Anesthetic Considerations
In the operating room, the patient is monitored with an electrocardiographic
(ECG) device, pulse oximetry, axillary temperature probe, and noninvasive blood pressure
cuff.
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 not immediately available during the surgery. The patient is sedated with a mild
sedative and prepared for 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 a single-lumen endotracheal tube, and its
placement is confirmed by listening to the chest and detecting carbon dioxide on
expiration. Anesthesia can be maintained with a volatile agent. Muscle relaxation
is paramount in avoiding any movements by the patient while the surgical instruments
are within 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 cavity is insufflated with carbon dioxide to a pressure
not to exceed 20 mm Hg.[23]
The trocar for the
camera is 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 cart to the patient's head, there is
limited access to the patient's airway and neck, and their head must be guarded against
inadvertent collision by the movements of the robotic arms.[1]
[24]
After the robot is engaged, the patient's
body
position cannot be changed. If the patient requires an increase in cardiac filling
pressures, and it cannot be provided by Trendelenburg's position, only after disengaging
the robot is it possible. 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 carbon dioxide, ventilator
adjustments may be required to normalize the exhaled carbon dioxide.[25]
Some surgeons argue that the benefit of invasive arterial monitoring 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 for port 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 steep reverse-Trendelenburg
position.[26]
At this point, the robot is brought
into position 45 degrees off the right head of the table, and instruments connected
to the trocars.
