Tips in Anesthesia for Robotic Surgery

Figure 55.1

Patients should be protected from robotic arms and other injuries

Figure 55.2

35–45° Trendelenburg position is given to patient

Pressure-Controlled Ventilation and Positive end expiration pressure [PEEP (5 cm H₂O) + 20 (max)] are recommended both for the prevention of atelectasis and barotrauma. It was found to result in greater dynamic compliance and lower peak inspiratory airway pressure, compared with volume-controlled ventilation. Mild hyperventilation is recommended to avoid development of hypercarbia and resultant metabolic and respiratory acidosis.

Complications and Management Strategies

The combination of pneumoperitoneum with the steep Trendelenburg position impairs respiratory mechanics, and it causes severe pulmonary complications such as; atelectasis, pulmonary edema, hypercarbia, and respiratory acidosis.

It should be considered, the pneumoperitonium may cause to vagal nerve stimulation resulting in bradycardia, nodal, atrioventricular dissociation, and asystole. Afterload increases significantly during the pneumoperitoneum. Heart rate and cardiac index increase significantly during RARP [8].

Tips and Tricks: Arterial vasodilation at the time of pneumoperitoneum may reduce afterload and myocardial oxygen demand.

Intra cranial pressure (ICP) increases during RARP procedure due to increased intraabdominal pressure that stops lumbar venous plexus venous return. Also steep Trendelenburg position increases ICP directly. Patients who had cerebrovascular ischemia or cerebrovascular disorders may develop severe complications result from both Trendelenburg position and pneumoperitoneum originated ICP increase [9]. These may all give rise of deterioration of cerebral oxygenation.

Tips and Tricks: NIRS monitorization may be useful in these patients groups. Mechanical ventilation strategy should be adjusted to preserve blood gases in normocapnic range and in order to eliminate the risk of increase in ICP [10].

Intraocular pressure (IOP) increases after pneumoperitoneum and the steep Trendelenburg position are established. Surgical duration and ETCO₂ are significant predictors of IOP increase in the Trendelenburg position [4]. This increase may be less with propofol than with sevoflurane anesthesia [11].

Tips and Tricks: Modifed Z Trendelenburg position may have a significant positive effect by lowering intraocular pressure and accelerating its recovery [12].

Pneumoperitoneum causes subcutaneous emphysema (SCE) in about 0.3–3.9 % cases. Risk factors for SCE are end tidal CO₂ levels more than 50 mmHg, multiple operative ports, prolonged operation time, and old patients. Venous gas embolism may be a life threatening complication in some cases. Sudden cardiovascular collapse may occur due to venous gas embolism with changes in caphnographic tracing [3]. Other potential complications of pneumoperitoneum include pneumothorax, pneumomediastinum, and pneumocardium.