ANAESTHESIA FOR ROBOTIC SURGERIES

CONDUCTOR- DR.CHAKOLE SIR

PRESENTER- DR.MONIKA SHARMA
The aim of this
technology is to
enable less invasive
complex surgeries
with greater
visibility, precision,
and flexibility than is
possible with
conventional
techniques.

Surgical robots
range widely in
terms of size,
autonomy, and
function.
 BENEFITS OF ROBOTIC SURGERY

The benefits of these minimally invasive approaches (such as laparoscopy and

thoracoscopy) included:
(i) reduced wound access trauma,
(ii) shorter hospital stay
(iii) improved visualisation
(iv) less postoperative wound complications (ranging from wound infections to
incisional hernias)
(v) less disfigurement

Technical advantages for the surgeon include:

The potential for better visualisation (higher magnification),elimination of hand

tremor allowing greater precision; and improved manoeuvring as a result of the
“robotic wrist” which in some systems allows up to seven degrees of freedom
(angles at which surgeons can use their instruments to operate on target organs).
There are improved kinematics where large external movements of the surgical
hands can be scaled down and transformed to limited internal movements of the
“robotic hands”.
This in turn improves ergonomics that extend the surgical ability to perform
complex technical tasks in a limited space.

The computerized nature of the surgical robot allows integration of real-time and
previously recorded data utilisation, so that it could accommodate complex intra-
operative factors such as compensating for the beating movement of the heart.

There may also be less need for assistance once surgery is under way.

Outcomes in the elderly have been shown to be better after robotic surgery in
comparison with open surgery, with reduced surgical and medical complications,
improved length of stay and quicker discharge home.

This may be as a result of reduced blood loss and transfusion rates, alongside
reduced wound and fascial complications despite longer operating times.
In terms of specialist surgeries, the benefits of robotic techniques have enabled
increasingly complex procedures such as retroperitoneal lymph node clearance
for treating testicular cancer.

Improving outcomes in cancer management and patient satisfaction and quality

of care.

First generation – stereotaxic robots

The first surgical robot in clinical practice was the PUMA 200, first utilised in the
same year as the first laparoscopic cholecystectomy.

This robot was utilised for stereotaxic brain biopsy with the surgeon placing the
arms of the robot in a position to perform its task.

This device acted as a forerunner to a modified brain tumour excision device

known as the Neuromate.
Second generation – endoscopic robots

The introduction of the second generation of surgical robots has resulted

in the greatest expansion of the concept of robotic surgery to date.

This has been as a result of the introduction of soft-tissue surgical

capability such as the PROBOT that can remove pre-defined prostate
gland volumes.

Here surgical robots could potentially offer some core advantages by

overcoming:

(i) difficulty in access to tissue places and organ systems such as the
pelvis or thoracic cavity.
(ii) instruments that lack precision for tasks such as vascular anastomosis
(iii) difficulties in visualisation of soft tissues.
Two of the best-known endoscopic robotic
systems were simultaneously developed and
introduced just before the millennium.

These were The Zeus robotic system (Computer

Motion, Goleta, CA, USA) which first became
commercially available in 1998, closely followed
by the da Vinci robotic system (Intuitive Surgical
Inc, Mountain View, CA, USA) in 2000.

Between 1998–1999 both the da Vinci system

and subsequently the Zeus were successfully
used in coronary artery surgery as a proof-of-
concept operative principle.

The da Vinci Xi Surgical System

(A) robotic arms
(B) console
(C) in the operating environment
D) performing a coronary anastomosis
As these second generation platforms are the most widespread and established
platforms in current clinical use.
These range from improved surgical visibility and visual information .

Third generation – bioinspired robots

The third generation of surgical robots has adopted these principles of biomimicry
and multiple articulation technology for multiple surgical pathologies.

Most of these robots have been designed in the past decade. Current systems can
be classified into

(i) Tendon-driven flexible systems such as Imperial College’s i-SNAKE and the
CardioArm.

(ii) Catheter-navigated systems that have been derived for cardiovascular

percutaneous intervention technology.
Fourth generation – microbots

Robots at a microscopic level could enter the body with minimal surgical
footprint and work as a solitary robot or more likely as a group of robots to
image and treat not only conventional surgical diseases but also non-surgical
diseases such as infective and immune processes that could be managed at a
cellular level.

Microbots occupy a millimetre scale ( a fraction of a millimetre to several

millimetres but larger than the nanometre scale)

Currently capsule endoscopes (such as the PillCam® WCEs-Wireless capsule)are

in clinical use, although these function as predominantly imaging modalities that
are passively mobile capsules being transported by the peristaltic motility of the
gastrointestinal system whilst taking images of the gastrointestinal tract.

The next generation of these microbots would include further advances in each
component of these robots ranging from vision, locomotion, localisation, power,
diagnosis and tissue manipulation.
Fifth generation – autonomous systems

Since the first generation of surgical robots have been designed to carry a degree of
autonomous capacity to perform individual pre-programmed tasks, the concept of fully
autonomous, human-level consciousness robots remains predominantly conceptual.

Autonomous robots will likely benefit from enhanced machine-learning capability that
will require next generation - Test intelligence (comparable to human-level intelligence
and consciousness).

They will take the form of the first four generation of robots with added autonomous
decision-making capability.

The anaesthetic risks associated with robotic surgery are largely associated with length
of operating time and positioning.

The most frequent complications are peripheral neuropathies, corneal abrasions,

vascular complications including compartment syndrome, rhabdomyolysis and
thromboembolic disease, and the effects of oedema (most significantly cerebral, ocular
and airway).
 APPLICATIONS OF ROBOTIC SURGERIES

Robotic surgery has been utilised in a range of specialities including urology,

gynaecology, cardiac, thoracic, upper and lower gastrointestinal and endocrine
surgery.

Prostatectomy

Robot-assisted laparoscopic radical prostatectomy (RALRP) is the most commonly

performed robotic surgery. Several studies have shown that RALRP reduces
hospital stay duration, blood loss, postoperative pain, and provided a more rapid
return of urinary function and higher rate of potency recovery. Additionally,
control of cancer by RALRP has been found to be comparable to open surgery.

Other genitourinary surgeries: nephrectomy, cystectomy, Other urological robotic

surgeries have seen increases in numbers. Regarding radical nephrectomy, robot-
assisted surgery failed to show any advantage compared with the laparoscopic
method.
However, in partial nephrectomy, it is thought to have advantages over the
laparoscopic method . Robot-assisted partial nephrectomy (RAPN) was associated
with a significant reduction in blood loss and surgical complications, and with a
shorter duration of hospitalization.
Gynecological surgery

It is difficult to perform complex tasks such as lymph node removal and

intracorporeal knot tying within the female pelvic cavity.

Laparoscopic gynecological surgeries thus have a slow learning curve, with

associated complications, and demand high surgical skills, especially when
the surgical anatomical field is affected by advanced pathology .

A robotic surgical system may offer many advantages over laparoscopic

surgery with regard to these difficulties.

Hysterectomy, myomectomy, tubal re-anastomosis, radical hysterectomy,

lymph node dissection, and sacrocolpopexy have been performed using
robotic surgical systems.
Some studies have shown that robot-assisted gynecological surgeries resulted in
reduced blood loss and shorter hospital stays than laparoscopic or open surgeries.

Abdominal surgery

Not only hollow viscus, but also solid abdominal organs, including the liver,
pancreas, and adrenal glands are included within the indications for robotic surgery.

Among the many types of abdominal surgery, fundoplication, rectal resection, and
gastric bypass have been particularly preferred for robotic surgery due to the
difficulties in orientation and dexterity, especially in small spaces when suturing is
needed or the instruments are at unergonomic angles .

During robot-assisted gastrectomy, the surgical cart is placed at the head side of the
patient and the anesthetic workstation and anesthesiologist are on the far left side
of the patient.

The table is tilted in 15° reverse Trendelenburg. With an experienced laparoscopic

surgeon, it is possible to achieve comparable clinical outcomes with robot-assisted
gastrectomy to a skilled laparoscopic surgeon.
However, prolonged operation durations have been reported due to
maneuvers that require repositioning of the robot and its arms, such as splenic
flexure mobilization and high ligation of the inferior mesenteric artery and vein,
which add significant time to the surgical procedure.

Robotic cardiac surgery

Various cardiac surgeries, including mitral valve surgery, coronary

revascularization, arrhythmia operation, left ventricular lead implantation,
congenital heart surgery, and aortic valve replacement, have been performed
with robot-assisted techniques.

Contraindications for robotic cardiac surgery are essentially identical to those

for one-lung ventilation: severe pulmonary hypertension, dense pleural
adhesions, recent coronary infarction or unstable coronary disease, and severe
atherosclerosis.
Transoral robotic surgery

Currently, the number of TORSs continues to increase. Traditional ENT operations

require wider surgical exposure than the actual surgical field.
However, the robotic surgical system, with a three-dimensional surgical field, can
provide adequate depth using various endoscopes, cameras, and dual eyepieces.

Thus, disfiguring mandibulotomies or tracheostomies can be avoided with TORS.

Additionally, the risks of chemoradiation therapy may be reduced or avoided, and
recovery of postoperative quality of life, such as speaking and eating, is known to
better and more rapid.
Possible problems related to the insertion of the robotic arm into the intraoral space
include facial skin lacerations, tooth injuries, mucosal lacerations, mandible
fractures, cervical spine fractures, and ocular injuries.

Radical tonsillectomy, tongue base resection, supraglottic laryngectomy, have been

performed using the da Vinci system.

Current indications for TORS are benign lesions of the oral cavity, larynx, and
pharynx, and all T1 and T2 malignancies. Exclusion criteria are known to be pediatric
diseases, lesions invading the mandible, and dental procedures.
Robotic surgery in pediatric patients

Several robot-assisted surgeries have been performed safely in pediatric

patients, including simple procedures, such as pyeloplasty, PDA closure,
and nephrectomy, and more complex procedures, such as Bochdalek
hernia repair, choledochal cyst excision .

Because the working space is limited and the abdominal wall is thinner
than in adults, proper positioning of ports is important and inadvertent
visceral injury during port introduction and instrument manipulation
should always be kept in mind .

With respect to pyeloplasty, hospital stay duration and postoperative pain

were reduced compared with open surgery, but comparable to
laparoscopic surgery .
ANAESTHETIC CONSIDERATIONS IN ROBOTIC SURGERY

General aspects

In robot-assisted operations, spatial restrictions due to the bulky equipment are a

universal issue. After the robot has been positioned and engaged, the
anesthesiologist is unable to readily access the patient.

Thus, any lines, monitors, and patient-protective devices must be placed beforehand
and should be secured to ensure no kinking or displacement .

It is impossible to allow changes in patient position or any kind of access to the

patient if the robot is not detached first.

Because this time delay in patient management may result in critical complications,
especially in unhealthy patients or pediatric cases , early detection of any problems
by the anesthesiologist and training of the surgical team for fast detachment of the
robotic system in emergency situations is needed.

Additionally, no type of movement is allowed during an operation. Movement of the

patient while robotic instruments are docked could lead to tearing or puncturing of
internal organs and vasculature, with potentially devastating consequences .
The anesthesiologist should give attention to the robotic arms and the patient
position to prevent pressure or crush injuries.

Longer operation durations and worse patient conditions were found to be

significant risk factors.

Robotic surgeries regarding intrathoracic or intra-abdominal pathologies require

the use of CO2 pneumoperitoneum.

Many complications related to these conditions have been noted during

laparoscopic surgery, such as subcutaneous emphysema, pneumothorax,
pneumomediastium, and, in the worst case, gas embolism.
Specific Anesthetic Considerations for Each Surgery

Prostatectomy

Two main concepts associated with robotic prostatectomy are the steep Trendelenburg
position and CO2 pneumoperitoneum. Several issues regarding them have been
noticed: RALRP requires a much steeper Trendelenburg position and a higher pressure
of CO2 pneumoperitoneum. Retroperitoneal dissection also increases the absorption of
CO2 .
The Trendelenburg position combined with pneumoperitoneum pushes the abdominal
contents cephalad; hence, FRC and lung compliance are reduced.

To overcome the negative influence of the steep Trendelenburg position to the lungs, a
tidal volume of 6-8 ml/kg and a positive end-expiratory pressure of 4-7 cmH2O are
recommended for the prevention of atelectasis, and maximal airway pressure should be
kept under 35 cmH2O .

Pressure-controlled ventilation was found to result in greater dynamic compliance and

lower peak inspiratory airway pressure, compared with volume-controlled ventilation

A prolonged inspiratory duration can be an alternative to producing better gaseous

exchange conditions and respiratory mechanics. I : E ratios of 2 : 1 or 1 : 1 provided
better oxygenation and lower PaCO 2 levels in the steep Trendelenburg position.
Regarding the cardiovascular system, central venous pressure, pulmonary artery
pressure, and pulmonary capillary wedge pressure are increased according to the
degree of head-down tilt , and, thus, the heart rate is decreased.

Especially during the initiation of CO 2 insufflation, severe bradycardia and asystole

have been noted. CO measured showed slight decreases during the head-down
position with pneumoperitoneum .

This is due to increased systemic vascular resistance (SVR) and afterload, and,
therefore, reduced stroke volume, transesophageal echocardiography, and showed
that this position increased mean arterial pressure and SVR.

While the Trendelenburg position itself may increase cardiac output, due to an
increase in venous return, aortic compression by pneumoperitoneum increases SVR
and thus the final stroke volume and cardiac output may decrease, rather than
increase.
These combined results may lead to an increase in myocardial oxygen demand, and
therefore caution is needed in patients with a reduced cardiac reservoir or impaired
baroreflex .
The Trendelenburg position increases intracranial pressure and intraocular
pressure (IOP) .
IOP was found to be increased by an average of 13 mmHg after being
positioned in the 25° Trendelenburg position with 15 mmHg of
CO2 pneumoperitoneum, compared with the preinduction value.

A unique consideration during CO2 insufflation is a variety of gas-related

complications. Regarding gas embolisms, the incidence of venous gas embolism
is less in RALRP than RRP (38% vs. 80%) .

Although subcutaneous emphysema itself is not a dangerous complication and

is quickly resolved after cessation of insufflation, mechanical ventilation should
be continued until hypercarbia is corrected to prevent any excessive increase in
the work of breathing .

The possibility of pneumothorax or pneumomediastium should always be

considered. Additionally, because CO2 readily permeates into the blood stream,
the resulting hypercarbia may cause sympathetic stimulation, leading to
increased heart rate and blood pressure .
Before anesthetic emergence and extubation, the significance of any upper airway
edema should be evaluated .

The steep Trendelenburg position is also prone to devastating ischemic optic

neuropathy and corneal abrasions. To prevent corneal abrasion, the incidence of
which is 3%, taping the eyes closed using a transparent occlusive dressing is
required .

Other urological surgeries

For RARC, anesthetic considerations are similar to those for robotic prostatectomy,
except that there is less volume restriction. RAPN is performed in a 45° lateral
decubitus position with flank elevation.

Gynecological surgery

Because of the similar positioning and pneumoperitoneum, most concerns

regarding anesthesia are the same as for a prostatectomy. A less-steep
Trendelenburg position, compared with urological surgery, is permitted.
Robotic cardiac surgery

For most robotic cardiac surgeries, the patient is in the supine position. The
arm on the side of the chest port placement is allowed to hang over the
edge of the table.

External defibrillation is essential, and the patches and ECG electrodes

should be away from the site of port placement .

Single-lung ventilation is required for most robotic cardiac surgeries and

sometimes CO2 insufflation is added to provide a better surgical field. These
situations cause hypercapnia and impede venous return, thus reducing
cardiac output and leading to possible acute cardiovascular collapse .

To avoid such situations, CO2 insufflation should be started 30-60 s after

pleural opening to ambient air at a slow rate (1 L/min).

Cardiopulmonary bypass is achieved with femoral artery and venous

cannulation, and a 17-F right internal jugular venous cannulation is needed
for venous drainage.
Robotic thoracic surgery

For thymectomy, the patient is placed in an incomplete side-up position, at a

30° right or left lateral decubitus position.

The arm of the elevated side is positioned at the patient's side, as far back as
possible, so the surgeon can gain enough space for the robotic arms .

This increases the concern for brachial plexus injury and special attention
must be given to the elevated arm or head to prevent crushing injuries by the
robotic arms.

CO2 insufflation to a pressure of 10-15 mmHg can be applied to keep the lung
away from the surgical field, but it can obstruct venous return and cause
profound hypotension.

The key issue for anesthesia during one-lung ventilation and capnothorax is
maintaining stable hemodynamics and oxygenation .
There is a high risk of positioning neuropathy during robotic thoracic surgery.
Inadequate padding or positioning and inadvertent robotic arm placement can
cause external nerve compression.
During positioning, the arms and shoulders should be well cared for by reducing
conflict with robotic arms and decreasing the risk of brachial plexus injury .

As in other robotic surgeries, the robotic arm monitors and surgical personnel
will occupy the area around the patient, so extensions for IV lines are necessary,
and injection ports or stopcocks need to be in accessible locations. Long
monitoring lines and anesthesia circuits are also mandatory.

After patient safety is considered, the aim for anaesthesia is to contribute to the
incremental gains offered by robotic surgery by providing optimal fluid
management, analgesia, reducing postoperative nausea and vomiting (PONV)
and cognitive dysfunction, improving recovery and discharge times and overall
patient satisfaction.

Postoperative analgesia may be improved with neuroaxial techniques such as

intrathecal opioids as reduced systemic opiate use, reduced pain scores and
increased patient and nursing staff satisfaction have been demonstrated with
this approach.
The increase in intraocular pressure intraoperatively has also meant that
glaucoma can be considered as a relative contraindication to some forms of
robotic surgery. Visual loss is rare, but has been described in association
with posterior ischaemic optic neuropathy.

Cerebral oedema can also be a significant complication causing confusion

or reduced levels of consciousness postoperatively.

The pathogenesis is likely because of increased venous pressure in the

Trendelenburg position with pneumoperitoneum leading to increased
intracranial pressure and capillary leak.

Preventative strategies include limiting operative time, minimising the

angle of Trendelenburg, limiting insufflation pressure to 8 mm Hg where
possible, and fluid restriction.

It is also advisable to maintain a normal end-tidal carbon dioxide

concentration. High-risk patients can be kept intubated for a period of time
postoperatively.

It is clear that a fluid restriction strategy may help to reduce complications

in association with oedema, but this obviously needs to be balanced
against compromise to the cardiovascular and renal systems.
There are several pitfallsto be considered regarding robot-assisted
surgery.

First, the equipment is extremely bulky and thus considerable

space is required.

Second, the large size of the robot itself may result in collisions
with its own arms, assistants, or patients.

Third, it is difficult for the anesthesiologist to quickly access the

patient during an operation.

In addition, it is almost impossible to reposition the patient once

the robot has been stationed.
 THE FUTURE OF ROBOTIC SURGERY

The future of robotic surgery hinges on five core TECAT dimensions:

(i) Technology, continual application of advancing and next generation technologies

to offer improved surgical precision in a wider range of cases with increased
usability to achieve better clinical outcomes.

(ii) Evidence, increased evidence to select the best robotic platforms for the most
appropriate population-base.

(iii) Cost, cost-efficacy for individuals, institutions and nations to afford robotic
surgical healthcare.

(iv) Awareness, increased societal and patient awareness and comfort in having
surgical procedures performed when appropriate.

(v) Training, enhanced training of surgical, anaesthetic and associated healthcare

staff to have increased familiarity and improved team outcomes when applying
surgical robotics.
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