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CHAPTER
66 Anesthesia for
Robotic Surgery
Ervant V. Nishanian and Berend Mets

History 0000 Background 0000

Radiosurgery of Spinal Lesions 0000
Robotic Systems 0000
Urologic Surgery 0000
General Surgery 0000
Transurethral Resection of the Prostate 0000
Gastrointestinal Surgery 0000
Radical Prostatectomy 0000
Nissen Fundoplication 0000
Anesthetic Implications 0000
Anesthetic Considerations 0000
Gynecologic Surgery 0000
Cardiac Surgery 0000
Background 0000
Anesthetic Implications 0000
Anesthetic Implications 0000
Mitral Valve Surgery 0000
Atrial Septal Defect Repair 0000 Orthopedic Surgery 0000
Internal Mammary Artery Harvest 0000 Total Hip Arthroplasty 0000
Coronary Artery Bypass Grafting 0000 Knee Replacement 0000
Future Directions 0000
Ophthalmologic Surgery 0000
Thoracic Surgery 0000
Summary 0000
Background 0000
Esophagectomy 0000 Key Points 0000
Neurosurgery 0000 References 0000

Robotic surgery is the resulting transformation of the HISTORY

minimally invasive surgical evolution. Robotic devices
are being introduced to surgery because they allow Robots were first developed by the National Aeronautics
unprecedented control and precision of surgical instru- and Space Administration (NASA) for use in space explo-
ments in minimally invasive procedures. The anticipated ration.2 These devices, or telemanipulators, were capable
benefits of robotic or robot-assisted surgery to the patient of doing manual tasks aboard a spacecraft or out in space.
include less pain and trauma, shorter hospital stays, The slave devices were controlled electronically from a
quicker recovery, and a better cosmetic result. With these remote master control on Earth or aboard a spacecraft.
technologic innovations, new anesthetic implications for Telemanipulators were used extensively aboard NASA’s
patient care are being discovered. As surgery evolves into Space Shuttle missions between 1983 and 1997. Research
the robotic era, anesthesiologists must keep abreast of in trajectory and missile guidance systems eventually led
these changes and their impact on patient care and to highly precise targeting mechanisms. Precision point-
safety. ing at targets, such as the Earth and stars, was crucial for
First-generation surgical robots are being installed in a Spacelab telescope experiments. Telemanipulators such
number of operating rooms around the world. These are as the Instrument Pointing System (IPS) was specifically
not true autonomous robots that perform surgical tasks; designed for extreme accuracy (±1.2 arcsec).3 Scientists at
rather, they are mechanical “helping hands” that offer NASA Ames Research Center were responsible for devel-
assistance in various fields of surgery. These machines oping virtual reality. The idea took root with contribu-
still require human intervention to operate or to provide tions of VPL, a visual programming language, and
input instructions. Robotic devices are here to help sur- Dataglove.4 Their integration made it possible to interact
geons, not to replace them. with three-dimensional virtual scenes. However, it took
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2 Section IV — Subspecialty Management

the integration of robotic engineering and virtual reality Optimal Positioning (AESOP)10 arm to be used in laparo-
to develop a dexterous telemanipulator for the anasto- scopic surgery. The device is controlled through voice
moses of nerves and vessels in hand surgery.5 activation to provide a flexible view of the surgical field.
From these applications, it became apparent to the Around the same time, the TISKA Endoarm became avail-
United States Department of Defense that virtual reality able, and it could act as a camera guided by electromag-
and telepresence might serve a useful function in treating netic friction and could work as a tissue retractor.11 While
wartime casualties on the battlefield. Through virtual foot pedals were being replaced by voice-activated sys-
reality, the surgeon could be brought to the patient’s side, tems, other manufacturers were designing cameras that
an idea described by the term telepresence. Data from moved in synchrony with the movements of the sur-
wounded casualties of the Vietnam War estimated that, geon’s head.12 Other devices provided finger “joysticks”
of all wounded soldiers, one third died of head and mas- that could be used to control the camera field.13
sive injuries and another third died of exsanguinating To combat dexterity problems, the master-slave tele-
hemorrhage but had the potential to survive if they were manipulator concept was developed for medical use in
treated in time.2 The Department of Defense sought to the early 1990s. The first master-slave manipulator for
improve medical presence on the battlefield given that one medical use was developed at Stanford Research Institute.
third of casualties can be saved. Telepresence allowed a The goal was to have computer algorithms that translate
surgeon located aboard an aircraft carrier to perform sur- a surgeon’s master manual movements to end-effector
gery (with the aid of telemanipulation) on wounded sol- slave instruments at a remote site. The robotic slave
diers located in a remote location on the battlefield. With arms mimic the natural movements of the surgeon’s
this idea in mind, The Department of Defense funded hand. Early designs had only 4 degrees of freedom,
much of the research in telemanipulation for remote but by 1992, a German prototype was developed with
mobile surgical units that would allow for telepresence. 6 degrees of freedom (Fig. 66-1).14 It was used experimen-
Engineers realized that the distance between patient and tally but never achieved clinical application.15 In 1994,
surgeon had an upper limit, beyond which accuracy and Intuitive Surgical obtained technologic rights and even-
dexterity of instrument control would suffer degradation. tually developed robotic instruments with 6 degrees of
Latency is the time it takes to send an electrical signal from freedom.
a hand motion to actual visualization of the hand motion Robots can be preprogrammed with limits set by the
on a remote screen. The lag time to send an electrical operator and run autonomously, or its kinematics can be
signal to a geosynchronous satellite at 22,300 miles above completely defined online in real-time tracking when
the earth and return is 1.2 seconds. This transmission immediate human interventions and decisions are
delay would prohibit practical surgery. Humans can required. The design of surgical robots must include
compensate for delays of less than 200 msec. Longer delays sterility barriers and enhanced patient safety features. It
compromise surgical accuracy. Tissue moves when force must meet operating room constraints and be compatible
is applied to it, and with a visual delay greater than with imaging equipment, as well as require special
200 msec, the movement would not be noticed fast ergonomic features.
enough to avoid cutting in an unintended place. The most To overcome endoscopic surgery handicaps, engineer-
optimistic attempt to provide telesurgical presence over ing technology has developed three-dimensional video
long distances was undertaken using high-bandwidth imaging, robot camera holders, and robotic flexible effec-
fiberoptic ground cable. The latency time of 155 msec tor instruments with the ability for tactile pressure sensa-
allowed Marescaux and Gagner6,7 to perform a robot- tion. Unfortunately, every instrument has different stress
assisted laparoscopic cholecystectomy between New York feedback characteristics, and the surgeon’s ability to
City and Strousbourg, France. “feel” the elastic properties of tissue are not yet fully
Phillipe Mouret8 performed the first video-laparoscopic developed. The robotic fingers can be made smaller than
cholecystectomy in Lyons, France, in 1987, but it was not those of the human hand to help reach confined spaces.
until Perissat9 presented the innovation to the Society of The robot can filter the surgeon’s hand tremor and scale
American Gastrointestinal Endoscopic Surgeons in 1988 the movements of the instruments to the level of high
that an exponential spread of laparoscopic surgical pro- precision and stability that is required for microsurgery.
cedures began. Although laparoscopic surgery provided Best of all these advantages, repetitive robot motions and
a great benefit for the patient, it brought tremendous tasks are not prone to fatigue.
surgical limitations, such as loss of three-dimensional
vision, impaired touch sensation, and poor dexterity pro-
vided by the long instruments and the fulcrum effect. ROBOTIC SYSTEMS
The fulcrum effect is a nonintuitive motion of the instru-
ment tips in opposite direction about a fixed point, usu- The word robot is a ubiquitous term that describes an
ally at the skin entrance site. New skills had to be learned. autonomous device capable of various tasks. Industrial
Initial attempts to surmount the burdens of endoscopic robots used in assembly lines perform highly precise,
surgery have provided the impetus for robotic support repetitive tasks. The robots are preprogrammed off-line,
systems that can enhance surgical skills and control of and tasks are invoked on command. Robots used in
instruments. The first of such systems in the medical field orthopedic surgery and neurosurgery are examples.16
were applied in surgical field camera guidance. Precise tasks such as drilling and probe insertion are
In 1994, the U.S. Food and Drug Administration (FDA) based on registration. Registration is a mathematical
approved the first Automated Endoscopic System for process that allows location and anatomic orientation in
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Chapter 66 — Anesthesia for Robotic Surgery 3

Outer pitch

Insertion

Outer yaw

Roll Fulcrum at chest wall

Figure 66–1 Degrees of

freedom (DOFs) in motion. A,
Conventional laparoscopic
instruments have only 4 DOFs Grip
and grip. Insertion (i.e.,
movement in the z axis), roll, and
movement along the x and y axis A
outside the body relative to a
fulcrum point constitute the
4 DOFs. B, Depiction of the Outer pitch
EndoWrist instrument with two
added intracorporeal joints
produce 6 DOFs along with grip. Insertion
(A and B,  1999 Intuitive
Surgical, Inc., Sunnyvale, CA.)

Yaw Outer yaw

Roll Fulcrum at chest wall

Pitch

Grip
B

three dimensions based on data derived from preopera- The da Vinci system has three components: a console,
tive computed tomography (CT) or magnetic resonance an optical three-dimensional vision tower, and a surgical
imaging (MRI). cart. The surgical cart has three arms that can be manipu-
A second type of robot is defined as an assist device, lated by the surgeon through real-time computer-assisted
such as AESO. These robots are used to control instru- control. One of the arms holds an endoscopic camera,
ment location and guidance. These robots are not and the other two are manipulator or instrument-
autonomous; they need input cues from the operator. holding arms. The system allows the surgeon to be phys-
A third type of robot is a telemanipulator. These robots ically remote from the patient. The system’s instruments
are under constant control of the operator. These devices are designed to have 6 degrees of freedom plus grasp,
mimic the operator’s hand motions in an exact or scaled which enables it to approach the identical articulation of
motion. There are several telemanipulator robotic devices the human wrist (Fig. 66-4). The system design incorpo-
available throughout the world. The da Vinci Robotic rates a frequency filter that eliminates hand tremor
Surgical System (Fig. 66-2) has been cleared by the greater than 6 Hz.17 Motion scaling can also be invoked
FDA for laparoscopy, thoracoscopy, and intracardiac up to a ratio of 5:1 (i.e., the surgeon moves 5 cm, and the
mitral valve repair surgery, and the ZEUS Surgical System robot moves 1 cm). Scaling allows for work on a minia-
(Fig. 66-3) has been developed in parallel and cleared for ture scale. The console also provides a three-dimensional
sale by the FDA for general and laparoscopic surgery. The image of the surgical field. The endoscope consists of
two systems are very similar, with some minor differences. dual, independent optical channels capable of transmit-
The da Vinci Robotic Surgical System is described in this ting digital images to the console’s visual monitor. At
chapter as a representation of most modern surgical the console, the surgeon is actually looking at two sepa-
robots. rate monitors; each eye sees through an independent
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4 Section IV — Subspecialty Management

Figure 66–2 Photograph of 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.)

A B

camera channel to create a virtual three-dimensional arms. The console has a foot pedal that disengages the
stereoscopic image. The images are controlled through robotic motions (i.e., clutching), another that allows
two independent light sources found on the optical adjustment of the endoscopic camera, and a third pedal
three-dimensional vision tower. for controlling the energy of electrical cauterization.
The surgeon sits at the console and controls the tele- The side cart of the robotic device has three arms that
scope arm and two robotic manipulator arms. The surgeon respond to the manipulative controls of the surgeon
has a viewing space that is similar to a double-eyepiece while sitting at the console. The cart is bulky and of
microscope. Each eyepiece displays a mirror reflection of tremendous weight. It requires wheeling to the vicinity
a computer monitor screen. Each monitor displays one of the patient’s surgical area and is locked into place.
channel of the stereo endoscope to an eye, creating a vir- Because of the proximity of the side cart to the patient,
tual three-dimensional stereoscopic image of the surgical the patient must be guarded against inadvertent contact
field. from the motions of the robotic arms. Even more impor-
The surgeon controls the manipulators with two masters. tant, after the instruments are engaged to the arms of
The masters are made of levers that attach to index fingers the robot and inside the patient, the patient’s body
and thumbs of each hand. Wrist movements replicate the position cannot be modified unless the instruments are
movements of the instruments at the end of the robotic disengaged entirely and removed from the body cavity.

A B
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 (B) hold instruments, and a third arm controls the camera. (Courtesy of Computer Motion, Inc., Goleta, CA.)
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Chapter 66 — Anesthesia for Robotic Surgery 5

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.

GENERAL SURGERY
Gastrointestinal Surgery

Robotic technology has pronounced itself in the field of

gastrointestinal laparoscopic surgery.18 The first surgical
operation using robotic telemanipulation was a laparo-
scopic cholecystectomy performed in 1997 in Brussels,
Belgium.19 Two U.S. companies have FDA and European
Union approval for clinical applications of their robotic
Figure 66–4 The EndoWrist instrument of the da Vinci System systems for general surgery. Robot-assisted surgical tech-
mimics the natural kinematics of the surgeon’s hand and wrist. niques permit the surgeon to provide the smallest possible
This design allows 6 degrees of freedom and grip. ( 1999 incision and lowest surgical stress. This technology allows
Intuitive Surgical, Inc., Sunnyvale, CA.) 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
Any patient movement from lack of muscle relaxant may and exploratory laparotomy, with antireflux surgery being
be disastrous. The clutching buttons allow for the robotic the most common.1
arms to be grossly positioned without moving the instru-
ments within the trocars or access ports. A clutching Nissen Fundoplication
function allows surgical assistants to exchange various
instruments. Anesthetized patients are prepared and draped in the usual
The optical tower contains the computer equipment fashion, and the abdominal cavity is insufflated with car-
needed to integrate the left and right optical channels to bon dioxide gas. Three incision ports are made as shown in
provide stereoscopic vision and to run the software Figure 66-5. The first port is for the telescope trocar, which
needed to control the kinematics of the robotic arms. The is placed 15 cm below the xiphoid process and slightly
computer interfaces the translated motion of the sur- to the left of midline. The robot arms are then inserted
geon’s hands to a digital code that moves mechanical through trocars located 10 cm on either side of the tele-
levers, motors, and cables that allow the robot to articu- scope while under laparoscopic vision. Other auxiliary
late the exact motions of the surgeon’s hand. ports can be placed at any time during the operation. The
The instruments in the body cavity must remain ster- side cart is wheeled and locked into place in anticipation
ile but interface with nonsterile robotic arms. Detachable of engaging the instruments within their respective
disposable instruments facilitate this interface. Each type trocars. The system can be activated to manipulate the
of instrument requires different forces and motion scal- robotic arms under the surgeon’s control. When a surgeon
ing intrinsic to the task at hand and requires specific requires instruments to be changed, the manipulation is
computer software processing. Additional operating stopped, and the assistant surgeon at the table is asked to
room staff is required for detaching and exchanging task disengage and replace the instrument.
specific instruments throughout the case. Monitors are
positioned on top of the tower so that all people in the Anesthetic Considerations
operating room have a view of the surgical field.
An obstacle that still needs research is tactile sensing. In the operating room, the patient is monitored with an
The feedback that the robot offers for the surgeon’s electrocardiographic (ECG) device, pulse oximetry, axillary
applied force is inferior. The robot offers some sensation, temperature probe, and noninvasive blood pressure cuff.
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6 Section IV — Subspecialty Management

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 loca-
tions and robot cart position (Fig. 66-6). The trocars are
inserted under direct visualization after a pneumoperi-
toneum is produced. After all trocars are in place, the
4
patient is placed in a steep reverse-Trendelenburg posi-
tion.26 At this point, the robot is brought into position
3 1 2 45 degrees off the right head of the table, and instru-
ments connected to the trocars.

CARDIAC SURGERY
Application of conventional endoscopic instruments has
paved the way for several cardiac procedures to be per-
formed with robotic assistance. Internal mammary artery
harvesting was successfully performed thoracoscopically
Figure 66–5 Numbered incision ports for Nissen fundoplication in 1997 by Nataf.27 In 1998, Loulmet and colleagues28
and location of the robotic arms. reported the first totally endoscopic coronary artery
bypass surgery. Cardiothoracic applications of robotically
assisted surgery has expanded and includes atrial septal
defect closures,29-31 mitral valve repairs,32-36 patent duc-
Bilateral peripheral intravenous access is valuable because tus arteriosus ligations,37,38 and totally endoscopic coro-
the left upper extremity is not immediately available nary artery bypass grafting.39-41
during the surgery. The patient is sedated with a mild Even though technical advances in minimally invasive
sedative and prepared for induction with oxygen. These surgery have introduced techniques that are done
patients usually have a history of gastroesophageal reflux through very small ports and may eventually make surgi-
and require a rapid sequence induction with cricoid cal sternotomy obsolete, surgeons must still be trained
pressure applied. The trachea is intubated with a single- and prepared to convert to an open sternotomy if the
lumen endotracheal tube, and its placement is confirmed need arises. Sternotomy alone carries a finite risk of
by listening to the chest and detecting carbon dioxide morbidity from an inflammatory response, but it is cer-
on expiration. Anesthesia can be maintained with a tainly less than that of exposure to cardiopulmonary
volatile agent. Muscle relaxation is paramount in avoid- bypass.42-44 Surgery on the beating heart without car-
ing any movements by the patient while the surgical diopulmonary bypass may avoid significant inflamma-
instruments are within the abdominal cavity. An oro- tory responses and should be the method of choice
gastric tube and a urinary bladder catheter are placed. whenever possible.
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 insuf-
flated with carbon dioxide to a pressure not to exceed
20 mm Hg.23 The trocar for the camera is placed manu-
ally. 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 prox-
imity of the side cart to the patient’s head, there is lim-
ited access to the patient’s airway and neck, and their 1
4
head must be guarded against inadvertent collision by
the movements of the robotic arms.1,24 After the robot is 3 2
engaged, the patient’s body position cannot be changed. 5
If the patient requires an increase in cardiac filling pres-
sures, and it cannot be provided by Trendelenburg’s posi-
tion, 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 Figure 66–6 Numbered incision ports for cholecystectomy and
benefit of invasive arterial monitoring does not outweigh location of the robotic arms.
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Chapter 66 — Anesthesia for Robotic Surgery 7

Anesthetic Implications Table 66–1 One-lung ventilation strategy

Knowledge of and expertise in cardiac and thoracic anes- Use FIO2 = 1.0.
thesia is imperative because both organ systems need to Begin one-lung ventilation with pressure control ventilation,
be managed safely. The ability to perform and maintain maintaining a plateau pressure of <30 cm H2O.
single-lung ventilation is mandatory, as is management Adjust the respiratory rate so that PaCO2 approaches
of the physiologic consequences. Preoperative assess- 40 mm Hg.
ment of lung function is indicated if a patient has signif- Check arterial blood gas pressure.
icant lung disease. Poor pulmonary function test results Apply continuous positive airway pressure to
may be a contraindication to robotically assisted cardiac nonventilated lung.
surgery because single-lung ventilation may be poorly Apply positive end-expiratory pressure to ventilated lung.
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 trans- probe is inserted to assess heart and valve function and to
esophageal echocardiography (TEE) has become a stan- guide central line placement. A mid-esophageal, bicaval
dard of care and has found a niche for several procedures view at 90 degrees is used for guidance in positioning the
required for safer robotically assisted surgery. superior vena cava (SVC) and inferior vena cava (IVC)
cannulas (Fig. 66-7). Initially, a left, 9-Fr introducer
Mitral Valve Surgery catheter is inserted by means of the Seldinger technique,
and an 8-Fr pulmonary artery catheter is floated into
In 1997, two independent groups reported the first robot- the pulmonary artery. Next, the right neck is prepared
ically assisted mitral valve repair.45,46 In November 2002,
the FDA approved the use of robot-assisted surgery in per-
forming 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 are 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 esti-
mate the degree coronary artery stenosis and to assess
valve function. Severe mitral regurgitation is a mechani-
cal problem that requires surgery for cure. Most patients
are medically treated with afterload reducers, such as
angiotensin-converting enzyme (ACE) inhibitors if they A
are hypertensive. An enlarged left atrium is often suscep-
tible 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 hyperten-
sion, 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 intra-
venous 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 pro-
vide automatic ST segment analysis for the detection of B
ischemia. After ample oxygenation, the patient is anes- Figure 66–7 A, Ultrasound image of the superior vena cava
thetized with a combination of midazolam, fentanyl, and cannula. B, Ultrasound image of a bicaval view depicting the
isoflurane. On muscle relaxation, the trachea is intubated inferior vena cava containing a J guidewire. Both views are
with a double-lumen endotracheal tube (Table 66-1). helpful in correctly placing cardiopulmonary bypass venous
Proper tube position is confirmed by bronchoscopy. A TEE cannulas.
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8 Section IV — Subspecialty Management

for insertion of a percutaneous, 17-Fr Biomedicus cannula. Table 66–2 Exclusion criteria for robotically
It is inserted directly into the internal jugular vein using assisted mitral valve repairs
the Seldinger technique, and its proper placement is con-
firmed by TEE. Experience shows that the long transtho- Severely calcified mitral annulus
racic aortic cross-clamp may impinge and occlude the Severe pulmonary hypertension
SVC. For this reason, an armored SVC neck cannula pro- Ischemic heart disease
vides resistance to occlusion or kinking. At the time of Surgery requiring multiple valve repairs
insertion, the cannula is flushed with 5000 units of Previous surgery to right hemithorax
heparin to ensure its patency. The cannula is anchored Severe aortic and peripheral atherosclerosis
with a purse-string suture at the skin and secured with
Kerlix gauze wrapped around the head.
After the patient’s pelvis is positioned supine and
the right shoulder is tilted 30 degrees to the left, transcu- This is facilitated by jugular and femoral vein cannula-
taneous defibrillation and pacing pads are applied. The tion and snaring the IVC and SVC. Cardiopulmonary
surgeon can then determine proper location for port bypass with cardioplegia administration into the aortic
access, which may vary according to a patient’s body root is used to arrest the heart. Methods of cardiopul-
habitus. monary bypass using endovascular clamping are
After the right femoral vessels are exposed and left- described in “Coronary Artery Bypass Grafting.” Dogan
sided, single-lung ventilation is established, a right-sided and coworkers29 reported the first successful closed-chest
mini-thoracotomy incision is made. The heart is exposed closure of an atrial septal defect.
after a pericardial opening is made. The pericardium is
anchored open to the chest wall by two percutaneous Internal Mammary Artery Harvest
stay sutures. After the patient is heparinized based on an
activated clot time (ACT)–guided protocol, the femoral Patients are monitored in the usual way for cardiac
vein and artery are cannulated in anticipation of femoral- surgery. A central venous line and a radial artery cannula
femoral cardiopulmonary bypass. First, the femoral vein are placed on the same side as the harvested internal
is cannulated, and a 21-Fr cannula is placed over a mammary artery. There is a mandate for single-lung ven-
guidewire and passed into the IVC-RA junction with the tilation with a double-lumen tube, a Univent tube, or
aid of TEE. One end hole and 12 side holes resist collapse bronchial blocker, the position of which is confirmed by
under the high negative pressure that is created by bronchoscopy. The patient is positioned supine, with the
augmented venous return pumps. Likewise, the femoral thorax rotated 20 degrees by placing a roll under the left
artery is cannulated with a 24-Fr cannula, and car- scapula. External defibrillation and pacing pads are
diopulmonary bypass is initiated with venous drainage applied to the left posterior chest and anterolateral right
from the femoral and jugular veins. Anterograde and chest. Raising the left arm provides more exposure and
retrograde cardioplegia cannulas are placed. Some surgi- thins the skin overlying the left anterolateral chest. The
cal teams prefer to cannulate the ascending aorta using a opposite can be done to the right chest when harvesting
Heartport Straight-shot.48 A transthoracic aortic cross- only the right internal mammary artery. Carbon dioxide
clamp is passed percutaneously through the right axilla insufflation is needed to provide exposure and counter-
and applied to the ascending aorta. The robotic arms traction. Carbon dioxide insufflation (5 to 10 mm Hg)
are engaged through their respective trocars lateral to into the left hemithorax pushes the mediastinal fat pad
the mini-thoracotomy incision while the camera arm medially and enlarges the space between the sternum
passes directly through the thoracotomy incision. The and heart to a small extent to provide a better view.
left atrium can be entered for mitral valve repair or When harvesting both internal mammary arteries, insuf-
replacement. flation of the left hemithorax is sufficient to expose the
Before terminating cardiopulmonary bypass, TEE is right internal mammary artery because of the leftward
used to evaluate the function of the mitral valve, residual position of the heart49 and the improved angle of sight.
valvular regurgitation and to confirm the disappearance Insufflation is begun in increments of 2 to 4 mm Hg. The
of intracardiac air. The anterior leaflet of the mitral valve insufflation flow rate is adjusted automatically to achieve
is further inspected for systolic anterior motion. a preset intrathoracic pressure limit. Caution should be
Patient selection is important for optimal results. exercised when insufflating the thorax in patients who
Table 66-2 lists the risk factors that make patients unsuit- have poor left ventricular function or are hypovolemic
able candidates for robotic mitral valve surgery. (central venous pressure <5 mm Hg). Patients should
have their volume status repleated before proceeding to
Atrial Septal Defect Repair full insufflation. Carbon dioxide insufflation and one-
lung ventilation increases central venous pressure and
Operations for atrial septal defects are similar to those for pulmonary artery pressure by a small amount.50 Bilateral
mitral valve repairs, except that a mini-thoracotomy is pneumothoraces are deliberately produced when doing
not required. A closed-chest procedure is possible. Like all bilateral internal mammary artery harvest. Most patients
robotic procedures that demand entrance into the thoracic studied tolerate small bilateral pneumothoraces well for
cavity, single-lung ventilation must be instituted during periods less than 1 hour.51 Table 66-3 lists patient criteria
surgery. Atrial septal defect repairs also require opening the to be avoided when attempting a robotically assisted
heart and preventing any blood from entering the heart. approach to surgery.
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Chapter 66 — Anesthesia for Robotic Surgery 9

Table 66–3 Exclusion criteria for robotically assisted confirming catheter placement. Pulmonary artery
endoscopic coronary artery bypass grafting catheters are judiciously used in the appropriate patient
population, but the data that the catheter provide may be
Contraindication to one lung ventilation redundant when TEE data are available. The patient is
Age older than 80 years positioned the same as for internal mammary artery take-
Ejection fraction higher than 40% down, and trocar positions are placed as depicted in
Severe noncardiac health issues Figure 66-8.
Severe peripheral vascular disease When cardiopulmonary bypass is anticipated, the left
Myocardial infarction for more than 7 days femoral artery is cannulated with a 17- or 21-Fr Remote
Previous thoracic surgery, pleural adhesions, Access Perfusion (RAP) catheter (Fig. 66-9) with an aortic
or emergency surgery occlusion balloon. Exclusion criteria for endovascular
Calcified left anterior descending artery or diffuse disease cardiopulmonary bypass are contained in Table 66-4.
Intramyocardial left anterior descending artery This catheter allows anterograde flow of 4 or 5 L/min,
Morbid obesity, with a body mass index of more than 32 respectively. The cannula has a separate lumen for deliv-
Large heart within the left chest ering 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
Coronary Artery Bypass Grafting inflated with a volume equal to the diameter (in milli-
liters) of the sinotubular junction of the aorta. A balloon
All patients are evaluated preoperatively by TEE to pressure above 300 mm Hg usually provides complete
exclude the possibility of persistent left SVC or patent occlusion of the aorta.32 Residual flow around the bal-
foramen ovale. Table 66-3 lists the major exclusion crite- loon can be seen and monitored with color flow on TEE.
ria for robotic coronary artery bypass grafting. The iliac The use of bilateral radial artery lines is useful in detect-
and femoral arteries should also be evaluated for their ing the migration of the occlusion balloon toward the
size by echo Doppler ultrasonography.30 innominate artery. Proximal migration of the balloon
Patients are prepared and monitored for anesthesia in can most easily be seen with TEE, preventing balloon her-
a manner similar to that for mitral valve surgery (see niation through the aortic valve.
“Mitral Valve Repair”). Monitoring of the right radial After full cannulation and being poised for cardiopul-
artery pressure tracing is imperative when using an monary bypass, the right lung is allowed to collapse, and
endovascular balloon-occlusion catheter. After the patient left lung ventilation is begun. The ventilator is adjusted
is asleep, inspired oxygen tension and expired carbon to provide an end-tidal carbon dioxide pressure of 35 to
dioxide are monitored. TEE is used routinely as the stan- 40 mm Hg. Ports can be safely placed after the right-sided
dard of care for determination of cardiac function and for pneumothorax has formed. Carbon dioxide is insufflated

Figure 66–8 Incision ports for

coronary artery bypass grafting.
Trocars are place in the third, sixth,
and eighth intercostal spaces.
Similar port positions are used for
bilateral internal mammary artery
dissection.
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10 Section IV — Subspecialty Management

Figure 66–10 Ultrasound image of the Remote Access Perfusion

Figure 66–9 Remote Access Perfusion (RAP) catheter (Estech (Estech Systems, Inc., Plano, TX) catheter balloon in situ.
Systems, Inc., Plano, TX). The endovascular catheter has a Transesophageal echocardiography allows the anesthesiologist
cylindrical balloon for endovascular aortic clamping. The catheter to keep track of migration of the catheter balloon. The balloon
provides anterograde perfusion of the aortic arch at a rate of should be positioned in the ascending aorta 2 to 4 cm distal to
5 L/min and cardioplegia administration to the aortic root. the aortic valve. Right radial pressure catheter dampening can
detect balloon malposition when occlusion of the innominate
artery occurs.

into the right hemithorax and continued at a pressure

of 5 to 10 mm Hg. This allows the affected lung to col-
lapse further and provides a larger visual field. It may also
prevent mediastinal shifts during one-lung ventilation devices have made beating-heart surgery commonplace
when large tidal volumes are used, such as in a patient with conventional sternotomy, and miniaturization of
with emphysematous lungs. Insufflation to produce a the stabilization devices have allowed their use in closed-
deliberate pneumothorax is not very effective at raising chest, robot-assisted surgery.58 Problems do exist and
the sternum above the anterior surface of the heart. For need to be overcome. Because tactile sensation or palpa-
this reason, some surgeons provide sternal lift retractors tion is not possible in closed-chest surgery, intramyocar-
to increase the retrosternal space and provide better dial arteries or vessels that are hidden under epicardial fat
exposure.52 are elusive. Internal thoracic arteries can also be less than
Robot-assisted, beating-heart coronary artery bypass superficial, adding to the problem. The proposed target
grafting can be accomplished with appropriate patient site may contain plaque or heavy calcification that may
selection. Articulating stabilizers passed through a subx- make the anastomosis difficult and inferior. Epicardial
iphoid port can stabilize the anterior surface of the heart ultrasound imaging could possibly circumvent poor tar-
to facilitate grafting.53 Bilateral internal mammary artery get sites and has been shown with the help of Doppler to
grafting has also been accomplished.54 locate the course of intramyocardial coronaries and arter-
ies hidden by epicardial fat.59
Future Directions Visualization systems are being developed that will
improve surgery on the beating heart. Advances in
Computer-assisted surgery has made it possible to per- motion gating technology will allow the heart to appear
form total endoscopic coronary artery bypass grafting on as if it is standing still. A properly timed strobe light that
the arrested heart.39-41 The interests in avoiding the mor- is synchronized with the heart rate will achieve the
bidity of cardiopulmonary bypass and performing coro- proper virtual image of a heart standing still or of virtual
nary artery bypass grafting on the beating heart have stillness.2
shown it to be applicable.52-57 Various stabilization

THORACIC SURGERY

Table 66–4 Contraindication for endovascular Background

cardiopulmonary bypass system
Thoracic surgery has incorporated video assistance thora-
Major vascular disease of the ileac, femoral, and abdominal
coscopy (VATS) as a standard of care when it is practical.
aorta found by Doppler ultrasound
A large thoracotomy incision may still be required for a
Severe atherosclerosis
complete pneumonectomy, although the thoracotomy
Aortic diameter greater than 4 cm
incision increases stress and morbidity. The use of tho-
Moderate to severe aortic valve incompetence
racic epidural analgesia is the standard of care for such
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Chapter 66 — Anesthesia for Robotic Surgery 11

large thoracic incisions. Robotic assistance for thoracic Three fiducial markers are required to define any point in
surgery may provide better patient outcomes, but studies three-dimensional space. A fourth is placed for redun-
are needed to prove their potential benefit. Selection cri- dancy in case one moves. These fiducial markers are fixed
teria for performing lung tumor resection using robotic to bony landmark laminae or facets and have a fixed rela-
assistance include lung lesions smaller than 5 cm in tionship with the bone in which they are implanted.
diameter, stage I status for primary lung carcinoma, no They allow accurate localization for stereotactic radio-
chest wall involvement, absence of pleural adhesions, surgery.
and clearly distinguishable interlobar fissures. The
da Vinci Robotic Surgical System was the first telemanip-
ulator system used.60 For this procedure, tactile sensation UROLOGIC SURGERY
is minimal, and it is often difficult to feel pulmonary
nodules that are not visible on the surface. This drawback Transurethral Resection of the Prostate
may require making a port large enough for finger inser-
tion to palpate the tumor. In 1995, Nathan and Wickham63 published their results
of a coring device used to assist in transurethral resection
Esophagectomy of the prostate (TURP). Traditionally, a resectoscope con-
taining a cutting tungsten wire at its distal end is inserted
Esophagectomy can be performed through a transhiatal into the urethra. As energy passes through the tungsten
approach or a traditional three-point approach. wire, it cuts into prostate tissue. Continuous flow of non-
Traditional esophageal dissections have started to take electrolytic solution is required to promote visibility.
advantage of robotic interventions. Traditional Coagulation electrocautery helps in hemostasis but may
esophagectomy is performed in three phases: abdominal, prolong the procedure. Unfortunately, prolonged resec-
thoracotomy, and cervical. The patient is initially in a tions lead to resorption of this fluid and produce dilution
supine position for the abdominal and cervical dissec- hyponatremia.
tion, followed by a left lateral decubitus position for the The Puma robot has been used to resect prostate tissue
thoracotomy.61 Robotically assisted surgery has replaced safely.64 The safety of the device is derived from a steel
the traditional thoracotomy phase with robotic circular frame that restricts and confines the robot to a
esophageal dissection. With the use of small trocar inci- precise arc of resection. The frame acts as a safety fixture
sions, the patient can avoid the stress of a thoracotomy. that prevents the surgeon from resecting outside the
Although the robotic surgery appears to be less painful, a bounds of the frame. Information about the size of the
thoracic epidural block for postoperative pain relief is prostate is obtained from an operative transurethral
beneficial. 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
NEUROSURGERY gland volume, are programmed into a computer for
reference.65 Such procedures can be done more quickly
Background by the robotic instrument, and because hemostasis is
done only once at the end of the procedure, there is less
From the late 1980s to 1993, neurosurgeons investigated time for absorption of irrigation fluid.
the use of robots to precisely position resection probes
and devices within neural parenchyma to provide mini- Radical Prostatectomy
mal invasive surgery and to protect normal tissue.
Stereotactic navigation during neurosurgery surgery has Guillonneau and Vallancien66 were the first to show the
provided an image-guided system for real-time tracking feasibility and efficacy of laparoscopic radical prostatec-
of surgical instrument tips. tomy. Several centers have shown the feasibility of a
robotically assisted prostatectomy.67,68
Radiosurgery of Spinal Lesions
Anesthetic Implications
Spinal vascular malformations and spinal tumors have
been treated with the use of image-guided frameless Patients are monitored with routine care. After inducing
stereotactic radiosurgery.62 Precise delivery of high-dose anesthesia, an arterial line may be placed for frequent
radiation limits the dose that would be delivered to nor- phlebotomy. An additional, large-bore intravenous line
mal adjacent tissue and improves morbidity. may be considered when the potential for large blood
Cervical vertebrae can be imaged clearly by x-ray cam- losses are foreseen. The patient is positioned in a supine
eras, and lesions are referenced to CT images. The tho- lithotomy position with 30 degrees of Trendelenburg
racic and lumbar areas have denser bodies that are more incline. The thighs are spread far enough apart to allow
difficult to image and provide poor contrast with sur- the approach of the robotic system between them.
rounding tissue. To overcome this limitation, additional Patients shorter than 6 feet are not placed in a lithotomy
radiographic landmarks are implanted percutaneously. position and have their legs in a frog-leg position. The
Implantation of fiducial markers can be done in the oper- prolonged Trendelenburg position may be relatively con-
ating room under conscious sedation. These fiducial mark- traindicated in patients with history of stroke or cerebral
ers are placed percutaneously under fluoroscopic guidance. aneurysm. Because of the long procedure, silicone gel pads
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12 Section IV — Subspecialty Management

are placed at every pressure point. Some surgeons more accurate than is achieved by manual methods.73
advocate tucking the patient’s arms while the patient is The robot gets its visual or coordinate cues from image-
awake to maintain optimal comfort and avoidance of based information such as MRI or CT. The accurate regis-
neurapraxia.69 After a 14-Fr Foley catheter is inserted, the tration of the femoral coordinates in three-dimensional
body is prepared and draped. A pneumoperitoneum is space is essential for precise bone milling of the femoral
created through an umbilical puncture needle, and the canal so that it can accommodate the surgical implant.
maximum pressure is set to 15 mm Hg. The trocar is Titanium pins are placed in the femoral condyles and the
inserted according to the standardized Heilbronn greater trochanter. The patient’s leg is then imaged by CT,
approach using a semilunar five-trocar arrangement, and three-dimensional information about the femoral
with a sixth in the suprapubic area.70 A procedure with bone and registration pins is recorded in a computer.
some modification of the Montsouris technique is used.69 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
GYNECOLOGIC SURGERY rigidly clamped and secured by the robot fixator. The
robot is allowed to recognize the three titanium registra-
Background tion pins and compares their location relative to the data
obtained from CT. In this manner, the robot has a perfect
Laparoscopic surgery is also finding robotically assisted sense of where the femur lies in three-dimensional space
procedures an improvement. Microsurgical techniques and can perform precise milling of the femoral canal. The
have benefited the most from the robotic scaling and remainder of the surgery proceeds manually.
tremor filtration. Several groups have applied robotic The ROBODOC-treated patients showed fewer gaps
assistance to fallopian tubal anastomoses71,72 after sterili- between the prosthesis and bone, and no intraoperative
zation or tubal ligation. In the future, vasectomy rever- femoral fractures occurred.74 The overall complication
sals may also be done more precisely with the aid of rate in one study was reduced to 11.6%.75
robotics. Hip dislocation after hip arthroplasty is the most com-
mon postoperative complication, with a rate of 1% to
Anesthetic Implications 5%.76 To surmount this complication, the HipNav system
is being developed. The system has a range-of-motion sim-
After induction of general anesthesia, the patient is ulator, a preoperative planner, and an intraoperative track-
positioned in a modified dorsal lithotomy with ing and guidance control. This system can optimize
Trendelenburg position. The thighs are abducted slightly acetabular orientation for a “best-fit” prosthetic implant.77
for vaginal access to manipulate the uterus. A pneu-
Knee Replacement
moperitoneum is created with carbon dioxide insuffla-
tion. Patency of the anastomosis is assessed with
Most total-knee replacements depend on a jig system to
injection of methylene blue dye through the uterine
guide bone sawing. The placement of the jig is based on
chromopertubator.
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
ORTHOPEDIC SURGERY approaches are used.78 Displacements as small as 2.5 mm
can produce a 20-degree alteration in the range of
Total Hip Arthroplasty motion of a joint.
Robotic surgical assistants have been developed to
In 1992, Paul, a veterinarian who worked in collabora- increase the accuracy of prosthetic joint alignment. For
tion with IBM, developed a robotic system that could be the robot to recognize specific landmarks, the pelvis and
used for hip replacement in dogs. The research collabora- the ankle must be fixed to the surgical table. Osseous
tion resulted in the first surgical robot—ROBODOC. This material is less likely to deform under pressure and can
was the first medical application, and it started with keep its shape.
orthopedic surgery. In this procedure, the femoral
implant is place into an axial canal of the proximal shaft
of the femur. The femoral component can be glued or OPHTHALMOLOGIC SURGERY
pressed in to the femoral shaft as a tight fit. Long-term
radiographs of after hip replacement surgery have shown The challenge of creating a robot that is accurate and has
that adhesives are prone to cracking, loosening, and pro- an extremely high level of dexterity and precision was
ducing osteolysis that leads to surgical failure of the pros- mandated for laser retinal surgery. Because blood vessels
thetic hip. Modern femoral implants have a porous in the retina are only 25 µm apart, high precision is
surface that allows for bone growth into the surface, pro- necessary. Collaboration between Stephen Charles and
moting better hip longevity. For this reason, a tight fit of the NASA Jet Propulsion Laboratory developed a Robot-
the implant into the femoral canal is essential. The for- Assisted Microsurgery System (RAMS).79 It is capable of
mation of this femoral canal is created with higher preci- performing laser microsurgery with 10-µm accuracy. The
sion by a robot than by the visual cues that are used in unaided human eye can discern an increment of only
the manual method. The cavity it creates is 10 times 200 µm. RAMS provides a 200-Hz gating system for eye
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Chapter 66 — Anesthesia for Robotic Surgery 13

tracking, and it eliminates the saccades of the eye, allow-

ing the eye to appear perfectly still to the observer. The 2. Robotically assisted surgery involves mechanical
system also provides a 100:1 scaling that allows for devices that move by a motorized system under par-
10-µm incremental movements. Tremor is filtered out tially programmed control and that can be instantly
between 8 and 14 Hz to eliminate inaccuracy. The ability controlled or modified by a surgeon’s intervention.
to work at such small scales is the robot’s strength. Newer 3. Computer-assisted surgery involves systems that are
robotic devices intended for microsurgical application manually controlled by the surgeon and that include
have an accuracy of 5 µm.80 Riviere and Jensen81 were a tracking system, sensors, and end-effector instru-
able to cannulate a retinal vein to administer therapy for ments. This system provides direct and continuous
retinal vein thrombosis. This would not be conceivable control of movements.
without the dexterity of robotic technology. 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
SUMMARY produce precise instrument movements at a distance
from a remote location.
The use of robots in surgery is likely to increase because 6. Telepresence refers to virtual projection of images
of its enhanced precision and control. Its minimally inva- from remote sites. This allows the surgeon to visual-
sive nature is better tolerated in terms of reducing the ize intended robotic movements at distant locations.
stress response, overall pain, tissue trauma, and length of It also enables telementoring, which is supervision
hospital stays, as well as hastening recovery from surgery and instruction from a distant location.
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
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