use during the procedure (Table 3.1).

In contrast, with the da Vinci^® Xi system, we typically establish pneumoperitoneum using a closed technique with the Veress needled placed through a stab incision at the base of the umbilicus. After pneumoperitoneum is established, an 8-mm trocar for the endoscope is placed using a blind technique. Subsequent trocars are then placed under direct visualization .

The da Vinci^® is available in four generations with five different models—standard , streamlined (S) , S-high definition (HD) , S-integrated (i)-HD , and most recently, the da Vinci^® Xi . Each system has three components: surgeon console, patient cart, and vision cart [2, 8]. There are several sterile accessories and EndoWrist^® (Intuitive Surgical, Inc., Sunnyvale, CA) instruments available for each system (Table 3.1). The standard system was released in 1999 and was originally offered with one camera arm and two instrument arms. A third instrument arm was introduced on newer systems or as an upgrade. In 2006, the da Vinci^® S system was introduced. This system has a similar platform to the standard system, but added numerous improvements including a motorized patient cart, color coded fiber-optic connections, easier instrument exchanges, quick click trocar attachments, increased range of motion and reach of instrument arms, and interactive video touchscreen display. In 2007, the S system became available with an HD camera and video system, and in 2009 the Si-HD system was released with enhanced HD vision at 1080i, an upgraded surgeon console, and dual console capability. The dual console feature connects two surgeon consoles to the same patient cart. This allows two surgeons to coordinate a surgical procedure by exchanging control over instruments arms and the endoscope . The dual console feature and HD visions could also be added to existing S systems as an upgrade by the manufacturer.

In 2014, the FDA approved the release of the da Vinci^® Xi system . This robot incorporates a different optic system and is designed to enhance four-quadrant surgery. A laser targeting feature is available for docking. The arms are smaller and lighter. The endoscope has been reconfigured to allow placement in any of the four arms. In the next several sections, we describe each of three components that make up the da Vinci^® system in detail, and we will highlight new features present with the Xi model. Of note, da Vinci^® robots have an optional fluorescence imaging feature that utilizes near infrared light from the endoscope along with administration of intravenous indocyanine green, an agent that binds to plasma proteins and allows identification of vascular structures. Further discussion regarding the exact uses of this new technology is beyond the scope of this chapter.