Safe Patient Positioning for Robotic Surgery

Safe Patient Positioning

It's all about safe positioning in robotic surgery: Protecting Patients, Promoting Safety.

D.Jacqueline Arroyo RN, MIS / Cardiac Robotic Specialist

Massachusetts General Hospital

According to the New England Journal of Medicine, more than 80,000 robotic surgery procedures have been performed since 2008[footnoteRef:1]. As a result, health care institutions are increasingly opting to invest in robotic technologies which offer patience the best quality of care and attractiveness as innovative methods. Although current literature is limited, studies show that patients who undergo robotic-assisted procedures experience reduced surgical time, scarring, blood loss, pain, infection rates, and lengths of stay compared with patients who undergo open or physician led laparoscopic procedures[footnoteRef:2]. Additionally, modern technology has been introduced to ensure three dimensional imaging for optimal patient monitoring and safety.[footnoteRef:3] It is because of these findings that many surgeons and hospitals alike are starting to recognize that robotic assisted techniques have the potential to reduce the invasiveness of surgical procedures and ensure greater precision. [1: Barbash 2010] [2: Herron 2008] [3: Ballantyne 2002]

Robot-assisted surgery has a much more complex level of patient preparation then traditional surgery. Because of this, the nature of robotic surgery enhances the role of the nurse as part of the medical care team. Nurses are becoming increasingly responsible for keeping up-to-date on scientific literature and learning the techniques and technologies that are involved in robotic surgery in order to recognize errors in setup and patient positioning. Along with this role comes the nurse's vital role in communicating calibration issues with doctors, anesthesiologists, and other members of the medical team. It is this role of the nurse that is critical to patient safety.

Patient positioning before, during, and after robotic surgery cannot be underestimated. When a patient is having robotic surgery, the medical team should lay out a plan of patient care. This plan not only includes the surgeon performing the procedure, but also the role of the anesthesiologist before, during, and after the procedure. Preoperative nurses and other members of the healthcare team should work together to plan the position of the patient depending on the operating room used, layout of the room, equipment size and location, staff in attendance, approach, and type of surgery, all of which is planned in advance by nurses. Additionally, nurses are responsible for evaluating patient readiness for robotic surgery including overall health and stability. Patients need to have adequate pulmonary capacity or be able to display a clean bill of cardiac health in order to proceed with the robotic surgery due to the type of anesthesia and surgical equipment used. The most important factor is the heart rate. A slow and steady heart rate is important for proper surgical conditions as an inconsistent heart rate could trigger errors with the machines.

There is a steep learning curve in operating and working around robot surgery methods. This is especially true for cardiac teams embarking in TECAB's (total endoscopic coronary bypass grafting), mitral valve repairs, asd repairs and Lima take downs using the robotic-assisted system. Unfortunately, there are only minimum basic training and progressive requirements using the robotic -- assisted system for all members of the operating room staff, and these requirements tend to not emphasize the importance of operating team integration.

Pre-Operative Patient Preparation

Surgical preparation and patient positioning for cardiac robotic -- assisted procedures. Set the room's temperature for typical OBCAB at 72 degrees Fahrenheit and prepare heater blankets. For valves, set the room's temperature at 65 to 68 degrees Fahrenheit with heater blankets available for warming after the pump run. The patient should be secured in supine position with proper cushioning of pressure points. A lower extremity sleigh should be used to support patient laterally. Once successful intubation with a double lumen-tube endo-tracheal tube is accomplished, place a central venous pressure or pulmonary artery catheter and arterial blood pressure line. A Foley catheter and a nasogastric tube are inserted after the patient receives anesthesia. Finally, carefully place the R2 external defibrillator pads on the patient's chest before positioning the patient for the procedure.

Patient Positioning

Align the patient's left chest with the edge of the operating room table for a TECAB'S/Lima take down's. This allows the left arm to hang down and remain clear of the instruments when working on anterior chest wall. For all other cardiac procedures, align the right chest with the edge of the operating room table and let the right arm hang down supported with gel pads and tucked with half a sheet. Both arms need to be adducted, supported, and padded appropriately. Be mindful of digits being free hanging and verify that there are no pressure points. Place a small 6-8" positioning roll, gel pad, or inflated pressure cuff under the left mid-thorax for TECAB's/lima take downs (right mid-thorax for all other cardiac procedures) caudal of scapula to lift thorax and drop shoulder and allow scapula uninhibited movement. Place the left arm for TECAB's/lima take downs or right arm for other cardiac procedures alongside the patient below table level and pad appropriately; do not elevate the shoulder. Secure and pad the head/neck of patient level with the anesthesiologist for monitoring. Prepare patient with betadine/chlohexidine for CABG and potential saphenous vein harvesting. Lower extremities need to be in a slight or full frog leg supported position. Patient needs to be secured to the OR table with safety strap.