Anesthesia for Robotic Surgery.you can run but you can't hide

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<ul><li> 1. Anesthesia for Robotic Surgeryyou can run but youcant hide (its coming your way)Julie Ann Lowery, CRNA, MSUpon conclusion of the lecture, the learner/participant will be able to: 1. Have a basic understanding of robotic principles and mechanisms 2. Identify some of the surgical advantages of using the robot with laparoscopicprocedures 3. Describe some of the anesthetic considerations for the patient having a roboticassisted laparoscopic surgical procedureRobotic surgery has transformed laparoscopic surgical procedures. More and more centersacross the United States are investing in robotic devices. While the initial cost may besubstantial, the end results and improved outcomes to the patient are worth the investment.Robotic devices offer the surgeon unprecedented control and precision of the surgicalinstruments employed during minimally invasive procedures. This results in lesspostoperative pain for the patient, shorter hospital stays, quicker recovery times, bettercosmetic effects, and physiologic function. Generally speaking, one may initially think of arobotic device in a sci-fi or futuristic reference, being autonomous and replacing the humansurgeon. This could not be farther from the truth. Robotics, while a sign of the times andthe future, require human intervention to operate. They help surgeons not replace them. a historical perspectiveRobots were initially designed by the National Aeronautics and Space Administration(NASA) for use in space travel. These robotic devices were employed in performing manualtasks aboard a spacecraft or out in space where a human could not go or, at least, movementwould be limited. Known as slave devices, these were controlled from a remote mastercontrol on Earth or from another spacecraft and were used extensively aboard the SpaceShuttle missions between 1983 and 1997. From that technology emerged virtual realitywhich allowed the interaction with three-dimensional virtual screens. Robotic engineeringand virtual reality were then coupled together to develop a dexterous telemanipulator for theanastomoses of nerves and vessels in hand surgery.</li></ul><p> 2. The U.S. Department of Defense recognized the applications that robotics andvirtual reality could provide in treating wartime casualties on the battlefield. Through theapplication of virtual reality, a wounded soldier could be brought to a surgeon. Thisbecame known as telepresence. Via this concept, a surgeon located on board an aircraftcarrier could perform surgical interventions on a wounded soldier who remained in a remotelocation near the battlefield. As a result, the Department of Defense went on to fund muchresearch utilizing telemanipulation combined with telepresence for use in mobile surgicalunits. In order to incorporate this technology to its full potential, engineers realized thatthe distance between the patient and the surgeon had limitations. To ensure the bestaccuracy and dexterity of the robotic device, the transmission delay or lag time between thesurgeons maneuvers and the robots reception of the commands and implementationrequired specific design. Delays exceeding 200 milliseconds would compromise the surgicalaccuracy and precision. Subsequently, the utilization of high-bandwidth fiberopticunderground cable over long distances was found to be the best solution at that time,allowing for a latency time of 155 milliseconds. The first video-laparoscopic cholecystectomy was performed in 1987 in France. In1988, the innovation of laparoscopic surgery was introduced to the Society of AmericanGastrointestinal Endoscopic Surgeons. From that point on, the implementation oflaparoscopy exploded! The advantages were soon realized: less invasive with better patientoutcomes. On the flipside, this was virtually a new surgical realm to master. Surgeons losttheir three-dimensional vision and impaired touch sensation. Additionally, a surgeon had tolearn how to manipulate long instruments within the patients body that were not directlybeing viewed. While advancements were made in regards to the logistics and the surgicalinstruments of laparoscopy, a better technique was on the horizon. Hence, the incentive forrobotic development. The ultimate goal was to develop a master-slave manipulator device which wouldmimic the natural movements of a surgeons hand and wrist. Early designs contained 4degrees of freedom and by 1992, an instrument was developed that allowed for 6 degrees ofmovement. In 1999, Intuitive Surgical acquired the rights for the existing technology,utilizing this to develop robotic instruments with 6 degrees of freedom which have evolvedto what is being widely used today. the da Vinci Robotic Surgical System Briefly, well just highlight one of the most modern surgical robotic systemsapproved by the FDA the da Vinci. This is a telemanipulator robot which means that it isunder constant control of the surgeon operator who sits in a remote console. It iscomprised of 3 components: a console, an optical three-dimensional vision tower, and asurgical cart. The surgical cart (the robotic component) consists of 3 arms that aremanipulated by the surgeon via real time computer assisted control. One arm holds theendoscopic camera and the other 2 hold surgical manipulators and instruments. The latteremploys 6 degrees of freedom plus grasp, equilibrating it to the articulation of the surgeonshand and wrist. This is a very heavy piece of equipment and extreme care must be takenwith moving it. After the patient is positioned for the surgical procedure, the cart must berolled into the surgical area and is then locked into position. It is imperative that the 3. patients position is not changed after the robotic side arm is docked to avoid injury topatient. The console allows for a three-dimensional image of the surgical field. Theendoscope transmits two separate optical and digital images to the consoles visual monitor.The surgeon is visualizing two separate monitors, each eye seeing through an independentcamera channel which creates a three-dimensional image of the surgical field. Within theconsole, there are 2 levers the masters, which attach to the surgeons index fingers andthumbs. There are also 3 foot pedals which allow the surgeon to disengage the roboticmotions, adjust the endoscopic camera, and control the cauterization. Lastly, the opticaltower consists of computer equipment which coordinates the left and the right eyes of thesurgeon providing stereotactic vision. The computer also translates the movement of thesurgeons hands into a digital format that corresponds to the robots articulations. Surgical applicationsRobotic technology has been successfully implemented in many surgical procedures,including gastrointestinal laparoscopic surgery, cardiac surgery, thoracic surgery,neurosurgery, urologic surgery, orthopedic procedures, and gynecologic procedures. I amthe most familiar with robotic assisted urologic and gynecologic procedures so that is what Iam going to specifically highlight. If robotics is being utilized in other types of surgicalprocedures listed above where you practice, I highly encourage you to learn about theanesthetic implications and volunteer to provide these patients anesthesia!Urologic surgery At the University of North Carolina at Chapel Hill, the urology surgeons areexcellent with the da Vinci. Some of the primary urologic surgical procedures that employthe da Vinci robot are: nephrectomy, pyeloplasty, cystectomy with ileal conduit, and radicalprostatectomy. The latter is probably the most frequent procedure which utilizes the daVinci robot. Prostate cancer is the leading form of cancer in males. It is the second highest causeof death in males in the US, killing more than 40,000 men annually. Early detection carriesthe best prognosis and allows patients to have more treatment options, including surgicalremoval of the prostate. In a nutshell, the goals surrounding a radical prostatectomy are: Remove the prostate and cancer Preserve urinary function Preserve erectile function (via a nerve-sparing procedure or approach) Analyze the prostate after surgery to assess the risk of recurrence of cancerAs outlined above, performing a robotic assisted laparoscopic radical prostatectomyoffers the surgeon AND the patient many advantages. The da Vinci system allows thesurgeon to have enhanced magnification, a 3-dimensional view of the operative field, andpreserve the nerves responsible for erections. The patient benefits greatly as well: Decreased blood loss Shortened length of hospital stay Decreased postoperative pain Less scarring Shorter urinary catheter time Faster return to regular activities Anticipation of improved potency and continence 4. Gynecologic surgeryRobotic assist is also being widely used in gynecologic procedures for various underlyingdisorders: fibroids, pelvic masses, abnormal bleeding, endometriosis, pelvic floor disorders,and precancerous/cancerous disease processes. Depending upon the problem, treatmentoptions may not necessarily include surgery. On the flipside, hysterectomy is the mostcommon surgical procedure performed in women and roughly numbers about 650,000 casesannually in the US. The primary reason is that it is the definitive solution for many types ofcommon gynecologic conditions. If surgery is indicated, minimally invasive surgical (MIS)procedures have numerous advantages which are quite similar to those outlined earlier: Minimal blood loss Preservation of fertility for fibroid removal/myomectomy Reduction in hospital stay Less postoperative pain Absence of a midline abdominal incision Quicker recovery time Anesthetic considerationsSeveral of the anesthetic implications specific to robotic procedures mimic those forany laparoscopic surgery. However, there are some considerations unique to theseprocedures that anesthesia providers need to appreciate and understand. Some of these aresurgeon preferences but nonetheless, have good rationale behind them as they lead tooptimal surgical conditions and in the long run, better outcomes for the patient. So, letshighlight a few of the main considerationsAnesthetic technique and agentsNo mystery or surprises here. For any of the robotic procedures mentioned abovespecific to urology and gynecology (my experience), these patients always receive a generalanesthetic. A regional block i.e. epidural catheter placement, either for anesthesiasupplementation and/or postoperative analgesia is just not indicated or even necessary. So,for those of us who really enjoy (and prefer) doing general anesthesia, this makes us happy.Each of us has our favorite anesthetic drugs, inhaled anesthetics, and techniques thatwe like to employ. Not a problem. As with any patient having any surgical procedure, theselected anesthetics should be catered around the patient, the patients history, and theiraccompanying co-morbidities.I personally avoid the use of nitrous oxide with laparoscopic procedures for severalreasons. But especially with the gynecologic procedures, postoperative nausea and vomitinghas a higher incidence. So, why make a potentially bad problem worse? Additionally, highnarcotic loads are not generally required as postoperative pain is much less a problem.Placement of IVs and additional invasive linesFor robotic assisted laparoscopic procedures, the patients arms will be tuckedin/secured at the sides. Additionally, you will not be able to access the patients arms orcheck the patency of the IV or fiddle with the noninvasive blood pressure cuff once the 5. robot is docked into position. There are several reasons for the latter. Not only is therobot a huge piece of equipment but it will be literally in the way of accessing the patient.Also, the entire area above the patient is considered sterile.So, here is the message place anything in the patient (additional IVs, an arterialline) PRIOR to the robot being positioned and locked into place above the patient. It is agreat idea to place a second large bore peripheral IV after induction. The patient usuallywill have had a bowel prep, probably will be dehydrated, and the surgeons are working inclose proximity to large blood vessels. In the event you need to give volume and/or bloodproducts quickly, you can do so without trouble if a second large IV is in place. And use afluid warmer with the second IV set up. An anesthesia colleague once told me that he neverhad to dc an IV STAT. Makes sensethe second IV can always be removed easily whenthe patient reaches the PACU. Once again, you will not be able to crawl up under thedrapes and start a second IV very easily in an emergent situation.Just a word about an arterial line...placing one or not placing one should bedetermined by the patient and the patients presenting history. As with other clinicalscenarios and patients, often times we place an arterial line for our convenience. Becausethe patients arms are tucked, having an arterial line for the sampling of ABGs, ahemoglobin level, or even a blood sugar can be invaluable. If the patient does not warrantan arterial line postoperatively, it is easy enough for the PACU nurse to remove it then.Lastly, make sure the IVs run well after the arms have been tucked in and the arterialline has an acceptable waveform.Positioning the patient The patient is under general anesthesia, the needed lines are in place, and now thesurgeons are ready to go! It is very important that all personnel in the operating room takean active role in properly positioning ANY patient for the surgical procedure. However,with robotic assisted procedures, there are a few nuances. Also, a surgeon may have aparticular positioning technique or strategy which is fine as long as its safe for the patient.Since my primary experience is with urology and gynecology procedures, that is what I amgoing to discuss. For the most part, both require similar positioning of the patient.Robot assisted laparoscopic prostatectomy Arms padded and tucked at sides and well secured. We place a beanbag high on the OR table with the U shaped tops wrapping aroundthe patients shoulders for stabilization. Blue foam donuts are also placed betweenthe shoulder AC joints and bean bag for padding. Padded shoulder blocks are thenplaced behind the bean bag for extra stabilization to prevent the patient sliding in thecephalad direction when placed into steep Trendelenburg. Towels are placed across the patients chest and then wide adhesive tape is crossedacross the patients chest and shoulders in an X formation to secure the patient tothe OR table. Our surgeons use a special OR table which splits the legs for surgical positioning.This minimizes the risk of peroneal nerve injury. Once all of that is done, a testing of the Trendelenburg position is performed toascertain that the patient is secure on the OR table and does not slide down in thecephalad direction. This is very important as the patient will be in steepTrendelenburg for quite some time. 6. Robot assisted pyelop...</p>