BJA Education, 19(12): 405e411 (2019)
doi: 10.1016/j.bjae.2019.09.002
Matrix codes: 1H02,
2A07, 3G00
Anaesthesia for video-assisted and robotic thoracic
surgery
P. McCall1,2,*, M. Steven1 and B. Shelley1,2
1
University of Glasgow Academic Unit of Anaesthesia, Pain and Critical Care Medicine, Glasgow, UK and
2
Golden Jubilee National Hospital, Glasgow, UK
*Corresponding author: philipmccall@nhs.net
Learning objectives
By reading this article, you should be able to:
 Summarise the thoracic surgical procedures that
can be performed by a minimally invasive
technique.
 Explain the considerations for anaesthesia spe-
cific to video-assisted thoracic surgery and robot-
assisted thoracic surgery (RATS), including the
need for successful lung isolation and the chal-
lenges of managing hypoxaemia during one-lung
ventilation.
 Describe the important features of providing
anaesthesia for RATS procedures, including
positioning, limited access to the patient, and the
need for well-rehearsed emergency drills.
The traditional approach for thoracic surgery is thoracotomy,
which allows good surgical access but involves an extensive
Philip McCall FRCA MD is a clinical lecturer in anaesthesia, pain and
critical care medicine at the University of Glasgow, and an advanced
trainee in cardiothoracic anaesthesia in the West of Scotland, based
at the Golden Jubilee National Hospital. He has a research interest in
cardiothoracic anaesthesia and has published on outcomes after
thoracic surgery.
Mark Steven FRCA MRCP is a consultant in cardiothoracic anaes-
thesia and lead thoracic anaesthetist at the Golden Jubilee National
Hospital. He is the thoracic representative on the Association for
Cardiothoracic Anaesthesia and Critical Care committee.
Ben Shelley FRCA FFICM MD is a consultant in cardiothoracic
anaesthesia and intensive care at the Golden Jubilee National Hos-
pital. He is an honorary clinical associate professor at the University
of Glasgow.
Accepted: 17 September 2019
© 2019 British Journal of Anaesthesia. Published by Elsevier Ltd. All rights reserved.
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Advance Access Publication Date: 22 October 2019
Key points
 Video-assisted thoracic surgery (VATS) and robot-
assisted thoracic surgery (RATS) are minimally
invasive surgical procedures.
 VATS and RATS have suggested benefits in terms
of reduced perioperative complications and
shorter lengths of stay compared with open
surgery.
 VATS is the preferred surgical approach for pa-
tients with poor cardiorespiratory reserve un-
dergoing lung resection.
 The success of VATS and RATS depends on
optimal lung isolation.
 RATS is a novel surgical technology that neces-
sitates a different approach for the whole oper-
ating team.
incision and rib spreading.1 In minimally invasive thoracic
surgery (MITS), thoracotomy is not performed and surgery
takes place with the operator’s hands outside the chest. In
video-assisted thoracic surgery (VATS) procedures, the sur-
geon directly manipulates instruments, whereas in robot-
assisted thoracic surgery (RATS) the surgeon is a step
further removed, at a separate console, controlling robotically
held instruments. These techniques have been developed as
less invasive approaches to thoracic surgery, with proponents
suggesting benefits in terms of less pain, reduced inflamma-
tion, less impairment in pulmonary function, reduced post-
operative morbidity, and shorter hospital stays.2
The main current use of MITS is with VATS for lung
resection. Although there are no published RCTs comparing
true VATS resection with thoracotomy, there is a suggestion
of benefit: small studies have shown reduced perioperative
morbidity, shorter hospital stays and recovery, and even
potentially improved long-term survival.3,4 In addition, there
405
Video-assisted and robotic thoracic surgery

are data demonstrating that some of these benefits may be

more pronounced in those patients with poor lung function Table 1 Procedures performed with VATS
(FEV1 <60% predicted).5 The Video Assisted Thoracoscopic
Lobectomy Versus Conventional Open Lobectomy for Lung Procedure type Indication
Cancer study (VIOLET), a large pragmatic RCT comparing
Diagnostic Pleural biopsy and thoracocentesi
VATS and thoracotomy for lung cancer resection, has recently Staging of lung, pleural and oesophageal
finished recruiting in the UK with results expected in 2020. malignancies
The proportion of lung resections performed by VATS in Diagnosis of parenchymal disease:
the UK increased from 15.7% in 2005 to 47.3% in 2015 (the most fibrosis, nodules and pneumonitis
recent data available).6 In appropriate patients, particularly Diagnosis of mediastinal tumours:
thymoma, sarcoma and germ cell
those with poor cardiorespiratory reserve, VATS is advocated
Pericardial disease: pericarditis and
as the preferred surgical approach.7 In addition to an tumours
increased proportion of lung resections performed by mini- Therapeutic Pleural disease: pleurodesis and
mally invasive methods, there is an increased absolute decortication
number of lung resections being performed.6 This is driven by Parenchymal disease: wedge resection,
efforts to improve outcomes in lung cancer. Clinical guide- segmentectomy, lobectomy,
pneumonectomy, bullae resection and
lines now advocate offering lung resection to patients previ-
lung-volume reduction surgery
ously considered unsuitable for surgery, as long as they are Mediastinal disease: tumour excision,
willing to accept the higher risks. This includes patients with thymectomy and chylothorax
disease that would have been considered inoperable, or pa- Oesophageal surgery: vagotomy,
tients previously considered too unfit for surgery. Therefore, myotomy and oesophagectomy
increasing numbers of higher-risk patients will continue to Sympathectomy
present for lung resection, with a larger proportion of mini-
mally invasive procedures, and safe perioperative manage-
ment is paramount. There is also a growing desire to minimise sleeve resections are challenging, and are often carried out via
the length of hospital stay and associated costs after thoracic an open approach.
surgery: enhanced recovery protocols have been developed, The detailed review of the selection of patients, and
with VATS being a vital component.7 assessment of suitability to undergo thoracic surgery is
As a development from VATS, there has been an increased beyond the scope of this article, but is based on factors related
use of robotic-assisted operations in thoracic surgery, in to the patient and factors related to the surgery being per-
keeping with trends in other surgical specialties. The use of formed. Factors related to the patient include pulmonary
narrower, high-precision instruments with 360 articulation, function and the presence of comorbidities whilst factors
placed through smaller ports, and with better (three-dimen- related to surgery include tumour type, anatomical location
sional and high definition) visualisation and increased surgi- and tumour, node and metastasis status.
cal comfort, are all thought to contribute to better outcomes. For VATS, there are very few absolute contraindications, but
Similar to VATS, there are no RCTs comparing outcomes factors considered include the following:10
after RATS with either VATS or thoracotomy. Despite the lack
(i) previous surgery or radiotherapy (with associated
of high-quality evidence, there is a suggestion from retro-
adhesions)
spective cohort studies that RATS is safe, with similar out-
(ii) extensive pleural disease
comes to VATS in terms of perioperative morbidity, mortality,
(iii) anatomical considerations (such as central or endo-
and cancer outcomes.4 Currently, the lack of robust evidence
bronchial lesions)
means that NHS England will not routinely commission RATS
(iv) large tumours (>6 cm).
for resection of primary lung cancer.8
The inability to tolerate one-lung ventilation (OLV) would
be an absolute contraindication for longer procedures, but
Video-assisted thoracic surgery short procedures, including biopsies and bullectomies, may be
possible with a VATS approach.
Surgical considerations Conversion to open lobectomy may be required during any
VATS describes the group of surgical procedures where a VATS procedure and can happen for a number of reasons:
video camera and instruments are inserted via ports to avoid
(i) intraoperative complications (mainly bleeding)
open surgery and associated rib spreading. The term can be
(ii) technical problems (e.g. poor visualisation)
applied to a number of similar but not identical procedures.
(iii) anatomical problems (e.g. poor interlobar fissure or
This means that VATS is usually performed with a 4e8 cm
diffuse pleural adhesions)
‘utility’ port for camera insertion, access, and specimen
(iv) oncological considerations (e.g. upstaging of tumours
removal, along with two further incisions for instrument
and unexpected chest wall involvement).
insertion.9 Alternatively, the camera and all instruments can
be inserted through a single portdreferred to as ‘uniportal’ The potential for injury to major vessels (aorta and pul-
VATS. The specific set-up depends on the surgery performed monary artery) with massive haemorrhage and the inability to
and operator preference. immediately obtain control remain significant risks to MITS.
Although the majority of thoracic surgical operations can Emergency conversion most frequently occurs for bleeding
be performed using VATS (Table 1), there are a number of that cannot be definitively treated by a VATS approach. In
procedures that would usually be carried out by thoracotomy. reality, control of haemorrhage can usually be achieved
The central location of structures and the angulation required thoracoscopically whilst a thoracotomy is performed in a
with VATS mean pneumonectomy, tracheal resection, and controlled manner.

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 Video-assisted and robotic thoracic surgery

Considerations for anaesthesia (ii) pleural adhesions or disease

(iii) chronic bronchitis: inflamed narrowed airways, copious
Anaesthesia for VATS is similar in many respects to anaes-
thickened secretions and impaired function of the
thesia for open thoracic surgery. Lung-protective ventilation
mucociliary elevator, all contributing to gas trapping in
and judicious fluid management are essential to try and
the alveoli
minimise postoperative pulmonary complications
(iv) emphysema: loss of lung tissue and reduced elasticity
(PPCs).7,11,12 However, there are a number of key differences.
(v) fibrosis
(vi) tumour with extrinsic or intrinsic narrowing of airways
General intraoperative management, including positioning promoting gas trapping.
Conduct of anaesthesia will vary depending on the VATS
Unfortunately, many of these conditions are evident in
procedure being performed. Smaller procedures may be per-
patients requiring thoracic surgery. Factors specific to VATS
formed with peripheral i.v. access, non-invasive arterial
include the need for prompt and effective lung isolation,
pressure monitoring, and short-acting agents. More prolonged
usually once the patient is positioned for surgery and place-
or major procedures will require larger-gauge i.v. access and
ment of the DLT has been confirmed with the fibreoptic
intra-arterial cannulation for monitoring and sampling. In
bronchoscope. Although the lung will not ‘collapse’ until the
those at increased risk of bleeding (previous surgery, exten-
pleura is breached, volume loss can be encouraged before
sive hilar resections, etc.), two large-bore cannulae should be
surgical incision, increasing pleural retraction pressure and
considered mandatory. Central venous cannulation is infre-
theoretically reducing the risk of direct lung injury at the time
quently used in VATS, but should be considered for individual
of surgical port insertion. This period, in which the lung is
patients, for example, those in which i.v. access is chal-
isolated and not collapsed, can lead to increased shunt and
lenging, or cardiac function is poor and vasopressors or
hypoxia before commencing surgery, which will not improve
inotropic drugs may be required.
until the pleura is incised and the lung collapses. Efforts must
The choice of anaesthetic technique depends on the
be made to avoid considerably prolonging OLV time; in thoracic
experience and preference of the anaesthetist, but neither
surgery, there is a direct association between duration of OLV
TIVA nor volatile anaesthesia has been shown to be superior
and risk of PPC.16 If significant delays are expected, then two-
for patients undergoing OLV.13 However, a recent large retro-
lung ventilation should be performed until surgery is ready to
spective study suggests the benefit for TIVA in patients un-
commence.
dergoing lung resection with a reduced incidence of
Techniques for improving lung collapse include:
unplanned admission to the ICU.14
As with open surgery, positioning is frequently in the (i) ventilating the lungs with 100% O2 before lung isolation to
lateral decubitus position. In contrast to thoracotomy, in remove nitrogen from the operative lung
MITS, the operating table is adjusted to promote extreme (ii) application of suction to the operative lung: if collapse is
lateral flexion, opening intercostal spaces and improving difficult in individual lobes, suction can be directed using
surgical access. This means care must be taken to ensure the the fibreoptic bronchoscope to ensure the large airways
patient is secured to the operating table; the combination of are clear of secretions.
back and arm supports and ‘suction bean bag’ have both been
As in open surgery, although there is no absolute level of
described. Whatever method is chosen, the priorities are to
hypoxia that is permitted, an oxygen saturation 90% is
ensure there is no scope for movement, that pressure points
generally accepted.12 The options for management of hypoxia
are padded effectively, and that the head and neck are
during OLV are similar to the patient undergoing thoracot-
adequately supported for a potentially long procedure.
omy, but caution needs to be exercised when applying them in
Caution must be taken to ensure airway devices, vascular
these patients.12 Similar to open surgery, initial management
cannulae, and monitors are not displaced at this stage. The
includes the optimisation of ventilation to the dependent,
double-lumen tracheal tube (DLT) can be displaced proximally
non-operative lung and ensuring cardiovascular function is
with the bronchial cuff above the carina, or distally with the
optimised with targeted use of fluids or vasoactive medica-
tracheal lumen in the bronchus, meaning it is essential that
tions as appropriate to the clinical situation. As it can interfere
final confirmation of correct placement occurs once the pa-
with surgical exposure, the use of CPAP on the operated lung
tient is in the final position for surgery.
should be the final step in managing hypoxia. Good commu-
nication is essential to ensure the surgeon is not at a point in
Lung isolation the operation where an impeded view could have catastrophic
Successful VATS is dependent on having a clear view of the consequences. However, the judicious use of CPAP, starting
operative field, with good lung isolation facilitating better low and increasing slowly, can be tolerated.
exposure. Details of lung isolation have been described
recently in this journal, and the techniques used often depend
Analgesia
on local preference and expertise.12 It has been suggested that
Pain after all thoracic surgery can be severe and may arise
a DLT is the preferred technique for lung isolation in VATS,
from retraction, fracture/dislocation of ribs, injury to inter-
with bronchial blockers seen as less suitable because of slower
costal nerves, or irritation resulting from chest drains. Even
lung collapse resulting from their narrower calibre. However,
with MITS, a large wound is still required for removal of a
this is not borne out in clinical practice, with bronchial
surgical specimen, and trying to minimise this size can in-
blockers widely utilised and studies demonstrating no clini-
crease distraction forces resulting in rib fractures. Despite
cally relevant differences between the two techniques.15
lower levels of pain compared with thoracotomy, pain after
There are several reasons why adequate lung collapse may
MITS should still be considered moderate to severe.17
not be achieved:
Good analgesia is essential to allow mobilisation and pre-
(i) misplaced DLT or bronchial blocker vent PPCs. Inadequate analgesia can further compromise

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Video-assisted and robotic thoracic surgery

impaired respiratory status by impeding cough and reducing
secretion clearance. The incidence of chronic pain after VATS
is 25% (compared with 33% after thoracotomy) and, given the
potential role of poorly controlled acute pain in its develop-
ment, good analgesia is vital.18
A multimodal approach, incorporating regional and sys-
temic analgesia, is required. The selection needs to balance
the risks and benefits, is tailored to the patient, and depends
on the extent of surgery. After thoracotomy, despite the his-
torical preference for thoracic epidural analgesia (TEA), there
is no clear analgesic benefit between TEA and paravertebral
blockade (PVB) with a lower incidence of minor adverse effects
with PVB.19 Likewise, there is no established gold-standard
regional analgesic technique advocated for VATS proced-
ures, and the choice often depends on factors specific to the
patient and the surgery. As in thoracotomy, PVB has been
shown to be non-inferior to thoracic epidural blockade in
VATS.20 This may account for the increased use of PVB with
opioids in these patients.21
Novel fascial plane techniques, such as serratus anterior
and erector spinae blocks, are increasingly being described
after VATS procedures. They may offer a less invasive alter-
native for analgesia, although their benefit has yet to be
proved in large, well-conducted studies.22,23
Spontaneously breathing and awake VATS
There are a number of potential anaesthetic techniques for
VATS that do not involve tracheal intubation and positive
pressure ventilation. These include awake surgery with
regional anaesthesia; and general anaesthesia with sponta-
neous ventilation but without intubation. The majority of
VATS procedures can be performed in awake patients with
regional anaesthesia along with sedation and local anaes-
thetic (topically to the lung, topically to the airway, stellate
ganglion block, or vagus nerve block) to suppress the cough
reflex.24 Case series describing procedures that have been
performed in awake patients range from simple pleural pro-
cedures to major lung resections (including lobectomy,
pneumonectomy, and lung volume reduction), thymectomy
and tracheal resections.24 The potential benefits of awake
thoracic surgery come from avoidance of the morbidity
associated with general anaesthesia (mechanical OLV, resid-
ual neuromuscular block, and haemodynamic instability)
along with the potential benefits of regional anaesthesia
(improved analgesia, reduced thrombotic complications and
decreased surgical stress response). Proponents believe these
will translate into reduced perioperative morbidity and
reduced hospital stay.24 Experience of the technique is
essential with careful selection of patients being key.
Although the technique shows potential, recent guidance by
the European Society of Cardiothoracic Surgeons states that
‘non-intubated’ anaesthesia for lung resection cannot
currently be recommended.7
Robot-assisted thoracic surgery
RATS is a novel technique in the UK and involves a totally new
style of operating with implications for the whole operating
team. All procedures performed by VATS could be performed
by RATS (Table 1). The robot’s high-precision instruments
with 360 angulation means that some surgical procedures,
such as sleeve resections, pneumonectomy and mediastinal
surgery, may even be easier with a robotic approach than with
VATS.
Surgical factors
In RATS, the principal operating surgeon is at a console
remote from the patient with a trained surgical assistant
scrubbed at the table for positioning of instruments and the
deployment of manual devices. Surgery is usually performed
through up to four ports in a single intercostal space with the
potential for an additional access port.
During RATS, there is a greater team responsibility with a
large number of team members needing to be trained in their
specific roles. The components of an operating team for RATS
are described in Table 2, and although the operating theatre
staff can perform multiple tasks, it is important that each
person’s specific roles are identified at the preoperative
briefing. The allocation of roles in emergencies is particularly
important, meaning if there are personnel changes during
surgery, a detailed handover of responsibilities must occur.
Similar to VATS, there is a steep learning curve recognised
for RATS procedures with increasing numbers translating to
shorter operating times; decreased conversion rates; and
improved surgical metrics, such as nodal upstaging rate (a
measure of the completeness of lymph node dissection).4 This
can mean that, in the early phase of a programme, operative
times can be expected to be much longer than the equivalent
VATS procedure.
Selection of patients is important to ensure they are
anatomically suitable for robotic resection, and have minimal
comorbidities. Although the aim was that all patients would
be suitable for RATS, the consideration of comorbidities is

Table 2 RATS operating theatre team

Team member Role

Lead surgeon Operates remote console controlling robotic arms

Surgical assistant Inserts/changes port access; changes robotic arms; deploys manual instruments
Scrub nurse Provides instruments and support to surgeons
Floor nurse Assists scrub staff
Robotic assistant Charged with docking and undocking the robot (including emergency)
Gown assistant Provides gown and gloves for lead surgeon in emergency
Instrument assistant Provides and opens instrument trays for emergency thoracotomy
Anaesthetist Responsible for anaesthesia, lung isolation and patient positioning
Anaesthetic assistant Supports the anaesthetist
Operating theatre assistant Supports the anaesthetic, surgical and scrub staff

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 Video-assisted and robotic thoracic surgery

particularly important when setting up a service and when in
the steep part of the learning curve, as operative times can be
particularly prolonged. This may expose patients to increased
risk of complications and delay recovery.
Logistics
A number of logistical factors need to be considered when
incorporating a RATS programme. Although there are poten-
tial cost benefits of reduced length of stay and less perioper-
ative morbidity, there are large capital and consumable costs
to be considered. A retrospective review from the USA in 2014
indicated that there was an increased hospital cost of
approximately $4,500 per RATS lobectomy case when
compared to a similar operation by VATS. In addition to the
financial cost, robotic systems have a large equipment foot-
print that needs to be considered when incorporating them
into existing facilities. The operating theatre needs to be large
enough to accommodate the robot and ancillary equipment,
and leaving space for access to the patient, space for nursing
and support staff, and for essential anaesthetic and operating
theatre apparatus (such as anaesthetic machine, monitoring,
fibreoptic bronchoscope, fridges, etc.). It is essential that a
pathway to drive and dock the robot is kept clear at all times
so that it can be removed in an emergency without
obstruction.
accepted as part of a permissive approach to hypercapnia as
long as it is tolerated haemodynamically and the patient has
no comorbidities precluding it, such as those at risk for raised
intracranial pressure where cerebral vasodilatation could
have catastrophic effects.
The robot works from a fixed position and lacks
compensatory movement, meaning movement of the patient
or table could result in serious injury as the robotic arms will
not move in response. Ensuring the table is locked and not
moved is essential, and should be part of any preoperative
checklist. Likewise, involuntary movements, such as cough-
ing or diaphragmatic excursion, could be catastrophic when
operating close to great vessels. This means that an adequate
depth of anaesthesia and neuromuscular block is essential
throughout the procedure, and many therefore see the use of
neuromuscular blocking agents by infusion, ideally with
quantitative monitoring of neuromuscular block, as a key
component.
Prolonged procedures may mean that the use of a urinary
catheter (no longer widely used in VATS) is required. Inter-
mittent pneumatic compression boots, for the prevention of
thromboembolism and to encourage venous return, should be
mandatory.

Anaesthetic factors
The delivery of anaesthesia is similar to VATS, and many of
the factors, such as induction, maintenance, lung isolation
and postoperative analgesia, can be directly applied to pa-
tients undergoing RATS. However, there are a number of key
considerations. There is severely restricted access to the pa-
tient, and positioning of equipment needs to be considered
when the arms of the robot are engaged (see Fig. 1A and B). This
will include the fibreoptic bronchoscope with limited ability to
access the airway during the procedure. The use of a left-sided
DLT where possible is preferred, given the lower chance of
displacement compared with a right-sided DLT or bronchial
blocker. The use of a left-sided DLT will have less risk of
displacement during the procedure, but this needs to be
balanced against the potential for obstruction of the tracheal
lumen during extreme lateral flexion when a left-sided tube is
used in a right-sided surgical procedure. Whatever airway
isolation device is chosen, confirmation of its correct place-
ment once the patient is in the final position for surgery is of
paramount importance. Venous and arterial access needs to
be positioned to enable access but to prevent snag/trip haz-
ards. The use of a clear head drape allows direct visualisation
of the patient.
In contrast to VATS, in which the chest cavity is open to
atmospheric pressure, during RATS, carbon dioxide is insuf-
flated through sealed ports to create positive intrathoracic
pressure of 5e10 cmH2O; this allows better operating condi-
tions by encouraging lung deflation and flattening the dia-
phragm. However, this can affect cardiovascular stability with Fig 1 Patient undergoing right-sided robotic-assisted thoracic surgery. (A)
compression of mediastinal vessels leading to hypotension The da Vinci robotic operating system in position at the head end of a
and bradycardia when higher pressures are used. These car- patient in the left lateral decubitus position. This illustrates the competi-
tion for space and limited access to the patient. The clear head drape
diovascular effects may be more prominent in those who are
allowing direct visualisation of the patient can be seen. (B) The view from
unable to compensate for the raised intrathoracic pressure, the anaesthetist’s perspective at the head end of the patient. The limited
such as those with poor ventricular function or hypovolaemia. space means that positioning of equipment required during surgery needs
Carbon dioxide insufflation can contribute to hypercapnia, to be carefully considered.
which may be challenging to manage during OLV. This can be

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Video-assisted and robotic thoracic surgery
Operating theatre layout and positioning of the patient
Planning of the operating theatre layout is key to allow place-
ment of equipment and to enable robot access and docking.
There has to be consideration for movement of the robot arms,
as they can exert significant pressure on the patient; without
haptic feedback to the operating surgeon, there is the risk of
injury to the patient. The surgeon is reliant on staff at the table
to inform them that the arms are clashing or touching the
patient. The majority of cases will be in an extremely flexed,
lateral decubitus position, and additional care needs to be
taken to ensure pressure areas are padded and the patient is
securely fixed to the operating table. Depending on the opera-
tive side, the position of the robot may be altered to allow the
patient’s face to be directed towards the anaesthetist, which
can help optimise access to the airway during surgery.
The need for accurate dissection planes and angulation
means RATS is particularly suited to mediastinal surgery.
Here, the patient is positioned supine, with the side of the
patient from which surgical access is required, being placed at
the edge of the operating table. On the operative side, the
patient’s arm needs to be positioned below the horizontal
plane of the thorax so as not to obstruct the surgical approach.
The addition of a sandbag under the torso helps facilitate this.
Postoperative analgesia is similar to VATS procedures with
all techniques previously described being suitable. Although
the ports inserted are smaller compared to VATS and are
usually in one intercostal space, there are often more of them,
meaning analgesic requirements can be similar. The size of
the surgical sample will continue to dictate the minimum
wound size and the risk of rib fracture. Placement of para-
vertebral blocks at the start of surgery, when ports are inser-
ted, allows regional analgesia to be provided throughout. This
can reduce anaesthetic requirement and is advantageous
during prolonged cases.
Emergency protocols
With the principal surgeon not scrubbed at the table, any
emergency that cannot be controlled by robotic instruments,
and therefore, requires immediate surgical intervention, has
two critical delays built into the resuscitation pathway:
(i) safe removal of the robot to allow resuscitation
(ii) expeditious movement of the surgeon to be scrubbed at
the patient.
In emergency events, such as catastrophic bleeding, short
delays can be critical and every attempt should be made to
minimise them.
The use of emergency protocols is necessary with clear
communication between all team members essential. Given
the proximity of surgery to the great vessels, surgical emer-
gencies are primarily for bleeding. If bleeding is being
controlled by a robotic instrument, the operating surgeon
needs to communicate to the scrub nurse which instruments
are in use and which can safely be removed. Bleeding can then
be controlled by the surgical assistant with a manual instru-
ment, and once all robotic instruments are removed, the robot
is undocked from the patient and a thoracotomy performed.
In uncontrolled bleeding, all surgical instruments should be
immediately released and the scrub nurse should undock all
robotic arms. The robot is then removed and a thoracotomy
performed immediately.
Anaesthetic emergencies can include loss of airway, car-
diac arrest, anaphylaxis or malignant hyperthermia. In this
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situation, an emergency should be declared, all instruments
should be released and removed, and then the robot is
undocked. The table should be flattened to a neutral position
with resuscitation continuing as normal.
Clear communication and awareness of roles are essential
to ensure the robot is undocked safely and efficiently.
Rehearsing and simulation of these emergencies as a team
will help safely manage them when they occur.
Conclusions
The increasing use of MITS procedures means the safe pro-
vision of perioperative care is becoming essential. VATS
numbers are increasing, with older and sicker patients pre-
senting for surgery. RATS is a novel surgical technique that
has implications for the whole operating theatre team.
Declaration of interest
The authors declare that they have no conflicts of interest.
MCQs
The associated MCQs (to support CME/CPD activity) will be
accessible at www.bjaed.org/cme/home by subscribers to BJA
Education.
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