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

Intracranial pressure estimated non-invasively and postoperative outcomes in surgery in the Trendelenburg position with pneumoperitoneum

BACKGROUND

Surgery in the Trendelenburg position (TP) with pneumoperitoneum (PP) is beneficial in several aspects but is associated with postoperative complications, such as postoperative nausea and vomiting (PONV). The mechanism behind this is unknown, but an increase in intracranial pressure (ICP) has been suggested. There are several studies of non-invasively estimated ICP during surgery in TP with PP. The association between perioperative estimated ICP and postoperative complications has not yet been reviewed.

METHODS

We performed a scoping review of peer-reviewed clinical studies reporting on both perioperative estimation of ICP and postoperative complications in patients undergoing surgery in TP with PP. The literature search was performed in February 2025 on PubMed, CINAHL, and Web of Science.

RESULTS AND CONCLUSIONS

Ten of 12 included studies suggested associations between perioperative elevation of estimated ICP and postoperative complications, most notably PONV. This may have clinical implications since elevated ICP can be treated. Future research should focus on the association between perioperative ICP estimation and postoperative complications and the effects of ICP-lowering strategies on postoperative outcomes.

Effects of individualized positive end-expiratory pressure on intraoperative oxygenation and postoperative pulmonary complications in patients requiring pneumoperitoneum with Trendelenburg position: a systematic review and meta-analysis

BACKGROUND

Whether individualized positive end-expiratory pressure (PEEP) improves intraoperative oxygenation and reduces postoperative pulmonary complications (PPCs) remains unclear. This systematic review and meta-analysis examined whether individualized PEEP is associated with improved intraoperative oxygenation and reduced PPCs for patients needing pneumoperitoneum with the Trendelenburg position during surgery.

METHODS

Medline, Embase, the Cochrane Library, and www.clinicaltrials.gov were searched for randomized controlled trials evaluating the effects of individualized PEEP on intraoperative oxygenation and PPCs in patients who required Trendelenburg positioning with pneumoperitoneum. The primary outcome was the oxygenation (PaO 2 /FiO 2 ) during the procedure. Secondary outcomes included PPCs, intraoperative respiratory mechanics (driving pressure, compliance), and vasopressor consumption. DerSimonian-Laird random effects models were used to calculate mean differences (MDs) and log risk ratios (log RRs) with 95% confidence intervals (CIs). The Cochrane Risk-of-Bias tool 2.0 was applied to assess the risk of bias in included studies. The protocol of this meta-analysis has been registered in PROSPERO.

RESULTS

We included 14 studies (1121 patients) that employed different individualized PEEP strategies. Compared with control groups, individualized PEEP groups exhibited a significantly improved intraoperative PaO 2 /FiO 2 (MD=56.52 mmHg, 95% CI: [33.98-79.06], P <0.001) and reduced incidence of PPCs (log RR=-0.50, 95% CI: [-0.84 to -0.16], P =0.004). Individualized PEEP reduced driving pressure while improving respiratory compliance. Intraoperative vasopressor consumption was similar between both groups. The weighted mean PEEP in the individual PEEP groups was 13.2 cmH 2 O [95% CI, 11.7-14.6]. No evidence indicated that one individualized PEEP strategy is superior to others.

CONCLUSIONS

Individualized PEEP seems to work positively for lung protection in the Trendelenburg position and pneumoperitoneum in patients undergoing general anesthesia.

Navigating challenges in anesthesia for robotic urological surgery: a comprehensive guide

Robotic surgery has emerged as a cornerstone in urological interventions, offering effectiveness and safety for patients. For anesthesiologists, this technological advancement presents a myriad of new challenges, spanning from patient selection and assessment to intraoperative dynamics and post-surgical pain management. This article aims to elucidate these challenges and provide guidance for anesthesiologists in navigating the complexities of anesthesia administration in robotic urological procedures. Through a detailed exploration of patient optimization, team coordination, intraoperative adjustments, and post-surgical care, this article serves as a valuable resource for ensuring the success of such interventions.

Ultrasonographic evaluation of diaphragmatic excursion changes after major laparoscopic surgeries in the Trendelenburg position under general anaesthesia: A prospective observational study

Background and Aims

Laparoscopic surgeries result in increased intra abdominal pressure and cephalad displacement of the diaphragm. The Trendelenburg position can augment these respiratory changes. The primary objective of this study was to compare diaphragmatic excursions before and after a major laparoscopic pelvic surgery under general anaesthesia in the Trendelenburg position using ultrasonography (USG).

Methods

This prospective observational study included 90 patients of either gender, aged 20-60 years, with American Society of Anesthesiologists physical status I/II. M-mode USG was used to assess diaphragm inspiratory amplitude (DIA) before induction of anaesthesia and 10 minutes after tracheal extubation. Factors such as age, gender, body mass index, positive end-expiratory pressure (PEEP), pain, peak airway pressures, duration of pneumoperitoneum, duration and degree of Trendelenburg position and duration of anaesthesia were recorded. Pearson's correlation and multiple linear regression were used to analyse the factors affecting change in DIA (ΔDIA).

Results

The mean difference (95% confidence interval (CI)) of measured DIA was 0.70 (0.598-0.809), P < 0.001. ΔDIA had a weak positive significant correlation with age, anaesthesia duration, pneumoperitoneum, and visual analogue scale (VAS) score 10 minutes after extubation. Multiple linear regression analysis showed 14.86% of the variance in DIA. Age (β = 0.008, P = 0.049), duration of anaesthesia (β = 0.002, P = 0.02) and VAS score 10 minutes after extubation (β = 0.128, P = 0.001) were significant independent predictors.

Conclusion

DIA decreased significantly after pelvic laparoscopic surgeries performed in the Trendelenburg position. Age, duration of anaesthesia and pain after the procedure were significant independent predictors.