Anaesthetic considerations for Robotic Surgery, What to expect, how to go ahead. An update and incite on the intricacies of Robotic Surgery and Anaesthetic implications.

1. ANAESTHESIA FOR ROBOTIC SURGERY
PRESENTER: DR. RANJITH R THAMPI
SECONDARY DNB RESIDENT,
DEPARTMENT OF ANAESTHESIA
GANGA MEDICAL CENTER HOSPITAL

2. Robotic Surgery
Also known as
Minimally Invasive surgery.
Robotic surgery, or robot-
assisted surgery, allows doctors
to perform many types of
complex procedures with more
PRECISION, FLEXIBILITY and
CONTROL than is possible with
conventional techniques.

3. HISTORY

4. HISTORY OF ROBOTIC SURGERY
• 1921: The word robot was first used by Capek in his play Rossum's Universal Robots.
Derived from the Czech word robota, meaning “FORCED LABOUR”
• Robots were first developed by the National Aeronautics and Space Administration
(NASA) for space exploration. These devices, or TELEMANIPULATORS, were capable of
doing manual tasks aboard a spacecraft or out in space.
• In 1985 a robot, The PUMA 560, was used to place a needle for a brain biopsy
using CT guidance. Three years later the same machine was used to perform a
transurethral resection.
• In 1987 robotics was used in the first Laparoscopic surgery, a cholecystectomy.
• In 1988, The PROBOT, developed at Imperial College London, was used to perform
prostatic surgery.

5. History of Robotic Surgery
PUMA 560- 1985

6. PROBOT- 1988

7. History of Robotic Surgery
1992: ROBODOC (Integrated Surgical Systems)
was introduced for grinding bone to make space
for prostheses in hip replacement surgery.
• By the mid-1990s, positioning robots :
1. Automated Endoscopic System for Optimal
Positioning (AESOP) was introduced for voice-
controlled optimal camera positioning
2. Laparoscopic Assisted Robotic Systems (LARS)
an automated robot, was introduced for organ
retraction.

8. History of Robotic Surgery
2001- ZEUS Robotic Surgical System produced by
robotics company COMPUTER MOTION was
cleared by FDA to assist in surgery
• Had 3 arms, remotely controlled by the
surgeon.
• Stopped production in 2003 following merger
with its rival Intuitive Surgical.
• In 1994, INTUITIVE SURGICAL obtained
technologic rights from Stanford Research
Institute, and a prototype DaVinci system was
released in 1997.

9. History of Robotic Surgery
DA VINCI SURGICAL
SYSTEM
Approved by the Food and Drug
Administration in 2000.
With already over 210 devices in
use throughout the United
States, Europe, and Japan,
Intuitive Surgical is the leading
company in the field of digital
surgery with its da Vinci Surgical
System.

11. History of Robotic Surgery
MAKO
Founded in 2004, the company
manufactures and markets
surgical robotic arm assistance
platforms
MAKO's first MAKOplasty Partial
Knee Replacement Procedure
was performed in June 2006
The company's first MAKOplasty
Total Hip Arthroplasty (THA)
procedure was performed in
October 2010.

13. PROCEDURE OF ROBOTIC SURGERY
• Robotic surgery is similar to laparoscopic surgery. It can be performed through
smaller cuts than open surgery. The small, precise movements that are possible with
this type of surgery give it some advantages over standard endoscopic techniques.
• The surgeon can make small, precise movements using this method. This can allow
the surgeon to do a procedure through a small cut that once could be done only with
open surgery.
• Once the robotic arm is placed in the abdomen, it is easier for the surgeon to use the
surgical tools than with laparoscopic surgery through an endoscope.
• The surgeon can also see the area where the surgery is performed more easily. This
method lets the surgeon move in a more comfortable way, as well.
• Robotic surgery can take longer to perform. This is due to the amount of time needed
to set up the robot. Also, many hospitals may not have access to this method.

14. BENEFITS OF LAPAROSCOPY
OVER OPEN SURGERY

15. LAPAROSCOPY OVER
OPEN SURGERY
• SMALL INCISIONS
• LESSER PAIN
• BETTER COSMESIS
• LESS POSTOPERATIVE TIME
• SHORTER HOSPITAL STAY
• FASTER RECOVERY
• LESS SCARRING
• REDUCED BLOOD LOSS
• LESS CHANCES OF POSTOP INFECTION

17. LAPAROSCOPY
PHYSIOLOGICAL CHANGES AND ANAESTHETIC
CONCERNS WITH PNEUMOPERITONEUM

18. RESPIRATORY
• Insufflation- IAP increases, diaphragm pushed up, Total lung volume
decreased. Compliance fall by 35-40%. Respiratory System resistance
increases. Hypoxaemia may occue from V/Q mismatch and intrapulmonary
shunting.
• CO2- insufflation at 1-2mL/min. Absorbed through peritoneum. Leads to
hypercapnia(increases by 5-7 mm Hg) and acidosis.

19. CARDIOVASCULAR
• Mainly from hypercarbia and raised Intra abdominal pressure.
• Hypercarbia has sympathoadrenal stimulating effects(>50 mm Hg)
• IAP > 15 mm Hg increases MAP by 35%, SVR by 65%, PVR by 90%, and
decreases cardiac index by 20%
• Increased PEEP (10cm H2O) decreases cardiac output and stroke index.

20. RENAL
• Commonest problem is oliguria
• Compression of renal vessels and parenchyma with IAP>20 mm Hg decreases
Renal blood flow by 30%. As a results RAAS is activated leading to renal
cortical vasoconstriction. Renal Blood Flow returns to normal within 2 hours
following desufflation.

21. SPLANCHNIC
• Raised IAP decreases MACRO and MICRO splanchnic circulation.
• IAP increase from 10-15 mm Hg showed reduction in blood flow of 40-54% in
stomach, 32% in Jejunum, 44% in Colon, 39% in Liver, and 60% in Peritoneum.

24. COMPLICATIONS
• Gas Embolism, Barotrauma, Hypoxaemia, Pulmonary Edema, Atelectasis,
Subcutaneous emphysema, Pneumothorax, Pneumomediastinum,
Pneumopericardium.
• CO2 embolism is rare. <0.6%
• Cardiovascular complications such as Hypertension, Arrhythmias, Hypotension and
cardiac arrest have been reported with pneumoperitoneum.
• Hypertension risk has higher incidence at beginning of insufflation when blood
volume in splanchnic vasculature is reduced due to increased IAP, thereby decreasing
preload and arterial pressure.
• Arrythmias occur in upto 14-27% of laparoscopies. Bradyarrhythmias arise due to
vagal nerve mediated cardiovascular response following acute stretching of the
peritoneum.

25. COMPLICATIONS
• IAP of 20 mm Hg or more results in compression of the IVC, reducing venous
return. Cardiac output is reduced leading to hypotension. Aggravated by high
intrathoracic pressure.
• POSITIONING::::
Trendelenburg- Raised ICP, IOP, Venous stagnation leading to cyanosis and
facial edema. Cephalad movement of carina leads to bronchial intubation.
• Lithotomy- Preload is increased, venous return further increased by
pneumoperitoneum.
• Right lateral decubitus- IVC compression- leads to hypotension.

26. ?Gas Embolism
• Surgeon should be asked to deflate the pneumoperitoneum
• Position the patient in left lateral position with head down, allows the gas
embolus to accumulate in the right ventricular apex, thus preventing it
reaching the pulmonary artery or impeding blood flow through the heart.
• Rapid elimination of CO2 by increasing the minute ventilation and administer
high flows of 100 % Oxygen.
• CPR must be performed in case of asystole, and insertion of a central venous
catheter may be considered to aspirate the gas, although this may not be
timely.
• Hyperbaric Oxygen therapy can be used if available.

27. DA VINCI ROBOTIC
SURGICAL SYSTEM

28. Da Vinci Surgical System
• 3 components-
SURGICAL CART, CONSOLE, OPTICAL 3D VISION
TOWER
• SURGICAL CART:
Heavy and Bulky.
Has 4 arms manipulated by surgeon in console
through real-time computer assisted control.
First 2 arms represent left and right arms of the
surgeon. Holds instruments
Third- Endoscope
Fourth- Enables to hold another instrument or allow
to do additional tasks. Such as giving counter
traction, following running sutures. Eliminates need
for patient side surgeon.

29. Da Vinci Surgical System
• The Arms have 7 degrees of freedom.
Vertical- up and down, horizontal- side to side, forward
extension to reach an object and retraction backwards,
rotation around central axis(supination and pronation),
wrist movement of extension and flexion, lateral
movement to radial and ulnar side, opening and closing
instrument for grasping. [Endo Wrist Technology]
Specials- More than 6Hz of hand tremor can be filtered.
Motion scaling can be invoked upto 5:1
(the surgeon moves 5 cm, and the robot moves 1 cm).
• Usually 2 surgeons needed. One in console and skilled
assistant at patient side to change trocars, instruments
and manipulates additional endoscopic instruments.

30. Da Vinci Surgical System
• Console:
Surgeon seat.
Attaches hands to manipulator. Hand motions
are translated into surgical instrument motion.
Three foot-Pedals.
Pedal 1- Disengaging robotic motion
Pedal 2- Alternating between robotic arms and
adjusting camera
Pedal 3- Controlling the energy of electric
cauterization or ultrasonic instruments.

32. Da Vinci Surgical System
• Contains computer equipment to
integrate left and right optical channels
and provide stereoscopic vision. Also
runs software to control kinetics of
robotic arms.

33. PREINDUCTION
&
INDUCTION

34. I) General considerations in all Robot assisted
surgeries
• A) Patient selection
• Selection of patients for robot assisted surgery depends on clinical judgement
and assessment as to whether the patient could withstand a prolonged period
in the extreme position. A history of significant cardiovascular comorbidity,
cerebrovascular disease, poor pulmonary function, pulmonary hypertension
and glaucoma are considered as independent risk factors for Robot assisted
surgeries.

35. I) General considerations in all Robot assisted
surgeries
B) Intraoperative preparation
• Two wide bore intravascular cannulae with extension tubings to administer
anaesthetic drugs and fluids intraoperatively.
• Antisialogouge agents are used in patients requiring extreme patient positioning.
• Monitoring includes ECG, noninvasive blood pressure, pulse oximetry, end-tidal CO2
and urine output.
• A central venous catheter is a reasonable consideration in certain procedures with
major fluid shifts as a monitor of central venous pressure (CVP).
• Similarly, arterial line for continuous arterial pressure measurement is dictated by the
nature of surgery and the preoperative functional status of the patient.
• The patient should be well strapped to the Table to prevent sliding after positioning
and a trial run of the final Table position should be done beforehand to check for any
strain on monitoring cables, circuit and intravenous tubings.
• Deep venous thrombosis prophylaxis should be followed strictly as per protocol.

36. I) General considerations in all Robot assisted
surgeries
• The assisting surgeon creates pneumoperitoneum and makes the ports in the
patient’s body. Robotic arms are docked into the ports and the chief surgeon starts
operating by controlling the robotic arms from the console which is kept a little away
from the patient.
• Difficult to access the patient intraoperatively. Some procedures require the patient’s
airway to be at a distance from the anaesthesiologist and the anaesthesia
machine/monitor.
• It becomes much more challenging if one-lung ventilation is required, since frequent
use of the fiberoptic bronchoscope may be necessary.
• It is important to have all monitors and safety devices (defibrillator pad,
Transesophageal echocardiography (TEE), left precordial stethoscope in pediatric
patients to detect inadvertent right bronchial intubation) in place before the Robot is
docked. Careful attention should also be given to prevent the robotic arms from
injuring the patient. Cameras and light sources should never be kept directly on
drapes or patient’s skin.

37. I) General considerations in all Robot assisted
surgeries
C) Patient positioning
• Common patient positions used are steep Trendelenburg with legs apart for
prostatectomy, supine or slight lateral decubitus (raising one side 15º to 30º)
position for anterior mediastinum pathology, 90º lateral position for hilar
mass and lobectomy and a nearly prone position for posterior mediastinal
mass.
• It is difficult to change the patient’s position once the Robot is docked. So,
proper patient positioning should be confirmed beforehand with the surgical
team.
• It is highly recommended that the anaesthesiologist is well versed with
various patient positions and their implications.
• Proper padding/cushions over pressure points should be used to avoid tissue
and nerve impingement. While using extreme patient positioning, restraints
must be used to prevent the risk of anaesthetized patient sliding off the Table.

38. I) General considerations in all Robot assisted surgeries
• Extreme patient positioning and pneumoperitoneum can cause endotracheal
tube migration into the main stem bronchus. Before docking of the Robot,
tube positioning must be confirmed.
• Cerebral oxygenation was shown to increase slightly provided PaCO2 was kept
within normal limit.
• IOP can increase on an average 13 mm Hg higher than the baseline. Surgical
duration and ETCO2 are significant predictors of IOP increase in the
Trendelenburg position.
• Severe oral ulceration and conjunctival burns may occur from reflux of
stomach acid onto the face. As a precautionary measure, stomach should be
decompressed by oro/ nasopharyngeal tube and the patients’ face kept visible
intraoperatively.

39. I) General considerations in all Robot assisted surgeries
D) Anaesthetic technique
• Oxygen, air mixture is used along with inhalational agent and
Fentanyl/Remifentanil infusion for maintenance of anaesthesia.
• Sevoflurane is the preferred agent in view of its recovery profile and lack of
significant central nervous system effects.
• Consider placement of an epidural catheter and an epidural infusion for not
only intra and post operative pain relief but also for the gut volume reduction.
Epidural test dose and initial bolus should be given well before patient
positioning.
• Continuous uniform depth of muscle relaxation is of prime importance in
avoiding any movements by the patient while the surgical instruments are in
place and starting an infusion of muscle relaxant is recommended.

40. I) General considerations in all Robot assisted surgeries
Fluid replacement: Initial fluid loading is inappropriate in extreme patient
positioning and in surgeries needing urethral anastomoses.
Suction, made up of a mixture of flush (saline), blood and urine, is not a reliable
measure of blood loss. In long operations and when there was evidence of
excessive blood loss, not tallying with the suction, intraoperative haematocrit
may give a rough guide.
Diuresis: Mannitol 1–2 g/kg or Furosemide can be used. The rationale is
threefold: to promote urine flow to flush out and maintain urinary tract
patency, to conserve renal function, and as a prophylaxis against cerebral
swelling in extreme Trendelenburg position.

41. I) General considerations in all Robot assisted surgeries
Cerebral protection: Fluid restriction, maintaining intraoperative ETCO2, using minimal
insufflation pressures and use of diuretics towards the end of the procedure are some
of the techniques commonly employed for avoiding cerebral oedema.
Reversal: Cognitive recovery may be delayed because of the cerebral oedema and
raised intracranial tension, especially after a long surgery in steep head down position.
So, early discontinuation of anaesthetic agents may be necessary as soon as the Robot
is withdrawn.
With more experience and skill and reduced operating time, the issue of delayed
cognitive recovery may resolved. Presence of peri-orbital oedema should alert the
Anaesthetist of the possibility of concomitant airway oedema. Maintenance of airway
and prevention of aspiration should be taken care of. There are reports of
compartment syndrome in the calves after prolonged lithotomy, necessitating routine
checks for calf tightness and tenderness.

42. II) Important issues related to specific surgeries

43. ANAESTHETIC CONSIDERATIONS
• RALRP- Most commonly performed robotic surgery. Blood loss around 150-
250 ml. Surgery completes in 2.5 hours.
• RARC
Using the six-port approach and the da Vinci system, pelvic lymphadenectomy
and cystoprostatectomy are performed. The specimen is removed in a bag
through a 5- to 6-cm suprapubic incision.
Through this incision, the bowel is exteriorized, and a neobladder is created
extracorporeally. Subsequently, urethroneovesical anastomosis is performed
with robotic assistance. RARC may have a less frequent rate of complications
than in patients undergoing an open procedure
Studies- rapid return of urinary function, higher rate of potency recovery,
better control of cancer.
UROLOGICAL & GYNAECOLOGICAL SURGERY

44. ANAESTHETIC CONSIDERATIONS
The da Vinci robot has been adapted to perform transnasal endoscopic skull base
procedures, even though it was not designed for use in neurosurgery.
ROSA’s computer system allows neurosurgeons to make 3-D maps of a patient’s brain.
They can look at the images from any angle, and at any depth. They use this image to
mark the exact areas they need to reach.
• The ROSA® system was developed to assist in a variety of minimally invasive brain and
spine surgical procedures while simultaneously increasing safety and reliability for
the surgeon and patient.
• In brain surgery, the device assists the surgeon with biopsies, electrode implantation
for functional procedures (stimulation of the cerebral cortex, deep brain stimulation),
open skull surgical procedures requiring a navigation device, endoscopic
interventions and other “key-hole” procedures.
• In spine surgery, the robot assists the surgeon in the treatment of degenerative spine
diseases, traumatology, deformities and spinal tumors.
NEUROSURGERY SURGERY

45. ANAESTHETIC CONSIDERATIONS
• There are two main types of robotic systems being used in orthopedic surgery:
autonomous and haptic
• Autonomous robotic systems have fallen out of favor as they are associated with
increased operating times and blood loss.
• MAKO is an example of a haptic robotic system.
These systems require active participation of the surgeon and use preoperative CT
scans to create a three dimensional model of the knee.
• The surgeon uses this model preoperatively to plan the sizing and placement of
components and intraoperatively to “merge” the preoperative model with the actual
anatomy of the knee. During the procedure the surgeon views the three-dimensional
model of the knee on the monitor while manipulating the burr. The robotic arm
provides auditory and haptic feedback, limiting the rotating burr to resect the bone
within the preplanned cutting zone. Such haptic systems have a short learning curve
and allow the surgeon to have greater precision
ORTHOPAEDIC SURGERY

46. ANAESTHETIC CONSIDERATIONS
• Robotic surgery may require unprecedented, prolonged one-lung ventilation.
This tests the limits of our knowledge and understanding of one lung
anaesthesia.
• Confirmed placement of a left-sided double-lumen endotracheal tube (DLT) is
necessary to allow for the single left-sided ventilation required for cardiac
exposure.
• DLT is preferred to Bronchial blockers in robot assisted cardiac surgery
because intermittent right lung inflation is necessary for adequate
oxygenation during weaning from Cardiopulmonary Bypass (CPB). Moreover,
isolation of the right lung may again be necessary to check for bleeding post
CPB. Knowledge of TEE is a must in robot assisted surgeries.
CARDIAC SURGERY

47. ANAESTHETIC CONSIDERATIONS
• Thoracic surgical procedures include thymectomy, mediastinal mass extirpation,
fundoplication, esophageal dissection, esophagectomy, and pulmonary
lobectomy(VATS).
• The principles that apply for thoracoscopic surgery apply for robotic assisted thoracic
surgery.
• A combination of patient position, one lung anaesthesia, and surgical manipulation
alter ventilation and perfusion profoundly. Frequently robotic assisted surgeries
require insufflation of CO2 in the chest (CO2 pneumothorax). This may lead to an
increase in the airway pressures and haemodynamic instability secondary to
decrease venous return and cardiac compliance. The rate of CO2 elimination is
difficult to match with the rate of CO2 absorption and production during one lung
anaesthesia as minute ventilation may already be maximized.
• Iatrogenic injury to the contra lateral pleura can result in occult blood loss and a
tension pneumothorax on the dependent chest.
THORACIC SURGERY

48. ANAESTHETIC CONSIDERATIONS
• For esophagectomy, the operation consists of three stages. The first is performed
with robot assistance, and the left lateral decubitus position with a 45o tilt toward the
prone position is preferred.
• For thoracic surgery in the lateral decubitus position, patient position also impairs
venous return. The thorax is the highest point for maximal robotic arm range and
maneuverability, so the lower extremities are below the level of the heart. There is a
high risk of positioning neuropathy during robotic thoracic surgery. Inadequate
padding or positioning and inadvertent robotic arm placement can cause external
nerve compression. During positioning, the arms and shoulders should be well cared
for by reducing conflict with robotic arms and decreasing the risk of brachial plexus
injury. As in other robotic surgeries, the robotic arm monitors and surgical personnel
will occupy the area around the patient, so extensions for IV lines are necessary, and
injection ports or stopcocks need to be in accessible locations. Long monitoring lines
and anesthesia circuits are also mandatory. During the surgical procedure,
compression of cardiac or major vascular structures may also result in hemodynamic
instability, with ECG changes.
•
THORACIC SURGERY

49. Robotic
Anaesthesia???

50. MCSLEEPY
"McSleepy" is a sort of
humanoid anesthesiologist that
thinks like an anesthesiologist,
analyses biological information
and constantly adapts its own
behavior, even recognizing
monitoring malfunction.
McGill University in Montreal,
Quebec ,Canada.

51. To manipulate the various components of general anesthesia, the automated system measures three separate
parameters displayed on a new: Integrated monitor of anesthesia (IMATM):
1.DEPTH OF HYPNOSIS via EEG analysis
2.PAIN via a new pain score, called AnalgoscoreTM
3.MUSCLE RELAXATION via phonomyographyTM.
The system then administers the appropriate drugs using conventional infusion pumps, controlled by a
laptop computer on which "McSleepy" is installed.

53. •Using these three separate parameters and complex algorithms, the
automated system calculates faster and more precisely than a human can
the appropriate drug doses for any given moment of anesthesia.
• "McSleepy" assists the anesthesiologist in the same way an automatic
transmission assists people when driving. As such, anesthesiologists can
focus more on other aspects of direct patient care.
•An additional feature is that the system can communicate with personal
digital assistants (PDAs), making distant monitoring and anesthetic
control possible. In addition, this technology can be easily incorporated
into modern medical teaching programs such as simulation centers and
web-based learning platforms.

54. Summary
There are several pitfalls to be considered regarding robot-assisted surgery.
First, the equipment is extremely bulky and thus considerable space is required.
Second, the large size of the robot itself may result in collisions with its own arms,
assistants, or patients.
Third, it is difficult for the anesthesiologist to quickly access the patient during an
operation. In addition, it is almost impossible to reposition the patient once the
robot has been stationed. Nevertheless, the application of robot-assisted surgery
will continue to increase and be extended to other fields.
Anesthesiologists should stay up-to-date with this latest surgical trend and be ready
to provide better anesthesia care for patients undergoing robot-assisted surgery.

55. REFERENCES
1. Miller Anaesthesia 8th Edition
2.Anesthetic considerations for robotic surgery
Jeong Rim Lee.
Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine,
Anesthesia and Pain Research Institute, Seoul, Korea
Korean J Anesthesiol 2014 January 66(1): 3-11
3. Robotic Surgery: A Current Perspective
Anthony R. Lanfranco, BAS, Andres E. Castellanos, MD, Jaydev P. Desai, PhD,*† and William C. Meyers, MD
4. Carbon dioxide pneumoperitoneum, physiologic changes and anesthetic concerns
Gobin Veekash MD*, Liu Xin Wei MD (Associate Professor)**, Min Su PhD (Professor)***
5. Robotic invasion of operation theatre and associated anaesthetic issues: A review
• Prem N Kakar, Jyotirmoy Das, Preeti Mittal Roy, Vijaya Pant
• Department of Anesthesiology Pain Management and Perioperative Care, Fortis Hospital, Shalimar Bagh,
• New Delhi, India