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Page 2 of 4 Stefan et al. Mini-invasive Surg 2021;5:23 https://dx.doi.org/10.20517/2574-1225.2021.24

procedures and to avoid the risk of injuries. Specific injuries which are due to poor positioning include slips,
compartment syndrome, facial oedema, and injuries on pressure points, including peripheral
[1,2]
neuropathy . Incorrect positioning of the upper and lower limbs on the operating table can lead to
[1]
peripheral nerve injuries (ulnar, peroneal) and brachial plexopathies, due to compression or stretching .

Robotic surgery adds another element to this complexity by the presence of the insensate robotic arms, and
the operator seated at a distance from the operating field. Accidental injuries caused by the robotic arms can
result in bruising, burns due to friction of the robotic arms against the body, and facial injuries with
[3]
potential dislodgement of the endotracheal tube .
The development of a standard operating policy for perioperative care in robotic surgery has been
advocated to prevent the above-mentioned complications. Awareness of these potential injuries should be
raised and discussed when the patient is consented for the operation, at the team brief meeting and during
the robotic procedure . Surgeons, anaesthetists and theatre teams are all responsible for ensuring that safety
[4]
measures are in place to reduce the risk of these complications .
[5]
The robotic surgical team at our institution has gained experience of over eight years. Working in a
multidisciplinary collaboration has enabled us to design a safe pathway for robotic surgery. We have been
able to minimise the risk and proceed with safe surgery by following these standardised operating
procedures.

We recommend the use of the “L” shaped safety bar above the patient’s face [Figure 1]. This bar is fixed to
the operating table and covers the patient’s face and the endotracheal tube, ensuring protection against
accidental injuries caused by the contact with the colliding robotic arms.

Various methods have been reported in literature to prevent the slipping of the patient off the table
[2]
intraoperatively, including straps, shoulder restraints, leg straps and anti-slip mattresses . We have found
that the anti-slip bean-bag mattress is an efficient piece of equipment for preventing slipping [Figure 2]. It is
also named surgical vacuum bean bag positioner and is used to prevent the movement of the patient during
the Trendelenburg positioning and tilted position of the operating table. Once vacuumed, it conforms to the
shape of the body for stable positioning and allows the extremities to lie in a natural position.

Secondly, protection of pressure points at the level of the hands and elbows is extremely important,
especially during lengthy procedures, to prevent neuropraxia and compartment syndrome in the hand and
[4]
forearm . The use of the inflated medical gloves placed in the hands of the patients is a new technique
developed at our institute. The hand and the wrist can rest in a relaxed fashion over these gloves, and the
fingers are well supported, too. The thumbs must be kept uppermost. This arrangement can protect the
pressure points and prevent neurological injuries [Figure 3].

Lastly, along with these standard procedures, the patient is returned to the supine neutral position for 15
min after every 4 h to avoid compartment syndrome, and calf compression pumps are preferred over the
anti-embolism stockings.

These techniques have been used in our institute for the last 10 years in both laparoscopic and robotic
surgery. The local incidence of patient slippage and pressure point injuries was 0.5%. This compares
favourably low with the overall incidence of 3.6% quoted in robotic rectal cancer operations performed in
lithotomy .
[5]