Anesthesia for robotic urology surgery's

Anesthesia for Robotic surgery is challenging , the presentation is a brief overview of the urology procedures

1. Anesthesia for
Robotic Surgery
Dr Mukul Kapoor
Director Anesthesia
Max Smart Super Speciality Hospital,
Saket, Delhi

2. 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

3. 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

4. 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

5. 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

6. 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

7. •“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
Precision Advantages of Robotic Surgery

8. Degrees of Freedom

9. Endo-wrist

10. 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

11. 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

12. 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

13. Surgical robots as ground-breaking for
surgeons as the LMA is for anesthetists

14. Da Vinci Robot
Deployed RobotRobotic Arms
Console Coronary Anastomosis

15. da Vinci System

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

25. 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 180
o
away from anesthesiologist and with robot
cephalad above the patient
•Mediastinal procedures require OR table to be rotated
90
o
away
•Access to patient’s airway is nearly impossible -
challenging if one lung ventilation is requested and
frequent use of fiberoptic bronchoscope is necessary

26. 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

27. 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

28. 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

29. 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

31. 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

32. 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

33. 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

34. 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