Reversal & Extubation
- Ensure adequate reversal of neuromuscular block (deep block was needed for immobility) — TOF-guided.
- Before extubation, rule out airway/laryngeal oedema (consider a cuff-leak test) after prolonged steep Trendelenburg.
- Some patients need post-operative ventilation — e.g. a history of hypercarbia, significant laryngeal oedema, or delayed emergence from cerebral oedema.
- Keep blood products available; monitor for delayed bleeding.
Common Mistakes
Inadequate depth/relaxation with the robot docked → patient movement → visceral injury.
Not re-checking the ETT after steep Trendelenburg + insufflation → unrecognised endobronchial intubation.
Liberal fluids early → airway/facial oedema, obscured field and POVL risk.
Extubating without checking for airway oedema after a long, steep case.
Poor eye protection / padding — corneal abrasion, brachial-plexus injury — irreversible once docked.
Viva-Ready Pearls
Steep Trendelenburg + pneumoperitoneum → ↑ preload, ↑ CO, ↑ SVR → ↑ myocardial O₂ demand; ↓ compliance; ↑ ICP/IOP.
POVL = ischaemic optic neuropathy from prolonged ↑ IOP/venous congestion — a signature robotic-prostatectomy complication.
Restrictive fluids until the urethral anastomosis is complete; give fluid afterwards.
Total immobility is mandatory — the patient cannot move while the arms are docked.
Relative contraindications to steep Trendelenburg: raised ICP, glaucoma, severe cardiac/respiratory disease, morbid obesity.
References
- Dr. Tanya Chawla — case notes on Robotic Prostatectomy (RARP).
- Miller's Anesthesia — Anesthesia for Robotic & Laparoscopic Surgery; the Trendelenburg position.
- Morgan & Mikhail's Clinical Anesthesiology — Anesthesia for Genitourinary Surgery.
- ASA Practice Advisory on Perioperative Visual Loss.