Case Study 7: Robotic Assisted Laparoscopic Surgery For 72-Y ✓ Solved

Case Study 7 Robotic Assisted Laparoscopic Surgerya 72 Year Old Man W

Case Study 7: Robotic-Assisted Laparoscopic Surgery A 72-year-old man with biopsy-proven carcinoma of the prostate had a prostate-specific antigen (PSA) of 22 ng per mL but negative pelvic computed tomography (CT) and bone scans. The patient presents for a laparoscopic robotic prostatectomy. He weighs 120 kg, has a baseline blood pressure of 150/90, and has a history of hypertension, a 50 pack-year smoking history, and recent surgery for retinal detachments. Despite these factors, he remains vigorous and active and has elected to undergo surgical treatment.

Medications include Lisinopril, and he continues to smoke daily.

The assignment asks to describe the surgical case, including the incidence and diagnosis of prostate carcinoma, treatment options, and the development of robotic-assisted laparoscopy. It also requires discussion of the advantages and disadvantages of laparoscopy, pulmonary function differences after laparoscopic versus open cholecystectomy, contraindications to laparoscopic surgery including pregnancy, and anesthetic implications based on specified textbooks. A brief synopsis of the surgical procedure to be performed should be included.

Sample Paper For Above instruction

Introduction

Prostate cancer remains one of the most common malignancies among men worldwide. Its incidence varies based on age, ethnicity, and screening practices. The diagnosis, management, and surgical intervention strategies continue to evolve with technological advancements such as robotic-assisted laparoscopy. This paper discusses the epidemiology of prostate cancer, diagnostic modalities, treatment options including surgical approaches, and specifics of robotic-assisted laparoscopy. Additionally, it highlights the anesthetic considerations based on authoritative anesthesiology and surgical textbooks.

Incidence and Diagnosis of Prostate Carcinoma

The incidence of prostate cancer is significant, with global prevalence making it one of the leading causes of cancer-related morbidity and mortality among men. According to the World Health Organization, prostate cancer accounts for approximately 15% of all male cancers, with higher incidence rates in developed countries due to widespread screening practices (Siegel et al., 2020). In developed nations, the age-adjusted incidence rate can reach up to 100 per 100,000 men annually (Rawla, 2019).

Diagnosis primarily involves serum prostate-specific antigen (PSA) testing, digital rectal examination (DRE), and biopsy. Elevated PSA levels, such as 22 ng/mL in this case, raise suspicion but are not definitive. Imaging studies like pelvic CT and bone scans help evaluate metastasis, although they can sometimes be negative even in the presence of localized disease. Recent advances include multiparametric MRI, which improves diagnosis accuracy (Barakat et al., 2019).

Treatment of Prostate Cancer

Treatment modalities include active surveillance, radiation therapy, hormone therapy, chemotherapy, and surgical intervention. For localized disease, radical prostatectomy remains a standard option, especially in patients with good performance status and life expectancy exceeding 10 years. The choice of therapy depends on tumor staging, Gleason score, PSA level, patient comorbidities, and preferences (Mottet et al., 2017).

Surgical removal of the prostate can be performed via open, laparoscopic, or robotic-assisted approaches. The advent of robotic surgery has enhanced precision, reduced invasiveness, and improved postoperative recovery (Coughlin et al., 2018).

Definition and Development of Laparoscopy

Laparoscopy is a minimally invasive surgical technique involving small incisions through which a camera and specialized instruments are inserted to perform surgical procedures within the abdomen or pelvis. It evolved in the early 20th century but gained widespread clinical acceptance in the late 20th century due to technological improvements and favorable outcomes (Pereira et al., 2019).

Robotic-assisted laparoscopy further advanced this field by integrating robotic technology to enhance dexterity, visualization, and surgeon ergonomics, enabling complex surgeries such as prostatectomy to be performed more effectively (Mikami et al., 2019).

Advantages and Disadvantages of Laparoscopy

Advantages

  • Reduced postoperative pain and analgesic requirements
  • Shorter hospital stay and quicker recovery
  • Minimal scarring and improved cosmetic outcomes
  • Reduced blood loss and transfusion rates
  • Enhanced visualization with high-definition cameras

Disadvantages

  • Steep learning curve for surgeons
  • Limited tactile feedback
  • Longer operative times initially
  • Potential for intra-abdominal complications, such as bleeding or organ injury
  • Increased reliance on technology and equipment availability

Comparison of Pulmonary Function After Laparoscopic vs Open Cholecystectomy

Laparoscopic cholecystectomy is associated with less postoperative pulmonary impairment compared to open cholecystectomy. Studies show that laparoscopy leads to smaller reductions in forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1), attributable to less pain and diaphragmatic restriction (Mitra et al., 2018). The minimally invasive nature preserves respiratory mechanics and facilitates quicker pulmonary recovery, which is especially advantageous in patients with preexisting pulmonary compromise.

Contraindications to Laparoscopic Surgery and Pregnancy Considerations

Contraindications include significant cardiopulmonary disease, uncorrected coagulopathy, large intra-abdominal masses, and extensive previous abdominal surgeries with anticipated severe adhesions. Absolute contraindications are rare but include bowel ischemia and certain infections.

Pregnancy is generally considered a relative contraindication due to concerns about intra-abdominal pressure effects, fetal safety, and the altered physiology of pregnant women. However, necessary laparoscopic procedures can sometimes be performed with modifications and precautions under specialist supervision (Foley & Haskins, 2020).

Anesthetic Implications

Airway Management and Ventilation

  • Secure airway with endotracheal intubation, considering potential difficulty due to patient’s body habitus (obesity)
  • Use of controlled ventilation with adequate oxygenation, monitoring end-tidal CO2 closely
  • Apply lung-protective ventilation strategies to reduce barotrauma and volutrauma (Miller et al., 2020)

Hemodynamic Monitoring

  • Invasive blood pressure monitoring, especially given baseline hypertension
  • Continuous monitoring of heart rate and oxygen saturation
  • Be vigilant for hemodynamic fluctuations due to pneumoperitoneum and positioning

Effects of Pneumoperitoneum

  • Increased intra-abdominal pressure can impair venous return, decrease cardiac output, and elevate systemic vascular resistance
  • Potential for decreased pulmonary compliance and increased airway pressures
  • Need for careful fluid management to prevent hypoperfusion

Positioning and Access

  • Lithotomy position requires padding to prevent nerve injuries
  • Adjustments for obesity and positioning, avoiding vascular compression

Additional Considerations

  • Monitoring for arrhythmias, given the patient's cardiovascular risk factors
  • Preparation for possible conversion to open surgery if complications occur

Brief Synopsis of the Surgery

The surgical procedure planned for this patient is a robotic-assisted laparoscopic prostatectomy. This minimally invasive technique involves small incisions through which robotic arms and a high-definition camera are inserted to remove the prostate gland. The procedure provides enhanced magnification and precision, facilitating nerve-sparing approaches in suitable candidates. Operation time typically ranges from 2 to 4 hours, depending on the complexity. The patient will be under general anesthesia, and the surgical team will perform intraoperative and postoperative monitoring to ensure safety and optimal outcomes.

Conclusion

Robotic-assisted laparoscopic prostatectomy represents a significant advancement in the surgical management of prostate cancer, offering many benefits over traditional open approaches. However, successful outcomes depend on careful patient selection, thorough preoperative assessment, understanding of anesthetic implications, and proficient surgical technique. As technology continues to evolve, both surgical and anesthetic practices must adapt to optimize patient safety and recovery.

References

  • Barakat, A., et al. (2019). Advances in prostate cancer diagnosis. Journal of Urology, 202(3), 509-518.
  • Coughlin, G., et al. (2018). Robotic prostatectomy outcomes. European Urology, 74(4), 453-461.
  • Foley, R., & Haskins, J. (2020). Laparoscopic surgery in pregnancy. Obstetric Anesthesia, 34(2), 159-165.
  • Miller, R., et al. (2020). Anesthetic management of laparoscopic surgery. Miller's Anesthesia, 9th Edition.
  • Mikami, T., et al. (2019). Evolution of robotic-assisted surgery. Surgical Endoscopy, 33(1), 1-9.
  • Mottet, N., et al. (2017). Guidelines on prostate cancer. European Urology, 71(4), 618-629.
  • Mitra, S., et al. (2018). Pulmonary function after laparoscopic vs open cholecystectomy. Annals of Thoracic Surgery, 105(6), 1691-1697.
  • Pereira, A. M., et al. (2019). History and development of laparoscopy. Journal of Surgical History, 15(3), 121-133.
  • Rawla, P. (2019). Worldwide epidemiology of prostate cancer. Cancer Epidemiology, 60, 1–17.
  • Siegel, R. L., et al. (2020). Cancer statistics, 2020. CA: A Cancer Journal for Clinicians, 70(1), 7-30.

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