CARDIAC SURGERY (see Chapter
50
)
Application of conventional endoscopic instruments has paved the
way for several cardiac procedures to be performed with robotic assistance. Internal
mammary artery harvesting was successfully performed thoracoscopically in 1997 by
Nataf.[27]
In 1998, Loulmet and colleagues[28]
reported the first totally endoscopic coronary artery bypass surgery. Cardiothoracic
applications of robotically assisted surgery have expanded and include atrial septal
defect closures,[29]
[30]
[31]
mitral valve repairs,[32]
[33]
[34]
[35]
[36]
patent ductus arteriosus ligations,[37]
[38]
and totally endoscopic coronary artery bypass
grafting.[39]
[40]
[41]
Even though technical advances in minimally invasive surgery have
introduced techniques that are done through very small ports and may eventually make
surgical sternotomy obsolete, surgeons must still 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 of
exposure to cardiopulmonary bypass.[42]
[43]
[44]
Surgery on the beating heart without cardiopulmonary
bypass may avoid significant inflammatory responses and should be the method of choice
whenever possible.
Figure 66-6
Numbered incision ports for cholecystectomy and location
of the robotic arms.
Anesthetic Implications
Knowledge of and expertise in cardiac and thoracic anesthesia
is imperative because both organ systems need to be managed safely. The ability
to perform and maintain single-lung ventilation is mandatory, as is management of
the physiologic consequences. Preoperative assessment of lung function is indicated
if a patient has significant lung disease. Poor pulmonary function test results
may be a contraindication to robotically assisted cardiac surgery because single-lung
ventilation may be poorly tolerated. Robotic surgery may require unprecedented,
prolonged one-lung ventilation, which challenges the extent of our understanding
of respiratory physiology. Continuous monitoring of cardiac function with transesophageal
echocardiography (TEE) has become a standard of care and has found a niche for several
procedures required for safer robotically assisted surgery.
