Anesthesia for Robotic

Surgery

Dr Mukul Kapoor
Director Anesthesia
Max Smart Super Speciality Hospital,
Saket, Delhi
 Introduction
• Robotic surgery is the offshoot of an increasing demand for greater
surgical precision, safer operations & increasing adoption of
minimal invasive surgery to enhance patient outcomes
• With the growing market pressures for minimally invasive
procedures, the role of robotic assisted surgery and its advantages
of improved surgical precision is likely to grow
• Robotic device is a “powered, computer controlled manipulator
with artificial sensing that can be reprogrammed to move and
position tools to carry out a wide range of tasks”
• Robotic systems used in surgery today are computer assisted
devices and are not true robots, because they lack independent
motions or preprogrammed actions
 History

•Clinical introduction of the Puma 560 in 1985 led to the first

surgical robot being applied to perform selective brain biopsies
•Telerobotic surgery was born with US Department of Defense
developing a system to allow surgeons treat soldiers
•In the early 1990’s, NASA and Stanford researchers joined to
develop a telemanipulator for hand surgery
•Convergence of telerobotic surgery with laparoscopic surgery led to
development of two robotic systems: da Vinci Robotic and Zeus
•First robotic assisted surgery was performed by Jacques Himpens &
Guy Cardiere using the da Vinci surgical system in April 1997
 Why Robotic

• Paradigm shift in surgical thinking as robots offer more than

“an equivalent-to-open operation with smaller incisions”
• An operation with a robot permits a higher level of tissue
discrimination, dissection and repair
•Offers advantages such as 3D view, visibility of difficult to reach
areas, easier instrument manipulation and the possibility of
remote site surgery
•Surgeon is “teleported to the operative site” with the robots
performing tasks as a “master-slave” relationship
 Advantages of Robotic Surgery

• Robotic assisted surgery is an evolutionary step in

advancement of minimally invasive surgical procedures. It is
associated with:
• reduced postoperative pain
• improved cosmesis (smaller incisions)
• shorter hospital stays
• faster postoperative recovery
• potentially lower costs
• improved patient satisfaction
 Vision Advantages of Robotic Surgery

• Improved operative field visibility with 3D imaging systems -

the surgeon views 3D images because each eye is linked to a
separate camera. The human brain processes each image giving
the surgeon depth perception as a synchronizer in the system
maintains each frame from each camera in phase
•Potential for better visualization by magnification &
stereoscopic views
 Precision Advantages of Robotic Surgery

•“Robotic wrist” allows up to seven degrees of freedom

•Robotic systems allow for more ergonomic, anatomic control of
instruments closely mimicking human wrist movement (7
degrees versus 4 degrees of motion with laparoscopy)
•Safety feature built is that an infrared sensor crosses the plane
of the viewer - The console will not move any robotic arms or
instruments unless the surgeon is in position to view the
surgical field. If surgeon is not in the plane of the infrared
sensor, the console will not follow commands
Degrees of Freedom
Endo-wrist
 Other Advantages of Robotic Surgery

•Improved kinematics - large external movements of surgical

hands scaled down and transformed to limited movements of
“robotic hands” - to perform complex tasks in limited space
•Eliminates hand tremor computer assisted scaling, improves
control of fine movements and reduces the “fulcrum effect”
which amplifies unwanted motions such as hand tremor - greater
precision
•Computerization allows integration of real-time/previously
recorded data to accommodate intra-op factors eg compensate
for movement of heart during cardiac surgery
• Less need of assistance
 Pitfalls of Robotic Surgery

• Bulky instruments need large amounts of OR space - space

constraints may be the limiting factor to fashion a Robotic OR
• Important to avoid collision of operating arms, assistants and/or
the patient
• Invasion of anesthetic work space impairs ability to access patient
• Repositioning a patient is almost impossible once the robot has
been stationed for surgery
• Robotic systems lack tactile feedback from the instruments so
surgeons must only rely on visual cues to modulate the amount of
tension and pressure applied to tissues to avoid organ damage
 Economic Constraints

• A contemporary da Vinci robotic platform costs approximately

£1.55 million, with a yearly service charge of £125000 and
instrument cost of approximately £2000 per case
• Each instrument in the system has a limited life and reordering
consumable instruments adds significant cost
• Other costs include
• initial increased OR setup time
• increased surgical times as individuals climb learning curve
• OR staff training
Surgical robots as ground-breaking for
surgeons as the LMA is for anesthetists
 Da Vinci Robot

Robotic Arms Deployed Robot

Console Coronary Anastomosis

da Vinci System
 da vinci System
• da Vinci® system has a control console where the surgeon sits to
view and control the robot
• Surgeon’s fingers are connected via the console and robot to the
surgical instruments
• Console has a 3D viewer
• Motion scaling can be adjusted form a 1:1 up to 5:1 ratio ie 5
inches of hand motion is translated to 1 inch of instrument motion
thus filtering out hand tremors
• Foot pedals allow the surgeon to control electrocautery, ultrasonic
instruments, adjust the focal point of the camera, and manipulate
robotic instruments
 da vinci System
• Second component of the system contains video equipment to
record and display images of the surgical site onto 2D monitors.
It also has other laparoscopic instruments such as insufflators
are on this tower
• Third component is the robot itself which consists of three or
four operative arms
• The central arm holds the video telescope while a right and left
arm perform manipulations.
• The original da Vinci® robot had three arms. A fourth arm was
later added which can be positioned and locked into place to
work as a stationary retractor
 Surgeries performed by
Robotics

• Robotic system was initially designed for cardiac surgeries

• Robotics have also been used in many cardio-thoracic,
gynecologic, neurosurgical, ophthalmologic, orthopedic and
urologic cases
• Robotic radical prostatectomy is the most common robotic surgery
performed world wide and is now standard of care for Ca Prostate
• With future developments in robotic systems, it is conceivable that
all surgeries may eventually be done with robotic assistance
 Anesthetic Concerns

Issues related to and specific to robotic surgeries include

• patient positioning
• duration of procedure
• development of hypothermia
• hemodynamic & respiratory effects of pneumoperitoneum
• hemodynamic & respiratory effects of positioning
• occult blood loss
 Patient Positioning
• Robotic surgery does not allow for changes in patient position on the
OR table once the robot has been docked - dock after positioning
• Patient positioning varies with each surgical procedure
• Pelvic surgery, such as prostatectomy, in lithotomy and steep
Trendelenburg position
• Upper abdomen & diaphragm surgery in supine & reverse
Trendelenburg positions
• Chest surgery in lateral position, with Trendelenburg or reverse
Trendelenburg tilt according to site
• Mediastinal surgeries require lateral position with lateral table tilt
• Extreme patient positioning required so that gravity helps move
obstructing organs away from surgical field
 Patient Mattress

• Extreme positioning increases risk of patients sliding off OR table

• restraints must be used
• taping a foam egg crate mattress to OR table with convoluted
side of the foam facing down and smooth side in patient contact
• traction generated to prevent patient movement
• Procedure are often lengthy, especially for inexperienced surgeons
- adequate pressure point padding is essential to avoid tissue &
nerve impingement (prior to draping & docking robot)
• Cameras and light sources should be carefully monitored & not
never left directly on drapes to avoid fires & thermal injury
 Airway Access
• Size & bulk of robot over patient & significant draping on both
robot and patient, make intraop patient access difficult
• Patient’s airway may be far from anesthesiologist & anesthesia
machine
• Upper abdominal & thoracic surgeries are done OR table rotated
180o away from anesthesiologist and with robot cephalad above
the patient
• Mediastinal procedures require OR table to be rotated 90o away
• Access to patient’s airway is nearly impossible - challenging if one
lung ventilation is requested and frequent use of fiberoptic
bronchoscope is necessary
 Hemodynamic Changes
• Physiologic perturbations are similar to laparoscopy/thoracoscopy
• Phasic changes in hemodynamics secondary to CO2 insufflation
• Increase in SVR, MAP, CVP
• Cardiac index decreases by 50% after initial CO2 insufflation
• Cardiac index gradually increases & SVR decreases 10 minutes
after CO2 insufflation
• CVP & PCWP may rise
• Hemodynamic changes correlate with increases in intraabdominal
pressure & its effect on diaphragm
• Hemodynamics affected by patient’s position
• Cardiac output decreases10-30% in Trendelenburg & reverse
Trendelenburg
 Other Changes

• Increases cerebral blood flow & ICP

• Decreases portal vein flow, hepatic vein flow, total hepatic blood
flow and flow through the hepatic microcirculation - there are no
changes in hepatic artery flow
• Decreases gastric pH, mesenteric blood flow & gastrointestinal
microcirculation blood flow
• Decrease in renal artery and vein blood flow, and a decrease in
medullary and cortical flow
 Respiratory System
• 30-50% decrease in pulmonary compliance in both healthy &
obese
• Reduced FRC due to diaphragmatic elevation
• Increased Paw, plateau pressure & intrathoracic pressure
• No significant changes in ventilation or perfusion
• Maintenance of normocarbia & acid base status may be
challenging in patients with poor preop respiratory status
• Increase in PaCO2 & respiratory acidosis due to peritoneal
absorption of CO2, increased dead space in patients with
coexisting lung disease, increased metabolism, inadequate
ventilation, subcutaneous emphysema, and/or CO2 embolism
 Anesthesia Technique
• An enhanced anesthesia recovery protocol contributes to the
incremental gains offered by robotic surgery by providing optimal
fluid management, analgesia, reducing PONV and POCD,
improving recovery and discharge times and overall patient
satisfaction
• Restrictive fluid management to avoid edema
• Some evidence suggests superiority of TIVA over volatile
anesthetic techniques but there is limited evidence to make
recommendations for its use in all types of robotic surgery
• Postoperative analgesia may be improved with neuroaxial
techniques such as intrathecal opioids for reduced systemic opiate
use, reduced pain scores and increased patient and nursing staff
satisfaction
 Common Complications
• The most frequent complications are
• peripheral neuropathies
• corneal abrasions
• vascular complications including compartment syndrome
• rhabdomyolysis
• thromboembolic disease
• effects of edema (cerebral, ocular and airway)
• Shoulder braces and beanbags have been implicated in brachial
plexus injuries and so should be avoided
• Chest banding to stabilize position may compromise lung
compliance
 Dependent Edema
• Dependent edema can become problematic, particularly after long
surgeries in the steep head down position
• Laryngeal edema may occur and presents as respiratory distress &
airway compromise
• The overall incidence of reintubation after robotic surgery is
around 0.7%, and delayed extubation 3.5%; but the incidence of
airway edema may be up to 26%
• Perform direct laryngoscopy and use a leak test before tracheal
extubation & consider airway exchange catheter
• Facial and periorbital edema is indicative of laryngeal edema
• Glaucoma is a contraindication for robotic as IOP increases
 Cerebral Edema
• Causes confusion or reduced levels of consciousness postop
• Pathogenesis is likely because of increased venous pressure in
Trendelenburg position with pneumoperitoneum leading to
increased ICP and capillary leak.
• Preventative strategies include
• limiting operative time, minimizing the angle of Trendelenburg
• limiting insufflation pressure to 8mm Hg
• fluid restriction
• maintain a normal EtCO2
• High-risk patients can be electively ventilated postop
 Systemic Review Robotic
• All literature for first 30 yr of robotic surgery (1985–2015) reviewed and
108 studies on 14448 patients identified
• Robotic vs Open surgery - 11 RCTs and 39 prospective studies, in Robotic
• 50.5% lower blood loss
• 27.2% lower transfusion rate
• 69.5% lower length of hospital stay
• 63.7% reduction of 30-day overall complication rate
• Robotic vs MIS - 21 RCTs and 37 prospective studies, in Robotic
• 85.3% mildly reduced blood loss
• 62.1% transfusion rate
• Similar length of hospital stay (98.2%)
• Similar 30-day overall complication rate (98.8%)
• In both comparisons, robotic had longer operative time (7.3% longer
than open surgery & 13.5% longer than MIS)

Tan A, et al. Robotic surgery: disruptive innovation or unfulfilled promise? A systematic

review and meta-analysis of the first 30 years. Surg Endosc 2016; 30: 4330–52