Anaesthesia for ROBOTIC SURGERY

1. Anaesthesia for Robotic
Surgery
Presenter : Dr Masudur Rahman
Moderator : Dr Amit Kundu

2. WHAT IS A ROBOT..?
• The word robota has been termed by the Czech playwright Karel
Capek in his 1920s play, Rossum’s Universal Robots (RUR).
• His description is colorful: slaves do human labor joyfully, so that
humans can enjoy life without concerns.
• Most modern definitions agree that a robot is a device that is self-
controlled, consisting of anything from mechanical, electrical, to
electronic units.

3. Introduction
• Robotic devices are being introduced to surgery because they allow
unprecedented control and precision of surgical instruments in minimally
invasive procedures.
• The anticipated benefits of robotic or robot-assisted surgery to the patient
include less pain and trauma, shorter hospital stays, quicker recovery, and a
better cosmetic result.
• These are not true autonomous robots that perform surgical tasks; rather, they
are mechanical “helping hands” that offer assistance in various fields of
surgery.
• anesthesiologists should keep abreast of these changes and their effect on
patient care and safety.

4. HISTORY
• The word robot was first used by Capek in his play Rossum’s Universal
Robots in 1921.
• It is derived from the Czech word robota, meaning “forced labor.”
• it became apparent to the U.S. Department of Defense (DOD) that virtual
reality and telepresence might serve a useful function in treating wartime
casualties on the battlefield.
• Although laparoscopic surgery provided great benefit for patients, it
brought tremendous surgical limitations, such as loss of three-dimensional
vision, impaired touch sensation, and poor dexterity provided by the long
instruments and the fulcrum effect.

5. • The first surgical robotic devices appeared in the 1980s for use in
stereotactic brain surgery.
• In 1992, ROBODOC (Integrated Surgical Systems, Sacramento, CA)
was introduced for grinding bone to make space for prostheses in hip
replacement surgery.
• The first master-slave manipulator for medical use was developed at
Stanford Research Institute in 1991.
• Early designs had only four degrees of freedom, but by 1992, a German
prototype was developed with six degrees of freedom.

6. ROBOTIC SYSTEMS
• Assist- device robots
• Telemanipulator
• da Vinci Robotic Surgical System
• the ZEUS Surgical System

7. da Vinci Robotic Surgical System

8. ZEUS Surgical System

9. da Vinci Robotic Surgical System
• It has been approved by the U.S. Food and Drug Administration (FDA)
for use in urologic procedures, general laparoscopic surgical procedures,
gynecologic procedures, transoral otolaryngology procedures, general
thoracoscopic procedures, and thoracoscopically assisted cardiotomy
procedures.
• The components of the da Vinci system include: a Surgeon Console, a
patient-side cart, EndoWrist instruments, and an optical vision tower

10. • The patient-side cart has four arms that can be manipulated by the
surgeon through real-time computer-assisted control.
• The EndoWrist instruments are designed to have seven degrees of
motion—a range of motion even greater than the human wrist.
• design incorporates a frequency filter that eliminates hand tremor
greater than 6 Hz.
• Motion scaling also can be invoked up to a ratio of 5:1

15. • Preoperative assessment of lung function is indicated if a patient has
significant lung disease.
• Poor pulmonary function test results or pulmonary hypertension may
be contraindications to robotically assisted cardiac surgery

16. PREOPERATIVE ASSESSMENT
• A systemic review of the patients history and physical examination is warranted
prior to robotic surgery
• Age, medications, allergies, surgical and anaesthetic history should be noted.
• Baseline, vital signs, should be obtained and a thorough airway examination
should be conducted.

17. PREOPERATIVE PREPARATION
• At a minimum preoperative studies for robotic surgery should include
Electrocardiogram,Chest radiograph and blood work,notably:blood
counts,coagulation status,renal function and basic electrolytes
• The Patients blood should be typed and screened for umusual antigens
• Fasting blood glucose should be noted before surgery for diabetic patients
• Reflux,infection and deep vein thrombosis prophylaxis should be considered
with non particulate antaacid,antibiotics(within 1 hour of surgical
incision),subcutaneous heparin and sequestial compression devices respectively.
• ASA status assigned(>4-higher risk)

18. ANAESTHETIC CONCERNS WITH ROBOTIC ASSISTED
SURGERY
Several important issues related to and specific to robotic surgeries include
• Patient positiniong
• Duration of procedure
• Development of hypothermia
• The haemodynamic and respiratory effects of pnemoperitoneum
• Occult blood loss

19. GETTING STARTED
• MONITORING-ECG,PULSE OXIMETRY,AXILLARY TEMPERATURE
PROBE,NIBP,CAPNOGRAM,
• TEE-For thoracic surgery is the standard of care
• Bilateral peripheral venous access
• Arterial Line haemodynamic monitoring should be considered in special cases
• Muscle relaxant is paramount
• Orogastric tube and Foleys catheter
• Convective air body warmers
• Ventilator adjustments to normalize exhaled CO2

20. INDUCTION
• Standard Intravenous induction is feasible,adjusting anaesthetic planning
based on the patient’s medical condition
• The endotracheal tube should be taped securely,appreciating that patient
positinioning may alter patients position over time,robotic instrumentation
may dislodge a tube and an obstructed view may delay recognition of a
tube that has disloged.
• Replacing an endotracheal tube would be challenging for robotic surgery
patients based on positioning and the time delay associated with
undocking

21. PROLONGED PREPARATION TIME
• Post induction,care should be taken to balance the need for continued sadation against any
haemodynamic instability that may result from the prolonged preparation time prior to
surgical stimulus.
• Processed Electroencephalographic Monitoring such as BIS or vasopressor agents may be
required to bridge the gap between induction and surgical incision

22. PATIENT POSITIONING
• Robotic Surgery With the DA VINCI SYSTEM does not allow for changes
in a patient position on the operating room table once the robot has been
docked
• Therefore the Robot should be docked only after the patient has been
optimally positioned for surgery
• Patient body position cannot be modified unless the instruments disengage
entirely and removed form the body cavity

23. ADEQUATE EXTENSIONS FOR ACCESSIBILITY
• Airway and IV access
• The size and bulk of the robot over the patient and the significant
draping on both the robot and patient,make it difficult to access the
patient intraoperatively
• Some procedures require the patients airway to be at a distance from
the anaesthesiologist and the Anaethesia machine/monitor

24. ACCESSIBILITY
• Upper abdominal and thoracic surgeries are done with table rotated 180 degrees
away from the anaesthesiologist and the robot positioned cephalad above the
patient
• Medistinal procedures require the table to be rotated 90 degrees away from the
anaesthesiologist.During these cases,access to the patient’s airway is nearly
impossible,thus field avoidance precautions must be exercised
• These cases are particularly challenging if one lung ventilation is requested
since frequent use of the fibreoptic bronchoscope may be necessary

25. PRESSURE POINTS
• It is imperative to ensure the patient is properly positioned with the pressure points
adequately padded prior to draping and docking the robot
• Robotically assisted surgeries are often lengthy procedures especially for
inexperienced surgeons,thus adequate pressure point padding is essential to avoid
tissue and nerve impingement
• Common nerve injuries to protect include brachial plexus,ulnar and lateral femoral
cutaneous nerves
• Attention should be paid to the degree of limb extension,stirrup location,padding of
bony prominences,and duration of immobility
• Prolonged,steep tredelenburg could result in plethoric facies and laryngeal edema as
well

26. • Once proper patient positioning has been achieved,there are intraoperative
considerations to be addressed
• The physiologic perturbations during robotic surgery are similar for both
laparoscopic and thoracoscopic procedures
Physiologic perturbatiobs

27. CO2
• The maintenance of normocarbia and acid base status may be challenging
in patients with poor preoperative respiratory status
• The main factors contributing to an increase in paco2 and respiratory
acidosis are the peritoneal absorptions of carbon dioxide,increased dead
space in patients with coexisting lung disease,increased
metabolism,inadequate ventilation,subcutaneous emphysema and/or
carbon dioxide embolism

28. THE SAME PRINCIPLES THAT APPLY FOR THORACOSCOPOIC
SURGERY APPLY FOR ROBOTIC ASSISTED THORACIC
SURGERY
• A combination of patient position,one lung anesthesia and surgical manipulation alter
ventilation and perfusion.
• Pulmonary shunting is the most important factor determining oxygenation during
surgery.This shunt may be limited in the non-ventilated lung by disease or hypoxic
pulmonary vasocontriction.
• The lateral position reduces shunting by following the principle of gravity and
decreasing blood flow to the non dependent lung.
• Normocarbia is usually easily maintained during one lung anesthesia due to high
solubility of CO2
• Frequently robotic assisted surgeries require insufflation of C02 in the chest(CO2
Pneumothorax)which increases the airway pressures during one lung anesthesia

29. CHEST INSUFFLATIONS
• The continuous insufflations of CO2 into the chest improves the surgical field by
collapsing the lung further and by shifting mediastinal structures away from the
surgical site
• Insufflations of the chest are usually achieved when the intrathoracic pressure is
10mmHG
• As intrathoracic pressure rises during chest insufflations,there can be both a
decrease in venous return and compliance of the heart which may result in
hypotension and haemodynamic instability
• Respiratory system is greatly impacted by CO2 insufflations
• Pneumoperitoneum may decrease pulmonary compliance by 30-50% in both
healthy and obese patients

30. • It reduces the functional residual capacity due to
diaphragmatic elevation
• Peak airway pressures,plateau pressure and intrathoracic
pressure are increased.However there are usually no significant
changes in ventilation or perfusion in healthy patients
• At the same time the dependent lung develops higher airway
pressures and ventilation can become difficult
• As CO2 is insufflated and absorbed,the rate of elimation must
also increase,A difficult feat to achieve during one lung
anesthesia as minute ventilation may also be maximized.

31. Additional complication
• Another important consideration during robotic thoracic procedures is that
there may be violation of the contralateral pleura which can result in occult
blood loss and a tension pneumothorax on the dependant chest.
• It may present as haemodynamic instability and near impossible ventilation
on the dependent lung
• Immediate discontinuation of CO2 insufflation is mandatory to alleviate the
tension pnemothorax

32. ONE LUNG VENTILATION(OLV) STRATIGIES
• During surgery the inspired oxygen(fio2)at 1.0
• The airway pressure kept below 30cm h20.Begin OLV with PCV
• The ventilation should be adjusted to maintain Paco2 around 40mmhg
• Serial blood gases should be considered
• The application of positive end expiratory pressure(PEEP) to the dependent
lung
• Or continuous positive airway pressure(cpap) to the non dependent lung may
assist in oxygenation

33. • Positioning,pneumoperitoneum and fluids combine to put the patient at risk for airway
edema and failed extubation
• Several reviews have suggested conducting an airway cuff leak test prior to extubation
as an indicator of risk for post extubation stridor
• Patients who do not meet strict extubation criteria should remain intubated in the post
anesthesia care unit(PACU) until criteria are met
EMERGENCE

34. POST EXTUBATION RESPIRATORY DISTRESS
• Airway complications such as stridor,laryndeal edema,obstruction,and tracheal
deviation result in post operative respiratory distress in roughly 0.7% of robotic
surgeries,requiring postoperative re-intubation
Recommendations are
• To restrict fluid replacement to 1-2 litres over the course of surgery,
• To use colloids
• And to ensure that the patient can breadth around an endotracheal tube with a
dilated cuff