The video demonstrates 4 minor technical mishaps during robotic pediatric urologic surgery. These caused no harm to the patient but did prolong the time it took to complete the operation.
1. Know your instruments
The manufacturer of robotic instruments makes them expire after a certain number of uses. Some instruments are just as good on the first and last use; however, other instruments can become useless after a few operations. It is important for robotic surgeons to know when the instrument needs to be replaced. The 3 instruments that I have found most problematic are:
- Monopolar scissors
- Black Diamond forceps
- Potts Scissors
Dull monopolar scissors will decrease surgical precision and likely prolong operative time. Prior operators could have damaged the scissors by to much cutting through hard tissue or material, or the instrument could have been damaged during sterile processing. The same goes for Potts scissors as demonstrated in the video: they can be really dull or really sharp!
Black diamond forceps are very delicate and likely to be damaged on the back table, by sterile processing, or while passing the instruments through the trocars. When brand new and well taken care of, they hold tissue beautifully without damaging it — which is great for pyeloplasties and ureteroureterostomies in infants. Quite often unfortunately, the black diamonds hold very poorly mostly due to poor handling outside the patient.
2. Remember the epigastrics
Although the epigastrics are easy to avoid when they are been watched, they can be injured when passing a needle with the medial umbilical ligament obscuring the view as shown in the video. My advice: do not ever pass a hitch stitch without the direct vision of the epigastrics.
This video demonstrates how to stop bleeding from an epigastric vessel injury:
3. Never tie holding the needle
There are a couple of reasons why is a bad idea to tie suture holding the needle:
- The needle can puncture other structures inadvertently, like the bowel or a vessel.
- The needle can detach from the suture.
The second one is the reason shown in the video. Having a free needle without a string attached to it makes it more likely to be lost: in a millisecond the needle went from the left lower quadrant of the patient to all the way behind the spleen! I watched the video on slow-motion trying to figure out where the needle went with no luck.
4. A resident classic: forgetting about the other hand
When learning to operate with the robot, it is difficult to be concious about both hands while operating; most trainees tend to focus intensely in one hand at a time and forget the other hand. This can lead to serious problems as when dissecting the ureter with one hand (right hand monopolar scissors) while retracting the ureter with the left hand (with an umbilical tape). Loosing track of the amount of traction exerted with the left hand could cause ureteral ischemia, avulsion or a postop leak.
The video shows the most common example of this problem, which every resident I have trained (including myself when I was a trainee) has commiteed: braking the suture while cinching the suture.
I hope the short video helps you avoid these minor but time-consuming mistakes.