Anesthesia For Robot Assisted Cystectomy: Our Initial Experience

摘要

Robot assisted surgeries though still not very common are now being undertaken in many Institutes. All India Institute of Medical Sciences, N Delhi, India is the first in South East Asia to procure a da Vinci Robot (Intuitive Surgical, Sunnyvale, CA, USA.) for robot assisted urologic surgeries. Robot assisted cystectomies have recently been undertaken in our Institute. We will discuss the perioperative management, in the learning curve of surgeons and the anesthetists, of the first 9 cases of robot-assisted cystectomies with formation of ileal conduit. Introduction The patients were premedicated with tablet diazepam 10mg and tablet ranitidine150mg the night before and coming morning. In the operation theatre, a 16 G cannula was inserted in the non-dominant hand. After standard monitoring of ECG, SPO2, NIBP, a lumbar epidural catheter was inserted. The patient was induced with standard anesthetic technique followed by insertion of endotracheal tube not more than 1.5-2 cm beyond the vocal cords. Anesthesia was maintained with air: O2 or N2O: O2 mixture with 0.5-2 MAC of isoflurane and intravenous boluses of morphine to maintain entropy to about 60 or whenever hear rate or /and blood pressure increased to more than 20% with the same value of end tidal CO2. After induction, capnomac, entropy, airway pressure, temperature, flow volume loop was measured. Radial arterial line was inserted for invasive blood pressure monitoring and blood gases, if required. Central venous pressures were monitored by either cannulation of internal jugular vein (if the hematocrit was <27) or right cephalic or basilic vein.The patient was then strapped to the bed. Thermal blankets were put over legs and chest. The eyes were covered with paraffin gauze and padded. A ryles tube was inserted. Temperature was monitored with nasopharyngeal probe. The patient was gradually positioned in steep trendelenburg position of 30-45°, keeping a watch on airway pressure. The robotic ports were inserted and pneumopetonium was created. The ventilation was either pressure controlled or volume controlled to maintain end tidal CO2 to 38-40 mmHg. Epidural boluses or infusions were not used at this stage. A close watch on fluids was kept. Only replacement and maintenance fluids were given. If the central venous pressure showed a higher value ( > 30cm H2O), then fluids were further restricted by giving only colloids (Hetastarch). At the end of robotic assisted cystectomy, which requires about 3-5 hours, patient was made supine and ports were removed. We gave epidural bolus at this stage, 0.25% bupivacaine 10-12 ml with 3 mg of morphine after negative test dose of 3ml of xylocaine with adrenaline. The surgeons then make a midline infraumblical incision to construct an ileal conduit. The central venous pressure and conjunctival edema were checked at this stage. If the CVP was still raised and/or with there is moderate to severe conjunctival edema, a bolus of furosemide 5-10 mg was given. The making of an ileal conduit till completion of surgery requires about 2-3 hours. Towards the end of surgery, ondanseteron 4-8 mg was given intravenously. The trachea was extubated on the operating table after reversal of muscle relaxants. Postoperatively, patients are usually kept in high dependency unit for 24 hours with epidural boluses/infusions, with rescue analgesia with either morphine 3 mg or tramadol 1mg/kg. Results 9 patients were operated for robot-assisted cystectomy with ileal conduit from January 2006 to December 2006. Out of these, 1 patient was converted to open procedure after 2 hours of anesthesia because of adherent tumour tissue to iliac vein. Out of these 7 were male patients and 1 was a female patient.The average age of the patients was 64.6 years with an average weight of 52 kg. Average time of anesthesia was 7.8 hours, with 10 hours anesthesia required for the female patient as ileal conduit was constructed robot assisted in this patient. Average anesthesia time in trend