P025: RHABDOMYOLYSIS FOLLOWING ROBOTIC SURGERY: ARE MUSCULAR PATIENTS AT INCREASED RISK?
Brandon W Radmall, MD, Christopher R Giordano, MD; University of Florida Department of Anesthesiology
Introduction: Robotic-assisted surgeries create some unique and challenging limitations for anesthesiologists. The docked robot limits access to the patient as well as limits the ability to alter patient positioning. This coupled with a standby surgical technician and a bedside surgeon further limits access for intraoperative changes regarding patient positioning. Robotic procedures tend to be lengthier cases due to positioning, docking, undocking, and the initial learning curve. This makes the initial decision of patient positioning a critical component to the overall success of the patient’s outcome.
Methods: We performed a literature search on patient and procedural risk factors pertinent to two cases of rhabdomyolysis that we encountered following robotic surgery. Our goal was to identify potential risk factors that may have contributed to these complications as well as other factors that our two patients shared that may have not been elucidated in the literature. Search terms included rhabdomyolysis, robot-assisted surgery, complications, and positioning.
Results: At our institution, we had two patients whose post-operative period was complicated by rhabdomyolysis, one that progressed to compartment syndrome requiring fasciotomy. Both underwent robot-assisted pyeloplasty in the right lateral decubitus position. The first had a BMI of 32 kg/m2, significant muscular mass, and underwent robotic surgery for 8 h. Upon emergence from anesthesia, the patient complained of right hip and gluteal pain. Labs were consistent with a diagnosis of rhabdomyolysis (CK 10,500 mcg/L, positive urine myoglobin) and compartment pressure was 26 mmHg. The patient was taken to the OR for fasciotomy and the wound was closed 4 days later. The second patient had a BMI of 32 kg/m2, significant muscular mass, and underwent robotic surgery for 6 h. The following day the patient complained of right hip pain and urine myoglobin and creatinine kinase were both consistent with rhabdomyolysis. The patient was treated conservatively and discharge several days later.
Our literature search revealed two retrospective cohort studies with a diagnosis of rhabdomyolysis following prolonged surgery attributed to positioning.
Gelpi-Hammerschmidt et al. conducted a population based, retrospective cohort study of patients who underwent extirpative renal surgery for treatment of renal tumor between 2004-2013. The cohort included 310,880 open, 174,283 laparoscopic and 69,880 robot-assisted surgeries. Of the individuals studied, 745 (0.001%) of them experienced postoperative rhabdomyolysis. They identified the combination of obesity (BMI 30 kg/m2 or greater), prolonged surgery (greater than 5 hours) and robot-assisted surgery significantly increased the odds of a major complication.
A retrospective review by Terry et al. included 315 consecutive patients over a 6-year period and found that the incidence of post-operative rhabdomyolysis was 3/315 (0.95 %). These patients were identified as having a higher BMI, Charlson Comorbidity Index, and median length of stay than those who did not.
Discussion: With the increased utility of robot assisted surgery comes new anesthetic challenges and complications. Several retrospective reviews have identified a higher BMI, long operative times, and robot-assisted surgery as risk factors for complications for rhabdomyolysis. As our cases demonstrated, patients described as being more muscular may also be at increased risk of complications.