Robotic instrument insulation failure: initial report of a potential source of patient injury

To report our experience with failures in the accessory tip covers that insulate the monopolar robotic cautery scissor instruments and the patient injuries that have resulted. Currently, there is no data in the literature regarding the failure rate of robotic instruments or their accessory components.

All robotic surgeries performed at our institution were recorded from July 2008 to January 2009. Instrument tip cover failures were recorded at the time of failure regardless of whether a patient complication occurred. Failure was identified by the arching of the electrical current from the insulated portion of the monopolar scissors or by an intraoperative injury.

Four-hundred fifty-four robotic procedures were recorded. A total of 12 accessory tip cover failures were discovered, demonstrating a failure rate of 2.6%, with a patient complication rate of 0.6% (25% of all failures).

Failure in robotic accessory tip covers can lead to patient complications. The cause for failure can be attributed to a variety of electrical and mechanical causes. All centers and surgeons performing robotic surgery should be aware of the potential for this problem to occur, and the possible interventions that may reduce tip cover failure.