Hysterectomy, Da Vinci Robotic-assisted Laparoscopic

Hysterectomy is the second most performed operation in the US after C-section.  Age range 30-90s years. Stress, urinary incontinence, and obesity are associated conditions.

Preop diagnosis

Uterine myoma (38% - can cause bleeding and infertility)

Malignancy (15%)

Pelvic pain or adhesions (5%)

Ovarian tumors (10%)

Uncontrolled uterine bleeding/dysmenorrhea (13%)

Adenomyosis (9% - ectopic glandular tissue in muscle)

Endometrial hyperplasia (3%)

Uterine prolapse (1%)

Less common are pelvic infections, complications from pregnancy, and delivery

Two possible approaches with several variations/combinations - Vaginal or abdominal, both receive pre-op antibiotics (Cefoxitin or Cefotan and Clindamycin).

Total Laparoscopic hysterectomy (TLH)

Advantages

Excellent visibility and exposure

Shorter recovery time

Rapid return of bowel function

Less pain

Lower wound complication rate

Disadvantages

Higher cost

Requires an increased level of surgical expertise

Procedures

Laparoscopic access to the abdomen via a Veress Needle or direct-trocar insertion, followed by CO2 insufflation and insertion of accessory trocars. CO2 insufflation to around 15 mmHg (pneumoperitoneum) for a better view. A diagnostic laparoscopy was performed. The course of ureters was noted, and the surrounding tissues were dissected to the free uterus. The bladder is also freed—possible use of 5-10 mL indigo carmine IV to verify intactness of bladder (can cause increased BP). The course of the ureters is noted through the peritoneum until they are no longer visible at the level of the cardinal ligaments (contains uterine artery and vein). The peritoneum is opened above or below the ureter, and hydro dissection (using an injection of water) is performed to lift the peritoneum off the ureter without damaging it. Hydro dissection can help identify tissue planes and limit blood loss (bleeding caught early).

If the uterus were removed via the vagina, pneumoperitoneum would be lost. Still, since the procedure is done laparoscopically, the pneumoperitoneum can be maintained by placing a glove with 2 4x4s in the vagina where the vaginal wall is cut circumferentially. The uterus pulled to mid-vagina, thus keeping the pneumoperitoneum. The vaginal cuff is closed transversely using laparoscopic sutures; any coexisting cystocele or enterocele is repaired.

Another option is morcellation of the uterus and removal via a 10-mm suprapubic port or placement in a specimen bag, which is removed via a small suprapubic incision. A mini-laparotomy is indicated for an enlarged uterus.

The abdominal cavity was reevaluated, irrigated, and cleared for blood and debris. Incisions closed.

Da Vinci Robot

Minimally invasive

The surgeon sits at a console away from the and has a three-dimensional view, 10x magnification, and manipulating instruments

Improved precision due to the robot's ability to reduce any surgical hand tremor using size scaling (5cm can be 1cm)

Outcomes improve with surgical volume and surgeon experience

Reduced blood loss, reduced analgesic requirements, reduced length of stay

Pt information pre-op

Swelling to face and eyes post-surgery

Possible throat soreness/hoarseness after ETT

Possible left shoulder pain after pneumoperitoneum

Allow time for set-up in the room.

EBL

100-800 depending on anatomy and dissection

Mortality

0.08-0.2/1,000

Morbidity

2.5% - overall complication rate

4.2/1,000 - conversion to laparotomy

Rare

• Air embolism, peroneal nerve damage from lithotomy, puncture of major vessel or viscous, insufflation of incorrect site

1.6% - urinary and ureteral trauma, including fistula

Pain score

6-9

Positioning

Lithotomy

High risk of neurological and vascular complications

Both legs should be simultaneously elevated and flexed at the hip to prevent hip dislocation or postoperative back and hip pain. Allen universal stirrups are used.

Check and pad pressure points, check eyes

Common peroneal nerve injury

Most common nerve injury with lithotomy position (Foot drop, lower-extremity paresthesia)

• Peroneal nerve damage can be prevented by padding the area of the leg that is leaning against stirrups (or padding the stirrup) and preventing hyperflexion of the hip, which can cause femoral and lateral femoral cutaneous nerve palsy, obturator and saphenous nerve injury

Femoral nerve or lumbosacral plexus stretch injuries

Caused by acute abduction and external rotation of the hips

Arterial or venous occlusion and nerve injury

Flexion of hips >90 degrees can cause kinking or compression of femoral neurovascular structures

Obstruction of the popliteal vein

Impeding venous outflow due to extreme flexion of the knee

Compromise of the vascular structures in the popliteal space from leg holders supporting the leg under the knee

Possible finger injury

When hands are tucked, and manipulation of the foot of the bed is happening without paying attention to the hands

• Consider arms to side with padding if possible or wrap hands

Ulnar nerve injury

Ulnar neuropathy is more frequently associated with preexisting asymptomatic neuropathy, prolonged hospital stays, and extremes of body habitus

Symptoms include numbness/tingling in the 4th and 5th finger, in severe cases, a "claw-like" deformity

• Prevent with hands supinated, < 90 degrees

Brachial plexus injury

Prevent with arm < 90degrees

Avoid pulling/stretching

Steep Trendelenburg

Help surgical visualization

Normotensive pt compensates for increased CVP and PAP with vasodilation and decreased HR due to stimulation of baroreceptor reflex.

Hypotensive pt may not be able to respond in the same manner.

Hypovolemia can be unrecognized in the lithotomy and Trendelenburg position, as MAP can appear normal.

Cardiac patients

Trendelenburg may increase myocardial work due to increased CVP, SV, and CO

• Pt may not be able to tolerate - may decrease CO

If PVD: increased risk of ischemia

POVL (post-operative vision loss) due to increased ocular venous pressure and a simultaneous decrease in perfusion pressure.

Anesthetic considerations

GA is needed due to pneumoperitoneum, the need for a muscle relaxant, and the management of patient discomfort—often shoulder and chest discomfort with pneumoperitoneum.

ETT to prevent any aspiration and possible OGT

Preoperative Considerations

Monitors

IV x 2, pulse ox x 2, ECG, NIBP x 2, Temp, Bair hugger. PNS if using muscle relaxants.

Antibiotics per surgeon

Possible Cefazolin

Incision

Laparoscopically with insertion of abdominal trocars.

Surgical time

2-6 hrs, depending on possible adhesions or endometriosis issues

Preop area

Verify NPO, consent signed, questions answered, then Versed 2 mg, Robinul 0.2mg IV

Induction

Preoxygenation

Lidocaine 1 mg/kg/IV

Propofol 1-2 mg/kg/IV

Fentanyl 1-3 mcg/kg/IV

Succinylcholine 0.5-1.5 mg/kg

LTA with ETT

Maintenance

Isoflurane

Vecuronium or Atracurium

Fentanyl

Emergence

Reverse with Neostigmine and glycopyrrolate, or sugammadex

Zofran 4mg IV

Toradol 30mg IV if ok with the surgeon (note renal issues, asthma, coagulation)

Avoid coughing on extubation and consider the use of lidocaine IV and via ETT

Consider deep extubation (spontaneous ventilation, suctioned, emerge on a mask)

Pneumoperitoneum   

Provides a view of the surgical area, room for instruments to move

There is a high risk for complications as the inferior vena cava, aorta, iliac arteries, and veins, as well as bladder, bowel, and uterus are close to the infraumbilical site

Gas embolism symptoms

Hypotension, dysrhythmias, cyanosis, pulmonary edema, Millwheel murmur.

Release Pneumoperitoneum, place on the left side and aspirate air if possible via CVP line

Risk of pneumothorax due to barotrauma (increased PIP due to decreased pulmonary compliance)

Left shoulder pain (CO2) - diaphragmatic irritation - alleviate with three big breaths after CO2 is released before the closure of the abdominal wall

Increased intraabdominal pressure, which predisposes to passive gastric regurgitation

Possible OG to decompress and minimize the risk of aspiration.

Increased intraabdominal pressure also appears to decrease splanchnic perfusion and hepatic blood flow significantly

Try to keep intra-abdominal pressure <15mm Hg

Advantages

Decreased post-op pain, less post-op pulmonary impairment, reduction in post-op ileus, shorter hospital stay, earlier ambulation, and smaller incision.

Complications

Brady dysrhythmias - see under cardiac

Bleeding - vascular puncture rare

• Hypothermia - secondary to large fluid volumes

Use a fluid warmer and Bair hugger

Extra-abdominal insufflation

• Possible VAE or subcutaneous air, which can compromise the airway in some cases

Neuropathies from Lithotomy position

Fluid overload - risk of CHF, edema

Organ considerations

Respiratory

Increased risk of atelectasis, decreased FRC, VC, and compliance

Increased Peak airway pressure and ventilation-perfusion mismatch (shunt with under ventilation compared to perfusion)

Pulmonary congestion and edema

Risk of hypercarbia from absorbed CO2, monitor ETCO2 and decreased PaO2

Avoid Nitrous oxide as it can diffuse into CO2-containing intraabdominal space and increase distention

Trendelenburg with increased risk of R main stem intubation

Reverse Trendelenburg with increased FRC and decreased work of breathing

Cardiac

May have ascites and pleural fluid present if cancer is involved. Evaluate pt for SOB and any underlying respiratory diseases

Evaluate exercise tolerance/cardiac status

Decreased venous return, decreased CO, and increased SVR

Increased MAP, increased HR (baroreceptor response)

Bradycardia due to peritoneal or fallopian-tube stimulation

• Stop the surgery, deflate Pneumoperitoneum, and administer Atropine 0.5mg  or glycopyrrolate 0.4-0.6 mg

Trendelenburg's position increases intrathoracic pressures (cephalad displacement of abdominal contents), which activates the baroreceptor reflex through CN IX in the carotid and CN X in the aortic arch, leading to increased PNS and decreased SNS activity.

Celiac reflex can be initiated indirectly because of Pneumoperitoneum

• The symptoms are bradycardia, apnea, and hypotension

Gastrointestinal

Dehydration and electrolyte abnormalities due to bowel prep/poor appetite

Higher risk for N/V

• Premedicate with ZRA (Zofran, Reglan, antacid)
  • Treat with Zofran and Decadron intraoperatively

Labs

Low H&H if persistent bleeding, so check H&H preop, T&C if indicated

F/C to monitor output/bleeding

Other

Muscle relaxant if laparoscopic procedure - reversal with neostigmine and Glycopyrrolate

Neuromuscular blockade

• Lower insufflation pressures, better visualization, prevent movement

Warm fluids, heat, and humidify gases

Pain

Consider IM/IV morphine for pain management post-op

Possible Toradol, if ok with the surgeon

Postoperative complications

PONV

VTE

Hypothermia