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A 65-year-old man presents for robotic-assisted laparoscopic prostatectomy (RALP). He is an ex-smoker with 50 pack-years of smoking and chronic obstructive pulmonary disorder (COPD). He is on salbutamol puffers as needed. He has no allergies. He weighs 90 kg (198 lb) and is 165 cm (5’4”) tall (BMI 33.1 kg·m−2). His oxygen saturation on room air was 95%.

Preoperative airway assessment reveals no predictors of difficult laryngoscopic intubation with Mallampati score of II, thyromental distance 3 finger breaths (5 cm), and normal range of cervical spinal motion and full dentition. Following induction with fentanyl, propofol, and rocuronium, a Cormack/Lehane Grade 2 view of the larynx is visualized via direct laryngoscopy using a # 3 Macintosh blade. The trachea is intubated using a 7.5 mm ID endotracheal tube (ETT) and secured at 24 cm at the lips. A 14 Fr orogastric (OG) tube is inserted and confirmed in the stomach via aspiration of a small amount of gastric contents. A gauze bite block is placed, and the eyes are protected with tape and hard goggles.

The patient is placed in steep Trendelenburg position with a tilt of 30 degree and secured using bean bag restraint. Pneumoperitoneum is achieved with a peak insufflation pressure of 12 mmHg and the robot docked in place.


What Is the Robotic-Assisted Laparoscopic Prostatectomy (RALP)?

RALP, also known as robotic-assisted radical prostatectomy [RARP]) is a minimally invasive procedure utilizing pneumoperitoneum to visualize intra-abdominal contents.1 The instruments are attached to an immobile robot via bulky arms that are remotely manipulated by the surgeon. The robot allows a higher degree of precision and better visualization of tissues than a standard laparoscopic technique. The goal of this technique is reduced surgical blood loss, decreased postoperative pain, and a shorter hospital stay than a traditional radical prostatectomy.2 Limited access to the patient due to the bulky robot, unintended injury from the robot, ensuring a completely immobile patient, and steep Trendelenburg position plus pneumoperitoneum with subsequent potential difficult ventilation are but a few of the anesthetic concerns with robotic-assisted prostate/pelvic surgery.

What Are Your Concerns When a Patient Is Placed in the Steep Trendelenburg Position for a Prolonged Period of Time?

Intra-abdominal robotic-assisted surgery involves gaining access to the desired anatomy via a traditional laparoscopic approach. The ports and instruments are placed by the surgeon and pneumoperitoneum is attained. The patient is then positioned head down, the robot rolled into position, and the instruments attached, typically to 4 to 6 arms. The robot is then docked and at this point, the patient is essentially attached to the robotic instruments and immovable. The robot is bulky, limiting access to the patient for assessment, airway adjustment, vascular access, and emergency procedures. Additionally, unanticipated injury is possible from the arms and instruments touching ...

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