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Anesthesia for Robotic Surgery:

Anesthesia for Robotic S urgery


Introduction Robotic surgery is the resulting transformation of the minimally invasive surgical evolution. These are not true autonomous robots that perform surgical tasks; rather, they are mechanical “helping hands” that offer assistance in various fields of surgery ( telemanipulators ). The first master-slave manipulator for medical use was developed at Stanford Research Institute in 1991. The goal was to have computer algorithms that translate a surgeon's master manual movements to end- effector slave instruments at a remote site.

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In 1994, Intuitive Surgical obtained technologic rights from Stanford Research Institute, and a prototype DaVinci system was released in 1997.

DaVinci system:

DaVinci system The da Vinci system has three components: a console, an optical three-dimensional vision tower, and a surgical cart. 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 arms.

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The console has a foot pedal that disengages the robotic motions, another that allows adjustment of the endoscopic camera, and a third pedal for controlling the energy of electric cauterization.

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Surgical console

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an optical three-dimensional vision tower,

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and a surgical cart

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The surgical cart has four arms that can be manipulated by the surgeon through real-time computer-assisted control. The first two arms represent the surgeon's right and left arms, to hold the instruments, and the third arm positions the endoscope. The optional fourth arm enables the surgeon to hold another instrument or perform additional tasks, such as holding counter traction and following running sutures, eliminating the need for a patient-side surgeon

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The system's instruments are designed to have 7 degrees of freedom, which enables it to approach the identical articulation of the human wrist. Seven degrees of freedom include three arm movements (in out, up down, side to side), and three wrist movements (side to side, left and right), ( up and down), and roll or rotational. The seventh degree of freedom is grasping or cutting.

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The system design incorporates a frequency filter that eliminates hand tremor greater than 6 Hz. Motion scaling also can 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.

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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. T he operator must rely on visual cues from tissue distortion to gauge how much pressure is being generated.

Application in cardiac surgeries:

Application in cardiac surgeries Internal mammary artery harvesting was successfully performed thoracoscopically in 1997 by Nataf . In 1998, Loulmet and colleagues reported the first totally endoscopic coronary artery bypass surgery. Cardiothoracic applications of robotically assisted surgery have expanded and include: atrial septal defect closures . mitral valve repairs. patent ductus arteriosus ligations. totally endoscopic coronary artery bypass grafting. minimally invasive atrial fibrillation surgery .

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Totally endoscopic coronary artery bypass (TECAB) surgery represents the most minimally invasive surgical approach to the treatment of coronary artery disease. Results to date show early and midterm outcomes are comparable to the conventional procedures

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Completely endoscopic approaches to coronary revascularization include: arrested-heart TECAB, beating-heart TECAB without cardiopulmonary bypass (CPB) beating-heart TECAB with CPB

Patient selection:

Patient selection Patient selection for TECAB is crucial in order to maximize the benefits and minimize perioperative morbidity and mortality. Patients should have an indication for CABG and be good surgical candidates.

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Current contraindications include: extensive pleural adhesions a history of pleuritis , radiation and inflammatory thoracic disease. lung disease that would prevent OLV and previous cardiac surgery.

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significant cardiomegaly with reduced intrathoracic space. robotic approach is not suitable for patients with acute ongoing myocardial ischemia, hemodynamic instability, or peripheral vascular disease.


I nvestigation pulmonary function testing is a part of the preoperative evaluation to rule out the presence of severe lung disease. Computed tomography (CT) angiogram of the chest, abdomen, and pelvis is mandatory to guide the cannulation strategy. Atherosclerosis may increase the risk of embolic stroke. Pre-existing, asymptomatic arterial dissections could propagate during retrograde CPB flow and tortuous vessels may impede passage of the EAOBC.

Anesthetics Consideration:

Anesthetics Consideration The anesthesiologist has additional challenges with TECAB over open CABG such as OLV, placement of special catheters (pulmonary artery vent and percutaneous coronary sinus catheter, if required), limited access to the patient. induced capnothorax , with its attendant consequences, including hemodynamic instability, especially in the hypovolemic patient. Also, remote-perfusion strategies for CPB require significant use of transesophageal echocardiography (TEE) to confirm the placement and positioning of various catheters and surgical cannulae .


P osition T he anesthesia machine are moved further cephalad , away from the operating room table, to avoid collision with the robot. The patient is placed supine with a 30 elevation of the operative hemithorax – special attention must be paid to ensure that the cephalad robot arm is not too close to the patient’s face. As internal defibrillation is not feasible in TECAB, defibrillator pads are applied to the chest.


Monitoring A standard general anesthetic technique is used in TECAB, with invasive monitoring and OLV that is achieved by the usual methods – double-lumen tubes, bronchial blockers, or Univent tubes. Invasive monitoring includes bilateral radial arterial lines to monitor balloon position if an EAOBC is used, pulmonary artery vent, percutaneous coronary sinus catheter on occasion, and TEE.


P rocedure After left-lung collapse, the camera port is inserted in the left fifth ICS. Carbon dioxide (CO2) is insufflated to target pressures of 10–12 mmHg to develop the intrathoracic surgical working space. Instrument ports are then inserted in the third and seventh ICSs – sometimes a 7-mm assistant port is used in the left fourth ICS and a left subcostal port for an endoscopic stabilizer The internal mammary arteries (IMAs) are harvested and heparin is administered.

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Simultaneously, the bedside surgeon cannulates the femoral vessels. In arrested-heart TECAB, CPB is instituted, the EAOBC inflated, and antegrade cardioplegia is delivered. Target vessels are identified, anastomoses are completed with suture, clips, or a stapling device, and graft patency is assessed. The EAOBC is then deflated, and after a stable rhythm is established, the patient is weaned from CPB. Protamine is administered and decannulation ensues.

Mitral valve repair, replacement:

Mitral valve repair, replacement 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.

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Following the same principles as TECAB. Procedures through the right hemithorax . SVC is cannulated through the Int. Jugular vein. IVC is cannulated through the femoral vein.

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