EXAM 3: Robotic-Assisted Lap Procedures

Question 1

Robotics procedures began in the late 1990s - the da Vinci Surgical System transformed laparoscopic urology.

Robotic ______ was the initial use - it now includes gallbladder, appendix, colon, and gynecological procedures.

The system has 3-4 arms: 1 arm ______ and the remaining arms are for _________.

Surgeons now market themselves as robotic surgeons.

Answer 1

prostatectomy

camera, instruments

Question 2

Advantages of Robotic Procedures:

1) Reduced ___ ____ from procedure
2) Reduced physiologic _____
3) Greater scale of ____ ______
4) Greater hand/eye ______
5) ___ degrees of freedom of the instruments
6) Surgeon can sit w/ reduced _____
7) 3D, HD stereotactic _____
8) Greater ____ perception

Answer 2

1 - blood loss
2 - tremor
3 - hand movements
4 - coordination
5 - 7
6 - fatigue
7 - vision
8 - depth

Question 3

Disadvantages of Robotic Procedures:

1) Higher ____
2) Lengthy set up, patient positioning, prep time
3) Inefficient in some surgeries vs. conventional laparoscopy
4) Bigger ____ ____ required
5) _____ ______ not cosmetically favorable
6) Limited ____ _____ to patient (have to pull trocars out, etc.)
7) No feedback regarding _____ and ______
8) Not easily ______ to open in emergency

Answer 3

1 - cost
4 - OR
5 - trocar placement 
6 - direct access 
7- tactile and force
8 - converted

Question 4

The ____ ______ position is NOT physiologic.

3 Primary Factors (Triple Threat) alter Physiology:

1) _____ position
2) ______ ______
3) ____ _______

Answer 4

steep Trendelenburg

1 - lithotomy
2 - abdominal insufflation (pneumoperitoneum)
3 - steep Trendelenburg

Question 5

Steep trendelenburg is defined as >___ degrees (max ___). This provides maximum surgical ______ and optimal _______.

Prostate & Gyn surgery are usually performed in ____ positioning. Once the robot is docked, table movement requires undocking. Surgeons avoid readjusting if more Trendelenburg is needed.

Surgical times are ______ w/ more experience.

Answer 5

> 30 - 45 max

exposure, visualization

max

decreasing

Question 6

______ considerations include the pulmonary system, cardiovascular, cerebrovascular, neurological, intracranial, intraocular, pneumoperitoneum, positioning, facial, and airway.

Answer 6

anesthetic

Question 7

In steep trendelenburg positioning, abdominal contents are shifted ______; the diaphragm can shift _____ as much as __-__ cm.

This results in reduced pulmonary ______ and _____.

Worsening ventilation-perfusion mismatch results in ____.

Peak inspiratory pressures (PiPs) increase as much as ___%. There is a risk of rupturing lung bullae w/ high PiPs.

Answer 7

cephalad, cephalad 8-10 cm

compliance, FRC

shunt

50%

Question 8

In addition to positioning, ____ _____ further reduces pulmonary compliance.

Chest binding + steep trendelenburg (45 degree) + high _______ pressures decreased pulmonary compliance by as much as 68%!

Some recommend insufflation pressures < __ mmHg.

Answer 8

chest binding
insufflation
<12 mmHg

Question 9

The pulmonary system is affected by pneumoperitoneum in 2 ways:

1)
2)

Answer 9

increased intra-abdominal pressure

CO2 acting as a drug (systemic absorption - have to increase rate to blow off CO2)

Question 10

Pulmonary management strategies must consider the additional CO2.

Elevated CO2 AFTER deflation is explained by large amounts of CO2 stored in _____ _____ of the body slowly redistributing or exhaled.

_____ of __ has been shown to improve oxygenation after prolonged pneumoperitoneum.

Answer 10

extravascular compartments

PEEP (5)

Question 11

You can use either volume control or pressure control mechanical ventilation while in steep trendelenburg. However, volume control ventilation leads to elevated ____.

_____ Vt and ______ RR are strategies used to maintain adequate ventilation.

Pressure control ventilation (PCV) has been found to be more efficient - ____ PiPs and _____ dynamic compliance resulted.

Answer 11

PiPs

Lowering Vt and increasing RR

lower PiPs, higher compliance

Question 12

Caution must be taken when utilizing PCV.

You may see inadequate ____ if the PC setting is too LOW.

Excessive Vt can lead to volutrauma when _______ is _______.

Answer 12

Vt

pneumoperitoneum is released

*Use PCV w/ volume guarantee

Question 13

Effects on the Cardiovascular System:

1) Up to 35% increase in _____ - increased ______/____, ____ compression via intra-abdominal pressure. Less than optimal cardiac function can lead to ____ symptoms.
2) Up to 3% increase in ____.
3) _____ renal, portal, splanchnic flow.
4) _____ PAP and wedge pressures.

Answer 13

1 - MAP - afterload, SVR; aortic compression; CHF

2 - CVP

3 - decreased

4 - increased

Question 14

Effects on the Cardiovascular System (cont.):

5) Decreased ____ up to 50% - decreased ___ and ___ _____.
6) Increased ______: increased ____ outflow results in increased _______; activation of _____ results in increased _______.
7) Cardiac _____ reported as high as 27% d/t increased ___ ____ and _______.

Answer 14

5 - (increased map leads to decreased) CO - HR and stroke volume
6 - (decreased CO leads to increased) SVR; SNS - catecholamines; RAS - vasopressin
7 - vagal tone (bradycardia), hypercapnia

Question 15

Review charts on slides 19-23:

Note how HR, MAP, CVP, stroke volume, and CO change from baseline, postinduction, CO2 insufflation, and time spent in steep trendelenburg.

Takeaway: Body figures out how to level out & adjust.

Answer 15

HR: initial decrease w/ induction, remains stable, back to baseline after supine/deflation

MAP: initial decrease w/ induction, increases w/ CO2 insufflation, and slightly declines in steep Tburg

CVP: Climbs with CO2 insufflation and then gradually declines the longer the patient is in steep Tburg

SV: initial decrease w/ induction, slightly increasing w/ Trendelenburg, but drastically increasing once supine/deflated

CO: initial decrease, remains stable, and then increases back to baseline after supine/deflated

Question 16

Venous CO2 gas embolism is suspected if sudden _____ ______ WITH _____ ______.

More common during initial _____ and dissection of deep ____ _____.

Answer 16

cardiovascular collapse with capnograph changes (flattened capnograph - think embolism)

insufflation
venous tissue

Question 17

Emboli Risk INCREASED if:

• CO2 > ___ mmHg
• __ or more ports
• Operative time > ____ min
• ___ patients

Answer 17

> 50 mmHg
6+ ports
200 min
older

Question 18

Pneumoperitoneum Considerations:

1) Venous CO2 gas embolus
2) CO2 _____ ____ incidence up to 3.9%
3) Post-op ____ ____ d/t residual CO2 irritating ____ nerve
4) Direct compression of _____ vasculature (important to maintain BP/perfusion pressure).
5) May have _____ UOP, creatinine clearance, GFR, and RBF leading to renal dysfunction.

Answer 18

2 - subcutaneous emphysema
3 - shoulder pain - phrenic
4 - renal
5 - decreased

Question 19

Cerebrovascular Effects:

1) Elevated PaCO2 - absorption of CO2 leads to cerebral ______ and _____ CBF.
2) Pneumoperitoneum causes abdominal compression and causes reduced venous ______
3) Steep Trendelenburg: gravitational forces cause a reduction in ____ ____, cranial _____ is reduced. CT scans have shown cerebral _____.

Answer 19

1 - vasodilation, increased CBF

2 - outflow

3 - venous return, drainage, edema

Question 20

Intracranial Effects:

1) Trendelenburg + Pneumoperitoneum can cause intracranial _____
2) There is a significant reduction in ____ ______ _____ in elderly patients. However, studies found rSO2 & CPP was not only preserved but _____ in patients w/out intracranial pathology b/c ____ is increased. CPP remained w/in the lower limits of where cerebral blood flow is maintained by ______.
3) Maintenance of _______ helps preserve cerebrovascular homeostasis.

Answer 20

1 - HTN
2 - regional oxygen saturation (rSO2) - increased - CBF increased - autoregulation
3 - normocarbia

Question 21

Is cerebral perfusion pressure maintained?

CPP = ____ - _____ (or ____ - whichever is higher)

CBF, ICP, and CVP are ALL elevated - the good news is the MAP is also elevated.

In other words, data is conflicting regarding cerebral _____ risks in healthy subjects. Risks are elevated in subjects w/ cerebral vascular disease or increased ICP.

Answer 21

CPP = MAP - ICP or CVP

ischemia

Question 22

There is debate whether autoregulation maintains OPP during steep trendelenburg - OPP = ____ - ____ or ____ (whichever is higher).

Increased ocular pressure has resulted in:

1) retinal ______
2) posterior ischemia optic ______
3) elderly have higher baseline ____ (even _____ rupture has occurred).

Answer 22

OPP = MAP - IOP or CVP

1 - detachment
2 - neuropathy
3 - IOP - eardrum

Question 23

Hypotensive ischemic optic neuropathy may be from a combination of periorbital _____ and increased ____ ______ leading to compartment syndrome of the ____ _____.

Answer 23

edema + venous congestion

optic nerve

Question 24

Review Chart on Slide 31:

Studies found that IOP reached peak levels at the ____ of steep trendelenburg averaging ___ mmHg HIGHER than at preanesthetic induction.

• Awad et al found after 60 minutes of ST the IOP
  increased 13.3 mmHg over baseline
• Molloy found a relationship between ______ ST and
  _____ ocular perfusion pressure.
• Hoshikawa et al found IOP increased above normal
  range while in ST and ______ to increase throughout case.

Answer 24

end - 13 mmHg

prolonged - reduced

continued

Question 25

Vision Loss:

ASA 2011 abstract: Reported 3 cases of permanent vision loss after robotic prostatectomy.

• Anesthetic duration 7.9-9.9 hours
• Onset within 24 hours postoperatively
• Exact mechanism for the vision loss remain undetermined

Weber et al reported 2 cases of increased risks of visual loss after robotic surgery (significant blood loss occurred)

Answer 25

Fort said do not give lots of fluids during these cases - can increase risk of periorbital edema, vision loss, etc.

Question 26

Positioning:

Sliding _____ (higher risk in morbidly obese) can cause _____ of port incision site.

_____ _____ stretch from shoulder straps/braces can occur resulting in weakness in shoulder adduction/elbow flexion. Many are recommending no longer using shoulder braces. X pattern ____ ____ are now preferred over braces.

Ischemic necrosis of _____ leading to ______ may be possible.

Answer 26

cephalad - tearing

brachial plexus - chest straps

occiput - alopecia

Question 27

The ____ _____ ____ positioners are the best for preventing sliding and injury.

Answer 27

pink anti-slide foam

Question 28

Nerve injuries are typically from ______ or _______.

The common _____ nerve is the most common injury complication in the lithotomy position - other nerves at risk include femoral, obturator, and sciatic.

One study showed that patients complained of lower extremity neuropathic symptoms indicating possible injury to the lateral femoral cutaneous, common peroneal, and obturator nerves.

Answer 28

overstretching, compression

common peroneal nerve

Question 29

Prolonged lithotomy & steep trendelenburg leads to hypoperfusion of lower extremities comparable to _____ ______. _________ forms from muscle ischemia and elevated serum ____ ____ levels.

____, ____, and _____ muscles are at the greatest risk.

Higher risk in BMI > ___.

Answer 29

compartment syndrome
Rhabdomyolysis
creatinine kinase

gluteal, back, shoulder

30

Question 30

Facial injuries may occur - robotic arms may contact face if ports are placed high - especially the camera port. The ___ and ____ are vulnerable to injury.

_____ _____ are the most common ocular complication. Most are d/t failure of eyelid to completely ___ resulting in corneal _____. Direct trauma causes up to 20%.

Face masks, eye shields, and foam padding (slide 41) have helped - do not have to use tape on eyes.

The corneas are very sensitive to _____ and _____ - tightly applied foam or misaligned eye protector can cause _____. Desquamation of epithelial layer more readily induces _____.

Answer 30

nose, mouth

corneal abrasion - close - drying

hypoxia and dryness
hypoxia
abrasion

Question 31

The ETT can migrate into the _____ after insufflation due to tracheal _____.

Answer 31

bronchus

shortening

*the ETT is not advancing from 21 to 23 - its that the lungs are shortening/moving up and the tube is then in the bronchus

Question 32

Most patients awaken w/ some degree of facial, pharyngeal, and laryngeal ____ from venous congestion.

A high degree of facial and conjunctiva edema may indicate _____ edema - delay extubation.

Answer 32

edema

laryngeal

**If they have eye conjunctiva sticking out, they have probably gotten too much fluid - DO NOT EXTUBATE

Question 33

Post-extubation respiratory distress may occur & reintubation may be necessary.

Some advocate for performing ETT ___ ___ prior to extubation if suspect laryngeal edema. A leak <15% of expired Vt between inflated and deflated cuff is associated w/ extubation _____.

_____ extubation until edema subsides - this may be indicated if the steep trendelenburg case was long or if difficult intubation occured.

Answer 33

leak test - deflate cuff, bellow should drop if no edema
failure

DELAY

Question 34

Intraoperative Fluid Considerations:

1) Periorbital edema was greater in patients receiving ___ than w/ ____ fluids.
2) Fluid restriction resulted in LESS operative ______
3) Fluid should be kept to < ____ mL of ______ - this not only reduces urine contamination in field during surgery, but minimizes facial, pharyngeal, laryngeal, and periorbital edema.

Answer 34

1 - LR, colloid
2 - complications
3 - <2000 mL crystalloid

Question 35

Anesthesia Considerations:

1) Insert lines, monitors, & protective equipment PRIOR to _____.
2) Brace torso w/ body fitting bean bag or egg crate to prevent _____ (pink anti-slide)
3) _____ consult if pre-existing intracranial pathology exists
4) Lesser degree of trendelenburg for a shorter duration = increased ____ ____ from head
5) Use ____ lithotomy positioning
6) ______ consult if preexisting intraocular pathology.
7) Many recommend avoiding aqueous gels, ointments, and moisture solutions in eyes - Fort says otherwise.
8) IOP risks can be higher in ___, ____, ____, and _____ - remember during of ST and higher _____ contribute to higher IOP.
9) If significant facial or conjunctiva edema - suggest ____ for ___ minutes for EACH hour of ST (requires timely undocking in Robotic cases, OK in non-robotic cases).
10) Consider ___ ___ to determine degree of airway edema.
11) Control ETCO2 to _____ limit of normal.
12) Use _____ control ventilation mode if available.

Answer 35

1 - draping
2 - sliding
3 - neurological 
4 - venous outflow
5 - low
6 - ophthalmology 
8 - DM, HTN, CAD, elderly - higher ETCO2
9 - supine for 5 min for each hour in ST
10 - leak test
11 - lower limit 
12 - pressure
12 -