Introduction
The rapid uptake of robotic procedures has necessitated development of new training methods and the establishment of bedside assistants. Taking on the position of bedside assistant for a surgical procedure is a responsible and pivotal task. A skilled bedside assistant is an essential part of an effective robotic surgery team.
Importantly, surgeons operating at the console are physically separated from the patient. Therefore, reliance on the bedside assistant as the sole scrubbed surgeon during the console time is crucial. Before starting the role as a bedside assistant, in-depth familiarization of the anatomy and surgical procedure and development in one’s own skills is critical. Internalized skills allow for performance of critical tasks. In addition, anticipation, active assisting and involvement of the bedside assistant will support the console surgeon’s efficiency and performance.
Over time, the bedside assistant has evolved to a more active role in providing proactive help to optimize efficiency and quality of the console surgeons’ performance. Active assistance delivered by the bedside assistant can have an immense impact on the success of the operation, provided they have expert bedside knowledge and skills.
The aim of this book chapter is to present a technical primer on the robotic operation from the bedside perspective and suggest tips and tricks for achieving proficiency.
Basic knowledge to assist bedside
To allow for operative efficiency for the console surgeon it is crucial that the bedside assistant is familiar with the surgical steps and their chronology. Basic anatomic knowledge—including most common variations of the vascular anatomy, specific landmarks of the particular operation, and understanding of surgical tissue planes and the appearance of those tissues in relation to surrounding structures (e.g., cobwebs, color of nerves, etc.)—is required to deliver safe assistance to the console surgeon.
To facilitate these requirements, participation in a validated, structured curriculum with further assessment of an assistant’s skills by experienced bedside assistants prior to assisting in “live” surgery is recommended.
Directed learning may begin with video reviews of recorded robotic cases, by watching live operations, or via e-learning modules followed by simulation-based training, including virtual reality simulators and dry lab exercises to train laparoscopic bedside skills and memory, which is crucial when using instruments (e.g., click applicator or grasper) close to fragile tissue (e.g., bowel, hilar vessels).
Consequently, the first several live-surgery cases should be performed under close observation of an experienced bedside assistant (e.g., mentor) until laparoscopic memory and maneuvers are mastered. Initially, the mentor should be scrubbed, followed by a phased transition to observation of the bedside assistant with instructions or touchscreen guidance.
Eventually, bedside assistance will become more time efficient by constantly planning and thinking a few steps ahead (e.g., preparing sutures in advance or facilitating early change of robotic instruments for the next surgical step). This leads to readiness and effective use of instruments that will augment the actions of the console surgeon. In order to optimize support for the surgeon, ambidexterity can be very beneficial.
Proactive assistance during the operation, constant communication with the console surgeon and repetitive exposure to cases to practice the skills mentioned will speed the learning curve.
As such, meticulous training and preparation will play an important role in robotic theater efficiency, thus improving the overall flow and management of unanticipated circumstances.
Basic skills to assist bedside
Patient preparation and positioning
The bedside assistant helps to ensure that the patient has been safely prepared (e.g., instruction for a nasogastric tube and placement of an indwelling catheter, vascular lines accessible for the anesthetist) and positioned (e.g., gel pads or supports placed at all pressure points, especially the ankle and knee to minimize neuropraxias, and securing the patient on the operation table with supports) ( Fig. 5.1 ).
Port placement
Port placement is a crucial step to optimize range of motion of the robotic arms (e.g., optimal space between the ports prevents clashing of instruments in and ex situ, and allows for free movement for dissection) and of the assistant’s instruments (e.g., allowance of free movement of the suction and clip applicator, especially in a body with limited space and poor visibility). Roughly 8 to 10 cm, or a handbreadth distance between two ports, is in general enough space to prevent clashing. However, depending on anatomical dimensions, port sites on each patient will differ slightly.
Even though the console surgeon selects the port sites, it is often the bedside assistant’s task to insert the ports (under direct vision to prevent trocar injury) in a 90 degree angle, in order to keep the optimal space in situ as well. For incisions that are too long a suture may be needed (to narrow the space between the port and the skin) to prevent gas leaks.
In brief, the camera port is inserted first (according to the open Hasson technique or following Veress needle insufflation) using a trocar and pneumoperitoneum is then created. The remaining ports are inserted under direct vision (using a sharp trocar) ( Fig. 5.2 A and B).
Maintenance of the pneumoperitoneum
During the case, the bedside assistant is responsible for the observation and maintenance of the pneumoperitoneum (by watching the surgical space on the screen, and the pressure values on the dashboard). This may require frequent port checks to ascertain the absence of leaks from the port sites or in the tubing system.
Robot docking
The assistant has an active role in the robot docking ( Fig. 5.3 ). When inserting the robotic instrument for the first time, it must be done under direct vision as the instrument has no memory and may go farther than anticipated. The authors recommend always inserting the instruments under direct vision (i.e., during the whole procedure), given that touching the clutch button of the robotic arm in the later course of the operation causes the instrument to lose its memory. As such, following these principles is important for avoiding injury to visceral organs and major vessels when inserting the robotic instruments. In brief, for the da Vinci Xi, targeting is performed first at the approximate location of interest (e.g., the renal hilum when performing a radical or partial nephrectomy). The remaining ports are then docked. To reduce clashes the robotic ports might be “burped,” or the arms might be adjusted accordingly.
Laparoscopic memory and mapping of the surgical field and spatial relations
Given that the assistant’s laparoscopic instruments are removed and reinserted a number of times during the same case, it is highly recommended that the bedside assistant assess the access through the assistant ports before the surgeon starts with the console work. Hereby, the assistant tries to get a broad overview of the operative field, and the laparoscopic bedside instruments are passed into the body cavity under direct vision. Free movement of the bedside instruments and a good view of the surrounding structures, as well as motion control (preventing erratic movements) when inserting the instruments, are required. This is of particular importance as the assistant’s instruments may cause injuries to vital structures such as vessels or viscera when inserted blindly.
Furthermore, the assistant tries to internalize the angle of passage while taking the patient’s position (e.g., supine vs. lateral position) and anatomic landmarks (e.g., pubis symphysis in radical prostatectomy) into account. This process ensures laparoscopic memorization and mapping of the surgical field and spatial relations. This created virtual map can be used to cognitively guide instrument insertion and hence optimizes time efficiency as the instruments (e.g., suction, clip applicator) can be inserted semi-blindly without the need for the console surgeon to always move the camera back in the overview position. In addition, wasted motions of the bedside assistant by repetitive failed trials to find the correct passage can be reduced.
In difficult anatomic circumstances (e.g., obese patient with limited space) the direction/axis of the robotic instruments or camera can be followed and used as a guide. In order to not lose the orientation and position of the laparoscopic instruments, the inexperienced bedside assistant may rest and focus the tip of the instruments on the edge of the screen and only move when required. However, this may be disadvantageous for the surgeon as the resting tip can be a distraction or, more importantly, limit the field of vision. The more experienced a bedside assistant is, the better the laparoscopic mapping becomes; and the instrument can be left in the background, but always ready when required to be in action.
Manual actions during the console time
Exchange of robotic instruments
Swapping out the various robotic instruments is a very frequent activity of the bedside assistant. Before the assistant takes out an instrument, it is recommended that they announce this to the console surgeon to prevent unexpected movements. Even though the robot memorizes the instrument position upon removal and guides repositioning of the respective instrument, it is required that the assistant moves the instrument under clear vision slowly back into its original position to ensure safety and prevent injury to vital structures. On one hand, memory loss owing to technical failure of the robotic system may arise, or intracorporal changes that require alteration of the instrument’s angle occur (e.g., bowels or fat tissue gravitate toward the port access).
If any resistance is encountered the movement must not be forced as the instrument may be running into a vital structure. The first check should always be port displacement back into the fascia, which needs port repositioning and repassage with or without undocking of the robotic arm and use of the (sharp or blunt) trocar.
Also, to prevent port displacement it is recommended to hold against the port when removing the instrument. It needs to be ensured that the robotic arm is unclutched and that the mono- and bipolar diathermy cables are reattached immediately after its reinsertion to sustain the surgical flow.
In general, robotic ports need to be checked frequently during a case as they can get dislodged from the abdominal cavity, necessitating reinsertion under vision.
Concept of providing traction and countertraction
Providing traction and countertraction (using haptic feedback and visual feedback) by the bedside assistant while the surgeon is dissecting tissue is crucial to help the surgeon with the development and dissection of tissue planes, and to keep them open, especially when dissecting deep structures (e.g., nerves or vessels) ( Fig. 5.4 ). The bedside assistant should always be wary about how much traction and pressure they put on a particular anatomic structure. To ensure concordant movements constant communication with the console surgeon is required, and both traction and countertraction are coordinated by the surgeon.
