Anesthesia for robotic surgery Dr S. Parthasarathy MD DA DNB PhD FICA , Dip software based statistics

Robot - What is it ? “powered, computer controlled manipulator with artificial sensing that can be reprogrammed to move and position tools to carry out a wide range of tasks. But ours cant perform independent tasks – Just computer assisted devices

History Today’s medical robotic systems can trace their origins to the United States Department of Defense’s (DOD) desire to decrease war casualties. The DOD sought a system that allowed combat surgeons rapid access to treat exsanguinating soldiers on the battlefield from a safe distance:

History two FDA approved telemanipulative robotic systems: da Vinci Robotic Surgical System Zeus Robotic Surgical System. In April of 1997, the first robotic assisted surgery was performed by Jacques Himpens, MD and Guy Cardiere, MD using the da Vinci surgical system.

Three parts

Console – surgeon sees and manipulates , operates pedals Side cart – arms – (four) two hands , one telescope and one for retaining retractor Vision system – insufflators and extra camera

Pros and cons Cost- initial 6-7 C and recurring 0.5 C But volume and precision – filter, scale - tremors ? Lure faculty Nurses – heavy equipment – OT size Injury, Draping, Sterility improved operative field visibility with three dimensional imaging systems. Less time Less post op pain , better post op period

No fatigue Can reproduce No tremors Scaling much

Seven degrees of freedom The arm can move up and down in a vertical plane (1), side to side in a horizontal plane (2), extend forward to reach an object and retract back (3), rotate around its central axis as when supinating and pronating the hand (4). the addition of a “wrist”, (5), laterally moved to the ulnar and radial sides (6), the hand (instrument) can open and close as if grasping (7).

Prostate !!

Anesthetic concerns

Preop assessment General Cardiac risk Obesity Renal Pulmonary Neuro and ocular risk GI

Ergonomics Access to patient Machine and the patient IV access Monitors and lines , urino meter Pads and cushion Once docked ?? That’s all

Usually lengthy operations Position -Depends on surgery – prostate , thoracic, Lap surgeries One lung ventilations for hours ?? Fibrescope and check position , can we do after docking ? Robot in head end !!

A lot of time from induction to incision No movement – pucca paralysis Oxygen, air mixture is used along with inhalational agent and Fentanyl/Remifentanil infusion for maintenance of anaesthesia.

Concerns – type of surgery Steep trendelenberg Cardio respiratory changes Pneumo peritoneum Occult blood loss Elevated IAP Cerebral protection and mannitol

Considerations differ Prostate Cardiac Thoracic Urological GI surgeries Considerations differ

Conduct position , fix , dock, assistant puts ports , console surgeon starts Movement of the patient while robotic instruments are docked could lead to tearing or puncturing of internal organs and vasculature, with potentially devastating consequences Undock – reverse

Complications

Other complications Hemiparesis Infarct Bystander injury Arm pressing the neck Air embolism The robot light source produces more heat than typical laparoscopy and therefore demands greater vigilance to prevent burns or fire

Regional !!??

Postoperative Extubation and reintubation Fluid shifts Nerve injuries Renal dysfunction Pain relief is via IV

Anesthetic robot A group of researchers at Montreal’s McGill University have invented an anaesthesia robot called “McSleepy” that can act like an anaesthesiologist, analyze biological information constantly adapts its own behaviour even recognizes monitoring malfunction

Summary Three parts and degrees of freedom history Type of surgeries Advantages Conduct . No regional - paralysis pucca docking then undock and reverse Complications Anesthetic robot

Thank you