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Robotic Surgery–Anaesthetic Considerations
Robotic platforms (e.g., da Vinci Xi®, Versius®) combine 3-D vision, articulated instruments and tremor-filtering to reproduce open-surgery dexterity through keyholes. Anaesthetic management therefore merges laparoscopic physiology with long procedures in extreme positions and limited patient access.
Benefits Compared with Conventional Laparoscopy
- Smaller or hidden incisions → lower wound-related complications and better cosmesis.
- Greater instrument dexterity and stable magnified vision → higher lymph-node yield, lower positive-margin rates in oncological series.
- Reduced conversion, blood loss and length of stay (1–2 days shorter in several 2020-24 meta-analyses).
- Ergonomic advantages for the surgeon, though at increased capital and maintenance cost.
Peri-operative Challenges
| Area | Key issues | Mitigation |
|---|---|---|
| Ergonomics & access | Patient surrounded by bulky arms; anaesthetist > 2 m away; lines under drapes. | Extend breathing circuit & IV extensions; mount stop-cocks and depth-of-anaesthesia cables at the head; ensure emergency undocking drill rehearsed. |
| Pneumoperitoneum (CO₂ 10–15 mm Hg) | ↑ HR/SVR, ↓ venous return; CO₂ absorption → hypercapnia, arrhythmias. | Pressure ≤ 12 mm Hg where possible; pressure-controlled ventilation, VT 6–8 mL kg⁻¹, moderate PEEP; ABG after 30 min. |
| Steep Trendelenburg (30–45°) | ↑ intracranial/intra-ocular pressure (IOP > 30 mm Hg after 3 h recorded), facial & airway oedema, brachial plexus stretch, raised intra-gastric pressure (risk of regurgitation). | Secure shoulders without shoulder braces; padded cross-chest strap; pressure-area care; check cuff-leak before extubation; head-up for 5 min before reversal. |
| Respiratory mechanics | ↓ FRC, compliance; ↑ peak pressures. | Volume-controlled ventilation with pressure limit; recruitment manoeuvres q 30 min. |
| Renal & splanchnic perfusion | ↓ renal blood flow; oliguria. | Goal-directed fluid (stroke-volume or PPV) and vasopressor rather than liberal crystalloid. |
| Long immobility | Risk of VTE, rhabdomyolysis, nerve injury. | LMWH within 6 h post-op, sequential compression, pressure-relieving foam, hourly flap-to-flap padding checks. |
Anaesthetic Management
Pre-operative
- Thorough cardiorespiratory assessment; optimise COPD, heart failure, uncontrolled hypertension, obesity.
- Document pre-existing eye disease (glaucoma), intracranial pathology, renal dysfunction.
- Explain prolonged immobilisation and post-op shoulder discomfort.
- Consent high-risk patients for possible postoperative ventilation.
Induction & Airway
| Simple robotic pelvic/abdominal cases | Complex or > 4 h Trendelenburg / thoracic |
|---|---|
| Rapid-sequence induction, ETT (RAE or reinforced) ± video-laryngoscopy. | Fibre-optic or video-scope as needed; consider 37-cm insertion to avoid tube migration. |
- Check eye protection; apply ophthalmic lubricant and transparent film.
- Tape ETT securely; re-confirm bilateral breath sounds after docking.
Maintenance
- General anaesthesia with volatile or propofol-TIVA; TIVA marginally limits IOP rise but evidence of outcome benefit is lacking.
- Deep neuromuscular blockade (post-tetanic count 1–2) improves surgical workspace and may reduce postoperative pain; reverse with sugammadex 4 mg kg⁻¹.
- Ventilation: VT 6–8 mL kg⁻¹, PEEP 5-8 cmH₂O, EtCO₂ 35-45 mm Hg; adjust for permissive hypercapnia if cardiovascularly tolerated.
- Monitor invasive BP for procedures > 3 h, ASA ≥ III or expected blood loss. Trendelenburg exaggerates cyclical MAP swings–damp arterial line and alarms.
- Restrictive, goal-directed crystalloid (≤ 3 mL kg⁻¹ h⁻¹) plus norepinephrine 0.02-0.08 µg kg⁻¹ min⁻¹ maintains perfusion without facial oedema.
Analgesia & PONV
| Technique | Evidence & typical dose | Comments |
|---|---|---|
| Intrathecal morphine ± bupivacaine (ITM 200-300 µg) | RCTs in robotic prostatectomy show 30-40 % lower 24-h opioid use and better QoR-15 scores without excess respiratory depression. | Place 30-60 min pre-induction; monitor respiration for 12 h. |
| Port infiltration (ropivacaine 0.25 %, 3-5 mg kg⁻¹) | Reduces early Was by 1-2 points. | Easy, minimal risk. |
| Rectus sheath/TAP block | Effective for multi-quadrant incisions. | Ultrasound guidance advantageous. |
Multimodal baseline: paracetamol 1 g 6-hourly, COX-2 inhibitor if eGFR > 60 mL min⁻¹. Use dual PONV prophylaxis (dexamethasone + ondansetron); add aprepitant for female, non-smoker, opioid use > 2 mg kg morphine equivalent.
Emergence & Extubation
- Return table to supine; empty stomach with orogastric tube; perform cuff-leak test.
- Delay extubation if cuff leak < 110 mL or face/airway oedema obvious; consider overnight ventilation.
- Head-up 20–30° during recovery; monitor urine output (oliguria often resolves within 6 h)
Post-operative
- Early mobilisation, incentive spirometry and shoulder physiotherapy from day 0.
- LMWH once haemostasis secure; continue 28 days for pelvic oncological cases.
- Observe high-risk eyes for visual disturbance; ophthalmology review if pain or vision loss.
Special Situations
| Scenario | Additional consideration |
|---|---|
| Robotic-assisted radical prostatectomy | Combined low-dose spinal (8 mg 0.5 % bupivacaine + 200 µg morphine) with GA facilitates fast-track discharge and opioid-sparing; ensure early voiding trial. |
| Elderly (> 75 y) | Frailty scoring, cerebral oximetry, strict avoidance of hypotension and anticholinergic agents to reduce delirium. |
| Pregnancy (second trimester) | Pneumoperitoneum ≤ 10 mm Hg, left-tilt, EtCO₂ 30-32 mm Hg, foetal heart monitoring pre/post procedure. |
Links
References:
- Suryawanshi CM, Shah B, Khanna S, Ghodki P, Bhati K, Ashok KV. Anaesthetic management of robot-assisted laparoscopic surgery. Indian J Anaesth. 2023 Jan;67(1):117-122. doi: 10.4103/ija.ija_966_22. Epub 2023 Jan 21. PMID: 36970478; PMCID: PMC10034944.
- Lee, J. R. (2014). Anesthetic considerations for robotic surgery. Korean Journal of Anesthesiology, 66(1), 3. https://doi.org/10.4097/kjae.2014.66.1.3
- Suryawanshi CM, Shah B, Khanna S, et al. Anaesthetic management of robot-assisted laparoscopic surgery. Indian J Anaesth. 2023;67:117-122. journals.lww.com
- Shim JW, Cho YJ, Moon HW, et al. Intrathecal morphine-bupivacaine improves early analgesia after robotic prostatectomy: a randomised trial. BMC Urol. 2021;21:30. bmcurol.biomedcentral.com
- Bajaj JS, Sharma S, Mehta N, et al. Positive cuff-leak before extubation in robotic Trendelenburg surgery: frequency and risk factors. Indian J Surg Oncol. 2022;13:896-901. pubmed.ncbi.nlm.nih.gov
- Ripa M, Schipa C, Kopsacheilis N, et al. Impact of steep Trendelenburg on intra-ocular pressure. J Clin Med. 2022;11:2844. pmc.ncbi.nlm.nih.gov
- Liu S, He B, Deng L, et al. Deep neuromuscular blockade and peri-operative outcomes: systematic review and meta-analysis. PLoS One. 2023;18:e0282790. journals.plos.org
- Negrut RL, Cote A, Caus VA, et al. Robotic-assisted versus laparoscopic surgery for colon cancer: outcomes 2020–24. Cancers (Basel). 2024;16:1552. mdpi.com
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