WHAT IS ROBOTIC SURGERY?
Traditional Open Surgery
For centuries, surgery has been done using “open” surgery. This involves making an incision in the body to access the area or organ that needs surgery. A large incision sometimes results in enough blood loss that the patient requires a blood transfusion with attendant risks of reaction to the transfusion or rarely, infection. Open surgery often leaves a large wound that requires time for the body to heal. The skin and superficial tissues must heal, muscles and “fascia” (strength layers) that have been cut through must heal and organs, sometimes even bones, must heal. This typically requires a hospital stay for several days and strong pain medicine.
The recovery period at home often involves six to eight weeks without strenuous activity or lifting more than fifteen pounds. During the healing process occasionally the incision can get infected, sometimes requiring drainage or even another surgery to correct the problem. After healing, hernias, or bulging of tissue can occur and can require another surgery to correct.
In the 1990s, a new method of accessing the inside of the body called laparoscopy or “keyhole” surgery was popularized. This technique involves placing a needle in the body and inflating the area of interest with gas, typically carbon dioxide. Small incision are then made, usually about 1/2 inch, and “ports” or access portals are placed in the body. A camera is placed through one of the ports to look inside the body. The camera is connected to a monitor that provides a view inside the body for the surgeon, assistant and surgical team. Tools on long thin instruments are placed inside the body through ports and surgery is performed.
In the 1993, the first kidney was removed via laparoscopy by Dr. Clayman and his team. Laparoscopy resulted in smaller incisions, less blood loss, less risk of transfusion, shorter hospital stay, less use of pain medicine and quicker recovery. Laparoscopy is now used in many types of surgery in urology, general surgery, colorectal surgery, gynecology, cardiothorasic surgery, orthopedic surgery and so on.
In the late 1990s, robotic surgery became available. Rather than the surgeon holding the tools on long thin instruments themself, the tools are connected to robotic arms and the robot is controlled by the surgeon. The robotic platform available today is called the da Vinci Surgical System by Intuitive Medical.
The Robotic Team
The surgeon sits in the “console” which is a specialized control center where one can control the camera, robotic arms and application of different types of electricity to stop bleeding. An assistant sits at the patient’s bedside using laparoscopic tools through ports to introduce stitches, provide suction, change robotic tools and make adjustments to the robotic arms as needed. A scrub technician sits at the other side of the patient to provide tools and sutures and make adjustments to the robotic arms. The anesthesiologist remains at the patient’s head, providing anesthesia and monitoring the patient’s heart and lungs.
The Robotic Interface
Using a robotic interface offers a number of important advantages. The robotic camera provides ten fold magnification and three dimensional vision rather than two dimensional vision used laparoscopy. The robotic arms can not only move in and out and control the instrument, but also introduce a “wrist” type motion for the surgeon, a whole other dimension of movement. In fact, the robotic wrist can twist over 360 degrees, more than a human wrist! The robotic interface provides motion scaling to make each of the surgeon’s movements more precise. The robot also makes fine adjustments to filter out human tremor, inherent in laparoscopy. Finally, robot surgery is more ergonomic (comfortable) for the surgeon and surgical team, resulting in less surgeon fatigue during long complex cases.
The Advantages of Robotic Surgery
All of these advantages result in smaller incisions than open surgery, less blood loss, lower risk of blood transfusion, shorter hospital day, decreased need for pain medication, quicker recovery and return to normal function and decreased risk of wound infection or hernia.
WHO IS A CANDIDATE FOR ROBOTIC SURGERY?
Robotic surgery is available for a number of urologic surgeries and to a wide variety of people. The da Vinci Surgical System is being used for benign and malignant (cancerous) procedures in adults and children.
Sometimes, people are unable to tolerate the inflation of the abdomen with carbon dioxide. This is most common in smokers, who already have higher levels of carbon dioxide in the blood than nonsmokers. In this case, it is difficult to provide enough oxygen to the body and it may be no longer safe to proceed. The robot would be removed and an open incision made to complete the surgery.
Occasionally people are unable to tolerate the positioning for some types of urologic surgery such as prostate removal, bladder removal or bladder suspension. For these surgeries, the bed is tilted with the head closer to the floor and the legs closer to the ceiling or “Trendelenburg” position. This causes the intestines to move away from the pelvis and provides better vision and access to the surgical area. This position can make it difficult to provide oxygen at a safe pressure to the lungs.
This is more common in overweight people as the Trendelenburg position shifts the weight of the intestines and the abdominal girth to put pressure on the respiratory muscle (diaphragm) and lungs. In this case, the robot would be removed and an open incision made to complete the surgery.
WHAT PROBLEMS CAN BE TREATED WITH ROBOTIC SURGERY?
Adrenal gland (gland above the kidney that makes hormones) - excisional biopsy, removal
Bladder – bladder cancer, refractory bladder pain requiring removal of the bladder
Kidney – kidney cancer; removal of kidney for lack of function, stone, refractory pain; cysts
Prostate – prostate cancer, prostate obstruction for very large prostates
Ureter (tube that carries urine from the kidney to the bladder) – ureteropelvic junction obstruction, vesicoureteral reflux, ureterovesicular junction blockage
Vagina – suspension for prolapse
WHAT SURGERIES ARE AVAILABLE ROBOTICALLY?
Many urologic surgeries are available using robotic surgery today and robotic technology is constantly being applied to new surgeries. Below is a list of some of the surgeries The Urology Group currently offers:
Adrenalectomy – removal of the gland above the kidney
Cyst decortication – opening up a kidney cyst
Cystectomy – removal of the bladder
Anterior pelvic exenteration – removal of the bladder, uterus, fallopian tubes, ovaries and anterior wall of the vagina (women with bladder cancer)
Cystoprostatectomy – removal of the bladder and prostate (men with bladder cancer)
Nephrectomy – removal of the kidney
Partial nephrectomy – removal of part of the kidney
Prostatectomy – removal of the prostate
Radical – removal for prostate cancer
Simple – removal for difficulty passing the urine
Pyeloplasty – reconstruction of ureteropelvic junction obstruction (abnormal tissue
where the kidney meets the kidney tube or ureter (carries urine down to the bladder)
Sacrocolpopexy – vaginal suspension for prolapse
Ureteral reimplant – reconstruction of where the kidney tube (ureter) meets the
COMPLICATIONS OF ROBOTIC SURGERY
Robotic surgery has risks inherent to the surgery itself as well as some risks unique to the robotic approach. Most of these are rare but still deserve discussion so you can make an informed decision about your surgery.
There are risks to positioning, such as the lungs being unable to tolerate Trendelenburg position (bed tilted with the head towards the floor, feet toward the ceiling). If this case, the robot is removed an open incision made to complete the surgery. Trendelenburg position often causes some temporary swelling of the face since the head was lower than the rest of the body during surgery. Patients may be more prone to rub their eyes while waking up and rarely can scratch the outer surface of the eye (corneal abrasion). Precautions are taken to protect the eyes for this reason.
Being in one position for a long surgery can also cause neurologic side effects like numbness, tingling, weakness or pain in the arms, legs or joints. This is usually temporary but rarely may require further testing or investigation with a neurologist or orthopedic surgeon. Let the anesthesiologist know if you have any arm, leg, joint or back problems or prior surgeries so we can take extra caution positioning this area.
Gaining access inside the body can result in injury to the intestines (guts), blood vessels or surrounding organs. Very rarely, a serious injury can occur and the surgery is emergently converted to an open approach to repair the damage. After a long surgery, sometimes the patient needs to stay on the ventilator (breathing machine) overnight. Rarely, prolonged ventilation or pneumonia ensue. Also rare are cardiovascular events like heart attack, stroke and even death.
It is extremely important to get out of bed and walk as soon as possible after surgery to decrease the risk of forming a blood clot in the leg (Deep Venous Thrombosis or DVT). A blood clot in the leg can travel to the lung (Pulmonary Embolus or PE) and cause difficulty breathing and rarely sudden death. Many patients will be asked to get up and walk the afternoon or evening of surgery.
Lastly, any surgical procedure has inherent risks of infection, bleeding, blood transfusion, need for repeat surgery, recurrence of disease and complications of general anesthesia.
WHAT CAN I EXPECT AFTER SURGERY?
After monitoring in the recovery room, you will be transferred to a hospital room. In contrast to open surgery, robotic surgery often requires only once night in the hospital. You may have throat discomfort from the breathing tube. Your face may be slightly swollen from the Trendelenburg position (bed tilted with the head toward the floor and feet toward the ceiling). These sensations will pass within a day or so.
You will be sore from surgery and should ask the staff for pain medicine as needed. Although you have small incisions, a big surgery was still done on the inside and the body needs to heal. You may also have nausea or vomiting from the anesthetic. Let the staff know and they will give you anti-nausea medicine as needed
It is extremely important to get out of bed to a chair and walk as soon as possible after surgery. This decreases the risk of blood clot in the leg (Deep Venous Thrombosis or DVT) or lung (Pulmonary Embolus or PE) which are uncommon but can be life-threatening complications. Walking also decreases the risk of pneumonia and infection and encourages the healing process. You will likely have “Sequential Compression Stockings” on the legs. These periodically inflate to massage the leg and decrease the risk of a blood clot forming. These need to be on and functioning whenever you are in bed.
You will likely have a breathing machine called an “Incentive Spirometer”. The staff will teach you how to suck in on this ten times an hour while awake. This helps re-expand the lung pockets after being on the breathing machine to prevent pneumonia.
Fluids will be given in the vein while you are recovering. This keeps you hydrated while the intestines recover. You will be started on a clear liquid diet and advanced to a solid diet. If you had bladder removal, you will need to pass gas before taking anything by mouth.
You will typically have a “foley catheter”, a tube that drains the bladder. This exits through the urethra (bladder or urine tube) that travels through the penis in men, and through the urethra in women. The catheter continuously drains the bladder so the surgical area can heal. For kidney and vaginal surgery, the catheter is typically removed the following morning. For prostate and bladder surgery, you will go home with the catheter and be taught how to attach the catheter to a leg bag during the day and a big bag at night.
You may have a surgical drain or “Jackson Pratt (JP) drain” which drains fluid from the surgery site. If the output is low, it may be removed the following morning. If the output remains high, you will be sent home with the drain and taught how to care for it. Keep a record of the output and bring it to your postoperative appointment so your provider knows when it is safe to remove the drain.
WHAT CAN I EXPECT DURING THE RECOVERY PERIOD?
You will be given discharge instructions according to your surgery before leaving the hospital. Make sure you and your family/friends read them and understand them before leaving. Clarify questions with the hospital staff before you go home.
If you are being discharged with a foley catheter, practice emptying it and changing the bag. Check that it is well secured to the leg at all times with plenty of slack so there is no pulling of the catheter at the surgery site. Periodically check that there are no kinks or twists in the catheter or tubing that could block the flow of urine and compromise the surgery site. Expect the urine to have blood, small clots and debris, intermittently over the next week or so. The more pink the urine, the more fluid you need to drink to flush the system and prevent clots.
Pain and soreness will resolve over the course of days or weeks. Pain medicine should be taken as needed. You may be prescribed narcotic pain medicine (eg. Vicodin). Narcotics can have side effects such as confusion, anxiety, nausea and constipation. If you have these side effects try over the counter acetaminophen (Tylenol), taking less medication or taking medication with food.
You may see minor spotting or oozing of clear fluid from the skin incisions. You may place a gauze from a drug store over this for a day or two if needed. You may have skin glue or skin strips that will come off on their own in 7-10 days.
Typically you may shower 24 hours after surgery is complete and should shower daily. Avoid baths for 48 hours. Let warm soapy water run over the incisions then pat dry. Usually you do not need to apply any dressings. Check with your surgeon for your particular surgery.
Avoid constipation by walking, staying hydrated and eating plenty of vegetables and fruits (eg. prunes). If you are constipated, take over the counter Senekot or SennoGen, one to two tabs by mouth twice daily. Avoid straining postoperatively as it may affect the surgical site and cause bleeding.
Stay hydrated and eat a bland diet with small frequent meals. Avoid large, heavy meals or spicy foods.
It is very important to walk at least three times per day. Each day increase the distance you walk. This decreases the risk of complications such as blood clots and promotes healing.
Avoid strenuous activity (jogging, elliptical) or lifting more than fifteen pounds for six weeks. Your surgeon may extend this to eight weeks if you had a long surgery or have risk factors for developing a hernia.
Call the office immediately or come to the emergency room for fever, catheter stops draining, inability to urinate, leg swelling or pain, if the incisions opens up with active bleeding, pus or bulge.
PREPARING FOR ROBOTIC SURGERY
Obtain and read your postoperative instructions prior to surgery so you will know what to expect. Plan to have family or a friend stay with you for a few days to help you during the immediate recovery.
Follow all preoperative instructions exactly. This may involve blood or urine tests, chest xray, electrocardiogram (EKG), ultrasound and/or CT scan. You may be asked to obtain medical or cardiac clearance with a primary care practitioner, internist or cardiologist to make sure your heart and lungs are safe for surgery and that all medical conditions are optimized.
Stop all blood thinners 7-10 days prior to surgery. Blood thinners include aspirin products, ibuprofen (Advil, Naproxen, Bufferin, Alleve, Nuprin, Anacin, etc), clopidogrel (Plavix) and warfarin (Coumadin). If you have a serious heart or blood condition, follow instructions from your cardiologist or medical doctor regarding management of blood thinners.
Stop all herbal medications and vitamin supplements 10 days prior to surgery. We often don’t know the effect of herbal medications and supplements on thinning the blood or their interaction with anesthetics. It is best to stop all of these 10 day prior to surgery to avoid any bleeding problems or medication interactions. It is particularly important to stop vitamin E supplements.
Nothing to eat or drink by mouth after midnight the day before your surgery. No fluids, no water, no mints, no candy, no gum, no food and no coffee. The only exception is that you need to take morning medications for your heart or blood pressure with a small sip of water.
You may be asked to clean out the intestines or gut with a “bowel prep” a day or two before surgery. Cleaning out the intestines makes the intestines take up less space in the abdomen and pelvis, this allows more room and better access to the surgery site. If can also decrease the risk of an infection if there is injury to the intestine. A bowel prep may involve and clear liquid diet one to two days before surgery, laxative medications by mouth and/or enemas.
Start or increase the amount you exercise. This will make your heart and lungs strong to prepare for surgery. A healthy body also recovers faster from surgery. Goal is 20-30 minutes of cardiovascular exercise 3-5 times a week.
Lose weight if you are overweight. A healthy weight makes access inside the body safer, makes the body better able to tolerate the positioning, makes surgery safer and faster, decreases the risk of complications during surgery, decreases the risk of wound infection and speeds healing.
Quit smoking. If surgery is not for a month, quitting smoking improves lung function and oxygen-carrying capacity of the blood as well as a myriad of other benefits. However, if surgery is within two weeks, do not quit until after surgery to prevent increased mucous production in the respiratory tract.
Lead a healthy lifestyle. A healthy body is more likely to have a safe surgery and quicker, uncomplicated recovery. A healthy lifestyle includes eating your vegetables and fruits, exercise and consider a multivitamin. Control your diabetes, blood pressure and cholestrol. Get plenty of rest to avoid getting a cough or cold prior to surgery which could result in having to reschedule when you are healthy.
Anesthesiologist – A member of the surgical team that puts the patient to sleep before surgery, administers medication to keep the patient asleep throughout surgery and monitors the patient’s heart and lungs
Open surgery – conventional surgery using an open incision (cut) to access the surgical area
Benign – describes a condition that is not cancerous
Bowel prep – preparing the bowel for surgery by emptying it out as much as possible. It typically involves a clear liquid diet for one to two days, laxative medications by mouth and/or enemas.
Console – specialized control center where the surgeon controls the camera and robotic arms inside the body to perform the surgery
Da Vinci robot – a type of surgical robotic system widely used for urologic surgery
Deep Venous Thrombosis (DVT) – a blood clot in the leg which can travel to the lung and cause life-threatening complications. This can be a complication of surgery and is more likely in people with cancer, recent surgery and prolonged time in bed. Risk is decreased by walking early and often after surgery.
Diaphragm – the respiratory muscle that expands the lungs
Incentive Spirometer – a breathing machine used after surgery to re-expand the lung pockets after surgery.
Jackson Pratt (JP) drain – a surgical drain which drains fluid from the surgery site
Fascia ¬ - the strength layer of the abdomen
Foley catheter - a tube that drains the bladder. This exits through the urethra (bladder or urine tube) that travels through the penis in men, and through the urethra in women. The catheter continuously drains the bladder so the surgical area can heal.
“Keyhole” surgery – refers to laparoscopic surgery, or surgery using a camera and long instruments through several small holes in the body
Laparoscopic surgery - surgery using a camera and long instruments through several small holes in the body
Malignant - cancerous
Ports – access portals placed in the body through small holes to perform laparoscopic or robotic surgery
Pulmonary Embolus (PE) - a blood clot in the lung that can cause life-threatening complications. Risk is decreased by walking early and often after surgery.
Robotic surgery – a surgical approach using surgical portals through small holes in the body and attaching long thin instruments to a specialized robot
Surgical technician – member of the surgical team who prepares instruments and supplies and assists with surgery
Trendelenburg position – a position used in robotic surgery with the bed tilted such that the head is closer to the ground and the feet toward the ceiling.
Copyright Jennifer L. Young MD. Robotic Surgery Center 2011. Do not duplicate without permission.