Vol. 80 – No. 1 MINERV A ANESTESIOLOGICA 83E X P E R T O P I N I O NAnno: 2014 [629464]

Vol. 80 – No. 1 MINERV A ANESTESIOLOGICA 83E X P E R T O P I N I O NAnno: 2014
Mese: JanuaryVolume: 80No: 1Rivista: MINERV A ANESTESIOLOGICACod Rivista: Minerva AnestesiolLavoro: titolo breve: Anesthetic complications of robotic thoracic surgery
primo autore: CAMPOS
pagine: 83-8

Minimally invasive surgery with the use of
the da Vinci® robot surgical system for
thoracic surgery of the lungs, mediastinum and esophagus is on the rise.
1-6 Therefore, the an-
esthesiologist must be familiar with the anes-thetic implications and potential complications that can occur with the use of evolving technol-ogy.
7-10 This review will focus on the potential
complications of robotic thoracic surgery involv-ing the lungs, mediastinum and esophagus.
The da Vinci® robot surgical system consists of
three major components: a console for the oper-ating surgeon, a patient-side cart with four inter-active robotic arms, and a vision cart including optical devices for the robotic camera. Figure 1 displays the da Vinci® robot surgical system with a console where the surgeon is seated. In the far back, the robotic unit (arm) is seen. The surgeon operates while seated at a console and views a 3D image of the surgical fields through the vi-sion system. The patient-side cart which is the actual robot unit consists of four robotic arms,
two or three instrument and one endoscope arm which houses the camera. A field range of EndoWrist (Intuitive Surgical) instruments are Update on anesthetic complications
of robotic thoracic surgery
J. CAMPOS, K. UEDA
Department of Anesthesia, University of Iowa Health Care, Iowa City, IA, USA
A B S T R A C T
In the last decade, there has been increasing use of the da Vinci® robot surgical system to perform minimally invasive
thoracic surgery. The robotic technology can be applied for surgery of the lungs, mediastinum, and esophagus. A number of case reports have been shown steep learning curve, and promising surgical outcome with this new technol-ogy. However, anesthesia management of the robotic thoracic surgery can be complex and requires further education. For example, most of the cases require sufficient lung collapse in order to provide adequate surgical field. In addition, a unique operative setting, such as patient positioning and capnothorax can make anesthesia management further challenging. Hence, anesthesiologists should have better awareness of adverse events or complications related to the robotic surgery to accomplish successful anesthesia management. This review will focus on the potential complica-tions of robotic thoracic surgery involving the lungs, mediastinum and esophagus. (Minerva Anestesiol 2014;80:83-8)
Key words:
R
obotics – Thoracic surgery – Surgical procedures, minimally invasive.
Figure 1.—da Vinci® Robot Surgical System with a console
where the surgeon is seated. The robotic unit (arm) is visible in the far back.
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CAMPOS ANE STHETIC CO MPLICATIONS OF RO BOTIC TH ORACIC SU RGER y
84 MINERV A ANESTESIOLOGICA Januar y 2014used to assist with the surgery. In practice the
first two arms, representing the surgeons left and right hands, hold the EndoWrist instruments; a third arm positions the endoscope. The surgical instruments are introduced via special ports and attached to the arms of the robot.
7
Anesthetic implications and potential
complications in thoracic surgical procedures
The basic principles applied for robotic-as-
sisted thoracic surgery includes: 1) patient po-sitioning (depending upon surgical procedure); 2) management of one-lung ventilation (OLV) techniques; and 3) carbon dioxide insufflation techniques. For thoracic surgical cases involving robotic techniques the preferred method for lung isolation is the use of left-sided double-lumen endotracheal tube (DLT) because of the greater margin of safety and reliable lung collapse. A dif-ferent alternative is the use of a single-lumen en-dotracheal tube and advancement of a bronchial blocker (i.e., Arndt, Cohen, Fuji blocker or E-Z blocker) into the bronchus where lung collapse takes place.
In general, careful attention must be given to
airway devices because changes in body position may be a potential for malposition of a device. In one report involving 34 cases scheduled for robotic lobectomy, one case had to be converted to open thoracotomy due to lack of lung isola-tion due probably to a malpositioned device.
11
Therefore, it is imperative that DLTs or bron-chial blockers are properly placed with fiberoptic bronchoscopy in supine, lateral decubitus posi-tion or when a malposition occurs.
12
Another potential surgical related complica-
tion is the potential to convert to an open proce-dure due to bleeding while robotic surgery takes place.
13 Major bleeding has been reported from
the pulmonary artery therefore during a robotic lobectomy the anesthesiologist must order blood and have available in the operating room in case of a conversion to open thoracotomy.
In a recent meta-analysis report Cao et al.,
1 it
was reported that the conversion rate for robotic video thoracoscopic surgery of the lung to open thoracotomy ranged from 0-19%. The effect of a steep learning curve for robotic video thora-coscopic surgery has been well documented. In fact, perioperative outcomes such as operating time and conversion rates have been shown to significantly improve after the initial learning period. One study by Veronesi, et al.
2 reported
that approximately twenty robotic thoracoscopy surgeries are required to obtain adequate skills. Therefore, anesthesiologists must consider this fact when participating in the care of robotic surgical cases while the surgeon is learning so mutual communication in case of potential bleeding occurs.
In general for robotic video thoracoscopic sur-
gery the patient’s bed is often turned 90
° from
the anesthesiologist. Quite often the head and hands are obscured by the robot, which makes access to them difficult after the robotic unit has been docked. Therefore, all vascular access and lung isolation devices must be secured properly before final patient positioning. In some cases, the head of the patient must be rotated to the side and either the DLT or a single-lumen tube with a bronchial blocker must be properly se-cured so no surgical interruptions because of malpositioned devices. In addition, in many ro-botic thoracic cases the patient is rotated onto the flank opposite to the lesion, with a slight splaying of the ribs with one of the arms up.
Another potential complication during ro-
botic video thoracoscopic surgery can be with the use of carbon dioxide (CO
2) used to facili-
tate surgical exposure while in the chest. The potential complications that we must be aware of include: venous gas embolism, venous return compromised, severe brachycardia or progres-sive arterial desaturation.
10 A study involving 20
patients undergoing thoracoscopic sympathec-tomy reported that in comparison to the left-side hemithorax, the impact of CO
2 insufflation
on the vena cava and the right atrium during right-sided procedures was associated with re-duction of venous return and low cardiac index and stroke volume.
14 In another study,15 it was
reported that a significant pressure-dependent increase in peak airway pressure and a decrease in dynamic lung compliance but no difference in tidal volume or minute ventilation.
Insufflation of CO
2 into the chest cavity
should start at low pressures of 4-5 mmHg and
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(either sporadically or systematically, either printed or electronic) of the Article for any purpose. It is not permitted to distribute the electronic copy of the article through online internet and/or intranet file sharing systems, electronic mailing or any other
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ANESTHETIC CO MPLICATIONS OF RO BOTIC TH ORACIC SU RGER y CA MPOS
Vol. 80 – No. 1 MINERV
A ANESTESIOLOGICA 85Robotic assisted mediastinal surgery
and potential complications
In a last decade, more than 30 case series of
mediastinal robotic surgery have been reported.
The majority of the cases in those series were surgery for disease of the thymus and lymphatic tissue. Also, ectopic thyroid, parathyroid glands and even posterior/inferior mediastinal pathol-ogy had been removed successfully with robotic surgery. When compared with non-robotic tho-racoscopic surgery, outcome was favorably in robotic surgery, specifically with thymectomy. gradually increase while monitoring the patient’s
vital signs. The use of intrathoracic pressure of more than 15 mmHg has not been reported in the literature and should be avoided because it increases the risk of cardiovascular collapse.
9
Ventilation during CO2 insufflation should be
titrated to keep adequate oxygenation and a nor-mal PCO
2 and pH. Anesthesiologists must be
aware that damage to the contralateral pleura may occur resulting in CO
2 flow to the contral-
ateral chest, making ventilation difficult, tension pneumothorax or severe subcutaneous emphy-sema producing a hemodynamic compromise.
Table I. —Mediastinal robotic surgery complications.
Author N. Diagnosis Complications
Rückert 16 74 Thymoma Conversion to sternotomy 1
Bleeding 1Phrenic nerve resection 1
Pandey
17 14 Thymoma Ventilatory difficulty– Capno thorax 2– others 2Hypotension/dysthymias 14Brachial plexus injury 1Hoarseness 1
Kajiwara
18, 19 3 Posterior mediastinal tumor 3
Pericardial cyst 4Thymoma 1Others 2Not reported
Melfi
20 69 Thymoma 39
Neurogenic tumor 13Pleuropericardial cyst 9Teratoma 3Others 2Conversion to open surgery 3General convulsions 1Pleural effusion 2Anemia 1Biliary colic 1
Schneiter
21 27 Thymoma No intraoperative complicationsSero-pneumothorax 1Supraventricular arrhythmias 1
Rea
22 108 Thymoma100
Neurogenic tumor 3Others 5No intraoperative complicationsChylothorax 1Hemothorax 2Fever 1
Freeman
23 75 Thymoma Superficial wound infection 2Pneumonia 1IMV injury 1
Cerfolio
24 153 Anterior mediastinal tumor 78
Inferior/posterior mediastinal pathology 75Conversion to thoracotomy 1Esophageal leak 1Atrial fibrillation 4Pneumothorax 2Gout 1Prolonged air leak 1
Goldstein
25 26 Thymoma Conversion to open surgery*IMA bleeding 2Flair of myasthenic symptoms 1Infected suture 1
IMV: internal mammary vein, * due to hypoxia during one-lung ventilation.
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CAMPOS ANE STHETIC CO MPLICATIONS OF RO BOTIC TH ORACIC SU RGER y
86 MINERV A ANESTESIOLOGICA Januar y 2014injury in an 18 year-old male after robotic as-
sisted thoracoscopic thymectomy. In this report, the left upper limb was in a slight hyperabduc-tion. It is important to keep in mind that hyper-abduction of the elevated arm to give optimal space to the operating arm of the robot can lead to a neurologic injury. All proper measures must be taken, including the use of soft padding and measure to avoid hyperabduction of the arm.
Robotic assisted esophagectomy
surgery and potential complications
The use of the daVinci® robot surgical system
has been used for thoracoscopic and transhiatal esophagectomy. The robot assisted technique fa-cilitates mobilization and chest anastomosis of the esophagus and completion of lymphoidecto-my. The rate of conversion from robot assisted to open procedure has been reported up to 15%.
26
Although the outcome of robotic assisted
minimally invasive esophagectomy compared to thoracic minimally invasive esophagectomy is comparable, one of the advantages of using robot technique is the reduced incidence of vocal cord paralysis. Three-dimensional image enhances identification of recurrent laryngeal nerve; there-fore, it could reduce the chance of damaging the nerve. Suda et al.
27 reported a reduced incidence
of vocal cord paralysis around 50%, when ro-Rückert et al.16 retrospectively compared the cu-
mulative complete remission rate of myasthenia
gravis for robotic with non-robotic thymectomy. They found robotic thymectomy had significant-ly higher complete remission rate after a follow-up of 42 months (39.3% versus 20.3%). Also,
complications were comparable between the groups. The procedure can be approached via
either left or right thorax and requires lung isola-tion. Notably, although majority of the reports showed few adverse events or complications, these could be under reported (Table I).
16-25
Pandey et al.17 prospectively collected periopera-
tive adverse events, including 17 patients dur-ing robotic assisted thoracoscopic thymectomy. They reported ventilation problems in 4 out of 17 patients during OLV. Two patients developed capnothorax in the ventilating side of thorax and two patients had increased peak airway pressure likely due to mechanical airway compression. Moreover, all the patients developed transient episode of intraoperative hypotension or dys-rhythmias. Therefore, monitoring hemodynam-ic and ventilation with vigilance is key factor for success of these complex procedures. Also, the patient positioning can be challenging. Particu-larly, special attention must be given to patient positioning with elevated arms or head to pre-vent crushing injuries with the robotic arms. A recent case report
17 showed a brachial plexus
Table II. —Robotic assisted esophagectomy complications.
Author N. Complications
Weksler 26 RAMIE 11
MIE 26Anastomosis leak 1 (RAMIE)
Supraventricular tachycardia 0 (RAMIE)
Vocal cord paresis/ paralysis 1 (RAMIE)
Pneumonia/atelectasis 1 (RAMIE)
Suda 27 RAMIE 16
MIE 20Vocal cord palsy 6 (RAMIE)
Anastomosis leak 6 (RAMIE)
Arrhythmia 2 (RAMIE)
Pneumonia 1 (RAMIE)
Dunn 28 RAMIE 40 Anastomosis leak 10
Recurrent laryngeal nerve injury 14
Pneumonia 8
Cerfolio 29 RAMIE 22 Anastomosis leak 1
Atrial fibrillation 1
Kim 31 RAMIE 21 Anastomosis leak 4
Vocal cord palsy 6
Bleeding 1
Atrial fibrillation 1
RAMIE: robotic-assisted minimally invasive esophagectomy (thoracoscopic); MIE: minimally invasive esophagectomy (thoracoscopic).
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use isnot permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo ,
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ANESTHETIC CO MPLICATIONS OF RO BOTIC TH ORACIC SU RGER y CA MPOS
Vol. 80 – No. 1 MINERV
A ANESTESIOLOGICA 87References
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R, Bianchi PP et al. Experience with robotic lobectomy for
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RJ, Bryant AS, Minnich DJ. Starting a robotic
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MA, Gao G, Furnary AP , Swanson J, Gately HL,
Handy JR. Application of robotic-assisted techniques to the surgical evaluation and treatment of the anterior mediasti-num. Ann Thorac Surg 2005;79:450-5.
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KH, DeArmond DT, Shamoun DM, Campos
JH. The first series of completely robotic esophagectomies with three-field lymphadenectomy: initial experience. Surg Endosc 2007;21:2285-92.
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Anesthesia for robotic thoracic surgery. In: Slin-
ger P , Blank RS, Campos JH, Cohen E, McRae K, editors. Principles and practice of anesthesia for thoracic surgery, 2011. p. 445-51. New
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pringer; 2011.
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aesthesia. Curr Opin Anaesthesiol 2010;23:1-6.
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Anaesthesia for robotic surgery: mediastinal
mass resection and pulmonary resections. Anaesthesia In-ternational 2011;19-22.
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11. Par
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12.
Campos JH.
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13.
Jang
HJ, Lee HS, Park S y, Z
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robot-assisted lobectomy experience to video-assisted tho-racic surgery lobectomy for lung cancer: a single-institution case series matching study. Innovations 2011;6:305-10.
14.
El-D
awlatly AA, Al-Dohayan A, Samarkandi A, Algahdam
F , Atef A. Right vs left side thoracoscopic sympathectomy: effects of CO2 insufflation on haemodynamics. Ann Chir Gynaecol 2001;90:206-8.botic assisted technique was used (6/38 versus
15/20) other reported complications include:
anastomosis leakage, bleeding, dysrhythmia and acute lung injury (Table II).
26-29
In order to facilitate robotic assisted thoracic
approach, right lung isolation is required with either a DLT or a bronchial blocker. A study by Choi et al.
30 showed no difference in respiratory
or hemodynamic variables during OLV between pressure-controlled and volume control ventila-tion. Nonetheless, it is essential to apply protec-tive ventilation strategies during OLV in order to minimalize postoperative respiratory compli-cations.
A recent report by Kim et al.
31 described 21
patients who underwent robotic assisted thora-coscopic esophagectomy performed in a prone position with the use of a Univent® bronchial blocker tube (Fuji Systems Corp, Tokyo, Japan). All thoracoscopic procedure were successfully completed with robotic assisted techniques fol-lowed by a cervical esophagogastrostomy. In Kim’s report, major complications included anastomotic leakage in 4 patients, vocal cord pa-ralysis in 6 patients and intraabdominal bleeding in 1 patient. Although, none of the patient de-veloped hemodynamic instability during surgery, the prone position led to an increase in central venous pressure and mean pulmonary arterial pressure and decrease in static lung compliance.
Conclusions
In summary, although robotic technology al-
lows performing thoracic surgery safely with less surgical complications, intraoperative hemody-namic compromise and/or hypoxemia can be a challenge. Anesthesiologists must be familiar with lung isolation techniques and aware of cap-nothorax effect for successful management of the operation, along with padding all extremities and proper flexion of 90
° in the extremities to
avoid nerve injury.
Key messages
—Anesthesiologists inv
olved in the
management of robotic assisted thoracic sur-gery must be familiar with the use of lung
isolation devices (double-lumen tube and/or bronchial blockers) and have skills in fiberoptic bronchoscopy to ensure complete lung collapse while surgery takes place.
—Be
aware of potential complications
with the use of carbon dioxide (CO2) to fa-
cilitate surgical exposure.
—Be
aware of potential conversion to
an open thoracotomy if robotic surgical ap-proach fails.
—Attention
must be given to the arms
to avoid nerve injury due to hyperextension.
COPYRIGHT© 2014 EDIZIONI MINERVA MEDICA
This document is protected by international copyright laws. No additional reproduction is authorized. It is permitted for personal use to download and save only one file and print only one copy of this Article. It is not permitted to make additional copies
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means which may allow access to the Article. The use of all or any part of the Article for any Commercial Use is not permitted. The creation of derivative works from the Article is not permitted. The production of reprints for personal or commercial use isnot permitted. It is not permitted to remove, cover, overlay, obscure, block, or change any copyright notices or terms of use which the Publisher may post on the Article. It is not permitted to frame or use framing techniques to enclose any trademark, logo ,
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