Anesthesia for Robotic Surgery

Dr. Sunila Sharma

M.D,MNAMS,PGDHA,PGDMLE,FICA
 Commercially available Robot

Da Vinci System [Intuitive Surgical ]

Autonomous, Reprogrammable Manipulator designed

to move and articulate specialized instruments
through programmed motions …[Telemanipulation]

…The . surgeon achieves a specific task by using

computer –assisted instruments from a remote
location .
Impossible access to airway during upper
abdominal, thoracic , head & neck surgeries
 Robotic Surgery
• Minimally invasive Surgery
• Overcomes several shortcomings of conventional
laparoscopic techniques [Two dimensional view, surgeon’s
restricted ergonomics , better instruments ]
• But it requires innovations in patient positioning
and overall arrangement of operative equipment
and personnel which may go against the
conservative nature of anesthesia care.

Jeong Rim Lee, Anesthesia and Pain Research Institute, Seoul, Korea.
 Type of Robotic Surgeries
Radical prostatectomy
Fundoplication
Heller Myomectomy
Bariatric Surgery
Colostomy
Cholecystectomy
For hysterectomy, there may be
potential risks but no advantages
Advantages
• Three-dimensional imaging
• Elimination of motion
reversal
• Motion scaling
• Filtering of resting tremors
of surgeon
• Ergonomically comfortable
position
 Patient Benefits of Robotic Surgery
• Ideal for complex and difficult to access surgeries

• Reduces pain and discomfort with faster recovery time

• Reduces blood loss and transfusions.

• Facilitates smaller incisions to heal , resulting in reduced risk of

infection

* Minimal scarring and shorter hospitalization

 Pre- anesthetic considerations
Preoperative anesthetic evaluation
and Preparation for Patient Selection *** Existence of a Pre-existing
Intracranial pathology
• Identify CVS disease [mass lesions and edema] is an…..
Myocardial ischemia,
Low functional status,
Signs of cardiac failure Absolute Contraindication to Robotic
Get Cardiovascular evaluation with TEE for Surgery
Systolic or diastolic dysfunction ,
Wall motion abnormalities
Valvular abnormalities
Hold Aspirin & antiplatelet drugs
• Tobacco abuse for two weeks before the procedure
• COPD, Anemia, Diabetes
DVT prophylaxis.
• Pulmonary Hypertension
• Renal abnormalities Preoperative sequential compression devices
• Glaucoma and
5000U of subcutaneous heparin
.
 Preparation & Premedication
Day before : Laxative + Antacid
• Preoperative :
antisialogue , antibiotic prophylaxis [Cefazolin
1-2 gm]
• Induction & Maintenance :
Two wide bore IV cannulae with extension
tubings
Monitors [CVP, Art line] as per functional status
of patient
Patient Well strapped
Patient positioning
Steep Trendelenburg position and
Pneumoperitoneum
a. push the abdominal contents
cephalad
b. decrease the lung compliance and
functional residual capacity [FRC].
Hence individual patients’ responses
need to be closely monitored for :
 *ventilation perfusion mismatch
*pulmonary edema
* atelectasis.
 Anesthetic Considerations….[a ]
1. Spatial Restrictions due to bulky equipment
2. Restricted access to patient after positioning and
engaging of robot
3. Invasive lines, monitors, patient protective
devices must be placed and secured beforehand
to prevent kinking or displacement.
4. Robot needs to be detached first for any kind of
patient access during emergency
5. Patient movement while robotic instruments are
docked can cause tear or puncture of internal
organs and vasculature.
 Anesthetic considerations …….[b]
6. Surgical Positioning –Steep Trendelenburg
requires restraints to prevent patient sliding.
- Decreases the lung compliance and functional
residual capacity [FRC].
- Needs watch for ventilation perfusion
mismatch, pulmonary edema and atelectasis.
- Prolonged operative durations may cause
Positioning Injuries by bulky robotic arms [6.6%
of 334 adult urological operations ]
7. Impossible access to airway during upper
abdominal, thoracic , head & neck surgeries
 Anesthesia
• Standard Induction ,ETT placement
• Fentanyl and Relaxant infusions to avoid
patient movements
• In one lung anesthesia ,Continuous CPAP to
non ventilated lung and PEEP to ventilated
lung maintaining plateau pressure of <30 cm
water and PaCO2 < 40mmHg [by RR
adjustment & ABG]
 Intraoperative Monitoring …… [c]

8. Aim to safeguard cardiac and cerebral perfusion

Importance to coronary and cerebral perfusion
pressures [CPPs] rather than more attention to
mean arterial pressure [MAP] is necessary .
 Complications of CO2
Pneumoperitoneum / Capnothorax

• Subcutaneous Emphysema
• Pneumothorax
• Pneumomediastinum
• Gas Embolism
• Increased CO2 absorption during retroperitoneal
dissections + steep Trendelenburg position ->
a. Pushes abdominal contents cephalad and reduces
FRC and Lung Compliance
 Risks between 2011 and Aug.2012
During robotic use Probably under reported

• Permanent Nerve Damage due to

 34 percent injuries steep head Down unnatural
[prompted the FDA to launch an Position
inquiry] .
• Injuries from hitting adjacent
 71 deaths organs due to lack of tactile
feedback to surgeons of cutting
[since the robot was introduced] directly into patients’ tissues

• Electric burns from the machine

.

Risks were Probably under reported : Johns Hopkins study

 Conclusion
• "All the studies so far show it's no better or worse,
but it takes longer and is more expensive"

• Reviews of studies on other operations, including gallbladder

removal, colorectal surgery and procedures to reverse reflux, have
reached similar conclusions.

James T. Breeden, M.D., immediate past president of the American Congress of Obstetricians and Gynecologists
 Anesthesiologists need to be prepared for screening
and selection of patients keeping in mind –

the steep learning curves of surgeons,

 long surgical hours,
 extreme patient positioning and
other previously unknown anesthetic
challenges brought about by the surgical
robot.

Kakar PN, Das J, Roy PM, Pant V. Robotic invasion of operation theatre and associated
anaesthetic issues: A review. Indian J Anaesth [serial online] 2011 [cited 2019 Apr
8];55:18-25. Available from: http://www.ijaweb.org/text.asp?2011/55/1/18/76577
 Patients will keep getting lured to the latest and fancy techniques
[if they are convinced and can afford them]

But -both -the anesthesiologist & the surgeon need to be in

sync with each other on common points and stand together
during their communications of the risks and benefits of the
procedure ,statistics of their probability and outcomes with
the family .

 If risks materialize --Seniors need to guide and oversee the

treatments instituted - as well as the final documentation
after patient is settled and handed over to the ICU personnel .

Ensure that the treatment given is in line with the prevailing

protocols and guidelines of the institution and the
professional societies.
 References:
• https://www.advancesinanesthesia.com/article/S0737-6146(12)00006-8/pdf-
Anesthetic Considerations for Robotic Surgery in the steep Trendelenburg
Position , Alain F.Kalmar, Andre M.De Wolf,Jan F.A.Hendrickx,
• https://www.bing.com: Anesthesia for robotic surgery
• Jeong Rim Lee
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3926998/Korean J
Anesthesiol. 2014 Jan; 66(1): 3–11. “Anesthetic considerations for robotic
surgery “
• https://www.medicalsearch.com.au/the-pros-and-cons-of-robotic-
surgery/f/16915
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4247445/
• Kakar PN, Das J, Roy PM, Pant V. Robotic invasion of operation theatre and
associated anaesthetic issues: A review. Indian J Anaesth [serial online] 2011
[cited 2019 Apr 8];55:18-25. Available from: http://www.ijaweb.org/text.asp?
2011/55/1/18/76577
Thank You
sunilasharma@hotmail.com