Anesthesia for Robotic Surgery May 12 th 2009

Anesthesia for Robotic Surgery May 12 th 2009 Department of Anesthesiology and Pain medicine Choi Sung Uk, MD, Ph. D

Contents u Introduction – History u Robotic System – da Vinci system – Advantages and Disadvantages – Current Applications u Anesthetic Concerns – General Surgery – Cardiac Surgery – Urologic Surgery u Summary

Introduction u Robotic device (technically) – “powered, computer controlled manipulator with artificial sensing that can be reprogrammed to move and position tools to carry out a wide range of tasks” – Autonomous device capable of various tasks

Introduction u Robots and Robotics – “Robot” • By the Czech brothers Karel and Josef Capek, in the play R. U. R (Rossum’s Universal Robots) in 1923 • The Czech word robota means drudgery – “Robotics” • By Isaac Asimov, in the short science fiction story "Runaround" in 1942

Introduction u In the future – Directed from vastly remote locations – Computer-controlled or autonomous function u Present-day – Mere instruments manipulated remotely by a surgeon using an electromechanical interface – Not autonomous

Introduction History u Surgical robotic systems grew out of the concept of telesurgery – First developed by the NASA for use in space exploration; Telemanipulators – Through virtual reality, the surgeon could be brought to the wounded soldiers’ side; Telepresence – Research in telemanipulation for remote mobile surgical units that would allow for telepresence by the Department of Defense

Introduction History u PUMA 560 – Neurosurgical biopsy by Kwoh et al. in 1988 u PROBOT – Robot-assisted TURP by Davies et al. in 1991

Introduction History u ROBODOC – First commercially available robotic system for orthopaedic hip surgery in 1992

Introduction History - ROBODOC

Introduction History u AESOP – Automated Endoscopic System for Optimal Positioning: voice-activated robotic arm for camera holder in 1994 (Computer Motion) – First approved surgical robotic system by FDA

Introduction History - AESOP

Introduction History u ZEUS – Marketed in 1998 (Computer Motion) – Transatlantic robot-assisted telesurgery between NY(USA) and Strasbourg(France) in 2001

History - ZEUS

Introduction History - ZEUS

Introduction History u da Vinci – Initially developed by US Department of Defense in 1991 – Intuitive Surgical acquired the prototype and commercialized the system – Approved by FDA in July 2000

Introduction History u da Vinci® Surgical System U. S. Installed Base 1999 – 2008

Robotic System – da Vinci

Robotic System Advantages over Laparoscopic Surgery 6 degrees of freedom compared to 4 degrees of freedom of laparoscopy u Magnification (10 -fold) u 3 -D view (=Depth perception) u Tremor filtration & Motion scaling u Better hand-eye coordination u Comfortable seat posture – ergonomic u Shorter learning curve u

Robotic System Degrees of Freedom in motion

Robotic System Advantages over Laparoscopic Surgery More precision u Fewer traumas to the tissues u Less blood loss u Lesser adhesion u Less postoperative pain u Early ambulation u Lesser postoperative complications u

Robotic System Disadvantages or Limitation Lack of tactile sensation u Risk of break down u Surgical skills required u Prolonged operating times u Significant surgeon fatigue u Anesthetic complications u Cost-effectiveness of Robotic surgery – high installation and maintenance costs u

Robotic System Current Applications u Approved by FDA – – – – – 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

Robotic System Current Applications u Urology – Radical prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteral reimplantation u Cardiothoracic – Mitral valve repair, ASD closure, PDA ligation, IMA mobilization and totally endoscopic CABG u Gynecology – Hysterectomy and myomectomy u Pediatrics – Pyeloplasty for ureteropelvic junction obstruction, gastroesophageal repair GERD, ligation of PDA u General Surgery – Cholecystectomy, Nissen fundoplication, Heller myotomy, gastric bypass, donor nephrectomy, adrenalectomy, splenectomy, bowel resection and thyroidectomy

Robotic System Operating Theatre

Anesthetic Concerns u Several important issues related to and specific to robotic surgeries – Patient positioning – Duration of the procedure – Development of hypothermia – Hemodynamic and Respiratory effects of the pneumoperitoneum – Occult blood loss

Anesthetic Concerns Pathophysiological changes during laparoscopy u Cardiovascular effects – Depends on • Intra-abdominal pressure (IAP) • Patient position • Volume of CO 2 absorption • Patient’s intravascular volume • Ventilatory technique • Surgical condition • Anesthetic agents used

Anesthetic Concerns Pathophysiological changes during laparoscopy u Cardiovascular effects – IAP • Below 15 mm. Hg : increased C. O. – Blood from splanchnic venous bed is “squeezed” – Vasoconstriction due to sympathetic activation – > Increased venous return • Upper than 15 mm. Hg: decreased C. O. – Vena cava and other collateral vessel is compressed

Anesthetic Concerns Pathophysiological changes during laparoscopy u Cardiovascular effects – Bradyarrthymias • Includes bradycardia, AV dissociation, asystole • Due to vagal stimulation of trocar, peritoneal stretch, CO 2 embolization – Tacchyarrhythmias • Includes tachycardia, hypertension, VF • Due to increased CO 2 and catecholamines – Can be reduced when induction of pneumoperitoneum is done in supine position

Anesthetic Concerns Pathophysiological changes during laparoscopy u Respiratory effects – Compromises pulmonary function by • Diaphragmatic elevation • Early closure of small airways → atelectasis • Preferential ventilation of nondependent parts of the lung → V/Q mismatch • Risk of endobronchial intubation – In pulmonary compromised patients • Preoperative PFT and ABGA

Anesthetic Concerns Pathophysiological changes during laparoscopy u Neurologic effects – Increased ICP and decreased CPP • Increased SVR • Head-down position • Elevation of IAP • Hypercapnia – Should be cautious when intracranial compliance is reduced

Anesthetic Concerns General Surgery u Gastrointestinal Surgery – Supine position with reverse Trendelenburg – Robot over the patient’s head or at a 45° angle from the bed – Robotic arms in very close proximity to the patient’s airway, face, and chest – Rapid sequence induction with cricoid pressure – Muscle relaxation is paramount

Anesthetic Concerns Monitoring 5 -lead ECG u (Non)invasive BP u Sp. O 2 u ETCO 2 / ET Gases u Airway pressure u Temperature u Entropy or BIS u NMT u

Anesthetic Concerns General Surgery

Anesthetic Concerns Cardiac Surgery Supine position with the thorax rotated 20° u Anesthetic Implications u – Knowledge of and expertise in cardiac and thoracic anesthesia – Single-lung ventilation – Transesophageal echocardiography (TEE) • Continuous monitoring of cardiac function • Guide central line placement (17 -Fr Biomedicus cannula) – 5~10 mm. Hg of Capnothorax

Anesthetic Concerns Cardiac Surgery

Anesthetic Concerns Cardiac Surgery Open Surgery vs. Robotic Surgery

Anesthetic Concerns Cardiac Surgery

Anesthetic Concerns Urologic Surgery Supine lithotomy with 30° Trendelenburg u Anesthetic Implications u – Monitored with routine care – Arterial line for frequent sampling – Large-bore intravenous line for potential large blood loss – Padding placed at every pressure point

Anesthetic Concerns Urologic Surgery

Anesthetic Concerns Urologic Surgery Physiological effects of pneumoperitoneum in the Trendelenburg Position Cardiovascular system ↑ Systemic vascular resistance, ↑ Mean arterial pressure ↓ Renal, portal, splanchnic flow Respiratory system Worsens VQ mismatch ↓ Pulmonary compliance, ↑ peak airway pressures ↓ Functional residual capacity Hypercarbia, respiratory acidosis Central nervous system ↑ Intracranial pressure ↑ Cerebral blood flow Endocrine system ↑ Catecholamine release Activation of renin-angiotensin system → ↑ Vasopressin

Anesthetic Concerns Urologic Surgery Morbidity from prolonged Trendelenburg/Lithotomy Neuropathies – common peroneal, saphenous Central venous pressure elevation Intraocular/intracranial pressure elevation Increased myocardial work Increased pulmonary venous pressure Decreased pulmonary compliance/FRC Clinical swelling of face, eyelids, conjunctiva, tongue

Summary u Future use of robotic technology in surgery is likely to increase at a rapid rate – – u Improved surgical precision Better visualization More intuitive/ergonomic instrument control Faster surgical learning curves for surgeons Anesthesiologists must be aware of these changes and adjust their practice in order to provide safe patient care

Questions and answers