Millers Anesthesia - Sixth Edition_Chapter 66 - Anesthesia for Robotic Surgery_233

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Miller: Miller's Anesthesia, 6th ed., Copyright 2005 Elsevier

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Chapter 66 - Anesthesia for Robotic Surgery

Ervant V. NishanianBerend Mets

Robotic surgery is the resulting transformation of the minimally invasive surgical evolution. Roboticdevices are being introduced to surgery because they allow unprecedented control and precision ofsurgical 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. With these technologic innovations, new anesthetic implications forpatient care are being discovered. As surgery evolves into the robotic era, anesthesiologists mustkeep abreast of these changes and their impact on patient care and safety.

First-generation surgical robots are being installed in a number of 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 humanintervention to operate or to provide input instructions. Robotic devices are here to help surgeons,not to replace them.

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HISTORY

Robots were first developed by the National Aeronautics and Space Administration (NASA) for usein space exploration.[2] These devices, or telemanipulators, were capable of doing manual tasksaboard a spacecraft or out in space. The slave devices were controlled electronically from a remotemaster control on Earth or aboard a spacecraft. Telemanipulators were used extensively aboardNASA's Space Shuttle missions between 1983 and 1997. Research in trajectory and missile guidancesystems eventually led to highly precise targeting mechanisms. Precision pointing at targets, such asthe Earth and stars, was crucial for Spacelab telescope experiments. Telemanipulators such as theInstrument Pointing System (IPS) were specifically designed for extreme accuracy (1.2 arcsec).[3]Scientists at NASA Ames Research Center were responsible for developing virtual reality. The ideatook root with contributions of VPL, a visual programming language, and Dataglove.[4] Theirintegration made it possible to interact with three-dimensional virtual scenes. However, it took

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the integration of robotic engineering and virtual reality to develop a dexterous telemanipulator forthe anastomoses of nerves and vessels in hand surgery.[5]

From these applications, it became apparent to the U.S. Department of Defense that virtual realityand telepresence might serve a useful function in treating wartime casualties on the battlefield.Through virtual reality, the surgeon could be brought to the patient's side, an idea described by theterm telepresence. Data from wounded casualties of the Vietnam War estimated that, of all woundedsoldiers, one third died of head and massive injuries and another third died of exsanguinatinghemorrhage but had the potential to survive if they were treated in time.[2] The Department ofDefense sought to improve medical presence on the battlefield given that one third of casualties canbe saved. Telepresence allowed a surgeon located aboard an aircraft carrier to perform surgery (withthe aid of telemanipulation) on wounded soldiers located in a remote location on the battlefield. Withthis idea in mind, the Department of Defense funded much of the research in telemanipulation forremote mobile surgical units that would allow for telepresence.

Engineers realized that the distance between patient and surgeon had an upper limit, beyond whichaccuracy and dexterity of instrument control would suffer degradation.Latency is the time it takes to

send an electrical signal from a hand motion to actual visualization of the hand motion on a remotescreen. The lag time to send an electrical signal to a geosynchronous satellite at 22,300 miles abovethe earth and return is 1.2 seconds. This transmission delay would prohibit practical surgery.Humans can compensate for delays of less than 200 msec. Longer delays compromise surgicalaccuracy. 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 mostoptimistic attempt to provide telesurgical presence over long distances was undertaken using high-bandwidth fiberoptic ground cable. The latency time of 155 msec allowed Marescaux and Gagner[6][7] to perform a robotassisted laparoscopic cholecystectomy between New York City andStrousbourg, France.

Phillipe Mouret[8] performed the first video-laparoscopic cholecystectomy in Lyons, France, in 1987,but it was not until Perissat[9] presented the innovation to the Society of American GastrointestinalEndoscopic Surgeons in 1988 that an exponential spread of laparoscopic surgical procedures began.Although laparoscopic surgery provided a great benefit for the patient, it brought tremendoussurgical limitations, such as loss of three-dimensional vision, impaired touch sensation, and poor


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dexterity provided by the long instruments and the fulcrum effect. Thefulcrum effectis anonintuitive motion of the instrument tips in opposite direction about a fixed point, usually at theskin entrance site. New skills had to be learned. Initial attempts to surmount the burdens ofendoscopic surgery have provided the impetus for robotic support systems that can enhance surgicalskills and control of instruments. The first of such systems in the medical field was applied insurgical field camera guidance.

In 1994, the U.S. Food and Drug Administration (FDA) approved the first Automated EndoscopicSystem for Optimal Positioning (AESOP)[10] arm to be used in laparoscopic surgery. The device iscontrolled through voice activation to provide a flexible view of the surgical field. Around the sametime, the TISKA Endoarm became available, and it could act as a camera guided by electromagneticfriction and could work as a tissue retractor.[11] While foot pedals were being replaced by voice-activated systems, other manufacturers were designing cameras that moved in synchrony with themovements of the surgeon's head.[12] Other devices provided finger "joysticks" that could be used tocontrol the camera field.[13]

To combat dexterity problems, the master-slave telemanipulator concept was developed for medicaluse in the early 1990s. The first master-slave manipulator for medical use was developed at StanfordResearch Institute. The goal was to have computer algorithms that translate a surgeon's mastermanual movements to end-effector slave instruments at a remote site. The robotic slave arms mimicthe natural movements of the surgeon's hand. Early designs had only 4 degrees of freedom, but by1992, a German prototype was developed with 6 degrees of freedom ( Fig. 66-1 ).[14] It was usedexperimentally but never achieved clinical application.[15] In 1994, Intuitive Surgical obtainedtechnologic rights and eventually developed robotic instruments with 6 degrees of freedom.

Robots can be preprogrammed with limits set by the operator and run autonomously, or itskinematics can be completely defined online in real-time tracking when immediate humaninterventions and decisions are required. The design of surgical robots must include sterility barriers

and enhanced patient safety features. It must meet operating room constraints and be compatiblewith imaging equipment, as well as require special ergonomic features.

To overcome endoscopic surgery handicaps, engineering technology has developed three-dimensional video imaging, robot camera holders, and robotic flexible effector instruments with theability for tactile pressure sensation. Unfortunately, every instrument has different stress feedbackcharacteristics, and the surgeon's ability to "feel" the elastic properties of tissue are not yet fullydeveloped. The robotic fingers can be made smaller than those of the human hand to help reachconfined spaces. The robot can filter the surgeon's hand tremor and scale the movements of theinstruments to the level of high precision and stability that is required for microsurgery. Best of all

these advantages, repetitive robot motions and tasks are not prone to fatigue.




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ROBOTIC SYSTEMS

The wordrobotis a ubiquitous term that describes an autonomous device capable of various tasks.Industrial robots used in assembly lines perform highly precise, repetitive tasks. The robots arepreprogrammed off-line, and tasks are invoked on command. Robots used in orthopedic surgery andneurosurgery are examples.[16] Precise tasks such as drilling and probe insertion are based onregistration.Registration is a mathematical process that allows location and anatomic orientation in

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Figure 66-1 Degrees of freedom (DOFs) in motion. A, Conventional laparoscopic instruments have only 4 DOFs andgrip. Insertion (i.e., movement in thez axis), roll, and movement along thex andy axis outside the body relative to afulcrum point constitute the 4 DOFs. B, Depiction of the EndoWrist instrument with two added intracorporeal jointsproduce 6 DOFs along with grip. (A andB, 1999 Intuitive Surgical, Inc., Sunnyvale, CA.)

three dimensions based on data derived from preoperative computed tomography (CT) or magneticresonance imaging (MRI).

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 inputcues 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. There are severaltelemanipulator robotic devices available throughout the world. The da Vinci Robotic Surgical


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System ( Fig. 66-2 ) has been cleared by the FDA for laparoscopy, thoracoscopy, and intracardiacmitral valve repair surgery, and the ZEUS Surgical System ( Fig. 66-3 ) has been developed inparallel and cleared for sale by the FDA for general and laparoscopic surgery. The two systems arevery similar, with some minor differences. The da Vinci Robotic Surgical System is described in thischapter as a representation of most modern surgical robots.

The da Vinci system has three components: a console, an optical three-dimensional vision tower, and

a surgical cart. The surgical cart has three arms that can be manipulated by the surgeon through real-time computer-assisted control. One of the arms holds an endoscopic camera, and the other two aremanipulator or instrument-holding arms. The system allows the surgeon to be physically remotefrom the patient. The system's instruments are designed to have 6 degrees of freedom plus grasp,which enables it to approach the identical articulation of the human wrist ( Fig. 66-4 ). The systemdesign incorporates a frequency filter that eliminates hand tremor greater than 6 Hz.[17] Motionscaling can also be invoked up to a ratio of 5:1 (i.e., the surgeon moves 5 cm, and the robot moves 1cm). Scaling allows for work on a miniature scale. The console also provides a three-dimensionalimage of the surgical field. The endoscope consists of dual, independent optical channels capable oftransmitting digital images to the console's visual monitor. At the console, the surgeon is actuallylooking at two separate monitors; each eye sees through an independent

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Figure 66-2 The da Vinci System Surgeon console (A) and of the cart with three mounted surgical arms for holding thecamera and instruments (B). (A andB, 1999 Intuitive Surgical, Inc., Sunnyvale, CA.)

camera channel to create a virtual three-dimensional stereoscopic image. The images are controlledthrough two independent light sources found on the optical three-dimensional vision tower.

The surgeon sits at the console and controls the telescope arm and two robotic manipulator arms.

The surgeon has a viewing space that is similar to a double-eyepiece microscope. Each eyepiecedisplays a mirror reflection of a computer monitor screen. Each monitor displays one channel of thestereo endoscope to an eye, creating a virtual three-dimensional stereoscopic image of the surgicalfield.


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The surgeon controls the manipulators with two masters. The masters are made of levers that attachto index fingers and thumbs of each hand. Wrist movements replicate the movements of theinstruments at the end of the robotic

Figure 66-3A, The console of the ZEUS robotic telemanipulation system consists of a video monitor and twoinstrument handles that translate the surgeon's hand motions into an electrical signal that moves the robotic instruments.B, Two table-mounted AESOP arms hold instruments, and a third arm controls the camera. (Courtesy of ComputerMotion, Inc., Sunnyvale, CA.)

arms. The console has a foot pedal that disengages the robotic motions (i.e., clutching), another thatallows adjustment of the endoscopic camera, and a third pedal for controlling the energy of electrical

cauterization.

The side cart of the robotic device has three arms that respond to the manipulative controls of thesurgeon while sitting at the console. The cart is bulky and of tremendous weight. It requires wheelingto the vicinity of the patient's surgical area and is locked into place. Because of the proximity of theside cart to the patient, the patient must be guarded against inadvertent contact from the motions ofthe robotic arms. Even more important, after the instruments are engaged to the arms of the robotand inside the patient, the patient's body position cannot be modified unless the instruments aredisengaged entirely and removed from the body cavity.

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Figure 66-4 The EndoWrist instrument of the da Vinci System mimics the natural kinematics of the surgeon's hand andwrist. This design allows 6 degrees of freedom and grip. ( 1999 Intuitive Surgical, Inc., Sunnyvale, CA.)

Any patient movement from lack of muscle relaxant may be disastrous. The clutching buttons allowfor the robotic arms to be grossly positioned without moving the instruments within the trocars oraccess ports. A clutching function allows surgical assistants to exchange various instruments.

The optical tower contains the computer equipment needed to integrate the left and right opticalchannels to provide stereoscopic vision and to run the software needed to control the kinematics ofthe 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 exactmotions of the surgeon's hand.

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 differentforces and motion scaling intrinsic to the task at hand and requires specific computer softwareprocessing. Additional operating room staff is required for detaching and exchanging task specificinstruments throughout the case. Monitors are positioned on top of the tower so that all people in theoperating room have a view of the surgical field.

An obstacle that still needs research is tactile sensing. The feedback that the robot offers for thesurgeon's applied force is inferior. The robot offers some sensation, but the applied force does notcorrelate well with the force applied to the tissues. This correlation varies with the type of instrumentand depends on the torque applied; the operator therefore must rely on visual cues from tissuedistortion to gauge how much pressure is being generated.

The ZEUS Surgical System is another example of a master-slave telemanipulator. It employs theassistance of the AESOP Robotic System for visualization. It is basically one mechanical arm usedby the physician to position the endoscope, which is a surgical camera inserted into the patient. Footpedals or voice-activated software allow the physician to position the camera, leaving his or herhands free to continue operating on the patient. The manipulators of the ZEUS system are freelymounted on the operating table, much like the AESOP. It provides tremor filtering and motionscaling from 2:1 to 10:1.



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GENERAL SURGERY

Gastrointestinal Surgery

Robotic technology has declared itself in the field of gastrointestinal laparoscopic surgery.[18] Thefirst surgical operation using robotic telemanipulation was a laparoscopic cholecystectomyperformed in 1997 in Brussels, Belgium.[19] Two U.S. companies have FDA and European Unionapproval for clinical applications of their robotic systems for general surgery. Robot-assisted surgicaltechniques permit the surgeon to provide the smallest possible incision and lowest surgical stress.This technology allows surgeons to work on a very small scale in cramped spaces. Other proceduresperformed include splenectomy,[20] Heller myotomy, bowel resection pyloroplasty,[21] adrenalectomy,[22] and exploratory laparotomy, with antireflux surgery being the most common.[1]




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Nissen Fundoplication

Anesthetized patients are prepared and draped in the usual fashion, and the abdominal cavity isinsufflated with carbon dioxide gas. Three incision ports are made as shown in Figure 66-5 . Thefirst port is for the telescope trocar, which is placed 15 cm below the xiphoid process and slightly tothe left of midline. The robot arms are then inserted through trocars located 10 cm on either side ofthe telescope while under laparoscopic vision. Other auxiliary ports can be placed at any time duringthe operation. The side cart is wheeled and locked into place in anticipation of engaging theinstruments within their respective trocars. The system can be activated to manipulate the roboticarms under the surgeon's control. When a surgeon requires instruments to be changed, themanipulation is stopped, and the assistant surgeon at the table is asked to disengage and replace theinstrument.




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Anesthetic Considerations

In the operating room, the patient is monitored with an electrocardiographic (ECG) device, pulseoximetry, axillary temperature probe, and noninvasive blood pressure cuff.

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Figure 66-5 Numbered incision ports for Nissen fundoplication and location of the robotic arms.

Bilateral peripheral intravenous access is valuable because the left upper extremity is notimmediately available during the surgery. The patient is sedated with a mild sedative and preparedfor induction with oxygen. These patients usually have a history of gastroesophageal reflux and

require a rapid sequence induction with cricoid pressure applied. The trachea is intubated with asingle-lumen endotracheal tube, and its placement is confirmed by listening to the chest anddetecting carbon dioxide on expiration. Anesthesia can be maintained with a volatile agent. Musclerelaxation is paramount in avoiding any movements by the patient while the surgical instruments arewithin the abdominal cavity. An orogastric tube and a urinary bladder catheter are placed.Convective-air body warmers are applied whenever possible.

With the patient in the supine position, the patient is prepared and draped, and the abdominal cavityis insufflated with carbon dioxide to a pressure not to exceed 20 mm Hg.[23] The trocar for the camerais placed manually. 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 proximity of the side cartto the patient's head, there is limited access to the patient's airway and neck, and their head must beguarded against inadvertent collision by the movements of the robotic arms.[1][24] After the robot isengaged, the patient's body position cannot be changed. If the patient requires an increase in cardiacfilling pressures, and it cannot be provided by Trendelenburg's position, only after disengaging therobot is it possible. The surgical team should be capable of rapidly disengaging the robotic device if


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an airway or anesthesia emergency arises. As with any laparoscopic procedure that requires apneumoperitoneum pressurized with carbon dioxide, ventilator adjustments may be required tonormalize the exhaled carbon dioxide.[25] Some surgeons argue that the benefit of invasive arterialmonitoring does not outweigh 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 forport locations and robot cart position ( Fig. 66-6 ). The trocars are inserted under direct visualization

after a pneumoperitoneum is produced. After all trocars are in place, the patient is placed in a steepreverse-Trendelenburg position.[26] At this point, the robot is brought into position 45 degrees off theright head of the table, and instruments connected to the trocars.




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CARDIAC SURGERY (see Chapter 50 )

Application of conventional endoscopic instruments has paved the way for several cardiacprocedures to be performed with robotic assistance. Internal mammary artery harvesting wassuccessfully performed thoracoscopically in 1997 by Nataf.[27] In 1998, Loulmet and colleagues[28]reported the first totally endoscopic coronary artery bypass surgery. Cardiothoracic applications ofrobotically assisted surgery have expanded and include atrial septal defect closures,[29][30][31] mitralvalve repairs,[32][33][34][35][36] patent ductus arteriosus ligations,[37][38] and totally endoscopic coronaryartery bypass grafting.[39][40][41]

Even though technical advances in minimally invasive surgery have introduced techniques that aredone through very small ports and may eventually make surgical sternotomy obsolete, surgeons muststill be trained and prepared to convert to an open sternotomy if the need arises. Sternotomy alone

carries a finite risk of morbidity from an inflammatory response, but it is certainly less than that ofexposure to cardiopulmonary bypass.[42][43][44] Surgery on the beating heart without cardiopulmonarybypass may avoid significant inflammatory responses and should be the method of choice wheneverpossible.

Figure 66-6 Numbered incision ports for cholecystectomy and location of the robotic arms.

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Anesthetic Implications

Knowledge of and expertise in cardiac and thoracic anesthesia is imperative because both organsystems need to be managed safely. The ability to perform and maintain single-lung ventilation ismandatory, as is management of the physiologic consequences. Preoperative assessment of lung


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function is indicated if a patient has significant lung disease. Poor pulmonary function test resultsmay be a contraindication to robotically assisted cardiac surgery because single-lung ventilation maybe poorly tolerated. Robotic surgery may require unprecedented, prolonged one-lung ventilation,which challenges the extent of our understanding of respiratory physiology. Continuous monitoringof cardiac function with transesophageal echocardiography (TEE) has become a standard of care andhas found a niche for several procedures required for safer robotically assisted surgery.




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Mitral Valve Surgery

In 1997, two independent groups reported the first robotically assisted mitral valve repair.[45][46] InNovember 2002, the FDA approved the use of robot-assisted surgery in performing mitral valverepairs. Mitral valves repair, initially done through mini-thoracotomy incisions, could be donecompletely with a closed chest. However, mitral valve replacements may still require a smallthoracotomy to introduce the new prosthetic valve.

Anesthetic Implications for Mitral Valve Surgery

Mitral valve surgery employing robotic devices is being done at a few cardiac centers in the UnitedStates and Europe. The anesthetic techniques and other relevant considerations have been describedpreviously.[47] Patients are initially evaluated by cardiac catheterization to estimate the degree of

coronary artery stenosis and to assess valve function. Severe mitral regurgitation is a mechanicalproblem that requires surgery for cure. Most patients are medically treated with afterload reducers,such as angiotensin-converting enzyme (ACE) inhibitors if they are hypertensive. An enlarged leftatrium is often susceptible to atrial fibrillation. Patients with persistent atrial fibrillation may betaking anticoagulants concomitantly with therapy for rate control. Chronic elevation in left atrialpressure may manifest with pulmonary hypertension, which may be further exacerbated byobstructive lung disease. Severe pulmonary hypertension renders a patient unsuitable for roboticsurgery.[48]

Patients are provided with a large peripheral intravenous line. Light sedation with midazolam andlocal anesthesia is offered before the placement of bilateral radial arterial lines. The patient isroutinely 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 provide automaticST segment analysis for the detection of ischemia. After ample oxygenation, the patient isanesthetized with a combination of midazolam, fentanyl, and isoflurane. On muscle relaxation, thetrachea is intubated with a double-lumen endotracheal tube ( Table 66-1 ). Proper tube position isconfirmed by bronchoscopy. A TEE

probe is inserted to assess heart and valve function and to guide central line placement. A mid-esophageal, bicaval view at 90 degrees is used for guidance in positioning the superior vena cava(SVC) and inferior vena cava (IVC) cannulas ( Fig. 66-7 ). Initially, a left, 9-Fr introducer catheter isinserted by means of the Seldinger technique, and an 8-Fr pulmonary artery catheter is floated intothe pulmonary artery. Next, the right neck is prepared

TABLE 66-1 -- One-lung ventilation strategy

Use FIO2

= 1.0.

Begin one-lung ventilation with pressure control ventilation, maintaining a plateau pressure of


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Figure 66-7A, Ultrasound image of the superior vena cava cannula. B, Ultrasound image of a bicaval view depicting theinferior vena cava containing a J guidewire. Both views are helpful in correctly placing cardiopulmonary bypass venouscannulas.

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for insertion of a percutaneous, 17-Fr Biomedicus cannula. It is inserted directly into the internaljugular vein using the Seldinger technique, and its proper placement is confirmed by TEE.Experience shows that the long transthoracic aortic cross-clamp may impinge and occlude the SVC.For this reason, an armored SVC neck cannula provides resistance to occlusion or kinking. At thetime of insertion, the cannula is flushed with 5000 units of heparin to ensure its patency. The cannulais anchored with a purse-string suture at the skin and secured with Kerlix gauze wrapped around thepatient's head.

After the patient's pelvis is positioned supine and the right shoulder is tilted 30 degrees to the left,transcutaneous defibrillation and pacing pads are applied. The surgeon can then determine properlocation for port access, which may vary according to a patient's body habitus.

After the right femoral vessels are exposed and left-sided, single-lung ventilation is established, a


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right-sided mini-thoracotomy incision is made. The heart is exposed after a pericardial opening ismade. The pericardium is anchored open to the chest wall by two percutaneous stay sutures. Afterthe patient is heparinized based on an activated clot time (ACT)-guided protocol, the femoral veinand artery are cannulated in anticipation of femoral-femoral cardiopulmonary bypass. First, thefemoral vein is cannulated, and a 21-Fr cannula is placed over a guidewire and passed into the IVC-RA junction with the aid of TEE. One end hole and 12 side holes resist collapse under the highnegative pressure that is created by augmented venous return pumps. Likewise, the femoral artery is

cannulated with a 24-Fr cannula, and cardiopulmonary bypass is initiated with venous drainage fromthe femoral and jugular veins. Anterograde and retrograde cardioplegia cannulas are placed. Somesurgical teams prefer to cannulate the ascending aorta using a Heartport Straight-shot.[48] Atransthoracic aortic cross-clamp is passed percutaneously through the right axilla and applied to theascending aorta. The robotic arms are engaged through their respective trocars lateral to the mini-thoracotomy incision while the camera arm passes directly through the thoracotomy incision. Theleft atrium can be entered for mitral valve repair or replacement.

Before terminating cardiopulmonary bypass, TEE is used to evaluate the function of the mitral valve,residual valvular regurgitation and to confirm the disappearance of intracardiac air. The anteriorleaflet of the mitral valve is further inspected for systolic anterior motion.

Patient selection is important for optimal results. Table 66-2 lists the risk factors that make patientsunsuitable candidates for robotic mitral valve surgery.




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Atrial Septal Defect Repair

Operations for atrial septal defects are similar to those for mitral valve repairs, except that a mini-thoracotomy is not required. A closed-chest procedure is possible. Like all robotic procedures thatdemand entrance into the thoracic cavity, single-lung ventilation must be instituted during surgery.Atrial septal defect repairs also require opening the heart and preventing any blood from entering theheart. This

is facilitated by jugular and femoral vein cannulation and snaring the IVC and SVC.Cardiopulmonary bypass with cardioplegia administration into the aortic root is used to arrest theheart. Methods of cardiopulmonary bypass using endovascular clamping are described in "CoronaryArtery Bypass Grafting." Dogan and coworkers[29] reported the first successful closed-chest closureof an atrial septal defect.


TABLE 66-2 -- Exclusion criteria for robotically assisted mitral valve repairs

Severely calcified mitral annulus

Severe pulmonary hypertension

Ischemic heart disease

Surgery requiring multiple valve repairs

Previous surgery to right hemithorax

Severe aortic and peripheral atherosclerosis



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Internal Mammary Artery Harvest

Patients are monitored in the usual way for cardiac surgery. A central venous line and a radial arterycannula are placed on the same side as the harvested internal mammary artery. There is a mandatefor single-lung ventilation with a double-lumen tube, a Univent tube, or bronchial blocker, theposition of which is confirmed by bronchoscopy. The patient is positioned supine, with the thoraxrotated 20 degrees by placing a roll under the left scapula. External defibrillation and pacing pads areapplied to the left posterior chest and anterolateral right chest. Raising the left arm provides moreexposure and thins the skin overlying the left anterolateral chest. The opposite can be done to theright chest when harvesting only the right internal mammary artery. Carbon dioxide insufflation isneeded to provide exposure and counter-traction. Carbon dioxide insufflation (5 to 10 mm Hg) intothe left hemithorax pushes the mediastinal fat pad medially and enlarges the space between thesternum and heart to a small extent to provide a better view. When harvesting both internal

mammary arteries, insufflation of the left hemithorax is sufficient to expose the right internalmammary artery because of the leftward position of the heart[49] and the improved angle of sight.Insufflation is begun in increments of 2 to 4 mm Hg. The insufflation flow rate is adjustedautomatically to achieve a preset intrathoracic pressure limit. Caution should be exercised wheninsufflating the thorax in patients who have poor left ventricular function or are hypovolemic (centralvenous pressure


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Coronary Artery Bypass Grafting

All patients are evaluated preoperatively by TEE to exclude the possibility of persistent left SVC orpatent foramen ovale. Table 66-3 lists the major exclusion criteria for robotic coronary artery bypassgrafting. The iliac and femoral arteries should also be evaluated for their size by echo Dopplerultrasonography.[30]

Patients are prepared and monitored for anesthesia in a manner similar to that for mitral valvesurgery (see "Mitral Valve Repair"). Monitoring of the right radial artery pressure tracing isimperative when using an endovascular balloon-occlusion catheter. After the patient is asleep,inspired oxygen tension and expired carbon dioxide are monitored. TEE is used routinely as thestandard of care for determination of cardiac function and for

Figure 66-8 Incision ports for coronary artery bypass grafting. Trocars are placed in the third, sixth, and eighthintercostal spaces. Similar port positions are used for bilateral internal mammary artery dissection.

confirming catheter placement. Pulmonary artery catheters are judiciously used in the appropriate

patient population, but the data that the catheter provide may be redundant when TEE data areavailable. The patient is positioned the same as for internal mammary artery takedown, and trocarpositions are placed as depicted in Figure 66-8 .

When cardiopulmonary bypass is anticipated, the left femoral artery is cannulated with a 17- or 21-Fr Remote Access Perfusion (RAP) catheter ( Fig. 66-9 ) with an aortic occlusion balloon. Exclusioncriteria for endovascular cardiopulmonary bypass are contained in Table 66-4 . This catheter allowsanterograde flow of 4 or 5 L/min, respectively. The cannula has a separate lumen for deliveringcardioplegia to the aortic root beyond the occlusion of the balloon. The aortic cannula is positionedin the ascending aorta, 2 cm above the aortic valve, with TEE guidance ( Fig. 66-10 ). The

endovascular balloon is inflated with a volume equal to the diameter (in milliliters) of the sinotubularjunction of the aorta. A balloon pressure above 300 mm Hg usually provides complete occlusion ofthe aorta.[32] Residual flow around the balloon can be seen and monitored with color flow on TEE.The use of bilateral radial artery lines is useful in detecting the migration of the occlusion balloontoward the innominate artery. Proximal migration of the balloon can most easily be seen with TEE,preventing balloon herniation through the aortic valve.


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After full cannulation and being poised for cardiopulmonary bypass, the right lung is allowed tocollapse, and left lung ventilation is begun. The ventilator is adjusted to provide an end-tidal carbondioxide pressure of 35 to 40 mm Hg. Ports can be safely placed after the right-sided pneumothoraxhas formed. Carbon dioxide is insufflated

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Figure 66-9 Remote Access Perfusion (RAP) catheter (Estech Systems, Inc., Plano, TX). The endovascular catheter hasa cylindrical balloon for endovascular aortic clamping. The catheter provides anterograde perfusion of the aortic arch at arate of 5 L/min and cardioplegia administration to the aortic root.

into the right hemithorax and continued at a pressure of 5 to 10 mm Hg. This allows the affectedlung to collapse further and provides a larger visual field. It may also prevent mediastinal shiftsduring one-lung ventilation when large tidal volumes are used, such as in a patient withemphysematous lungs. Insufflation to produce a deliberate pneumothorax is not very effective atraising the sternum above the anterior surface of the heart. For this reason, some surgeons providesternal lift retractors to increase the retrosternal space and provide better exposure.[52]

Robot-assisted, beating-heart coronary artery bypass grafting can be accomplished with appropriate

patient selection. Articulating stabilizers passed through a subxiphoid port can stabilize the anteriorsurface of the heart to facilitate grafting.[53] Bilateral internal mammary artery grafting has also beenaccomplished.[54]




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Future Directions

Computer-assisted surgery has made it possible to perform total endoscopic coronary artery bypassgrafting on the arrested heart.[39][40][41] The interests in avoiding the morbidity of cardiopulmonarybypass and performing coronary artery bypass grafting on the beating heart have shown it to beapplicable.[52][53][54][55][56][57] Various stabilization

Figure 66-10 Ultrasound image of the Remote Access Perfusion (Estech Systems, Inc., Plano, TX) catheter balloon in

situ. Transesophageal echocardiography allows the anesthesiologist to keep track of migration of the catheter balloon.The balloon should be positioned in the ascending aorta 2 to 4 cm distal to the aortic valve. Right radial pressure catheterdampening can detect balloon malposition when occlusion of the innominate artery occurs.

devices have made beating-heart surgery commonplace with conventional sternotomy, andminiaturization of the stabilization devices have allowed their use in closed-chest, robot-assistedsurgery.[58] Problems do exist and need to be overcome. Because tactile sensation or palpation is notpossible in closed-chest surgery, intramyocardial arteries or vessels that are hidden under epicardialfat are elusive. Internal thoracic arteries can also be less than superficial, adding to the problem. Theproposed target site may contain plaque or heavy calcification that may make the anastomosisdifficult and inferior. Epicardial ultrasound imaging could possibly circumvent poor target sites and

has been shown with the help of Doppler to locate the course of intramyocardial coronaries andarteries hidden by epicardial fat.[59]

Visualization systems are being developed that will improve surgery on the beating heart. Advancesin motion gating technology will allow the heart to appear as if it is standing still. A properly timed

TABLE 66-4 -- Contraindications for endovascular cardiopulmonary bypass system

Major vascular disease of the ileac, femoral, and abdominal aorta found by Doppler ultrasound

Severe atherosclerosis

Aortic diameter greater than 4 cm

Moderate to severe aortic valve incompetence


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strobe light that is synchronized with the heart rate will achieve the proper virtual image of a heartstanding still or of virtual stillness.[2]




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THORACIC SURGERY (see Chapter 49 )

Background

Thoracic surgery has incorporated video assistance thoracoscopy (VATS) as a standard of care whenit is practical. A large thoracotomy incision may still be required for a complete pneumonectomy,although the thoracotomy incision increases stress and morbidity. The use of thoracic epiduralanalgesia is the standard of care for such

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large thoracic incisions. Robotic assistance for thoracic surgery may provide better patient outcomes,

but studies are needed to prove their potential benefit. Selection criteria for performing lung tumorresection using robotic assistance include lung lesions smaller than 5 cm in diameter, stage I statusfor primary lung carcinoma, no chest wall involvement, absence of pleural adhesions, and clearlydistinguishable interlobar fissures. The da Vinci Robotic Surgical System was the firsttelemanipulator system used.[60] For this procedure, tactile sensation is minimal, and it is oftendifficult to feel pulmonary nodules that are not visible on the surface. This drawback may requiremaking a port large enough for finger insertion to palpate the tumor.




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Esophagectomy

Esophagectomy can be performed through a transhiatal approach or a traditional three-pointapproach. Traditional esophageal dissections have started to take advantage of robotic interventions.Traditional esophagectomy is performed in three phases: abdominal, thoracotomy, and cervical. Thepatient is initially in a supine position for the abdominal and cervical dissection, followed by a leftlateral decubitus position for the thoracotomy.[61] Robotically assisted surgery has replaced thetraditional thoracotomy phase with robotic esophageal dissection. With the use of small trocarincisions, the patient can avoid the stress of a thoracotomy. Although the robotic surgery appears tobe less painful, a thoracic epidural block for postoperative pain relief is beneficial.




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NEUROSURGERY (see Chapter 53 )

Background

From the late 1980s to 1993, neurosurgeons investigated the use of robots to precisely positionresection probes and devices within neural parenchyma to provide minimal invasive surgery and toprotect normal tissue. Stereotactic navigation during neurosurgery surgery has provided an image-guided system for real-time tracking of surgical instrument tips.




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Radiosurgery of Spinal Lesions

Spinal vascular malformations and spinal tumors have been treated with the use of image-guidedframeless stereotactic radiosurgery.[62] Precise delivery of high-dose radiation limits the dose thatwould be delivered to normal adjacent tissue and improves morbidity.

Cervical vertebrae can be imaged clearly by x-ray cameras, and lesions are referenced to CT images.The thoracic and lumbar areas have denser bodies that are more difficult to image and provide poorcontrast with surrounding tissue. To overcome this limitation, additional radiographic landmarks areimplanted percutaneously. Implantation of fiducial markers can be done in the operating room underconscious sedation. These fiducial markers are placed percutaneously under fluoroscopic guidance.Three fiducial markers are required to define any point in three-dimensional space. A fourth isplaced for redundancy in case one moves. These fiducial markers are fixed to bony landmark

laminae or facets and have a fixed relationship with the bone in which they are implanted. Theyallow accurate localization for stereotactic radiosurgery.




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UROLOGIC SURGERY (see Chapter 54 )

Transurethral Resection of the Prostate

In 1995, Nathan and Wickham[63] published their results of a coring device used to assist intransurethral resection of the prostate (TURP). Traditionally, a resectoscope containing a cuttingtungsten wire at its distal end is inserted into the urethra. As energy passes through the tungsten wire,it cuts into prostate tissue. Continuous flow of nonelectrolytic solution is required to promotevisibility. Coagulation electrocautery helps in hemostasis but may prolong the procedure.Unfortunately, prolonged resections lead to resorption of this fluid and produce dilutionhyponatremia.

The Puma robot has been used to resect prostate tissue safely. [64] The safety of the device is derived

from a steel circular frame that restricts and confines the robot to a precise arc of resection. Theframe acts as a safety fixture that prevents the surgeon from resecting outside the bounds of theframe. Information about the size of the prostate is obtained from an operative transurethralultrasound inspection. These data are used to construct a three-dimensional image of the entireprostate. Limits of resection, which usually amount to 38% of the prostate gland volume, areprogrammed into a computer for reference. [65] Such procedures can be done more quickly by therobotic instrument, and because hemostasis is done only once at the end of the procedure, there isless time for absorption of irrigation fluid.




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Radical Prostatectomy

Guillonneau and Vallancien[66] were the first to show the feasibility and efficacy of laparoscopicradical prostatectomy. Several centers have shown the feasibility of a robotically assistedprostatectomy. [67][68]




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Patients are monitored with routine care. After inducing anesthesia, an arterial line may be placed forfrequent phlebotomy. An additional, large-bore intravenous line may be considered when thepotential for large blood losses are foreseen. The patient is positioned in a supine lithotomy positionwith 30 degrees of Trendelenburg incline. The thighs are spread far enough apart to allow theapproach of the robotic system between them. Patients shorter than 6 feet are not placed in alithotomy position and have their legs in a frog-leg position. The prolonged Trendelenburg positionmay be relatively contraindicated in patients with history of stroke or cerebral aneurysm. Because ofthe long procedure, silicone gel pads

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are placed at every pressure point. Some surgeons advocate tucking the patient's arms while thepatient is awake to maintain optimal comfort and avoidance of neurapraxia. [69] After a 14-Fr Foleycatheter is inserted, the body is prepared and draped. A pneumoperitoneum is created through anumbilical puncture needle, and the maximum pressure is set to 15 mm Hg. The trocar is insertedaccording to the standardized Heilbronn approach using a semilunar five-trocar arrangement, with asixth in the suprapubic area.[70] A procedure with some modification of the Montsouris technique isused.[69]




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GYNECOLOGIC SURGERY

Background

Laparoscopic surgery is also finding robotically assisted procedures an improvement. Microsurgicaltechniques have benefited the most from the robotic scaling and tremor filtration. Several groupshave applied robotic assistance to fallopian tubal anastomoses[71][72] after sterilization or tuballigation. In the future, vasectomy reversals may also be done more precisely with the aid of robotics.




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After induction of general anesthesia, the patient is positioned in a modified dorsal lithotomy withTrendelenburg position. The thighs are abducted slightly for vaginal access to manipulate the uterus.A pneumoperitoneum is created with carbon dioxide insufflation. Patency of the anastomosis isassessed with injection of methylene blue dye through the uterine chromopertubator.




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ORTHOPEDIC SURGERY (see Chapter 61 )

Total Hip Arthroplasty

In 1992, Paul, a veterinarian who worked in collaboration with IBM, developed a robotic system thatcould be used for hip replacement in dogs. The research collaboration resulted in the first surgicalrobotROBODOC. This was the first medical application, and it started with orthopedic surgery. Inthis procedure, the femoral implant is placed into an axial canal of the proximal shaft of the femur.The femoral component can be glued or pressed in to the femoral shaft as a tight fit. Long-termradiographs after hip replacement surgery have shown that adhesives are prone to cracking,loosening, and producing osteolysis that leads to surgical failure of the prosthetic hip. Modernfemoral implants have a porous surface that allows for bone growth into the surface, promotingbetter hip longevity. For this reason, a tight fit of the implant into the femoral canal is essential. The

formation of this femoral canal is created with higher precision by a robot than by the visual cuesthat are used in the manual method. The cavity it creates is 10 times more accurate than is achievedby manual methods.[73] The robot gets its visual or coordinate cues from image-based informationsuch as MRI or CT. The accurate registration of the femoral coordinates in three-dimensional spaceis essential for precise bone milling of the femoral canal so that it can accommodate the surgicalimplant. Titanium pins are placed in the femoral condyles and the greater trochanter. The patient'sleg is then imaged by CT, and three-dimensional information about the femoral bone and registrationpins is recorded in a computer.

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 rigidly clamped and secured by therobot fixator. The robot is allowed to recognize the three titanium registration pins and comparestheir location relative to the data obtained from CT. In this manner, the robot has a perfect sense ofwhere the femur lies in three-dimensional space and can perform precise milling of the femoralcanal. The remainder of the surgery proceeds manually.

The ROBODOC-treated patients showed fewer gaps between the prosthesis and bone, and nointraoperative femoral fractures occurred.[74] The overall complication rate in one study was reducedto 11.6%.[75]

Hip dislocation after hip arthroplasty is the most common postoperative complication, with a rate of1% to 5%.[76] To surmount this complication, the HipNav system is being developed. The system hasa range-of-motion simulator, a preoperative planner, and an intraoperative tracking and guidancecontrol. This system can optimize acetabular orientation for a "best-fit" prosthetic implant. [77]




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Knee Replacement

Most total-knee replacements depend on a jig system to guide bone sawing. The placement of the jigis based on the surgeon's visual cues from the exposed bone surfaces. These inaccuracies canproduce patellofemoral pain and limited flexion in 40% of the patients when conventionalapproaches are used.[78] Displacements as small as 2.5 mm can produce a 20-degree alteration in therange of motion of a joint.

Robotic surgical assistants have been developed to increase the accuracy of prosthetic jointalignment. For the robot to recognize specific landmarks, the pelvis and the ankle must be fixed tothe surgical table. Osseous material is less likely to deform under pressure and can keep its shape.




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OPHTHALMOLOGIC SURGERY (see Chapter 65 )

The challenge of creating a robot that is accurate and has an extremely high level of dexterity andprecision was mandated for laser retinal surgery. Because blood vessels in the retina are only 25 mapart, high precision is necessary. Collaboration between Stephen Charles and the NASA JetPropulsion Laboratory developed a Robot-Assisted Microsurgery System (RAMS).[79] It is capable ofperforming laser microsurgery with 10-m accuracy. The unaided human eye can discern anincrement of only 200 m. RAMS provides a 200-Hz gating system for eye

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tracking, and it eliminates the saccades of the eye, allowing the eye to appear perfectly still to the

observer. The system also provides a 100:1 scaling that allows for 10-m incremental movements.Tremor is filtered out between 8 and 14 Hz to eliminate inaccuracy. The ability to work at such smallscales is the robot's strength. Newer robotic devices intended for microsurgical application have anaccuracy of 5 m.[80] Riviere and Jensen[81] were able to cannulate a retinal vein to administer therapyfor retinal vein thrombosis. This would not be conceivable without the dexterity of robotictechnology.




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KEY POINTS

1. Robotic surgery is accomplished by an autonomous, reprogrammable manipulator designed tomove and articulate specialized instruments through programmed motions that achieve aspecific task. A robot can be given three-dimensional coordinates from any imaging devices(e.g., CT) that allow 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 systemunder partially programmed control and that can be instantly controlled or modified by asurgeon's intervention.

3. Computer-assisted surgery involves systems that are manually controlled by the surgeon andthat 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 electronically produce precise instrument movements

at a distance from a remote location.6. Telepresence refers to virtual projection of images from remote sites. This allows the surgeon

to visualize intended robotic movements at distant locations. It also enables telementoring,which is supervision and instruction from a distant location.




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