Robot-assisted minimally invasive esophagectomy (RAMIE): tips and tricks from the bedside assistant view—expert experiences

ABSTRACT

The role of bedside assistants in robot-assisted minimally invasive esophagectomy is important. It includes knowledge of the procedure, knowledge of the da Vinci Surgical System, skills in laparoscopy, and good communicative skills. An experienced bedside assistant will likely improve efficiency and safety of robot-assisted minimally invasive esophagectomy.

INTRODUCTION

In 2000, the da Vinci Surgery System (Intuitive Surgical Inc., Sunnyvale, CA) became the first FDA-approved all-encompassing system of surgical instruments and camera/endoscopic utensils.¹ The robotic platform has expanded over several surgical services to include both cardiac, thoracic, and abdominal surgical procedures. Robot-assisted minimally invasive esophagectomy (RAMIE) was developed in 2003, to enhance surgery and to reduce morbidity of esophagectomy and was proven feasible and safe.^2–5

RAMIE has gained popularity over the recent years and the ROBOT trial provides evidence that RAMIE results in less cardiopulmonary complications, less postoperative pain, and better short-term postoperative functional recovery compared to open transthoracic esophagectomy.⁶

For RAMIE, there is evidence showing a faster trainee learning curve for the console surgeon when following structured proctoring pathways involving experienced proctoring surgeons.^7–9 Most of the literature concerning learning curves in RAMIE focus on the performance of the console surgeon, the importance of an experienced and dedicated bedside assistant is mostly not addressed. General opinion dictates that a dedicated team approach with an experienced bedside assistant optimizes efficiency of procedures and decreases the chance of complications.¹⁰ Most literature about the importance and/or role of bedside assistants is descriptive.^11–14 In urologic and gynecological procedures, there is some evidence that an experienced bedside assistant is essential in robotic surgery, resulting in shorter operating time, reducing the chances of potential complications, and reducing the risk of conversion.^15,16

Robotic surgery provides extra challenges compared to laparoscopy. In laparoscopy both the surgeon and assistant are at the bedside, allowing interchange between surgeon and assistant. In robotic surgery, the remote location of the unscrubbed surgeon in the console impedes this interchange. Communication and coordination between bedside assistant and console surgeon are even more crucial compared to laparoscopy since the console surgeon has no direct sight on the bedside assistant nor on the patient and on the actions performed at the patient’s bedside.

However, literature about the role of the bedside assistant in RAMIE is lacking. The objective of this manuscript is to provide an overview of the bedside assistant’s role in RAMIE, enhancing the efficiency and safety of the procedure and to give pragmatic tips to optimize the bedside assistant’s role which also includes proper room setup, patient positioning, trocar placement, and docking of the da Vinci system in the abdominal phase as well as the thoracic phase.

TRAINING A BEDSIDE SURGEON

In the USA and increasingly in Europe, the bedside assistant’s role is assumed by a physician assistant, but this can also be a resident of staff surgeon. Physician assistants are licensed medical professionals with limited scope of practice. Physician assistants can independently perform medical duties, but the capacity of duties is determined in consultation with their supervising physician and state law. Responsibilities of a physician can include, for example, making rounds, performing patient exams, ordering and interpreting tests, developing treatment plans, prescription of medication, and assisting in surgery.

During education, there is no dedicated robotic or laparoscopic training, and most of the surgical expertise is acquired on the field by their proctoring attending surgeon. The training pathway, as for a surgical resident, is based on a mentorship model. The trainee is scrubbed at the bedside in multiple consecutive cases with an experienced mentor learning the steps of the procedure and acquiring the techniques needed to facilitate the operation. It includes knowledge of treatment of esophageal cancer, knowledge of the procedure, knowledge of the da Vinci Surgical System, skills in laparoscopy, and good communicative skills.

BEDSIDE ASSISTANT TIPS AND TRICKS IN RAMIE

Room setup

The da Vinci Xi® system (Intuitive Surgical Inc., Sunnyvale, USA) is placed on the right side of the patient (Figs 1 and 2) or left side of the patient (Figs 3 and 4), according to surgeons preference. The da Vinci Surgical System is maintained on one side of the patient during the entirety of the procedure to prevent delay due to repositioning of the system in between the abdominal and thoracic phase. After room setup, the settings of the da Vinci Surgical System, diathermia, and insufflator are checked (according to preferences of the center). It is important to ensure availability of open procedure trays in case conversion is necessary and should be part of the room setup.

Depending on the center, room setup can be performed by the bedside assistant or by an experienced and dedicated OR nurse.

The esophagogastroduodenal scope is tested, and endoscopy is performed before start of RAMIE to identify the tumor and to place the nasogastric tube for stomach decompression.

Patient positioning abdominal phase

For the abdominal phase, the patient is placed in supine position with the arms tucked on the sides. All joints are padded to prevent nerve injury. To get optimal exposure, the patient is placed in reverse Trendelenburg position and if preferred tilted to the right. A footboard with gel pad for the feet or bean bag is used to allow for reverse Trendelenburg position (Fig. 5). If there is no TRUMPF Medical TruSystem™ 7000dV OR table with integrated table motion for the da Vinci Surgical System, reverse Trendelenburg and slight right tilt patient position should be applied before docking of the da Vinci Surgical System; after docking no changes in table position can be made.

Patient positioning thoracic phase

For the thoracic phase, the patient is placed on a bean bag and positioned in left lateral decubitus position tilted towards prone (Fig. 6). This will allow for better exposure of the posterior mediastinum and esophagus and will keep the lung retracted anteriorly. In case of an obese patient with a large abdomen, left table tilt can be used to simulate prone position. A table break at the level of the tip of the scapula can be used to enlarge the intercostal space, facilitating trocar placement. The bean bag should be vacuumed only after breaking the table to prevent it from breaking and allowing support to the patient’s body fully positioned. The head and neck of the patient can be supported by lifting the bean bag at that level or by placing pillows or folded blankets. A shoulder roll can be used to decrease axillary compression. The right arm is kept low at a 90 degree angle, allowing the scapula to move medially, in order to create space for trocar placement and robotic instrument mobility. If the right upper arm is too far up, this will limit the reach of the most cranial robotic arm and instrument and will restrict the assistant workspace due to compression on the shoulder when trying to reach the diaphragm. In case arm boards are used, it is important to ensure these are adjusted cranially to the table; this will create space for the bedside assistant standing at the table. Finally, patient positioning is checked with particular attention to compression points to make sure patient is padded appropriately to prevent nerve injury and compartment syndrome. Special attention should be considered for the legs, the left elbow, which might be on the edge of the bean bag, and the left shoulder, which might be positioned too far posterior resulting in upper extremity venous congestion. Repositioning should be considered at this point if there are areas of concern.

During patient draping the bedside assistant communicates with the anesthesia team to keep the sterile drapes down to allow for free motion of the robotic arms.

Trocar placement

Attention to distance between each trocar is critical to allow the robotic arms to move freely without external collisions. A distance of at least one intercostal space during the thoracic phase or about 6 cm for the abdominal phase is advised. In the abdominal phase as well as in the thoracic phase, all trocars are placed under vision to prevent injury. Prior to placement of the thoracic trocars, confirm with the anesthesia team that single (left) lung ventilation has been achieved. Trocars are placed at the superior side of the rib, to prevent damage to the neurovascular bundle. After placement of the first trocar, single-lung ventilation is confirmed, and CO₂ insufflation at low pressure (8 mmHg) is started in the chest. This should be communicated to the anesthesia team, and vital signs should be monitored to avoid tension pneumothorax physiology. The bedside assistant should switch the CO₂ tube from the camera trocar to a different trocar to prevent fogging of the camera caused by cold air on the camera tip. The bedside assistant needs to make sure that the non-robotic assistant port is not too close in proximity to the camera trocar to prevent involuntary movement or restriction of the assistant instrument due to the camera. During the thoracic phase, one of the trocars can be opened a little bit to air and to prevent re-expansion of the lung during suction.

Docking of the da Vinci Xi system

The correct settings of the da Vinci Surgical System need to be checked prior to deploying for docking according to the surgeon’s preference. The bedside assistant should communicate with the circulating nurse and the anesthesia team to maintain sterility during deploying for docking and positioning of the da Vinci Surgical System, making sure that all external monitors and overhead OR lights are not colliding with the robotic arms. If experiencing difficulties attaching the robotic arms to the trocars, the alignment of the trocar and the robotic arm should be checked as most likely they may not be parallel to each other; the instrument and port clutch buttons can be used to change positions of the arms. After attaching the camera, the camera trocar should be held in place during targeting to prevent dislocation of the trocar. Before targeting, align the camera arm placing the arm parallel to the cross at the boom (Fig. 7). The camera horizon should be kept straight, and during targeting while the robotic arms move into position, their sterility needs to be maintained. After targeting is completed a final “burp” is given to the camera’s trocar to release tension on the abdominal and thoracic wall. The remaining trocars are then docked to the robotic arms. In the abdominal phase, the liver retractor should be positioned carefully in order to avoid collision with the robotic arms.

Intraoperative

The bedside assistant should be well informed about the case, the anatomy and the different surgical steps of RAMIE.

During (re)placement of instruments the bedside assistant must pay attention to avoid inserting an instrument against resistance. The da Vinci Surgical System remembers position of the last robotic instrument installed when exchanging instruments. However, due to change of anatomy, structures can be punctured during blind replacement of instruments. When resistance is met, robotic instrument position should be changed by hand and under direct visualization, using the instrument clutch button. Be aware that resistance can also be a result of dislocation of trocars from the abdominal or chest wall; repositioning in such instance is required. If the instruments are not recognized by the da Vinci system, it is wise to check the draping of the robotic arm as the cartridges might not be appropriately secured or there might be extra plastic drape in the connection with the robotic arm. In case of difficulties during instrument exchange, communication with the console surgeon is important, since he/she might not be aware of what happens at the table.

In case of a red alert, the sterile robot wrench can be used to unlock and remove robotic instruments. Also, removing trocar and instrument by hand while attached to the robotic arm might be considered. However, if you chose to do the latter make sure the instrument is free and it is removed under direct visualization.

Awareness of internal and external collisions of robotic arms and instruments should always be maintained by the bedside assistant and should be communicated to the surgeon at the console so adjustments can be made for patient safety. The patient clearance button should be utilized so that the posterior elbows of the robotic arms face downward allowing greater freedom of motion of the arms. The patient clearance buttons can be adjusted during the procedure, while the robotic instruments in place since the instrument will not change position.

During surgery the bedside assistant provides blunt traction, counter traction, and triangulation with the suction irrigator, endo-peanut, or laparoscopic grasper to help facilitate tissue dissection and retrieval of lymph nodes. The surgical field is kept free from blood, to enhance good visualization of structures and to prevent absorption of light. Direct suction on the omentum should be avoided, as it will get stuck in the suction device. The bedside assistant should determine whether it is better to place the assisting instrument over or under the robotic arm in order to avoid disruption to the operating surgeon movements and for optimal reach of the assistant instrument. Robotic emergency sponge sticks/gauze should be ready for insertion in case of bleeding.

In case of emergency in which conversion to open is necessary, the bedside assistant will communicate with the surgeon about instruments and camera removal, undocking the robot and removing the robot away from the patient quickly while the surgeon is scrubbing in. Communication between the bedside assistant, the nurses, the anesthesia team, and the surgeon is key to the success of the operation, and it is usually supervised by the bedside assistant.

Abdominal phase: points of extra attention

During the transhiatal dissection of the esophagus, either the right or left pleura can be opened. This might cause hemodynamic instability due to tension pneumothorax. In such event communication with the anesthesia team is important, and maneuvers can be done to mitigate the situation. The insufflation pressure can be decreased, the airways pressure can be increased, and if a robotic table is available, the patient can be taken off reverse Trendelenburg. If preferred, a left-sided chest drain can be placed before starting the abdominal phase, because access to the left chest is limited by the robotic arms.

Before the conduit is made, the bedside assistant should ask the anesthesia team to pull back the nasogastric tube to avoid it being included in the staple line. After using the robotic stapler, the trocar reducer should be replaced in the 12-mm robotic trocar to avoid losing pneumoperitoneum.

Thoracic phase: points of extra attention

During the thoracic phase, pay extra attention to the direction of insertion of the instrument in order to avoid injury to the lung or mediastinal wall and structures.

During dissection of the pericardium, the bedside assistant should check cardiac rhythm abnormalities, and directly communicate with the anesthesia team if vital signs are compromised by compression of the heart. Particular attention is given to avoid injury to the pulmonary veins and the airways. Firm pressure of the membranous portion of the trachea and bronchi should be avoided.

DISCUSSION

This manuscript is the first to describe the role of the bedside assistant in RAMIE. Manuscripts about the role of the bedside assistants in other robotic procedures are mainly descriptive.

Outcomes of limited studies comparing the influence of degree of experience of the bedside assistant are contradictory. Some retrospective studies showed that the experience level of the assistant has no influence on operative time, blood loss perioperative, or postoperative complications in robot-assisted prostatectomy and robot-assisted partial nephrectomy.^17,18 Neither of these studies exactly describes the level of experience of the bedside assistant in robotic procedures. A different retrospective study showed that in robot-assisted total hysterectomy, the presence of specially trained assistants resulted in lower complications and lower conversion rates.¹⁶ Other descriptive manuscripts, for example, in colorectal and urologic robotic procedures, all state that skilled bedside assistants are essential for safety and efficiency of the procedure.^11,12,14

The literature describing learning curves for RAMIE mainly focus on the learning curve of the console surgeon.^8,9,19 The possible influence of the level of experience of the bedside assistant to this learning curve is not taken into account, even though it is acknowledged that an experienced bedside assistant can guide the surgeon and can reduce training and operation times of the surgeons at the console.^13,20,21 Structured training pathways to implement RAMIE don’t address the training of the bedside assistant.

The role of bedside assistants in robot-assisted minimally invasive esophagectomy is important. It includes knowledge of the procedure, knowledge of the da Vinci Surgical System, skills in laparoscopy and good communicative skills.

In our opinion an experienced bedside assistant in RAMIE will likely result in a shorter OR time, given the quicker room setup, faster and efficient trocar placement, and improved exposure.

The experience will likely result in decreasing the change of intraoperative complications. Moreover, effective communication with the console surgeon, nurses, and anesthesiology team is ensured by an experienced bedside assistant. The bedside assistant thereby enhances the efficiency and safety of RAMIE.

The implementation of structured training pathways for bedside assistants in RAMIE should be developed.

ACKNOWLEDGMENTS

Prof. Dr. J.P. Ruurda and Prof R. van Hillegersberg are proctors for intuitive surgical. We would like to thank K. Noboa, PA-C, U. Patel, PA-C, and S. Kelly, PA-C for their contribution to this manuscript and their commitment to our patients.

REFERENCES

Author notes