The Role of AirSeal in Robotic Urologic Surgery: A Systematic Review

Perioperative outcomes and safety of valveless insufflation system in minimally invasive urological surgery: a systematic review and meta-analysis

BACKGROUND

With the rapid development of laparoscopic and robot-assisted surgery, many technological innovations and improvements have emerged to optimize minimally invasive surgery and ensure minimal patient risk. Although AirSeal has been widely reported in the field of urology, its perioperative outcomes and safety in minimally invasive urological surgery remain unclear because of inconsistent levels of evidence.

OBJECTIVES

The authors performed this meta-analysis to evaluate the perioperative outcomes and safety of the valveless insufflation system (VIS) in minimally invasive urological surgery compared with the conventional insufflation system (CIS).

METHODS

The authors comprehensively searched PubMed, Web of Science, Cochrane Library, and Embase databases to identify eligible studies published up to January 2024. Review Manager software (version 5.3.0) was used for the statistical analysis. Eligible studies were randomized controlled trials (RCTs) or non-RCTs of minimally invasive urological surgery with VIS vs CIS. The study outcomes included perioperative outcomes and safety. The authors excluded publication types, including letters, reviews, case reports, and animal and pediatric studies.

RESULTS

The authors finally identified five RCTs and eight non-RCTs in this meta-analysis. The meta- analysis indicated that the operative time was comparable between the groups ( P =0.57, I2 =91%). However, a VIS may increase blood loss ( P =0.0004, I2 =45%) and shorten hospital stays ( P <0.00001, I2 =90%). Due to the high heterogeneity of the results, the authors carefully evaluated all included studies and discovered that the studies by Bucur and Ferroni may be the sources of heterogeneity. When these two studies were excluded, heterogeneity was significantly reduced, and the operative time for VIS was significantly shorter than that for CIS ( P =0.0002). Adjusted blood loss showed no difference between the VIS and CIS groups ( P =0.10). In terms of safety, the pooled results revealed that the incidence of Clavien-Dindo III-IV complications in the VIS group was significantly lower than that in the CIS group ( P =0.02, I2 =0%). Moreover, VIS significantly reduced general pain ( P =0.02, I2 =15%) and shoulder pain ( P =0.001, I2 =0%) 12-24 h postoperatively. No significant differences were observed in total complications ( P =0.06, I2 =0%), blood transfusion ( P =0.14, I2 =0%), and subcutaneous emphysema ( P =0.96, I2 =63%) between the two groups.

CONCLUSIONS

Our meta-analysis revealed additional perioperative advantages of the VIS in minimally invasive urological surgery. Moreover, VIS is superior to CIS owing to less severe complication rates, general pain, and shoulder pain.

A systematic review and meta-analysis compared the safety and effectiveness of the AirSeal system with traditional pneumoperitoneum systems in robot-assisted laparoscopic urologic surgery

This study aimed to analyze perioperative results in robot-assisted laparoscopic urological surgeries, comparing the AirSeal system with traditional pneumoperitoneum systems. This study adhered to the PRISMA guidelines for conducting systematic reviews and meta-analyses. Extensive searches were conducted in PubMed, EMBASE, and Google Scholar, including randomized controlled trials (RCTs) and cohort studies up to June 15, 2024. A combined examination of the studies found that the AirSeal system had superior results in terms of surgery duration, end-tidal carbon dioxide levels, and tidal volume compared to the traditional pneumoperitoneum system. During robotic-assisted partial nephrectomy, the AirSeal team experienced a notable decrease in surgical time, ETCO2, and VT. In addition, the occurrence of SCE was lower in the AirSeal group. However, there were no significant differences observed between the groups regarding EBL, LOHS, overall complications, and major complications. Compared to conventional pneumoperitoneum systems, the AirSeal system offers several advantages in robot-assisted laparoscopic urological surgery: reduced operative time, lower end-tidal CO2 pressure, and decreased tidal volume. Furthermore, implementing the AirSeal system does not lead to higher rates of complications, estimated blood loss, or lengthier hospital stays.

Subcutaneous emphysema associated with laparoscopic or robotic abdominal surgery: a retrospective single-center study

BACKGROUND

Subcutaneous emphysema (SCE) is a common complication in laparoscopic surgery. However, its precise incidence and impact on the clinical course are partially known. In this study, the incidence and risk factors of SCE were retrospectively analyzed.

METHODS

Patients who underwent laparoscopic/robotic abdominal surgery (e.g., gastrointestinal, hepatobiliary, gynecologic, and urologic surgery) between October 2019 and September 2022 were retrospectively analyzed. The presence of SCE was confirmed by either conclusive findings obtained through chest/abdominal X-ray examination immediately after operation, or intraoperative palpation conducted by nurses. X-ray examination was performed in the operation room before extubation.

RESULTS

A total of 2503 patients treated with laparoscopic/robotic abdominal surgery between October 2019 and September 2022 were identified and all of them were included in the analysis. SCE was confirmed in 23.1% of the patients (i.e., 577/2503). SCE was identified by X-ray examination in 97.6% of the patients. Extubation failure was observed in 10 patients; however, pneumothorax was not observed. Female sex (odds ratio [OR]: 2.09; 95% confidence interval [95%CI]: 1.69-2.57), age ≥ 80 years (OR 1.63; 95%CI 1.19-2.22), body mass index < 20 (OR 1.32; 95%CI 1.06-1.65), operation time > 360 min (OR 1.97; 95%CI 1.53-2.54), robotic surgery (OR 2.54; 95%CI 1.91-3.38), maximum intraabdominal pressure with CO2 > 15 mmHg (OR 1.79; 95%CI 1.02-3.16), and endo-tidal CO2 > 50 mmHg (OR 1.32; 95%CI 1.08-1.62)were identified as independent factors of SCE. Regarding the extubation failure due to SCE, age (OR 5.84; 95%CI 1.27-26.8) and maximum intraabdominal pressure with CO2 (OR 21.7; 95%CI 4.76-99.3) were identified as risk factors.

CONCLUSION

Although the presence of SCE is associated with a low risk of severe complications, monitoring of the perioperative intraabdominal pressure is essential for performing safe laparoscopic/robotic surgery, particularly in elderly patients.

Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy

Subcutaneous emphysema (SE), a complication of robotic gastrectomy (RG), occurs when the gas used to establish pneumoperitoneum escapes and enters the soft tissue. SE typically does not result in major clinical problems, but massive SE can have life-threatening consequences. Hence, developing adequate preventive methods against postoperative SE is essential. We aimed to determine whether an existing protective device, the LAP PROTECTOR™ (LP), can be used to reduce the incidence of SE after RG. We analyzed the data of 194 patients who underwent RG at our hospital between August 2016 and December 2022. Since September 2021 (the 102nd patient), we have used the LP (FF0504; Hakko Medical, Hongo, Tokyo, Japan) at the trocar site, as this was expected to reduce the incidence of SE. The primary endpoint of this study was the efficacy of the LP in reducing the incidence of clinically relevant SE (defined as SE extending into the cervical area) a day after RG. Univariate analysis revealed that sex, body mass index (BMI), and LP usage differed significantly between patients with and without postoperative SE. Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15-0.72, P < 0.001), high BMI (OR: 0.13, 95% CI: 1.23-4.45, P = 0.009), and LP usage (OR: 0.11, 95% CI: 0.04-0.3, P < 0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE. Placing an LP at the trocar site may be a safe and effective method of preventing SE after RG.