When Your Co-Worker is a Robot

How surgical robots have changed the operating room

OR Today Magazine | August | Cover When Your Coworker is a robot

It has been just a decade since robotic surgery was first introduced. But during this short period of time, robotics has already revolutionized surgical procedures in a wide range of different specialties. More than 350,000 robotic surgery procedures are now performed in the U.S. each year.

“Robotic surgery is here to stay,” says Dr. John Valvo, the attending physician at Rochester General Hospital and Executive Director of the Polissini Center for Robotic and Minimally Invasive Surgery. “It has changed the way both patients and surgeons look at surgery. Patients anticipate a much shorter stay in the hospital for even major procedures. And surgeons know that if a procedure can be performed robotically, the patient will benefit. So when they look at a surgical task, they try to determine if it can be done robotically.”

According to Valvo, robotic surgery started out in urology but has since expanded into many other different types of surgery — from gynecology to ear, nose and throat, gall bladder and general surgery. “It will undoubtedly be morphed into even more specialties as the need grows to do more minimally invasive procedures in a more ergonomic way.”

BENEFITS OF ROBOTIC SURGERY

The term “robotics” brings to mind space-age images of robots, but robotic surgery is performed by highly skilled surgeons using their own hand movements to operate robotic arms to control miniaturized instruments. Like other minimally invasive surgical techniques, the instruments are inserted into the patient through a tiny incision, which makes surgery safer and allows for faster recovery times.

The surgeon performs his or her tasks in a robotic console that’s physically located up to 30 feet away from the patient, viewing a high-resolution 3D image of the surgical site through a camera. Robotics is safe for patients of all ages (including children) and offers greater surgical precision, increased range of motion, improved dexterity, enhanced visualization and improved access for surgeons.

Intuitive Surgical’s da Vinci Surgical System is the only multipurpose robotic surgery system on the market and is currently used in all robotic surgery programs. However, Valvo says a next-generation robotic platform is currently being developed that is smaller and more economical and will allow robotic surgeries to be performed in even more specialties.

One new development in robotic surgery is the recent introduction of a new Sony 3D recorder and 42-inch monitor that enables everyone in the OR to view the robotic procedure in 3D just like the surgeon sees it. “This gives everyone, including the OR nurses, the same sensory input that the surgeon has,” says Dr. Louis Eichel, Chief, Rochester General Division of Urology. “When the nurses can also see the procedure in 3D, it gives them a better idea of exactly what’s going on, which results in more accuracy and safety and a more streamlined process.”

HOW ROBOTIC SURGERY IS DIFFERENT

Robotic surgical procedures differ from traditional open and even laparoscopic surgeries in many ways. Therefore, there is a significant learning curve involved for OR nurses who want to participate in robotic surgery.

“As is the case with any new medical or surgical technology, everyone on the surgical team needs specialized training in order to become competent with the tool,” says Gail Horvath, MSN, RN, CNOR, a patient safety analyst ECRI Institute. “And the training needs to be ongoing — it can’t be limited to an article on your electronic learning module system that you just read and answer some questions.”

ECRI Institute recently hosted a webinar that addressed the training and credentialing necessary with the da Vinci Surgical System. “We believe that what is done together as a team should be trained together as a team, so interdisciplinary simulation training that includes the OR nurse is crucial,” says Horvath.

“OR nurses need to learn all about the robotic technology, how it interfaces with patient care and how to disseminate information,” Valvo adds. “Robotic surgery is an advanced technical procedure, so OR nurses need to be well-trained in order to understand its usefulness as well as critical safety features like patient positioning, for example.”

Dr. Mutahar Ahmed, the director of Robotic Urology at Health East Ambulatory Surgical Center (HEASC) in Englewood, N.J., has been doing robotic surgeries since 2002, and he recently performed one of the first robotic surgeries at an outpatient surgery center at Health East Ambulatory Surgical Center (HEASC) in Englewood, N.J. “The layout of the OR for a robotic surgery is drastically different from the OR layout for a traditional open surgery,” he says, starting with the fact the surgeon is physically located away from the patient, with the nurses located physically around the OR table. “So communication between the surgeon and nurses takes place across the operating room, not across the table.”
OR Today | August | Cover

Also, he says the surgeon does not scrub in for the procedure, but the nurses do. “So nurses often have to do more troubleshooting. They have to be in tune with how the robotic device is working and prepared to adjust the robotic arm in a certain way. And they have to know how to set up the robotic equipment so it’s ready to go for the surgery, including hooking up wires to the monitors and setting up different camera angles. There are many little things to learn about robotics that add up to a lot.”

According to Dr. Ahmed, although OR nurses should receive formalized training in robotic surgery, most of their learning occurs over time on the job. “In my opinion, it takes from 50-100 cases before most nurses become really adept at robotic surgery. OR nurses should do their own reading and research to improve their skills and shorten the learning curve.”

Christopher Schabowsky, PhD, Senior Project Officer in ECRI Institute’s Health Devices division, says that OR nurse proficiency in robotic surgery is less about the number of surgeries they’ve been involved in and more about how quickly nurses pick up on the specialized skills and responsibilities required. “Some nurses who are more technologically savvy pick it up quickly after just a few procedures, while others need to participate in many procedures before they master their role. But I don’t think you can judge competency based on a surgery count.”

DEDICATED ROBOTIC SURGERY TEAMS

According to Eichel, most facilities have created teams of OR nurses that specialize in robotic surgeries. “It’s a very specialized technology, so creating teams with dedicated skills helps streamline the process and results in less variability, more efficiency and more safety.”

Due to the need for dedicated robotic surgery teams, Horvath says robotics can create scheduling challenges for OR managers. “The times of day set aside for robotic surgeries in the hospital may be limited, so you need to have your team ready. There are also issues that have to be planned for, such as the OR footprint, workflow, spacing and OR setup time, which tends to be longer.

“Also, robotic surgeries will usually take longer, at least initially until everyone is comfortable in their roles. But this tends to plateau and may eventually approach the time required for traditional open and laparoscopic surgeries.”

As robotics continue to branch out into more surgical specialties, there will be more demand for nurses with these specialized skill sets, which could create lots of new career opportunities. “I believe that OR nurses should strive to learn about and gain proficiency in robotic surgery,” says Dr. Eichel. “It’s going to become a bigger part of OR nursing in the future.”