Anesthesia for robotic surgery

1. Presented by-Dr.Aditya Kumar Kejriwal
JR-3 Department of Anesthesia
ROHILKHAND MEDICAL COLLEGE
HOSPITAL
BAREILLY
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2.  1. Robotic surgery is accomplished by an autonomous,
reprogrammable manipulator designed to move and
articulate specialized instruments through
programmed motions that achieve a specific task.
 A robot can be given three-dimensional coordinates
from any imaging device (e.g., computed tomography)
that allows it to recognize surfaces on which it will do a
specific, programmed task.
 2. Robotically assisted surgery involves mechanical
devices that move by a motorized system under
partially programmed control, and that can be instantly
controlled or modified by a surgeon's intervention.
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Introduction to Robotic Surgery

3.  3. Computer-assisted surgery involves systems that
are manually controlled by the surgeon, and that
include a tracking system, sensors, and end-effector
instruments. This system provides direct and
continuous control of movements.
 4. Telesurgery refers to the ability to perform surgery
using computer-assisted instruments from a remote
location.
 5. Telemanipulation refers to the ability to produce
electronically precise instrument movements at a
distance from a remote location.
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4.  6. Telepresence refers to virtual projection of images
from remote sites. This virtual projection allows the
surgeon to visualize intended robotic movements at
distant locations. It also enables telementoring, which
is supervision and instruction from a distant location.
 7. Initially, robotically assisted surgical thoracic
procedures increased the duration of required general
anesthesia.
 Concomitantly, the duration of one-lung ventilation has
been taken to new time extremes, which has given us
insight into the respiratory physiology of prolonged
one-lung ventilation.
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5.  As surgeons gain expertise with robotically assisted
surgery, operative times are expected to shorten
dramatically to approach those for traditional open
surgery.
• 8. Because of the proximity of the side cart to the
patient, the patient must be guarded against
inadvertent contact from the motions of the robotic
arms.
 Even more important, after the instruments are
engaged to the arms of the robot and are inside the
patient, the patient's body position cannot be modified
unless the instruments are disengaged entirely and
removed from the body cavity.
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6.  Robotic surgery is the resulting transformation of the
minimally invasive surgical evolution.
 Robotic devices are being introduced to surgery
because they allow unprecedented control and
precision of surgical instruments in minimally invasive
procedures.
 The anticipated benefits of robotic or robot-assisted
surgery to the patient include less pain and trauma,
shorter hospital stays, quicker recovery, and a better
cosmetic result.
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7.  First-generation surgical robots are being installed in
numerous operating rooms around the world. These are
not true autonomous robots that perform surgical
tasks; rather, they are mechanical “helping hands” that
offer assistance in various fields of surgery.
• These machines still require human intervention to
operate or to provide input instructions.
 Robotic devices are here to help surgeons, not to
replace them.
History
• The word robot was first used by Capek in his play
Rossum's Universal Robots in 1921. It is derived from the
Czech word robota, meaning “forced labor.”Robots were
first developed by theNASA for use in space exploration.7

8. Figure 76-1 Degrees of freedom (DOF) in motion. A, Conventional laparoscopic
instruments have only 4 DOF and grip. Insertion (i.e., movement in the z axis), roll,
and movement along the x and y axis outside the body relative to a fulcrum point
constitute the 4 DOF
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9. B, Depiction of the EndoWrist instrument with two added intracorporeal joints,
producing 7 DOF.
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10.  Engineers realized that the distance between patient
and surgeon had an upper limit, beyond which accuracy
and dexterity of instrument control would become
degraded.
 Latency is the time it takes to send an electric signal
from a hand motion to actual visualization of the hand
motion on a remote screen.
 The lag time to send an electric signal to a
geosynchronous satellite at 22,300 miles above the Earth
and return is 1.2 seconds.
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11.  This transmission delay would prohibit practical
surgery. Humans can compensate for delays of less than
200 msec. Longer delays compromise surgical accuracy.
 Tissue moves when force is applied to it, and with a
visual delay greater than 200 msec, the movement
would not be noticed fast enough to avoid cutting in an
unintended place.
 The most optimistic attempt to provide telesurgical
presence over long distances was undertaken using
high-bandwidth fiberoptic ground cable. The latency
time of 155 msec allowed to perform a robot-assisted
laparoscopic cholecystectomy between New York City
and Strausbourg, France, in 2001.
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12.  In 2003, a telerobotic surgical service was established
between a teaching hospital in Canada, and a
community hospital 250 miles away.
 This service was designed to provide telerobotic
assistance by an “expert” surgeon to a community-based
surgeon. Some of the procedures performed include
laparoscopic Nissen fundoplication, laparoscopic right
hemicolectomy, laparoscopic sigmoid/anterior
resection, and laparoscopic hernia repair.
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13.  The robots are preprogrammed off-line, and tasks are
invoked on command.
 Robots used in orthopedic surgery and neurosurgery
are examples.Precise tasks, such as drilling and probe
insertion, are based on registration.
 Registration is a mathematical process that allows
location and anatomic orientation in three dimensions
based on data derived from preoperative computed
tomography (CT) or magnetic resonance imaging
(MRI).
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14.  A second type of robot is defined as an assist device,
such as AESOP. These robots are used to control
instrument location and guidance. Assist-device robots
are not autonomous; they need input cues from the
operator.
 A third type of robot is a telemanipulator. These robots
are under constant control of the operator. These
devices mimic the operator's hand motions in an exact
or scaled motion.
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15.  Several telemanipulator robotic devices are available
throughout the world.
 The da Vinci Robotic Surgical System has been
approved by the U.S. Food and Drug Administration
(FDA) for laparoscopy, thoracoscopy, and intracardiac
mitral valve repair surgery, and the ZEUS Surgical
System has been developed in parallel and approved by
the FDA for general and laparoscopic surgery
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16. Figure - The da Vinci Robotic Surgical System: Surgical console, patient cart
with four mounted surgical arms, and an optical tower.
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17.  The da Vinci system has three components: a console,
an optical three-dimensional vision tower, and a
surgical cart.
 The surgical cart has four arms that can be manipulated
by the surgeon through real-time computer-assisted
control. The first two arms represent the surgeon's right
and left arms, to hold the instruments, and the third
arm positions the endoscope.
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18.  The optional fourth arm enables the surgeon to hold
another instrument or perform additional tasks, such
as holding countertraction and following running
sutures, eliminating the need for a patient-side
surgeon. The system allows the surgeon to be physically
remote from the patient
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19. Figure -Operating room schematic of the use of a robotic surgical system in cardiac
surgery. 19

20.  The system's instruments are designed to have 7 degrees
of freedom, which enables it to approach the identical
articulation of the human wrist . Seven degrees of
freedom include three arm movements (in out, up
down, side to side), and three wrist movements—yaw
(side to side, left and right), pitch (up and down), and
roll or rotational.
 The seventh degree of freedom is grasping or cutting.
The system design incorporates a frequency filter that
eliminates hand tremor greater than 6 Hz. Motion
scaling also can be invoked up to a ratio of 5 : 1 (i.e., the
surgeon moves 5 cm, and the robot moves 1 cm). Scaling
allows for work on a miniature scale.
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21.  The console also provides a three-dimensional image of
the surgical field. The endoscope consists of dual,
independent optical channels capable of transmitting
digital images to the console's visual monitor..
 At the console, the surgeon is actually looking at two
separate monitors; each eye sees through an
independent camera channel to create a virtual three-
dimensional stereoscopic image.
 The images are controlled through two independent
light sources found on the optical three-dimensional
vision tower
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22. Figure -The da Vinci Robotic Surgical System: Master controls that translate the
surgeon's hand, wrist, and finger movement into real-time movements of surgical
instruments inside the patient. 22

23. • The surgeon sits at the console and controls the
telescope arm and three robotic manipulator
arms. The viewing space provided is similar to a
double-eyepiece microscope .
• Each eyepiece displays a mirror reflection of a
computer monitor screen. Each monitor displays
one channel of the stereo endoscope to an eye,
creating a virtual three-dimensional stereoscopic
image of the surgical field.
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24. Figure -The da Vinci Robotic Surgical System: Stereo viewer that creates a virtual
three-dimensional stereoscopic image. 24

25.  The surgeon controls the manipulators with two
masters .
 The masters are made of levers that attach to index
fingers and thumbs of each hand. Wrist movements
replicate the movements of the instruments at the end
of the robotic arms.
 The console has a foot pedal that disengages the robotic
motions (i.e., clutching), another that allows
adjustment of the endoscopic camera, and a third pedal
for controlling the energy of electric cauterization.
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26. Figure -The EndoWrist instrument of the da Vinci Robotic Surgical System mimics
the natural kinematics of the surgeon's hand and wrist. This design allows 7 degrees
of freedom. 26

27.  The side cart of the robotic device has four arms that
respond to the manipulative controls of the surgeon
while sitting at the console. The cart is bulky and very
heavy.
 It has to be wheeled to the vicinity of the patient's
surgical area and is locked into place.
 Because of the proximity of the side cart to the patient,
the patient must be guarded against inadvertent
contact from the motions of the robotic arms.
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28.  Even more important, after the instruments are
engaged to the arms of the robot and inside the patient,
the patient's body position cannot be modified unless
the instruments are disengaged entirely and removed
from the body cavity.
• Any patient movement from lack of muscle relaxant
may be disastrous.
• The clutching buttons allow for the robotic arms to be
grossly positioned without moving the instruments
within the trocars or access ports. A clutching function
allows surgical assistants to exchange various
instruments. 28

29.  The optical tower contains the computer equipment
needed to integrate the left and right optical channels
to provide stereoscopic vision and to run the software
needed to control the kinematics of the robotic arms.
 The computer interfaces the translated motion of the
surgeon's hands to a digital code that moves mechanical
levers, motors, and cables that allow the robot to
articulate the exact motions of the surgeon's hand.
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30.  The instruments in the body cavity must remain sterile,
but interface with nonsterile robotic arms. Detachable
disposable instruments facilitate this interface.
 Each type of instrument requires different forces and
motion scaling intrinsic to the task at hand and
requires specific computer software processing.
Additional operating room staff is required for
detaching and exchanging task-specific instruments
throughout the case.
• Monitors are positioned on top of the tower so that all
individuals in the operating room have a view of the
surgical field.
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31.  An obstacle that still needs research is tactile sensing.
The feedback that the robot offers for the surgeon's
applied force is inferior. The robot offers some
sensation, 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 must rely
on visual cues from tissue distortion to gauge how much
pressure is being generated.
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32. General Surgery
 Procedures most commonly performed include
cholecystectomy, fundoplication, Heller myotomy,
bariatric surgery, and colectomy.
 Robotic surgery overcomes some of the disadvantages
of conventional laparoscopic procedures with three-
dimensional imaging, elimination of motion reversal,
motion scaling, and filtering of resting tremors, while
offering an ergonomically comfortable position.
.
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33.  Other reported apparent advantages of robotic
laparoscopic surgery are a short learning curve,better
quality of repair,and ease of operation in morbidly
obese patients because stiff instruments help
counteract abdominal wall torque.
 Robotic laparoscopic surgery also is associated with
high patient satisfaction
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34. Anesthetic Considerations
 In the operating room, the patient is monitored with an
electrocardiogram, pulse oximetry, axillary
temperature probe, and noninvasive blood pressure
cuff.
 Bilateral peripheral intravenous access is valuable
because the left upper extremity is not immediately
available during the surgery.
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35. • A standard induction and airway control with a tracheal
tube is appropriate. Anesthesia can be maintained with
a volatile agent. Many anaesthetists choose to run a
background infusion of remifentanil.
• Muscle relaxation —usually with a continuous infusion of
a non-depolarizing neuromuscular blocking agent is
of paramount importance in avoiding any movements
by the patient while the surgical instruments are within
the abdominal cavity.
• The position of the tracheal tube should be checked
regularly.
• An orogastric tube and a urinary bladder catheter are
placed. Convective-air body warmers are applied
whenever possible. 35

36. • With the patient in the supine position, the patient is
prepared and draped, and the abdominal cavity is
insufflated with carbon dioxide (CO2) to a pressure not
to exceed 20 mm Hg.
• The trocar for the camera is placed manually. The side
cart robot is brought very close to the patient's head to
engage the other trocars with visual guidance from the
robotic camera.
• Because of the proximity of the side cart to the patient's
head, there is limited access to the patient's airway and
neck, and the head must be guarded against
inadvertent collision with the robotic arms when
moving.
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37.  After the robot is engaged, the patient's body position
cannot be changed. 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 CO2, ventilator
adjustments may be required to normalize the exhaled
CO2.Some surgeons argue that the benefit of invasive
arterial monitoring does not outweigh the risks.
 This issue should be considered for each patient based
on a risk/benefit analysis.
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38. 1.Use FIO2= 1.0
2.Begin one-lung ventilation with pressure control
ventilation, maintaining a plateau pressure of <30 cm H2O
3.Adjust respiratory rate so that PaCO2 approaches
40 mm Hg
4.Check arterial blood gas pressure
Anaesthetic considerations in robot
assisted Cardiothoracic Surgery
One-Lung Ventilation Strategy
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39.  5.Apply continuous positive airway pressure to
nonventilated lung
 6.Apply positive end-expiratory pressure to ventilated
lung
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40. 40
Robotic Lap Chole Single Port

41. Da Vinci Robotic System
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42. Summary
 The use of robots in surgery is likely to increase because
of enhanced precision and control.
 Anesthesiologists need to be aware of this fast-
changing field and how it affects anesthetic techniques
and their delivery.
 The duration of one-lung ventilation has been taken to
new time extremes, which has given us insight into the
respiratory physiology of prolonged one-lung
ventilation.
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43.  Anesthesiologists have experienced working in
locations that are remote from the patient's airway.
Improved monitoring methods are needed to make
remote anesthesia safe and practical.
 Perhaps the “minimally invasive” revolution will
advocate earlier patient recovery and the increased
implementation of regional anesthetic techniques.
 The extent of the surgical stress response may be
attenuated, ultimately minimizing the inflammatory
response.
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44.  Preoperative diagnostic imaging in combination with
virtual reality simulators will allow the surgeon to
rehearse the complex procedures in advance and
program the robot to avoid any vital structures during
the surgery.
 Visualization systems are being developed that will
improve surgery on mobile structures, such as the
beating heart.
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45. Thank u
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