Rapid undocking protocol for the da Vinci surgical robot during emergency situations

Sir,

Time is the key factor in crisis situations. Limited access to the patient, a hallmark of robotic surgery, can delay the commencement of effective measures to handle potentially fatal emergency.[1,2] To improve robotic crises management undocking drills on simulators in accordance with well-framed emergency-undocking protocols, enhance the performance, knowledge and confidence of the entire operation theatre (OT) team during emergency situations.[3,4] A skill session on emergency undocking should be incorporated into the training programme of robotic surgery, and both surgeons and anaesthesiologists be aware of it. Based on the cause of emergency, there may be four different end points of emergency undocking [Figure 1]. An anaesthesiologist plays a lead role in emergency undocking situations like airway complications, cardiac arrest and bradycardia (e.g., during capnoperitoneum creation), anaphylaxis and code red (fire). Airway complications are more common with trans oral robotic surgeries (TORS) where hyperextension of neck may result in displacement of endotracheal tube (ETT) or use of laser may be associated with airway fire leading to cuff ablation (real risk of aspiration of regurgitant stomach contents or surgical debris since placement of a nasogastric tube and oral pack are avoided intraoperatively to facilitate TORS).

Figure 1.

Start and end points of emergency undocking. (Colour coded as red/yellow/green in decreasing order of their time sensitivity. Red: Emergencies primarily managed by the anaesthesiologist. Yellow: Emergencies primarily managed by surgeons. Green: Emergencies primarily managed by OT technical staff. Redocking if robotic malfunction is corrected)

Surgeon at console leads the OT team in emergency scenarios like robotic malfunctioning, technical issues, massive surgical emphysema[5] and uncontrolled haemorrhage. Regular simulation drills as per institutional protocols reduce time to access the patient (undocking time), improve knowledge of predefined critical actions with delineation of OT personnel roles and boost confidence of the entire OT team in emergency undocking. Training sessions should be conducted in situ in the robotic OT with the robotic patient cart coupled with a mannequin/hollow training torso. Confidence, knowledge and performance of participants are initially assessed in the formative simulation. This is followed by a review session with didactic lectures and supply of reading material. The final (summative) simulation session again evaluates the performance, confidence and knowledge (multiple choice question based) and ends with participants filling up feedback forms. The entire OT team (anaesthesiologists, console and assistant surgeons, scrub and circulating nurses, OT technicians) must be fully aware of the trigger word ‘Emergency undock’ and their specific role in emergency undocking.[3,4] Only the console surgeon (surgical emergency) or the primary anaesthetist (airway emergency/cardiac arrest) is allowed to utter the trigger word which triggers the protocolized undocking cascade into motion.

Clear closed-loop communication between all members of the robotic surgery team is essential. One such institutional protocol practised at our tertiary-care oncology centre is delineated here for ready reference in times of emergency [Figure 2].

Figure 2.

Role clarity for OT personnel following crisis during robotic surgery. (mainly sequential but occurring in tandem wherever possible)

Routine undocking after robotic surgery (RALP, RRH, robotic oesophagectomy, etc.) takes 2–3 mins in a high-output centre like ours. Emergency undocking is a time-sensitive procedure and needs to be accomplished within one minute or less. Newer versions of the robot would need less time to undock.

Emergency protocols enable prompt and effective responses to emergency situations, potentially minimizing medical errors, reducing the chances of injury, promoting patient safety and enhancing patient outcomes.[6]

There may be inter-individual variability in response of medical practitioners towards an emergency situation because of their varied educational backgrounds, training and experiences. By standardizing patient care, protocols help us overcome such situations, and best care practice can be established.[6] We were faced with situations necessitating emergency undocking on three occasions, severe surgical emphysema[5]; inferior vena cava rent; arterial bleeder (causing uncontrolled haemorrhage), and have been able to reduce our emergency undocking time from 3 min in the first case (index case which prompted us to formulate and practise protocolized mock-drills for undocking) to 40 seconds in the third case.

Crisis situations during robotic surgery are unique. While ‘immediate intervention’ is the key factor affecting the overall outcome, robotic emergency situations have likelihood of ‘delayed intervention’ as the patient is almost ‘enveloped’ by the robotic arms and is not readily accessible.

Thus, the first and foremost task is rapid access of the patient to enable immediate intervention for managing the crisis. The protocol stated above should be rehearsed regularly to prevent uncalled for delays and ensure role clarity of the involved personnel.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.