The rise of robotic surgery means that City of Hope surgeons have mastered the art of operating remotely — but they are not the only ones who have had to become experts in high-tech medicine. Anesthesiologists are crossing the same technological frontiers.

When surgeons use the da Vinci Surgical System to remove a prostate or resect a lung tumor, it often leaves only a few tiny scars, leading some to think the surgeries are easy and just a less traumatic sibling of more traditional, open procedures. But City of Hope anesthesiologists know the procedures are far from simple. They have come to keenly recognize how differently patients’ bodies react — from their blood pressure to their breathing – during robotic surgeries.

“Robotic minimally invasive surgery isn’t a walk in the park for us as anesthesiologists,” said Michael W. Lew, M.D., chair of the Division of Anesthesiology. “We see greater changes in hemodynamics during these procedures.”

That perspective has drawn attention to Lew and his fellow City of Hope colleagues. Lew and anesthesiologists Michael J. Sullivan, M.D., Andres Falabella, M.D., and Walter Chang, M.D., provide a guide to assessing patients for robotic surgery in the July issue of Anesthesiology News, for example. And in June, Falabella presented the group’s research results on circulatory changes linked to robotic surgery at the European Society of Anaesthesiology’s annual meeting in Madrid.

City of Hope surgeons keep their three da Vinci robots busy, using them for a variety of procedures, from colon surgeries to esophagectomies, and the hospital’s urologic surgeons are among the nation’s top performers of robotic prostate surgery. That means that City of Hope anesthesiologists, in turn, assess hundreds of patients before robotic surgery, keep them stable during the procedures and provide pain relief afterward.

Their experience has taught them some lessons they are sharing with colleagues.

For one, Lew explained, robotic surgeries share some of the same issues as laparoscopic surgeries. For example, patients undergoing a lower-abdominal surgery are placed in a slanted position, their feet higher than their head, so that abdominal organs slide and push against the diaphragm; physicians then inflate the abdomen with carbon dioxide (a process called insufflation) to create a working space. Positioning and insufflation both pose challenges to the body.

“Insufflating pushes up on the diaphragm and squeezes the heart, so the heart rate then goes up,” Lew said. Blood pressure rises, as do several other measures of circulatory function. Anesthesiologists must manage these cardiovascular changes until the patient’s body compensates and adjusts to the pressure. But that is not all. During these procedures, blood flow may rise to the brain and decrease from the liver, the stomach may become more acidic, and lung capacity may decrease, among other changes. Anesthesiologists must understand how the procedures can affect a patient’s entire body, and use special tools and expertise to keep all the patients’ systems working normally.

Aside from that, anesthesiologists must make sure patients stay warm and avoid hypothermia during the often-long robotic procedures. And after the procedure is over, the physicians cannot assume that patients will not need their pain management services. “Just because it’s minimally invasive surgery doesn’t mean patients won’t have pain,” Lew said.

As robotic surgery takes hold within surgical practices, the City of Hope anesthesiologists call on their colleagues nationwide to carefully consider how best to maintain patients’ health during and after the procedures. “Robotic surgery is the future,” Lew said. “We need to make sure, as anesthesiologists, that we are adjusting accordingly to keep our patients safe so they have the best recovery possible.”