robotic surgery in urology

1. Da vinci robotic surgical
system
Dr.Omar K. Ibrahim
urosurgery

2. Background
 The word robot, taken from the Czech word
“robota,” meaning forced work
 The first time a robot was used to assist a
surgical intervention was in 1985 in the
Memorial Hospital of Los Angeles brought the
industrial Unimation PUMA 200 robot into the
operative room to hold a laser for
neurosurgical interventions.

3.  Surgical robots fit into three categories: active;
semi-active; and the so-called master−slave
systems. The active system consists of a robot
performing tasks autonomously under the
supervision of the surgeon. Semiactive systems
have an autonomic and a surgeon-driven
component. Master−slave systems allow the
surgeon to directly

4.  telemanipulate the robot from a more or less
remotely placed command center. In this
situation, the surgeon’s movements are
translated into robotic motion.In urology,
robots have been tested in two areas:
endourology and laparoscopic surgery.

5. Instrumentation
 Robotic-Assisted Laparoscopic Prostatectomy
 da Vinci S or Si Surgical System (Intuitive
Surgical, Sunnyvale, CA)
 Endowrist Maryland bipolar forceps or PK
dissector (Intuitive Surgical, Sunnyvale, CA)
 Endowrist curved monopolar scissors
(Intuitive Surgical, Sunnyvale,CA)

6.  Endowrist ProGrasp forceps (Intuitive Surgical,
Sunnyvale, CA)
 Endowrist needle drivers (2) (Intuitive
Surgical, Sunnyvale, CA)
 InSite Vision System with 0-degree and 30-
degree lens (IntuitiveSurgical, Sunnyvale, CA)
 12-mm trocars (2)
 8-mm metal robotic trocars (3 if using a fourth
robotic arm)
 Small and medium-large Hem-o-Lok clips
(Teleflex Medical,Research Triangle Park, NC)

8. Patient Positioning
 After induction of general endotracheal
anesthesia, the patient is placed in a
supine position in steep Trendelenburg
with arms tucked and padded at the
sides. Sequential compression stocking
devices are placed on both legs and
activated. The patient’s legs are spread
apart and supported by spreader bars to
allow for access to the rectum and
perineum.

9.  Alternatively, the patient’s legs may be
placed in stirrups in the low lithotomy
position. The patient is then secured to
the table using tape and egg-crate
padding. An orogastric tube and urethral
catheter are placed to decompress the
stomach and bladder, respectively.

12. Operating Room Personnel
 LRP and RALP require that the
surgical team including the scrub
technician, circulating nurse, and
surgical assistant(s) be fully trained
and skilled in the instrumentation,
operative setup, and technical steps
of these minimally invasive
techniques.

14. Steps of the transperitoneal
access in RALRP
 Trendelenburg up to30°
 Peri- or supraumbilical incision to insert the
trocar for the optics Insertion under vision
control of five others trocars (three for the robot
and two for the assistant if four-arm system)
 Anterior peritoneum incision and primary
lowering/extraperitonealizing of the bladder
 Exposure of the anterior face of the prostate
and internal face of the obturator fossa

15.  A V starting at the root of the penis helps
to locate the position of the two 8-mm
trocars of the robot at 18 cm distance,
with a space corresponding to a hand on
both sides of the umbilical trocar. A 12-
mm VerSastep trocar (Tyco, Norwalk,
Conn.) is inserted two fingers inside and
two fingers upward of the right anterior
iliac crest

16.  Through this trocar one can insert the
camera and control the placement of the
umbilical trocar and guide the insertion
of a 5-mm trocar between the right arm
and the optical instrument . On the left
side, in the same way, a 5-mm/8-mm
trocar (assistant tool or fourth arm of the
robot) is inserted.

17.  The robot is then connected
 and the position of the operating table is
locked. The umbilical trocar with
 the camera exerts a discrete rise of the
abdominal wall. The pressure of
insufflation is decreased to 12 mmHg.

20. Access to the Pelvis and
Incision of the Anterior
Peritoneum The optics 30° is directed to the top (up on the
console), and the surgeon at the console
 handles a bipolar forceps on the left arm, and
of the monopolar scissors on the right
 arm, and a grasper on the third arm (if
available). The electric current is regulated
 between 20 and 40 W on the bipolar forceps
and has 40 W on the monopolar scissors.
 The assistants hold a Johan forceps and a
suction device.

21.  The sigmoid loop is released from
possible adherences and the small
intestine is pulled back upwards. The
peritoneum is incised by dividing the
umbilical arteries, and while going down
to the deep inguinal ring, the vas
deferens is retracted or divided to give
more mobility to the bladder

22.  The pneumoperitoneum facilitates the
dissection of cellulo-fatty space, and the
assistant using the suction device
contributes to complete the lowering of
the bladder exposing the pubic arc and
the Cooper ligament, the internal face of
the obturator fossa, and the anterior face
of the prostate

23.  All the fatty tissue covering the prostate, the
endopelvic fascia, and the puboprostatic
 ligaments is removed. The transperitoneal
access is then accomplished and the
 radical prostatectomy can start.