Mr roboto positioning tips

[turnupthevapor]

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Looking for some Jedi tricks for positioning for robotic prostates/sacral colpo & tvh

Trying to get a general consensus

1. How to prevent sliding
2. Tips to tuck and protect the arms
3. Preventing nerve injury


We are currently bringin 2 inch silk tape from the side rails over egg crates (above the elbow) across the chest and back to the side rail.

This has been working okay for us but seems a little inexact and primitive. I worry as the trendy increases that the tape tightens across the chest and arm (long thoracic, median n)

We do not use a bean bag but instead use a gel pad which is in direct contact with the pts skin and does work pretty well due to the friction. Arms we tuck with arm length foam pads. Is any one using arm sleds?

Thanks for your insight👍

 

[Ronin2258]

I was asked about this topic when I interviewed for residency, given my surgical background. It was the nerve damage that was worrying my interviewer. I know the tech isn't going away, as the urologists have the data to back up how much less morbidity is associated with the robotic techniques. So it has been racking my brain for the last few months.

I have been pondering the problem off and on again since the interview/acceptance. As I haven't seen one of the robotic surgeries yet (my last place was lobbying for the DaVinci when I was leaving,) I would like to see how the positioning happens and try to brainstorm then.

 

[jwk]

Looking for some Jedi tricks for positioning for robotic prostates/sacral colpo & tvh

Trying to get a general consensus

1. How to prevent sliding
2. Tips to tuck and protect the arms
3. Preventing nerve injury


We are currently bringin 2 inch silk tape from the side rails over egg crates (above the elbow) across the chest and back to the side rail.

This has been working okay for us but seems a little inexact and primitive. I worry as the trendy increases that the tape tightens across the chest and arm (long thoracic, median n)

We do not use a bean bag but instead use a gel pad which is in direct contact with the pts skin and does work pretty well due to the friction. Arms we tuck with arm length foam pads. Is any one using arm sleds?

Thanks for your insight👍

Sounds fairly reasonable. We use the egg-crate foam (taped to the bed) under the patient with no sheet over it. It seems to do a good job at keeping the patient from sliding down the table. We use the foam armrests with a long draw sheet tucked around the arms. I like sleds, but they're hard to come by in our facilities. We do a ton of robots for GU and GYN and haven't had any issues with sliding or nerve problems.

I am far more concerned about POVL with robots - it's gonna happen if it hasn't already. 6-8 hours in steep T-Berg for the robot newbies? It's a disaster waiting to happen.

 

[Frank Rizzo]

I am far more concerned about POVL with robots - it's gonna happen if it hasn't already. 6-8 hours in steep T-Berg for the robot newbies? It's a disaster waiting to happen.

Exactly. We do about 4 robot cases a day. Its just a matter of time, IMHO.

 

[C.P.]

we did a lot of robotics, and in the hands of a good operator/surgeon (and choosing he right paient), they're fast (under an hour) and almost bloodless (under 100ml). No joke.
But. . . we had the full spectrum of surgeons usng it. The other end were the ones that tried taking out 3rd trimester sized prostates and couldn't even find the "on" button for the machine.
In those cases I wasn't just worried about the patient's position but whether I'd develop decub ulcers from sitting there so long.

A few things I've learned to watch closely:

EXCELLENT leg positioning. Make sure the device securing the legs is locked on TIGHT, and the legs are positioned well. This alone will help keep the patent in position, and also prevent malpositioning of the legs.
As for the arms.
I wrapped circumferentially around the elbows with egg crates.
Laterally ran a length of egg crate foam along the forearms and then "tucked the arms using the sheet the patent was on.

This was actually really important. The thing I worried about the most was the patient sliding, but their arms not, and then pulling on the shoulders. With the arms wrapped in the sheet, if the patient slid, their arms went with them (this is as opposed to having the arms taped to the table).
The wide patients got arm sleds/tobogans/whatever you want to call them.
On top of this, we had shoulder braces to help support the patient (well padded and wide to avoid too much pressure on the brachial plexi).

Positioning was always a concern, but the two other big concerns:
1) swelling from fluid shifts: always check a leak on the cuff before going anywhere with the ET-tube.
2) crepitus from CO2 tracking. Maybe someone else has a good explanation for this (I'll start another thread if it becomes a debate, to avoid hijacking this discussion). Even though the patient is in trendelenberg, the long robotics often had a significant amount of upper supraclavicular crepitus (sometimes causing us to leave the patient intubated overnight). Inflation pressures were never extravagant (in the teens), but it happened enough that we weren't surprised when it occurred, and always checked throughout the case to see if/how it was progressing.

my 2 cents.

 

[Dhanwanthari]

Arms in sleds with egg crate around the arms (padding against the bed and the sled).

Cross-wise taping w/ 2" silk. (Wrapping from deltoid/upper arm area of sled on one side up, up and over chest to lower arm area of other side's sled) Hands sandwiched in eggcrate.

No bean bag, just the "tempur-pedic" OR table, not covered with any sheet (creates more friction).

Steep trendelenberg initiated.

Custom-made (extra low height) mayo stand lowered to just above the nose of the patient (protects face, surgeons can rest the camera here when not on the arm.

Never seen patient slide with this taping. (our ralps are done in 3.5-4h)

Our robo vag hys however is another story... the URO team's technique is slowly being adopted by the GYN team (with the help of the anesthesia providers).

 

[cchoukal]

Arms in sleds with egg crate around the arms (padding against the bed and the sled).

Cross-wise taping w/ 2" silk. (Wrapping from deltoid/upper arm area of sled on one side up, up and over chest to lower arm area of other side's sled) Hands sandwiched in eggcrate.

No bean bag, just the "tempur-pedic" OR table, not covered with any sheet (creates more friction).

Steep trendelenberg initiated.

Custom-made (extra low height) mayo stand lowered to just above the nose of the patient (protects face, surgeons can rest the camera here when not on the arm.

Never seen patient slide with this taping. (our ralps are done in 3.5-4h)

Our robo vag hys however is another story... the URO team's technique is slowly being adopted by the GYN team (with the help of the anesthesia providers).

This fits our practice as well.

I've done maybe 100 of these (my residency program did tons) and I've never seen the crepitus described above.

One thing I haven't seen mentioned here is the risk of eye injury (not POVL, per se). There's a very high incidence of scleral edema which can either be misdiagnosed as a corneal abrasion or, in and of itself, cause the patient to itch and scratch their eye, thereby causing an actual abrasion.

I warn patients about this ahead of time, in addition to the other positioning injuries.

 

[turnupthevapor]

For our Kidney stuff:

Pretty straight forward: note that between the arms we use half a adductor pillow from our hip cases. this is nice because it allows access to the down arms radial artery in case the case gets ugly.