Positioning Protocol for Robotic Prostatectomy

[Mofeen]

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Our hospital has seen a few brachial pleoxopathies develop after robotic prostatectomies, particularly in obese patients. Anyone have a special positioning protocol for these cases? Things to do or avoid besides the obvious? Thanks.

 

[Gern Blansten]

Dr Warner at the Mayo Clinic had an interesting approach which he told me about. He challenged the surgeons that they did not need such steep Trendelenburg. They argued that they did. He asked them how come "these other surgeons" can do it with 20 degrees, but you need steep T-burg. He called their surgical talents into question and said that with each case, they would lessen the degree of T-burg by 5-10%. He said that after a slow progression, the surgeons learned to do the surgery without the non physiologic positioning that most robotic surgeons think is a requirement because they learned it that way. He said their trendelenburg is now quite modest and they have lessened the risk to the patient significantly. I wish I could say that we had solved it where I am. We do a lot of padding and a preformed bean bag contoured to provide some shoulder support without impingement. It is a complex ritual, but I think it works pretty well. No disasters...yet.

 

[sevoflurane]

You should be tucking the arms on all robots with extreme t-burg. Also keep 'em dry... restrict fluids to 500-800ccs until after you level them out. O/W you will eventually see laryngeal edema with a possible bad outcome. I'll take a pic during my next robot to demonstrate our positioning protocol. I'm still afraid of berry aneurysms and extreme T-burg with a new surgeon during a 6+ hr. case. (no evidence though... just a feeling).

 

[Gern Blansten]

You should be tucking the arms on all robots with extreme t-burg. Also keep 'em dry... restrict fluids to 500-800ccs until after you level them out. O/W you will eventually see laryngeal edema with a possible bad outcome. I'll take a pic during my next robot to demonstrate our positioning protocol. I'm still afraid of berry aneurysms and extreme T-burg with a new surgeon during a 6+ hr. case. (no evidence though... just a feeling).

Good points. I worry about ischemic optic neuropathy more.

 

[jwk]

Good points. I worry about ischemic optic neuropathy more.

Ditto - I think POVL in these extended steep T-berg cases is a disaster waiting to happen.

 

[IN2B8R]

Dr Warner at the Mayo Clinic had an interesting approach which he told me about. He challenged the surgeons that they did not need such steep Trendelenburg. They argued that they did. He asked them how come "these other surgeons" can do it with 20 degrees, but you need steep T-burg. He called their surgical talents into question and said that with each case, they would lessen the degree of T-burg by 5-10%. He said that after a slow progression, the surgeons learned to do the surgery without the non physiologic positioning that most robotic surgeons think is a requirement because they learned it that way. He said their trendelenburg is now quite modest and they have lessened the risk to the patient significantly. I wish I could say that we had solved it where I am. We do a lot of padding and a preformed bean bag contoured to provide some shoulder support without impingement. It is a complex ritual, but I think it works pretty well. No disasters...yet.

They like steep T-berg because they claim that gravity works as a "retractor" to get the abdominal contents out of the way.... While I may agree with this, I think that they overshoot everytime they place the patient on his head to do the surgery....