The crucial role of the single assistant in four arm robotic radical prostatectomy - A video analysis

Abstract

Introduction: This video paper aims to describe the technical aspects, role, and responsibilities of a single surgical assistant for both standard and complicated cases. A review of the literature yields descriptions of surgical technique and case series using three or four arm systems with two assistants, but no characterisations of the procedure employing only one assistant. We aimed to create an instructional video demonstrating some of the key manoeuvres required for the procedure. By utilising multimedia, we aimed to improve the educational value and accessibility of the paper. Patients and Methods: Multiple robotic radical prostatectomies were observed and analysed. Critical roles were identified in consultation with both the operating surgeon and assistants. All operative footage was externally recorded. An external HD video camera and a head mounted HD camera were used to record the assistant. Recordings of past cases were examined retrospectively for further footage. Patient consent was obtained for all cases. Results: Pre-operatively, the assistant is integral for patient preparation including positioning, robot docking, and port insertion. Assistance during this time is crucial for patient safety, ergonomic and operative efficiency. Specifics and video are provided. Intra-operatively, the assistant's role is multifactorial. The assistant requires an intimate awareness of the surgeon's field of view as well as the patient's anatomy in order to avoid obstruction of the camera, instrumental hindrance, and to avoid damage during blind insertion and removal of instruments. Proficiency at instrument changes and troubleshooting is also important. Techniques in both complicated and uncomplicated patients are discussed with accompanying video. During analysis, the importance of the role of non-verbal communication became apparent. Two-way gesture based communications between the surgeon and assistant demonstrate areas of bleeding, desired direction of retraction, and clip placement. Sympathetic and anticipatory assistance is required. A competent assistant also provides an added layer of security as a second set of eyes monitoring potential problems and equipment settings. Conclusions: The single assistant in four arm robotic prostatectomy plays a crucial role for operative safety and efficiency. Non-verbal communication is also a central component for experienced teams. We believe that video analysis represents a useful training tool and that careful attention to the role of the assistant helps to minimise operative time and potential complications.