Medical Robotics: The Impact On Perioperative Nursing Practice Paula Francis Howard N. Winfield M edical robotics is revolutionizing med- ical care both inside and outside operat- ing rooms. The field of surgery has not seen such innovation since the first laparoscopic chole- cystectomy procedure was per- formed in 1985 (Reynolds, 2001). The market for minimally inva- sive surgery (MIS) procedures has been driven steadily higher by technological advances that have enabled physicians to provide surgical patients with numerous benefits including improved postoperative comfort and decreased pain, better cosmesis and quality of life, faster recov- ery, decreased hospital stay, quicker return to activities of daily living, fewer complica- tions, and reduced cost (Hanly et al., 2004; Lanfranco, Castellanos, Desai, & Meyers, 2004; Mack, 2001). Medical robotics is used to enhance the performance of physicians during minimally Robotic technology and the increased use of minimally invasive surgery approaches is altering the environment in which operating room personnel work and affecting how nurses must care for patients. An understanding of the history of robotics, current appli- cations of the technology, and perioperative nursing responsibilities is needed to assure quality patient care in the wake of continued advances in technology. Paula Francis, BSN, RN, CNOR, CCRC, is a Nurse Clinician-Specialist, Robotics Department of Nursing, Perioperative Division, The University of Iowa Hospitals and Clinics, University of Iowa, Iowa City, IA. Howard N. Winfield, MD, FRCS, is a Professor, Department of Urology, and Director, Laparoscopy/Minimally Invasive Surgery, The University of Iowa Hospitals and Clinics, University of Iowa, Iowa City, IA. Note: CE Objectives and Evaluation Form appear on page 109. invasive procedures (Taylor, Lavallee, Burdea, & Mosges, 1996). The number of procedures performed each year with robotic assistance is growing, as well as the number of surgical special- ties using robotics (Chandra & Frank, 2003). The nursing care that patients require has been affected by procedures being performed with a minimally invasive approach. For example, patient education strategies have been revised to do more teaching pre- operatively, since patients are no longer hospitalized for 3 to 7 days postoperatively. Likewise, the creation of freestanding ambulatory surgical centers has helped shift the focus of nursing activities from inpatient to outpa- tient care. MIS has also impacted the nursing role by increasing the amount and complexity of tech- nology support the operating room nurse must provide for these cases. Thus, it is important that nurses seek opportunities to educate themselves about this technology, assess its impact, and determine how to best care for patients in the future. This article contains a brief history of med- ical robotics, some background on reasons for robotic technology use, and the perioperative aspects of caring for patients undergoing robotically assisted surgery. Medical Robotic History Industrial robots evolved throughout the 20th century, and entered mainstream American life in 1961 when they were installed in the first automobile manufacturing line at a General Motors factory (ROVer Ranch, 2005). Medical robotic systems were slower to develop in a com- mercial capacity due to financial constraints (see Table 1). Some of the first medical applications for robotic technology to be investi- gated were in the fields of neuro- surgery and orthopedics (Falcone & Goldberg, 2003; Gerhardus, 2003; Nathoo, Pesek, & Barnett, 2003). Robotics entered the field of urology in the late 1980s with the application of a robotic arm, nick-named PUMA 560, for transurethral resection of the prostate (TURP) (Lanfranco et al., 2004). This early medical robot was approved for a limited clini- cal trial in humans (Satava, 2002; Taylor et al., 1996). It did not become a treatment of choice for TURP due to poor ultrasound UROLOGIC NURSING / April 2006 / Volume 26 Number 2 99 C O N T I N U I N G E D U C A T I O N
Transcript
Medical Robotics: The Impact On Perioperative Nursing PracticePaula FrancisHoward N. Winfield
Medical robotics isrevolutionizing med-ical care both insideand outside operat-
ing rooms. The field of surgeryhas not seen such innovationsince the first laparoscopic chole-cystectomy procedure was per-formed in 1985 (Reynolds, 2001).The market for minimally inva-sive surgery (MIS) procedures hasbeen driven steadily higher bytechnological advances that haveenabled physicians to providesurgical patients with numerousbenefits including improvedpostoperative comfort anddecreased pain, better cosmesisand quality of life, faster recov-ery, decreased hospital stay,quicker return to activities ofdaily living, fewer complica-tions, and reduced cost (Hanly etal., 2004; Lanfranco, Castellanos,Desai, & Meyers, 2004; Mack,2001).
Medical robotics is used toenhance the performance ofphysicians during minimally
Robotic technology and the increased use of minimally invasivesurgery approaches is altering the environment in which operatingroom personnel work and affecting how nurses must care forpatients. An understanding of the history of robotics, current appli-cations of the technology, and perioperative nursing responsibilitiesis needed to assure quality patient care in the wake of continuedadvances in technology.
Paula Francis, BSN, RN, CNOR,CCRC, is a Nurse Clinician-Specialist,Robotics Department of Nursing,Perioperative Division, The Universityof Iowa Hospitals and Clinics,University of Iowa, Iowa City, IA.
Howard N. Winfield, MD, FRCS, is aProfessor, Department of Urology, andDirector, Laparoscopy/MinimallyInvasive Surgery, The University ofIowa Hospitals and Clinics, Universityof Iowa, Iowa City, IA.
Note: CE Objectives and EvaluationForm appear on page 109.
invasive procedures (Taylor,Lavallee, Burdea, & Mosges,1996). The number of proceduresperformed each year with roboticassistance is growing, as well asthe number of surgical special-ties using robotics (Chandra &Frank, 2003).
The nursing care thatpatients require has been affectedby procedures being performedwith a minimally invasiveapproach. For example, patienteducation strategies have beenrevised to do more teaching pre-operatively, since patients are nolonger hospitalized for 3 to 7days postoperatively. Likewise,the creation of freestandingambulatory surgical centers hashelped shift the focus of nursingactivities from inpatient to outpa-tient care. MIS has also impactedthe nursing role by increasing theamount and complexity of tech-nology support the operatingroom nurse must provide forthese cases. Thus, it is importantthat nurses seek opportunities toeducate themselves about thistechnology, assess its impact, anddetermine how to best care forpatients in the future. This articlecontains a brief history of med-ical robotics, some backgroundon reasons for robotic technology
use, and the perioperativeaspects of caring for patientsundergoing robotically assistedsurgery.
Medical Robotic HistoryIndustrial robots evolved
throughout the 20th century, andentered mainstream Americanlife in 1961 when they wereinstalled in the first automobilemanufacturing line at a GeneralMotors factory (ROVer Ranch,2005). Medical robotic systemswere slower to develop in a com-mercial capacity due to financialconstraints (see Table 1). Some ofthe first medical applications forrobotic technology to be investi-gated were in the fields of neuro-surgery and orthopedics (Falcone& Goldberg, 2003; Gerhardus,2003; Nathoo, Pesek, & Barnett,2003).
Robotics entered the field ofurology in the late 1980s with theapplication of a robotic arm,nick-named PUMA 560, fortransurethral resection of theprostate (TURP) (Lanfranco et al.,2004). This early medical robotwas approved for a limited clini-cal trial in humans (Satava, 2002;Taylor et al., 1996). It did notbecome a treatment of choice forTURP due to poor ultrasound
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imaging capabilities of theprostate (Allaf, Patriciu, Mazilu,Kavoussi, & Stoianovici, 2004).
The next application forrobotics in urology was in assist-ing the urologist with intra-oper-ative percutaneous renal access.Many attempts to develop a high-ly precise, mechanical method ofpercutaneous renal access haveled to a robotic surgical systemthat has been modified severaltimes, but has now demonstratedan 87% accuracy rate in gainingrenal access (Allaf et al., 2004;Kim & Schulam, 2004). Anextended clinical trial of therobotic system demonstratedrates for the number of attempts,and time to renal access, whichwere comparable to the standardtechnique (Allaf et al., 2004).Further development and contin-ued clinical trials are necessaryto duplicate results demonstrat-ing that this robotic surgical sys-tem can produce results compa-rable or better than the standardmethod of renal access (Allaf etal., 2004).
Through the mid to late 1980s,scientists at the National Aeronauticsand Space Administration (NASA)-Ames Research Center were workingon development of virtual realityand telemedicine technology(Satava, 2003). Virtual reality isdefined as “the simulation of areal or imagined environmentthat can be experienced visuallyin the three dimensions of width,height, and depth and that mayadditionally provide an interac-tive experience visually in fullreal-time motion with sound andpossibly with tactile and otherforms of feedback” (VirtualReality, 2005). Telemedicine isthe concept of a physician moni-toring, diagnosing, and treating apatient without physically beingin the patient’s presence. Virtualreality technology connects thephysician with the environmentthe patient is in, and allowing thephysician the illusion of beingpresent in this other environ-ment, referred to as telepresence.Once telepresence has beenachieved, medical robotics then
allows the physician to manipu-late the environment in whichthe patient exists without physi-cally being present in that envi-ronment. Thus medical robotictechnology is the key element intelemedicine that enables aphysician to treat a patient with-out being physically present.
The NASA group teamed upwith mechanical engineers work-ing on robotics from StanfordResearch Institute (SRI) to createtelemedicine technology thatallowed manipulation of thepatient (Satava, 2003). A generalsurgery endoscopist (Richard M.Satava, MD), who was workingfor the United States Army, wasintroduced to the NASA and SRIteams after meeting one of theSRI team members at a confer-ence. Dr. Satava made the U.S.Army aware of the NASA-SRIproject, and its potential benefitsfor telemedicine on the battle-field (Satava, 2003). Realizing thepossible applications of medicalrobotics and telemedicine, theU.S. Army directed a largeamount of funding for researchand development of medicalrobotic technology (Satava,2003).
In 1989, Yulun Wang, PhD, agraduate engineer and acquain-tance of Dr. Satava, founded hisown medical robotics companywith funding from the U.S. gov-ernment and private industry. Hiscompany, Computer Motion, Inc.®,launched AESOP® (AutomatedEndoscopic System for OptimalPositioning), a robotic telescopemanipulator, and the robotic surgi-cal system ZEUS® (Marescaux &Rubino, 2003; Satava, 2003).AESOP was FDA approved foruse in 1994, and is currently mar-keted in the United States(Marescaux & Rubino, 2003).Computer Motion, Inc. receivedFDA approval to market ZEUS in2001 (Marescaux & Rubino,2003).
In 1995, another physicianwith a keen business sense sawthe commercial value of the
Table 1.Abbreviated Time Line of Medical Robotic Development
1921 Playwright (Karel Capek) describes robots as “dumb”machines for repetitive work in Rossum’s Universal Robots
1946 Computer development arises
1950-60s Development of industrial robots
1961 First industrial robot in use at GM automobile factory inNew Jersey, called Unimate
1985 First laparoscopic surgery performed (cholecystectomy)
1980s Puma 560 arm used for transurethral resection of theprostate
1980s Robotic arm assisted with intraoperative percutaneousrenal access
Late1980s Stanford Research Institute working on robotics and telemanipulation
1989 Computer Motion Inc. formed (AESOP™) Robotic armdesigned to manipulate endoscope and camera during surgical procedure developed
1995 Intuitive Surgical Inc. formed
2003 Computer Motion Inc. and Intuitive Surgical Inc. merge
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type of open procedure (see Table3).
The first limitation of MIS isthe loss of three-dimensionalvision of the human eye.Traditional laparoscopic camerasystems provide surgeons withonly two-dimensional vision.Robotic camera systems bondtwo telescopes and two cameraheads together, side-by-side, andincorporate a synchronizer intothe system (Marescaux & Rubino,2003). This creates a right andleft “eye,” which provides theprimary operating surgeon with athree-dimensional view. Anothermethod of providing a three-dimensional view is to place theoperative image on a shutterscreen, or on two monitors incor-porated into a headset or glassesthat the operative surgeon wears(Boehm, Detter, Arnold, Deuse, &Reichenspurner, 2003). This pro-vides a much better view thanthat of the two-dimensional tra-
ditional laparoscopic/throaco-scopic cameras, by providingdepth perception.
The second limitation of MISis awkward ergonomics. Surgeonsare required to stand, holding longinstruments, in uncomfortablepositions. Medical robotics al-lows the primary operating sur-geon to sit while operating, andprovides armrests. This greatlyimproves the primary operatingsurgeon’s ergonomics, and thuscomfort (Stylopoulos & Rattner,2003). Medical robotics improvesthe surgeon’s ergonomics evenfurther, by creating a computerinterface between the surgeon’shands and the instrument tips.This translates the natural/intu-itive movement of the surgeon’shands into the desired movementof the robotic instrument,bypassing the handle and shaft ofthe laparoscopic instrument(Stylopoulos & Rattner, 2003).
Robotic technology provides
emerging robotic technology.Frederic H. Moll, MD, acquiredthe license to the telepresencerobotic surgical system devel-oped by the NASA-SRI teams,and started a company calledIntuitive Surgical Inc.® (IntuitiveSurgical Inc., 2005; Satava,2003). Intuitive Surgical Inc.used the telepresence robotictechnology pioneered by theNASA-SRI team to develop amaster-slave telepresence roboticsurgical system they nameddaVinci®.
There are currently two robot-ic surgical systems approved formarketing in the United States forlaparoscopic and thoracoscopicsurgery: daVinci and ZEUS.Intuitive Surgical Inc. owns rightsto both of them, after mergingwith Computer Motion, Inc. inJune of 2003 (Intuitive SurgicalInc., 2005; Kim & Schulam,2004). The merger also gave therights to AESOP to IntuitiveSurgical Inc. The daVinci roboticsurgical system has beenapproved for use in adult andpediatric urologic surgical proce-dures, general laparoscopic sur-gical procedures, gynecologiclaparoscopic surgical proce-dures, general non-cardiovascu-lar thoracoscopic surgical proce-dures, and thoracoscopicallyassisted cardiotomy procedures(Intuitive Surgical Inc., 2005).The ZEUS surgical system isbeing supported by IntuitiveSurgical Inc., but not activelymarketed (see Table 2).
Robotic Technology’sImprovement to MinimallyInvasive Surgery
The benefits of MIS, as dis-cussed earlier, for both thepatient and the medical insur-ance providers are well docu-mented (Hanly et al., 2004;Lanfranco et al., 2004). However,minimally invasive surgery haslimitations that are obstacles sur-geons must overcome. Thesesame limitations prevent a mini-mally invasive approach to every
Sources: UIHC, Cornell University (www.cornellurology.com/uro/cornell/roboticprostatectomy), Cooper University (www.cooperhealth.org/con-tent/minsurg_abdominal.asp), University of Southern California (www.cts.usc.edu/rsi-article-surgicalfirstwithroboticassistance.html), and IntuitiveSurgical Inc. (www.intusurg.com)
Genitourinary Radical prostatectomy, pyeloplasty, cystectomy,radical and partial nephrectomy
Gastrointestinal Cholecystectomy, colectomy, and other bowelprocedures; gastric bypass; Nissen fundoplica-tion; Heller myotomy; cyst and tumor excisions
Cardiovascular Mitral valve repair, epicardial lead placement,internal mammary artery harvest, and coronaryartery bypass grafting
Endocrine Thymectomy, adrenalectomy, cyst and tumorexcisions
Lymphatic Spleenectomy, cyst and tumorexcisions
Pulmonary Cyst and tumor excisions
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the means to overcome many ofthe limitations of MIS, while alsoproviding improved dexterity forsurgeons as well. This is accom-plished in four ways. First, therobotic instruments themselveshave five to seven degrees of free-dom of movement compared tothe four degrees of freedom ofmovement in traditional laparo-scopic instruments (Ballantyne &Moll, 2003; Boehm et al., 2003).Second, the computer in therobot eliminates the fulcrum
effect, which in traditionallaparoscopic/thoracoscopicsurgery creates the need for thesurgeon to move his/her hand inthe opposite direction in whichthe tip of the instrument isintended to go. As mentionedpreviously, the computer createsan interface that bypasses thelaparoscopic/thoracoscopicinstrument handle and shaft, andtranslates the natural movementsa surgeon’s hands make to theinstrument tips, with corrections
for the fulcrum effect. Third, therobotic computer is also pro-grammed to filter out the physio-logic tremor in the human hand,which can be greatly magnifiedat the end of a very long instru-ment. Finally, robotic computersallow the surgeon to choose toscale, either up or down, the ratioof the size of the movement of hisor her hands to the movement atthe instrument tips (Ballantyne &Moll, 2003).
All of these capabilities make
Source: Adapted from Lanfranco et al., 2004
Table 3.MIS vs. Robotic Advantages and Disadvantages
MIS Advantages MIS Disadvantages Robotic Advantages Robotic Disadvantages
2-D visualization only 3-D visualization
Poor ergonomics for sur-geon (craning head to seeTV and hold long instru-ments)
Improved ergonomics:Surgeon sits, arm rest, surgical movements areintuitive
Enables some tactile feedback
No tactile feedback
Compromised dexterity:Fulcrum effect, magnifica-tion of tremors, only fourdegrees of freedom ofmovement
Improved dexterity: 7degrees of freedom ofmovement, fulcrum effecteliminated, physiologictremors eliminated
Sufficient number of casesto train surgeons and sup-port staff
Insufficient number ofcases to train residentsand support staff
Many operating roomsincorporating MIS needsinto design
Large size of systems
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Every health care professionalinvolved in the utilization of arobotic surgical system has thepotential, through human error,to cause an unwanted outcome.The chance of this happeningcan be greatly reduced by provid-ing education and training to allpersonnel involved in operating,setting up, and maintaining arobotic surgical system (seeFigure 1).
PERIOPERATIVE CARE OFROBOTIC SURGERY
PATIENTS
Pre-Operative Care Pre-operative care of the
robotic surgical patient popula-tion differs only slightly from pre-operative care of the non-roboticMIS patient population (laparo-scopic/thoracoscopic surgery).Pre-operative care instructionsshould be given in writing, andreviewed with the patient verbally(Alexander, 1999; Davison, Moore,MacMillan, Bisaillon, & Wiens,2004; Lithner & Zilling, 2000).Attention should be given to con-sistency between the written andverbal instructions (Otte, 1996),and identification of any patientswho do not have literacy skillsadequate to comprehending thewritten material (Alexander,
1999). For all patients undergo-ing MIS, regardless if it is roboticor not, the same pre-operativefunctions of assessment, plan-ning, implementation, and evalu-ation are carried out. Thepatient’s level of anxiety or fearshould be assessed. Additionally,pre-operative teaching contentshould be adjusted to addressany issues associated with thepatient’s attitudes and feelingsrelated to the MIS procedure andits outcome (Hathaway, 1986). Ifthe nurse is able to lessen thepatient’s level of anxiety or fearthrough discussion of theseissues, or having misconceptionscorrected, there will be a higherretention level of material onspecifics of postoperative careand medications. The overallcontent of the educational pro-gram does not need to be alteredfor patients, but modifying theorder of things presented, or thetime they are presented for eachpatient, may create a better learn-ing environment (Hathaway,1986).
Patients undergoing roboti-cally assisted procedures havethe same need for education onwhat to expect postoperativelyfor pain, activity level, possiblecomplications, and care of theirsurgical site. They also have
medical robotics ideal for MISprocedures that require very fineor difficult dissection, intracor-poreal suturing, high magnifica-tion, or surgery on small infantsor children. Thus, robotic surgi-cal systems are valuable in assist-ing surgeons in performing manyMIS procedures with greaterease. It also enables a surgeon toperform MIS procedures thatmay be too difficult to performwith a traditional laparoscopic/thoracoscopic approach (Tooher& Pham, 2004).
The daVinci surgical systemwas intentionally built toimmerse the surgeon in the oper-ative field by using a viewer forthe surgeon that is the same aslooking through a microscope(Ballantyne & Moll, 2003). Thesurgeon can hear what is occur-ring in the operating room, butmust remove his or her face fromthe viewer to see what is occur-ring in the operating room. TheZeus system places the surgicalview in front of the operating sur-geon as if it were a televisionshow. The surgeon can also seewhat is occurring in the operat-ing room by turning his/herattention from the screen.
Both the daVinci and ZEUSsurgical systems are referred to as“master-slave” systems (Ballantyne& Moll, 2003; Boehm et al., 2003;Lanfranco et al., 2004). Thisrefers to the principle that therobotic surgical system is depen-dant on human motion directedinto it through some type ofinterface such as a joystick ormouse so as to generate anymovement of the robotic armsand instruments. The robot com-puter itself does not generate anymovements. These systems arereally just an extension of a sur-geon’s hands and fingers.
This should not, however,lull medical professionals or theconsumer into a false sense ofsecurity. These systems requirehighly trained personnel to oper-ate, setup, and maintain (Connor,Reinbolt, & Handley, 2001).
Figure 1.Robotic Surgical System
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questions about the robotic pro-cedure and surgical system.Currently the only availablepatient education materials relat-ed to robotic surgical proceduresare generic resources from themanufacturers. Robotic surgeryis being talked about in themedia in relation to its cutting-edge technology. However, verylittle is actually being circulatedto educate the layperson on howmedical robotic systems func-tion, and what role they play inhealth care. Clearly moredetailed information for patientsis needed to ensure their under-standing of this treatment option,and to facilitate their decisionmaking.
The word robot can conjureup images of Star Wars’ C3PO, orthe more recent movie, I Robot. Itcan be very intimidating topatients to think they are givingup control of their medical careto a machine. For this reason it isimportant for them to understandthe master-slave relationship ofthe robotic surgical system to thesurgeon. Emphasis should beplaced on the fact that the robot-ic surgical system is a tool usedby the surgeon to performsurgery, and not a medical devicethat is preprogrammed or acts onits own. It is also important forthe patient to understand the rea-sons for the use of this technology(see the previous section: RoboticTechnology’s Improvement toMinimally Invasive Surgery), andappreciate that the surgeon feelsusing the robotic surgical systemin their case is beneficial.
Intra-Operative CareIntra-operative nursing func-
tions are affected the most bymedical robotic technology.Nursing personnel must knowhow to properly connect, cali-brate, and setup the equipmentpieces of the surgical robotic sys-tem. They must also be familiarwith the robotic instrumentationneeds for each type of procedure,including how to properly load,
handle, and clean these special-ized instruments. The nursingpersonnel should also under-stand the robotic system wellenough to know how to trou-bleshoot problems for the primary/non-sterile operative surgeon at therobotic surgical system and thesurgeon at the patient’s side. Thepatient-side surgeon assists theprimary/non-sterile operativesurgeon by exchanging sterileinstruments, retracting patienttissues, and manipulating non-robotic sterile instruments usedto assist the procedure.
The ability of the nursingpersonnel to interpret and reactto messages displayed on therobotic television monitor is crit-ically important to the flow andsuccess of the procedure, andallows the surgeons to focus fullyon the surgical procedure. It issometimes necessary to abort arobotic MIS procedure for rea-sons of bleeding, unexpectedanatomical findings at the time ofsurgery, or a surgeon’s decisionthat the patient’s anatomy is notbest accessed by MIS. For thesereasons nursing personnel in theoperating room must also befamiliar with emergency proce-dures for removing the roboticsystem from the patient’s side,and assembling the necessaryequipment, instruments, andsupplies in order to move to theequivalent laparoscopic or openprocedure.
Assigning one additionalstaff member to the case efficient-ly facilitates introducing a robot-ic surgical system into an operat-ing room. This provides the nec-essary person to move, setup,and monitor the robotic system;while allowing the other twostaff members to focus on thepatient, and the sterile instru-ment setup. Once staff membersare trained and familiar with pro-cedures it is possible to performrobotic procedures with two staffmembers, depending on wherethe robotic surgical system isstored, and how much time and
assistance they are given to setprocedures up.
Postoperative Care Postoperatively, patients un-
dergoing robotically assisted sur-gery need to be treated with thesame standards and care thatpatients undergoing the same non-robotic minimally invasive proce-dure would receive. Postoperativecare should be tailored to thepatient’s specific expected surgicaloutcomes.
However, hospital stays maybe shortened for patients under-going robotically assisted proce-dures when compared to openprocedures. Earlier postoperativedischarge decreases the amountof time there is for patient educa-tion, and increases the responsi-bility perioperative nurses havein patient education (Fox, 1998).Shorter postoperative hospitalstays also necessitate changes inthe content, method, and timingof postoperative patient educa-tion.
Patient education contentmust change to include materialnecessary for care of the patientat home during the first 3 dayspostoperatively. Earlier postoper-ative discharge places an addi-tional responsibility directly onthe patient and/or their homecare attendant for care relating torecovery from anesthetic agents,recovery of full gastrointestinaland urological function, andmanagement of postoperativepain, complications, and activitylevel appropriate for the first 48hours postoperatively (Fox,1998; Marley & Swanson, 2001).For patients, “recovery” isdefined as the return to a pre-operative level of performingactivities of daily living(Kleinbeck & Hoffart, 1994). It isestimated that 60% or more ofoutpatients required 3 daysbefore they were able to return totheir pre-operative level of activ-ities of daily living (Philip, 1992).Discharging patients on postop-erative day 1 or 2 makes it criti-
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cally important that periopera-tive nurses ensure that patientsunderstand how to transitionback to their pre-operativelifestyles.
Patients can become over-whelmed with the amount ofmaterial being presented to themin a shortened time span, espe-cially when their level of func-tioning is compromised fromanesthesia, pain medications,and stress. This makes it evenmore important to assess the edu-cational needs of each patient,and his/her ability at any specifictime to assimilate and compre-hend new information. A patientexperiencing postoperative nau-sea/vomiting is ready and may beable to learn techniques for cop-ing with, and reducing nausea/vomiting, but is not preparedand/or interested in learninghow to care for his or her incisionsite(s).
Providing postoperative careinstructions in written form andallowing for adequate time forpatient review give patients timeto formulate questions andenhances understanding of thecontent (Lithner & Zilling, 2000).Any written educational materialmust also be followed up by spe-cific verbal instructions, in non-medical terms, that are consis-tent with the written material(Alexander, 1999; Fox, 1998;Lithner & Zilling, 2000).Presenting verbal instructionscreates an opportunity forpatients to ask questions. Theverbal educational sessionshould also be used to assess thepatient’s literacy level, andunderstanding of the writtenmaterial (Alexander, 1999).
Future Direction of MedicalRobotics
Medical robotic surgical sys-tems certainly will not be usedfor every type of surgical proce-dure, or on every patient. Theextra cost of the system, instru-ments, disposable supplies, andpersonnel costs necessitate that
medical robotic applications becarefully evaluated with respectto patient outcomes. Currentmedical robotic users are devel-oping their skills, and searchingfor surgical procedures that haveincreased patient benefits suchas increased surgical accuracy,decreased operating times, short-er hospital stays, and fewer com-plication rates when compared tothe standard current surgicalapproaches.
Medical robotics is a growingand developing technology thatwill undergo many changes as itsuse evolves and is refined. Manyinstitutions are currently attempt-ing to add a “fourth arm” to theirrobotic surgical systems. In addi-tion to the two robotic arms thathold and manipulate the surgicalinstruments that perform surgery,and a third robotic arm that holdsand manipulates the telescope/camera that provides for visual-ization inside the patient, thisfourth arm would provide theoperating surgeon with a thirdarm which can hold an instru-ment to retract patient tissues ora suture. This provides the oper-ating surgeon with more flexibil-ity in maneuvering patient tis-sues to access the surgical site,without depending on the assis-tance of the patient-side surgeon;and it enables the operating sur-geon more accuracy in retracting,and can also sometimes decreaseoperating times.
In the future, two surgeonswill be able to control roboticarms on the same system, andswap with each other what armthey control. This will allow theassistant surgeon the same three-dimensional view and sevendegrees of freedom of movementto the operating instrumentsbeing used (Ballantyne & Moll,2003). Also, training simulatorsusing virtual reality technologywill be available to enable thesurgeon to develop basic skillsfor use with robotic surgical sys-tems, as well as practice a certainprocedure on a computer-gener-
ated image of a particularpatient’s anatomy before actuallyperforming the procedure in theoperating room (Ballantyne &Moll, 2003; Lemke et al., 2002).
Development of a three-dimensional capable “imageshift” endoscope is underway.This endoscope system willallow a surgeon to go from a mag-nified view of specific anatomy,to a wide-angle view of the wholesurgical field, without movingthe telescope (Lemke et al.,2002). It will also increasepatient safety by enabling thesurgeon to easily and quicklyvisualize the whole surgicalfield, while maintaining a moreaccurate ability for the surgeon tovisualize specific anatomy betterthan with the human eye.Additionally, the development ofhaptic and force feedback tech-nology will allow surgeons toexperience tactile and pressuresensation feedback in theirhands, which is not possiblewith robotic surgical systemscurrently in use (Lemke et al.,2002).
Finally, the U.S. military hasdesigned and field tested a newtransport system called LifeSupport for Trauma andTransport (LSTAT) (Hudson &Grimes, 2002). LSTAT is essen-tially a mobile intensive caremonitoring system incorporatedinto a transport bed that is beingtested for use on a battlefield.Commercial applications may befound for this system in thefuture, in high-tech operatingrooms where the patient isplaced on an LSTAT at the begin-ning of his hospital stay, andtravel from the operating room torecovery or an intensive care uniton the same bed (Satava, 2002;2003).
Adapting to New TechnologyRobotics is entering the med-
ical world in more areas than theoperating room. Robots areinvading pharmacies, chart con-trol, and certain aspects of home
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care nursing (Sussman, 2000). Itis important for nurses toembrace this technology, and useit to clarify nursing functions.Failure to recognize the impact ofthis technology on nursing prac-tice will compromise the chanceto guide our future and define therole of nursing in the health caretechnology revolution. However,in utilizing this technology andbecoming masters of it, we cancarve out a new niche for our-selves. As nurses, we can main-tain the patient focus in thishigh-performance, automated,and sometimes cold world oftechnology by focusing on solidnursing principles of assessment,planning, implementation, andevaluation to provide compas-sionate, nurturing care withattention to patient safety.Adhering to the basic tenets ofnursing practice will enable us toretain the human side of caring,but with the advanced knowl-edge necessary to ensure success-ful outcomes from MIS proce-dures. We must work hard toeducate and train ourselves onall the new technology thatenters our workplace, while atthe same time recognizing andseizing the opportunities that lieahead.
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