1. Anaesthesia For Robotic Cardiac
Surgery
Presented by- Dr. Tanuja
Moderator- Dr. Indu Verma

2. Introduction
• Robotic surgical technology was developed with the idea of
performing remote operations and procedures in difficult
spaces.
• These machines allow surgical maneuvers to be performed
by instruments on robotic arms that are controlled by the
operator from a console situated away from the operating
table.
• A slow stepwise approach to learning completely
endoscopic techniques is mandatory .
• cardiac anesthetists to have a working knowledge of these
systems to formulate an anesthetic plan, recognize
potential complications, provide safe patient care and
adapt to the fast developing field.

3. History
• In May 1998, Dr. Friedrich using the da Vinci Surgical System
performed the first robotically assisted heart bypass.
• In 1998, Loulmet et al performed the world’s first totally
endoscopic coronary arterybypass (TECAB) procedure using robotic
assistance
• September 1999, Dr. Wolf and Michler - first robotically assisted
heart bypas.
• In October 1999 the world's first surgical robotics beating heart
coronary artery bypass graft (CABG) was performed by Dr. Douglas
Boyd using the ZEUS surgical robot.
• In November 1999 – the first closed-chest beating heart cardiac
hybrid revascularization procedure is performed (London)
• In May 2006 the first AI doctor-conducted unassisted robotic
surgery on a 34 year old male to correct heart arrhythmia.

4. Benefits of Minimally Invasive Heart Surgery
• Minimally invasive heart surgery offers several advantages
compared to open-chest procedures, including:
• Faster return to normal activities. patients can return to
work usually within three weeks.
• Shorter hospital stay.
• No splitting of the breastbone.
• Smaller incisions.
• Quicker resolution of pain.
• Elimination of the heart-lung bypass machine, in most
cases.
• Minimal blood loss and less need for transfusion.
• Little scarring.

5. • Two surgical robotic systems are in use today:
Zeus Surgical System (Computer Motion,
California, USA)
da Vinci Surgical System (Intuitive Surgical,
California,USA).

6. The da Vinci System
• consists of three parts-
I. The control console.
II. An instrument tower.
III. The robot with three
arms (four arms in the
new version).

8. Robotic cardiac surgery procedure
The surgeon is seated to the left at the da Vinci console, where he controls
the system's robotic arms to perform the surgery. The robotic arms are
shown at right, directly above the patient.

9. Arrangement in Robotic operative room

11. Zeus System uses a voice activated camera which can move in or out,
based on the surgeon's voice command, and the robotic arms are
attached to the table itself

12. Surgical Procedure performed with robotic
assistance

13. Contraindications for Robotic cardiac
surgery

14. Perioperative Anesthesia Plan
• The perioperative anesthetic plan should keep in
view -
The primary cardiac disease of the patient.
 Restrictions set by the use of the robot,
implication of one lung physiology in the setting
of cardiac disease,
 prolonged percutaneous cardiopulmonary
bypass (CPB) with its problems,
 Management of any complications.

15. Perioperative Anesthesia Plan Cont.
Patient selection-
 Adequate patient size
 Ability of the patient to tolerate one lung ventilation.
• Elective CPB using femoral cannulation may be needed
in these cases prolonging CPB times if OLV is not
tolerated.
• Conditions such as chronic renal, hepatic failure,
coagulopathy(regional anaesthesia) or a previous
neurological event such as stroke which may not allow
prolonged CPB should be screened.
• The condition of the thoracic spine, and the skin
overlying the T1-T5 area should be examined .

16. Preparation and Monitoring
• Cardiac medication, including beta blockers, calcium
channel blockers, and nitrates should be continued on the
day of surgery.
• Angiotensin converting enzyme inhibitors should be
omitted.
• Antiplatelet drugs such as clopidogrel need to be stopped
five to seven days earlier.
• Smoking should be stopped and preoperative
bronchodilators started.
• Serum electrolytes especially K + and Mg ++ should be
normalized
Premedication may include an oral benzodiazepine such as
Midazolam 0.1 mg/Kg

17. Monitoring
• ECG,
• end tidal CO 2 concentration,
• Pulse oximeter,
• CVP,
• Right and left radial intraarterial pressure,
• bispectral index (BIS),
• nasopharyngeal temperature
• urine output.
• Specialized cardiac monitoring may include a
pulmonary artery catheter (PAC) and TEE.

18. Monitoring Cont.
• Right radial or bilateral radial arterial pressure
is used for monitoring.
• This is done to detect migration of the
endovascular balloon cannula causing
obstruction of the innominate artery, if the
heart port cannula is used for endovascular
CPB.

19. Role of TEE

20. TEE

21. Important issues specific to management of
robotic cardiac surgery
Patient positioning,
long duration of the procedure,
Patient hypothermia,
Respiratory and hemodynamic effects of OLV
and concealed blood loss

22. Patient position:
• Proper position allows robotic arm movement without obstruction and allows
easy initiation of percutaneous CPB if needed for the procedure.
• Access to the patient chest and airway is nearly impossible after docking of the
robot inside the patient chest through the working ports.
• Precautions must be taken to confirm the position of the double lumen
endotracheal tube (DLT) before final patient position using a fiberoptic
bronchoscope.
• For most robotic cardiac surgeries, the patient is positioned supine. The arm on
the side of the chest port placement is allowed to hang over the edge of the table
in a sling to allow space for port placement.
• Pads may be placed below the chest to elevate this hemithorax by 25 30 to allow
port placement in a triangular arrangement.
• change in the electrical axis of the heart after creation of a capnothorax may make
ST segment analysis on ECG unreliable.

23. Induction and Maintenance Of General
Anesthesia
• Anesthetic techniques are primarily narcotic-
based, induction being with a hemodynamically
stable agent such as Etomidate with Rocuronium
for muscle relaxation.
• Longer acting muscle relaxants may
subsequently be added to ensure patient
immobility after port placement.
• Intubation is done with an appropriate sized DLT.
Either a left or a right sided DLT may be used but
it may be advisable to intubate the bronchus on
the side to be ventilated.

24. Regional Anaesthesia+GA
• Use of regional anesthesia as general anesthesia adjuvant
allows lighter levels of GA during surgery, with minimal
intraoperative hemodynamic changes and a smooth
transition to postoperative analgesia.
• RAVECAB procedures, technique of choice may be
combination of thoracic PVB and light GA.
• Pre-induction placement reduces intraoperative anesthetic
requirements and can provide cardiac sympathectomy.
• When PVB has been established, the GA is induced with a
small dose of narcotic (fentanyl 3-5 mg/kg) and of propofol
(0.5-1 mg/kg) and rocuronium (1 mg/kg).
• Because the RAVECAB procedure currently requires four to
six hours, an infusion of rocuronium and low dose propofol
(50 mg/kg/min) is maintained throughout surgery.

25. Creation of Capnothorax
CO 2 is insufflated into the hemithorax through the side
being operated upon, to prevent smoke formation and
hazard of gas explosion in the hemithorax.
• Increased CO 2 pressure, above 5-10 mmHg, may reduce
venous return to the heart or result in increased arterial
CO2 tension.
• 18G venous cannula in the pleural space can be used to
measure pleural pressure and also act as a vent for excess
CO 2 , avoiding tension capnothorax.
• Gastric decompression with a nasogastric tube may
prevent rise of airway or intrapleural pressures from gastric
distention.
• The capnothorax may interfere with TEE monitoring.

26. Physiological Perturbation
Respiratory System-:
Need for OLV and creation of a capnothorax with
CO2 insufflation on the side of robotic port
placement causes
 Respiratory embarrassment.
 Ventilation-Perfusion (V/Q) mismatch
 Increase in shunt flow
 large [P (A-a) O 2 ] gradient
 and low (PaO 2 ).

27. Management
• Continuous positive airway pressure (CPAP) of 5
cm is applied on the collapsed lung to improve
oxygenation and reduce shunt fraction.
• Continual vigilance and monitoring of
insufflation pressure, airway pressure, expired
tidal volume, and central venous pressure is
essential.
• Hypoxia and hypercarbia should be avoided as it
can elevate pulmonary artery pressure and
pulmonary vascular resistance as well as reduce
cardiac output.

28. Physiological Perturbation Cont.
Cardiovascular system-:
• CO2 insufflation into the non-ventilated hemithorax
with the deflated lung causes rise in intrathoracic
pressure and decreases venous return.
• causes reduced cardiac output, increased CVP, mPAP,
and PCWP.
• SvO 2 decreases in OLV, recover on resumption of TLV
• Rise in PaCO2 during OLV and Capnothorax can cause
coronary vasoconstriction.

29. Management
• Maintaining insufflation with CO 2 at two to three
liters per minute, avoiding intrapleural pressures
above 10 mmHg, reduces chances of
cardiorespiratory compromise.
• Infusion of nitroglycerin is used to control ST
segment changes or elevations of pulmonary
capillary wedge pressure.
• Maintain a heart rate between 50-80 bpm.
• External defibrillator pads are applied before
induction of anesthesia

30. Hypothermia
• Occurs Because of exposure, prolonged surgery,
use of cold intravenous fluids, respiratory gases
and CO 2 insufflation.
• Delaying extubation or causing shivering in the
postoperative period that may increase oxygen
requirements significantly.
• Ambient air warmers may be used to maintain
normothermia [Sessler 1992]

31. Fluid management
• Titrate fluid therapy to maintain pulmonary
capillary wedge pressure (PCWP) at patients’
preoperative values, 12-15 mmHg.
• In the event that conversion to CPB is required
after several hours, the addition of pump prime
solution may result in significant crystalloid fluid
overload.
• The perfusionist must be aware of this potential
for fluid overload, with the possible requirement
for ultrafiltration during rescue CPB in such stand-
by cases.

32. Cardiopulmonary Bypass Management
Placement of Cannulae-
Arterial access: Femoral arterial cannulation is the standard .
• TEE assessment of the descending aorta is essential to rule out
severe atherosclerosis.
Arterial cannulae of sizes 15 Fr to 19 Fr can be introduced
transfemorally using Seldinger technique with a side port for distal
limb perfusion for conventional femorofemoral CBP.
• 10.5 Fr intra-arotic balloon clamp introduced transfemorally into
the ascending aorta.
• on inflation, it internally cross clamps the aorta and has a distal port
for aortic root venting, antegrade delivery of cardioplegia and for
active suctioning and deairing at the termination of CPB.

33. Cardiopulmonary Bypass Management
cont.
Venous access:
• Transfemoral cannulae may not empty the ventricles completely requiring
additional cannulation of superior vena cava via internal jugular vein.
• TEE is helpful to guide cannulations, guide wire placement and final positioning of
the SVC and inferior vena cava (IVC) cannulae.
• For percutaneous CPB, the anesthesiologist places a PAC for venting the
pulmonary artery and a Coronary Sinus catheter for retrograde cardioplegia
through the right IJV, with positioning of both catheters confirmed by TEE.
• On inflating the CS catheter balloon a previously right atrial trace changes to a
right ventricular trace.
• A 100 units/kg dose of heparin is recommended before CS manipulation to avoid
CS thrombosis.
• The PA vent catheter allows passive venting of the pulmonary artery at
approximately 50ml/min.

34. Commencement of CPB and aortic cross clamp
• Bypass is initiated with
monitoring of right radial
arterial pressure, aortic root
pressure and with vacuum
assisted or kinetic assisted
venous drainage.
• If the percutaneous
Endoclamp system is used, The
endoaortic balloon is inflated
to 250 - 300 mmHg pressure
after TEE guided position
check, to produce an internal
crossclamp.
• Decompression of the heart
may be aided by the PA
catheter vent.

35. TEE image showing endoaortic
balloon position

36. Commencement of CPB and aortic
cross clamp cont.
• Cardioplegia can be administered antegrade, through a
distal port in the endovascular aortic cannula and the aortic
root can subsequently be vented, through this port.
Cardioplegia can be given retrogradely through a CS
catheter if required.
• Apart from the Endoclamp system, another system in use
is the Estech which is similar, except for a port distal to the
balloon to allow antegrade aortic flow.
• Transthoracic aortic clamping can be performed by use of-
 A Softclamp which can be placed transthoracically on the
aorta. or
 long bladed aortic cross clamp.

37. Aortic cross clamp cont.
• Pump flows may need to be reduced during cross clamping for all
the above clamps both transthoracic and endovascular, for proper
placement and prevention of damage to the aorta.
• Dislodgement of the balloon of an endovascular catheter can lead
to obstruction of the innominate artery, with cerebral
hypoperfusion and neurological injury.
• For detecting balloon migration TEE and the radial artery pressure
trace are used.
• Occasionally the balloon may migrate proximally obstructing the
coronary arteries, causing myocardial dysfunction.
• Use of the endoaortic balloon catheter should be avoided in heavily
atherosclerotic aorta for fear of dislodgement and embolization of
plaque.

38. De-airing and weaning
• De-airing of the heart is difficult after CPB, in robotic
cardiac surgery.
• There is lack of direct access to the heart for the
surgeon and with the use of the slight lateral tilted
position, the intracardiac air tends to be retained along
dorsal interventricular septum and right pulmonary
veins.
• Use of CO 2 insufflation into the hemithorax tends to
displace any air from the exposed areas of the heart
and this is supplemented by hand ventilation to expel
air from the pulmonary veins.
• Weaning off CPB is done under TEE guidance following
standard practices as for the type of surgery with
conventional CPB.

39. De-airing and weaning Cont.
• At the end of the procedure, after reversal of heparin with
protamine, the DLT is changed for a single lumen endotracheal tube
using a tube changer, if difficulty is anticipated due to airway
edema.
• If surgical trauma to the lung has resulted in intrabronchial
bleeding, use of the DLT for lung separation may be continued into
the intensive care unit, till bleeding is controlled.
• Air and CO 2 act as electrical insulators, increasing transthoracic
electrical impedance and defibrillation thresholds.
• Reversal of the capnothorax and institution of two lung ventilation
may help in successful defibrillation using the external defibrillation
patch electrodes.

40. Problems specific to Robotic Cardiac
Surgeries

41. Procedure likely to be performed using
robotic assistance(Future trends)

42. Future Trends in Robotic Cardiac
Surgery cont.
Off Pump Cardiac Repair: (OPCARE)
• Beating heart off pump intracardiac repair was
studied in bovine experiments using a robotic
system with two ultrasound based intracardiac
visualization systems allowing for two different
but simultaneous planes of the heart, and
identification of both, intracardiac structures and
the robotic instruments, within the heart
chambers.
• Intracardiac ultrasound probe introduced
through the bovine femoral vein.

43. Prototype epicardial crawling device
• Endoscopic robotic device for intrapericardial
intervention on the beating heart .
• The device adheres to the porcine epicardium
and crawl like an inch worm at 8 cm / min under
surgeon control to reach any site on the surface
of the beating heart.
• The first application being planned is for
epicardial lead placement for cardiac
resynchronization therapy and delivery of stem
cell or myoblasts to areas of failing myocardium
for regenerative therapy.

44. epicardial crawling device

45. Robotic fetal techniques
:
• Fetal cardiac disease can now be diagnosed as early as
16 weeks of gestation.
• Using robotic telemanipulation, direct visualization of
the choroidal vessels is possible, allowing access to
fetal cardiac chambers with catheters and the
opportunity for intracardiac manipulation.
• With real time 3 dimensional imaging, prenatal cardiac
intervention for human fetal aortic valve stenosis can
reduce left ventricular hypoplasia, restoring ventricular
growth and function .

46. Conclusion
• Robotically assisted CABG is reproducible and seems to
meet general safety standards in coronary surgery. (beating
and arrested heart robotic operations)
• Minithoracotomy & totally endoscopic port-only
approaches reduce surgical trauma while providing
cosmetic benefits and preservation of structural thoracic
integrity.
• Given the ongoing development in hardware, software, and
surgical techniques, robotically assisted CABG is here to
stay, and broader application is most likely.
• For the future, robotics is guaranteed to offer exciting
prospects for the surgical treatment of coronary artery
disease.

47. THANK YOU