Emergency Undocking in Robotic Surgery: A Simulation Curriculum

The overall goal of this simulation curriculum is to better prepare robotic surgeons for this potentially life-threatening scenario. This method can help prepare operating room personnel and robotic surgeons for emergency undocking. The main advantage of this technique is that it focuses on team roles for reducing time until intervention can be performed for the patient.

This method can provide insight into proper allocation of resources in an emergency undocking, as well as other operating room emergencies, such as cardiac arrest. Generally, individuals new to this method will struggle because they may have never encountered this scenario. We first had the idea for this curriculum when we discovered learners had a limited knowledge of the emergency undocking process.

Visual demonstration of the undocking steps is critical for long-term retention of the skills. After collecting the materials, use a scalpel to make one incision above the umbilicus and one each in the right and lower left quadrants of a hollow, draining torso large enough to accommodate a laparoscopic instrument trocar. To simulate a vessel and subsequent vessel injury, cut one piece of rubber tubing from a water seal chest drain for the vena cava and one for the descending aorta.

Using Y-connectors, connect two approximately 12-inch pieces of tubing for the right and left common iliac veins, and two approximately 12-inch tubes for the common iliac arteries to the vena cava and aorta. Create a notch at the distal end of the common iliac artery to allow the simulated blood to escape in the case of a vessel injury, and glue the mock vessels against the posterior wall of the torso. Then, protrude the access point to the vessel through the cephalad portion of the torso.

After painting, coat the vessels with a clear enamel spray, and inject red food dye into a one liter bag of IV fluid until the fluid has a color consistent with blood. Then hook the bag to the vessel and place the table in a steep Trendelenburg position. Next, drape the torso with operating room drapes used for laparoscopic surgery or laparotomy, so that the entire table is covered, and place laparoscopic trocars into the training torso through the incisions.

Move the robotic patient side cart to the bedside and attach robotic arms to the trocars. Using the trocars, dock the robotic training instrument and camera to the torso, and direct at least four embedded standardized persons to their appropriate positions around the table according to their roles. Then start up the surgeon console so that it is ready for the surgeon to assume control of the robotic instruments.

When the console is ready, instruct the surgeon to adjust the positional settings of the console without taking control of the instruments. Introduce the embedded standardized persons to the surgeon and read a case stem. At the end of the case orientation, instruct the surgeon to take control of the instruments and have the anesthesia embedded standardized person initiate bleeding from the vessel.

The IV tubing should be wide open, allowing for brisk bleeding. Allow the surgeon up to five minutes to complete the emergency undocking. Then debrief, emphasizing the key points of personnel roles, the key equipment used, including the instrument arms and patient side cart and the use of closed loop communication.

The embedded standardized persons can then be repositioned for a second case to reinforce the lessons learned during the debriefing. After incorporating this training curriculum as just demonstrated, robotic surgeons who completed the curriculum reported an increase in confidence when faced with an emergency undocking, compared to their reported baseline levels of confidence and knowledge about the procedure. Undocking times and critical actions performed out of seven possible measured actions, also improved, likely representing a combination of the robotic surgeon's ability to recognize the need for an emergency undocking sooner and having the opportunity to simulate the entire emergency undocking process in an in situ environment with immediate feedback from content experts.

Once mastered, this curriculum can be completed in under one hour if it is performed properly. While attempting this procedure, it is important to remember to clearly assign the roles using closed loop communication. Following this procedure, other scenarios can be run to further emphasize the learning.

After its development, this technique paved the way for other quality improvement projects within the operating room, including Code Blue drills to maximize patient care. After watching this video, you should have a good understanding of how to perform an emergency undocking of the robot. Don't forget that working with surgical equipment poses an innate risk and that care should always be taken to avoid injury.