1.31 Robotic Surgery

Question 1

Discuss anaesthetic problems encountered during robot assisted laparoscopy
How addressed

Answer 1

1) Patient position

2) CO2 Pneumoperitoneum
CVS
Resp
Other

3) Robot

Question 2

Patient position

Resp

Answer 2

1) Steep Trendelenburg
+lithotomy

2) Decreased FRC
Compliance
+ Atelectasis d/t abdo pressure on diaphragm
- consider PCV minimises risk of barotrauma

3) Poorly tolerated in patients with High PAP
eg MS

Stimulation of pulmonary oedema
Altered position of lung relation to LA

Question 3

Patient position

Answer 3

1. Careful eye protection
   Gastric secretions + robotic instruments
2. Risk cerebral oedema
   Tight ETCO2 control
   Cautious intraop fluid admin
   (consideration also to surgical field)
3. Rapid assessment and wake up necessary at end
   short acting desirable

4. Facial oedema
if significant can indicate upper airway oedema
possible difficulties post extubation
(obstruction failed reintubation)
Exacerbated by pneumoperitoneum

5. Upward movement of trachea
   - endobronchial intube
   (exacerb pneumoperitoneum)
   Ensure regular tube checks
6. Neuropraxia
   Lower limbs - Lithotomy
   Upper limbs shoulder braces
7. Compartment syndrome

Question 4

2. CO2 Pneumoperitoneum

CVS

Answer 4

CVS

↑ CVP / PAP / SVR / MAP /
↑ HR ( may drop w/ vagal stretch)

↓CO

Altered parameters tolerated in healthy
May = myocardial ischaemia / pulmonary Oedema
- in pt w/ Cardiac disease

Invasive monitoring
CVP in patient w/ CVS dysfxn

↑ afterload Rx inhalational agents
Nitrates
a2 agonist

Question 5

2. CO2 Pneumoperitoneum + Respiratory

Answer 5

1. ↑V/Q MM / Airway pressure
2. ↓ Compliance FRC VC
3. Hypercarbia
   Risk of CVS Instability
   (HTN/ Arr )

Cerebral Oedema - vdilation
Minimise w/ altering ventilation to maintain normocapnia

Question 6

CO2 pneumoperitoneum Other

Answer 6

Regurgitation and aspiration gastric contents
Tracheal intubation
NG tube
Preop antacid prokinetic considered

Risk of VAE
Laparoscopic procedure
Operation site above cardiac level

aware sudden CVS collapse and consider arterial embolism
20% patients PFO
Requires deflation of pneumo and supportive Rx

Question 7

The Robot

Answer 7

Space + anaesthetic access intraop
limited size machinery and nature surgery
-Multiple port in abdo and pelvis

Ensure ETT / Venous / Arterial access
Line extension
Body warmers
Core temp monitor

pressure area
VTE protection devices

ALL SECURE prior to surgery

Must remain motionless
movement / coughing disastrous - fixed ports
Monitoring and ?infusion NDMR +/- Remifentanil commonest