Robot-assisted thoracoscopic thymectomy: perianaesthetic concerns

Abstract

Background: Robot-assisted thoracoscopic thymectomy has brought new challenges to the anaesthesiologists. Here we present a study of 17 patients undergoing robotic thymectomy.

Patients and methods: The present study was a prospective study, which included 17 patients with myasthenia gravis scheduled for robot-assisted thoracoscopic thymectomy. Preoperatively, all scheduled medications were continued along with incentive spirometry.In the operating room, routine monitors were attached. Radial artery cannula and central venous catheter were inserted. Anaesthesia was induced with fentanyl, propofol and sevoflurane in oxygen and nitrous oxide. The neuromuscular blockade was achieved with atracurium. Airway was secured with double lumen tube. The capnography, entropy, neuromuscular junction and temperature monitoring were initiated. After patient positioning, one-lung ventilation was initiated prior to insertion of trocar. Thereafter, the robot was docked and surgery was started. During the surgical dissection, capnomediastinum was created. At the end of the surgery, double lumen tube was changed to single lumen endotracheal tube size. After extubation in ICU, continuous positive airway pressure of 5 mmHg was administered.

Results: Intraoperatively, all patients had transient episodes of arrhythmias and hypotension. The airway pressure increased from 23.7 +/- 2 to 28 +/- 2.7 cmH2O and central venous pressure increased from 12.9 +/- 1 to 19.2 +/- 1.6 mmHg after creation of capnomediastinum. The accidental rent in the right-sided pleura occurred in two patients. Intraoperatively, ventilatory difficulty was encountered in another two patients. One patient had brachial plexus injury. Two patients had hoarseness of voice.

Summary: Refinement of the surgical technique is required to avoid compression by robotic arms on any portion of the patient, particularly the upper extremities. The use of beanbag for positioning of the ipsilateral arm needs to be evaluated further. The double lumen tube is to be positioned in such a way as to avoid any obstacle in the movement of robotic arm. We suggest pulse oximeter and arterial blood pressure monitoring in the abducted arm ipsilateral to the surgical approach. The airway pressure and capnography are to be monitored continuously for detection of capnothorax. Patient of robot-assisted thoracoscopic thymectomy should be observed for any nerve injury.