Fig. 1
(a) Operating room setup: patient’s marking. (b) Operating room setup: OR staff positioning. (c) Operating room setup: overall positioning
In the second place we need to think of the OR staff and the ergonomics involved in the procedure to be done in the room. Now there are different people with various roles to be allocated [5]. The surgeon will lead the team, not just during the operation, but she will help determine the complete setup in the room, troubleshooting the system, and eventual changes in plans and parts’ placement. The first assistant has to have a similar knowledge of the space and he will be the person beside the patient during the procedure, in a way that he has to master the trocar placement, laparoscopic skills, and basic surgical actions such as irrigation, clipping, suction, and retraction.
Another important part is the anesthesiologist . She will be close to the patient at all times to secure the best relaxation and take care of possible changes in respiratory pressure, blood flow alterations, and fluids. This member of the team has a very important role in the hernia surgery. It is well known that this kind of repair needs a very good relaxation and can lead to changes in the abdominal pressure and consequently in the respiratory physiology. With that professional, come the anesthesia cart and the cannulas such as the endotracheal cannula and peripheral lines.
At last the OR nurses have to be well allocated in order to move throughout the room and help with large and small materials. They can move the devices and bring new things inside the room at any time (Fig. 1b).
Having them placed, now it is time to allocate the large devices that robotic surgery entails [6]. There are three main parts [7]: the master console , the patient’s cart , and the core cart . The first one is where the surgeon has the controls of the robotic arms, can see the surgical tridimensional image, input other information from previous exams, and even make a call or receive orientation from a tutor. This console can be moved around as necessary. The second one is the device that carries the robotic arms and is placed close to the patient during the procedure. The choice of its position is crucial to facilitate the progression of the procedure, despite that the new robot generation has changed the limits of moving this cart all over for a better level. In some aspects it can be detached and reallocated as a second docking from the patient after the beginning of the operation. It is prepared with sterile drapes by the OR nurse, before the surgery starts. This cart has to move in many directions because it can be docked in various ways depending on the type of abdominal wall defect. In that manner, it has to have great mobility around the patient.
At last the core cart is where the image processor, light source, energy source, and insufflator are placed. It can be close to the patient and its cart in order to have no large cables on the OR’s ground (Fig. 1c).
All the other cables, cannulas, and other small devices are then placed respecting the robotic pathway as well as the surgical staff mobility. It is important not to have cables misplaced or in positions that could cause accidents to the electrical devices or people.
After all that setup it is important to think of the possibilities that can happen before, during, and after the procedure. Before the surgery, other devices can be placed in the room, such as energy cables or other screens, and it is important not to cause problems for the OR parts placed earlier. During the surgery is even worse because that is when unexpected problems occur. Conversions to open surgery or changes in robotic docking have to be foreseen so that possible changes in the OR setup can be made. And at the end of the procedure the patient has to come off the table to the bed, and the room setup has to be ready for it.
In the beginning of each procedure a checkout list has to be made to make sure the entire setup is done properly, so that no problems can occur during surgery. At the end it is important to check for possible problems that occurred during the operation so they can be corrected in other procedures and discussed in planned OR meetings. One person could be in charge of the complete setup, including the surgical room setup, care with the specific materials, and the patient’s preparation and positioning.
Patient’s Preparation and Positioning
Another important part of the setup begins with the preparation and positioning of the patient on the surgical table. Many studies show the influence of these items in the efficiency and outcome of the procedure [8]. With respect to that, all the materials to be used and placed on the patient as well as the possible types of positioning have to be well known before the surgery starts.
In order to have a standardized practice, all patients receive the same treatment and preparation for the robotic procedures to be done (Table 1).
Table 1
Patient’s preparation
Patient’s preparation |
|---|
Antibiotics |
Urinary catheter |
Peripheral lines |
Fixation strap |
Chest protector |
Head/eye protector |
Endotracheal cannula |
Anesthesia cannulas |
Energy cables |
Surgical drapes |
Sterile film |
Heater device |
Patients are positioned on the table depending on hernia location, that is, the concept to keep trocars over 20 cm from the main object (hernia imaginary center). After that, they receive only one dose of antibiotics, depending on the guidelines of each hospital, in our case a second-generation cephalosporin. Following that, the anesthesia is done and all the cannulas are placed lateral to the patient, contralateral to the wall defect. A urinary catheter and peripheral lines are installed; depending on the patient’s comorbidities, sometimes a central line is placed. He is secured with a fixation strap, at the chest and legs, and a head and/or eye protector. A body heater is then placed above the xyphoid or at the legs with a blanket.
The patient is then prepped from the xyphoid to the perineum and draped. After that a sterile film is placed, leaving the entire anterior abdominal area exposed. All the energy cables and other devices are now placed lateral to the patient and secured so as not to cause problems.
There are many types of procedures to be done robotically, and when we talk about hernia they can be very different one from the other. The abdominal wall is very wide and it has many angles on which to work. Depending on the defect one can work upwards, downwards, or both. Thinking about that and a way to standardize, the patient’s position on the table is planned to wide-expose the abdomen, combining lumbar flexure, anterior abdomen hyperextension, lateral right or left tilt degree, and the same freedom to move throughout the room to secure the best robotic docking possible (Fig. 2).
