Anesthetic Considerations for Robotic Assisted Vats/Lobectomy

Anesthetic Considerations for Robotic Assisted VATs/Lobectomy

Basics: 2 large bore IV’s with adequate extension tubing, A-line with extension tubing, double lumen tube, fiber optic bronchoscope, central line if indicated.

Positioning: After intubation the patient will be turned clockwise 90 degrees. Depending on which lung they are operating on they will be in the either left or right lateral decubitus position (either facing you or facing away from you). The patients arms will be in front of them in a modified prayer position utilizing an arm board and pillows between their arms. It will be necessary to adequately pad and secure the arms using tape in as much of an anatomically acceptable position as possible. The robot will dock over the head of the bed above the patient. Always be mindful of the robot arms and where they are moving in regards to your patient. Once the patient is positioned, draped, and the robot docked it is extremely difficult to access the patient. Make sure your IV’s are running and you are able to draw back on your a-line prior to draping and docking. Additionally, the Surgeons will often find their way into the space between you and the patient – they will step on your tubing and vent circuit so be aware.

Pre-Op set-up: Type and cross for PRBC’s. Make sure blood products are available quickly as it can take up to 15 minutes to undock the robot and open equipment for the surgeons to open in the event of catastrophic bleeding. You will need at least 1 extension on all IV tubing lines and your a. line pressure tubing. It may also be helpful to put an extension on your phenylephrine pump so that you can attach it proximal to the patient – I would do this before the case begins because it will be hard to attach once the patient is draped. Have the FOB at the head of the bed (there will not be much space) it will be just long enough to confirm placement after you are positioned. Once the patient is positioned be mindful of where the tubing and circuit are located – make sure they have a low profile and the robot (or surgeon) will not be able to extubate your patient under the drapes.

Intra-Op: It is very important to keep the patient fully relaxed while the robot is docked but there is no good place to monitor for a TOF – consider a foot. Additionally, they will use insufflation so keep an eye on your BP.

Pain Management: They will generally not need an epidural but there will be 4-5 port sites so loading with a long acting narcotic is not a bad idea. Remind to surgeon to use local. Paravertebral blocks are a good post op rescue if needed.