anaesthesia in robotic surgery

ANAESTHESIA FOR ROBOTIC SURGERY

Presenter: Dr pankaj bhosale

Moderator: Dr .Balavenkat

WHY THE NEED FOR ROBOTS IN SURGERY?* resulting transformation of the minimally invasive surgical evolution

• allow unprecedented control and precision of surgical• instruments in minimally invasive procedures.

OTHER ANTICIPATED BENEFITS:

less pain and trauma, shorter hospital stays, quicker recovery better cosmetic result.

• NEW ANAESTHETIC IMPLICATIONS• ANAESTHETIST SHOULD KEEP ABREAST WITH ALL THE DEVELOPMENTS .• “ NOT AUTONOMOUS” ROBOTS BUT TRUE HELPING HANDS

HISTORY

• THE WORD ROBOT WAS FIRST USED BY CAPEK IN HIS PLAY ROSSUM’S UNIVERSAL ROBOTS IN 1921

• ROBOT MEANING FORCED LABOUR• ROBOTS WERE FIRST DEVELOPED BY THE NATIONAL AERONAUTICS AND

SPACE ADMINISTRA- TION (NASA) FOR USE IN SPACE EXPLORATION. • TELEMANIPULATORS

TELEMANIPULATORS

• TELEPRESENCE• SURGEONS ABOARD AN AIRCRAFT CARRIER• LIMITATIONS OF LAPAROSCOPIC SURGERY-ANOTHER STIMULUS • LOSS OF THREE-DIMENSIONAL VISION, IMPAIRED TOUCH SENSATION, AND

POOR DEXTERITY PROVIDED BY THE LONG INSTRUMENTS AND THE FULCRUM EFFECT.

• FIRST SURGICAL ROBOTIC DEVICES APPEARED IN THE 1980S FOR USE IN STEREOTACTIC BRAIN SURGERY.

• 1992, ROBODOC WAS INTRO- DUCED FOR GRINDING BONE TO MAKE SPACE FOR PROSTHESES IN HIP REPLACEMENT SURGERY.

• THE AUTOMATED ENDOSCOPIC SYSTEM FOR OPTIMAL POSITIONING (AESOP) WAS INTRODUCED FOR VOICE-CONTROLLED OPTIMAL CAMERA POSITIONING, AND LAPAROSCOPIC ASSISTED ROBOTIC SYSTEMS (LARS) AN AUTOMATED ROBOT, WAS INTRODUCED FOR ORGAN RETRACTION.

• THE FIRST MASTER-SLAVE MANIPULATOR FOR MEDICAL USE • WAS DEVELOPED AT STANFORD RESEARCH INSTITUTE IN 1991.

PROTOTYPE DAVINCI SYSTEM WAS RELEASED IN 1997.

• ENGINEERS REALIZED THAT THE DISTANCE BETWEEN PATIENT AND SURGEON HAD AN UPPER LIMIT, BEYOND WHICH ACCURACY AND DEXTERITY OF INSTRUMENT CONTROL WOULD BECOME DEGRADED.

• LATENCY• HIGH-BANDWIDTH FIBEROPTIC GROUND CABLE.

STATISTICS• IN 2000, 1500 ROBOTIC PROCEDURES WERE PERFORMED.

• IN 2004, MORE THAN 20,000 ROBOTIC PROCEDURES WERE PERFORMED.

• IN 2011, 360,000 SURGICAL PROCEDURES WERE PERFORMED WORLDWIDE WITH THE DA VINCI SURGICAL SYSTEM. OF THE ESTIMATED 360,000 SURGICAL PROCEDURES, APPROXIMATELY 146,000 WERE HYSTERECTOMIES AND APPROXIMATELY 113,000 WERE PROSTATECTOMIES.

ROBOTIC SYSTEMS

• 3 TYPES OF ROBOTIC SYSTEMS:• 1) INDUSTRIAL ROBOTS-ASSEMBLY LINE• 2) AN ASSIST DEVICE, SUCH AS AESOP. • 3) TELEMANIPULATOR.

• THE DA VINCI ROBOTIC SURGICAL SYSTEM IS A REPRESENTATION OF MOST MODERN SURGICAL ROBOTS.

• IT HAS BEEN APPROVED BY THE U.S. FOOD AND DRUG ADMINISTRATION (FDA) FOR USE IN UROLOGIC PROCEDURES, GENERAL LAPAROSCOPIC SURGICAL PROCEDURES, GYNECOLOGIC PROCEDURES, TRANSORAL OTOLARYNGOLOGY PROCEDURES, GENERAL THORACOSCOPIC PROCEDURES, AND THORACOSCOPICALLY ASSISTED CARDIOTOMY PROCEDURES.

DA VINCI ROBOTIC SURGICAL SYSTEM

SURGEON CONSOLE

3D STEREO VIEWER

3 D IMAGE

DEGREES OF

FREEDOM

PATIENT SIDE CART

TOWER

ENDO WRIST

ZEUS ROBOTIC SURGICAL SYSTEMS

ADVANTAGES

THREE-DIMENSIONAL VIEW, VISIBILITY OF DIFFICULT TO REACH AREAS, EASIER INSTRUMENT MANIPULATION AND THE POSSIBILITY OF REMOTE SITE SURGERY.

MINIMALLY INVASIVE DECREASE IN STRESS RESPONSE, PAIN, TISSUE TRAUMA HOSPITAL STAY,QUICKER RECOVERY & BETTER COSMETIC RESULT

ADVANTAGES OVER LAPAROSCOPYLIMITATIONS OF LAPAROSCOPYLOSS OF 3D VISIONIMPAIRED TOUCH SENSATIONPOOR DEXTERITY DUE TO LONG INSTRUMENTSMOTION REVERSAL, MOTION SEALINGFULCRUM EFFECT

ROBOTIC SX- SHORT LEARNING CURVE, BETTER QUALITY OF REPAIR AND EASE OF SURGERY IN MORBIDLY OBESE PATIENT.

PRE OPERATIVE ASSESSMENT

• A SYSTEMATIC REVIEW OF THE PATIENT’S HISTORY AND PHYSICAL EXAMINATION IS WARRANTED PRIOR TO ROBOTIC SURGERY.

• • AGE, MEDICATIONS, ALLERGIES, SURGICAL AND ANESTHETIC HISTORY SHOULD BE NOTED.

• BASELINE VITAL SIGNS SHOULD BE OBTAINED AND A THOROUGH AIRWAY EXAMINATION SHOULD BE CONDUCTED.

• CARDIAC, PULMONARY, RENAL, GASTRO INTESTINAL, NEUROLOGICAL & OCULAR(RAISED IOP), CANCER RISKS

PRE OPERATIVE PREPARATION

• AT A MINIMUM, PREOPERATIVE STUDIES FOR ROBOTIC CANCER SURGERY SHOULD INCLUDE ELECTROCARDIOGRAM, CHEST RADIOGRAPH, AND BLOOD WORK, NOTABLY: BLOOD COUNTS, COAGULATION STATUS, RENAL FUNCTION, AND BASIC ELECTROLYTES.

• THE PATIENT’S BLOOD SHOULD BE TYPED AND SCREENED FOR UNUSUAL ANTIGENS. • FASTING BLOOD GLUCOSE SHOULD BE NOTED BEFORE SURGERY FOR DIABETIC PATIENTS. • REFLUX, INFECTION AND DEEP VEIN THROMBOSIS PROPHYLAXIS SHOULD BE CONSIDERED

WITH NON-PARTICULATE ANTACID, ANTIBIOTICS (WITHIN 1 HOUR OF SURGICAL INCISION), SUBCUTANEOUS HEPARIN AND SEQUENTIAL COMPRESSION DEVICES RESPECTIVELY.

• ASA STATUS ASSIGNED. (>4 – HIGHER RISK)

ANESTHETIC CONCERNS WITH ROBOTICALLY-ASSISTED SURGERY

SEVERAL IMPORTANT ISSUES RELATED TO AND SPECIFIC TO ROBOTIC SURGERIES INCLUDE

• PATIENT POSITIONING,• DURATION OF THE PROCEDURE, • DEVELOPMENT OF HYPOTHERMIA,• THE HEMODYNAMIC AND RESPIRATORY EFFECTS OF THE PNEUMOPERITONEUM AND• OCCULT BLOOD LOSS.

GETTING STARTED

• MONITORING – ECG, PULSE OXIMETRY, AXILLARY TEMPERATURE PROBE, NIBP, CAPNOGRAM.

• TEE FOR THORACIC SURGERY IS THE STANDARD OF CARE• BILATERAL PERIPHERAL VENOUS ACCESS• ARTERIAL LINE HEMODYNAMIC MONITORING SHOULD BE CONSIDERED IN SPECIAL CASES.• MUSCLE RELAXANT IS PARAMOUNT• OROGASTRIC TUBE AND FOLEYS CATHETER• CONVECTIVE AIR BODY WARMERS• VENTILATOR ADJUSTMENTS TO NORMALISE EXHALED CO2

INDUCTION• STANDARD INTRAVENOUS INDUCTION IS FEASIBLE, ADJUSTING ANAESTHETIC PLANNING

BASED ON THE PATIENT’S MEDICAL CONDITION.

• THE ENDOTRACHEAL TUBE SHOULD BE TAPED SECURELY, APPRECIATING THAT PATIENT POSITIONING MAY ALTER TUBE PLACEMENT OVER TIME (UNINTENDED EXTUBATION OR MAINSTEM INTUBATION), ROBOTIC INSTRUMENTATION MAY DISLODGE A TUBE, AND AN OBSTRUCTED VIEW MAY DELAY RECOGNITION OF A TUBE THAT HAS BECOME DISLODGED.

• REPLACING AN ENDOTRACHEAL TUBE WOULD BE CHALLENGING FOR ROBOTIC SURGERY PATIENTS BASED ON POSITIONING AND THE TIME DELAY ASSOCIATED WITH UNDOCKING.

PROLONGED PREP. TIME

• POST-INDUCTION, CARE SHOULD ALSO BE TAKEN TO BALANCE THE NEED FOR CONTINUED SEDATION AGAINST ANY HEMODYNAMIC INSTABILITY THAT MAY RESULT FROM THE PROLONGED PREPARATION TIME PRIOR TO SURGICAL STIMULUS.

• PROCESSED ELECTROENCEPHALOGRAPHIC MONITORING SUCH AS BIS OR VASOPRESSOR AGENTS MAY BE REQUIRED TO BRIDGE THE TIME BETWEEN INDUCTION AND SURGICAL INCISION

PATIENT POSITIONING

• ROBOTIC SURGERY WITH THE DA VINCI SYSTEM DOES NOT ALLOW FOR CHANGES IN PATIENT POSITION ON THE OPERATING ROOM TABLE ONCE THE ROBOT HAS BEEN DOCKED.

• THEREFORE, THE ROBOT SHOULD BE DOCKED ONLY AFTER THE PATIENT HAS BEEN OPTIMALLY POSITIONED FOR SURGERY.

• PATIENT BODY POSITION CANNOT BE MODIFIED UNLESS THE INSTRUMENTS DISENGAGE ENTIRELY & REMOVED FROM BODY CAVITY.

• PATIENT POSITIONING VARIES WITH EACH SURGICAL PROCEDURE AND THE ANESTHESIOLOGIST SHOULD BE COGNIZANT OF OPTIMAL PLACEMENT PRIOR TO DOCKING THE ROBOT.

PROCEDURES IN THE PELVIS SUCH AS• PROSTATECTOMY ARE USUALLY DONE IN THE LITHOTOMY AND STEEP TRENDELENBURG

POSITION, WHILE THOSE IN THE UPPER ABDOMEN AND THE DIAPHRAGM ARE BEST PERFORMED IN THE

SUPINE AND REVERSE TRENDELENBURG POSITIONS.

STABLE POSITIONING

PROCEDURES IN THE CHEST ARE COMMONLY DONE IN THE LATERAL POSITION, WITH VARIATIONS OF TRENDELENBURG OR REVERSE TRENDELENBURG POSITION ACCORDING TO THE SURGICAL SITE.

MEDIASTINAL SURGERIES OFTEN REQUIRE THE LATERAL POSITION WITH LATERAL TABLE TILT.

• MANY LAPAROSCOPIC SURGICAL PROCEDURES REQUIRE EXTREME PATIENT POSITIONING IN ORDER TO TAKE ADVANTAGE OF GRAVITATIONAL EFFECT THAT ALLOWS MOVEMENT OF OBSTRUCTING ORGANS FROM THE SURGICAL FIELD.

• SINCE EXTREME POSITIONING OFTEN INCREASES THE RISK OF PATIENTS SLIDING OFF THE OR TABLE, RESTRAINTS MUST BE USED.

ADEQUATE EXTENSIONS FOR ACCESSIBILITY

• AIRWAY AND IV ACCESS

• THE SIZE AND BULK OF THE ROBOT OVER THE PATIENT AND THE SIGNIFICANT DRAPING ON BOTH THE ROBOT AND PATIENT, MAKE IT DIFFICULT TO ACCESS THE PATIENT INTRAOPERATIVELY.

• SOME PROCEDURES REQUIRE THE PATIENT’S AIRWAY TO BE AT A DISTANCE FROM THE ANESTHESIOLOGIST AND THE ANESTHESIA MACHINE/MONITOR.

ACCESSIBILTY

• UPPER ABDOMINAL AND THORACIC SURGERIES ARE DONE WITH THE OR TABLE ROTATED 180 DEGREES AWAY FROM THE ANESTHESIOLOGIST AND WITH THE ROBOT POSITIONED CEPHALAD ABOVE THE PATIENT.

• MEDIASTINAL PROCEDURES REQUIRE THE OR TABLE TO BE ROTATED 90 DEGREES AWAY FROM THE ANESTHESIOLOGIST. DURING THESE CASES, ACCESS TO THE PATIENT’S AIRWAY IS NEARLY IMPOSSIBLE, THUS FIELD AVOIDANCE PRECAUTIONS MUST BE EXERCISED.

• THESE CASES ARE PARTICULARLY CHALLENGING IF ONE LUNG VENTILATION IS REQUESTED SINCE FREQUENT USE OF THE FIBEROPTIC BRONCHOSCOPE MAY BE NECESSARY.

PRESSURE POINTS• IT IS IMPERATIVE TO ENSURE THE PATIENT IS PROPERLY POSITIONED WITH PRESSURE

POINTS ADEQUATELY PADDED PRIOR TO DRAPING AND DOCKING THE ROBOT.

• ROBOTICALLY ASSISTED SURGERIES ARE OFTEN LENGTHY PROCEDURES, ESPECIALLY FOR INEXPERIENCED SURGEONS, THUS ADEQUATE PRESSURE POINT PADDING IS ESSENTIAL TO AVOID TISSUE AND NERVE IMPINGEMENT.

• COMMON NERVE INJURIES TO PROTECT AGAINST INCLUDE: BRACHIAL PLEXUS, ULNAR, AND LATERAL FEMORAL CUTANEOUS NERVES.

• ATTENTION SHOULD BE PAID TO THE DEGREE OF LIMB EXTENSION, STIRRUP LOCATION, PADDING OF BONY PROMINENCES, AND DURATION OF IMMOBILITY.

• PROLONGED, STEEP TRENDELENBERG COULD RESULT IN PLETHORIC FACIES AND LARYNGEAL EDEMA AS WELL.

AVOID DIRECT CONTACT

• CAREFUL ATTENTION SHOULD ALSO BE GIVEN TO THE ROBOTIC ARMS TO PREVENT THEM FROM CONTACTING THE PATIENT.

• PRESSURE OR CRUSH INJURIES MAY OCCUR IF CONSTANT VIGILANCE IS NOT EXERCISED.

• AS A REMINDER, CAMERAS AND LIGHT SOURCES SHOULD BE CAREFULLY MONITORED AND NEVER LEFT DIRECTLY ON DRAPES TO AVOID OPERATING ROOM FIRES AND THERMAL INJURY TO THE PATIENT.

PHYSIOLOGIC PERTURBATIONS

• ONCE PROPER PATIENT POSITIONING HAS BEEN ACHIEVED, THERE ARE INTRAOPERATIVE CONSIDERATIONS MUST BE ADDRESSED.

• THE PHYSIOLOGIC PERTURBATIONS DURING ROBOTIC SURGERY ARE SIMILAR FOR BOTH LAPAROSCOPIC AND THORACOSCOPIC PROCEDURES.

CO2

THE MAINTENANCE OF NORMOCARBIA AND ACID BASE STATUS MAY BE CHALLENGING IN PATIENTS WITH POOR PREOPERATIVE RESPIRATORY STATUES.

THE MAIN FACTORS CONTRIBUTING TO AN INCREASE IN PACO2 AND RESPIRATORY ACIDOSIS ARE THE PERITONEAL ABSORPTION OF CARBON DIOXIDE, INCREASED DEAD SPACE IN PATIENTS WITH COEXISTING LUNG DISEASE, INCREASED METABOLISM, INADEQUATE VENTILATION, SUBCUTANEOUS EMPHYSEMA, AND/OR CARBON DIOXIDE EMBOLISM.

THE SAME PRINCIPLES THAT APPLY FOR THORACOSCOPIC SURGERY APPLY FOR ROBOTIC

ASSISTED THORACIC SURGERY.

• A COMBINATION OF PATIENT POSITION, ONE LUNG ANESTHESIA, AND SURGICAL MANIPULATION ALTER VENTILATION AND PERFUSION.

• PULMONARY SHUNTING IS THE MOST IMPORTANT FACTOR DETERMINING OXYGENATION DURING SURGERY. THIS SHUNT MAY BE LIMITED IN THE NON-VENTILATED LUNG BY DISEASE OR HYPOXIC PULMONARY VASOCONSTRICTION.

• THE LATERAL POSITION REDUCES SHUNTING BY FOLLOWING THE PRINCIPLE OF GRAVITY AND DECREASING BLOOD FLOW TO THE NONDEPENDENT LUNG.

• NORMOCARBIA IS USUALLY EASILY MAINTAINED DURING ONE LUNG ANESTHESIA DUE TO THE HIGH SOLUBILITY OF CO2.

• FREQUENTLY ROBOTIC ASSISTED SURGERIES REQUIRE INSUFFLATION OF CO2 IN THE

CHEST (CO2 PNEUMOTHORAX) WHICH INCREASES THE AIRWAY PRESSURES DURING ONE LUNG ANESTHESIA.

CHEST INSUFFLATIONS• THE CONTINUOUS INSUFFLATION OF CO2 INTO THE CHEST IMPROVES THE SURGICAL FIELD

BY COLLAPSING THE LUNG FURTHER AND BY SHIFTING MEDIASTINAL STRUCTURES AWAY FROM THE SURGICAL SITE.

• INSUFFLATIONS OF THE CHEST ARE USUALLY ACHIEVED WHEN THE INTRATHORACIC PRESSURE IS 10 MMHG.

• AS INTRATHORACIC PRESSURE RISES DURING CHEST INSUFFLATION, THERE CAN BE BOTH A DECREASE IN VENOUS RETURN AND COMPLIANCE OF THE HEART WHICH MAY RESULT IN HYPOTENSION AND HEMODYNAMIC INSTABILITY.

• LAPAROSCOPIC PROCEDURES ARE ASSOCIATED WITH PHASIC CHANGES IN HEMODYNAMIC PARAMETERS SECONDARY TO CO2 INSUFFLATION.

• INCREASES IN SYSTEMIC VASCULAR RESISTANCE, MEAN ARTERIAL PRESSURE, FILLING PRESSURES AND A 50% REDUCTION IN CARDIAC INDEX MAY OCCUR AFTER INITIAL CARBON DIOXIDE INSUFFLATION.

• THE CARDIAC INDEX GRADUALLY INCREASES AND SYSTEMIC VASCULAR RESISTANCE DECREASES 10 MINUTES AFTER CO2 INSUFFLATION.

• CENTRAL VENOUS PRESSURE AND PULMONARY CAPILLARY WEDGE PRESSURES MAY RISE DURING PNEUMOPERITONEUM.

• HEMODYNAMIC CHANGES CORRELATE WITH INCREASES IN INTRAABDOMINAL PRESSURE AND ITS EFFECT ON THE DIAPHRAGM.

• HEMODYNAMIC CHANGES ARE ALSO AFFECTED BY THE PATIENT’S POSITION. MOST STUDIES HAVE SHOWN A 10-30% REDUCTION IN CARDIAC OUTPUT IN TRENDELENBURG AND REVERSE TRENDELENBURG POSITIONS.

• CO2 INSUFFLATION CARRIES THE RISKS FOR VENOUS GAS EMBOLISM, DECREASED VENOUS RETURN TO THE HEART, VAGAL NERVE ACTIVATION OF PARASYMPATHETICS, AND ACUTE CARDIOVASCULAR COLLAPSE.

PNEUMOPERITONEUM AFFECTS MANY ORGANS.

• IT INCREASES CEREBRAL BLOOD FLOW, AND INCREASES INTRACRANIAL PRESSURE. • IN THE LIVER IT DECREASES PORTAL VEIN FLOW, HEPATIC VEIN FLOW, TOTAL HEPATIC

BLOOD FLOW, AND FLOW THROUGH THE HEPATIC MICROCIRCULATION; HOWEVER, THERE ARE NO CHANGES IN HEPATIC ARTERY FLOW.

GASTROINTESTINAL SYSTEM - DECREASES GASTRIC PH, MESENTERIC BLOOD FLOW, AND

GASTROINTESTINAL MICROCIRCULATION BLOOD FLOW. • THE PNEUMOPERITONEUM PRODUCES A DECREASE IN RENAL ARTERY BLOOD FLOW, RENAL

VEIN BLOOD FLOW, AND A DECREASE IN MEDULLARY AND CORTICAL FLOW.

RESPIRATORY SYSTEM IS GREATLY IMPACTED BY CO2 INSUFFLATION.

PNEUMOPERITONEUM MAY DECREASE PULMONARY COMPLIANCE BY 30-50% IN BOTH HEALTHY AND OBESE PATIENTS.

IT REDUCES THE FUNCTIONAL RESIDUAL CAPACITY DUE TO DIAPHRAGMATIC ELEVATION.

PEAK AIRWAY PRESSURE, PLATEAU PRESSURE, AND INTRATHORACIC PRESSURE ARE INCREASED; HOWEVER, THERE ARE USUALLY NO SIGNIFICANT CHANGES IN VENTILATION OR PERFUSION IN HEALTHY PATIENTS.

• AT THE SAME TIME THE DEPENDENT LUNG DEVELOPS HIGHER AIRWAY PRESSURES AND VENTILATION CAN BECOME DIFFICULT.

• AS CO2 IS INSUFFLATED AND ABSORBED, THE RATE OF ELIMINATION MUST ALSO INCREASE, A DIFFICULT FEAT TO ACHIEVE DURING ONE LUNG ANESTHESIA AS MINUTE VENTILATION MAY ALREADY BE MAXIMIZED.

ADDITIONAL COMPLICATION

• ANOTHER IMPORTANT CONSIDERATION DURING ROBOTIC THORACIC PROCEDURES IS THAT THERE MAY BE VIOLATION OF THE CONTRA LATERAL PLEURA WHICH CAN RESULT IN OCCULT BLOOD LOSS AND A TENSION PNEUMOTHORAX ON THE DEPENDENT CHEST.

• IT MAY PRESENT AS HEMODYNAMIC INSTABILITY AND NEAR IMPOSSIBLE VENTILATION OF THE DEPENDENT LUNG.

• IMMEDIATE DISCONTINUATION OF CO2 INSUFFLATION IS MANDATORY TO ALLEVIATE THE TENSION PNEUMOTHORAX.

ONE LUNG VENTILATION(OLV) STRATEGIES

• DURING SURGERY THE INSPIRED OXYGEN (FIO2) AT 1.0• THE AIRWAY PRESSURE KEPT BELOW 30 CM H2O. BEGIN OLV WITH PCV• THE VENTILATION SHOULD BE ADJUSTED TO MAINTAIN PACO2 AROUND 40 MMHG• SERIAL BLOOD GASES SHOULD BE CONSIDERED• THE APPLICATION OF POSITIVE END EXPIRATORY PRESSURE (PEEP) TO THE DEPENDENT

LUNG • OR CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) TO THE NONDEPENDENT LUNG MAY

ASSIST IN OXYGENATION.

OBESITY

• PATIENT HEIGHT, AND WEIGHT SHOULD BE CAREFULLY CONSIDERED AS OBESITY (BMI >30) MAY BE ACCOMPANIED BY PHYSIOLOGIC CHANGES SUCH AS OBSTRUCTIVE SLEEP APNEA AND RESTRICTIVE PULMONARY DISEASE, DIFFICULT INTUBATION, DELAYED GASTRIC EMPTYING, DIFFICULT VASCULAR ACCESS OR CO-MORBID CONDITIONS SUCH AS CARDIOVASCULAR DISEASE OR DIABETES MELLITUS.

• OBESE PATIENTS MAY BE AT INCREASED RISK FOR CONVERSION TO OPEN OR ABORTED PROCEDURES.

OBESE PATIENTS

• SOME CONCERNS HAVE BEEN RAISED ABOUT THE APPLICABILITY OF ROBOTIC AND LAPAROSCOPIC SURGERY IN THE OBESE PATIENT.

• ARTERIAL OXYGENATION AND A(A) DO2 ARE SIGNIFICANTLY IMPAIRED IN OVERWEIGHT PATIENTS UNDER GENERAL ANESTHESIA IN TRENDELENBERG POSITION.

• PNEUMOPERITONEUM MAY TRANSIENTLY REDUCE IMPAIRMENT IN ARTERIAL OXYGENATION AND DECREASE A(A) DO2.

• HEMODYNAMIC PARAMETERS ARE NOT AFFECTED BY BODY WEIGHT.

EMERGENCE

• POSITIONING, PNEUMOPERITONEUM AND FLUIDS COMBINE TO PUT THE PATIENT AT RISK FOR AIRWAY EDEMA AND FAILED EXTUBATION.

• SEVERAL REVIEWS HAVE SUGGESTED CONDUCTING AN AIRWAY CUFF LEAK TEST PRIOR TO EXTUBATION AS AN INDICATOR OF RISK FOR POST-EXTUBATION STRIDOR.

• PATIENTS WHO DO NOT MEET STRICT EXTUBATION CRITERIA SHOULD REMAIN INTUBATED IN THE POST-ANESTHESIA CARE UNIT (PACU) UNTIL CRITERIA ARE MET.

POST EXTUBATION RESPIRATORY DISTRESS

• AIRWAY COMPLICATIONS SUCH AS STRIDOR, LARYNGEAL EDEMA, OBSTRUCTION, AND TRACHEAL DEVIATION RESULT IN POSTOPERATIVE RESPIRATORY DISTRESS IN ROUGHLY 0.7% OF ROBOTIC SURGERIES, REQUIRING POSTOPERATIVE RE-INTUBATION .

RECOMMENDATIONS ARE• TO RESTRICT FLUID REPLACEMENT TO 1-2 LITERS OVER THE COURSE OF SURGERY,• TO USE COLLOIDS • AND TO ENSURE THAT THE PATIENT CAN BREATHE AROUND AN ENDOTRACHEAL TUBE WITH

A DEFLATED CUFF.

ROBOTIC-ASSISTED SURGERY: FUTURE DIRECTIONS

• THE FUTURE OF ROBOTICALLY-ASSISTED SURGERY SEEMS PROMISING; HOWEVER, THERE ARE STILL MANY UNANSWERED QUESTIONS AS THE TECHNIQUE IS STILL IN ITS INFANCY.

• REGARDING THE EFFECTIVENESS OF THESE SURGERIES FEW CLINICAL OUTCOME STUDIES HAVE BEEN PERFORMED AS OF YET, THEREFORE, FURTHER RESEARCH ADDRESSING THESE ISSUES MUST FOLLOW.

• FURTHERMORE, WITH THE CURRENT FOCUS ON HEALTH CARE COST CONTAINMENT, COST EFFECTIVE STUDIES WILL BE INCLUDED.

• OTHER LIMITATIONS TO CURRENT ROBOTIC SYSTEMS THAT WILL BE ADDRESSED INCLUDE START UP COSTS. AS IS THE CASE WITH MOST MANUFACTURED GOODS, INCREASING VOLUMES OF ROBOTS SHOULD DECREASE THE UNIT COST OF PRODUCTION.

• ADVANCES IN THE ROBOTS ARE CONTINUALLY BEING MADE AS PHYSICIANS AND INDUSTRIES COLLABORATE.

ROBOTS IN ANAESTHESIA

• ROBOTS IN ANESTHESIA CAN BE DIVIDED INTO :• PHARMACOLOGIC ROBOTS, WHICH DELIVER DRUGS TO ESTABLISH OR MAINTAIN

COMPONENTS OF ANESTHESIA• MANUAL ROBOTS, WHICH ARE ABLE TO ASSIST OR REPLACE HUMAN GESTURES IN

ANESTHESIA. • DECISION SUPPORT SYSTEMS CAN BE DEFINED IN THIS CONTEXT AS PREDECESSORS OF

ROBOTS IN ANESTHESIA, BECAUSE THEY MEASURE PARAMETERS AND MAKE DECISIONS, BUT LEAVE ACTION TAKING TO THE HUMAN USER.

DECISION SUPPORT SYSTEMS• CONSIDERED AS PREDECESSORS TO ROBOTS

• DSSS USE ALGORITHMS OF PREDEFINED SCENARIOS TO CREATE SPECIFIC ADVICE: DIAGNOSTIC SUGGESTIONS, TREATMENT OPTIONS, OR TRIAGE EVALUATIONS. THESE ALGORITHMS ARE BASED ON MANY INPUTS, SUCH AS PATIENT DEMOGRAPHIC DATA, VITAL SIGNS, BLOOD LOSS, INTRAVENOUS (IV) FLUID ADMINISTRATION, AND MANY OTHER TYPES OF ADVANCED INFORMATION.

• ANESTHESIA INFORMA- TION MANAGEMENT SYSTEMS (AIMS) • SMART ANESTHESIA MANAGER (SAM)

• THE ONLY DSS DESIGNED AND CLINICALLY TESTED FOR ANESTHESIA DELIVERY DURING SURGERY IS PART OF THE HYBRID SEDATION SYSTEM (HSS).

• SPECIFICALLY DEVELOPED TO RECOGNIZE CRITICAL HEMODYNAMIC AND RESPIRATORY EVENTS DURING SEDATION WITH PROPOFOL IN PATIENTS WHO HAD RECEIVED A SPINAL ANESTHESIA.

• POP-UP MENUS OFFER THE VARIOUS REASONS FOR THE ALARM, AND THE TREATMENT OPTIONS DISPLAYED ON A TOUCH SCREEN WITH TOUCH BUTTONS; THE ANESTHESIOLOGIST THEN NEEDS TO CONFIRM THE ACTIONS TO BE TAKEN, WHICH ARE RECORDED FOR MEDICOLEGAL REASONS.

HYBRID SEDATION SYSTEMS

CLOSED LOOP SYSTEMS

• CLOSED-LOOP SYSTEMS IN ANESTHESIA ARE PHARMACOLOGIC ROBOTS; THEY ALLOW THE AUTONOMOUS CONTROL OF ANESTHESIA;

• MOST SYSTEMS HAVE BEEN DEVELOPED AS RESEARCH TOOLS FOR THE ADMINISTRATION OF PROPOFOL.

• ALL STUDIES CONFIRM AN EQUAL OR MOSTLY SUPERIOR PERFORMANCE AND MAINTENANCE OF A GIVEN TARGET, IN COMPARISON TO MANUAL CONTROL.

. KENNY AND GROUP

. LIU

. ROCKSTOCK

. PURI

. STRYS AND DE-SMET GROUP

. MCSLEEPY

MC SLEEPY LOOP SYSTEMS

• THE FEATURES OF MCSLEEPY CAN BE SUMMARIZED AS FOLLOWS:

• FULLY AUTOMATIC OR SEMIAUTOMATIC MODE (E.G., CLOSED- LOOP HYPNOSIS CONTROL, COMBINED WITH MANUAL ANALGESIA CONTROL) • THREE CLOSED LOOP CONTROLLERS FOR INDUCTION AND MAINTENANCE

• SELF-ADAPTIVE PID FOR HYPNOSIS USING BIS OR ANY OTHER • DEPTH OF CONSCIOUSNESS MONITORING PARAMETER AS • FEEDBACK

• SELF-ADAPTIVE PID FOR ANALGESIA USING THE ANALGOSCORE • AS FEEDBACK PARAMETER

• ON/OFF CONTROLLER FOR NEUROMUSCULAR BLOCK USING ANY • AVAILABLE NEUROMUSCULAR BLOCKING DEVICE

• LARGE TOUCH SCREEN INTERFACE AS COMMUNICATION

• PLATFORM WITH USER• FOUR DIFFERENT SCREENS: SETUP SCREEN, INDUCTION SCREEN,

• MAINTENANCE SCREEN, AND EMERGENCE SCREENS WITH • AUTOMATIC CHANGE IN-BETWEEN

• COMMUNICATION WITH USER: OUTPUT BY VOICE COMMANDS; • INPUT AT DIFFERENT STAGES OF SURGERY

• TELEMEDICAL CAPABILITY: CONNECTION VIA BLUETOOTH OR • INTERNET WITH ANY WIRELESS DEVICE • BISPECTRAL INDEX• LIVE VIDEO FEEDS • RECORDING AND MONITORING OF DATA

• SIMILAR TO SURGICAL ROBOTS, MANUAL ROBOTS HAVE BEEN DEVELOPED THAT ASSIST ANESTHESIOLOGISTS TO PERFORM MANUAL GESTURES, SUCH AS ENDOTRACHEAL INTUBATION OR REGIONAL NERVE BLOCKS.

KEPLER INTUBATION SYSTEM

TELEPRESENCE IN ANAESTHESIA

ROBOTS IN REGIONAL ANAESTHESIA

• ROBOTICALLY-ASSISTED SURGERY IS ESTABLISHED AND WILL LIKELY PLAY AN INCREASINGLY LARGE ROLE IN THE FUTURE OF SURGICAL PRACTICE.

• THE TECHNOLOGY OF ROBOTIC ASSISTANCE HAS OVERCOME THE LIMITATIONS OF CONVENTIONAL LAPAROSCOPY, THUS SECURING ITS UTILITY IN MICROSURGICAL PROCEDURES.

THESE ADVANTAGES INCLUDE IMPROVED SURGICAL PRECISION, BETTER VISUALIZATION, AND MORE INTUITIVE/ERGONOMIC INSTRUMENT CONTROL THUS LEADING TO FASTER SURGICAL LEARNING CURVES FOR SURGEONS.

ANESTHESIOLOGISTS MUST BE AWARE OF THESE CHANGES AND ADJUST THEIR PRACTICE IN ORDER TO PROVIDE SAFE PATIENT CARE.

REFERENCES

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