Evolution of Surgery 1 st Generation Open Surgery 2 nd
Generation Minimally Invasive Surgery 3 rd Generation Robotic
Surgery
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VOGUE
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Intuitive is considered to represent the market
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da Vinci Surgical System U.S. Installed Base 1999 2008
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Apr 1997 : General surgical assistance Jul 2000 : General
laparoscopic procedures Mar 2001 : Non-cardiac thoracoscopic
procedures May 2001 : Prostatectomy procedures Nov 2002 :
Cardiotomy procedures Jul 2004 : Cardiac revascularization
procedures Mar 2005 : Urologic surgical procedures Apr 2005 :
Gynecologic surgical procedures Jun 2005 : Pediatric surgical
procedures Approved by FDA
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Machine that resembles a human and does mechanical, routine
tasks on command. Machine that resembles a human and does
mechanical, routine tasks on command. Robots Computer controlled
and used to improve therapeutic outcomes. A robot is not a
machine.it is an information system with arms.
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Classification of Robots Shared Control (Semi- Active)
Supervisory-Controlled (Active) Telesurgical (Passive)
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Classification of Robots Classification is based on how much
involvement is required from the surgeon performing the surgical
procedure
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Supervisory-Controlled (Active) Most automated. Can carry out
treatment without immediate input from surgeon. Requires input of
data into the robotic system, planning, testing, appropriate
placement and overseeing on part of the surgeon.
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Supervisory-Controlled : No room for error robot does not
adjust in real time E.g. RoboDoc system commonly used in orthopedic
surgeries; Cyberknife
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Shared Control (Semi- Active) Surgeon and robot share control.
Surgeon manually operate surgical tools, while the robot assists
when needed. The surgeon programs the robot to recognize the areas
of the surgical field as forbidden, boundary, close and safe
areas.
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Shared Control (Semi- Active) As the surgeon nears these
dangerous areas, the robotic system locks up to prevent further
injury. E.g. Aesop system (Automated Endoscopic System for Optimal
Positioning) -Voice activated mechanical arm
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Telesurgical (Passive) Robot is manipulated by the surgeon in
real-time through remote control through any given distance
Provides 3-D visualization, and access to hard-to- reach places
like the heart
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Telesurgical (Passive) Enhances wrist dexterity and control of
tiny instruments. Allows quicker, controlled and more accurate
movements Latency - time delay between console & robot E.g. Da
Vinci Surgical System
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Da Vinci Surgical System
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Da Vinci robot consists of A surgical console Patient-side cart
Instruments and imaging processing
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Surgical console
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Instruments and imaging processing
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Patient-side cart
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Procedures Performed with daVinci Urology Radical
prostatectomy, pyeloplasty, cystectomy, nephrectomy, ureteral
reimplantation Cardiothoracic Mitral valve repair, ASD closure, PDA
ligation, IMA mobilization and totally endoscopic CABG Gynecology
Hysterectomy and myomectomy
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Procedures Performed with daVinci Pediatrics Pyeloplasty for
ureteropelvic junction obstruction, gastroesophageal repair GERD,
ligation of PDA General Surgery Cholecystectomy, Nissen
fundoplication, gastric bypass, donor nephrectomy, adrenalectomy,
splenectomy, bowel resection and thyroidectomy
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Advantages to the Surgeon Image is magnified 12 times
Stereoscopic 3-HD view of surgical field Robotic wrist with 6
degrees of freedom
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Advantages to the Surgeon Movements are scaled, filtered,
translated Tremor reduction Better tissue targeting higher
precision Improved positioning & surgeon comfort Better
hand-eye coordination
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Advantages to the Patient Less risk of infection Less blood
loss and transfusions Less invasive procedures Less scarring Faster
recovery & shorter hospital stay Less pain & quicker return
to normal activities
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daVinci Robotic Prostatectomy
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Disadvantages Bulky; requires large amounts of OR space Lack
tactile feedback from the instruments Steep surgical learning curve
Increased staff training/competence Increased OR set-up/turnover
time
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Cost Institutional cost- $1.2 million Maintenance cost-$100,000
after first year Intra - operative cost of each case- $2800
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ANESTHESIA CONCERNS
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Pneumoperitoneum Intra abdominal pressure of at least 12 15mmHg
is required. Decreased blood flow to organs in the abdominal cavity
due to mechanical compression. Increased CVP, PCWP, PAP and
decreased CO at beginning of surgery.
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Pneumoperitoneum Increased cardiac afterload Decreased venous
return Increased sympathetic tone Increase in MAP / SVR Increase/
decrease in HR Ventricular Ectopy- Hypercarbia, local reflexes, gas
emboli
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Pneumoperitoneum Most hemodynamic changes are transient and
usually return to baseline in 20-30 minutes. Thought to be due to
neurohormonal mechanisms
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Pneumoperitoneum Compromises pulmonary function by
Diaphragmatic elevation Early closure of small airways atelectasis
Preferential ventilation of nondependent parts of the lung V/Q
mismatch In pulmonary compromised patients Preoperative PFT and
ABG
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Pneumoperitoneum Increased ICP and decreased CPP Increased SVR
Head-down position Elevation of IAP Hypercapnia Should be cautious
when intracranial compliance is reduced If patient has a VP shunt,
check patency post op
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Pneumoperitoneum Increased plasma lactate levels and lactic
acidosis Alterations in liver enzymes Appearance of oxidative
stress markers due to splanchnic ischemia reperfusion. Mesentric
thrombosis, splanchnic ischemia & bowel necrosis
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Pneumoperitoneum Oliguria due to parenchymal compression, but
no permanent damage. It does not effect post operative function
Release of vasoactive substances including vasopressin,
angiotensin, cortisol and ACTH Level of vasopressin increase during
insufflation due to decrease in atrial transmural pressure gradient
Time course of increased SVR seems to parallel that of vasopressin
release
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Complications of Pneumoperitoneum Hypercarbia Pressure of CO2
in the peritoneal cavity is higher than atmospheric pressure with a
diffusion gradient of 700mmHg Peritoneal capillary barrier and
contact surface areas are such that hypercarbia is usually well
controlled with hyperventilation Very seldom are arrhythmias or
unmanageable HTN seen
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Complications of Pneumoperitoneum The most feared complication
is venous gas embolism Increased with hypovolemia 20% of patients
have a Foramen ovale Subcutaneous Emphysema Pneumothorax and
Pneumomediastinum Hypothermia
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ANESTHETIC MANAGEMENT
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Pre operative Evaluation Robotic surgery is elective Need to
optimize the circulatory, respiratory, metabolic and other systems
Patients with cardiac disease must have a thorough evaluation Blood
should be available even though bleeding is infrequent
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Choice of anesthetic technique General ETT Monitoring is
similar to other surgeries ETT must be secured such that it does
not move or kink
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Positioning Proper positioning is CRITICAL! Must provide access
to the operative site while accommodating the robotic camera and
arms. Decreased work space area for the CRNA Once the robot is
docked There can be no adjustment of position Movement of the OR
table
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Positioning Patient needs to be secured such that there is no
accidental movement during surgery. Arms and hands should be
positioned in such a way that IV lines, non invasive BP cuff, A -
line, pulse oximeter may function uninterrupted.
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Positioning All pressure points are padded with gel pads. Arms
are tucked Better to start a second large bore IV after
induction
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Eye Protection Eyes need to be taped Goggles Careful in
trendelenburg position - gastric juices regurgitated during surgery
can fill the goggles and cause severe conjunctival burns
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Insufflation Be ready to treat severe bradycardia, tachycardia,
HTN, hypotension and arrhythmias If proper attention was not paid
to to IV and monitoring lines during positioning, the patient can
die before any derangements can corrected or even recognized.
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Ventilation Increased airway pressures Worse in COPD and
reactive airway patients Bronchodilator puffs help If too high,
check for kinks/ occlusion of ETT Pressure control ventilation
helps obtain better mechanics and gas exchange
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Fluid Replacement Blood loss is minimal but fluid requirements
are large Insufflation with dry gas Third Spacing Trend is to keep
patients dry Albumin is preferred over crystalloids Fluids rate is
increased once the patient is flattened
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Muscle Relaxants Patients have to be paralyzed until the robot
is undocked Continuous drip of non depolarizing agent can be used
Any bucking or coughing will lead to serious trauma &
injury
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Emergence and extubation If patient was in Trendelenburg
position and the surgery was prolonged look for facial and buccal
swelling. If present do not extubate! If extubated, patient will
obstruct and and reintubation will be difficult Keep intubated
until edema subsides even if patient is awake.
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Cardiac Arrest The OR staff should be trained with an emergency
drill for the removal of the robotic chart Discontinue insufflation
and deflate the abdomen CPR is initiated in the Trendelenburg
position until the robot is undocked
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Communication The successful use of the robot to assist in
surgery depends on excellent communication between all members of
the anesthesia team
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Gastrointestinal Surgery Supine position with reverse
Trendelenburg Robot over the patients head or at a 45 angle from
the bed Robotic arms in very close proximity to the patients
airway, face, and chest Rapid sequence induction with cricoid
pressure Muscle relaxation is paramount
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Cardiac Surgery Supine position with the thorax rotated 20
Anesthetic Implications Knowledge and expertise in cardiac and
thoracic anesthesia Single-lung ventilation Transesophageal
echocardiography (TEE) Continuous monitoring of cardiac function
Central line placement 5~10 mmHg of Capnothorax
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Cardiac Surgery
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Urological Surgery Lithotomy with 30 Trendelenburg Anesthetic
Implications Monitored with routine care Arterial line for frequent
sampling Large-bore intravenous line for potential large blood loss
Padding placed at every pressure point
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Trendelenburg position
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Trendelenburg position Trendelenburg position FRC &
Atelectasis Pulmonary edema Lingual and buccal nerve neuropathy
ICP, CVP, IOP, PCWP, Swelling of face, eyelids, conjunctiva, and
tongue Peripheral nerve injury Cerebral stasis Cardiac Output
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Trendelenburg position If significant upper airway edema is
present, delay extubation. Position can also cause an upward
displacement of the ETT and migration into a main stem bronchus.
Pulse oximetry probe should not be placed on the earlobe---
potential of erroneous readings
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Trendelenburg position Intraocular pressure may increase more
than 4X over 1-2 hrs in a steep Trendelenburg position IOP
increases by 0.05 mmHg for every minute of surgery Greater risk for
visual disturbances and blindness Patients with pre-existing eye
disease should be evaluated and counseled about the potential
risks