State-of-the-art: anesthetic management for robotic surgery: the MD Anderson Cancer Center Experience
Epublication WebSurg.com, Sep 2014;14(09). URL: http://websurg.com/doi/lt03enmena001
Background: Robotic-assisted surgery has evolved over the past decade and has paved the way for the future surgical approach in multiple subspecialty disciplines. Technological advancements present potential advantages for our oncologic patients as well as new challenges for anesthesia and surgery teams. Robotic head and neck, plastic and thoracic surgery carry specific associated risks that require a precise anesthetic perioperative management plan in order to prevent catastrophic events such as airway fire, life-threatening hemodynamic instability and flap failure, from happening. The main goals are to estimate and minimize the risk of morbidity and mortality associated with robotic surgery and anesthesia. Description: The three most important anesthetic considerations during TransOral Robotic Surgery (TORS) are: airway management, facial trauma prevention and fire prevention strategies. The surgical bed is usually rotated 180 degrees away from the anesthesiologist and securing the airway becomes pivotal in order to prevent accidental disconnection or extubation caused by the patient-robot conflict. Facial trauma, and specifically ocular trauma including retinal detachment, is prevented by the routine use of surgical goggles. The risk of fire is high during TORS and specific strategies must be put in place in order to prevent such a catastrophic event from occurring. Strategies include: a fire checklist including precise knowledge of oxygen shutoff location outside the OR and fire extinguisher location inside the OR, as well as decreasing oxygen concentration to less than 35% as tolerated by oxygen saturation. During robotic reconstructive plastic surgery fluid management must be precise because very conservative fluid administration can lead to hypotension and hypoperfusion of the flap due to a decrease in oxygen delivery and potential ischemia. Over-administration of fluids can lead to interstitial edema putting flap integrity at risk, due to an increase in the distance oxygen molecules travel from the endothelium to the cells, to contribute with adequate tissue oxygenation and aerobic metabolism. Excessive fluid administration leads to dilution anemia increasing the need for blood transfusions, which negatively impact immunomodulation in cancer patients as demonstrated by several meta-analyses. We currently have new minimally invasive hemodynamic monitoring technology such as Flo Trac, Vigileo and LiDCO at our fingertips, which allows to monitor beat-to-beat precise fluid administration to maintain a perfect state of euvolemia. Minimally invasive thoracic surgery such as Da Vinci® assisted robotic surgery and Video-assisted thoracoscopic surgery (VATS) are routine procedures at our institution. Enhanced Recovery After Surgery (ERAS) and specifically Enhanced Recovery After Thoracic Surgery (ERATS) strategies are currently used as part of our thoracic surgical protocols in order to decrease morbidity, length of stay (LOS), opioid consumption and costs to the healthcare system and institution. These strategies are the result of scientifically and evidence-based data from RCT’s and multiple meta-analyses. The role of multimodal analgesia for perioperative pain management with pharmacological opioid sparing strategies using Lyrica (Pregabalin), Tramadol ER (Ultram), Celebrex (Celecoxib), IV Acetaminophen (Ofirmev) and Ketorolac IV (Toradol) have clearly shown to decrease the use of opioids by more than 50%. Opioids are clearly known to lead to side effects such as ileus, urinary retention, respiratory depression and immunomodulation which are all associated with increased LOS, morbidity and costs. Total Intravenous Anesthesia (TIVA) using continuous intraoperative infusions of propofol, dexmedetomidine (Precedex) and lidocaine are part of the ERATS strategies to decrease opioid use and to avoid the side effects of inhaled volatile agents. Surgical strategies such as intercostal block with Exparel (Liposomal Encapsulated Bupivacaine) and incisional port injection with Exparel as well as early chest tube removal (24-48 hours) allow early patient mobilization and discharge while maintaining the same outcomes and increasing patient satisfaction. Discussion: Team work between surgeons and anesthesiologists as well as constant communication and a thorough understanding of the physiological, hemodynamic, oncologic and analgesic implications minimizes the risk of morbidity and mortality associated with robotic surgery and anesthesia. Anesthesiologists must have in-depth knowledge of specific anesthetic considerations and implications associated with TORS such as airway fire and fire prevention strategies. Precise fluid administration and Enhanced Recovery After Surgery (ERAS) strategies during plastic robotic surgery as well as thoracic robotic surgery are pivotal in the perioperative period and for accelerated recovery while maintaining same quality of care and patient satisfaction. As surgical approaches change with robotic surgery, it is necessary to understand the impacts these changes have on perioperative care to optimize surgical success, safety, patient satisfaction, decreased LOS, opioid usage and Institutional costs. References: 1. Campos JH. An update on robotic thoracic surgery and anesthesia. Curr Opin Anaesthesiol 2010;23:1-6. 2. Steenwyk B, Lyerly R 3rd. Adavancements in robotic-assisted thoracic surgery. Anesthesiol Clin 2012;30:699-708. 3. Selber JC. 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