Anesthetic Management during Robotic-Assisted Minimal Invasive Thymectomy Using the Da Vinci System: A Single Center Experience

Abstract

: Background: Robotic-assisted surgery is gaining more adaption in different surgical specialties. The number of patients undergoing robotic-assisted thymectomy is continuously increasing. Such procedures are accompanied by new challenges for anesthesiologists. We are presenting our primary anesthesiologic experience in such patients. Methods: This is a retrospective single center study, evaluating 28 patients who presented with thymoma or myasthenia gravis (MG) and undergone minimal invasive robotic-assisted thoracic thymectomy between 01/2020–01/2022. We present our fast-track anesthesia management as a component of the enhanced recovery program and its primary results. Results: Mean patient's age was 46.8 ± 18.1 years, and the mean height was 173.1 ± 9.3 cm. Two-thirds of patients were female (n = 18, 64.3%). The preoperative mean forced expiratory volume in the first second (FEV1) was 3.8 ± 0.7 L, forced vital capacity (FVC) was 4.7 ± 1.1 L, and the FEV1/FVC ratio was 80.4 ± 5.3%. After the creation of capnomediastinum, central venous pressure and airway pressure have been significantly increased from the baseline values (16.5 ± 4.9 mmHg versus 13.4 ± 5.1 mmHg, p < 0.001 and 23.4 ± 4.4 cmH2O versus 19.3 ± 3.9 cmH2O, p < 0.001, respectively). Most patients (n = 21, 75%) developed transient arrhythmias episodes with hypotension. All patients were extubated at the end of surgery and discharged awake to the recovery room. The first 16 (57.1%) patients were admitted to the intensive care unit and the last 12 patients were only observed in intermediate care. Postoperatively, one patient developed atelectasis and was treated with non-invasive ventilation therapy. Pneumonia or reintubation was not observed. Finally, no significant difference was observed between MG and thymoma patients regarding analgesics consumption or incidence of complications. Conclusion: Robotic-assisted surgery is a rapidly growing technology with increased adoption in different specialties. Fast-track anesthesia is an important factor in an enhanced recovery program and the anesthetist should be familiar with challenges in this kind of operation to achieve optimal results. So far, our anesthetic management of patients undergoing robotic-assisted thymectomy reports safe and feasible procedures.

Cardiac Tamponade Caused By Carbon Dioxide Insufflation During Robot-Assisted Thoracic Surgery: A Case Report

“…RATS for mediastinal masses is considered noninferior to thoracoscopic and open chest surgeries in terms of safety. 1 Anesthesia methods may not differ significantly 6 ; however, careful anesthesia management is necessary to address specific hypotension during RATS. The unique causes of hypotension during RATS include CO 2 insufflation, potentially producing pneumomediastinum, organ compression by the robotic arms and forceps, and tension pneumothorax.…”

Advancing airway management for enhanced patient outcomes: a narrative review

“…Although evidence accumulation is not easy and unpractical in emergency response, there are various case reports on the airway management trouble during the maintenance of anesthesia. 21,22,23 Sudden airway loss in the prone position is a high risk, especially during robot-assisted surgery. 24 Pneumothorax or asthma attack is also a high-risk complication during mechanical ventilation.…”

Predictive factors for postoperative myasthenic crisis in patients with myasthenia gravis

“…In recent years, with the development of minimally invasive surgical techniques and the idea of fast-track surgery, early extubation after thymectomy in MG patients has been gradually accepted [ 6 , 7 ]. This procedure could reduce the risk of postoperative pulmonary infection and the length of intensive care unit (ICU) stay [ 8 ].…”