Robotic Column The robotic column has three or four robotic arms, depending on the selection at the time of purchase (Fig. 25.1). The fourth arm is extremely useful for assisting with tissue retraction. The robotic arms always function in the direction toward the robotic column and not away from it. For this reason the robotic column must be positioned strategically in response to the location of the surgery that will be performed.
For pelvic surgery the robotic column is commonly situated between the patient’s legs (Fig. 25.6), while for upper abdominal surgery it is positioned at the patient’s head. For procedures to the right or left of the abdomen, the robotic column is positioned at the opposite side of the patient. For instance, for extraperitoneal left aortic lymphadenectomy, the robotic column is at the patient’s right side. For procedures where easy access to the entrance of
Figure 25.3 Robotic laparoscope and two robotic arms with robotic instruments inserted.
The tip of the instruments can be appreciated in the insert.
Figure 25.4 The robotic trocars are metallic and can be seen to the right of the picture. The escape valve was added because the original trocars did not have it. The three types of available trocar obturators are on the left of the picture: blunt (left), tissue-spreading (middle) and cutting (right).
Figure 25.5 Robotic instruments commonly used in gynecologic surgeries. A: Monopolar curved scissors. B: Monopolar spatula.
Figure 25.5 (Continued) C: PK (plasma kinetic) dissecting forceps, bipolar. D: Prograsp forceps, bipolar.
the vagina and rectum is necessary, the robotic column is positioned lateral to the right or to the left of the patient’s legs.
Robotic Console The surgeon sits at the console (Fig. 25.2) away from the patient (Fig. 25.7) and the assistant sits next to the patient (Fig. 25.6). The surgeon has a stereoscopic image, which is different from the laparoscopic image, and controls the movements of the robotic arms using two hand
Figure 25.5 (Continued) E: Tenaculum forceps used for myomectomy. F: Needle grasper used for suturing.
controls and five foot switches: clutch, camera, focusing, monopolar (cutting and coagulating), and bipolar. The surgeon’s arms and hands can be maintained in a comfortable working position, because pressing the clutch foot switch disengages the robotic arms from the surgeon hands. This allows the surgeon to reposition the arms to an appropriate and comfortable position without moving the portion of the robotic arms connected to the patient.
Figure 25.6 The robotic column is usually positioned between the patient legs for pelvic surgery. The assistant is seated to the left of the patient and is scrubbed for the procedure.
Figure 25.7 The surgeon is seated at the console and is able to maintain a relaxed position for the arms and legs.
Because the surgeon is separated from the patient, there is a time delay that permits the performance of telesurgery, as long as the latency time does not exceed 150 milliseconds. The surgeon can control the movements of the robotic arms and instruments in a patient located at a different geographic location (11). Telementoring allows the mentor surgeon to guide another surgeon through a surgical procedure at a remote location by using superimposed electronic signals (telestration), direct voice commands, and control of the laparoscope via joystick and the electrosurgical instruments (12). Robotic movements are intuitive; the tip of the instrument mimics the movement of the surgeon’s hands, in contrast to the experience in laparoscopy when the movements of the tip of the instrument are counterintuitive, opposite to the movements of the surgeon’s hands.