Robotic Patient selection

[turnupthevapor]

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Tommorows Robotic prostatectomy:

70 y/o 280lb, 6'2"

My question for postulating is:

Should this surgery be offered to patients like this who are guaranteed to have peak airway pressures of 40+++ for 6 hours and hanging over the sides of the bed putting them at risk for every nerve injury known to mankind. especially considering our surgeons have slow operative times (6-7 hours)

Are patients this size routinely done with Mr. Roboto?

👍 or 👎

 

[TheEleventhReel]

It seems like all of our patients scheduled for robotic TAH/BSO have a BMI of 40+.

 

[imfrankie]

Tommorows Robotic prostatectomy:

70 y/o 280lb, 6'2"

My question for postulating is:

Should this surgery be offered to patients like this who are guaranteed to have peak airway pressures of 40+++ for 6 hours and hanging over the sides of the bed putting them at risk for every nerve injury known to mankind. especially considering our surgeons have slow operative times (6-7 hours)

Are patients this size routinely done with Mr. Roboto?

👍 or 👎

Interesting point--the weenie still works but the other plexii don't.

 

[Trisomy13]

Are patients this size routinely done with Mr. Roboto?

👍 or 👎

One of our bariatric surgeons does a lot of his lap roux-en-Y cases with the Da Vinci.

So yeah, lotsa big puffies get the million dollar time waster applied to their abdomen.

 

[RxBoy]

Tommorows Robotic prostatectomy:

70 y/o 280lb, 6'2"

My question for postulating is:

Should this surgery be offered to patients like this who are guaranteed to have peak airway pressures of 40+++ for 6 hours and hanging over the sides of the bed putting them at risk for every nerve injury known to mankind. especially considering our surgeons have slow operative times (6-7 hours)

Are patients this size routinely done with Mr. Roboto?

👍 or 👎

All surgeons care about is if you can ventilate (meaning enough to keep them alive). They don;t care about the subsequent ALI or pneumonia it will cause. I think surgeons can bill more for the robots. In any case I totally agree with you, ASA should have some say on the patient qualifications.

Had a pt in her 20s with a BMI of 40+ for davanci myomectomy. Patient lost 3 liters of blood before they decided to open (of course they didn't know it was 3 liters because it was all sitting in the lower abdomen even though I kept telling them her HR is climbing/BP decreasing). Patient ended up in the ICU on the vent. So much for "minimally invasive". Luckily for her she was back on the floor the next day.

We just started doing robotic thoractomies at my place too.... take about a **** show.

 

[B-Bone]

All surgeons care about is if you can ventilate (meaning enough to keep them alive). They don;t care about the subsequent ALI or pneumonia it will cause. I think surgeons can bill more for the robots. In any case I totally agree with you, ASA should have some say on the patient qualifications.

Had a pt in her 20s with a BMI of 40+ for davanci myomectomy. Patient lost 3 liters of blood before they decided to open (of course they didn't know it was 3 liters because it was all sitting in the lower abdomen even though I kept telling them her HR is climbing/BP decreasing). Patient ended up in the ICU on the vent. So much for "minimally invasive". Luckily for her she was back on the floor the next day.

We just started doing robotic thoractomies at my place too.... take about a **** show.

Robot definitely has a learning curve. Our surgeons have just started to get pretty good with it and times have really come down. Our robotic thoracotomies now basically have the same operating times as VATS, but obviously setting up/docking the robot adds some time.

Our group has addressed positioning and length of surgery with our surgeons (particularly GYN) and they are sensitive to our concerns. In talking with them, I understand that it's the larger pts who have the most to gain from minimally invasive surgery (more difficulty healing/more infections/etc) and would be more technically challenging/impossible to do laparoscopically without the robot. If we tell our surgeons the positioning isn't safe or ventilation is dangerous/detrimental to the patient, they tend to listen and convert to open. I think a little communication goes a long way.

 

[jetproppilot]

Tommorows Robotic prostatectomy:

70 y/o 280lb, 6'2"

My question for postulating is:

Should this surgery be offered to patients like this who are guaranteed to have peak airway pressures of 40+++ for 6 hours and hanging over the sides of the bed putting them at risk for every nerve injury known to mankind. especially considering our surgeons have slow operative times (6-7 hours)

Are patients this size routinely done with Mr. Roboto?

👍 or 👎

I hear ya man.

Unfortunately we have to deal with obese patients all day every day in this country, and it

stretches our limits

when said obese patient is on the table in front of us and we're expected to anesthetize them for a prolonged period

in deep Trendelenberg.

Laparoscopic case, what with all the ventilatory sequelae that comes with Free Willy Patient/Trendelenberg/Belly Full Of Laparoscopic Air.😱

Gotta do the best you can.

I assure you you're gonna see

many more.

ONE BIG THING THAT CAN HELP YOU PLIGHT:

PCV-VG.

Seriously.

I didn't believe it's potential impact myself until I used it.👍

 

[jetproppilot]

.

 

[sevoflurane]

PCV-VG. Don't have it. Sounds nice. Looks like you get both your desired tidal volume and pressure limit. Nice. Haven't used it, but want to 👍.

I've often wondered why berry aneurysms are not contraindicated with robotics/extreme T burg. You can see the facial hyperemia in some of these patients.... Haven't had a robotic case with a significant aneurysm, but I would push to have it done open if this scenario presents itself. Don't like the potential pop!

Risk>Benefit IMO. But I have no data... just what I perceive to be an unnecessary risk.

 

[Idiopathic]

PCV-VG. Don't have it. Sounds nice. Looks like you get both your desired tidal volume and pressure limit. Nice. Haven't used it, but want to 👍.

I've often wondered why berry aneurysms are not contraindicated with robotics/extreme T burg. You can see the facial hyperemia in some of these patients.... Haven't had a robotic case with a significant aneurysm, but I would push to have it done open if this scenario presents itself. Don't like the potential pop!

Risk>Benefit IMO. But I have no data... just what I perceive to be an unnecessary risk.

while cerebral static pressures rise, cerebral perfusion pressure stays the same, i want to believe that this is protective somewhat

 

[TrustMe]

Our ENT's are starting to do robotic radical tosillestomies. No robotic thoracotomies yet, though. I hate, hate, hate the robotic GYN room.

 

[btbam]

Our ENT's are starting to do robotic radical tosillestomies. No robotic thoracotomies yet, though. I hate, hate, hate the robotic GYN room.

Wow, never even heard of that....I've only seen them used in GYN thus far...

 

[B-Bone]

Wow, never even heard of that....I've only seen them used in GYN thus far...

we were doing it for transoral robotic laryngectomies where I trained.

looks like fun, eh?

 

[TrustMe]

we were doing it for transoral robotic laryngectomies where I trained.

looks like fun, eh?

Ours are working up to that, but are starting small with tonsils first. Not too excited about ever having to sit through a robotic laryngectomy. Hopefully I won't have to. No robots in the ICU.