Surgery with a Robot?!

The first time I heard the term robotic surgery, I pictured a surgeon lounging in a chair telling a robot what to do as it operated on a patient. When I tell my patient that I want to do robotic surgery, I can see on their faces that they are picturing a similar scenario. Well, the truth is far from that.

Robotic surgery is a form of minimally invasive surgery called laparoscopy. In standard laparoscopy, a scope is placed through a small incision (usually 5 -12 mm) in the belly button. The view the surgeon gets from the scope is a 2-D view like on your TV. Other instruments are placed through small incisions near the pubic bone or out near the hip bones. The instruments can open and close, and sometimes they can be turned to point a different direction, but that’s usually it. This can make surgery more challenging than traditional open surgery where a surgeons hands can move in many different directions and angles rather than just opening and closing (think of a adult learning to eat with chopsticks). Robotic surgery is done through through the same small incisions, but the instruments can move like a surgeon’s hands. The view is also 3-D because there are 2 small scopes rather than just one. All of this has made it possible to do surgery that would otherwise require a large incision with the minimally invasive laparoscopic technique.

In the US, the da Vinci Surgical System (www.davincisurgery.com) is the “robot” that is used. The scope and instruments are hooked up to robotic arms that the surgeon controls. The surgeon sits at a console and looks through eyepieces that give him or her a 3-D view of the surgical site. His or her fingers are in little sleeves so that when he or she moves his or her hands or even just fingers, the robot does the same thing with the instruments at the surgical site. He or she can zoom in and out and move the scope around as well. Movements can be scaled down so that the surgeon, when doing very fine work, can make normal-sized movements, and the robot makes tiny little movements. I use this when putting fallopian tubes back together after a tubal ligation. It is much easier than trying to make tiny little movements yourself. Someday it may even become common to do remote surgery this way with the surgeon in a hospital and the patient on the battlefield, let’s say.

The advantages to robotic surgery over traditional open surgery are obvious. Because the incisions are much smaller, the patient gets out of the hospital faster (the same day or the next day rather than 2-3 days later) and recovers faster (3-5 days rather than 4-6 weeks). Because the patient is up walking around faster, there is less risk of developing blood clots in the legs or lungs. The patient goes back to work much faster, and so the economic impact to the patient is usually lessened. The advantages over standard laparoscopic surgery are more tricky. With the extra mobility of the instruments, difficult laparoscopic cases can be made easier and finer work can be done. Simple laparoscopic cases may be better off with standard laparoscopy, though. With simple laparoscopic cases, the surgeon often needs only 2 incisions. The robot requires 4 incisions, and so the patient is better served by doing plain-old laparoscopy. For me, the greatest advantage is being able to take a case where I would have had to make a large incision and turn it into a minimally invasive case by using the robot.

If your surgeon has recommended that you have robotic surgery, this is what you can expect. The night before, you will be told not to eat or drink anything (and they do mean anything–no gum, no mints, nothing unless you are told otherwise!). If you have medication you take in the morning, ask you doctor whether you should take it or not. You will usually be asked to arrive at the hospital about 2 hours before the surgery. Wear comfortable, loose-fitting clothes and slip-on shoes. You won’t really feel like bending over to tie shoes after the surgery. Don’t bother with lots of make-up, it’s just going to get smeared while you are asleep. Your doctor may ask you to take some medications and/or a special diet the day before to empty out your bowels. This is helpful when working in the pelvis or belly, because the intestines are all around the organs. By emptying them, and so making them smaller, it is easier to see.

When you arrive at the hospital, there will be paperwork to fill out and sign. You will probably be asked for your insurance card and a picture ID, so don’t forget to bring those along. Bring a book or something too, as there may be some waiting too. The pre-op (before surgery) nurse will then call you back to the pre-op area. He or she will get your height and weight, blood pressure, pulse, and temperature. You will be given one of those lovely hospital gowns to change into (yes, it’s true, you have to take your underwear off too). Most hospitals will also give you socks with treads or slippers to keep you feet warm too. The nurse will insert an IV into a vein in you arm and start giving you fluids. He or she will confirm your identity and review your medical history with you. You will probably be asked what type of surgery you are going to have. This is not because the nurse wants to know (she already knows), but because she wants to make sure you understand what type of surgery is going to be done. The nurse may also wrap you legs in these devices that squeeze your legs and keep the blood moving around while you are asleep to help prevent blood clots. The anesthesiologist will come and visit you as well. He or she will explain how the anesthesia is administered. If you have problems with motion sickness or you have gotten nauseous from anesthesia in the past, tell the anesthesiologist. There are lots of way to prevent nausea, if we know that it is an issue. Your surgeon will also come and see you before the surgery. If there is one side that is to be operated on (for instance you have a cyst on the left ovary), then the surgeon may make an X on that side of your belly with a marker. If you have any last minute questions, write them down so you don’t forget to ask your surgeon. You will also meet his or her assistant. Often times this is a resident, and it is the person who will stay by your side and help while the surgeon is at the console. The final person you will meet will be the “circulating nurse”. This is the nurse who will be in the operating room with you. She is likely to ask you the same questions everyone else has. This is just to double check everything. She will be the one to wheel or walk you back into surgery. If you have friends and family members with you, they will usually be able to stay with you until that time.

As you go back into the operating room, you will notice that it gets colder and colder. We keep the OR rooms on the cold side, because the surgical team has on gowns and gloves and masks and are under large OR lights. All of this makes them very warm. Since you want the people operating on you to be comfortable so that they can concentrate on you, it’s going to be cold in the room. The circulating nurse will have lots blankets that have been warmed up to put on you, so don’t be afraid to tell him or her that you are cold and need more. You may be asked to give them your name and birth date one final time. At this point, you may have been given some relaxing medicine, but you will still be awake. Once you are moved onto the operating table, they will start putting all kinds of monitors on you and the anesthesiologist will start giving you medication through your IV to put you to sleep. He or she may also ask you to breath oxygen through a mask as you are going off to sleep. The masks are plastic and smell like a beach ball. If you makes you feel claustrophobic, just let them know. They can hold it away from you face a bit.

The next thing you know, you will be waking up. It feels like time literally stopped, and it will be hard to believe that the operation is over. Most people don’t have any dreams under anesthesia. You will think that you just went to sleep, when it really has been hours since you dozed off. You will be taken the the post-op area (after surgery). You will be asked to rate you pain on a scale of 1 to 10. The nurses will give you pain medication or anti-nausea medication, if you need it. Then you will probably snooze for a while. Once you are awake and staying awake, they may allow one or two of your friends and family to come sit with you. For a while, your short term memory will be a little fuzzy. You may ask the same question several times, not remembering that it has been asked and answered. The nurses will give you something to drink and some crackers or something to eat. Don’t ask for water; it tends to make you nauseous, even if you aren’t to start with. I recommend ginger ale; it seems to combat nausea. After a while, the post-op nurse will get you up to the bathroom and let you get changed back into your clothes. You will notice that your belly is kind of sore. That’s why loose clothing is a good idea. Take it slowly, and ask for help if you need it. When you look in the mirror, your face make look a little swollen. This is normal. During the surgery, they tilt the bed so that your feet are up in the air and your head is pointed toward the ground. This will help shift all the intestines up towards your chest to expose the area the surgeon will be working on. Being tilted on your head like that for an hour or more will cause fluids to pool in the top of your body, making your face kind of puffy. It will go away in a few hours or so. Before you go home, the nurses will give you a written set of instructions to follow for the next few days and prescriptions for medications, if you doctor has not already given them to you.

When you go home, you will likely still have some effects from the anesthesia, so you may want to take another nap. Don’t be afraid to tell friends and family that you need some quiet time. They will understand. Plan on taking it easy for a few days afterwards, so stock up on good books and movies for your recovery. It’s OK to go up and down stairs and walk around, you are just going to want to do it slower and less often than usual. Usually by the fourth day, you are pretty much back to normal. The incisions aren’t hurting anymore, unless something is pushing on them. Tight jeans or your dog jumping on your belly are still not a good idea. Other than that, your life should be back to normal. The only things your doctor is likely to ask you not to do until he or she sees you back in the office to check the incisions will be baths or putting anything into the vagina (like tampons, douches, or intercourse), if you have pelvic surgery. Once your doctor sees you back in the office and checks that your incisions are healing well, he or she will probably lift those restrictions. Write down and bring any questions you still have to this visit. You will probably not have a lot of time with the doctor, and you don’t want to forget anything!

Overtime, the incisions will lose their redness and become small lines. Sometimes there is also some bruising around the incision, and that will go away over a week or two as well. If you have any numbness around the incisions, this will often resolve over several months. Soon the surgery will be a distant memory as, hopefully, will the problem that caused you to need the surgery in the first place!

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