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.

• Positioning: Lithotomy with Trendelenburg (20–30°); shoulder supports, vacuum-secured pillow, fixation of legs in padded "boots."
• Table Motion (if available): Only with the Xi system for intraoperative repositioning without undocking.
• Port Placement and Skin Marking: Trocar placement adapted to the surgical target structure and patient's anatomy (8 mm trocars in line, distance ≥ 7 cm).
• Technique: Capnoperitoneum via Veress or optical trocar, adjustment of the robot according to target anatomy ("Targeting"), instrument insertion under vision.
• Team Coordination: Communication between console and assistants is important; clear role distribution required.

• Monitoring: Standard monitoring in the recovery room. Monitoring of circulation, pain, urine output, and drainage if necessary.
• Analgesia: Usually a combination of acetaminophen + NSAID. Opioids only as needed. PCA for major procedures (e.g., oncological surgery).
• Early Mobilization: Starting 6 hours postoperatively; continue thrombosis prophylaxis until the 7th postoperative day or according to individual risk.
• Nutrition: Fluids a few hours postoperatively, gradual diet advancement as tolerated.
• Wound Care: Check trocar sites, change dressings after 24–48 hours, suture removal depending on material (often absorbable).

• Criteria: Mobility, oral nutrition, adequate pain management, spontaneous micturition, stable circulatory conditions.
• Incapacity for work: Depending on the duration of the procedure and occupational stress, 7–21 days.
• Follow-up care: Check-up after 7–10 days with the gynecologist or, depending on the surgical findings, in the outpatient clinic.
• Pathology: Postoperative discussion of findings is essential for oncological procedures; possibly tumor conference.