Anesthetic issues for robotic cardiac surgery

Unilateral Pulmonary Edema After Robotically Assisted Mitral Valve Repair Requiring Veno-Venous Extracorporeal Membrane Oxygenation

Unilateral pulmonary edema (UPE) is an uncommon yet potentially life-threatening complication of minimally invasive cardiac surgery (MICS). Most frequently described after robotically assisted mitral valve (MV) repair, it is characterized by right lung edema, hypoxemia, hypercapnia, pulmonary hypertension, and hemodynamic instability beginning minutes-to-hours after separation from cardiopulmonary bypass (CPB). The authors describe a severe case with refractory hypoxemia requiring veno-venous (VV) extracorporeal membrane oxygenation (ECMO) after robotically assisted MV repair.

Robot-assisted coronary artery bypass surgery: a systematic review and meta-analysis of comparative studies

BACKGROUND

Robot-assisted coronary bypass (RCAB) surgery has been proposed as an alternative to conventional coronary artery bypass grafting (C-CABG) for managing coronary heart disease, but the evidence on its performance compared to other existing treatments is unclear. The aim of this study was to assess, through a systematic review of comparative studies, the safety and clinical effectiveness of RCAB compared to C-CABG and other minimally invasive approaches for the treatment of coronary heart disease.

METHODS

We conducted a systematic review of primary studies in the English-language literature comparing RCAB to existing treatment options (C-CABG, minimally invasive direct coronary artery bypass [MIDCAB] and port-access coronary artery bypass [PA-CAB]) following Cochrane Collaboration guidelines. Meta-analyses were performed where appropriate.

RESULTS

We reviewed 13 studies: 11 primary studies of RCAB (v. C-CABG in 7, v. MIDCAB in 3 and v. PA-CAB in 1) and 2 multicentre database studies (RCAB v. non-RCAB). The overall quality of the evidence was low. Most studies showed no significant benefit of RCAB over other treatments in a majority of outcome variables. Meta-analyses showed that RCAB had lower rates of pneumonia or wound infection than C-CABG, and shorter intensive care unit length of stay than C-CABG or MIDCAB. Individual studies showed that RCAB had some better outcomes than C-CABG (ventilation time, transfusion, postoperative pain, hospital length of stay) or MIDCAB (transfusion, postoperative pain, time to return to normal activities, physical functioning and hospital length of stay). The review of the database studies showed that RCAB was statistically superior to non-RCAB approaches in postoperative pain, renal failure, transfusion, reoperation for bleeding, stroke and hospital length of stay; however, the difference between the 2 groups in several of these outcomes was small.

CONCLUSION

Although the findings from this review of comparative studies of RCAB appear promising and suggest that RCAB may offer some benefits to patients, in the absence of randomized controlled trials, these results should be interpreted cautiously.

Cardiothoracic robotic assisted surgery in times of COVID-19

The coronavirus disease 2019 (COVID-19) pandemic poses an immense threat to healthcare systems worldwide. At a time when elective surgeries are being suspended and questions are being raised about how the remaining procedures on COVID-19 positive patients can be performed safely, it is important to consider the potential role of robotic assisted surgery within the current pandemic. Recently, several robotic assisted surgery societies have issued their recommendations. To date, however, no specific recommendations are available for cardiothoracic robotic assisted surgery in COVID-19 positive patients. Here, we discuss the potential risks, benefits, and preventive measures that need to be taken into account when considering robotic assisted surgery for cardiothoracic indications in patients with confirmed COVID-19. It is suggested that robotic assisted surgery might have various advantages such as early recovery after surgery, shorter hospital stay, and reduced loss of blood and fluids as well as smaller incisions. However, electrosurgical and ultrasonic devices, as well as CO2 insufflation should be managed with caution to prevent the risk of aerosolization of viral particles.

Robotic Cardiac Surgery Part II: Anesthetic Considerations for Robotic Coronary Artery Bypass Grafting

Coronary artery bypass grafting represents one of the most commonly performed cardiac surgeries worldwide. Recently, interest has increased in providing patients with a less invasive approach to cardiac surgery, such as thoracotomy and endoscopic techniques using robotic technology as an alternative to traditional sternotomy. As the population gets older, the need for additional methods to provide care for sick patients will continue to expand. These advancements will further allow physicians to provide cardiac surgical procedures with less pain and faster recovery for patients.

Minimal volume ventilation during robotically assisted mitral valve surgery

INTRODUCTION

A minimal volume ventilation method for robotically assisted mitral valve surgery is described in this study. In an attempt to reduce postoperative pulmonary dysfunction, 40 of 174 patients undergoing robotically assisted mitral valve surgery were ventilated with a small tidal volume during cardiopulmonary bypass.

METHODS

After propensity score matching, 31 patients with minimal volume ventilation were compared with 54 patients with no ventilation. Total ventilation time, PaO₂/FiO₂ ratio, arterial lactate concentration, and the rate of unilateral pulmonary edema in the matched minimal ventilation and standard treatment groups were evaluated.

RESULTS

Patients in the minimal ventilation group had shorter ventilation times, 12.0 (interquartile range: 9.9-15.0) versus 14.0 (interquartile range: 12.0-16.3) hours (p = 0.036), and lower postoperative arterial lactate levels, 0.99 (interquartile range: 0.81-1.39) versus 1.28 (interquartile range: 0.99-1.86) mmol/L (p = 0.01), in comparison to patients in the standard treatment group. There was no difference in postoperative PaO₂/FiO₂ ratio levels or in the rate of unilateral pulmonary edema between the groups.

CONCLUSION

Minimal ventilation appeared beneficial in terms of total ventilation time and blood lactatemia, while there was no improvement in arterial blood gas measurements or in the rate of unilateral pulmonary edema. The lower postoperative arterial lactate levels may suggest improved lung perfusion among patients in the minimal volume ventilation group. The differences in the ventilation times were in fact small, and further studies are required to confirm the possible advantages of the minimal volume ventilation method in robotically assisted cardiac surgery.

Anaesthetic issues in robotic-assisted minimally invasive surgery

Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.

Medical robots in cardiac surgery - application and perspectives

Medical robots offer new standards and opportunities for treatment. This paper presents a review of the literature and market information on the current situation and future perspectives for the applications of robots in cardiac surgery. Currently in the United States, only 10% of thoracic surgical procedures are conducted using robots, while globally this value remains below 1%. Cardiac and thoracic surgeons use robotic surgical systems increasingly often. The goal is to perform more than one hundred thousand minimally invasive robotic surgical procedures every year. A surgical robot can be used by surgical teams on a rotational basis. The market of surgical robots used for cardiovascular and lung surgery was worth 72.2 million dollars in 2014 and is anticipated to reach 2.2 billion dollars by 2021. The analysis shows that Poland should have more than 30 surgical robots. Moreover, Polish medical teams are ready for the introduction of several robots into the field of cardiac surgery. We hope that this market will accommodate the Polish Robin Heart robots as well.

Anesthetic considerations in robotic mitral valve surgery

The robotic approach to cardiac surgery offers patients numerous potential advantages compared with a traditional sternotomy approach including shorter hospital length of stay, reduced pain, fewer blood transfusions, and a quicker return to normal daily activities. At the same time, robotic cardiac surgery requires that the anesthesiologist employs several subspecialty skillsets in order to provide optimal care for these patients. Multiple different regional anesthesia techniques may be used to improve analgesia, reduce opioid dosages, and facilitate rapid extubation at the conclusion of the case. Several peripheral cannulation strategies for cardiopulmonary bypass (CPB) exist and the anesthesia team may assist with percutaneous cannulation of the superior vena cava (SVC) or positioning of an endo-pulmonary vent. Similarly the anesthesiologist may be asked to percutaneously cannulate the coronary sinus for retrograde cardioplegia delivery. The need for one-lung ventilation (OLV) and heavy reliance on transesophageal echocardiography (TEE) occupy much of the anesthesiologist's attention during these cases. Variations in institutional practice exist. Reviews of current practice and future studies may help refine the anesthetic approach to robot-assisted cardiac surgery.