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Chapter 78. Robotically Assisted Laparoscopic Prostatectomy

Nitin K. Sekhri, MD; Ervant Nishanian, PhD, MD

  • Robots allow surgeons unprecedented control and precision of surgical instruments in minimally invasive procedures
  • Benefits
    • Less pain
    • Less trauma
    • Less blood loss (mean 150 mL vs. 1200 mL for open) and transfusion
    • Shorter hospital stays (1 vs. 3 days)
    • Quicker recovery
    • Improved cosmetic and functional (sexual function, incontinence) results (not conclusively demonstrated)

  • Relative contraindications
    • Because of intraoperative cardiovascular changes (see below), a thorough cardiac evaluation must be done
    • CHF (must be optimized)
    • Valvular disease (may require repair or replacement prior to surgery)
    • Hemorrhage could be difficult to control intraoperatively, therefore, anticoagulation and antiplatelet therapy must be held
    • Prior abdominal surgery may increase duration of surgery due to adhesions
  • Prolonged Trendelenburg position may be relative contraindication in patients with history of stroke or cerebral aneurysm
  • Patients with elevated PA pressure may not tolerate the position well

  • GA with ETT because of pneumoperitoneum and positioning
  • Monitoring
    • Arterial line for blood sampling and beat-to-beat BP monitoring
  • Maintenance
    • Patient is placed in steep Trendelenburg position
      • Reduction of FRC, increased atelectasis
      • Increased pulmonary blood content causes further decrease in FRC and pulmonary compliance
      • Increases CVP, ICP, IOP, myocardial work, and pulmonary venous pressure
      • Upward displacement of the trachea: ETT may migrate into a main-stem bronchus
    • Thighs spread far apart to allow docking of the robotic system
    • The patient’s arms will be tucked at the side and the drapes will keep the patient far away from the reach of the anesthesiologist; position and pad with care (risk of nerve injury)
    • Peripheral nerve injury is relatively common (most frequent: median nerve palsy)
    • IVs, monitoring lines, and ETT have to be secured in such a way that they will not kink or pull out
    • When robot is docked over the patient, no way to move the patient or to initiate resuscitative measures without removing the robot (which can take several minutes)
    • In the hands of an experienced surgeon, a straightforward prostatectomy can be done in two and a half hours of operative time
    • Large bore intravenous line as potential for large blood loss
    • Insufflation of carbon dioxide for production of a pneumoperitoneum
      • Increases CVP, PAOP, and PA pressures, and decreases cardiac output
      • Coexisting cardiovascular disease can cause even more pronounced impairment of cardiac function, which may thrust a compensated heart failure into decompensation or a marginally perfused myocardium into an ischemic episode
      • Insufflation reduces blood flow to organs within the abdominal cavity by direct mechanical compression
      • Bradycardia possible, usually responds to atropine; exsufflate if persists
    • Hypercarbia
      • CO2 highly diffusible into the bloodstream from the peritoneal cavity
      • Only rarely is the hypercarbia severe enough to cause arrhythmias or unmanageable hypertension that requires conversion to an open procedure
    • No difference between VCV and PCV, as long as CO2 and Vt monitored
    • Venous gas embolism (can occur with open procedure as well)
      • Suspected when sudden cardiovascular collapse
      • Treatment
        • Discontinue insufflation
        • Cardiopulmonary resuscitation if necessary
        • Only return the patient to horizontal position once robot is unlocked for resuscitation
    • Blood loss
      • Typical ...

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