Page 13 - Journal of WALS

WJOLS

Making Robotic Surgery Easier and Safer: A Clinical Review

earlier, bring the third arm around the back of the robot
to the left of the robot.
2. Always dock the third arm first and then the first arm, it
makes the docking easier.
3. Dock the second arm of the robot to the left of the
patient’s abdomen.

Instrument Selection Procedures (Figs 7 to 9)

1. Put the unipolar scissors in the first arm, which is usually
in the right upper quadrant.
2. The fenestrated bipolar or a grasper goes in the third
Fig. 2: Relation between the base of the robot and the
foot of the bed arm in the right lower quadrant. I have a separate foot
pedal next to my right foot for the Bipolar graspers.
PORT PLACEMENT AND I switch between my scissors and the fenestrated
INSTRUMENT SELECTION grasper in my right hand. So you see that I either use
my scissors or I use the fenestrated bipolar. In essence,
Where are my Scissors?
when I use my fenestrated bipolar in the third arm,
The DaVinci technique of port and instrument placement then my scissors in the first arm are fixed and thus
for benign gynecology is to put the scissors on the right cannot move or get lost reducing the risk of inadvertent
side of the abdomen and to put one or two graspers on the injury to vital structures. On a side note, when I am
left side of the abdomen. It could be a W or a M placement. not using the scissors, I leave them near the anterior
Therefore, if you are right handed you have two graspers abdominal wall, away from the bowel and vascular
that you are toggling in the left hand while dissecting and structures.
cutting with the scissors in the right hand. I feel that my 3. I put the Gyrus grasper in the second arm on the left
ability to use the two graspers to their full capacity was lower or mid quadrant of the patient’s abdomen.
compromised in the Da Vinci technique, and thus the 4. My assistant port could be in suprapubic or in the left
invention of the Jain technique. upper quadrant. The site is dependent on the size of the
The Jain technique of port and instrument placement is patient and the pathology.
opposite to the DaVinci technique and practically eliminates
this limitation. I recommend the following. Note: If I have a clear vision of the pelvis with no redundant
bowel, I use a suprapubic port. That port is used essentially
Port Placement and Docking Technique (Figs 5 and 6) for suction irrigation, passage of the suture and removal of
the specimens. However, if I see a need for exposure and
1. Dock the first and the third arms of the robot on the
right side of the patient’s abdomen. As I mentioned bowel retraction, I use the assistant port in the left upper
quadrant. It is easier for the assistant to then use a retracting
device like a paddle or a fan retractor.
In cases of endometriosis resection, I use my bipolar
graspers to pull the peritoneum with endometriosis away
from vital structures like the ureters, bladder, bowel and
the blood vessels. I then use the scissors and the Gyrus to
superficially remove the pathology.
Another benefit with the Jain technique is that the two
graspers are coming from two opposite sides, which make
the retraction and dissection much easier, closely duplicating
an open laparotomy.
Also use of the two graspers are very convenient for
traction and pulling organs away from vital structures. I
believe doing this makes the anatomy clearer and the areas
of dissection much more distinct, specifically in robotic
Fig. 3: Robot is docked on Fig. 4: Third arm is brought to
the right side of the bed the right side of the robot cases with the 3D vision.
World Journal of Laparoscopic Surgery, May-August 2012;5(2):67-71 69