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JVS-377; No. of Pages 9

Journal of Visceral Surgery (2014) xxx, xxx—xxx

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SURGICAL TECHNIQUE

Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy A. Valverde ∗, N. Goasguen , O. Oberlin Service de chirurgie viscérale, groupe hospitalier Diaconesses Croix-Saint-Simon, 125, rue d’Avron, 75020 Paris, France

KEYWORDS Robotics; Laparoscopy; Remote manipulation; Gastro-intestinal and visceral surgery

Use of robotics in gastro-intestinal surgery has steadily gained ground since its appearance in the early 21st century. The term ‘‘robotic surgery’’ is an inadequate semantic shortcut to designate this new technology, however, which in fact should be considered as an aid to laparoscopy. Rather than ‘‘robotic surgery’’, it seems more appropriate to speak about ‘‘robotic-assisted telemanipulated laparoscopy’’. Many people seem to compare roboticassisted telemanipulated laparoscopy in opposition to conventional laparoscopy, but the former is just a technological complement, aiming to facilitate the latter. Table 1 summarizes the benefits obtained by remote manipulation via a robotic system. In this technical article, we aim to summarize the fundamental benefits and set-up of robotic-assisted telemanipulated laparoscopic surgery for gastro-intestinal and visceral surgery with the only apparatus currently in use worldwide.

Comparison between conventional laparoscopy and robotic-assisted telemanipulated laparoscopy The learing curve for laparoscopy is long and difficult because the technique entails nonergonomical gestures performed with two-dimensional vision, working on an anatomic target while seeing the target area on a distant video monitor; the operator must deal with reduced movements, reversal of action (to move the instrument to the right, the operator’s hand moves to the left), as well as uncomfortable ergonomic positions imposed on the operator. The robotic tool renders the surgical gestures more intuitive (Table 1).



Corresponding author. E-mail address: [email protected] (A. Valverde).

http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004 1878-7886/© 2014 Published by Elsevier Masson SAS.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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A. Valverde et al. Table 1

Comparison between conventional laparoscopy/robotic-assisted laparoscopy.

Conventional laparoscopy

Robotic-assisted laparoscopy

Loss of eye-hand coordination Reversed movements Camera not held by operator Constrained movements (rigid fixation of instrument axis) 2-D vision Non-ergonomic position

Regain of eye-hand axis Intuitive movements Operator controls the vision 7 degrees of freedom of motion 3-D vision Ergonomic position

Variable movement ratio for 1 procedures

In laparoscopic surgery, there is a disproportion between motor and visual performance. Manual dexterity is hindered by the disparity between the extra- and intra-corporeal lengths of the shaft of the instrument on either side of the fulcrum point determined by the trocar placement (a). With robotic assistance, disproportionate movements are minimized and visual imaging can be magnified and set at a ratio of up to 5:1 at the console desk, allowing all surgical movements to be extremely precise (b).

Organization of the operation room 2 dedicated to the robot

The ‘‘robot’’ consists of three elements: the patient side cart (PC), the video tower (V) (light source, camera, insufflator) and the operator’s console (C). These three elements are interconnected by cables which may potentially encumber the movements of the robot arms. The operating room (OR) where the robot is located must be dedicated (i.e. the robot does not move from room to room) and should be set up accordingly (large dimensions, reinforced floor, overhead structures should not interfere with free movement of the PC). The operating table should be displaceable. A second 3-D video monitor is very useful to allow everyone in the room to follow the operation. All these prerequisites create architectural constraints that must be adapted to each operation according to pre-set protocols. The console is a fixed element that is usually placed in one of the corners of the OR. Conversely, the video tower and PC should be mobile to allow positioning around the patient according to whether the procedure is upper or lower abdominal. Fig. 2 provides a few examples of operative set-ups: bariatric surgery and esophageal hiatus surgery (a), colorectal surgery (b), hepatic and right colonic surgery (c), pelvic surgery (d). In all cases, the access dedicated to surgical assistants should always be from behind the robot arms and in alignment with the video tower (pink field in each figure).

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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The console

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Manipulation of instruments at the console: the manipulators

The console is where the surgeon sits and remotely controls the robotic arms. The console allows the surgeon to focus the image, fix the position of the camera, manipulate the instruments, coagulate, and communicate by microphone with the personnel around the operating table. Correct positioning of each element (screen, manipulators, foot pedals) allows the operator to work in optimal ergonomic postures: back straight, head slightly tilted, elbows bent at 90◦ and resting on pads on the console desk, thighs at 90◦ .

The surgical instruments are controlled by the surgeon’s hands in the manipulators at the console. The golden rule is that the operator must never lose sight of the instruments being used throughout the entire procedure. If even one of the instruments disappears from view, the operator must immediately stop working and ask one of the assistants to replace the instruments in the field of vision, in order to avoid injury to any intra-abdominal structure. The console manipulators are ideally held with three fingers (a): thumb and middle finger are inserted through the rings while the index finger controls the clutch. The clutch is one of the key elements of robotic surgery: this allows the surgeon to keep his or her hands permanently in the same working space, fore-arms pressed against the console workbench (b), maintaining optimal ergonomics even when intra-corporeal movements are of large magnitude.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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The patient side cart

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The camera arm

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The instrument arm

This is the heaviest and most cumbersome element. Three or four robotic arms are positioned according the type of procedure (cf. Fig. 2). The choice of cart position is governed by alignment along a virtual line passing through the optical device, the anatomic target and the center of the PC. The ‘‘optical’’ arm is in the center and must be aligned with the axis of the apparatus. The other ‘‘instrument’’ arms are placed to obtain a triangulation set-up centered on the target. Each of these arms is draped with sterile drapes. This draping is quick and can be performed while the pneumoperitonum is created and the trocars are inserted in order not to prolong the operation.

This arm supports the telescope and the camera head, both of which are heavy. Therefore this arm should be positioned and fixed as soon as possible in order to disencumber the field as soon as possible. As described before (Figs. 2 and 5), the optical device must be aligned with the central axis of the PC. The arm is manipulated with two clutch buttons. During the procedure, the arm itself does not move, but the camera position can be controlled by the clutch button (a,b) located atop the arm (c). This lights up in blue when the arm is under the control of the console and blinks when disconnected: in this case, the assistant can take control and manipulate the instruments from the peri-operative field.

Each instrument arm has two components: the set-up arm that is positioned using one of the two ‘‘clutch’’ buttons at the time of docking (a and b), and the surgical arm which holds the instrument and is disengaged using the ‘‘clutch’’ button located on top (c). This button blinks when the clutch is engaged and lights in blue when the arm is under control from the console. The positioning arm remains rigidly fixed once the procedure starts whereas the surgical arm can be manipulated throughout the procedure.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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Position of trocars

There are two types of trocars: ‘‘robot-specific’’ trocars that are grasped by the robotic arms at docking and ‘‘free trocars’’ inserted when necessary and manipulated by the assistant according to the habits of each surgeon. The depth of Insertion of an operative trocar is defined by a black ring landmark (1) that should be located within the thickness of the abdominal wall: this landmark defines a neutral fulcrum point where any mobilization excercised by the machine does not put any constraint on the wall (8a). The set-up of the trocars is essential and must respect certain rules (8b): • the optical trocar should always be positioned a bit further back compared to where it is usually inserted in traditional laparoscopy; • the position of the optical trocar determines the position of the other trocars along a line that can be either straight or, better, slightly convex; • the distance between the trocars must be at least 8 cm to avoid mechanical interference between the surgical arms; • the ‘‘free trocars’’ should be positioned outside the convexity of the line and always between two ‘‘robot trocars’’ rather than at their level. This facilitates the assistant’s gestures (traction, exposure, stapling, insertion of needles) even though these movements are still quite constrained and limited by the encumberment of the robot arms.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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Pre-operative preparation for docking

Preparation before final fixation (docking) of the set-up trocar arms should include: •] • positioning the patient and the table (roll, tilt) which cannot be modified during the procedure. The PC is not yet positioned near the operation table; • the PC and the instrument arms are then brought toward the patient (not yet prepped) into the eventual position of the trocars with manual simulation of the movements of the arms to ensure that there is no conflict between the arm joints, which must be corrected at this time; • the PC is then backed away and covered as the laparoscopic procedure is started. The PC can then be advanced at the time of docking using the same pre-determined landmarks; • laparoscopic procedure: introduction of trocars, checking for intra-peritoneal adhesions, which are lysed as necessary, arrangement of the small intestines (this is the only step where the camera must be hand-held); • the PC is then draped and brought back for docking.

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Docking: 1st step

The PC is positioned as determined by the simulation exercise during the preceding step. The set-up arms are mobilized by pressing on the appropriate clutch buttons, bringing them into position to grasp the trocars, always docking the optical arm first. The instrument arms are positioned to converge toward the target according to the principals of triangulation (a). Once again, the surgeon should check that there is no conflict between the joint positions of the arms. The arms are then connected harmoniously as shown in the overhead view (b): •] • the middle joint of the optical arm is determined by the blue arrow inside the line (see insert); • when using a 4 arm configuration, the optical arm is set up on the side of the single arm, the positioning arms are angled harmoniously and smoothly, always checking for any possible conflict.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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Side-docking

Sometimes it is not possible to place the scope on the central column of the PC, especially when this is at the patient’s side, as this would make the optical arm too short (a). This may be overcome by lateralizing the position of the arms (b): the optical arm is set up on the side, but keeping it in line with the target while the other arms are lateralized in parallel remaining the same distance from the central axis.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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Docking: 2nd step (optical arm)

The scope is always the first element to dock. The optical device arm is manipulated with the left hand (a) while the lateral bar of the positioning arm is manipulated with the right hand (b). The arm is brought near the trocar. The optical arm is then aligned with the axis of the trocar and docked by clipping the blue nut wings onto the trocar. The optical device is then introduced into the trocar and locked into the arm. Its cable is passed over the arm and fixed laterally in the yellow clamp specifically destined to hold it. As soon as that is done, all the other maneuvers are accomplished by tilting the optical device toward its intended target under visual control.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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Docking: 3rd step (instrument 13 arm)

Once the optical arm is docked, the instrument arms are docked from lateral to medial. For each trocar, the scope is directed to allow direct observation of the trocar insertion. The set-up arm is then positioned at a height corresponding to the top of the trocar. The surgical arm positioned is then fine-tuned by disengaging the clutch button to align it in the same direction as the axis of the trocar (a). The trocar is held with one hand while the other hand disengages the clutch button located behind the nut wings to adjust the arm, which is then clamped to the trocar head (b). The trocar can then be locked in place if the insertion is perfect. It is not necessary to exercise any force for this maneuver, but simply to check that the surgical arm is parallel to the vertical axis of the trocar. Once locked, the operative instrument is affixed in the instrument holder, introduced into the abdomen under visual control, and positioned with its tip close to the anatomical target. The other trocars are each docked in the same way. The surgeon can only begin working from the console when all the instruments are in view.

Disclosure of interest The authors declare that they have no conflicts of interest concerning this article.

Please cite this article in press as: Valverde A, et al. Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy. Journal of Visceral Surgery (2014), http://dx.doi.org/10.1016/j.jviscsurg.2014.03.004

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Fundamentals of robotic surgery or of robotic-assisted telemanipulated laparoscopy.

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