ANAESTHESIA FOR ROBOTIC PROCEDURES

Dr Azrin Mohd Azidin, Dr Noorul Hana Sukarnakadi Hadzrami, Dr Amiruddin Nik Mohamed KamilDepartment of Anaesthesia and Intensive Care, Hospital Kuala Lumpur

CONTENTS

IntroductionA)

Anaesthesia for Urological Procedures1.

Robotic prostatectomy/Cystectomy (and pelvic procedures)

1.1.

Anaesthetic Considerations1.2.

Problems associated with Trendelenberg position1.3.

Conduct of Anaesthesia1.3.1.

Preoperative assessment1.3.2.

Positioning1.3.3.

Intraoperative management1.4.

Ventilatory srategies and targets1.5.

Fluid management1.6.

Extubation and postoperative management

Robotic pyeloplastyB)

Anaesthesia for Gastrointestinal Procedures1.

Robotic gastrectomy

1.1

Anaesthetic Considerations1.2

Positioning1.3

Anaesthetic Technique

Anaesthesia for Endocrine Procedures1.

Robotic Thyroidectomy

1.1

Anaesthetic Considerations1.2 Positioning1.3 Anaesthetic Technique

ConclusionReference

INTRODUCTION

Robotic surgery refers to a surgical technology that works on a computer-assistedelectromechanical device as an interface between the surgeon and the patient

It involves mechanically translating surgeon’s movements from a visuallyenhanced master console to a remote surgical cart which houses mechanicalarms that mimics the same movements on the patients with a higher degree ofprecision and control than is normally possible.In the last 5 years , there have been tremendous advancement in the use ofrobotic technology for various surgical procedures. Although its use were initiallyconfined to prostatectomies, with widespread advances and training, roboticprocedures have now expanded to other surgical specialties such ascardiothoracic, endocrine, colorectal and gynaecolology.

Anaesthesia for Urological Procedures1.

Robotic Prostatectomy/Cystectomy (and pelvic surgeries)

The most common procedure done and the most physiologically demandingfor patients.

Surgically similar to laparoscopic technique with the difference of morepresicion and stability for dissection of critical structures due to thetridimensional view from the surgeon’s console.

The problems associated are a consequence of 3 main factors.

•

Extreme steep Trendelenberg position

•

Insufflation of carbon dioxide (CO2)

•

Spatial restrictions due the bulk of the surgical cart

1.1 Anaesthetic Considerations

•

Altered Physiology due to steep Trendelenberg position

•

Access to patient-

Restricted access due to the bulk of surgical cart and position ofassisstants and equipments

•

Airway-

displacement of ETT due to mediastinal movement-

oedema of the head and neck due to prolonged Trendelenbergposition

•

Position of patients-

supine with arms by the side and strapped to OT table or casted ona ‘bean bag’ ( vacuum applied beaded mattress)-

legs held apart in lithotomy position with padded leg rests

•

Problems due to laparoscopic procedures

Pneumoperitoneum-

CO2 insufflation and hypercarbia

Three components of robotic operating moduleSurgeons ConsolePatient CartVision Cart

moderate hyperventilation may result in pneumothorax,pneumomediastinum and more commonly subcutaneous emphysema. (Due to hyperventilation at high inspired pressures with pneumoperitoneum) -

possibility of visceral injury

•

Problems due to prolonged surgery- Hypothermia