What can go wrong during robot-assisted surgery? Plenty. To name a few: burned organs from stray electricity, nicked bowels, stabbed arteries and retained robjects (yes, broken or burned pieces of the robot falling into the patient's body). Yes, when a robot malfunctions during surgery, bad things can happen, including inconvenience, injury or even death.

As more surgeons in more specialties trade in their scalpels for joysticks and foot pedals, it's important not to lose sight of the serious risks that accompany the many benefits of robotic systems for minimally invasive surgery. Here's how to handle technical difficulties and in-procedure complications.

1. Troubleshooting training.

What if the arm locks up? What if we lose power? What if the patient makes an unexpected movement that disrupts the entire procedure? What if the table moves while the trocar is in the patient?

These what-if questions are invaluable to rehearse with your surgeon and staff. After all, a minimally invasive robotic surgery can become an emergency open procedure in an instant. You want to keep your OR team calm, cool and collected during a robotic emergency — and ensure they perform like a well-oiled machine.

2. Staff accordingly.

A typical robotic case generally involves more than 5 team members, as well as support staff from sterile processing and the distribution/sterile processing department. We're also big believers in using physician assistants (PAs) who are directly assigned to the robot. The PAs are a godsend because not only are they experts on the technical aspects, they're also able to move the big, bulky robots with ease. Before the PAs, our nurses or techs would move the robots. Because the machinery was so heavy and cumbersome, some staff got hurt and wound up on disability in the pre-PA era.

You also need to have adequate back-up personnel at-the-ready in the event of a problem. For example, if anesthesia runs into a problem with the lines, extra scrub techs and circulators must be available to come in right away.

One thing that can't be overstated is the team element of successful robotic surgeries. The entire OR team — from surgeons to anesthesiologists to nurses to techs — must communicate like a single organism, ready to adapt and react without delay. That means everybody must be on high alert. Even during the most mundane processes, like when you're charting with your back turned, you've got to keep your ears perked for the slightest sign something's amiss.

3. Practice role-based, worst-case training and simulation.

Like any procedure, training is paramount with robotic procedures. You want to prepare everybody involved not only for the routine aspects of the case, but also for the situations that you hope never happen.

From spontaneous system resets and malfunctions to loss of quality video feeds and broken or burnt pieces of the robot falling into the patient's body, make sure everyone is aware of anything and everything that can go wrong — and what their role should be if it does. Hint: Be sure staff have access to the robotic key should the arm unexpectedly lock during the procedure.

Be aware of factors that often complicate a successful robotic procedure. Comorbidities like obesity, prior surgery and lung disease increase the chances you'll have to convert to an open procedure. Certain positions, such as the Trendelenburg, are difficult for obese patients to sustain and could lead to unexpected emergent conversions.

Head and neck procedures present their own unique challenges — especially for the anesthesia providers. Reason: The OR bed is turned 180 degrees, which leaves the anesthetist little access to the patient's airway and IV lines because they're on the opposite side of the patient. Precepting nurses should ensure anesthesia double-checks that their lines will be long enough well before they set foot inside the OR for the main event.

Training should also highlight the little things your team can do to prevent an emergency. For example, you can prevent unsafe movement of the OR table after the instruments have been placed in the patient's body cavity simply by disabling the bed control after docking.

We prepare our team through detailed simulation training and pre-procedure discussion — a discussion that encourages everyone on the OR team to ask, "What happens if..." — as well as during the time out. We saw how effective this type of preparation and acute preparation could be during a laparoscopic procedure where the patient had a bleed. As soon as that happened, our PA was right on top of the situation, applying suction and doing the repair just as he should. But something seemed just a bit off, so I said, "Let me just take a closer look at the suction canister." Turns out, we were using 500ccs of suction when we should have been using maybe 50ccs, something we were able to fix right away — thanks in large part to our problem-spotting approach.

4. Put together a contingency plan.

There is no harm in hoping for the best as long as you are prepared for the worst. Stephen King's famous quote wasn't about robotic surgery — but it certainly could've been.

OR teams that can create detailed contingency plans for the rare cases when the robotic procedures don't go as planned are the ones that will come out of a potentially catastrophic situation unscathed. This starts with the floor plan. With the average OR suite measuring around 600 square feet and a robot and operating physician taking up at least one-third of that area, it's easy to see why space is such an issue during robotic procedures.

To accommodate an MIS-to-open conversion, keep the pathway around the surgical field free of obstructions to allow for instant emergency access for staff and their equipment. This can be a real challenge when you factor in all the cords and wires in a typical OR. Key: You'll want to group everything — machines, booms and cords — as closely together and out of the way as possible, while still providing easy access for your team.

Of course, emergent situations mean extra equipment. So your contingency plan should factor all of these variables into the equation. Should the surgery require an emergency conversion to an open approach, you'll need all supplies, specialty instrument trays and equipment at your team's fingertips. Another tip: Open and count your basic open-approach instrument trays before the start of all robotic surgeries to prevent delays in the event of a conversion. Specialty trays for vascular needs, on the other hand, should be unopened in the OR or close by right outside of it. If keeping extra instruments in the OR is a priority, you can free up space by adding extra ring stands, small back tables and prep stands.

5. Take full advantage of the time out.

On top of confirming the patient's identify, the surgical site and the planned procedure, the time out offers a prime opportunity for robotic safety and efficiency. This is the time where your surgeon should be reviewing the contingency plan, reminding staff of their roles in the event of a change and listing all the available resources — open-approach supplies, specialty instrument trays, back-up scrubs and circulators — that may be needed. Use the time to announce the blood status of the patient and quickly summarize your facility's transfusion protocols, so you can react more quickly during crunch time.

Proper planning prevents ...

Yes, proper planning prevents poor performance. Even the most well-planned robotic procedures can go off the rails in an instant, but the difference between a disaster and a positive outcome lies in the OR team's preparation. With the right planning, any capable, well-practiced team can turn an emergency into a great outcome for your patient and your facility. OSM