1. Care of the Robotic Surgical Patient Jessica McCann RN, BSN

2. Introduction Worked in the Operating room at St. Elizabeth since 2006 Member of the Robotic Team since start of Robotic Program at St. Elizabeth in 2009. Robotics Program Coordinator at St. Elizabeth Healthcare since May 2012.

3. What is Robotic Surgery? Robotic surgery is a type of minimally invasive surgery. “Minimally invasive” means that instead of operating on patients through large incisions, we use miniaturized surgical instruments that fit through a series of quarter-inch incisions.

4. Evolution of Surgical Robot In 2000 the da Vinci® Surgical System became the first robotic platform commercially available in the US to be cleared by the FDA for use in general surgery. There are more than 1,700 da Vinci® Systems installed in hospitals world wide. More than 775,000 patients worldwide have had a da Vinci® procedure. Roughly three out of 4 prostate cancer surgeries are performed using the da Vinci® System. More women now chose da Vinci® surgery for minimally invasive hysterectomy than conventional laparoscopy or vaginal surgery 88% of urology residency programs in the U.S. have a da Vinci® System. All 42 gynecologic oncology fellowship programs in the U.S. have a da Vinci ® System

5. Benefit to Robotic Surgery Our surgeons are able to perform a growing number of complex urological, gynecological, cardiothoracic and general surgical procedures. Surgeons are able to work in smaller body cavities through small incisions as opposed to conventional open incisions Surgeon benefits Greater visualization Enhanced dexterity Greater Precision Patient benefits Less trauma on the body Minimal scarring Reduced pain and discomfort Faster recovery time Decreased length of stay Smaller incisions resulting in reduced risk of infection Reduced blood loss and lower transfusion rate compared to open technique

6. Why Robotic over Lap?

7. What type of procedures utilize a robot? Cardiac Mitral Valve Repair Revascularization Thoracic Lobectomy-Wedge Resection General Cholecystectomy Colon Resection Lower Anterior Resection Gynecology Hysterectomy Myomectomy Endometrial Resection Sacralcolpopexy Head and Neck Urology Prostatectomy Nephrectomy Radical Cystectomy

8. Pre-op Considerations History of glaucoma in a patient undergoing a procedure that requires lithotomy step trendelenburg position Need for a large bore IV due to positioning of the arms being tucked Need for blood band to verify that patients have been typed and screened. Need for a thorough skin assessment both pre and post- operatively Lithotomy steep trendelenburg Positioning: Increases the patient for risk of skin breakdown related to shear and friction as well as gravitational forces that pull the patient toward the head of the bed.

9. Patient Assessment Peri-operative nurses should assess patients risk for pressure ulcer development based on: Patient’s Braden Scale score Patient’s BMI Length and type of surgery Position required High Braden Scale score: Need for increased padding on bony prominences.

10. Pre-operative Teaching Care differs only slightly for the robotic patient compared to the non-robotic patient. Need to explain robotic surgery to the patient is important. Emphasis for patient education should be based on the fact that the robot is a tool used by a surgeon to perform surgery. The robot is not programmable and does not act on its own.

11. Intra-operative Concerns Intraoperative concerns for patients: Hemodynamic changes Increased Blood Pressure Increased Intraocular Pressure Increased Intracranial Pressure Difficulty with ventilation

12. Positioning for GYN and Urology Patients are positioned intra-operatively on the OR table with either an air-inflated positioning device or a high-density foam padding. Arms are tucked bilaterally using pillow cases Legs are in stirrups in a low lithotomy position Final positioning requires patients to be in a steep trendelenburg position for the robot to be docked. To assure that the patient does not move; they are placed in the steep trendelenburg position prior to be prepped and draped. If the patient shift during the initial test the table is returned to neutral and the patient is repositioned before returning to steep trendelenburg. Patients eyes are covered with a tegaderm.

15. Positioning for Thoracic or Urology cases Patients are lateral on either a bean bag positioning device or with a large bump behind them. An axillary roll is utilized to prevent brachial plexus compression. Patients are positioned with their flank on the kidney rest portion of the bed due to the fact that when they are done being positioned the bed is flexed allowing full expansion on the operative site. This allows not only a wider area for port placement but with the legs downward it allows the hip to drop so that the robotic camera arm is able to be manipulated and not obstructed by the hip.

17. Post-operatively Immediate post-op care: Stable vital signs Pain control Catheter output Drain output (if applicable) Immediately post-op JP drainage may be increased due to irrigation solution used intra-operatively. Increased JP drainage may also be related to urine leak in prostate patients, lymph leak in patients that have had lymph node sampling performed, or pelvic bleeding

18. Post-operative concerns Patients in steep trendelenburg may have peri-orbital edema it is important for the nurse to make sure the patient does not scratch their eyes. With robotic procedures there have been higher incidences of corneal abrasions post-operatively. Patients should be treated with the same standards and care as a patient undergoing the same procedure non-robotic minimally invasive Care should be tailored to the patient’s specific expected surgical outcome

19. Get the caregiver involved… Recovery is defined as a return to a normal state of health, mind, or strength It is estimated that 60% or more of outpatients require 3 days before they were able to return to their pre-operative level of daily living. Hospital stays may be shorter, which means there is a decrease length of time for educating the patient and at home care giver. Due to the shorter hospital stay, the need for education is more important than ever in the pre-operative area

20. Before they leave… Due to early discharge it is important to educate about: Recovery from anesthetic agents Recovery of full gastrointestinal and urological function Management of post-operative pain Possible complications Appropriate activity level for the first 48 hours post-op Surgical site care

21. Bibliography http://robotic-surgery.med.nyu.edu/for-patients/what-robotic- surgery http://robotic-surgery.med.nyu.edu/for-patients/what-robotic- surgery http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1356187/ http://www.ncbi.nlm.nih.gov/pubmed/9826140 http://www.meja.aub.edu.lb/downloads/19_5/p967-982.pdf