New anesthetic challenges for novel surgical technique: intraoperative management of robot-assisted one lung transplantation.

IntroductionMinimally invasive surgery has been gaining momentum lately. Amongst them, robot-assisted procedures have proved substantial benefits for the patients' recovery, however, they present important challenges for the anesthetic team. We present this case of a single lung transplantation completed under robot-assistance without thoracotomy. To our knowledge, this is the first ever case of such characteristics reported in the bibliography.MethodsOur patient of 65-year-old with chronic end-stage idiopathic lung fibrosis was transplanted the right lung, following our institution´s protocol for lung transplantation under total intravenous anesthesia. The patient was placed in supine position, with an airbag under the right chest to facilitate chest exposure.In preparing a multidisciplinary round, our team had decided to not go onto elective cardiopulmonary bypass (CPB) ab initio. Nevertheless, femoral artery and vein were dissecated in case of emergent requirement.ResultsThe surgery could be completed without CPB or vasoactive drugs support. Furthermore, the receptor's diseased lung and the graft were removed and introduced respectively through a subxiphoid incision avoiding a thoracotomy, which significantly reduced the patient's perioperative analgesic requirements. At the end of an uneventful procedure, bronchus suture and vessel patency were assessed by bronchoscopy and transesophageal echocardiography respectively. The doble lumen tube was replaced with a single lumen one before transferring the patient to the ICU.The patient was discharged from the hospital after 44 days. Remarkably, the absence of pain allowed effective pulmonary rehabilitation.DiscussionClassical surgical approaches are not exempt from serious and even life-threatening complications. Clam-shell incision, thoracotomies or medial sternotomy provide the surgeon with a good access to hilar structures; however, they are aggressive approaches with a high prevalence of wound complications such as delayed wound healing, acute and chronic pain, opioid abuse, or poor respiratory recovery. Moreover, in open surgery the heart and the superior vena cava must often be separated or compressed by the surgical team, which can cause hemodynamic alterations, lung congestion and cardiac arrythmias; thereby increasing the likelihood of needing extracorporeal circulatory support.Robotic surgery, on the other hand, enhanced by subxiphoid access, can reduce these issues while enabling a better surgical view (through the robot-assisted retraction arm). This, in turn, minimizes hemodynamic instability. All of these advantages notwithstanding, from an anesthetic point of view it a clear strategy was required in order to prevent untoward events, in a situation where emergent central CPB instauration is impossible, hence the decision to dissect the groins in advance, and having large venous accesses. To conclude, if needed precautions are taken, this novel technique provides excellent hemodynamic stability, avoids the drawbacks of thoracotomies, and enables a more comfortable postoperative period for the patient.