Millers Anesthesia - Sixth Edition - Chapter 66 - Anesthesia For Robotic Surgery - 233

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Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier
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Chapter 66 - Anesthesia for Robotic Surgery

Ervant V. Nishanian Berend Mets
Robotic surgery is the resulting transformation of the minimally invasive surgical evolution. Robotic devices are being introduced to surgery because they allow unprecedented control and precision of surgical instruments in minimally invasive procedures. The anticipated benefits of robotic or robotassisted surgery to the patient include less pain and trauma, shorter hospital stays, quicker recovery, and a better cosmetic result. With these technologic innovations, new anesthetic implications for patient care are being discovered. As surgery evolves into the robotic era, anesthesiologists must keep abreast of these changes and their impact on patient care and safety. First-generation surgical robots are being installed in a number of operating rooms around the world. These are not true autonomous robots that perform surgical tasks; rather, they are mechanical "helping hands" that offer assistance in various fields of surgery. These machines still require human intervention to operate or to provide input instructions. Robotic devices are here to help surgeons, not to replace them.
Copyright 2005 Elsevier Inc. All rights reserved.
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HISTORY
Robots were first developed by the National Aeronautics and Space Administration (NASA) for use in space exploration.[2] These devices, or telemanipulators, were capable of doing manual tasks aboard a spacecraft or out in space. The slave devices were controlled electronically from a remote master control on Earth or aboard a spacecraft. Telemanipulators were used extensively aboard NASA's Space Shuttle missions between 1983 and 1997. Research in trajectory and missile guidance systems eventually led to highly precise targeting mechanisms. Precision pointing at targets, such as the Earth and stars, was crucial for Spacelab telescope experiments. Telemanipulators such as the Instrument Pointing System (IPS) were specifically designed for extreme accuracy (1.2 arcsec).[3] Scientists at NASA Ames Research Center were responsible for developing virtual reality. The idea took root with contributions of VPL, a visual programming language, and Dataglove.[4] Their integration made it possible to interact with three-dimensional virtual scenes. However, it took
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the integration of robotic engineering and virtual reality to develop a dexterous telemanipulator for the anastomoses of nerves and vessels in hand surgery.[5] From these applications, it became apparent to the U.S. Department of Defense that virtual reality and telepresence might serve a useful function in treating wartime casualties on the battlefield. Through virtual reality, the surgeon could be brought to the patient's side, an idea described by the term telepresence. Data from wounded casualties of the Vietnam War estimated that, of all wounded soldiers, one third died of head and massive injuries and another third died of exsanguinating hemorrhage but had the potential to survive if they were treated in time.[2] The Department of Defense sought to improve medical presence on the battlefield given that one third of casualties can be saved. Telepresence allowed a surgeon located aboard an aircraft carrier to perform surgery (with the aid of telemanipulation) on wounded soldiers located in a remote location on the battlefield. With this idea in mind, the Department of Defense funded much of the research in telemanipulation for remote mobile surgical units that would allow for telepresence. Engineers realized that the distance between patient and surgeon had an upper limit, beyond which accuracy and dexterity of instrument control would suffer degradation. Latency is the time it takes to send an electrical signal from a hand motion to actual visualization of the hand motion on a remote screen. The lag time to send an electrical signal to a geosynchronous satellite at 22,300 miles above the earth and return is 1.2 seconds. This transmission delay would prohibit practical surgery. Humans can compensate for delays of less than 200 msec. Longer delays compromise surgical accuracy. Tissue moves when force is applied to it, and with a visual delay greater than 200 msec, the movement would not be noticed fast enough to avoid cutting in an unintended place. The most optimistic attempt to provide telesurgical presence over long distances was undertaken using highbandwidth fiberoptic ground cable. The latency time of 155 msec allowed Marescaux and Gagner[6] [7] to perform a robotassisted laparoscopic cholecystectomy between New York City and Strousbourg, France. Phillipe Mouret[8] performed the first video-laparoscopic cholecystectomy in Lyons, France, in 1987, but it was not until Perissat[9] presented the innovation to the Society of American Gastrointestinal Endoscopic Surgeons in 1988 that an exponential spread of laparoscopic surgical procedures began. Although laparoscopic surgery provided a great benefit for the patient, it brought tremendous surgical limitations, such as loss of three-dimensional vision, impaired touch sensation, and poor
dexterity provided by the long instruments and the fulcrum effect. The fulcrum effect is a nonintuitive motion of the instrument tips in opposite direction about a fixed point, usually at the skin entrance site. New skills had to be learned. Initial attempts to surmount the burdens of endoscopic surgery have provided the impetus for robotic support systems that can enhance surgical skills and control of instruments. The first of such systems in the medical field was applied in surgical field camera guidance. In 1994, the U.S. Food and Drug Administration (FDA) approved the first Automated Endoscopic System for Optimal Positioning (AESOP)[10] arm to be used in laparoscopic surgery. The device is controlled through voice activation to provide a flexible view of the surgical field. Around the same time, the TISKA Endoarm became available, and it could act as a camera guided by electromagnetic friction and could work as a tissue retractor.[11] While foot pedals were being replaced by voiceactivated systems, other manufacturers were designing cameras that moved in synchrony with the movements of the surgeon's head.[12] Other devices provided finger "joysticks" that could be used to control the camera field.[13] To combat dexterity problems, the master-slave telemanipulator concept was developed for medical use in the early 1990s. The first master-slave manipulator for medical use was developed at Stanford Research Institute. The goal was to have computer algorithms that translate a surgeon's master manual movements to end-effector slave instruments at a remote site. The robotic slave arms mimic the natural movements of the surgeon's hand. Early designs had only 4 degrees of freedom, but by 1992, a German prototype was developed with 6 degrees of freedom ( Fig. 66-1 ).[14] It was used experimentally but never achieved clinical application.[15] In 1994, Intuitive Surgical obtained technologic rights and eventually developed robotic instruments with 6 degrees of freedom. Robots can be preprogrammed with limits set by the operator and run autonomously, or its kinematics can be completely defined online in real-time tracking when immediate human interventions and decisions are required. The design of surgical robots must include sterility barriers and enhanced patient safety features. It must meet operating room constraints and be compatible with imaging equipment, as well as require special ergonomic features. To overcome endoscopic surgery handicaps, engineering technology has developed threedimensional video imaging, robot camera holders, and robotic flexible effector instruments with the ability for tactile pressure sensation. Unfortunately, every instrument has different stress feedback characteristics, and the surgeon's ability to "feel" the elastic properties of tissue are not yet fully developed. The robotic fingers can be made smaller than those of the human hand to help reach confined spaces. The robot can filter the surgeon's hand tremor and scale the movements of the instruments to the level of high precision and stability that is required for microsurgery. Best of all these advantages, repetitive robot motions and tasks are not prone to fatigue.
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ROBOTIC SYSTEMS
The word robot is a ubiquitous term that describes an autonomous device capable of various tasks. Industrial robots used in assembly lines perform highly precise, repetitive tasks. The robots are preprogrammed off-line, and tasks are invoked on command. Robots used in orthopedic surgery and neurosurgery are examples.[16] Precise tasks such as drilling and probe insertion are based on registration. Registration is a mathematical process that allows location and anatomic orientation in
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Figure 66-1 Degrees of freedom (DOFs) in motion. A, Conventional laparoscopic instruments have only 4 DOFs and grip. Insertion (i.e., movement in the z axis), roll, and movement along the x and y axis outside the body relative to a fulcrum point constitute the 4 DOFs. B, Depiction of the EndoWrist instrument with two added intracorporeal joints produce 6 DOFs along with grip. (A and B, 1999 Intuitive Surgical, Inc., Sunnyvale, CA.)
three dimensions based on data derived from preoperative computed tomography (CT) or magnetic resonance imaging (MRI). A second type of robot is defined as an assist device, such as AESOP. These robots are used to control instrument location and guidance. Assist-device robots are not autonomous; they need input cues from the operator. A third type of robot is a telemanipulator. These robots are under constant control of the operator. These devices mimic the operator's hand motions in an exact or scaled motion. There are several telemanipulator robotic devices available throughout the world. The da Vinci Robotic Surgical
System ( Fig. 66-2 ) has been cleared by the FDA for laparoscopy, thoracoscopy, and intracardiac mitral valve repair surgery, and the ZEUS Surgical System ( Fig. 66-3 ) has been developed in parallel and cleared for sale by the FDA for general and laparoscopic surgery. The two systems are very similar, with some minor differences. The da Vinci Robotic Surgical System is described in this chapter as a representation of most modern surgical robots. The da Vinci system has three components: a console, an optical three-dimensional vision tower, and a surgical cart. The surgical cart has three arms that can be manipulated by the surgeon through realtime computer-assisted control. One of the arms holds an endoscopic camera, and the other two are manipulator or instrument-holding arms. The system allows the surgeon to be physically remote from the patient. The system's instruments are designed to have 6 degrees of freedom plus grasp, which enables it to approach the identical articulation of the human wrist ( Fig. 66-4 ). The system design incorporates a frequency filter that eliminates hand tremor greater than 6 Hz.[17] Motion scaling can also be invoked up to a ratio of 5:1 (i.e., the surgeon moves 5 cm, and the robot moves 1 cm). Scaling allows for work on a miniature scale. The console also provides a three-dimensional image of the surgical field. The endoscope consists of dual, independent optical channels capable of transmitting digital images to the console's visual monitor. At the console, the surgeon is actually looking at two separate monitors; each eye sees through an independent
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Figure 66-2 The da Vinci System Surgeon console (A) and of the cart with three mounted surgical arms for holding the camera and instruments (B). (A and B, 1999 Intuitive Surgical, Inc., Sunnyvale, CA.)
camera channel to create a virtual three-dimensional stereoscopic image. The images are controlled through two independent light sources found on the optical three-dimensional vision tower. The surgeon sits at the console and controls the telescope arm and two robotic manipulator arms. The surgeon has a viewing space that is similar to a double-eyepiece microscope. Each eyepiece displays a mirror reflection of a computer monitor screen. Each monitor displays one channel of the stereo endoscope to an eye, creating a virtual three-dimensional stereoscopic image of the surgical field.
The surgeon controls the manipulators with two masters. The masters are made of levers that attach to index fingers and thumbs of each hand. Wrist movements replicate the movements of the instruments at the end of the robotic
Figure 66-3 A, The console of the ZEUS robotic telemanipulation system consists of a video monitor and two instrument handles that translate the surgeon's hand motions into an electrical signal that moves the robotic instruments. B, Two table-mounted AESOP arms hold instruments, and a third arm controls the camera. (Courtesy of Computer Motion, Inc., Sunnyvale, CA.)
arms. The console has a foot pedal that disengages the robotic motions (i.e., clutching), another that allows adjustment of the endoscopic camera, and a third pedal for controlling the energy of electrical cauterization. The side cart of the robotic device has three arms that respond to the manipulative controls of the surgeon while sitting at the console. The cart is bulky and of tremendous weight. It requires wheeling to the vicinity of the patient's surgical area and is locked into place. Because of the proximity of the side cart to the patient, the patient must be guarded against inadvertent contact from the motions of the robotic arms. Even more important, after the instruments are engaged to the arms of the robot and inside the patient, the patient's body position cannot be modified unless the instruments are disengaged entirely and removed from the body cavity.
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Figure 66-4 The EndoWrist instrument of the da Vinci System mimics the natural kinematics of the surgeon's hand and wrist. This design allows 6 degrees of freedom and grip. ( 1999 Intuitive Surgical, Inc., Sunnyvale, CA.)
Any patient movement from lack of muscle relaxant may be disastrous. The clutching buttons allow for the robotic arms to be grossly positioned without moving the instruments within the trocars or access ports. A clutching function allows surgical assistants to exchange various instruments. The optical tower contains the computer equipment needed to integrate the left and right optical channels to provide stereoscopic vision and to run the software needed to control the kinematics of the robotic arms. The computer interfaces the translated motion of the surgeon's hands to a digital code that moves mechanical levers, motors, and cables that allow the robot to articulate the exact motions of the surgeon's hand. The instruments in the body cavity must remain sterile but interface with nonsterile robotic arms. Detachable disposable instruments facilitate this interface. Each type of instrument requires different forces and motion scaling intrinsic to the task at hand and requires specific computer software processing. Additional operating room staff is required for detaching and exchanging task specific instruments throughout the case. Monitors are positioned on top of the tower so that all people in the operating room have a view of the surgical field. An obstacle that still needs research is tactile sensing. The feedback that the robot offers for the surgeon's applied force is inferior. The robot offers some sensation, but the applied force does not correlate well with the force applied to the tissues. This correlation varies with the type of instrument and depends on the torque applied; the operator therefore must rely on visual cues from tissue distortion to gauge how much pressure is being generated. The ZEUS Surgical System is another example of a master-slave telemanipulator. It employs the assistance of the AESOP Robotic System for visualization. It is basically one mechanical arm used by the physician to position the endoscope, which is a surgical camera inserted into the patient. Foot pedals or voice-activated software allow the physician to position the camera, leaving his or her hands free to continue operating on the patient. The manipulators of the ZEUS system are freely mounted on the operating table, much like the AESOP. It provides tremor filtering and motion scaling from 2:1 to 10:1.
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GENERAL SURGERY
Gastrointestinal Surgery Robotic technology has declared itself in the field of gastrointestinal laparoscopic surgery.[18] The first surgical operation using robotic telemanipulation was a laparoscopic cholecystectomy performed in 1997 in Brussels, Belgium.[19] Two U.S. companies have FDA and European Union approval for clinical applications of their robotic systems for general surgery. Robot-assisted surgical techniques permit the surgeon to provide the smallest possible incision and lowest surgical stress. This technology allows surgeons to work on a very small scale in cramped spaces. Other procedures performed include splenectomy,[20] Heller myotomy, bowel resection pyloroplasty,[21] adrenalectomy, [22] and exploratory laparotomy, with antireflux surgery being the most common.[1]
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Nissen Fundoplication Anesthetized patients are prepared and draped in the usual fashion, and the abdominal cavity is insufflated with carbon dioxide gas. Three incision ports are made as shown in Figure 66-5 . The first port is for the telescope trocar, which is placed 15 cm below the xiphoid process and slightly to the left of midline. The robot arms are then inserted through trocars located 10 cm on either side of the telescope while under laparoscopic vision. Other auxiliary ports can be placed at any time during the operation. The side cart is wheeled and locked into place in anticipation of engaging the instruments within their respective trocars. The system can be activated to manipulate the robotic arms under the surgeon's control. When a surgeon requires instruments to be changed, the manipulation is stopped, and the assistant surgeon at the table is asked to disengage and replace the instrument.
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Anesthetic Considerations In the operating room, the patient is monitored with an electrocardiographic (ECG) device, pulse oximetry, axillary temperature probe, and noninvasive blood pressure cuff.
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Figure 66-5 Numbered incision ports for Nissen fundoplication and location of the robotic arms.
Bilateral peripheral intravenous access is valuable because the left upper extremity is not immediately available during the surgery. The patient is sedated with a mild sedative and prepared for induction with oxygen. These patients usually have a history of gastroesophageal reflux and require a rapid sequence induction with cricoid pressure applied. The trachea is intubated with a single-lumen endotracheal tube, and its placement is confirmed by listening to the chest and detecting carbon dioxide on expiration. Anesthesia can be maintained with a volatile agent. Muscle relaxation is paramount in avoiding any movements by the patient while the surgical instruments are within the abdominal cavity. An orogastric tube and a urinary bladder catheter are placed. Convective-air body warmers are applied whenever possible. With the patient in the supine position, the patient is prepared and draped, and the abdominal cavity is insufflated with carbon dioxide to a pressure not to exceed 20 mm Hg.[23] The trocar for the camera is placed manually. The side cart robot is then brought very close to the patient's head to engage the other trocars with visual guidance from the robotic camera. Because of the proximity of the side cart to the patient's head, there is limited access to the patient's airway and neck, and their head must be guarded against inadvertent collision by the movements of the robotic arms.[1] [24] After the robot is engaged, the patient's body position cannot be changed. If the patient requires an increase in cardiac filling pressures, and it cannot be provided by Trendelenburg's position, only after disengaging the robot is it possible. The surgical team should be capable of rapidly disengaging the robotic device if
an airway or anesthesia emergency arises. As with any laparoscopic procedure that requires a pneumoperitoneum pressurized with carbon dioxide, ventilator adjustments may be required to normalize the exhaled carbon dioxide.[25] Some surgeons argue that the benefit of invasive arterial monitoring does not outweigh the risks.[24] This issue should be considered for each patient. For cholecystectomy, the patient is handled the same as for Nissen fundoplication surgery, except for port locations and robot cart position ( Fig. 66-6 ). The trocars are inserted under direct visualization after a pneumoperitoneum is produced. After all trocars are in place, the patient is placed in a steep reverse-Trendelenburg position.[26] At this point, the robot is brought into position 45 degrees off the right head of the table, and instruments connected to the trocars.
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CARDIAC SURGERY (see Chapter 50 )

Application of conventional endoscopic instruments has paved the way for several cardiac procedures to be performed with robotic assistance. Internal mammary artery harvesting was successfully performed thoracoscopically in 1997 by Nataf.[27] In 1998, Loulmet and colleagues[28] reported the first totally endoscopic coronary artery bypass surgery. Cardiothoracic applications of robotically assisted surgery have expanded and include atrial septal defect closures,[29] [30] [31] mitral valve repairs,[32] [33] [34] [35] [36] patent ductus arteriosus ligations,[37] [38] and totally endoscopic coronary artery bypass grafting.[39] [40] [41] Even though technical advances in minimally invasive surgery have introduced techniques that are done through very small ports and may eventually make surgical sternotomy obsolete, surgeons must still be trained and prepared to convert to an open sternotomy if the need arises. Sternotomy alone carries a finite risk of morbidity from an inflammatory response, but it is certainly less than that of exposure to cardiopulmonary bypass.[42] [43] [44] Surgery on the beating heart without cardiopulmonary bypass may avoid significant inflammatory responses and should be the method of choice whenever possible.
Figure 66-6 Numbered incision ports for cholecystectomy and location of the robotic arms.
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Anesthetic Implications Knowledge of and expertise in cardiac and thoracic anesthesia is imperative because both organ systems need to be managed safely. The ability to perform and maintain single-lung ventilation is mandatory, as is management of the physiologic consequences. Preoperative assessment of lung
function is indicated if a patient has significant lung disease. Poor pulmonary function test results may be a contraindication to robotically assisted cardiac surgery because single-lung ventilation may be poorly tolerated. Robotic surgery may require unprecedented, prolonged one-lung ventilation, which challenges the extent of our understanding of respiratory physiology. Continuous monitoring of cardiac function with transesophageal echocardiography (TEE) has become a standard of care and has found a niche for several procedures required for safer robotically assisted surgery.
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Mitral Valve Surgery In 1997, two independent groups reported the first robotically assisted mitral valve repair.[45] [46] In November 2002, the FDA approved the use of robot-assisted surgery in performing mitral valve repairs. Mitral valves repair, initially done through mini-thoracotomy incisions, could be done completely with a closed chest. However, mitral valve replacements may still require a small thoracotomy to introduce the new prosthetic valve.
Anesthetic Implications for Mitral Valve Surgery
Mitral valve surgery employing robotic devices is being done at a few cardiac centers in the United States and Europe. The anesthetic techniques and other relevant considerations have been described previously.[47] Patients are initially evaluated by cardiac catheterization to estimate the degree of coronary artery stenosis and to assess valve function. Severe mitral regurgitation is a mechanical problem that requires surgery for cure. Most patients are medically treated with afterload reducers, such as angiotensin-converting enzyme (ACE) inhibitors if they are hypertensive. An enlarged left atrium is often susceptible to atrial fibrillation. Patients with persistent atrial fibrillation may be taking anticoagulants concomitantly with therapy for rate control. Chronic elevation in left atrial pressure may manifest with pulmonary hypertension, which may be further exacerbated by obstructive lung disease. Severe pulmonary hypertension renders a patient unsuitable for robotic surgery.[48] Patients are provided with a large peripheral intravenous line. Light sedation with midazolam and local anesthesia is offered before the placement of bilateral radial arterial lines. The patient is routinely monitored with ECG leads II and V5 , pulse oximetry and a right radial artery pressure line to exclude endovascular aortic balloon misplacement. Modern ECG monitors can provide automatic ST segment analysis for the detection of ischemia. After ample oxygenation, the patient is anesthetized with a combination of midazolam, fentanyl, and isoflurane. On muscle relaxation, the trachea is intubated with a double-lumen endotracheal tube ( Table 66-1 ). Proper tube position is confirmed by bronchoscopy. A TEE TABLE 66-1 -- One-lung ventilation strategy Use FIO2 = 1.0. Begin one-lung ventilation with pressure control ventilation, maintaining a plateau pressure of <30 cm H2 O. Adjust the respiratory rate so that PaCO2 approaches 40 mm Hg. Check arterial blood gas pressure. Apply continuous positive airway pressure to nonventilated lung. Apply positive end-expiratory pressure to ventilated lung. probe is inserted to assess heart and valve function and to guide central line placement. A midesophageal, bicaval view at 90 degrees is used for guidance in positioning the superior vena cava (SVC) and inferior vena cava (IVC) cannulas ( Fig. 66-7 ). Initially, a left, 9-Fr introducer catheter is inserted by means of the Seldinger technique, and an 8-Fr pulmonary artery catheter is floated into the pulmonary artery. Next, the right neck is prepared
Figure 66-7 A, Ultrasound image of the superior vena cava cannula. B, Ultrasound image of a bicaval view depicting the inferior vena cava containing a J guidewire. Both views are helpful in correctly placing cardiopulmonary bypass venous cannulas.
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for insertion of a percutaneous, 17-Fr Biomedicus cannula. It is inserted directly into the internal jugular vein using the Seldinger technique, and its proper placement is confirmed by TEE. Experience shows that the long transthoracic aortic cross-clamp may impinge and occlude the SVC. For this reason, an armored SVC neck cannula provides resistance to occlusion or kinking. At the time of insertion, the cannula is flushed with 5000 units of heparin to ensure its patency. The cannula is anchored with a purse-string suture at the skin and secured with Kerlix gauze wrapped around the patient's head. After the patient's pelvis is positioned supine and the right shoulder is tilted 30 degrees to the left, transcutaneous defibrillation and pacing pads are applied. The surgeon can then determine proper location for port access, which may vary according to a patient's body habitus. After the right femoral vessels are exposed and left-sided, single-lung ventilation is established, a
right-sided mini-thoracotomy incision is made. The heart is exposed after a pericardial opening is made. The pericardium is anchored open to the chest wall by two percutaneous stay sutures. After the patient is heparinized based on an activated clot time (ACT)-guided protocol, the femoral vein and artery are cannulated in anticipation of femoral-femoral cardiopulmonary bypass. First, the femoral vein is cannulated, and a 21-Fr cannula is placed over a guidewire and passed into the IVCRA junction with the aid of TEE. One end hole and 12 side holes resist collapse under the high negative pressure that is created by augmented venous return pumps. Likewise, the femoral artery is cannulated with a 24-Fr cannula, and cardiopulmonary bypass is initiated with venous drainage from the femoral and jugular veins. Anterograde and retrograde cardioplegia cannulas are placed. Some surgical teams prefer to cannulate the ascending aorta using a Heartport Straight-shot.[48] A transthoracic aortic cross-clamp is passed percutaneously through the right axilla and applied to the ascending aorta. The robotic arms are engaged through their respective trocars lateral to the minithoracotomy incision while the camera arm passes directly through the thoracotomy incision. The left atrium can be entered for mitral valve repair or replacement. Before terminating cardiopulmonary bypass, TEE is used to evaluate the function of the mitral valve, residual valvular regurgitation and to confirm the disappearance of intracardiac air. The anterior leaflet of the mitral valve is further inspected for systolic anterior motion. Patient selection is important for optimal results. Table 66-2 lists the risk factors that make patients unsuitable candidates for robotic mitral valve surgery.
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Atrial Septal Defect Repair Operations for atrial septal defects are similar to those for mitral valve repairs, except that a minithoracotomy is not required. A closed-chest procedure is possible. Like all robotic procedures that demand entrance into the thoracic cavity, single-lung ventilation must be instituted during surgery. Atrial septal defect repairs also require opening the heart and preventing any blood from entering the heart. This TABLE 66-2 -- Exclusion criteria for robotically assisted mitral valve repairs Severely calcified mitral annulus Severe pulmonary hypertension Ischemic heart disease Surgery requiring multiple valve repairs Previous surgery to right hemithorax Severe aortic and peripheral atherosclerosis is facilitated by jugular and femoral vein cannulation and snaring the IVC and SVC. Cardiopulmonary bypass with cardioplegia administration into the aortic root is used to arrest the heart. Methods of cardiopulmonary bypass using endovascular clamping are described in "Coronary Artery Bypass Grafting." Dogan and coworkers[29] reported the first successful closed-chest closure of an atrial septal defect.
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Internal Mammary Artery Harvest Patients are monitored in the usual way for cardiac surgery. A central venous line and a radial artery cannula are placed on the same side as the harvested internal mammary artery. There is a mandate for single-lung ventilation with a double-lumen tube, a Univent tube, or bronchial blocker, the position of which is confirmed by bronchoscopy. The patient is positioned supine, with the thorax rotated 20 degrees by placing a roll under the left scapula. External defibrillation and pacing pads are applied to the left posterior chest and anterolateral right chest. Raising the left arm provides more exposure and thins the skin overlying the left anterolateral chest. The opposite can be done to the right chest when harvesting only the right internal mammary artery. Carbon dioxide insufflation is needed to provide exposure and counter-traction. Carbon dioxide insufflation (5 to 10 mm Hg) into the left hemithorax pushes the mediastinal fat pad medially and enlarges the space between the sternum and heart to a small extent to provide a better view. When harvesting both internal mammary arteries, insufflation of the left hemithorax is sufficient to expose the right internal mammary artery because of the leftward position of the heart[49] and the improved angle of sight. Insufflation is begun in increments of 2 to 4 mm Hg. The insufflation flow rate is adjusted automatically to achieve a preset intrathoracic pressure limit. Caution should be exercised when insufflating the thorax in patients who have poor left ventricular function or are hypovolemic (central venous pressure <5 mm Hg). Patients should have their volume status augmented before proceeding to full insufflation. Carbon dioxide insufflation and one-lung ventilation increases central venous pressure and pulmonary artery pressure by a small amount.[50] Bilateral pneumothoraces are deliberately produced when doing bilateral internal mammary artery harvest. Most patients studied tolerate small bilateral pneumothoraces well for periods less than 1 hour.[51] Table 66-3 lists patient criteria to be avoided when attempting a robotically assisted approach to surgery.
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TABLE 66-3 -- Exclusion criteria for robotically assisted endoscopic coronary artery bypass grafting Contraindication to one lung ventilation Age older than 80 years Ejection fraction higher than 40% Severe noncardiac health issues Severe peripheral vascular disease Myocardial infarction for more than 7 days Previous thoracic surgery, pleural adhesions, or emergency surgery Calcified left anterior descending artery or diffuse disease Intramyocardial left anterior descending artery Morbid obesity, with a body mass index of more than 32 Large heart within the left chest
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Coronary Artery Bypass Grafting All patients are evaluated preoperatively by TEE to exclude the possibility of persistent left SVC or patent foramen ovale. Table 66-3 lists the major exclusion criteria for robotic coronary artery bypass grafting. The iliac and femoral arteries should also be evaluated for their size by echo Doppler ultrasonography.[30] Patients are prepared and monitored for anesthesia in a manner similar to that for mitral valve surgery (see "Mitral Valve Repair"). Monitoring of the right radial artery pressure tracing is imperative when using an endovascular balloon-occlusion catheter. After the patient is asleep, inspired oxygen tension and expired carbon dioxide are monitored. TEE is used routinely as the standard of care for determination of cardiac function and for
Figure 66-8 Incision ports for coronary artery bypass grafting. Trocars are placed in the third, sixth, and eighth intercostal spaces. Similar port positions are used for bilateral internal mammary artery dissection.
confirming catheter placement. Pulmonary artery catheters are judiciously used in the appropriate patient population, but the data that the catheter provide may be redundant when TEE data are available. The patient is positioned the same as for internal mammary artery takedown, and trocar positions are placed as depicted in Figure 66-8 . When cardiopulmonary bypass is anticipated, the left femoral artery is cannulated with a 17- or 21Fr Remote Access Perfusion (RAP) catheter ( Fig. 66-9 ) with an aortic occlusion balloon. Exclusion criteria for endovascular cardiopulmonary bypass are contained in Table 66-4 . This catheter allows anterograde flow of 4 or 5 L/min, respectively. The cannula has a separate lumen for delivering cardioplegia to the aortic root beyond the occlusion of the balloon. The aortic cannula is positioned in the ascending aorta, 2 cm above the aortic valve, with TEE guidance ( Fig. 66-10 ). The endovascular balloon is inflated with a volume equal to the diameter (in milliliters) of the sinotubular junction of the aorta. A balloon pressure above 300 mm Hg usually provides complete occlusion of the aorta.[32] Residual flow around the balloon can be seen and monitored with color flow on TEE. The use of bilateral radial artery lines is useful in detecting the migration of the occlusion balloon toward the innominate artery. Proximal migration of the balloon can most easily be seen with TEE, preventing balloon herniation through the aortic valve.
After full cannulation and being poised for cardiopulmonary bypass, the right lung is allowed to collapse, and left lung ventilation is begun. The ventilator is adjusted to provide an end-tidal carbon dioxide pressure of 35 to 40 mm Hg. Ports can be safely placed after the right-sided pneumothorax has formed. Carbon dioxide is insufflated
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Figure 66-9 Remote Access Perfusion (RAP) catheter (Estech Systems, Inc., Plano, TX). The endovascular catheter has a cylindrical balloon for endovascular aortic clamping. The catheter provides anterograde perfusion of the aortic arch at a rate of 5 L/min and cardioplegia administration to the aortic root.
into the right hemithorax and continued at a pressure of 5 to 10 mm Hg. This allows the affected lung to collapse further and provides a larger visual field. It may also prevent mediastinal shifts during one-lung ventilation when large tidal volumes are used, such as in a patient with emphysematous lungs. Insufflation to produce a deliberate pneumothorax is not very effective at raising the sternum above the anterior surface of the heart. For this reason, some surgeons provide sternal lift retractors to increase the retrosternal space and provide better exposure.[52] Robot-assisted, beating-heart coronary artery bypass grafting can be accomplished with appropriate patient selection. Articulating stabilizers passed through a subxiphoid port can stabilize the anterior surface of the heart to facilitate grafting.[53] Bilateral internal mammary artery grafting has also been accomplished.[54]
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Future Directions Computer-assisted surgery has made it possible to perform total endoscopic coronary artery bypass grafting on the arrested heart.[39] [40] [41] The interests in avoiding the morbidity of cardiopulmonary bypass and performing coronary artery bypass grafting on the beating heart have shown it to be applicable.[52] [53] [54] [55] [56] [57] Various stabilization TABLE 66-4 -- Contraindications for endovascular cardiopulmonary bypass system Major vascular disease of the ileac, femoral, and abdominal aorta found by Doppler ultrasound Severe atherosclerosis Aortic diameter greater than 4 cm Moderate to severe aortic valve incompetence
Figure 66-10 Ultrasound image of the Remote Access Perfusion (Estech Systems, Inc., Plano, TX) catheter balloon in situ. Transesophageal echocardiography allows the anesthesiologist to keep track of migration of the catheter balloon. The balloon should be positioned in the ascending aorta 2 to 4 cm distal to the aortic valve. Right radial pressure catheter dampening can detect balloon malposition when occlusion of the innominate artery occurs.
devices have made beating-heart surgery commonplace with conventional sternotomy, and miniaturization of the stabilization devices have allowed their use in closed-chest, robot-assisted surgery.[58] Problems do exist and need to be overcome. Because tactile sensation or palpation is not possible in closed-chest surgery, intramyocardial arteries or vessels that are hidden under epicardial fat are elusive. Internal thoracic arteries can also be less than superficial, adding to the problem. The proposed target site may contain plaque or heavy calcification that may make the anastomosis difficult and inferior. Epicardial ultrasound imaging could possibly circumvent poor target sites and has been shown with the help of Doppler to locate the course of intramyocardial coronaries and arteries hidden by epicardial fat.[59] Visualization systems are being developed that will improve surgery on the beating heart. Advances in motion gating technology will allow the heart to appear as if it is standing still. A properly timed
strobe light that is synchronized with the heart rate will achieve the proper virtual image of a heart standing still or of virtual stillness.[2]
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THORACIC SURGERY (see Chapter 49 )

Background Thoracic surgery has incorporated video assistance thoracoscopy (VATS) as a standard of care when it is practical. A large thoracotomy incision may still be required for a complete pneumonectomy, although the thoracotomy incision increases stress and morbidity. The use of thoracic epidural analgesia is the standard of care for such
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large thoracic incisions. Robotic assistance for thoracic surgery may provide better patient outcomes, but studies are needed to prove their potential benefit. Selection criteria for performing lung tumor resection using robotic assistance include lung lesions smaller than 5 cm in diameter, stage I status for primary lung carcinoma, no chest wall involvement, absence of pleural adhesions, and clearly distinguishable interlobar fissures. The da Vinci Robotic Surgical System was the first telemanipulator system used.[60] For this procedure, tactile sensation is minimal, and it is often difficult to feel pulmonary nodules that are not visible on the surface. This drawback may require making a port large enough for finger insertion to palpate the tumor.
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Esophagectomy Esophagectomy can be performed through a transhiatal approach or a traditional three-point approach. Traditional esophageal dissections have started to take advantage of robotic interventions. Traditional esophagectomy is performed in three phases: abdominal, thoracotomy, and cervical. The patient is initially in a supine position for the abdominal and cervical dissection, followed by a left lateral decubitus position for the thoracotomy.[61] Robotically assisted surgery has replaced the traditional thoracotomy phase with robotic esophageal dissection. With the use of small trocar incisions, the patient can avoid the stress of a thoracotomy. Although the robotic surgery appears to be less painful, a thoracic epidural block for postoperative pain relief is beneficial.
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NEUROSURGERY (see Chapter 53 )

Background From the late 1980s to 1993, neurosurgeons investigated the use of robots to precisely position resection probes and devices within neural parenchyma to provide minimal invasive surgery and to protect normal tissue. Stereotactic navigation during neurosurgery surgery has provided an imageguided system for real-time tracking of surgical instrument tips.
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Radiosurgery of Spinal Lesions Spinal vascular malformations and spinal tumors have been treated with the use of image-guided frameless stereotactic radiosurgery.[62] Precise delivery of high-dose radiation limits the dose that would be delivered to normal adjacent tissue and improves morbidity. Cervical vertebrae can be imaged clearly by x-ray cameras, and lesions are referenced to CT images. The thoracic and lumbar areas have denser bodies that are more difficult to image and provide poor contrast with surrounding tissue. To overcome this limitation, additional radiographic landmarks are implanted percutaneously. Implantation of fiducial markers can be done in the operating room under conscious sedation. These fiducial markers are placed percutaneously under fluoroscopic guidance. Three fiducial markers are required to define any point in three-dimensional space. A fourth is placed for redundancy in case one moves. These fiducial markers are fixed to bony landmark laminae or facets and have a fixed relationship with the bone in which they are implanted. They allow accurate localization for stereotactic radiosurgery.
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UROLOGIC SURGERY (see Chapter 54 )

Transurethral Resection of the Prostate In 1995, Nathan and Wickham[63] published their results of a coring device used to assist in transurethral resection of the prostate (TURP). Traditionally, a resectoscope containing a cutting tungsten wire at its distal end is inserted into the urethra. As energy passes through the tungsten wire, it cuts into prostate tissue. Continuous flow of nonelectrolytic solution is required to promote visibility. Coagulation electrocautery helps in hemostasis but may prolong the procedure. Unfortunately, prolonged resections lead to resorption of this fluid and produce dilution hyponatremia. The Puma robot has been used to resect prostate tissue safely. [64] The safety of the device is derived from a steel circular frame that restricts and confines the robot to a precise arc of resection. The frame acts as a safety fixture that prevents the surgeon from resecting outside the bounds of the frame. Information about the size of the prostate is obtained from an operative transurethral ultrasound inspection. These data are used to construct a three-dimensional image of the entire prostate. Limits of resection, which usually amount to 38% of the prostate gland volume, are programmed into a computer for reference. [65] Such procedures can be done more quickly by the robotic instrument, and because hemostasis is done only once at the end of the procedure, there is less time for absorption of irrigation fluid.
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Radical Prostatectomy Guillonneau and Vallancien[66] were the first to show the feasibility and efficacy of laparoscopic radical prostatectomy. Several centers have shown the feasibility of a robotically assisted prostatectomy. [67] [68]
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Anesthetic Implications Patients are monitored with routine care. After inducing anesthesia, an arterial line may be placed for frequent phlebotomy. An additional, large-bore intravenous line may be considered when the potential for large blood losses are foreseen. The patient is positioned in a supine lithotomy position with 30 degrees of Trendelenburg incline. The thighs are spread far enough apart to allow the approach of the robotic system between them. Patients shorter than 6 feet are not placed in a lithotomy position and have their legs in a frog-leg position. The prolonged Trendelenburg position may be relatively contraindicated in patients with history of stroke or cerebral aneurysm. Because of the long procedure, silicone gel pads
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are placed at every pressure point. Some surgeons advocate tucking the patient's arms while the patient is awake to maintain optimal comfort and avoidance of neurapraxia. [69] After a 14-Fr Foley catheter is inserted, the body is prepared and draped. A pneumoperitoneum is created through an umbilical puncture needle, and the maximum pressure is set to 15 mm Hg. The trocar is inserted according to the standardized Heilbronn approach using a semilunar five-trocar arrangement, with a sixth in the suprapubic area.[70] A procedure with some modification of the Montsouris technique is used.[69]
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GYNECOLOGIC SURGERY
Background Laparoscopic surgery is also finding robotically assisted procedures an improvement. Microsurgical techniques have benefited the most from the robotic scaling and tremor filtration. Several groups have applied robotic assistance to fallopian tubal anastomoses[71] [72] after sterilization or tubal ligation. In the future, vasectomy reversals may also be done more precisely with the aid of robotics.
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Anesthetic Implications After induction of general anesthesia, the patient is positioned in a modified dorsal lithotomy with Trendelenburg position. The thighs are abducted slightly for vaginal access to manipulate the uterus. A pneumoperitoneum is created with carbon dioxide insufflation. Patency of the anastomosis is assessed with injection of methylene blue dye through the uterine chromopertubator.
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ORTHOPEDIC SURGERY (see Chapter 61 )

Total Hip Arthroplasty In 1992, Paul, a veterinarian who worked in collaboration with IBM, developed a robotic system that could be used for hip replacement in dogs. The research collaboration resulted in the first surgical robotROBODOC. This was the first medical application, and it started with orthopedic surgery. In this procedure, the femoral implant is placed into an axial canal of the proximal shaft of the femur. The femoral component can be glued or pressed in to the femoral shaft as a tight fit. Long-term radiographs after hip replacement surgery have shown that adhesives are prone to cracking, loosening, and producing osteolysis that leads to surgical failure of the prosthetic hip. Modern femoral implants have a porous surface that allows for bone growth into the surface, promoting better hip longevity. For this reason, a tight fit of the implant into the femoral canal is essential. The formation of this femoral canal is created with higher precision by a robot than by the visual cues that are used in the manual method. The cavity it creates is 10 times more accurate than is achieved by manual methods.[73] The robot gets its visual or coordinate cues from image-based information such as MRI or CT. The accurate registration of the femoral coordinates in three-dimensional space is essential for precise bone milling of the femoral canal so that it can accommodate the surgical implant. Titanium pins are placed in the femoral condyles and the greater trochanter. The patient's leg is then imaged by CT, and three-dimensional information about the femoral bone and registration pins is recorded in a computer. In the operating room, the surgeon removes the native femoral head and places the acetabular cup into its place in the routine manual procedure. The femur is then rigidly clamped and secured by the robot fixator. The robot is allowed to recognize the three titanium registration pins and compares their location relative to the data obtained from CT. In this manner, the robot has a perfect sense of where the femur lies in three-dimensional space and can perform precise milling of the femoral canal. The remainder of the surgery proceeds manually. The ROBODOC-treated patients showed fewer gaps between the prosthesis and bone, and no intraoperative femoral fractures occurred.[74] The overall complication rate in one study was reduced to 11.6%.[75] Hip dislocation after hip arthroplasty is the most common postoperative complication, with a rate of 1% to 5%.[76] To surmount this complication, the HipNav system is being developed. The system has a range-of-motion simulator, a preoperative planner, and an intraoperative tracking and guidance control. This system can optimize acetabular orientation for a "best-fit" prosthetic implant. [77]
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Knee Replacement Most total-knee replacements depend on a jig system to guide bone sawing. The placement of the jig is based on the surgeon's visual cues from the exposed bone surfaces. These inaccuracies can produce patellofemoral pain and limited flexion in 40% of the patients when conventional approaches are used.[78] Displacements as small as 2.5 mm can produce a 20-degree alteration in the range of motion of a joint. Robotic surgical assistants have been developed to increase the accuracy of prosthetic joint alignment. For the robot to recognize specific landmarks, the pelvis and the ankle must be fixed to the surgical table. Osseous material is less likely to deform under pressure and can keep its shape.
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OPHTHALMOLOGIC SURGERY (see Chapter 65 )

The challenge of creating a robot that is accurate and has an extremely high level of dexterity and precision was mandated for laser retinal surgery. Because blood vessels in the retina are only 25 m apart, high precision is necessary. Collaboration between Stephen Charles and the NASA Jet Propulsion Laboratory developed a Robot-Assisted Microsurgery System (RAMS).[79] It is capable of performing laser microsurgery with 10-m accuracy. The unaided human eye can discern an increment of only 200 m. RAMS provides a 200-Hz gating system for eye
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tracking, and it eliminates the saccades of the eye, allowing the eye to appear perfectly still to the observer. The system also provides a 100:1 scaling that allows for 10-m incremental movements. Tremor is filtered out between 8 and 14 Hz to eliminate inaccuracy. The ability to work at such small scales is the robot's strength. Newer robotic devices intended for microsurgical application have an accuracy of 5 m.[80] Riviere and Jensen[81] were able to cannulate a retinal vein to administer therapy for retinal vein thrombosis. This would not be conceivable without the dexterity of robotic technology.
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SUMMARY
The use of robots in surgery is likely to increase because of its enhanced precision and control. Its minimally invasive nature is better tolerated in terms of reducing the stress response, overall pain, tissue trauma, and length of hospital stays, as well as hastening recovery from surgery and improving cosmetic results.[82] Anesthesiologists need to be aware of this fast-changing field and how it affects anesthetic techniques and their delivery. Initially, robotically assisted surgical thoracic procedures increased the duration that patients are under general anesthesia. Concomitantly, the duration of one-lung ventilation has been taken to new time extremes, which has given us insight into the respiratory physiology of prolonged one-lung ventilation. As surgeons gain expertise with robotically assisted surgery, operative times will shorten dramatically to the point of traditional open surgery. The inability to move the patient while the robot is engaged to the patient will be a challenge when attempting to alter cardiac filling pressures by gravity, causing pharmacologic agents to be used more often. Anesthesiologists have experienced working in locations that are remote from the patient's airway. It should come as no surprise that robotically assisted surgery of the upper body will also provide that challenge. Improved monitoring methods will be needed to make remote anesthesia safe and practical. Perhaps the "minimally invasive" revolution will advocate earlier patient recovery and the increased implementation of regional anesthetic techniques. The extent of the surgical stress response may be attenuated, ultimately minimizing the inflammatory response. We have entered a new age of practical robotic applications that will ultimately improve surgical care. As with all new innovations, we must progress but with optimistic caution.
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KEY POINTS 1. Robotic surgery is accomplished by an autonomous, reprogrammable manipulator designed to move and articulate specialized instruments through programmed motions that achieve a specific task. A robot can be given three-dimensional coordinates from any imaging devices (e.g., CT) that allow it to recognize surfaces on which it will do a specific, programmed task. 2. Robotically assisted surgery involves mechanical devices that move by a motorized system under partially programmed control and that can be instantly controlled or modified by a surgeon's intervention. 3. Computer-assisted surgery involves systems that are manually controlled by the surgeon and that include a tracking system, sensors, and end-effector instruments. This system provides direct and continuous control of movements. 4. Telesurgery refers to the ability to perform surgery using computer-assisted instruments from a remote location. 5. Telemanipulation refers to the ability to electronically produce precise instrument movements at a distance from a remote location. 6. Telepresence refers to virtual projection of images from remote sites. This allows the surgeon to visualize intended robotic movements at distant locations. It also enables telementoring, which is supervision and instruction from a distant location.
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Chapter 66 - Anesthesia for Robotic Surgery

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CARDIAC SURGERY (see Chapter 50 )

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NEUROSURGERY (see Chapter 53 )

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Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

UROLOGIC SURGERY (see Chapter 54 )

Copyright 2005 Elsevier Inc. All rights reserved.

Bookmark URL: /das/book/view/44274406-2/1255/1967.html/top

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

Copyright 2005 Elsevier Inc. All rights reserved.

Bookmark URL: /das/book/view/44274406-2/1255/1968.html/top

Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

Copyright 2005 Elsevier Inc. All rights reserved.

Bookmark URL: /das/book/view/44274406-2/1255/1969.html/top