What is the recommended approach for Certified Registered Nurse Anesthetist (CRNA) management during robotic laparoscopic cholecystectomy?

CRNA Management for Robotic Laparoscopic Cholecystectomy

For robotic laparoscopic cholecystectomy, CRNAs should implement a multimodal anesthetic approach with monitored anesthesia care (MAC) as the preferred technique when appropriate, while ensuring proper positioning and vigilant monitoring of hemodynamic and respiratory parameters throughout the procedure.

Preoperative Assessment and Planning

• Evaluate for comorbidities that may increase risk during laparoscopic procedures, particularly focusing on cardiopulmonary status, as robotic cholecystectomy requires pneumoperitoneum and steep positioning 1
• Identify high-risk patients including those with advanced age (>80 years), cirrhosis (especially Child C), and those with septic shock, as these conditions may require special consideration 1
• Assess for potential difficult airway management, as robotic procedures often require steep Trendelenburg positioning which can complicate airway access during the procedure 2

Anesthetic Technique Selection

• Consider monitored anesthesia care (MAC) as the first-line approach for appropriate candidates, as this has been shown to have fewer adverse events compared to general anesthesia in similar endoscopic procedures 1
• General anesthesia with endotracheal intubation is recommended for robotic laparoscopic cholecystectomy when:
  • Patient has contraindications to MAC
  • Procedure is expected to be complex or prolonged
  • Steep positioning is required for optimal surgical exposure 2

Intraoperative Management

Positioning and Setup

• Ensure proper padding and positioning to prevent nerve injuries, particularly when using steep Trendelenburg position required for robotic access 2
• Secure all lines and tubes before robot docking, as access to the patient will be limited once the robot is in position 3

Ventilation Management

• Use lung-protective ventilation strategies to mitigate the respiratory effects of pneumoperitoneum and positioning 2
• Consider higher PEEP (5-10 cmH2O) to improve oxygenation during pneumoperitoneum 2

Hemodynamic Management

• Anticipate and manage hemodynamic changes associated with pneumoperitoneum (increased systemic vascular resistance, decreased cardiac output) 2
• Maintain adequate fluid management to optimize tissue perfusion while avoiding fluid overload 1

Pain Management

• Implement multimodal analgesia approach to minimize opioid requirements:
  • Local anesthetic infiltration at incision sites 4
  • Consider low-pressure pneumoperitoneum when surgically feasible 4
  • Active gas suction at the end of the procedure to reduce shoulder pain 4
  • NSAIDs should be administered if not contraindicated 1, 4
  • Consider opioid-free anesthesia techniques using combinations of esketamine, dexmedetomidine, and lidocaine when appropriate 5

PONV Prevention

• Administer prophylactic antiemetics for patients undergoing laparoscopic cholecystectomy, as this procedure carries a high risk of PONV 1, 6
• Consider ondansetron 4mg IV before surgery, which has been shown to significantly reduce PONV after laparoscopic cholecystectomy (7% vs 47% in placebo) 6

Postoperative Care

• Ensure adequate pain control using oral analgesics when feasible, avoiding intramuscular route 1
• For moderate to severe pain unresponsive to other treatments, consider PCA with appropriate opioids 1
• Early mobilization should be encouraged to reduce postoperative complications 1
• Monitor for specific complications related to robotic laparoscopic procedures, including subcutaneous emphysema and respiratory issues 2

Special Considerations

Elderly Patients

• Laparoscopic approach is safe and recommended even in elderly patients, with benefits including shorter hospital stays and fewer complications 1
• Be prepared for potential conversion to open procedure, which occurs more frequently in elderly patients due to anatomical challenges 1

Patients with Liver Disease

• For patients with Child A and B cirrhosis, laparoscopic approach remains the first choice but requires careful anesthetic management 1
• For Child C cirrhosis, consider avoiding cholecystectomy unless absolutely necessary 1

Common Pitfalls and How to Avoid Them

• Limited access to the patient during robotic procedures: Ensure all lines, monitoring, and airway are secure before robot docking 3
• Respiratory complications from pneumoperitoneum and positioning: Use appropriate ventilation strategies and monitor closely 2
• Inadequate pain control: Implement multimodal analgesia starting preoperatively 4, 5
• PONV: Provide prophylactic antiemetics for this high-risk procedure 1, 6