Anaesthesia for robotic gynaecological surgery.
Robots are being used in urological, cardiac, orthopaedic, gynaecological, thoracic, neurosurgical, ear, nose and throat, and general surgery (1-11). The gynaecological robotic operations which are being performed are myomectomy, total and supracervical hysterectomy, ovarian cystectomy, sacral colpopexy, tubal reanastomosis, lymph node dissection, surgery of retroperitoneal ectopic pregnancy, the Moskowitz procedure and endometriosis surgery (2-7,12-21). Robot-assisted laparoscopic radical hysterectomy for cervical cancer has been introduced recently (3,15). We are performing most of these operations in our institute. The Da Vinci system (Intuitive Surgery,
Mountain View, California, USA) is presently the only commercially available robotic system, having received Food and Drug Administration approval for use in gynaecological surgery in 200 (52).
The advantages of robotic surgery over open surgery and laparoscopic surgery (6,7,12-21) include: 1) three-dimensional movement of the robotic hand, leading to increased dexterity; 2) improved articulation of the instruments; 3) easier access to inaccessible surgical sites; 4) better visualisation of fine structures; 5) stereoscopic vision; 6) smaller incisions; 7) faster recovery and shorter hospital stay; 8) steeper learning curve by the surgeon; 9) reduced blood loss and transfusion; 10) reduced postoperative pain; 11) tremor reduction; and 12) motion downscaling--4:1. Robots are especially useful for obese patients (22).
[FIGURE 1 OMITTED]
Gynaecological laparoscopic surgery is performed in a confined space, the female pelvis. There is limitation of the degrees of freedom of movement and of dexterity with the use of conventional laparoscopy, leading to difficulty in performing complex tasks such as lymph node removal and intracorporeal knot-tying. Other limitations are a two-dimensional field of vision, a limited degree of instrument movement inside the body and tremor amplification. Robotic gynaecological surgery overcomes these problems (12,13,15,17).
The enhanced dexterity and the seven degrees of freedom of movement of the robotic hands give the surgeon an ability to perform finer, tremor-free dissection and removal or reconstruction of the tissue (15-17). Three degrees are provided by the robotic arms, attached to the abdominal wall trocars (insertion, pitch, yaw) and four degrees by the rested instruments (pitch, yaw, roll and grip). During the surgical procedure, the high definition, three-dimensional vision provided at the console enhances the ability to identify the tissue planes, blood vessels and nerves more easily than with open surgery. These factors lead to decreased intraoperative blood loss (13,17).
The robotic system allows accurate excision of the lymph nodes and adhesions from previous surgery, thereby assisting radical cancer surgeries (13,15). Robotic surgery can help maintain the fertility of the women (19,21). After myomectomy during pregnancy, accuracy of the repair of the uterus keeps it strong during the later months of pregnancy (19,21). A comfortable working position has been shown to reduce surgical fatigue, surgical difficulties and learning curves compared with standard laparoscopy (18).
Various studies (12-14) comparing robotic laparoscopic hysterectomy to conventional laparoscopic hysterectomy and open laparotomy found a significantly decreased blood loss and a shorter hospital stay with the robotic approach. Conversion rates to laparotomy for robotic and laparoscopic groups were similar. In a retrospective study, Advincula et al (6) found significantly decreased blood loss and a shorter hospital stay in patients who underwent robot-assisted laparoscopic myomectomy, compared with abdominal myomectomy.
Complication rates were higher in the laparotomy group than in the robotic myomectomies. In contrast, Nezhat et al (20) found that postoperative complications were not significantly different between conventional laparoscopic and robotic myomectomy.
Robotic sacrocolpopexy, when compared with abdominal sacrocolpopexy (16), was associated with less blood loss (103[+ or -]96 vs 255[+ or -]155 ml, P <0.001), longer total operative time (328[+ or -]55 vs 225[+ or -]61 minutes, P <0.001) and shorter hospital stay (1.3[+ or -]0.8 vs 2.7[+ or -]1.4 days, P <0.001). Boggess et al15 found the highest lymph node yields with the robotic hysterectomy approach.
The learning curve in robotic surgery is very steep, allowing the surgeon to achieve competence sooner when performing a laparoscopic gynaecological procedure, using a robotic technique, compared to learning a conventional technique. Pitter (17) compared the mean operative times in the first 20 and the second 20 cases of robotic hysterectomy of a single surgeon and found it to be significantly shorter in the second 20 cases (151 minutes), compared to the first 20 cases (212 minutes) (P <0.05). Lenihan et al (18) found that the learning curve for different benign surgical interventions stabilised after approximately 50 cases. Total operative time for hysterectomy studied sequentially stabilised to approximately 95 minutes after 50 cases (18). Payne et al (14), in the retrospective review of their last 200 consecutive hysterectomy cases, also noted a significant improvement in the mean operative times when comparing their last 25 cases with the first 25 robotic laparoscopic hysterectomies (79 vs 134 minutes). There were no bladder or ureteric injuries and no significant adverse effects.
The disadvantages of the robotic system are: 1) increased time required for docking and undocking of the robot; 2) absence of haptic/ tactile feedback; 3) bulkiness of the robotic system; and 4) increased cost of the surgery (2-7,19-21,23,24). Bulkiness and positioning of the robot makes the patient inaccessible to the anaesthetist after the start of the surgical procedure. Rapid access to the patient is difficult. The staff need to be trained to rapidly de-dock the robot from the patient, in case of an emergency.
Dharia et al (19) compared robotic tubal reanastomosis with an open technique and found a significantly longer operative time (201 vs 155 minutes), but a significantly shorter hospital stay (4 vs 35 hours) and a faster return to normal routine (11 vs 28 days). Nezhat et al (20) noted the longer mean surgical time for robotic myomectomy (234 minutes; range 140 to 455 minutes) compared with laparoscopic myomectomy (203 minutes; range 95 to 330 minutes).
Rodgers et al (21) compared robotic tubal anastomosis with outpatient mini-laparotomy and also found that the robotic surgery took significantly longer (mean time 229 minutes) compared with mini-laparotomy (mean time 181 minutes, P=0.001). Mean anaesthesia time for the robotic technique was 253 (range 267 to 290) versus 205 (range 107 to 230) minutes (P <0.001) for mini-laparoscopy. The time to return to work was shorter by one week in the robotic system group (P=0.13).
The cost of setting up a robotic unit (US$1,390,000), annual maintenance costs and the cost of disposables (US$1500 per procedure) are significant. Robotic procedures have proven more costly, with a median difference in cost of US$1446 (95% confidence interval US$1112 to US$1812, P <0.001) (21). This extra cost is supposedly balanced by the reduced hospital stay and an earlier patient return to full function. Venkat et al11 collected data from the hospital billing records and concluded that the direct costs and charges associated with the robotic gynaecological surgery were higher compared to the laparoscopic surgery. However, actual reimbursements to the hospital, surgeon, and anaesthetist were not significantly different (11).
Complications reported with robotic laparoscopic gynaecological surgery are transient ischaemic attack, port-site hernia managed through trocar incision, periumbilical haematoma managed conservatively, and a vaginal cuff haematoma that required insertion of a ureteric stent for a partial ureteric stenosis (9,23).
The first surgical robot was manufactured in the United States by the Department of Defense to operate on war victims from a safe distance, in the battlefield (10,25). National Aeronautics and Space Administration in the USA conducted research to develop a robot that can perform surgery in space from a console on earth25. These surgeries could not be accurately performed because of the great distance.
In 1985, the first surgical robot PUMA-560 performed a needle biopsy of the brain, under computed tomography guidance (26). In 1988, the first robotic prostatic surgery was performed by PROBOT, which was developed at the Imperial College, London. In 1992, ROBODOC (from the Integrated Surgical Systems) was used to mill precise fittings in the femur, for hip replacement surgery.
ZEUS Robotic Surgical System was a three-armed robot, produced by an American robotics company, Computer Motion (27). It received Food and Drug Administration approval to assist surgery in 1994. The first arm, AESOP (Automated Endoscopic System for Optimal Positioning), was a voice-activated endoscope which allowed the surgeon to see inside the patient's body. ZEUS was discontinued in 2003 following the merger of Computer Motion with a rival, Intuitive Surgical.
The first robotic gynaecological operation was a reanastomosis of the Fallopian tube and was performed in Cleveland, USA in 1997, using the ZEUS system. The first robotic laparoscopic cholecystectomy was performed using the Da Vinci surgical system in April 1997 in Belgium (28).
The Da Vinci system is composed of three Parts (10,28). First there is a remotely located console where the surgeon sits and controls the arms/fingers of the robot (Figure 2). This console provides a three-dimensional view of the surgical site (28). A computer controls the console which simulates the surgical field for the surgeon (28). The foot pedals are used by the surgeon to control the electrocautery, ultrasonic instruments and the video camera. One foot pedal controls the movement (left/right, up/down, in/out) and horizontal orientation, while another pedal controls the focus of the camera.
[FIGURE 2 OMITTED]
The second component is a tower, which has video equipment to record and display the surgery on a monitor kept on the top of the tower. The laparoscopic set with its monitor is also kept on this tower (10). The third component is the robot with three or four arms (10). The central arm holds the video telescope while the side arms perform different manipulations.
The main anaesthetic considerations for these Procedures (28,29) are: 1) access to the patient is restricted, because of the large size of the robotic equipment and the spatial restriction after the final positioning and docking of the robot; 2) the patient is in a steep Trendelenburg position for most of the procedure; 3) once the robot is docked, the position of the patient cannot be changed; 4) the surgery is prolonged; and 5) the impact of pneumoperitoneum from carbon dioxide insufflation.
The steep Trendelenburg position
In most robotic procedures the patient is placed 25 to 45 degrees head down from the horizontal plane, for better surgical exposure. For gynaecological surgery, a less steep (30 to 35 degrees) angle is required compared to urological surgery. The steep head-down position causes cephalad movement of the diaphragm by the abdominal contents, thus reducing the functional residual capacity and pulmonary compliance (30-36). Deadspace ventilation increases but returns to normal after resuming the supine position (37). In obese patients, these effects are magnified further, making ventilation extremely difficult. Most of the lung tissue may be in zone 3/4 leading to ventilationperfusion mismatch, atelectasis and pulmonary interstitial oedema (34-36).
The intraocular pressure increases by 10 to 15 mmHg (38) and there is an increase in intracranial pressure and central venous pressure (39,40). There can be a decrease in heart rate, accompanied by an increase in stroke volume and cardiac output due to increased preload (31).
Prolonged head-down positioning may lead to laryngeal, facial, conjunctival and tongue oedema (10,11,22,40-43). Brachial plexus injury caused by the shoulder braces has been reported (40). There have been reports of cerebral haemorrhage, lingual or buccal nerve neuropathy and median nerve palsy (40-43). If significant laryngeal oedema is present, the patient should be electively ventilated until the oedema subsides and should be extubated only when the cuff leak test is positive (40).
The Trendelenburg position may push the trachea cephalad and cause the endotracheal tube to migrate distally into the right main bronchus (44). This may be exacerbated by peritoneal insufflation of carbon dioxide, which shifts the mediastinal structures further cephalad.
The insufflation of carbon dioxide into the peritoneal cavity causes elevation of the diaphragm, ventilation-perfusion mismatch and a decrease in functional residual capacity (30,31,35,36,42). It increases central venous pressure, pulmonary arterial pressure, mean arterial pressure, systemic vascular resistance and pulmonary vascular resistance, and decreases venous return and cardiac output (30-33). The cardiac index gradually increases and systemic vascular resistance decreases following the insufflation. Cardiac arrhythmias, especially bradycardia, can occur due to a reflex increase of the vagal tone by the sudden stretching of the peritoneum (32,33). This vagal stimulation is increased by light anaesthesia, especially in patients on betablockers. The treatment involves interruption of peritoneal insufflation and reduction of intraabdominal pressure, administration of atropine and deepening of anaesthesia (36).
Jakimowics et al (45) reported a 53% decrease in the portal blood flow with abdominal insufflation to a pressure of 14 mmHg, causing hepatic hypoperfusion and acute hepatocyte injury. Pneumoperitoneum also decreases the urine output, due to decreased renal blood flow and release of antidiuretic hormone, renin and aldosterone (46). The increase in intra-abdominal pressure decreases gastric blood flow and gastric pH (47). Carbon dioxide insufflation causes an increase in plasma lactate levels, by decreasing perfusion of visceral organs due to direct mechanical compression (48).
Carbon dioxide is a highly diffusible gas which can permeate into the bloodstream from the peritoneal cavity (35). Hypercarbia causes sympathetic stimulation, leading to increased heart rate and blood pressure. These patients need to be hyperventilated intraoperatively to eliminate the carbon dioxide (42) and this may be difficult in patients with poor pulmonary compliance.
Venous gas embolism
This is a rare, but feared complication of laparoscopic surgery (35), detected by characteristic changes in the capnographic waveform and sudden cardiovascular collapse. There is an initial increase in end-tidal carbon dioxide due to the increased pulmonary excretion of carbon dioxide absorbed into the blood (35,42). This is followed by a sudden decrease in the end-tidal carbon dioxide due to a decreased cardiac output. A millwheel murmur may be present on auscultation.
The treatment is to stop the peritoneal insufflation and to deflate the abdomen (42). Access to the patient for cardiopulmonary resuscitation is restricted due to the docking of the robot. Cardiopulmonary resuscitation, if required, should be started in the Trendelenburg position until the surgeon undocks the robot and the patient is horizontal (49). External defibrillation electrodes can be placed before docking of the robot for high-risk patients. A direct current shock can be delivered with the robot docked in position, if required. The theatre team should practise an emergency drill for the de-docking of the robotic system.
Most robotic gynaecological surgeries are of prolonged duration (28). The cleaning antiseptic solution, insufflated carbon dioxide and glycine used for wash, are cold. These factors lead to a cooling of the patient in the first hour of the operation, even before surgery has started (50). An air-warming mattress and the fluid warmer should be used as soon as the patient enters the operating theatre. The surgical area (abdomen and legs) are exposed to cool air in the operating theatre for a long duration, so the legs should be wrapped in cotton to prevent direct exposure and the patient's temperature monitored throughout.
Subcutaneous emphysema is commonly seen in the perineal area (35). The gas enters into the subcutaneous layer of the skin and can extend into the thoracic and neck areas, especially in prolonged procedures. Treatment is bed rest, analgesia and oxygen administration. If the subcutaneous emphysema extends to the chest and interferes with respiration, the patient can be ventilated to allow time for the absorption of the air. Rarely, air is removed using large bore needles, skin incisions or subcutaneous catheterisation.
The increased abdominal pressure leads to compression of the inferior vena cava and iliac veins, thus decreasing lower extremity venous flow. Sequential compression--decompression devices are used for prophylaxis against deep venous thrombosis (35,42). They provide a sequential pressure gradient on the lower extremities that accelerates venous flow and facilitates venous emptying (51).
Some patients with severe medical disorders, especially cardiorespiratory disease, may not tolerate the steep Trendelenburg positioning for a prolonged duration. Morbid obesity is another common limitation. Patients with increased intracranial pressure or increased intraocular pressure (glaucoma) should not undergo robotic surgery in the steep Trendelenburg position.
All patients must be optimised preoperatively (28,42), especially those with cardiac or obstructive/ restrictive lung disease. Low molecular weight heparin, oral ranitidine and anxiolytics, if required, may be administered before surgery.
These patients should be monitored intraoperatively with ECG, non-invasive blood pressure, pulse oximetry, end-tidal carbon dioxide and a temperature monitor (28). Use of central venous and arterial catheters should be based on individual needs. We consider the latter useful for patients with specific co-morbidities who require continuous blood pressure monitoring or repeated intraoperative blood gas sampling. Patients at high risk of deep venous thrombosis should be administered heparin subcutaneously (28).
Anaesthesia is induced in the supine position, on an electrically-operated, remote-controlled, operating table. After securing all invasive lines and the endotracheal tube, the patient is placed initially in the lithotomy position and subsequently in the steep Trendelenburg position (5,31). Pressure points should be padded generously to prevent neurapraxia as a result of the prolonged surgical procedure (10,35). The arms should be padded and secured at the sides. Closed claims reports suggest that nerve injury, especially of the ulnar nerve, is the most common complication. The legs of the patient are placed into padded leg holders and bent at the knee (28). Excessive flexion or extension of the leg can injure the sciatic nerve, so the lower limbs should be kept in a relaxed mid-position, with both the knees padded and the legs placed symmetrically. Excessive pressure in lithotomy stirrups on the common peroneal nerve lateral, or saphenous nerve medial to the knee joint must be prevented.
Padded shoulder blocks should be placed judiciously as excessive pressure over the acromioclavicular joint can cause brachial plexus injury. The patient should be firmly secured to the operating table, using foam pads on the chest strapped in an X-like pattern, to prevent sliding down the table (10,35). There should be no compression of the monitoring devices and lines (28).
Preoperatively, peripheral intravenous cannulae must be firmly secured and extension tubing connected. The endotracheal tube should be secured firmly (avoiding tying which may worsen facial oedema), because the patient becomes inaccessible after docking of the robot. The eyes should be padded with protective gauze pieces and taped (10), because there can be reflux of acidic gastric contents or secretions onto the face and the eyes in the steep head-down position.
Difficult access to the patient
We secure a second large bore intravenous cannula after induction as a precaution should there be a need to administer fluids rapidly intraoperatively. These cannulae should be secured and connected to extension tubing and a three-way connector, making them accessible intraoperatively after docking of the robot.
Good communication between all members of the theatre team is essential. The surgeon sits behind a console away from the site of operation and should maintain regular communication with the anaesthetist and his operative assistant at the patient's bedside, this being aided by addition of the audio speakers to the video tower, which transmits the operating surgeon's voice.
Balanced general anaesthesia with infusion of a neuromuscular blocking drug is the technique of choice (10). Total intravenous anaesthesia has been advocated as advantageous during robotic laparoscopic radical cystectomy (52). Our practice is to administer ondansetron for anti-emesis, propofol for induction, atracurium for muscle relaxation, fentanyl for analgesia and midazolam for amnesia. Anaesthesia is maintained with oxygen or air and isoflurane. Nitrous oxide is avoided because it may increase nausea and vomiting postoperatively. Coughing or movement of the patient prior to undocking of the robot can cause injury to the patient or his viscera by the strong robotic arms, so complete immobility of the patient is recommended throughout the surgery (28). Glycopyrrolate is administered to decrease patient secretions. Hydrocortisone is used to decrease conjunctival and laryngeal oedema (28); prophylactic antibiotic is given within the first hour of incision (28) and the blood sugar of diabetic patients is maintained between 8 to 11 mmol/l.
Pressure-controlled ventilation is suggested to improve oxygenation of the lungs in the steep Trendelenburg position, especially in obese patients. Inspired pressures are set to achieve a tidal volume of 6 to 8 ml/kg and positive end-expiratory pressure of 4 to 7 cm[H.sub.2]O used to reduce atelectasis. Pressure-controlled ventilation helps to limit the peak pressures, with maximum airway pressure allowed to increase to 35 cm[H.sub.2]O after insufflation of carbon dioxide (35).
We prefer to limit fluid administration to minimise laryngeal and conjunctival oedema (10,42). Most of the intravenous fluid is given in the last 30 minutes after correcting the steep Trendelenburg position. Blood loss in these operations is usually less than 500 ml2-7 so blood transfusion is rarely required.
The trachea should not be extubated if there is significant laryngeal oedema or prolonged surgical time (42). Before extubation, routine examination of the larynx by direct laryngoscopy is performed and an endotracheal tube cuff leak test can be performed. In our experience only one patient developed significant laryngeal oedema and needed elective ventilation for four hours in the intensive care unit before being extubated.
Postoperative pain relief
Postoperative pain relief is provided with nonopioids and opioids (28). As the incision is small in robotic surgery, low doses of opioid are adequate for analgesia. Trabuls et al concluded from their retrospective study that a multimodal analgesic approach with pregabalin and celecoxib preoperatively had decreased intraoperative and postoperative opioid use in patients undergoing robotic-assisted laparoscopic radical prostatectomy (53). Although some centres have used epidural Analgesia (54), there is no evidence of any advantage, as most gynaecological surgeries are laparoscopic.
Post-anaesthesia care unit
The commonest complaint of the recovering patient in the post-anaesthesia care unit is their need to urinate (35). They need to be reassured that a urinary catheter is in place and functioning. Complications reported after robotic surgeries include corneal abrasion, neuropathy, abdominal distension, postoperative ileus and bowel injury (10,35,42).
Robotic surgery has enjoyed a rapid growth over the last few years in several fields, including gynaecology. Robotic gynaecological surgery can be performed safely, providing the impact of the effects of the steep Trendelenburg position and pneumoperitoneum are considered. The benefits of this type of surgical procedure should be weighed against the risk for patients with an underlying cardiopulmonary problem. The higher cost of the robotic surgery is balanced by the reduced costs from a shorter hospital stay and earlier return to full function. Robots cannot replace doctors but can help to achieve higher standards.
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K. GUPTA *, Y. MEHTA ([dagger]), A. SARIN JOLLY ([double dagger]), S. KHANNA ([double dagger])
Department of Anaesthesia, Medanta Medicity Hospital, Gurgaon, Delhi, India
* MB, BS, DA, DNB, MNAMS, Assistant Professor and Associate Consultant, Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi.
([dagger]) MB, BS, MD, Chairman.
([double dagger]) MB, BS, MD, Senior Consultant.
Address for correspondence: Dr K. Gupta, Assistant Professor, Department of Anaesthesia and Critical Care, Vardhman Mahavir Medical College & Safdarjung Hospital, New Delhi, India. Email: email@example.com
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|Author:||Gupta, K.; Mehta, Y.; Jolly, A. Sarin; Khanna, S.|
|Publication:||Anaesthesia and Intensive Care|
|Date:||Jul 1, 2012|
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