Comments from 1st case:
A. Trendelenburg: about 30 degree angle, both arms tucked
I had problems with pulse oximetry initially, as the regular
slide-on finger probe was compressed by the weight of the
patient's buttock(s), and the signal became progressively
weaker, subsequently non-functional. So I tried a number of
positions on the face, earlobe, nose, cheek, etc., but those too
didn't work, presumably from the venous congestion due to
the steep T-Berg. So I asked the circulator to slither
under the drapes and try to free up the hand and restore
circulation, which she did, and I had no further problems. I can
see real problems in wide-body patients, though, and I wonder if
the clear plastic toboggan(s) might be a good solution.
Also, these first cases are going to be LONNNGGGG. I started at
8:30 (Thurs) and was relieved at 3:30; the case was still going
strong. That's a long time in the T-berg position, and
facial/neck/airway edema could be a real problem. If so, it may
be a good idea to leave the patient intubated, head-elevated, in
PACU for a couple of hours to let the edema subside. As
proficiency develops, these cases should last only 3- 3.5 hrs.
B. Estimating blood loss is almost impossible (just like
other open prostates). Yes you can measure suction and subtract
irrigation, but who knows how much blood is pooled up near the
diaphragm until you eventually level the patient out? The good
news is that blood loss seems substantially less, as there is
meticulous attention to hemostasis during the dissection.
C. Surgeons asked me to limit fluid replacement to
<1500 cc; the goal is to reduce urine output, as the bladder
is open much of the time and profuse urine production makes for
more difficult visualization. This request seemed reasonable for
a 3-4 hr case; when the case stretched on and on however, and
blood loss mounted, I had to
give more crystalloid. Excessive urine output was not a problem.
I did the Tegaderm trick to the eyelids; worked well I think.
The reasoning here is that steep Trendelenburg may cause oral
secretions to seep out onto the face, possibly dripping into
unprotected eyes and setting up a real good conjunctivitis.
Judiciously applied Tegaderm seals the lids and prevents this. Also Bair Hugger to the Torso (I used a pediatric
"Bottom" drape; maybe there are models for adult
torsos, but I couldn't find one)
Shoulder restraints: Surgeons don't want problems from
these any more than we do. They are trying various forms of
restraint. Today's method was lots of foam on the shoulders,
held on by tape, and then two velcro table restraints criss-crossed
like bandoliers across the chest. The patient was nice and thin,
and I think this worked well.
Peak Airway Pressures: With the T-Berg and abdominal
insufflation, I regularly ran Peak Airway Pressures of
38-42, despite my best efforts to adjust flow rates, tidal
volumes, etc. The cost of doing business, I guess. Also,
CO2 retention (EtCO2 in the 50-60 range)
can be a problem.
Anesthesia: I used Forane/fentanyl/O2/air (no nitrous);
Forane 1.5%-3.0% range (if running this for 6 hrs, good luck
waking up!!) But once that robot is in place, you really don't
want the patient moving around. I suppose I could have used a
lot of NMBs, and I would have if the patient didn't tolerate the
The robot itself is very cool. It offers significant advantages,
especially in tight places like the pelvis, and we're going to
see a lot more if it.