Suzannah Sorin, MSPAS, PA-C Robotics Coordinator Physician Assistant Manager NYU Langone Medical Center NARUS February 16, 2018

Transcription

1 TROUBLESHOOTING SCENARIOS- As seen from the assistant Suzannah Sorin, MSPAS, PA-C Robotics Coordinator Physician Assistant Manager NYU Langone Medical Center NARUS February 16, 2018

2 Financial Disclosure J&J Ethicon / Google / Verb - robotics consultant Medtronic - robotics consultant CSATS - independent video reviewer 2

3 What to do when the unexpected happens We have a tendency to want to shut down, be quiet, not make waves That is when it is MOST important to communicate! The console can be a physical barrier and an emotional detachment Talk to the surgeon, so they feel connected to the room and to the patient photo credit: Edvard Munch 3

4 Your Back-up Plan To ensure that your are readily equipped with all of the tools needed to keep your Da Vinci system functioning, you should have a back-up for all of the times listed below: ETHERNET CABLE (Xi/Si) CAMERA CABLE AND CAMERA HEAD DA VINCI Si EMERGENCY INSTRUMENT WRENCH Si/Xi LIGHT GUIDE FOR DA VINCI Si SYSTEM BLUE FIBEROPTIC CABLE (Xi/Si DAVINCI SYSTEM) MONOPOLAR (GREEN CORD) & BIPOLAR (BLUE CORD) CORDS HAVE 100 USES. HAVE SEVERAL OF EACH CORD STERILE PEEL PACKED TO REPLACE IF CORD STOPS WORKING DURING CASE. 4

5 More tips on troubleshooting Work in a stepwise fashion Don t try changing everything all at once Communicate to the rest of the room your steps working though the problem Ongoing updates to the team if the case progresses while you continue to troubleshoot 5

6 SCENARIO #1 You are the assistant nurse and are about to start setting up your first case for the day. You press the power ON button for your dv Xi or Si system and continue to assist your scrub nurse opening supplies for the case. A few moments later you notice that the system has not powered on. What should you do? 6

7 SCENARIO #1 SOLUTIONS Check all components: Surgeon console, patient cart, and vision tower are all plugged into a working outlet. Ensure that the outlets are active and all dv components are on with orange power light and blue light at blue fiberoptic outlet site. Did you know that plugging all components into a single circuit can cause an overload? Try to plug into different circuits. Check the AC power connections Check the circuit breaker switches on all components on the dv system. Make sure the breaker switch is in the I position. On the patient cart make sure that the EPO- emergency power off red button is not depressed If the system is not powering up, you may need to "hard cycle" power system. To hard cycle, turn the breaker switch off (O position) on each dv component and press the EPO switch on the back of the patient cart. Turn off for 10 second and then restart the system 7

8 SCENARIO #2 You are about to dock the patient cart when you notice that you have a lot of resistance to drive the cart forward. You check the cart and notice the small door in front of the cart is open, so you try to close it but the door won't close. What should you do? 8

9 SCENARIO #2 SOLUTIONS Check the red lever and ensure that the lever is not in the manual mode. Turn the lever to the left to the powered steering mode. The handle may not have fully engaged power mode Do not force the door closed if its in manual mode Ensure there are not any cords or anything obstructing the door or the feet under the patient cart. The patient cart weighs 1850 lbs. Refrain from placing cart on sloped surfaces. When powering up the system, don t try to drive the cart or move the arms until the system boot-up sequence is complete. 9

10 SCENARIO #3 You are docking the patient cart and as you drive forward with the patient cart you notice "Error Code 23" appears on the touch screen of the patient cart, seconds later the code changes to "Error 252" and the screen reads "unrecoverable fault". What should you do to fix this? 10

11 SCENARIO #3 SOLUTIONS Check the blue fiberoptic cable connections at the patient cart and the vision tower. It was probably not fully seated into the fiberoptic outlet or it got caught on something and pulled out accidentally Ensure that the blue fiberoptic cable is not damaged (ie. pins bent) If it is compromised, retrieve a new cable. Power system down and restart. Place blue fiberoptic cable back into patient cart, ensuring that it is seated properly with the red indicator facing at the 12 o'clock position. Listen for the audible click once the blue cable is inserted. Give the cable a slight tug to ensure a connection is made. power the system back on. 11

12 SCENARIO #4 You are in the middle of a robotic prostatectomy and the surgeon reports the image is foggy. What should you do? 12

13 SCENARIO #4 SOLUTIONS Wipe tip of scope with a dry gauze. Check for any soiling or smudges Recommended practice is 55 Celcius (130 F) water to clean/heat scope tip. Its recommended to not keep the scope sitting in the warmer longer than 10 seconds or submerged in warmer, which can damage the scope. Remember the chip of the camera is in the tip of the scope Fogging can occur because of a temperature difference between the cold scope tip and the warm body cavity. Or a warmed scope tip that has cold CO2 gas insufflating too close to the scope tip. Ensure the endoscope is beyond the cannula tip Connect insufflation to a non-camera port Recommended practice is to plug in scope at least 30 minutes prior to insertion Its possible that smoke within the cavity may be mistaken for fogginess. Suction out any residual smoke caused by cautery and use smoke evacuator (various types). 13

14 Smoke Evacuator Options: Active evacuation Poor Man Don t attach to your camera port 14

15 Smoke Evacuator Options: active evacuation Suction machine settings Stryker Neptune 15

16 Active smoke evacuation with charcoal filtration 16

17 Smoke Evacuator Options: Passive auto Filtration Pall Laparoshield 17

18 SCOPE WARMER and SURFACTANT 18

19 JUST FOR FUN What are some funny names you use for the scope warmer? Hot hot (why do we say it twice?) Fred Igloo Snail Gary medicalproducts/surgicalandacutecare/ac-surgical/images/ 47_fmt2.jpg Gary_Movie.png/revision/latest?cb=

20 SCENARIO #5 You are about to start a robotic nephrectomy and you notice that as soon as the scope is inserted past the cannula tip, the field of view is dim. 20

21 SCENARIO #5 SOLUTIONS Check the brightness settings. Use the brightness slider on the touchscreen or console touchpad to adjust to the desired level Always check the scope plug to ensure there isn't any water or moisture that could potentially damage the endoscopic controller Remove the scope and examine tip for any debris or damage Place scope into warmer for no longer than 10 seconds and wipe with a dry gauze Check cannula to ensure its not dislodged Change endoscope if the problem persists 21

22 SCENARIO #6 The surgeon is about to start a robotic prostatectomy and the surgeon reports no energy coming from the monopolar scissors. You also notice that the grounding pad is not showing an illuminated lightning bolt sending energy to the instrument. 22

23 SCENARIO #6 SOLUTIONS Its recommended practice to is to turn off the ERBE in between cases. The ERBE is like a computer software if overloaded the system stops working You can power cycle the ERBE without affecting the dv system itself When the grounding pad is not detected, check the grounding pad. Ensure that the long edge of the grounding pad points toward the operating field. If poor contact with the grounding pad due to patient with excessive lotion on skin, wash with a CHG scrub sponge and dry before replacing with a new grounding pad Check the instrument cord for any damage. Check instrument for any damage. May need to replace cord or instrument. Each cord has 100 uses. Ensure the surgeon footplate is deployed Ensure that the arrows on the energy cords are facing upward position and matching the generator 23

24 Disconnected or bad connection Arrows lined up Correct connection 24

25 SCENARIO #7 The surgeon is ready to use the tilepro feature and they activate tilepro on the surgeon console, but it is not working. What should you do? 25

26 SCENARIO #7 SOLUTIONS Connect the s-video, SDI, or DVI cord to the column labeled "Tilepro" on the back of the surgeon console or vision tower Make sure the video cable in connected in the correct column. ie. not in the auxiliary column. Inspect the cord for damage, usually found at the pin sites from excessive pulling or bending If using the dv Si system, once the cord is connected to "video source" on the vision tower. Ensure that the word "Tilepro" is illuminated blue. On the dv Xi system, tap the home button on the vision tower touchscreen and the word "tilepro" should be illuminated white. Check the energy source ie. Ultrasound or laparoscopic tower is turned on. Sometimes connecting the ultrasound pribe before powering on the dv system may not read probe. May need to re-boot the ultrasound and then reconnect the ultrasound probe. It may be helpful to apply color-coded tape the ends of each cord to help find what is connected to each input/output 26

27 Tile-Pro is not connected - greyed out 27

28 Color Code Blue Fiberoptic Cords 28

29 SCENARIO #8 You power on your dv Si system and notice that the vision tower has a flickering image on the screen. You check the surgeon console and notice the same flickering image. What should you do? 29

30 SCENARIO #8 SOLUTIONS Check the brightness settings on the surgeon console and/or the vision tower. If Si system, press the arrow and to "advanced video adjustments" and select "restore factory settings" Confirm that the brightness indicator is not up in the orange area on the touch screen If an Si system, tighten the camera cable on the vision tower and camera head. Make sure there is not yellow seen, you should only see blue If the flickering image persists, you may need to change the camera head cable. 30

31 Si camera cable Yellow visible 31

32 SCENARIO #9 On the dv Si system you have placed the scope into the camera head and inserted the camera into the camera arm. You notice that the image is blurry. Your surgeon complains of blurry vision in the left eye on the surgeon console. What should you do? 32

33 SCENARIO #9 SOLUTIONS Check the endoscope for debris or smudges. Wipe scope and check clarity During the setup, look into the surgeon console to make sure both eyes in view are the same. ie. One eye should not be darker or different from the other Check the blue fiberoptic cable for a bent pin (make sure power is off if going to disconnect it) Rotate the scope 180 degrees. Did the blurred image move to the other eye? If yes, the scope is your culprit; check both ends of the scope and clean if dirty. If its is not dirty or did not move eyes, change the scope. Check the lens of the camera head to see if smudged, dirty, or scratched. Wipe camera head lens with a Q-tip if needed May need to change the camera head 33

34 SCENARIO #10 You are in the middle of a case and the bedside assistant or surgeon reports that the instruments are locked in place while grasping tissue or that tissue will not release from the instrument. The instrument arm will not move. What should you do? 34

35 SCENARIO #10 SOLUTIONS Prepare to use the emergency tool wrench by placing the robot into a fault state- First press the red button. Never use the wrench on a system that's not in a fault state. Wrench should be sterile and readily accessible. Bedside assistant will use the wrench and insert it in the emergency grip release socket, turn counter clockwise to open the jaws of the endowrist instrument. Once instrument is released, check the instrument. May need to be replaced. 35

36 SCENARIO #11 While clutching and advancing the monopolar scissors through the robotic cannula you meet resistance. What should you do? 36

37 SCENARIO #11 SOLUTIONS Check the port. Make sure that the port is fully through the cannula wall at the remote center line If not, use the obturator to replace the port Check the monopolar scissor to ensure it is not bent or compromised. If so, replace the instrument Check the scissor guard protector to ensure that the energy protector is not pushed past the orange safety zone. Adjust the scissor guard or replace the scissor guard as needed Reseat the sterile adaptor. Check if you encounter the same resistance with a different instrument 37

38 cover all orange, but not beyond it 38

39 SCENARIO #12 You are in a robotic assisted cystoprostatectomy with bowel resection for ileal conduit. The surgeon is ready to use the robotic stapler. She clamps the stapler across the small bowel. The closed clamp reads at 75% on the davinici monitor. What should you do? 39

40 SCENARIO #12 SOLUTIONS The stapler should remain clamped in place for seconds and allow the nearby edematous tissue to push away from the staple line. It should then be unclamped and reclamped in the same exact spot. With each successive clamp attempt you should gain progress until it allows a 100% clamp, then it may be fired. This technique works for various thick tissue types: lung resection, small bowel, inflamed large bowel, gastrectomy, pancreatectomy, etc. 40

41 SCENARIO #13 You are in a robotic assisted prostatectomy with the patient in steep trendelenberg position. When the nurse drives the patient cart forward to the bed, the boom on the cart collides with the OR light boom. What should you do? 41

42 SCENARIO #13 SOLUTIONS Unlock and adjust the table position prior to docking. Move it north/south/east/west on the floor as needed. Be sure to lock it again! Adjust the table height down Adjust the patient cart boom lower 42

43 SCENARIO #14 The surgeon has removed the robotic cannulae and trocars, and is about to close fascia, while you are starting to count. What should you have on your mayo stand to prepare for closure so that the surgical team can progress with closure while you count? 43

44 SCENARIO #14 SOLUTIONS Closure readiness example: May straight scissor Needle driver x2 Vicryl suture (UR6) Monocryl suture x2 S retractors / Army-Navy / Narrow Richardson retractors Lap Pad or 4x4s 44

45 Brief Before and Debrief After Each Case 45

46 Remember to keep your cool and communicate 46

47 Any Questions? Thank you! 47