Anaesthetic Challenges and Perioperative Management in Robotic Living Donor Hepatectomy

Dear Editor, Minimally invasive surgery is currently experiencing a significant surge, with robot-assisted procedures gaining popularity due to their ability to address limitations associated with conventional laparoscopic techniques.[1] To gain a comprehensive understanding of anesthetic challenges during robotic surgery, we report a rare case of a live liver donor posted for robotic hepatectomy performed with the da Vinci Robotic surgical system, the first case in our institute. A 28-year-old female (58 kg, 162 cm tall) volunteered to donate the right lobe of her liver to her husband, 36 years old affected with extrahepatic portal venous thrombosis. Donor, a housewife, was a known case of hypothyroidism on thyroxine 100 μg OD for 6 years. She underwent assessment by multidisciplinary living donor team and was approved for liver donation by the donor advocacy team and patient selection committee. Preoperative three-dimensional (3D) liver reconstruction aided volumetric analysis done, using right lobe graft along with routine blood investigations, chest X-ray, electrocardiogram (ECG), and 2D echocardiogram were within normal limits. Total hepatic volume was 1562 ml while the right lobe volume was 383 ml. The patient was accepted under American society of anesthesiology (ASA) II, thyroxine 100 mcg continued till the day of surgery, consents were checked, and Nill by mouth (NBM) status was confirmed and placed 18 G cannula in the left hand. He was premedicated with the injection of midazolam 0.02 mg/kg, injection of glycopyrrolate 4 μg/kg, injection of fentanyl 2 μg/kg, and injection of Loxicard 1.5 mg/kg and induced with injection of propofol 2 mg/kg and injection atracurium 0.5 mg/kg. The patient was intubated with 7.5 endotracheal tube and 7 Fr triple lumen central venous catheter was placed in the right internal jugular vein with ultrasound guidance along with that 3 Fr 8 cm leader Cath secured in the right radial artery. Monitoring included ECG, invasive arterial pressure, pulse oximetry, central venous pressure (CVP), end-tidal CO2, bispectral index, temperature, urine output hourly, and arterial blood gas (ABG) two hourly. After surgical positioning, we placed several foam pads to cover pressure points and gave semi-lithotomy, reverse Trendelenburg supine position with left tilt. The table was at a distance from the ventilator with the robot positioned cephalad above the patient for better performance of the manipulator [Figure 1]. To prevent from sliding, we strapped the patient at the forehead and shoulder. Maintenance was obtained by sevoflurane at 2% with O2: air (50:50) and flows of 1.6 L/min on pressure control mode with peak inspiratory pressure at 25mmHg. Infusions of injection of fentanyl 0.5 μg/kg/h, injection of atracurium 0.6 mg/kg/h, and injection of acetylcysteine (NAC’s) 1.3 mg/kg/h were started. Injection morphine 5 mg IV was given for excellent analgesia with stable hemodynamics through the procedure. IV fluid Plasma-Lyte was given 1 ml/kg/h using high flow fluid warmer till portal venous clamping, keeping central venous pressure central venous pressure (CVP) within the range of 1–2 mm Hg and ensuring collapse of inferior vena cava. During resection with cavitron ultrasonic surgical aspirator (CUSA), the aim was to achieve an optimal surgical field with minimum bleeding, requiring a pringle maneuver time maximum of 44 min over four instances. Lactates toward the end of surgery for 10 h were 3.4 with minimal metabolic changes. During resection, the patient was hemodynamically stable with mean arterial pressure 65 mm Hg, heart rate -72/min, CVP-1–2 mm Hg, pulse pressure variation (PPV) 12–14, urine output 0.5 ml/kg/h, temperature above 36°C, and total blood loss of 350 ml. Intra-abdominal pressures were not more than 12 mm Hg during pneumoperitoneum. Whole surgery was performed by minimally invasive technique and just extraction of graft from the abdomen was done through Pfannenstiel incision. After extraction, IV fluids were given @4–5 ml/kg/h. After 10 h of the procedure, the patient extubated uneventfully with normal ABG, absolute no pain, and shifted to liver transplant Intensive care uni (ICU). Till postoperative day 3, infusion of injection acetylcysteine 20 mg/cc @4 ml/h was continued along with injection albumin 20% 100 ml @10 ml/h. Postoperative pain was managed with 10 mg buprenorphine patch. The patient’s liver function tests were deranged until 3rd day after which they returned to normal.Figure 1: Positioning of patient and Da Vinci robotic surgical systemCommonly, a graft–body weight ratio of 0.8 is used to ensure the donated lobe is adequate for the recipient.[1] Robotic-assisted procedures have enhanced precision, curtailed blood loss, less painful, and quicker recovery.[2] Historical perioperative mortality in liver resection surgery was 20% attributed to bleeding and liver failure. Advance in anatomy, patient selection, surgery, and anesthesia have reduced this to 3%.[3] Da Vinci Robotic surgical system has 3D visualization with superior magnification, stability of robotic arms, and in-built indocyanine green dye-guided resection, which facilitates dissection of the liver hilum and controls hemostasis. Challenges we faced during robotic hepatectomy were patient positioning, limited operating room space, limitation to patient access, hypothermia, hemodynamic effects of pneumoperitoneum, and long operating time,[4] which were very well managed. Low CVP and high PPV reduce blood loss and aid good resection field by decreasing hepatic sinusoidal pressure.[1] PPV is the dynamic index for hemodynamic monitoring to assess fluid responsiveness. NAC has the potential to preserve metabolic balance and liver function making it a valuable intervention for donor well-being.[5] Morphine acts as an excellent analgesic intraoperatively and additionally causes peripheral vasodilation, resulting decrease in intravascular volume pulmonary wedge pressure and CVP. We avoided thoracic epidural catheter with the risk of postoperative deranged coagulation profile. Due to lack of adequate data, we discussed step-wise approach for anesthesia management in robotic liver hepatectomy, to ensure safety patient care in living hepatic donor who is a crucial part of liver transplants. Declaration of patient consent The patient consent has been taken for participation in the study and for the publication of clinical details and images. Patients understand that the names and initials would not be published, and all standard protocols will be followed to conceal their identity. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.