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Abstract
Introduction
Case Report
Discussion
Conclusions
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  Table of Contents 
CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 1  |  Page : 6-9
 

Clinical pearls of anesthesia for radio-guided, robot-assisted retroauricular parathyroidectomy


Department of Anaesthesia, Rajiv Gandhi Cancer Institute, Rohini, New Delhi, India

Date of Submission08-Dec-2015
Date of Acceptance10-Jan-2016
Date of Web Publication17-Jun-2016

Correspondence Address:
Soumi Pathak
Flat No. 6, Kamdhenu Apartment, Rohini - 110 085, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-0311.183575

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  Abstract 


Robot assisted transaxillary and retroauricular parathyroidectomy provides a safe, precise, 3-dimensional (3D) magnified dissection for parathyroid surgery without the need for CO2insufflation, and with a better cosmetic outcome due to an invisible scar in the axillary or retroauricular region. Robotic surgery requires innovations with regard to patient positioning and the overall arrangement of operative equipment and personnel. Anaesthesiologists should become familiar with these changes by learning the basic features of robotic surgical systems to provide good anaesthetic care.


Keywords: Anesthetic considerations, retroauricular parathyroidectomy, robot-assisted


How to cite this article:
Pathak S, Chowdhury I, Goel N, Bhargava CA. Clinical pearls of anesthesia for radio-guided, robot-assisted retroauricular parathyroidectomy. Indian Anaesth Forum 2016;17:6-9

How to cite this URL:
Pathak S, Chowdhury I, Goel N, Bhargava CA. Clinical pearls of anesthesia for radio-guided, robot-assisted retroauricular parathyroidectomy. Indian Anaesth Forum [serial online] 2016 [cited 2017 Mar 28];17:6-9. Available from: http://www.theiaforum.org/text.asp?2016/17/1/6/183575



  Introduction Top


Radio-guided parathyroidectomy utilizes 99mTc-methoxyisobutylisonitrile (MIBI) scan to localize the abnormal parathyroid gland. Robot-assisted transaxillary and retroauricular approach by da Vinci Si surgical system (Intuitive Surgical, Sunny Vale, CA, USA) has provided a safe, precise, three-dimensional magnified dissection for parathyroid surgery without the need for CO2 insufflation, and with a better cosmetic outcome due to an invisible scar in the axillary or retroauricular region. Anesthetic technique must be tailored to cater for such advances in surgery. We describe the management of a case of radio-guided robot-assisted retroauricular parathyroidectomy.


  Case Report Top


A 52-year-old diabetic patient had presented with pain in the neck for 10-month duration. On evaluation, her parathyroid hormones (PTHs) were elevated, and a well-defined nodular lesion posterior to the left thyroid lobe was detected by ultrasound, and she was posted for robotic parathyroidectomy. In the past, she had undergone left percutaneous nephrolithotomy and Double J stenting for staghorn calculus. Her laboratory investigations revealed serum calcium 10.2 mg/dl (8.1–10.4 mg/dl), serum phosphorous 2.7 mg/dl, (1.7–2.7 mg/dl), and PTH 188 pg/ml (10–65 pg/ml). Rest of her blood investigations was normal. The patient was given tablet alprazolam 0.5 mg and tablet ranitidine 150 mg a night before and on the morning of the surgery. She was injected with the MIBI isotope Te-99 approximately 2 h prior to surgery. On arrival to the operation theater, monitors including ECG, noninvasive blood pressure, pulse oximeter, temperature probe, BIS, and neuromuscular monitors were applied, and 16-gauge intravenous access was secured and an antecubital central venous access was taken. After preoxygenation with 100% oxygen (O2) for at least 4–5 min, anesthesia was induced with injection propofol 60 mg, fentanyl 100 mcg, and injection succinyl choline. C-Mac D blade was used to facilitate endotracheal intubation with a cuffed armored endobronchial tube of 7.0 mm ID. The intubation response was abolished with small dose of injection fentanyl 30 mcg and injection esmolol. Anesthesia was maintained with 40% O2, 60% nitrous oxide, and 1–4% sevoflurane maintaining BIS value of 50–60. Injection atracurium infusion 0.4 mg/kg/h was used in titrated manner with neuromuscular monitoring maintaining ten post-tetanic count. Extension of neck was done by resting the head on a padded ring and putting sand bag in between shoulder blades, thus exposing the parathyroid and thyroid gland to the maximum for ease of surgery, and head-up position was given to enable the gravitational drainage of blood and to decrease the vascularity of gland. A 100 ml extension line was attached to the intravenous access as thoracic-cephalic area was occupied by the surgeons. Both the inspiratory and expiratory limbs of the circuit were extended using Life sol breathing system and the anesthesia machine was kept at the foot end of the patient. Eyes were covered to prevent any corneal dryness and/or abrasion. Just after induction, a blood sample was sent for PTH level and serum calcium level. Thereafter, through a retro-auricular incision, skin flap was raised and docking of the da Vinci Si surgical system robot was done [Figure 1].
Figure 1: Retroauricular incision

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The robotic wristed instruments permit the surgeon to reduce physiological tremors and increase the surgeon's operative free dexterity of movement. Three robotic instruments (Maryland dissector, proGrasp forceps, and Harmonic curved shears) and a dual-channel camera were needed. By placing the camera through the retroauricular incision and using an endoscope with 30° down orientation, principles from the conventional cervical approach can be applied safely to this endoscopic technique. During development of the working space, electrocautery, a vascular DeBakey forceps, and various retractors (army-navy, right-angled and lighted breast retractors) were used for subcutaneous flap dissection and elevation [Figure 2]. At the time of docking, the patient developed ventricular extra systoles which were probably the response of the hypercalcemic-sensitized myocardium to a small surge of catecholamine, which resolved spontaneously, and the rest of surgery went uneventful. The gamma probe was used to localize the abnormal parathyroid glands to direct the incision site and localize the abnormal parathyroid glands during the surgery. After removal of the suspected adenoma, the gamma probe was used again to confirm the high metabolic activity within the resected tissue as well as monitor the surgical bed to make sure no additional hyperactive glands are left behind. On completion of the surgery, an arterial blood gas (ABG) analysis was also done to ensure a normal blood PH and calcium level. ABG report showed: pH 7.35, pCO2 43.9, pO2 136, bicarbonate 24.6, and calcium ionized 1.14 mmol/l. Then, the patient was reversed with injection neostigmine and glycopyrrolate after the return of four twitch of train of four, and extubation was done when the patient was fully awake, after establishing a regular breathing pattern with adequate tidal volume and muscle strength. She was then shifted to Intensive Care Unit for monitoring and injection morphine was given through a patient-controlled analgesia pump for analgesia. Her postoperative period was uneventful, pain free, and her electrolytes were also normal. The patient was supplemented with calcitriol 0.25 mcg twice daily and elemental calcium 1 g twice daily. Duration and extent of Vitamin D and calcium supplementation was based on preoperative bone mineral density and interdisciplinary management with an endocrinologist.
Figure 2: Robotic arms after docking

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  Discussion Top


Changes in the management of primary hyperparathyroidism occurred since the introduction of minimally invasive parathyroidectomy and robot-assisted surgeries.[1],[2],[3],[4] These innovative surgical techniques can be performed with equal cure rates as standard cervical exploration (up to 97%), with no present evidence of delayed recurrence. One of the advantages of the robotic-assisted approach is facilitation of an endoscopic neck surgery while maintaining a three-instrument approach. It gives the surgeon the ability to retract, view target surgical anatomy, and still have two arms to operate, while maintaining traction and counter traction. In robot-assisted operations, spatial restrictions due to the bulky equipment are a universal issue. After the robot has been positioned and engaged, the anesthesiologist is unable to readily access the patient. Thus, all lines, monitors, and patient-protective devices must be placed beforehand and should be secured to ensure no kinking or displacement.[5],[6] It is impossible to allow changes in patient position or any kind of access to the patient if the robot is not detached first. Movements of the patient while robotic instruments are docked could lead to tearing or puncturing of internal organs and vasculature, with potentially devastating consequences.[7] During positioning, the arms and shoulders should be well-cared for by reducing conflict with robotic arms and decreasing the risk of brachial plexus injury.

In hyper parathyroid patients, anesthetic management is further complicated because of the presence of cardiac arrhythmias and skeletal muscle weakness. Low-serum albumin and alteration in the acid base status in the preoperative period can affect the serum calcium level and thus adds to the existing problem.[8] The catecholemic surge during intubation can cause rise in the PTH level, resulting in dyselectrolytemia and arrhythmias. Anesthetic management of patients with secondary and tertiary hyperparathyroidism due to end-stage renal disease is even more difficult, due to their increased risk of cardiovascular co-morbidity, increased severity of cardiovascular disease, leading to a mortality rate that is 6.4–7.8-fold higher than the general population.[9] Successful management of these patients requires effective cooperation and communication between anesthesia, surgical, endocrinology, and nephrology staff.

The most striking electrolyte disturbance during parathyroid surgery is the imbalance of calcium levels in the body, and the main emphasis during the entire peri-operative period revolves around the maintenance of normal serum calcium. Anesthetics such as thiopentone and volatile agents and other drugs causing prolong QTc interval quinolones, macrolides, and antifungals should be avoided.[10],[11] Renal scans and ultrasound are sometimes carried out for the diagnosis of renal stones for the formulation and planning for peri-operative renal protection strategies.[12] Patients with tendency for pathological fractures due to prolonged hypocalcaemia should be dealt in a meticulous manner during laryngoscopy as the chances for quadriplegia are high due to unstable cervical spine as a result of lytic lesions. Cervical collar and manual in line traction of the neck by an assistant is a better option for preventing any dislocation or possible fracture of the cervical vertebrae. Availability of fiberoptic bronchoscope and C-Mac D blade can ease the pressure. It is imperative to proceed with smooth process of intubation and extubation so as to avoid any stress response and accidental hemorrhage from the operative site.[13] Hypocalcaemia may also cause inadequate reversal due to unpredictable augmentation of nondepolarizing neuromuscular blockade, thus possibly leading to postoperative hypoxemia and respiratory obstruction. Use of train of four stimulations can be of immense significance to monitor the degree of neuromuscular blockade not only during the extubation phase, but is also helpful in titrating the doses of muscle relaxants during the intra-operative period. Postoperatively, these patients should be monitored for cardiac failure, dysarrhythmias, neuromuscular irritability hemolysis, platelet dysfunction, leukocyte dysfunction, bleeding, hypocalcaemia seizures and tetany, and recurrent laryngeal nerve palsy and transient renal dysfunction.[13],[14]


  Conclusions Top


Thus, a thorough preoperative evaluation, meticulous monitoring of neuromuscular blockade, ABG, serum calcium level, intraoperative PTH level, use of C Mac D blade, proper positioning of the patient, and rearrangement of the operation theater, along with skeptical vigilance and pre-emptive thinking is required to deal with the challenges posed by the robotic parathyroid surgery.

Acknowledgment

The authors thank their patients and departments.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Noureldine SI, Lewing N, Tufano RP, Kandil E. The role of the robotic-assisted transaxillary gasless approach for the removal of parathyroid adenomas. ORL J Otorhinolaryngol Relat Spec 2014;76:19-24.  Back to cited text no. 1
    
2.
Katz L, Abdel Khalek M, Crawford B, Kandil E. Robotic-assisted transaxillary parathyroidectomy of an atypical adenoma. Minim Invasive Ther Allied Technol 2012;21:201-5.  Back to cited text no. 2
    
3.
Landry CS, Grubbs EG, Morris GS, Turner NS, Holsinger FC, Lee JE, et al. Robot assisted transaxillary surgery (RATS) for the removal of thyroid and parathyroid glands. Surgery 2011;149:549-55.  Back to cited text no. 3
    
4.
Foley CS, Agcaoglu O, Siperstein AE, Berber E. Robotic transaxillary endocrine surgery: A comparison with conventional open technique. Surg Endosc 2012;26:2259-66.  Back to cited text no. 4
    
5.
Baltayian S. A brief review: Anesthesia for robotic prostatectomy. J Robot Surg 2008;2:59-66.  Back to cited text no. 5
    
6.
Mariano ER, Furukawa L, Woo RK, Albanese CT, Brock-Utne JG. Anesthetic concerns for robot-assisted laparoscopy in an infant. Anesth Analg 2004;99:1665-7.  Back to cited text no. 6
    
7.
Steenwyk B, Lyerly R 3rd. Advancements in robotic-assisted thoracic surgery. Anesthesiol Clin 2012;30:699-708.  Back to cited text no. 7
    
8.
Lundgren E, Lind L, Palmér M, Jakobsson S, Ljunghall S, Rastad J. Increased cardiovascular mortality and normalized serum calcium in patients with mild hypercalcemia followed up for 25 years. Surgery 2001;130:978-85.  Back to cited text no. 8
    
9.
Mihai R, Farndon JR. Parathyroid disease and calcium metabolism. Br J Anaesth 2000;85:29-43.  Back to cited text no. 9
    
10.
Yildirim H, Adanir T, Atay A, Katircioglu K, Savaci S. The effects of sevoflurane, isoflurane and desflurane on QT interval of the ECG. Eur J Anaesthesiol 2004;21:566-70.  Back to cited text no. 10
    
11.
Silay E, Kati I, Tekin M, Guler N, Huseyinoglu UA, Coskuner I, et al. Comparison of the effects of desflurane and sevoflurane on the QTc interval and QT dispersion. Acta Cardiol 2005;60:459-64.  Back to cited text no. 11
    
12.
Bajwa SJ, Sharma V. Peri-operative renal protection: The strategies revisited. Indian J Urol 2012;28:248-55.  Back to cited text no. 12
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13.
Abbas G, Dubner S, Heller KS. Re-operation for bleeding after thyroidectomy and parathyroidectomy. Head Neck 2001;23:544-6.  Back to cited text no. 13
    
14.
Bajwa SJ, Sehgal V. Anesthetic management of primary hyperparathyroidism: A role rarely noticed and appreciated so far. Indian J Endocrinol Metab 2013;17:235-9.  Back to cited text no. 14
    


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