Robotic Anything

Anesthesia Implications

Time: 2-4 hours (long)
Blood Loss: Low (10-50 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

Robotic surgeries are broadening to multiple types/kinds. In this case, we are covering abdominal cases, which are the most common.

Peritoneum insufflation – for abdominal cases, the patient’s peritoneum is insufflated (which is called a pneumoperitoneum), and instrumentation will be inserted into the abdomen.  Often, the patient is also placed in steep trendelenburg (see below).  The pressure in peritoneum affect the organs of that space.  Anything more than 10 mmHg will begin to alter hemodynamics. Cardiac output is decreased and SVR is increased. Renal vessels will be compressed, which reduces flow to the kidneys, and activates the renin angiotensin aldosterone system (RAAS).  Reduced blood to the kidney means reduced urine output.  Peak inspiratory and plateau pressures will also increase.  The gas used to insufflate the peritoneum is most commonly CO2, so hypercarbia can develop, and with it, acidosis.  Sometimes, you’ll see this reflected in the end-tidal CO2. This is all contributing to the stress response we try to avoid in anesthesia.

Eye protection – The trendelenburg position along with robotic equipment close to the patient’s face, will often lead to something resting on the eyes. Watch for this closely and protect the eyes!

Keep the bed remote handy – The surgeon will have the patient repositioned frequently throughout the case.

Fast Closure – The entry points of the robot are small and will take minimal time to suture closed. Make sure to have your plan together to be able to wake the patient up quickly.

Trendelenburg Position (general considerations):
1. General anesthesia with ETT tube
2. Facial edema – take precautions for upper airway obstruction or stridor. Avoid excessive fluid administration
3. OG tube – this is a good consideration to empty the contents of the stomach. Regurgitation of stomach contents can ulcerate the airway and/or damage the eyes. Consider throat packs and/or eye lubrication to further protect the patient
4. Brachial nerve injury – this is also a strong possibility. Be very careful with head and shoulder brace positioning
5. Peroneal nerve injury – this can happen if the patient is also in the lithotomy position. Make sure pressure points are padded. If there’s peroneal nerve damage, it will manifest as foot drop
6. Increased IOP – Take precaution with patients that have glaucoma
7. Conjunctival swelling – this will sometimes be irritating to the patient post-operatively. Patients with this problem like to rub their eyes, so be aware and prevent an inadvertent corneal abrasion.
8. Increased ICP – Cerebral perfusion pressure = MAP-ICP. Make sure you keep the MAP up.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

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Long procedure (general considerations): Procedures anticipated to last longer than 2 hours generally require a urinary catheter. Also consider checking lines and positioning regularly as the risks of infiltration and nerve damage are increased with procedure time. Consider an IV fluid warmer and a forced air warmer to keep the patient euthermic.

In spite of the problems associated, the laparoscopic or robotic instrumentation is more precise, which means less tissue damage.  Patients are able to recover quicker, and there’s more appeal cosmetically (small, less obvious scars).  On top of that, theres less time in the hospital, which means less cost.  Studies are also showing less intraoperative bleeding, better postoperative respiratory function, and fewer infections.