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Anesthesia for Robotic Surgery Maria Vaz SRNA

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Evolution of Surgery 1 st Generation Open Surgery 2 nd Generation Minimally Invasive Surgery 3 rd Generation Robotic Surgery

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VOGUE

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Intuitive is considered to represent the market

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da Vinci Surgical System U.S. Installed Base 1999 2008

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Apr 1997 : General surgical assistance Jul 2000 : General laparoscopic procedures Mar 2001 : Non-cardiac thoracoscopic procedures May 2001 : Prostatectomy procedures Nov 2002 : Cardiotomy procedures Jul 2004 : Cardiac revascularization procedures Mar 2005 : Urologic surgical procedures Apr 2005 : Gynecologic surgical procedures Jun 2005 : Pediatric surgical procedures Approved by FDA

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Machine that resembles a human and does mechanical, routine tasks on command. Machine that resembles a human and does mechanical, routine tasks on command. Robots Computer controlled and used to improve therapeutic outcomes. A robot is not a machine.it is an information system with arms.

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Classification of Robots Shared Control (Semi- Active) Supervisory-Controlled (Active) Telesurgical (Passive)

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Classification of Robots Classification is based on how much involvement is required from the surgeon performing the surgical procedure

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Supervisory-Controlled (Active) Most automated. Can carry out treatment without immediate input from surgeon. Requires input of data into the robotic system, planning, testing, appropriate placement and overseeing on part of the surgeon.

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Supervisory-Controlled : No room for error robot does not adjust in real time E.g. RoboDoc system commonly used in orthopedic surgeries; Cyberknife

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Shared Control (Semi- Active) Surgeon and robot share control. Surgeon manually operate surgical tools, while the robot assists when needed. The surgeon programs the robot to recognize the areas of the surgical field as forbidden, boundary, close and safe areas.

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Shared Control (Semi- Active) As the surgeon nears these dangerous areas, the robotic system locks up to prevent further injury. E.g. Aesop system (Automated Endoscopic System for Optimal Positioning) -Voice activated mechanical arm

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Telesurgical (Passive) Robot is manipulated by the surgeon in real-time through remote control through any given distance Provides 3-D visualization, and access to hard-to- reach places like the heart

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Telesurgical (Passive) Enhances wrist dexterity and control of tiny instruments. Allows quicker, controlled and more accurate movements Latency - time delay between console & robot E.g. Da Vinci Surgical System

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Da Vinci Surgical System

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Da Vinci robot consists of A surgical console Patient-side cart Instruments and imaging processing

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Surgical console

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Instruments and imaging processing

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Patient-side cart

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Procedures Performed with daVinci Urology Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteral reimplantation Cardiothoracic Mitral valve repair, ASD closure, PDA ligation, IMA mobilization and totally endoscopic CABG Gynecology Hysterectomy and myomectomy

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Procedures Performed with daVinci Pediatrics Pyeloplasty for ureteropelvic junction obstruction, gastroesophageal repair GERD, ligation of PDA General Surgery Cholecystectomy, Nissen fundoplication, gastric bypass, donor nephrectomy, adrenalectomy, splenectomy, bowel resection and thyroidectomy

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Advantages to the Surgeon Image is magnified 12 times Stereoscopic 3-HD view of surgical field Robotic wrist with 6 degrees of freedom

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Advantages to the Surgeon Movements are scaled, filtered, translated Tremor reduction Better tissue targeting higher precision Improved positioning & surgeon comfort Better hand-eye coordination

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Advantages to the Patient Less risk of infection Less blood loss and transfusions Less invasive procedures Less scarring Faster recovery & shorter hospital stay Less pain & quicker return to normal activities

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daVinci Robotic Prostatectomy

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Disadvantages Bulky; requires large amounts of OR space Lack tactile feedback from the instruments Steep surgical learning curve Increased staff training/competence Increased OR set-up/turnover time

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Cost Institutional cost- $1.2 million Maintenance cost-$100,000 after first year Intra - operative cost of each case- $2800

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ANESTHESIA CONCERNS

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Pneumoperitoneum Intra abdominal pressure of at least 12 15mmHg is required. Decreased blood flow to organs in the abdominal cavity due to mechanical compression. Increased CVP, PCWP, PAP and decreased CO at beginning of surgery.

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Pneumoperitoneum Increased cardiac afterload Decreased venous return Increased sympathetic tone Increase in MAP / SVR Increase/ decrease in HR Ventricular Ectopy- Hypercarbia, local reflexes, gas emboli

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Pneumoperitoneum Most hemodynamic changes are transient and usually return to baseline in 20-30 minutes. Thought to be due to neurohormonal mechanisms

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Pneumoperitoneum Compromises pulmonary function by Diaphragmatic elevation Early closure of small airways atelectasis Preferential ventilation of nondependent parts of the lung V/Q mismatch In pulmonary compromised patients Preoperative PFT and ABG

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Pneumoperitoneum Increased ICP and decreased CPP Increased SVR Head-down position Elevation of IAP Hypercapnia Should be cautious when intracranial compliance is reduced If patient has a VP shunt, check patency post op

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Pneumoperitoneum Increased plasma lactate levels and lactic acidosis Alterations in liver enzymes Appearance of oxidative stress markers due to splanchnic ischemia reperfusion. Mesentric thrombosis, splanchnic ischemia & bowel necrosis

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Pneumoperitoneum Oliguria due to parenchymal compression, but no permanent damage. It does not effect post operative function Release of vasoactive substances including vasopressin, angiotensin, cortisol and ACTH Level of vasopressin increase during insufflation due to decrease in atrial transmural pressure gradient Time course of increased SVR seems to parallel that of vasopressin release

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Complications of Pneumoperitoneum Hypercarbia Pressure of CO2 in the peritoneal cavity is higher than atmospheric pressure with a diffusion gradient of 700mmHg Peritoneal capillary barrier and contact surface areas are such that hypercarbia is usually well controlled with hyperventilation Very seldom are arrhythmias or unmanageable HTN seen

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Complications of Pneumoperitoneum The most feared complication is venous gas embolism Increased with hypovolemia 20% of patients have a Foramen ovale Subcutaneous Emphysema Pneumothorax and Pneumomediastinum Hypothermia

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ANESTHETIC MANAGEMENT

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Pre operative Evaluation Robotic surgery is elective Need to optimize the circulatory, respiratory, metabolic and other systems Patients with cardiac disease must have a thorough evaluation Blood should be available even though bleeding is infrequent

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Choice of anesthetic technique General ETT Monitoring is similar to other surgeries ETT must be secured such that it does not move or kink

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Positioning Proper positioning is CRITICAL! Must provide access to the operative site while accommodating the robotic camera and arms. Decreased work space area for the CRNA Once the robot is docked There can be no adjustment of position Movement of the OR table

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Positioning Patient needs to be secured such that there is no accidental movement during surgery. Arms and hands should be positioned in such a way that IV lines, non invasive BP cuff, A - line, pulse oximeter may function uninterrupted.

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Positioning All pressure points are padded with gel pads. Arms are tucked Better to start a second large bore IV after induction

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Eye Protection Eyes need to be taped Goggles Careful in trendelenburg position - gastric juices regurgitated during surgery can fill the goggles and cause severe conjunctival burns

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Insufflation Be ready to treat severe bradycardia, tachycardia, HTN, hypotension and arrhythmias If proper attention was not paid to to IV and monitoring lines during positioning, the patient can die before any derangements can corrected or even recognized.

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Ventilation Increased airway pressures Worse in COPD and reactive airway patients Bronchodilator puffs help If too high, check for kinks/ occlusion of ETT Pressure control ventilation helps obtain better mechanics and gas exchange

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Fluid Replacement Blood loss is minimal but fluid requirements are large Insufflation with dry gas Third Spacing Trend is to keep patients dry Albumin is preferred over crystalloids Fluids rate is increased once the patient is flattened

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Muscle Relaxants Patients have to be paralyzed until the robot is undocked Continuous drip of non depolarizing agent can be used Any bucking or coughing will lead to serious trauma & injury

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Emergence and extubation If patient was in Trendelenburg position and the surgery was prolonged look for facial and buccal swelling. If present do not extubate! If extubated, patient will obstruct and and reintubation will be difficult Keep intubated until edema subsides even if patient is awake.

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Cardiac Arrest The OR staff should be trained with an emergency drill for the removal of the robotic chart Discontinue insufflation and deflate the abdomen CPR is initiated in the Trendelenburg position until the robot is undocked

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Communication The successful use of the robot to assist in surgery depends on excellent communication between all members of the anesthesia team

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Gastrointestinal Surgery Supine position with reverse Trendelenburg Robot over the patients head or at a 45 angle from the bed Robotic arms in very close proximity to the patients airway, face, and chest Rapid sequence induction with cricoid pressure Muscle relaxation is paramount

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Cardiac Surgery Supine position with the thorax rotated 20 Anesthetic Implications Knowledge and expertise in cardiac and thoracic anesthesia Single-lung ventilation Transesophageal echocardiography (TEE) Continuous monitoring of cardiac function Central line placement 5~10 mmHg of Capnothorax

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Cardiac Surgery

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Urological Surgery Lithotomy with 30 Trendelenburg Anesthetic Implications Monitored with routine care Arterial line for frequent sampling Large-bore intravenous line for potential large blood loss Padding placed at every pressure point

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Trendelenburg position

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Trendelenburg position Trendelenburg position FRC & Atelectasis Pulmonary edema Lingual and buccal nerve neuropathy ICP, CVP, IOP, PCWP, Swelling of face, eyelids, conjunctiva, and tongue Peripheral nerve injury Cerebral stasis Cardiac Output

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Trendelenburg position If significant upper airway edema is present, delay extubation. Position can also cause an upward displacement of the ETT and migration into a main stem bronchus. Pulse oximetry probe should not be placed on the earlobe--- potential of erroneous readings

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Trendelenburg position Intraocular pressure may increase more than 4X over 1-2 hrs in a steep Trendelenburg position IOP increases by 0.05 mmHg for every minute of surgery Greater risk for visual disturbances and blindness Patients with pre-existing eye disease should be evaluated and counseled about the potential risks

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Questions