**6. Anesthetic approach**

Team coordination and communication are fundamental aspects to prevent complications in any surgical operation. This is especially important during robotic-assisted surgery, considering the physical distance between team members. Therefore, we recommend that all team members (consisting of a console surgeon, tableside assistant, anesthesiologist, perfusionist, circulating nurse, and all others who are involved) are equipped with Bluetooth headsets to ensure smooth and effective communication.

**81**

*Robotic Coronary Artery Bypass Grafting: History, Current Technique, and Future Perspectives*

To be on par with rapid advancements in the field of robotic surgery, anesthesiologists had to overcome new challenges such as longer surgical times, problems with single-lung ventilation in the presence of coronary artery disease, and enhanced expertise in transesophageal echocardiography (TEE) [39]. Other drawbacks include the higher physical distance from the patient than usual, dealing with a bulky device onto the operative field, managing the specific patient positioning, and maintaining patient immobility while preventing prolonged postoperative

Because of the reasons stated above, robotic-assisted CABG procedures require an experienced cardiothoracic anesthesiologist. The console surgeon, tableside surgeon, and anesthesiologist must all be coordinated and in harmony throughout

Anesthetic management consists of single-lung ventilation, as well as right radial artery pressure monitoring and central venous catheterization for hemodynamic monitorization throughout the surgery. Single-lung ventilation may be accomplished with either a double-lumen endotracheal tube or a single-lumen endotracheal tube with the usage of a left endobronchial balloon blocker. External defibrillator pads should be located across the heart beforehand, one on the right lateral chest and the other one on the left scapula. Near-infrared spectroscopy (NIRS) is also strongly advised to prevent postoperative cognitive dysfunction [40]. Due to the closed nature of the operation, monitoring TEE throughout the procedure is essential. TEE contributes invaluable information regarding baseline cardiac capacity and may be used to diagnose undetected pathologies. TEE ensures secure and a pinpoint positioning of guidewires and cannula for peripheral cardiopulmonary bypass. TEE is imperative for the management and safety of robotic CABG procedures since it allows for immediate detection of rare but catastrophic complications of peripheral cannulation, including superior vena cava injury or

Some preliminary steps including patient set up, cardiopulmonary perfusion, placement of the ports, and robotic-assisted harvesting of LITA are in the same manner for both robotic-assisted CABG surgeries. While the MIDCAB procedure continues with de-novo incision after LITA harvesting for making a direct handsewn anastomosis between the LITA and the coronary target, the TECAB procedure

After the left lung is deflated, three robotic ports are placed into the left thoracic cavity under direct view. First, the camera port is located in the left fourth intercostal space in the anterior axillary line. The right and left robotic instrument ports are placed under endoscopic visualization in the second and sixth intercostal spaces,

The robotic-assisted anastomosis part of the TECAB surgery requires two additional ports which should be placed after robotic ITA harvesting and graft preparation. A 12-mm 4th robotic port is used to insert the Endo-wrist™ stabilizer, placed in the left subcostal space, medial side of the midclavicular line. And finally, to deliver the Cardica Flex A™ anastomotic device, a 15-mm port (Ethicon Surgical, Somerville

After the ports placed, the table is lowered and tilted 10° to the right, and the da Vinci Si system (Intuitive Surgical, Sunnyvale, California, United States) is docked

NJ) is inserted in the 2nd intercostal space on the left midclavicular line.

continues with robotic-assisted coronary anastomosis [31].

respectively, in alignment with the camera port.

recovery time due to the excessive use of neuromuscular blocking agents.

*DOI: http://dx.doi.org/10.5772/intechopen.99399*

the entire procedure.

aortic dissection [41].

**7. Surgical procedure**

**7.1 Patient positioning**

#### *Robotic Coronary Artery Bypass Grafting: History, Current Technique, and Future Perspectives DOI: http://dx.doi.org/10.5772/intechopen.99399*

To be on par with rapid advancements in the field of robotic surgery, anesthesiologists had to overcome new challenges such as longer surgical times, problems with single-lung ventilation in the presence of coronary artery disease, and enhanced expertise in transesophageal echocardiography (TEE) [39]. Other drawbacks include the higher physical distance from the patient than usual, dealing with a bulky device onto the operative field, managing the specific patient positioning, and maintaining patient immobility while preventing prolonged postoperative recovery time due to the excessive use of neuromuscular blocking agents.

Because of the reasons stated above, robotic-assisted CABG procedures require an experienced cardiothoracic anesthesiologist. The console surgeon, tableside surgeon, and anesthesiologist must all be coordinated and in harmony throughout the entire procedure.

Anesthetic management consists of single-lung ventilation, as well as right radial artery pressure monitoring and central venous catheterization for hemodynamic monitorization throughout the surgery. Single-lung ventilation may be accomplished with either a double-lumen endotracheal tube or a single-lumen endotracheal tube with the usage of a left endobronchial balloon blocker. External defibrillator pads should be located across the heart beforehand, one on the right lateral chest and the other one on the left scapula. Near-infrared spectroscopy (NIRS) is also strongly advised to prevent postoperative cognitive dysfunction [40].

Due to the closed nature of the operation, monitoring TEE throughout the procedure is essential. TEE contributes invaluable information regarding baseline cardiac capacity and may be used to diagnose undetected pathologies. TEE ensures secure and a pinpoint positioning of guidewires and cannula for peripheral cardiopulmonary bypass. TEE is imperative for the management and safety of robotic CABG procedures since it allows for immediate detection of rare but catastrophic complications of peripheral cannulation, including superior vena cava injury or aortic dissection [41].
