The impact of obesity on pulmonary deterioration in patients undergoing robotic-assisted laparoscopic prostatectomy

Risk Factors of Difficult Intubation in Patients with Severe Obesity Undergoing Bariatric Surgery: A Retrospective Cohort Study

BACKGROUND

Obesity poses significant challenges by altering upper airway anatomy and making mask ventilation and tracheal intubation difficult. In 2023, 46.1% women and 35.9% men > 18 years were classified as obese in Qatar, yet intubation complications in this group have not been extensively studied. The aim of this study was to evaluate the frequency and types of intubation complications in adults with severe obesity undergoing bariatric surgery and to identify incidence of difficult intubation and associated risk factors.

METHODS

In this retrospective cohort study, 2421 patients (1664 females and 746 males) were analyzed. All patients with severe obesity aged over 18 years with a BMI of 40 kg/m2 or higher, who underwent bariatric surgery from January 2014 to January 2024, were included. Difficult intubation was defined as the need for video laryngoscopy, cricothyrotomy, intubation via a supraglottic airway device, use of a stylet or bougie, more than one intubation attempt, or desaturation during intubation.

RESULTS

None of the patients experienced any complications of interest. Video laryngoscope was used in 85 patients (3.5%), first-attempt intubation success rate was 95.4%, with more than one attempt required in 4.6% of cases. Logistic regression revealed that the odds of complicated intubation were 1.5 times higher in patients with a BMI > 60, 8.9 times higher in those with Cormack-Lehane class IV, and 5.1 times higher in patients with Mallampati score of IV. Comorbidities increased the odds by 1.3 times, with asthmatic patients having 2.1-fold higher odds.

CONCLUSION

This study highlights the challenges of tracheal intubation in patients with severe obesity undergoing bariatric surgery and the need for tailored strategies to manage these difficulties.

Impact of Class III Obesity (Morbid Obesity) on the Perioperative, Functional, and Oncological Outcomes of Robotic-Assisted Radical Prostatectomy

Background: The growing prevalence of obesity, particularly morbid obesity (BMI > 40 kg/m2), presents unique challenges in surgical management. In robotic-assisted radical prostatectomy (RARP) for prostate cancer, morbid obesity is associated with longer operative times, increased blood loss, and complex nerve-sparing procedures. These challenges may impact functional and oncological outcomes, making it essential to understand how high BMI affects RARP results. However, data on outcomes for patients with morbid obesity remain limited. Methods: We retrospectively reviewed 14,444 patients who underwent RARP by a single surgeon from 2008 to 2023. A total of 183 patients with morbid obesity (BMI > 40 kg/m2) were matched 1:1 with 183 normal-weight patients (BMI 18.5-24.9 kg/m2) using propensity-score matching based on age, PSA levels, clinical staging, ISUP grade, comorbidities, and baseline urinary and sexual function scores. We compared perioperative variables, complications, and oncological and functional outcomes between groups. Results: Patients with morbid obesity had longer console times (median 90 vs. 75 min, p < 0.001) and higher rates of estimated blood loss over 100 mL (39% vs. 22%, p = 0.001). Full nerve-sparing was less frequent in this group (16.9% vs. 38.8%, p < 0.001), and postoperative lymphocele formation rates were higher (12.7% vs. 6.0%, p = 0.021). While patients with morbid obesity demonstrated a higher incidence of pT3a disease (34.4% vs. 20.2%, p = 0.015), no significant differences were observed in BCR and PSM (24% vs. 18%, p = 0.25) or functional outcomes, such as potency and urinary continence, at 12 and 24 months after operation. Conclusions: RARP in patients with morbid obesity is safe and feasible, with low rates of complications and no observed differences in functional and oncological outcomes compared to normal-weight patients. Further studies are needed to assess long-term outcomes in this growing patient population.

The Strategy of Robot-assisted Hysterectomy in Patients with Morbid Obesity

Robotic hysterectomy has emerged as a superior surgical approach for patients with obesity, providing significant benefits including reduced incidence of myocardial infarction, peripheral nerve injury, wound infections, and urinary tract infections. However, these unique considerations require careful attention when managing such cases. Therefore, this study aimed to propose several key strategies for achieving optimal outcomes, including maintaining a mild Trendelenburg position (12°), ensuring the patient's secure positioning, avoiding the lithotomy position, considering a slightly higher pneumoperitoneum insufflation pressure (12 mmHg), and using a 30° endoscope for improved visualization rather than a 0° endoscope. We present three cases of stage IA atypical endometrial hyperplasia and carcinoma. All three patients underwent robotic hysterectomy and bilateral salpingo-oophorectomy, with body mass indices of 53.3, 43.8, and 43.7 kg/m2.

Perioperative, function, and positive surgical margin in extraperitoneal versus transperitoneal single port robot-assisted radical prostatectomy: a systematic review and meta-analysis

BACKGROUND

Extraperitoneal and transperitoneal approaches are two common modalities in single-port (SP) robot-assisted radical prostatectomy (RARP), but differences in safety and efficacy between the two remain controversial. This study aimed to compare the perioperative, function, and positive surgical margin of extraperitoneal with transperitoneal approaches SP-RARP.

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, this study is registered with PROSPERO (CRD 42023409667). We systematically searched databases including PubMed, Embase, Web of Science, and Cochrane Library to identify relevant studies published up to February 2023. Stata 15.1 software was used to analyze and calculate the risk ratio (RR) and weighted mean difference (WMD).

RESULTS

A total of five studies, including 833 participants, were included in this study. The SP-TPRP group is superior to the SP-EPRP group in intraoperative blood loss (WMD: - 43.92, 95% CI - 69.81, - 18.04; p = 0.001), the incidence of postoperative Clavien-Dindo grade II and above complications (RR: 0.55, 95% CI - 0.31, 0.99; p = 0.04), and postoperative continence recovery (RR: 1.23, 95% CI 1.05, 1.45; p = 0.04). Conversely, the hospitalization stays (WMD: 7.88, 95% confidence interval: 0.65, 15.1; p = 0.03) for the SP-EPRP group was shorter than that of the SP-TPRP group. However, there was no significant difference in operation time, postoperative pain score, total incidence of postoperative complications, and positive surgical margin (PSM) rates between the two groups (p > 0.05).

CONCLUSIONS

This study demonstrates that both extraperitoneal and extraperitoneal SP-RARP approaches are safe and effective. SP-TPRP is superior to SP-EPRP in postoperative blood loss, the incidence of postoperative Clavien-Dindo grade II and above complications, and postoperative continence recovery, but it is accompanied by longer hospital stays.

The intraoperative management of robotic-assisted laparoscopic prostatectomy

PURPOSE OF REVIEW

Robotic-assisted laparoscopic radical prostatectomy has become the second most commonly performed robotic surgical procedure worldwide, therefore, anesthesiologists should be aware of the intraoperative pathophysiological consequences. The aim of this narrative review is to report the most recent updates regarding the intraoperative management of anesthesia, ventilation, hemodynamics and central nervous system, during robotic-assisted laparoscopic radical prostatectomy.

RECENT FINDINGS

Surgical innovations and the advent of new technologies make it imperative to optimize the anesthesia management to provide the most holistic approach possible. In addition, an ageing population with an increasing burden of comorbidities requires multifocal attention to reduce the surgical stress.

SUMMARY

Total intravenous anesthesia (TIVA) and balanced general anesthesia are similar in terms of postoperative complications and hospital stay. Reversal of rocuronium is associated with shorter hospital stay and postanesthesia recovery time. Adequate PEEP levels improve oxygenation and driving pressure, and the use of a single recruitment maneuver after the intubation reduces postoperative pulmonary complications. Restrictive intravenous fluid administration minimizes bladder-urethra anastomosis complications and facial edema. TIVA maintains a better autoregulation compared with balanced general anesthesia. Anesthesiologists should be able to optimize the intraoperative management to improve outcomes.

Ventilation strategy during urological and gynaecological robotic-assisted surgery: a narrative review

Robotic-assisted surgery has improved the precision and accuracy of surgical movements with subsequent improved outcomes. However, it requires steep Trendelenburg positioning combined with pneumoperitoneum that negatively affects respiratory mechanics and increases the risk of postoperative respiratory complications. This narrative review summarises the state of the art in ventilatory management of these patients in terms of levels of positive end-expiratory pressure (PEEP), tidal volume, recruitment manoeuvres, and ventilation modes during both urological and gynaecological robotic-assisted surgery. A review of the literature was conducted using PubMed/MEDLINE; after completing abstract and full-text review, 31 articles were included. Although different levels of PEEP were often evaluated within a protective ventilation strategy, including higher levels of PEEP, lower tidal volume, and recruitment manoeuvres vs a conventional ventilation strategy, we conclude that the best PEEP in terms of lung mechanics, gas exchange, and ventilation distribution has not been defined, but moderate PEEP levels (4-8 cm H2O) could be associated with better outcomes than lower or highest levels. Recruitment manoeuvres improved intraoperative arterial oxygenation, end-expiratory lung volume and the distribution of ventilation to dependent (dorsal) lung regions. Pressure-controlled compared with volume-controlled ventilation showed lower peak airway pressures with both higher compliance and higher carbon dioxide clearance. We propose directions to optimise ventilatory management during robotic surgery in light of the current evidence.

Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy: an update

The anesthetic concerns of patients undergoing robotic-assisted laparoscopic radical prostatectomy (RALP) are primarily related to the use of pneumoperitoneum in the steep Trendelenburg position. This combination will affect cerebrovascular, ocular, respiratory, and hemodynamic homeostasis. Possible non-surgical complications range from mild subcutaneous emphysema to devastating ischemic optic neuropathy. The anesthetic management of RALP patients involves a thorough preoperative evaluation, careful positioning on the operative table, managing ventilation issues, and appropriate fluid management. Close coordination between the anesthesia and surgical teams is required for a successful surgery. This updated review will discuss the anesthetic concerns and perioperative management of patients presenting for RALP.

Journal of Clinical Monitoring and Computing 2018-2019 end of year summary: respiration

This paper reviews 28 papers or commentaries published in Journal of Clinical Monitoring and Computing in 2018 and 2019, within the field of respiration. Papers were published covering endotracheal tube cuff pressure monitoring, ventilation and respiratory rate monitoring, lung mechanics monitoring, gas exchange monitoring, CO2 monitoring, lung imaging, and technologies and strategies for ventilation management.

Morbid obesity is adversely associated with perioperative outcomes in patients undergoing robot-assisted laparoscopic radical prostatectomy

INTRODUCTION

Robot-assisted laparoscopic radical prostatectomy (RALRP) may be more challenging in obese individuals. This study aimed to evaluate whether obesity had an adverse effect on perioperative outcomes following RALRP.

METHODS

Hospitalized patients who underwent RALRP from 2008-2014 were identified using the National Inpatient Sample database. We grouped RALRP patients into non-obese, obesity class I-II, and obesity class III (morbid obesity). Rates of blood transfusion, intraoperative and postoperative complications, in-hospital mortality, prolonged length of stay, and total costs were compared among the three groups by univariate regression, multivariate regression, and propensity score weighting analysis.

RESULTS

Of 53 301 patients identified, 48 725 were non-obese, 3572 were diagnosed with obesity class I-II, and 1004 were diagnosed with morbid obesity. Compared to non-obesity (7.62%), overall postoperative complications were commonly observed in obesity class I-II (10.55%) and morbid obesity (17.11%). Multivariable analyses suggested that morbid obesity was associated with increased overall postoperative (odds ratio [OR] 2.00, 95% confidence interval [CI] 1.65-2.42), cardiac (OR 1.63, 95% CI 1.03-2.58), respiratory (OR 4.03, 95% CI 3.04-5.36), genitourinary (OR 1.77, 95% CI 1.08-2.90), miscellaneous medical (OR 1.94, 95% CI 1.58-2.39) complications, prolonged hospitalization (OR 1.86, 95% CI 1.57-2.21), and 12% higher total cost. Propensity score weighting analysis yielded similar results. Adequate covariate balance was achieved for all variables after weighting.

CONCLUSIONS

Morbid obesity is adversely associated with perioperative outcomes in RALRP. Close management is required in patients undergoing RALRP with morbid obesity for potential worse prognosis.