Perioperative management - Docking DaVinci step by step

Robot-assisted laparoscopic surgery (e.g., using the da Vinci system) is an established method in gynecological practice for the treatment of both benign and malignant diseases. Perioperative management generally follows the standards of minimally invasive surgery but must take into account the specific requirements of robotics.

• Medical History: Recording of internal and gynecological pre-existing conditions, previous surgeries (especially in the abdomen/pelvis), bleeding history, medication plan including anticoagulants.
• Gynecological Examination: Assessment of uterine mobility, adnexal status, vaginal anatomy (especially in cases of prolapse or adhesions).
• Imaging: Transvaginal ultrasound for surgical planning; if malignancy is suspected, additionally MRI/CT.
• Risk Stratification: Assessment of anesthesia risk (ASA score), comorbidities, obesity (BMI > 35), VTE risk, pulmonary limitations (Trendelenburg position!).

The patient must be thoroughly informed about the specifics and potential risks of robot-assisted surgery:

• Procedure: Explanation of the da Vinci system (console, robotic arms, visualization), indirect operation via control console, no autonomous "robot action."
• Risks: General surgical risks (bleeding, infection, organ injury), specific: technical failure, longer surgery time due to complexity or learning curve, rare conversion to laparotomy.
• Positioning: Note on lithotomy and Trendelenburg position with potential neurological positioning complications.
• Alternatives: Conventional laparoscopy, laparotomy, possibly vaginal approach.
• Postoperative Expectations: Early mobilization, minimal scarring, rapid recovery.

• Thrombosis prophylaxis: Standard low molecular weight heparin (e.g., Enoxaparin 40 mg s.c.) for increased risk; additionally, compression stockings or intermittent pneumatic compression during the operation.
• Skin disinfection and hair removal: Only if necessary on the day of surgery, not routinely.
• Bowel preparation: Generally, no oral bowel evacuation necessary. Individual indication for deep infiltrating endometriosis or lymphadenectomy.
• Fasting: No solid food 6 hours before surgery, clear fluids allowed up to 2 hours preoperatively.
• Antibiotic prophylaxis: Single dose perioperatively, e.g., Cefazolin 2 g i.v. (alternative Clindamycin for penicillin allergy).
• Urinary catheter: Common intraoperatively for relief in pelvic surgeries, remove early postoperatively.