The development of “minimally invasive surgery” or “minimal access surgery” has revolutionized the field of surgery. The growth of laparoscopic surgical procedures is due to the use of smaller incisions that reduce surgical stress and postoperative pain as well as reduce overall morbidity, thus resulting in rapid recovery, earlier ambulation, shorter hospital stay, and rapid return to daily living activities (Table 43-1). These benefits are achieved without compromising surgical outcomes.¹,²,³,⁴,⁵,⁶ In addition, a minimally invasive approach has allowed several procedures to be performed on an outpatient basis, where previously a hospital stay was necessary.⁷,⁸,⁹,¹⁰,¹¹ Furthermore, it has allowed the implementation of rapid rehabilitation recovery programs that have been shown to further improve perioperative outcome and reduce hospital stay.¹² Overall, there is potential for significant cost savings.

With growing surgical expertise and continuing improvements in technology, more extensive laparoscopic procedures are being performed in a wide range of patients, including morbidly obese, older, and sicker patients with significant comorbidities as well as pregnant and pediatric patients.¹ However, conventional laparoscopy has several technical limitations, such as reduced range of motion and instrument dexterity as well as a two-dimensional view of the operative field.⁶ Technologic advances in computer power and robotic engineering have allowed us to address some of these limitations. Robotic surgery improves depth perception through a high-definition, magnified, and three-dimensional view of the operative field and provides intuitive instrument control that mimics natural hand and wrist movements and eliminates surgeon tremor. Overall, robotic surgery enhances surgeons’ skills and thus has the potential to transform technically challenging open or laparoscopic procedures, particularly those requiring improved visualization and/or complex reconstruction necessitating extensive suturing, into technically feasible minimally invasive procedures. Robotic surgery can be applied to virtually every surgical subspecialty (e.g., general, colorectal, head and neck, gynecologic, thoracic, and cardiac surgeries). The advantages of robotic surgery are expected to broaden the application of the minimally invasive surgical paradigm.

Despite the potential advantages of laparoscopic and robotic surgeries, they are associated with significant physiologic changes as well as new complications (some potentially life-threatening) that are usually not seen with the traditional open approach ¹ (Table 43-2). In addition, robotic procedures can have significantly prolonged operative times and require patients to be placed in extreme positions. Because the robotic system is large, it limits the access to the patient and invades the anesthesia working space. Overall, this presents significant challenges in anesthetic management. Therefore, a thorough understanding of potential physiologic changes and perioperative complications associated with laparoscopic and robotic surgeries is necessary to provide optimal patient care and improve perioperative morbidity and mortality.

This chapter discusses the anesthetic management of adult patients undergoing laparoscopic and abdominal robotic surgeries. However, endoscopic and robotic cardiac and thoracic surgeries (e.g., video-assisted thoracic surgery [VATS]) that are increasingly performed are discussed elsewhere (Chapter 37).

Laparoscopic procedure entails intraperitoneal insufflation of carbon dioxide (CO₂) to create pneumoperitoneum that allows surgical exposure and manipulation. Carbon dioxide is used because it is noncombustible and more soluble in blood, which increases the safety margin and decreases the consequences of gas embolism. Unlike nitrous oxide (N₂O), CO₂ does not support combustion and, therefore, can be used safely with diathermy. Compared to helium, the high blood solubility of CO₂ and its capability for pulmonary excretion reduce the risk of adverse outcomes in the event of gas embolism. An abdominal wall lift system (i.e., a gasless laparoscopy) has been developed to achieve surgical space while avoiding the cardiopulmonary effects of CO₂ pneumoperitoneum.¹³ Although this approach appears to be safe,
it has not been accepted in routine clinical practice because it increases operating times and surgical costs without improving clinical outcomes.¹³

The initial access necessary for CO₂ insufflation could be achieved either through a blind insertion of a Veress needle that consists of a blunt-tipped, spring-loaded inner stylet and sharp outer needle through a small subumbilical incision or a trocar inserted under direct vision. The open insertion of the trocar using a minilaparotomy approach guarantees safe creation of pneumoperitoneum and avoids the dangers of blind insertion.

Upon confirmation of appropriate placement, a variable flow electronic insufflator that automatically terminates gas flow at a preset intra-abdominal pressure (IAP) is used to achieve pneumoperitoneum. It is standard of care to maintain the IAP below 15 mm Hg, because higher pressures can have significant physiologic consequences and can increase the incidence of intraoperative complications. An access port is then inserted in place of the needle to maintain insufflation during the procedure. A video laparoscope, inserted through the port, allows visualization of the operative field. Additional access ports are inserted through a number of small skin incisions, which allow the introduction of surgical dissection and suction instruments. The secondary ports are placed under direct vision, preferably with the help of transillumination of the abdominal wall to identify superficial abdominal wall vessels.

The Da Vinci Surgical System (Intuitive Surgical Inc., Sunnyvale, California) is the most common robotic platform used currently. It consists of three components: a control console where the surgeon sits and operates the robotic arms and camera (Fig. 43-1), an equipment tower that includes an optical system, and the patient side cart that includes robotic arms.³,⁴,⁶ Similar to a laparoscopic procedure, robotic surgery involves development of pneumoperitoneum and placement of a video camera (a high-definition three-dimensional vision system) and ports. This is followed by placement of the robotic arms, a crucial and tedious part of the procedure (Fig. 43-2). An assistant is at the patient side for suctioning, retraction, and passage of suture or sponges.

Patient position during minimally invasive surgery varies significantly based on the surgical procedure. Patients undergoing upper abdominal procedures require a reverse Trendelenburg (head-up) position, while those undergoing lower abdominal procedures require Trendelenburg (head-down) position. The head-up or head-down position can be steep. In addition, the operating tables may be rotated laterally (right or left lateral) to further facilitate surgical exposure. Also, patients undergoing pelvic surgery (e.g., radial prostatectomy and hysterectomy) may be placed in a lithotomy position. Patients undergoing urologic surgery, particularly renal procedures, may be placed in lateral or semilateral positions combined with a flexion (i.e., jackknife) position. The considerations related to patient positioning are discussed in Chapter 28.

The physiologic consequences of laparoscopy can be complex and depend on the interactions between the patient’s pre-existing cardiopulmonary status and surgical factors such as the magnitude of IAP, degree of CO₂ absorption, alteration of patient position, and the type of surgical procedure.²,¹⁴,¹⁵ In addition, the anesthetic technique may influence the physiologic changes; however, these effects may be minimal with modern anesthetic techniques. Of note, physiologic changes are well tolerated by most healthy patients; however, they could have adverse consequences in patients with limited cardiopulmonary reserve.

An optimal anesthetic technique would provide excellent intraoperative conditions while ensuring rapid recovery and low incidence of adverse effects as well as allowing early return to daily living activities.³⁹,⁴⁰ Local and regional anesthesia (spinal and epidural) can be used for shorter laparoscopic procedures, such as diagnostic laparoscopy, which requires lower IAP and minimal head-down tilt.⁴⁰,⁴¹ Nevertheless, patient discomfort associated with creation of pneumoperitoneum and extreme position changes during the procedure can be significant. In addition, neuraxial anesthesia can cause significant sympathetic denervation, which may be associated with adverse ventilatory and circulatory responses, complicating perioperative management. Therefore, balanced general anesthesia with tracheal intubation and mechanical ventilation with acceptance of higher end-tidal carbon dioxide levels remains the best practice for minimally invasive surgical procedures.