ROBOTIC SURGERY IMPACT ON THE PREPARATION AND RECOVERY OF SURGICAL PATIENTS. Melissa M Hardesty, MD. MPH Alaska Women s Cancer Care

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1 ROBOTIC SURGERY IMPACT ON THE PREPARATION AND RECOVERY OF SURGICAL PATIENTS Melissa M Hardesty, MD. MPH Alaska Women s Cancer Care

2 OBJECTIVES 1. Understand the advantage of robotic vs. open or traditional laparoscopic procedure.

3 OBJECTIVES 1. Understand the advantage of robotic vs. open or traditional laparoscopic procedure. 2. Describe reason for converting from robotic to open procedure.

4 OBJECTIVES 1. Understand the advantage of robotic vs. open or traditional laparoscopic procedure. 2. Describe reason for converting from robotic to open procedure. 3. List complication risk for GYN robotic patients.

5 OBJECTIVES 1. Understand the advantage of robotic vs. open or traditional laparoscopic procedure. 2. Describe reason for converting from robotic to open procedure. 3. List complication risk for GYN robotic patients. 4. Describe the role of positioning plays in complications and recovery of patient.

6 Pros of MIS: Shorter hospital stay (this makes cost neutral/effective) MINIMALLY INVASIVE VS OPEN SURGERY

7 Pros of MIS: Shorter hospital stay (this makes cost neutral/effective) Much faster recovery and return to work MINIMALLY INVASIVE VS OPEN SURGERY

8 Pros of MIS: Shorter hospital stay (this makes cost neutral/effective) Much faster recovery and return to work Significantly fewer post op complications and readmissions (this makes cheaper than open) Infections, blood loss and transfusions etc. MINIMALLY INVASIVE VS OPEN SURGERY

9 Pros of MIS: Shorter hospital stay (this makes cost neutral/effective) Much faster recovery and return to work Significantly fewer post op complications and readmissions (this makes cheaper than open) Infections, blood loss and transfusions etc. Less pain MINIMALLY INVASIVE VS OPEN SURGERY

10 Pros of MIS: Shorter hospital stay (this makes cost neutral/effective) Much faster recovery and return to work Significantly fewer post op complications and readmissions (this makes cheaper than open) Infections, blood loss and transfusions etc. Less pain Nicer looking incisions MINIMALLY INVASIVE VS OPEN SURGERY

11 Pros of MIS: Shorter hospital stay (this makes cost neutral/effective) Much faster recovery and return to work Significantly fewer post op complications and readmissions (this makes cheaper than open) Infections, blood loss and transfusions etc. Less pain Nicer looking incisions Cons: skill of surgeon to do. MINIMALLY INVASIVE VS OPEN SURGERY

12 LAPAROSCOPY VS ROBOTIC Main advantage here is the ability to Do cases that would have been open, with MIS.

13 LAPAROSCOPY VS ROBOTIC WRISTED INSTRUMENTS BETTER CAMERA/VIEW

14 Disadvantages?? LAPAROSCOPY VS ROBOTIC

15 LAPAROSCOPY VS ROBOTIC Disadvantages?? 747 vs. Cesna... (More complicated technology a problem with low volume vs high volume)

16 LAPAROSCOPY VS ROBOTIC Disadvantages?? 747 vs. Cesna... (More complicated technology a problem with low volume vs high volume) Pressure from industry to expand applications of this technology may pressure some to take cases that would have been easily done with a vaginal or laparoscopic approach....

17 Case not technically feasible via MIS WHY WOULD YOU HAVE TO OPEN?

18 WHY WOULD YOU HAVE TO OPEN? Case not technically feasible via MIS 1. Cannot safely get in abdomen (adhesions from surgery or infection)

19 WHY WOULD YOU HAVE TO OPEN? Case not technically feasible via MIS 1. Cannot safely get in abdomen (adhesions from surgery or infection) 2. Lesion to be removed too large for safe MIS

20 WHY WOULD YOU HAVE TO OPEN? Case not technically feasible via MIS 1. Cannot safely get in abdomen (adhesions from surgery or infection) 2. Lesion to be removed too large for safe MIS 3. Case completion requires skills beyond operator ability MIS (bowel resection etc.)

21 WHY WOULD YOU HAVE TO OPEN? Case not technically feasible via MIS 1. Cannot safely get in abdomen (adhesions from surgery or infection) 2. Lesion to be removed too large for safe MIS 3. Case completion requires skills beyond operator ability MIS (bowel resection etc.) 4. Patient cannot tolerate Trendelenburg

22 WHY WOULD YOU HAVE TO OPEN? Case not technically feasible via MIS 1. Cannot safely get in abdomen (adhesions from surgery or infection) 2. Lesion to be removed too large for safe MIS 3. Case completion requires skills beyond operator ability MIS (bowel resection etc.) 4. Patient cannot tolerate Trendelenburg 5. Cannot safely see due to bowel, lesions etc.

23 WHY WOULD YOU HAVE TO OPEN? Bleeding 1. Vascular injury unable to be controlled MIS. 2. Excessive blood loss/inadequate visibility due to bleeding

24 Case not appropriate for MIS Unexpected cancers/spread Equipment failure WHY WOULD YOU HAVE TO OPEN?

25 WHEN THINGS GO WRONG Surgical complications: 1. Visceral perforation May be minor, small cystotomy or enterotomy amenable to robotic repair. This can result in no major differences in the immediate post op care of the patient. Can be significant resulting in conversion to open or significant extension in the time of the case. 2. Vascular injuries 3. Nerve injuries (intra op)- rare 4. Conversion to open for previously mentioned reasons

26 WHEN THINGS GO WRONG Upper airway edema/facial edema: Related to prolonged Trendelenburg. This can result in airway problems and exacerbation of OSA issues. More common with longer cases More problematic with obese patients

27 WHEN THINGS GO WRONG Sub Q emphysema: related to gas leakage during the case. More common in thin, elderly patients. Can result in Apnea related to excess CO2. Takes time to resolve. Easy to palpate in chest and abdominal wall

28 WHEN THINGS GO WRONG Bleeding: Can be detected during the case and addressed Can also occur undetected in the abdomen and result in s/sx of hemorrhage, hypotension, tachycardia, low UOP

29 PATIENT POSITIONING For GYN cases: Low lithotomy with stirrups. Steep Trendelenburg Arms tucked

30 Nerve Injuries Peroneal nerve (from back of stirrups) PATIENT POSITIONING

31 Nerve Injuries Peroneal nerve (from back of stirrups) Femoral nerve (improper leg positioning) PATIENT POSITIONING

32 Nerve Injuries Peroneal nerve (from back of stirrups) Femoral nerve (improper leg positioning) Ulnar (elbow padding) PATIENT POSITIONING

33 Nerve Injuries Peroneal nerve (from back of stirrups) Femoral nerve (improper leg positioning) Ulnar (elbow padding) Brachial Plexusshoulders PATIENT POSITIONING

34 Nerve Injuries Peroneal nerve (from back of stirrups) Femoral nerve (improper leg positioning) Ulnar (elbow padding) Brachial Plexusshoulders WATCH FOR SLIDING PATIENT POSITIONING

35 THANKS