Anesthesia for robotic thoracic surgery

Abstract

Minimally invasive surgery involving the thoracic cavity is on the rise. With the introduction of the da Vinci robot system more than 10 years ago, cardiac and thoracic operations have been performed. The literature on this topic currently includes case reports or series of clinically prospective or retrospective observational reports with the use of robotic systems, involving the thoracic cavity (mediastinal mass resection, lobectomies, esophagectomies, mitral valve surgery, assisted endoscopic coronary artery bypass grafting and atrial septal defect repair). The basic principles applied to minimally invasive surgery of the chest apply to robotic-assisted thoracic surgery. The combination of patient position management, of one-lung ventilation techniques and surgical manipulations after ventilation and perfusion from dependent and non-dependent or collapsed lung. The preferred method for lung isolation during robotic assisted thoracic surgery is the use of a left-sided double-lumen endotracheal tube because of the greater margin of safety and faster lung collapse. Visualization during robotic thoracic surgery may be enhanced by continuous intrathoracic carbon dioxide insufflation which may increase airway pressures and depress hemodynamic performance. Patient positioning during robotic thoracic surgery represents a challenge for anesthesiologists each particular case might require specific patient position so the surgeon can gain enough space in the axilla for the robot arms and accessory port/instruments in thoracic surgery. Special attention should be given to avoid unnecessary stretching of the elevated arms because it can damage brachial plexus. The success of robotic thoracic and cardiac surgery includes skills in lung isolation techniques, fiberoptic bronchoscopy techniques, the use of transesophageal echocardiography (cardiac cases) and clear understanding of the concept of robotic surgery and anesthesia.