Here’s my technique for anaesthetising patients for robotic-assisted laparoscopic radical prostatectomy and I’d be interested to hear any thoughts, comments and ideas.
Pre-op. I try to fast the patients for as short a time as possible and also include pre-operative carbohydrate loading. This is in line with Enhanced Recovery After Surgery (ERAS) Guidelines for major bowel surgery and has been shown to reduce the negative nitrogen balance that occurs following major surgery. I use 200ml cartons of Polycal, which is clear and non-particulate, prescribed 12 and 3 hours pre-operatively. Clear fluids are encouraged up to 2 hours pre-op as this improves gastric emptying and minimises pre-operative dehydration.
Intra-op. I use a mixed technique of both general and regional anaesthesia. The general consists of a fairly standard technique with a Propofol induction and maintenance with Desflurane and a Remifentanil infusion. To reduce post-operative nausea and vomiting I use ondansetron, cyclizine and dexamethasone. The regional part is a spinal anaesthetic using 0.5% Hyperbaric Bupivacaine with additional intrathecal Diamorphine. Regional anaesthesia has been shown to reduce peri-operative DVT formation, probably by blocking sympathetic activity and improving blood flow through the legs, it also produces profound muscular relaxation enabling better pelvic vision and easier insufflation. In addition there is some evidence that appears to suggest regional anaesthesia may reduce the recurrence rate of prostate cancer. As the patients are positioned in a steep trendelenberg they are all intubated and ventilated with a small amount of additional PEEP to reduce pulmonary atelectasis.
Post-op. Intrathecal diamorphine usually provides 12-14 hours of good quality post operative analgesia. Intrathecal opiates act locally producing segmental analgesia and therefore do not produce the systemic side effects to the same degree as intravenous opiates. The ondansetron given peri-operatively may reduce the incidence of opiate induced pruritus as well as acting as an excellent antiemetic. Additional analgesia will be required but usually paracetamol and ibuprofen are sufficient. It is unusual for patients to require any additional stronger opioid medications and this is helpful in ensuring that gastric stasis and reduced gut motility do not occur. This enables the patients to be rapidly progressed on to a light solid diet that in turn further reduces the occurrence of a post-operative ileus.
Fluid Management. Using this starvation policy, patients should commence their surgery with only a minimum degree of dehydration. Remifentanil produces an extremely cardio-stable anaesthetic and with the patients being head down peri-operative hypotension is unusual. Should this however occur blood pressure should be maintained with the judicial use of vasopressors and fluid if necessary. Post-operative urine output can be maintained if required with plasma expanders and diuretics.
Richard Morey qualified from MHMS in 1987 and has been a Consultant Anaesthetist in SE London since 1997. His particular interests are ERAS/ Laparoscopic Surgery along with ENT and Difficult Airways.
I agree, the time course for your spinal injection of Bupivicaine should have it well fixed by the time they are head down. Post-op euphoria is not something we see as we have no access to diamorphine in Australia (just the intrathecal morphine). I had some experience with diamorphine used in an epidural when I was working in England. Micro doses of Naloxone helped alleviate symptoms in some patients in the same way that it can work with pruritis. I enthusiastically support the idea of a 'cancer anaesthetic' and stress response reduction (such as your spinal) may be a part of this. Beta blockers too? This may be a part of the statistical signal that occasionally gets picked up on cancer recurrence studies examining alterations in intra-operative anaesthesia techniques. Avoidance of opioids may also be a part of the potential benefit; many of the studies have not acknowledged the intense pro-opioid effect of the intra-operative Remifentanyl commonly used if the technique is done under regional anaesthesia. Difficult to know how to handle this. Thanks for your thoughts, Jonathan
Thank you for your description - a very useful discussion. I am an anaesthetist and also work with Declan and Jonathan and we have just finished looking at the anaesthesia for the first 2 years of the robotic prostatectomies in our hospital. The analgesia has been discussed already but the highest pain scores in PACU were low (median 4/10 IQR 0-5/10) so it seems that even without IT opioid pain is not a major concern. However, the 'cancer anaesthetic' is certainly something we should be striving to optimise.
In your comments you mention an operative time of 2 hours which is quite a bit faster than we usually see in our teaching setting - is this a fairly standard time in your institution? The times in the private sector are usually shorter but we are trying to strike a balance between efficiency and trainee experience.
We have certainly had a few challenges with ventilation at times due to the Trendelenburg positioning and the duration of the case and most of us are using a pressure controlled mode and accepting that the CO2 will be elevated by the end of he case. What ventilation strategy do you usually employ and do you find it troublesome to manage in these cases? Do you have any weight limitations on those accepted for robotic surgery?
Many thanks, Meg
Thanks for the comments.
There is no teaching component which probably explains the operative time being shorter than you experience. I haven't included induction time but in reality this is not usually much more than 15-20 mins including the performance of the spinal.
I agree ventilation can be tricky. I prefer volume control with the addition of 4-5cm PEEP. Whereas the mechanics of pressure control should provide better gas exchange I tend to find that fluctuating pressures within the abdominal cavity play havoc with minute volume and unless one is extremely vigilant can lead to significant hypoventilation. In reality most of the patients are not head down for more than 90 mins and so I have not had a major problem that hasn't been resolved by a a few minor ventilatory adjustments.
I am intrigued by your relatively low pain scores without the use of regional blockade. If not using spinals I have found that most of the patients still require supplemental opioids in recovery. Spinals plus 2 hour ops produce a pain score of 1-2 in recovery a situation I'm comfortable with.
Hope this is of interest
Richard