This is a technology that requires a tremendous financial investment, so you might no see it at every community hospital in the near future. However, as with all technology, the price will likely fall quickly as the applications are expanded, as more widespread adoption occurs, and as the field of robotics experiences additional breakthroughs. For now, many major academic institutions are beginning to purchase and deploy these systems.

The use of robots in surgery is clearly a "gee-whiz" activity that is of interest to those in medicine that advocate for the application of technology. However, it also presents the anesthesiologist with significant challenges and requires careful patient screening and intraoperative management to assure patient safety. Major challenges include the use of transesophageal echocardiography, the placement of multiple access catheters, management of one-lung ventilation, etc. In addition, the initial use of these systems results in a steep learning curve for the surgeons and involves long hours in the operating room caring for patients with perhaps significant disease.

RECENT DEVELOPMENTS ALLOW BETTER RESULTS
Minimally invasive surgery is not a new concept. Laparoscopic surgery for procedures such as the removal of a gallbladder have been performed for almost twenty years. However, it has only been in the last decade or so that technology has progressed to the point of allowing procedures such as cardiac surgery to be performed. Today, the ability to do cardiac surgery without bypass, cardiac stabilizing hardware, full motion robotic joints, software enhancement of surgical hand movement and three-dimensional remote viewing are all possible. As a result, the cardiac surgeon utilizing the robotic system for surgery actually has better instrument control and improved dexterity versus standard "hands-on" surgical technique. Similar benefits are achieved in prostate surgery where dissectino is more precise and nerve preservation is more reliable.

THERE ARE RISKS, HOWEVER...
Of course, there is always another perspective to the story. As with any new procedure, there are risks that we may not know about yet. In addition, in bringing so much cutting-edge technology to bear, there are bound to be technical difficulties and areas in need of improvement. The steep learning curve has already been mentioned and the fact that these surgeries can be lengthy and demanding for the surgeon should not be overlooked.

Of course, the surgeon isn't the only one that will have new things to learn and face possibly demanding patient care issues. There are significant anesthetic challenges that the use of robotic surgery presents. As we see more of this technology, anesthesiologists will have to develop new methods of patient care in order to continue in their role as patient advocate and protector. This will involve not only issues in the operating room during surgery, but also proper screening of patients preoperatively.

TECHNICAL ISSUES ARE NUMEROUS
From the moment the care of the patient begins, there are a number of technical issues that will be faced. For example, during the surgery the use of a large robotic device makes access to the patient difficult. It will be important to have all monitors and safety devices (for example, defibrillator pad) in place well in advance. It will be difficult to place to change the position of these once the surgery has begun. Similarly, patient positioning will have to be very carefully done to prevent any chance to injury from pressure points. Often these patients will be placed on one side and require maintenance of that position for a long period of time.

The fact that the patient will require one-lung ventilation presents other technical issues to the anesthesiologist of placing the endotracheal tube in the right position, being ready to treat arrhythmias that might occur, etc. Conversion to the standard open technique will be required in a small percentage of cases, especially early in the learning process, and the entire surgical team must be prepared to quickly go onto cardiopulmonary bypass should unforseen complications arise.

PATIENT SELECTION IS VERY IMPORTANT
Clearly, careful patient selection becomes extremely important in order to not expose patients to undue risks. The need for possible prolonged one-lung ventilation requires, for example, that the patient have adequate pulmonary reserve. A prolonged pneumothorax is required, exposing patients to possible hypotension if cardiac function is poor. Cardiac status is even more important than in patients undergoing traditional cardiac surgery. The use of perioperative beta-blockade is becoming more standard today, but becomes an issue of special importance in these cases - not only is it cardioprotective, but a slow and steady heart rate is important for proper surgical conditions. Lastly, patients will need to be evaluated in terms of their suitability for regional anesthesia as plans for postoperative pain relief is an increasingly important part of the management plan.

SUMMARY
Technology allows amazing things to be accomplished. Robotic surgery is a new and expensive tool that is beginning to see adoption. Minimally invasive surgery with a robot and without bypass is the next logical step in the development of cardiac surgery. It is beginning to show clear benefits for patients and this means that it will likely become more and more popular with time and as the price falls.

Of course, any new technique brings with it risks and the possibility of technical difficulties. Anesthesiologists should be prepared for steep learning curves, frustrated surgeons and very long surgeries. In addition, they should be ready to tackle new challenges related to proper patient screening and selection as well as intraoperative care of the patient. As always, anesthesiologists must do their part to be the patient advocate and patient protector in the operating room. Robotic surgery raises new issues that must be addressed.