Perioperative complications of robotic surgery anesthetic concerns

Introduction Robotic assisted surgery (RAS) provides many advantages such as less pain, smaller incisions, decreased blood loss, shorter hospital stay, and greater precision, but it also comes with several complications, many of which impact anesthetic care. Over the past two decades, the number and indications for RAS have increased rapidly. In fact, most major medical centers incorporate this technology, meaning anesthesiologists must have an awareness and understanding of the difficulties that may occur. Problems arise mainly from positioning, creation of a pneumoperitoneum, and restricted access imposed by the robot. Positioning The most critical part of RAS is patient positioning, which should always be undertaken as a team effort with the surgeon physically present. Compared with other minimally invasive surgery approaches, RAS gives the surgeon better control over the surgical instruments and a better view of the surgical site but only if the patient is in the optimal position. Failure to achieve the appropriate angle results in tedious procedures and even compromise of patient outcome. Moreover, once the robotic arms are docked, little or no change in position can be made. Surgery in the pelvis and lower abdomen requires a steep Trendelenburg position. Although supine, the position of the robot severely limits access to the airway in head and neck surgery. Generally arms are tucked in the sides, restricting access to intravenous and monitoring devices such as pulse oximetry or arterial cannulae. Changing the table position from supine to Trendelenburg predisposes patients to sliding cephalad and even off the table. Various methods have been used including braces, leg suspension, and iliac supports. Shoulder braces and straps are also frequently used. All of these devices can result in nerve injury. An antiskid foam has been suggested as a means to decrease the incidence of neuropathic injury. But prevention requires first of all awareness of the possibility of injury and then meticulous attention to padding. Steep Trendelenburg position may cause facial, pharyngeal, and laryngeal edema associated with gravitational effects, amount of intravenous fluids given, and/or reduction of venous outflow due to pneumoperitoneum. Restricting fluid administration and reducing the time in the head-down position may limit this complication.