Robotic Hiatal Hernia Repair

Anesthesia Implications

Position: Reverse Trendelenburg, airplaned right, arms tucked
Time: 1-2 hours (average)
Blood Loss: Very Low (5-10 ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Yes

GERD/Reflux – These patients very often have severe GERD. Consider RSI on induction. OG/NG tubes are also a very good consideration to empty the contents of the stomach.

Intraop EGD – Very often, the surgeon will want to do an EGD after induction. For this, you’ll need a bite block in the mouth. The surgeon will be at the head of the bed and you may need to get under the drapes to assist with moving the scope past your ETT.

Tucked Arms (general considerations): Consider a second IV – once the procedure has started, it’s going to be VERY difficult to handle IV issues – especially if your only IV has problems. Ensure the IV is running and monitors are still functioning after tucking the patient’s arms

[/if 126]

Reverse Trendelenburg Position (general considerations): Improves access to the organs of the upper abdomen. To avoid patient slipping, use a foot board if an extreme angle is used. This position results in blood pooling in the abdomen and lower extremities. Reductions will be seen in stroke volume, cardiac filling, and cardiac output. The greater the angle, the greater these affects. Increases will be seen in FRC and compliance, which will be especially the case with obese patients. Ulnar nerve injuries can result if pressure is placed on the ulnar groove at the elbow. Any ‘bump’, rise, or IV pole along on the arm board between the elbow and the shoulder can result in radial nerve injury. Pad all pressure points (emphasis on head, sacrum, elbows, and heels) and ensure any straps used to secure limbs are loose enough to allow normal blood flow. Ensure the patient is not lying on IV tubing, monitor lines, or knots