Anesthetic Implications
Patients are monitored with routine care. After inducing anesthesia,
an arterial line may be placed for frequent phlebotomy. An additional, large-bore
intravenous line may be considered when the potential for large blood losses are
foreseen. The patient is positioned in a supine lithotomy position with 30 degrees
of Trendelenburg incline. The thighs are spread far enough apart to allow the approach
of the robotic system between them. Patients shorter than 6 feet are not placed
in a lithotomy position and have their legs in a frog-leg position. The prolonged
Trendelenburg position may be relatively contraindicated in patients with history
of stroke or cerebral aneurysm. Because of the long procedure, silicone gel pads
are placed at every pressure point. Some surgeons advocate tucking the patient's
arms while the patient is awake to maintain optimal comfort and avoidance of neurapraxia.
[69]
After a 14-Fr Foley catheter is inserted,
the
body is prepared and draped. A pneumoperitoneum is created through an umbilical
puncture needle, and the maximum pressure is set to 15 mm Hg. The trocar is inserted
according to the standardized Heilbronn approach using a semilunar five-trocar arrangement,
with a sixth in the suprapubic area.[70]
A procedure
with some modification of the Montsouris technique is used.[69]
