anaesthetic concerns during robotic urological surgery

1. ANAESTHETIC CONCERNS FOR
ROBOTIC ASSISTED UROLOGICAL
SURGERIES
Dr. Abhishek Nagarajappa
Assistant Professor
Department of Anaesthesiology, Pain medicine and critical care
AIIMS, New Delhi

2. ROBOT
A powered, computer controlled manipulator
with artificial sensing
that can be reprogrammed
to move & position tools
to carry out a wide range of tasks’

3. ROBOT
• Czech word
‘ROBOTA’  ‘forced labor’
• 1985: first documented use of a robot-assisted surgical procedure
PUMA 560 robotic surgical arm

4. Robotic–Assisted Surgery
Good communication + Knowledge of robotic surgery
have the potential to
• improve patient outcomes
• increase efficiency
• reduce surgical and anesthetic complications.

5. ROBOTIC SYSTEMS
• Industrial robots
• Assist devices
• Telemanipulator

6. Industrial robots
• Perform highly precise, repetitive tasks
• Preprogrammed off-line
• Tasks are invoked on command
• Precise tasks are programmed based on Registration :
based on pre-op CT or MRI
eg. Orthopedics (drilling), neurosurgery (probe insertion)
ROBOTIC SYSTEMS

7. Assist devices
• AESOP (Automated Endoscopic System for Optimal Positioning) surgical system
• Function: to manoeuvre an endoscope inside the patient's body during the
surgery
• Camera moves based on voice commands by the surgeon.
• Voice activation allows the surgeon to use it while still holding on to the controls
for the other two arms
• Endoscope can also be controlled by a computer
ROBOTIC SYSTEMS

8. Telemanipulator
• Are under constant control of the operator
• Mimic the operator’s hand motions in an exact
or scaled motion
• Types :
A. da Vinci Robotic Surgical System : approved
for laparoscopy, thoracoscopy & intracardiac
mitral valve repair surgery
B. ZEUS Surgical System : approved for general &
laparoscopic surgery
ROBOTIC SYSTEMS

9. da VINCI SURGICAL ROBOTIC SYSTEM

11. da Vinci Surgical Robotic System
1. Control console
• Has a 3D magnified HD viewer
with control panels
• controls the robot from remote
location
• Simulates experience of being
present in the operative field
• Foot pedals control
electrocautery & ultrasonic
instruments

12. da Vinci Surgical Robotic System
2. Robot / surgical cart
• Has 3 or 4 arms
• Central arm : holds the video
telescopes
• Left & right arms : perform
manipulations
• Fourth arm : stationary retractor
• Wheeled to the vicinity of the
surgical area & is locked into place

13. da Vinci Surgical Robotic System
3. Vision cart
• Monitor
• Video recording equipment
• Laparoscopic instruments like
insufflators
• IAP monitors

14. Robotic urological surgeries
• Robotic-assisted Radical Prostatectomy (RaRP)
• Robotic-assisted Radical cystectomy (RaRC)
• Robotic-assisted Pyeloplasty
• Robotic-assisted TURP
• Renal and adrenal surgery (adults and children)
newer indications are developing

15. Advantages of Robotic-assisted surgery
1. Reduced trauma and pain
2. Reduced stress response
3. Cosmetically better (less scarring)
4. Ease of operation in morbidly obese (stiff instruments help counteract
abdominal wall torque)
5. Quicker recovery & shorter hospital stay

16. Advantages of Robotic-assisted surgery
6. Decreased blood loss
7. Improved patient satisfaction
8. Greater 3D visualization with greater clarity
9. 7 degrees of freedom allowing better control & precision movements
10. Better dissection
11. Tele-surgery

17. Laparoscopic Limitations/Robotic Solutions
Laparoscopic Problems/Limitations Robotic Surgery Solutions/Potential
Two-dimensional vision of surgical field displayed on
the monitor impairs depth perception
Binocular systems and polarizing filters create 3-
dimensional view of the field
Movements are counterintuitive (ie, moving the
instrument to the right appears to the left on the
screen due to mirror-image effect)
Movements are intuitive (ie, moving the control to the
right produces a movement to the right on the viewer)
Unstable camera held by an assistant Surgeon controls camera held in position by robotic
arm, allowing solo surgery
Diminished degrees of freedom of straight
laparoscopic instruments
Microwrists near the tip that mimic the motion of the
human wrist
Surgeon forced to adopt uncomfortable postures
during operation
Superior operative ergonomics: surgeon comfortably
seated on the control console
Steep learning curve Shorter learning curve

18. Disadvantages of Robotic-assisted surgery
1. Very expensive
2. Need of muscle relaxation
(uncompromised)
3. Large space
4. Limited accessibility
5. Prolonged procedure
6. Positioning related problems
7. Pneumoperitoneum related
problems
8. Need for extra monitoring
(invasive- CVP, Arterial)
9. Absence of touch sensation

19. Anesthetic challenges in Urology patients
Related to
• Lithotomy position
• Steep Trendelenburg position (30-450)
• Pneumoperitoneum
• Limited access to the patient
• rigidly placed intraabdominal trocars
attached to the robotic arms

20. Anesthetic challenges in Urology patients
COMBINED EFFECTS
• Hypercarbia
• Hypoxemia
• Increased intraocular pressure
• Increased intracranial pressure
• Decreased perfusion pressure to lower extremities
• Positional injuries

21. Positioning
Lithotomy position
Steep Trendelenburg position (30-450)
Pneumoperitoneum
Limited access to the patient
rigidly placed intraabdominal trocars attached to the robotic arms

22. Positioning
• Lithotomy position
• Steep trendelenberg position (upto 450 headdown tilt)

23. Patient safety is of
Prime importance

24. Lithotomy
• Supine position
• Arms: may be abducted out to the side
or adducted (tucked) alongside the body
• Hand and forearm: Supination or neutral position
• Bony points padded

25. Lithotomy
• Hips: flexed 800 -1000 from the trunk
• Legs: abducted 300 -450 degrees from the midline
• Knees: flexed until the lower legs are parallel to the torso
• Supports or stirrups hold the legs in position.

26. Lithotomy
Supports
• Candy-cane
• Calf support
• Knee-crutch

30. Lithotomy
• Recommended position of the
arms: on armrests far from the
table hinge point.
If the arms must be tucked at the
patient’s side:
• hands need to be visualized
• confirmed to be safe whenever
the leg section is manipulated.

31. Lithotomy position: Initiation
• Co-ordinated positioning by 2 assistants
• to avoid torsion of the lumbar spine.
• Both legs should be raised together, simultaneously flexing the hips
and knees.
• Lower extremities padded
• to prevent compression against the stirrups.

32. Lithotomy position: after surgery
• Returned to the supine position in a coordinated manner.
• Care of hand position.
• Legs should be simultaneously removed from the holders
• Knees brought together in the midline
• Legs slowly straightened and lowered onto the surgical table.

33. Lithotomy – physiology changes
 Cardiovascular
• Venous return
• Cardiac output
• Cerebral venous and intracranial pressure
Respiratory
• Compliance
• Tidal volume

34. Lithotomy – Nerve injuries
• Common Peroneal nerve injury
(MC-78%)
• Sephanous nerve injury
• Femoral nerve injury
• Obturator nerve injury
• Compartment syndrome (>3.5
hours of duration)

35. Trendelenberg position
• Friedrich Trendelenburg (German surgeon) for abdominal surgeries
• Increases central venous pressure
• Increases intracranial pressure
• Increases intraocular pressures
• Have significant cardiovascular and respiratory consequences

37. Steep Trendelenberg position
• >30-450 tilt
Special care
• taken to prevent patients from slipping cephalad on the surgical table
• to avoid compression of the brachial plexus by the torso against the
shoulder girdle

38. Steep Trendelenberg position
Prevent sliding
• antiskid bedding
• knee flexion
• beanbag cradling
• padded cross-torso straps
• shoulder braces not recommended

39. Steep Trendelenberg position
 Hemodynamic effects
• perfusion pressure of lower extremities
• MAP at the circle of Willis
• central blood volume
• cardiac output
• perfusion of vital organs in a normovolemic patient.

40. Steep Trendelenberg position
 Respiratory effects
• compliance
• vital capacity
• functional residual capacity
• lung volumes
• ventilation-perfusion mismatch
These effects compound the effects of pneumoperitomeum

41. Steep Trendelenberg position
Complications
• Pressure alopecia
• Backache
• Peripheral nerve injury
• Most common- Ulnar neuropathy
• Prolonged Head-down
• swelling of the face, conjunctiva, larynx, and tongue
• postoperative upper airway oedema (Extubate?)
• postoperative visual loss

42. Steep Trendelenberg position
 Other potential problems
• Regurgitation --> increased their risk of aspiration
• Increased intracranial pressure
• Increased intraocular pressure
• Venous air embolism
• Brachial plexopathy
• Arthralgias
• Compartment syndrome
• Finger injuries
• Bronchial migration of ETT

43. Steep Trendelenberg position
potential risks in patients with cardiac disease
• Increased myocardial oxygen consumption
• Ischemia
• Arrhythmias
• Decreased oxygen delivery

44. Positioning
Lithotomy position
Steep Trendelenburg position (30-450)
Pneumoperitoneum
Limited access to the patient
Intraabdominal trocars attached to the robotic arms

45. Pneumoperitoneum
• Air, Oxygen, Carbon dioxide, Argon, Helium
Ideal gas:
• Non toxic
• Colourless
• Readily soluble in blood
• Easily ventilated through lungs
• Non flammable
• Inexpensive

46. Pneumoperitoneum
• IAP 12-14mm Hg
• Initial flow rate: 3-6 L/Min
• Maintenance rate: 200-400 ml/Min

47. CO2 Pneumoperitoneum
• Hypercapnia (within 15 to 30 minutes of carbon dioxide insufflation)
• Hypercarbia
• Acidosis
• Tachycardia
• Arrhythmias
• Increase in mechanical ventilation can obviate these changes in most
patients, and most healthy patients tolerate the changes even though
they are clinically significant

48. Pneumoperitoneum
• Ventilatory and respiratory changes include
• decreased compliance (30-50%)
• Decreased FRC
• increased airway pressures
• increased ventilation-perfusion mismatch.
• Hemodynamic changes include
• decreased venous return
• decreased cardiac output
(despite an increase in filling pressures indicative of increased intrathoracic
pressures)

49. Pneumoperitoneum
• CNS:↑ Cerebral blood flow & Intracranial pressure
• Liver:↓ portal & hepatic vein flow, total hepatic blood flow. No
change in hepatic artery flow
• GIT: ↓gastric Ph, mesenteric blood flow & GI microcirculation blood
flow
• Renal:↓renal artery & vein blood flow, ↓ medullary & cortical renal
flow

50. Pneumoperitoneum
Risks associated
• Damage to solid viscera, bowel, bladder, blood vessels
• Large vessel vascular injuries
• Venous gas embolism
• Ventilation-perfusion mismatch
• Lower limb compartment syndrome

51. Pneumoperitoneum
Pneumoperitoneum
Pressure over IVC
Decreased venous return
Peripheral pooling of blood
Decreased preload
Decreased cardiac output
Decreased BP, increased heart
rate
Peritoneal stretching
Increased vagal
stimulus
Bradycardia
Decreased diaphragm
mobility
Decreased tidal
volume
decreased total
lung capacity
increased airway
pressures
Pressure over renal artery
decreased renal
blood flow
decreased GFR
RAAS stimulation
increased aldosterone
increased sodium
retention

52. Gasless laparoscopy?
• Abdominal wall lift
• Compromises surgical exposure
• Technically difficult
• Appealing for patients with severe cardiac and pulmonary disease

53. Positioning
Lithotomy position
Steep Trendelenburg position (30-450)
Pneumoperitoneum
Limited access to the patient
Intraabdominal trocars attached to the robotic arms

54. Limited access
• Surgical cart robot placed very close to pt’s head
• Limited access to pt’s airway & neck
• Head must be guarded to prevent collision with robotic arms
when moving
• After engaging robot, pt’s body position cannot be changed

55. Positioning
Lithotomy position
Steep Trendelenburg position (30-450)
Pneumoperitoneum
Limited access to the patient
Intraabdominal trocars attached to the robotic arms

56. Intraabdominal trocars attached to the robotic arms
• In case of emergencies:
• Cardiac arrest
• Accidental extubation
• Earthquake!
• Etc
• Rapidly disengaging the robot
• Be prepared for resuscitation as required

57. Preoperative evaluation
• Factors which may be of concern with prolonged pneumoperitoneum
& extremes of positioning :
1. CNS - elevated ICP, CVA, aneurysm, glaucoma, pre-existing neuropathy or
susceptibility
2. CVS - cardiomyopathy, CAD or MI, valvular disease
3. Pulmonary – COPD, bullous emphysema, spontaneous pneumothorax,
reactive airway disease
4. Renal insufficiency
5. Cervical spine disease, back pain

58. Anaesthetic management
Monitoring:
• Non invasive:
• ECG, pulse oximetry
• NIBP
• Temperature
• Capnography
• Urine output
• neuromuscular monitoring
• Invasive:
• Arterial BP
• CVP (individualized to each patient)

59. • Requirements :
1. Bilateral peripheral large bore iv access
2. Orogastric tube
3. Urinary bladder catheterisation
4. Convective-air body warmers
5. Careful positioning
6. Eye care
7. Head support
8. Sequential compression stockings

60. • GA with endotracheal intubation
• Neuraxial techniques are currently not recommended
• Pressure controlled ventilation with PEEP
• Mild hyperventilation to prevent hypercarbia
• Head protection with guards
• Thromboprophylaxis for prolonged surgery

61. Complete Muscle relaxation
• Absolute essential
• Unlike Laparoscopic surgery, trocars are fixed
• laparoscopic surgeon can move their insturments if patients move
• Robotic surgeon can see tiny movements before anesthesia provider at times
• It is essential to keep an open line of communication with surgeon

62. The advent of anaesthesia
has made it so that
any idiot can become a surgeon!
-Dr. William Stewart Halsted (1852-1922)
(founding professor at John Hopkins Hospital)

63. Thank you..

64. Additional material for exams

65. KEPLER INTUBATION SYSTEM

66. SEDASYS

67. CLINICAL APPLICATIONS OF ROBOTS IN SURGERY
A. ABDOMINAL SURGERIES
• Nissen fundoplication
• Cholecystectomy
• Heller’s myotomy
• Gastric-bypass, pancreatoduodenectomy
• Esophagectomy & gastrectomy
• Bowel resection
• Adrenalectomy
B. UROLOGIC SURGERIES
• TURP
• Radical prostatectomy
• Ureter repair, pyeloplasty, nephrectomy

68. CLINICAL APPLICATIONS OF ROBOTS IN SURGERY
C. CARDIOTHORACIC SURGERIES
• Internal mammary artery harvesting
• ASD repair
• CABG
• Mitral valvuloplasty
• Lung surgeries
D. GYNAECOLOGIC SURGERIES
• Tubal re-canalization
• Hysterectomy
• Ovary resection

69. E. NEUROSURGERIES
• Complement image guided surgery
• Radiosurgery
F. ORTHOPAEDIC SURGERIES
• Total hip replacement
• Total knee replacement
• Spine surgeries
G. OTHERS
• Laser surgeries (retinal)
• Airway surgeries
CLINICAL APPLICATIONS OF ROBOTS IN SURGERY