The effects of steep trendelenburg positioning on intraocular pressure during robotic radical prostatectomy

Anesthetic considerations in robotic surgery: a comprehensive review

Recent advancements have led to a rise, in the demand for surgical methods with robot-assisted procedures becoming increasingly popular for addressing the limitations of traditional laparoscopy. However, incorporating surgery involves making changes in the way patients are positioned and logistical planning, which can challenge conventional approaches to providing anesthesia care. Despite these obstacles robotic technology shows potential for bringing about improvements in therapy. Anesthesiologists play a role in ensuring safety and delivering high quality anesthesia care during robotic surgery. Having an understanding of the elements of robotic surgical systems is essential for adjusting anesthesia practices effectively. Keeping up to date with the developments in surgery is key to achieving optimal outcomes for patients. Effective collaboration between teams and anesthesiologists is essential for managing the complexities of anesthesia during surgery. By promoting communication and cooperation across disciplines healthcare professionals can enhance safety and results. In summary while the introduction of surgery presents challenges in anesthesia care it also offers opportunities for innovation and advancement. Anesthesiologists need to embrace these advancements adapt their practices accordingly and engage in education and collaboration to ensure the safe and successful integration of robotic technology, into surgical procedures ultimately improving patient care.

A Prospective Study of the Effects of General Anesthesia on Intraocular Pressure in Healthy Children

Purpose

To determine the effect of general anesthesia on intraocular pressure (IOP) in children with no intraocular pathology and determine which postanesthetic time point is most predictive of preinduction IOP.

Design

Prospective observational study.

Participants

Children with no intraocular pathology ≤ 18 years scheduled for general anesthesia as part of their routine care followed by a pediatric ophthalmologist at Nanjing Medical University.

Methods

Participants underwent a standardized general anesthetic protocol using a mask induction with sevoflurane and propofol maintenance. Intraocular pressure was measured at the following 7 time points: preinduction (taken in the preoperative area), postinduction minutes 1, 3, and 5, and postairway placement minutes 1, 3, and 5 for a total time period of 10 minutes after induction. A generalized estimating equation was used to evaluate the effect of anesthesia on IOP and the effect of patient factors (age, gender, vital signs, and airway type) on preanesthetic and postanesthetic IOP. An IOP prediction model was developed using the postanesthesia IOP measurements for predicting preinduction IOP.

Main Outcome Measures

Intraocular pressure and change in IOP at prespecified time points.

Results

Eighty-five children were enrolled with a mean ± standard deviation (SD) age of 7.5 ± 2.9 years. Mean ± SD preinduction IOP was 20.1 ± 3.7 mmHg. Overall, IOP was lowest at 3 minutes postinduction, decreased to a mean of 13.4 ± 3.7 mmHg (P < 0.001). After this, IOP rose 5 minutes postinduction to 16.5 ± 4.2 mmHg, which did not reach preinduction IOP levels (P < 0.001). The IOP prediction model showed that combining 1 minute postinduction and 3 minutes postairway was most predictive (R2 = 0.13), whereas 1 minute postairway was least predictive of preinduction IOP (R2 = 0.01).

Conclusions

After the induction of general anesthesia in children, IOP temporarily decreases with a trough at 3 minutes postinduction before increasing and remaining stable just below preinduction levels. Intraocular pressure measurements taken 1 minute after induction with 3 minutes after airway placement are most predictive of preinduction IOP, though predictive value is relatively low.

Financial Disclosures

Proprietary or commercial disclosure may be found in the Footnotes and Disclosures at the end of this article.

Postoperative vision loss due to bilateral vitreous hemorrhage after robot-assisted laparoscopic hysterectomy: A case report

Purpose

To report a case of bilateral vitreous hemorrhage (VH) resulting in postoperative vision loss (POVL) after robot-assisted laparoscopic hysterectomy in a 71-year-old female patient.

Observations

At initial presentation, best-corrected visual acuity was hand motion at 20 cm in the right eye and 20/666 in the left eye. VH in both eyes and preretinal hemorrhage in the left eye was observed. As the hemorrhage gradually resolved, a full-thickness macular hole was discovered in the right eye, for which the patient did not agree with a surgical treatment.

Conclusions and importance

This report describes a rare incidence of bilateral VH as a cause of POVL after non-ophthalmic surgery, which may be related to Trendelenburg positioning, CO2 pneumoperitoneum, and a long surgical duration. Given that POVL can cause severe visual impairment, consultation with ophthalmologists is crucial.

Underneath Images and Robots, Looking Deeper into the Pneumoperitoneum: A Narrative Review

Laparoscopy offers numerous advantages over open procedures, minimizing trauma, reducing pain, accelerating recovery, and shortening hospital stays. Despite other technical advancements, pneumoperitoneum insufflation has received little attention, barely evolving since its inception. We explore the impact of pneumoperitoneum on patient outcomes and advocate for a minimally invasive approach that prioritizes peritoneal homeostasis. The nonlinear relationship between intra-abdominal pressure (IAP) and intra-abdominal volume (IAV) is discussed, emphasizing IAP titration to balance physiological effects and surgical workspace. Maintaining IAP below 10 mmHg is generally recommended, but factors such as patient positioning and surgical complexity must be considered. The depth of neuromuscular blockade (NMB) is explored as another variable affecting laparoscopic conditions. While deep NMB appears favorable for surgical stillness, achieving a balance between IAP and NMB depth is crucial. Temperature and humidity management during pneumoperitoneum are crucial for patient safety and optical field quality. Despite the debate over the significance of temperature drop, humidification and the warming of insufflated gas offer benefits in peritoneal homeostasis and visual clarity. In conclusion, there is potential for a paradigm shift in pneumoperitoneum management, with dynamic IAP adjustments and careful control of insufflated gas temperature and humidity to preserve peritoneal homeostasis and improve patient outcomes in minimally invasive surgery.

Perioperative lung function following flow controlled ventilation for robot-assisted prostatectomies in steep trendelenburg position: an observational study

BACKGROUND

Steep Trendelenburg position combined with capnoperitoneum can lead to pulmonary complications and prolonged affection of postoperative lung function. Changes in pulmonary function occur independent of different modes of ventilation and levels of positive end-expiratory pressure (PEEP). The effect of flow-controlled ventilation (FCV) has not been evaluated yet. We perioperatively measured spirometric lung function parameters in patients undergoing robot-assisted prostatectomy under FCV. Our primary hypothesis was that there is no significant difference in the ratio of the maximal mid expiratory and inspiratory flow (MEF50/MIF50) after surgery.

METHODS

In 20 patients, spirometric measurements were obtained preoperatively, 40, 120, and 240 min and 1 and 5 days postoperatively. We measured MEF50/MIF50, vital capacity (VC), forced expiratory volume in 1 s (FEV1), and intraoperative ventilation parameters.

RESULTS

MEF50/MIF50 ratio increased from 0.92 (CI 0.73-1.11) to 1.38 (CI 1.01-1.75, p < 0.0001) and returned to baseline within 24 h, while VC and FEV1 decreased postoperatively with a second nadir at 24 h and only normalized by the fifth day (p < 0.0001). Compared to patients with PCV, postoperative lung function changes similarly.

CONCLUSION

Flow-controlled ventilation led to changes in lung function similar to those observed with pressure-controlled ventilation. While the ratio of MEF50/MIF50 normalized within 24 h, VC and FEV1 recovered within 5 days after surgery.

Guidelines in Practice: Positioning the Patient

Positioning the patient is an important perioperative task; the recently updated AORN "Guideline for positioning the patient" provides perioperative personnel with background information and evidence-based best practices for perioperative patient positioning and focuses on maintaining patient and staff member safety. The revised guideline includes recommendations for placing patients safely in a variety of positions and avoiding positioning injuries, such as postoperative vision loss. This article provides an overview of positioning recommendations for assessing patients' risk for injury, implementing safe positioning practices, placing patients in the Trendelenburg position, and preventing intraocular injuries. It also includes a patient-focused scenario on preventing adverse events associated with the Trendelenburg position that aligns with information discussed in the article. Perioperative nurses should review the guideline in its entirety and implement appropriate recommendations for positioning patients during procedures.

Frequency of Positive Cuff Leak Test Before Extubation in Robotic Surgeries Done in Steep Trendelenburg Position

Anaesthesia for robotic surgeries done in steep trendelenburg position are associated with risks such as facial oedema, conjunctival chemosis, raised intraocular pressure, laryngeal oedema, and delayed awakening. We proposed the use of the cuff leak test in them to record the frequency of laryngeal oedema at the end of surgery and attempted to find its correlation with probable risk factors. We conducted a prospective observational study of 100 patients aiming primarily to assess the frequency of positive cuff leak test in robotic abdominal surgeries performed in trendelenburg position. The secondary outcomes were to check its correlation with intravenous fluid administration, duration of pneumoperitoneum, and angle of trendelenburg position. We also recorded the frequency of chemosis, the frequency of post-extubation stridor in 24 h post-operatively, and the frequency of reintubation. Out of 100 participants undergoing elective abdominal robotic surgery in trendelenburg position, ninety were analysed. Total 31.6% (n = 30) participants showed positive cuff leak test. Chemosis was observed in 31 (32.6%) participants. No patient experienced post-extubation stridor or required reintubation during post-operative follow up. There was a no correlation between cuff leak test and intravenous fluid, duration of pneumo-peritoneum, or with angle of trendelenburg. The frequency of positive cuff leak test was high in patients at the end of robotic surgery but none of these patients had post-extubation stridor or required reintubations. There was no correlation with the fluid, angle, or duration of surgery. Clinical Trials Registry of India (CTRI/2017/04/008289), ctri.nic.in.

Effects of Positive End-Expiratory Pressure on Intraocular Pressure during One-Lung Ventilation in the Lateral Decubitus Position-A Prospective Randomized Trial

Background and Objectives: The effect of positive end-expiratory pressure (PEEP) on intraocular pressure (IOP) is debatable. There have been no studies investigating the effects of PEEP on IOP during one-lung ventilation (OLV). We aimed to investigate the effects of PEEP on IOP in patients undergoing OLV for video-assisted thoracoscopic surgery (VATs). Materials and Methods: Fifty-two patients undergoing VATs were divided into a zero-PEEP (ZEEP) and a 6 cmH₂O of PEEP (PEEP) groups. IOP, ocular perfusion pressure (OPP), and respiratory and hemodynamic parameters were measured before induction (T1), immediately following endotracheal intubation (T2), 30 min (T3) and 60 min (T4) after a position change to the lateral decubitus position (LDP) and OLV, and 10 min following two-lung ventilation near the end of the surgery (T5). Results: There was no significant difference in IOP and OPP between the two groups. The IOP of the dependent eye was significantly higher than that of the non-dependent eye during LDP in both groups. Peak inspiratory pressure was significantly higher in the PEEP group than in the ZEEP group at T3-T5. Dynamic compliance was significantly higher in the PEEP group than in the ZEEP group at T2-T5. The ratio of arterial oxygen partial pressure to fractional inspired oxygen was significantly higher in the PEEP group than in the ZEEP group at T4. Conclusions: Applying 6 cmH₂O of PEEP did not increase IOP but enhanced dynamic compliance and oxygenation during OLV. These results suggest that 6 cmH₂O of PEEP can be safely applied during OLV in LDP.

The Impact of Steep Trendelenburg Position on Intraocular Pressure

Intraocular pressure occurring during the Trendelenburg position may be a risk for postoperative visual loss and other ocular complications. Intraocular pressure (IOP) higher than 21 mmHg poses a risk for ocular impairment causing several conditions such as glaucoma, detached retina, and postoperative vision loss. Many factors might play a role in IOP increase, like peak expiratory pressure (PIP), mean arterial blood pressure (MAP), end-tidal CO2 (ETCO2) and surgical duration and some others (anaesthetic and neuromuscular blockade depth) contribute by reducing IOP during procedures requiring both pneumoperitoneum and steep Trendelenburg position (25-45° head-down tilt). Despite transient visual field loss after surgery, no signs of ischemia or changes to the retinal nerve fibre layer (RNFL) have been shown after surgery. Over the years, several studies have been conducted to control and prevent IOPs intraoperative increase. Multiple strategies have been proposed by different authors over the years to reduce IOP during laparoscopic procedures, especially those involving steep Trendelenburg positions such as robot-assisted laparoscopic prostatectomy (RALP), and abdominal and pelvic procedures. These strategies included both positional and pharmacological strategies.

Robot-assisted kidney transplantation: an update

Renal transplantation has become the gold-standard treatment for the majority of patients with established renal failure. Recent decades have seen significant progress in immunosuppressive therapies and advances in post-transplant management of recipients, resulting in improved graft and patient outcomes. However, the open technique of allograft implantation has stood the test of time, remaining largely unchanged. In a world where major advances in surgery have been facilitated by innovations in the fields of biotechnology and medical instrumentation, minimally invasive options have been introduced for the recipient undergoing kidney transplantation. In this review we present the evolution of minimally invasive kidney transplantation, with a specific focus on robot-assisted kidney transplant and the benefits it offers to specific patient groups. We also discuss the ethical concerns that must be addressed by transplant teams considering developing or referring to robotic programs.

Intraocular pressure during handgrip exercise: The effect of posture and hypercapnia in young males

PURPOSE

As part of our investigations of intraocular pressure (IOP) as a potential contributing factor to the spaceflight-associated neuro-ocular syndrome using the 6° head-down tilt (6°HDT) bed rest experimental model, we compared the effect of rest and isometric exercise in prone and supine 6°HDT positions on IOP with that observed in the seated position.

METHODS

Ten male volunteers (age = 22.5 ± 3.1 yrs) participated in six interventions. All trials comprised a 10-min rest period, a 3-min isometric handgrip exercise at 30% of participant's maximum, and a 10-min recovery period. The trials were conducted under normocapnic (NCAP) or hypercapnic (FI CO2  = 0.01; HCAP) conditions, the latter mimicking the ambient conditions on the International Space Station. IOP, systolic and diastolic pressures, and heart rate (HR) were measured during the trials.

RESULTS

Isometric exercise-induced elevations in HR and mean arterial blood pressure. IOP in the prone 6°HDT position was significantly higher (p < 0.001) compared to IOP in supine 6°HDT position and seated trials at all time points. IOP increased with exercise only in a seated HCAP trial (p = 0.042). No difference was observed between trials in NCAP and HCAP. IOP in the prone 6°HDT position was constantly elevated above 21 mmHg, the lower limit for clinical ocular hypertension.

CONCLUSIONS

IOP in the prone 6°HDT position was similar to IOP reported in astronauts upon entering microgravity, potentially indicating that prone, rather than supine 6°HDT position might be a more suitable experimental analog for investigating the acute ocular changes that occur in microgravity.

Sugammadex, the Guardian of Deep Muscle Relaxation During Conventional and Robot-Assisted Laparoscopic Surgery: A Narrative Review

High intra-abdominal pressure induced by artificial pneumoperitoneum can obviously impair respiratory and circulatory functions and has a negative effect on the prognosis of patients undergoing conventional and robot-assisted laparoscopic surgery. The application of deep neuromuscular blockade during the operation is reported to lower the intra-abdominal pressure and improve patients’ outcome. However, concern lies in the risks of postoperative residual muscular paralysis with the use of deep neuromuscular blockade. Sugammadex, a specific antagonist for aminosteroids muscle relaxants, can effectively and rapidly reverse rocuronium and vecuronium induced neuromuscular blockade of different depths. Thus, sugammadex allows the ability to safeguard the application of deep neuromuscular blockade in laparoscopic operations and helps to alleviate the adverse complications associated with pneumoperitoneum. Here, we review the application of deep neuromuscular blockade in different laparoscopic surgeries and discuss the benefits and possible risks of sugammadex administration in the reversal of deep neuromuscular blockade in these operations.

Laparoscopic gynaecological surgery in the context of maintaining normal intracranial pressure

A nulliparous patient in her early 20s was referred to a fertility specialist for fertility preservation, before commencing chemo-radiation therapy for a recently diagnosed malignant brain tumour. Two weeks prior, she had presented with seizures and undergone emergency craniotomy and tumour resection. Taking into consideration of the tight time frame and her comorbidities, several measures were undertaken to minimise the potential increase in intracranial pressure that may lead to cerebral oedema during laparoscopy. Preoperatively, the anaesthetist administered 8 mg dexamethasone as prophylaxis. Intraoperatively, the degree of head-down tilt was minimised to 10, which was just adequate to displace bowel cranially for visualisation of pelvic structures. Finally, a shorter operative time was achieved by ensuring the most senior surgeon performed the operation, and the procedure itself was altered from the standard approach of ovarian harvesting to unilateral oophorectomy. The patient made a quick recovery and was discharged home day 1 postoperatively.

Postoperative peripheral neuropathies associated with patient positioning during robot-assisted laparoscopic radical prostatectomy (RARP): A systematic review of the literature

OBJECTIVE

To perform a systematic review of the literature concerning postoperative peripheral neuropathies associated with patient positioning during robot-assisted laparoscopic radical prostatectomy (RARP).

PATIENTS AND METHODS

A systematic review on articles published from January 1, 1990 to March 15, 2020 was performed in accordance with the PRISMA declaration (Preferred Reporting Items for Systematic Reviews and Meta-Analysis). The electronic search was done searching through the Cochrane Registry, PubMed/EMBASE, Medline, and Scopus. Relevant papers addressing postoperative peripheral neuropathies related to patient positioning during RARP were integrated into the analyses.

RESULTS

After screening 4975 articles, one randomized controlled trial and five retrospective studies with a total of 63,667 patients were included in this review. Peripheral neuropathies of the upper extremities were documented in three articles with a total of 15 patients, peripheric neuropathies of the lower extremities were reported in five articles with a total of 76 patients. Analysis of the data was exploratory, since screening techniques, systematically reporting, and description of positioning techniques was not standardized or not reported.

CONCLUSIONS

The incidence of peripheral neuropathies at RARP varies between 1.3% and 10.8%. Lower extremities are more affected than upper extremities and the most important risk factors are intraoperative time duration, patients comorbidities, and ASA score. High-quality prospective randomized studies to better assess the impact of patient positioning during RARP on the development postoperative peripheral neuropathies are needed.

Anesthetic management of a morbidly obese patient with endometrial cancer during robot-assisted laparoscopic surgery

Background

The number of robot-assisted surgeries being performed has increased in recent years, even in patients with risk factors, such as obesity, owing to advancements in medical technologies. We here report the anesthetic management of a morbidly obese woman who underwent robot-assisted surgery.

Case presentation

A 44-year-old woman (height, 165 cm; weight, 147 kg; body mass index, 54 kg/m²) was scheduled to undergo robot-assisted laparoscopic hysterectomy for endometrial cancer. Preoperative weight loss and rehearsal of positioning during induction of anesthesia and surgical procedures greatly contributed to the surgical success. Monitoring of oxygen reserve index in combination with SpO₂ was useful for appropriate airway and respiratory management. During anesthesia induction, the ramp position using a special commercially available cushion facilitated manual mask ventilation and tracheal intubation. Lung-protective ventilation using a limited tidal volume with moderate PEEP was applied during the robot-assisted surgical procedure.

Conclusion

We successfully managed anesthesia without any complications.

Intraocular pressure during robotic-assisted laparoscopic prostatectomy: a prospective observational study

Background and objectives

Although previous reports have shown intraocular pressure changes during robotic-assisted laparoscopic prostatectomy, they did not discuss the time course of changes or the timing of the largest change. We conducted this study to quantify pressure changes over time in patients assuming the steep Trendelenburg position during robotic-assisted laparoscopic prostatectomy.

Methods

Twenty-one men were enrolled. Intraocular pressure was measured before anesthesia induction in the supine position (T0); 30 (T1), 90 (T2), and 150 minutes after assuming the Trendelenburg position (T3); and 30 minutes after reassuming the supine position (T4). End-tidal carbon dioxide and blood pressure were also recorded. To compare intraocular pressure between the time points, we performed repeated-measures analysis of variance. A mixed-effects multivariate regression analysis was conducted to adjust for confounding factors.

Results

The mean (standard deviation) intraocular pressure was 18.3 (2.4), 23.6 (3.0), 25.1 (3.1), 25.3 (2.2), and 18.1 (5.0) mmHg at T0, T1, T2, T3, and T4, respectively. The mean intraocular pressure was higher at T1, T2, and T3 than at T0 (p < 0.0001 for all). There was no significant difference between T0 and T4, and between T3 and T2 (p > 0.99 for both).

Conclusions

The Trendelenburg position during robotic-assisted laparoscopic prostatectomy increased intraocular pressure. The increase was moderate at 90 minutes after the position was assumed, with the value being approximately 7 mmHg higher than the baseline value. The baseline intraocular pressure was restored at 30 minutes after the supine position was reassumed.

Trial registration

UMIN ID 000014973

Date of registration

August 27, 2014

The effect of robotic surgery on intraocular pressure and optic nerve sheath diameter: a prospective study

Background and objectives

To investigate the effect of the steep Trendelenburg position (35° to 45°) and carbon dioxide (CO2) insufflation on optic nerve sheath diameter (ONSD), intraocular pressure (IOP), and hemodynamic parameters in patients undergoing robot-assisted laparoscopic prostatectomy (RALP), and to evaluate possible correlations between these parameters.

Methods

A total of 34 patients were included in this study. ONSD was measured using ultrasonography and IOP was measured using a tonometer at four time points: T1 (5 minutes after intubation in the supine position); T2 (30 minutes after CO2 insufflation); T3 (120 minutes in steep Trendelenburg position); and T4 (in the supine position, after abdominal exsufflation). Systolic and diastolic arterial pressure, heart rate, and end-tidal CO2 (etCO2) were also evaluated.

Results

The mean IOP was 12.4 mmHg at T1, 20 mmHg at T2, 21.8 mmHg at T3, and 15.6 mmHg at T4. The mean ONSD was 4.87 mm at T1, 5.21 mm at T2, 5.30 mm at T3, and 5.08 at T4. There was a statistically significant increase and decrease in IOP and ONSD between measurements at T1 and T4, respectively. However, no significant correlation was found between IOP and ONSD. A significant positive correlation was found only between ONSD and diastolic arterial pressure. Mean arterial pressure, heart rate, and etCO2 were not correlated with IOP or ONSD.

Conclusions

A significant increase in IOP and ONSD were evident during RALP; however, there was no significant correlation between the two parameters.

Changes in intraocular pressure during coronary artery bypass graft surgery: an observational study

Background

In this study, the effects of pulsatile and non-pulsatile on-pump Coronary Artery Bypass Graft surgery (CABG) and off-pump CABG techniques on the intraocular pressure were investigated.

Methods

Forty-five patients who planned to elective coronary artery bypass surgery with on-pump pulsatile (n = 15), non-pulsatile (n = 15), or off-pump (n = 15) were included. Intraocular Pressure (IOP) measurements were performed on both eyes at nine time-points: 1) Before the operation, 2) After anesthesia induction, 3) 3 minutes after heparin administration Left Internal Mammary Artery (LIMA) harvesting, 4) End of the first anastomosis, 5) End of LIMA anastomosis, 6) 3 minutes after protamine administration, 7) End of the operation, and 8) Second hour in Intensive Care Unit (ICU), 9) Fifth hour in ICU. Mean Arterial Pressure (MAP) and Central Venous Pressure (CVP) were also recorded at the same time points as IOP.

Results

In Cardiopulmonary Bypass (CPB) groups (pulsatile or non-pulsatile CPB) with the beginning of CPB, there were significant decreases in IOP values when compared to baseline (p = 0.012). This decrease was more prominent in the non-pulsatile group when compared to the pulsatile group (T₄ IOP values: pulsatile, 9.7 ± 2.6; non-pulsatile, 6.8 ± 1.9; p = 0.002; T₅ IOP values: pulsatile, 9.5 ± 1.9; non-pulsatile, 6.7 ± 2.1; p = 0.004). At the end of the surgery (T₇), IOP values returned to the baseline and stayed stable at the remaining time-points. In-off pump group, IOP values significantly increased with a head-down position (T₄ IOP values: off-pump surgery, 19.7 ± 5.2; p = 0.015). IOP values remained high until the normalization of head-down position (T₆) and stayed stable through the rest of all remaining time-points.

Conclusion

During cardiac surgery regardless of the technique (on-pump CABG, off-pump CABG), intraocular pressures remain in the normal ranges. It should be kept in mind that patients should be avoided from long and extreme Trendelenburg position, low CVP, and MAP levels during cardiac surgery to prevent eye-related complications.

Quantitative rise in intraocular pressure in patients undergoing robotic surgery in steep Trendelenburg position: A prospective observational study

BACKGROUND AND AIMS

Raised intraocular pressure (IOP) is one of the known causes of anterior ischemic optic neuropathy. In the case of robotic urological-gynecological surgeries, patient is kept in steep Trendelenburg supine-lithotomy position. Aim of this study was to observe the quantitative rise in IOP in steep Trendelenburg position (>45°) in robotic-assisted prostatectomy and hysterectomy.

MATERIAL AND METHODS

After institutional ethical clearance and written informed consent, 100 patients undergoing robotic surgeries in steep Trendelenburg position were recruited for the study. IOP was measured at different time intervals in steep Trendelenburg position using Schiotz tonometer: Post intubation (T1), post pneumoperitoneum (T2), post steep Trendelenburg (T3), and rest readings were taken 30 min apart. T9 was taken 10 min after patient is made supine and parallel to the ground. Mean arterial pressure (MAP), positive inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2) values were recorded at different time points. Descriptive analysis, linear regression analysis, and Freidman's nonparametric tests were used to analyze the results.

RESULTS

Ninety-five patients were included for statistical analysis as five patients were excluded due to intraoperative interventions leading to alteration of results. Mean IOP at T1 was 19.181/18.462 mmHg in L/R eye. A gradual rise in IOP was observed with every time point while patient was in steep Trendelenburg position which reverts back to near normal values once the patient is changed to normal position 21.419/20.671: Left/right eye in mm of Hg. Uni and multiple regression analysis showed insignificant P value, thus no correlation between MAP, PIP, and EtCO2 with IOP.

CONCLUSION

Steep Trendelenburg position for prolong duration leads to significant rise in intraocular pressure.

The Effect of Increased Intraocular Pressure During Steep Trendelenburg Positioning in Robotic Prostatectomy and Hysterectomy on Structural and Functional Ocular Parameters

BACKGROUND

Robotic prostatectomy and robotic hysterectomy require steep Trendelenburg positioning. Many authors documented significant increases in intraocular pressure (IOP) during steep Trendelenburg. However, the long-term biological effect of a significant increase in IOP on the structural and functional ocular system is unknown. This study examines the effect of a significant increase in IOP on the visual acuity, retinal nerve fiber layer thickness (RNFLT), and ganglion cell complex (GCC) thickness in 52 patients without preexisting ocular disease of both genders before and 3 months after their procedures.

METHODS

This was a prospective cohort study. The total number of patients included was 56, then 3 females and 1 male case were excluded, totaling 28 robotic hysterectomies and 24 robotic prostatectomies were performed. Patients underwent complete eye examination before the procedure and 3 months after, measuring the main outcome of RNFLT and the secondary outcomes of GCC thickness, foveal threshold (FT), mean deviation (MD), and pattern standard deviation (PSD). These outcomes were analyzed using linear mixed-effects models. On the day of surgery, we examined the IOP after induction of anesthesia, at the end of steep Trendelenburg, and in the recovery room.

RESULTS

There were significant differences in IOP values at the end of steep Trendelenburg versus after induction and 45-60 minutes post-awakening (P < .001 for both groups). No difference between IOP 45 and 60 minutes post-awakening and IOP after induction was observed in either group. The highest IOPs occurred at the end of the steep Trendelenburg time point for both groups. The mean duration of steep Trendelenburg in robotic prostatectomy was 184.6 minutes (standard deviation [SD] = 30.8), while the mean duration in robotic hysterectomy was 123.0 minutes (SD = 29.8). All ophthalmologic examinations were normal preoperatively and 3 months postoperatively. The ocular parameters in the retina and optic disk did not differ significantly before surgery and 3 months after.

CONCLUSIONS

There is a significant increase in IOP during steep Trendelenburg positioning. There was no significant difference in the ocular parameters examined 3 months after the procedure in this cohort.

Attenuation of increased intraocular pressure with propofol anesthesia: A systematic review with meta-analysis and trial sequential analysis

Attenuation of an increase in intraocular pressure (IOP) is crucial to preventing devastating postoperative visual loss following surgery. IOP is affected by several factors, including the physiologic alteration due to pneumoperitoneum and patient positioning and differences in anesthetic regimens. This study aimed to investigate the effects of propofol-based total intravenous anesthesia (TIVA) and volatile anesthesia on IOP. We searched multiple databases for relevant studies published before October 2019. Randomized controlled trials comparing the effects of propofol-based TIVA and volatile anesthesia on IOP during surgery were considered eligible for inclusion. Twenty studies comprising 980 patients were included. The mean IOP was significantly lower in the propofol-based TIVA group after intubation, pneumoperitoneum, Trendelenburg positioning, and lateral decubitus positioning. Moreover, mean arterial pressure and peak inspiratory pressure were also lower after intubation in the propofol-based TIVA group. Trial sequential analyses for these outcomes were conclusive. Propofol-based TIVA is more effective than volatile anesthesia during surgery at attenuating the elevation of IOP and should be considered, especially in at-risk patients.

Prospective evaluation of visual function in patients with ocular diseases after robot-assisted laparoscopic prostatectomy

OBJECTIVES

To investigate intraocular pressure and visual function in patients with ocular diseases undergoing robot-assisted laparoscopic prostatectomy.

METHODS

We carried out a prospective clinical study of patients undergoing robot-assisted laparoscopic prostatectomy for localized prostate cancer at The University of Tokyo Hospital from December 2015 to March 2017. An ophthalmologist measured intraocular pressure, and carried out visual field testing at 0-2 months before and 7 days after robot-assisted laparoscopic prostatectomy. During the surgery, an anesthesiologist measured intraocular pressure at specified time points.

RESULTS

A total of 110 patients were enrolled and 98 eligible patients were analyzed; 37 were diagnosed with ocular diseases before robotic-assisted laparoscopic prostatectomy (17 with glaucoma, 20 with other ocular diseases). Intraocular pressure significantly increased during robot-assisted laparoscopic prostatectomy. Transient postoperative visual field defect was detected in 24 eyes of 17 patients, including six patients with ocular diseases at 7 days after surgery. At 3 months after surgery, one of 34 glaucomatous eyes and one of 40 eyes with non-glaucomatous ocular diseases continued to show visual field defect, although visual field defect in the remaining patients recovered to preoperative conditions within 3 months.

CONCLUSIONS

Our findings suggest that robot-assisted laparoscopic prostatectomy can be safely carried out in patients with ocular diseases, even those with glaucoma, after precautionary consultation with an ophthalmologist.

Intraoperative changes in whole-blood viscosity in patients undergoing robot-assisted laparoscopic prostatectomy in the steep Trendelenburg position with pneumoperitoneum: a prospective nonrandomized observational cohort study

Background

The aim of this study was to investigate the effect of the steep Trendelenburg position (STP) with pneumoperitoneum on whole-blood viscosity (WBV) in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). The study also analyzed the associations of clinical patient-specific and time-dependent variables with WBV and recorded postoperative outcomes.

Methods

Fifty-eight adult male patients (ASA physical status of I or II) undergoing elective RALP were prospectively analyzed in this study. WBV was intraoperatively measured three times: at the beginning of surgery in the supine position without pneumoperitoneum; after 30 min in the STP with pneumoperitoneum; and at the end of surgery in the supine position without pneumoperitoneum. The WBV at a high shear rate (300 s^− 1) was recorded as systolic blood viscosity (SBV) and that at a low shear rate (5 s^− 1) was recorded as diastolic blood viscosity (DBV). Systolic blood hyperviscosity was defined as > 13.0 cP at 300 s^− 1 and diastolic blood hyperviscosity was defined as > 4.1 cP at 5 s^− 1.

Results

The WBV and incidences of systolic and diastolic blood hyperviscosity significantly increased from the supine position without pneumoperitoneum to the STP with pneumoperitoneum. When RALP was performed in the STP with pneumoperitoneum, 12 patients (27.3%) who had normal SBV at the beginning of surgery and 11 patients (26.8%) who had normal DBV at the beginning of surgery developed new systolic and diastolic blood hyperviscosity, respectively. The degree of increase in WBV after positioning with the STP and pneumoperitoneum was higher in the patients with hyperviscosity than in those without hyperviscosity at the beginning of surgery. Higher preoperative body mass index (BMI) and hematocrit level were associated with the development of both systolic and diastolic blood hyperviscosity in the STP with pneumoperitoneum. All patients were postoperatively discharged without fatal complications.

Conclusions

Changes in surgical position may influence WBV, and higher preoperative BMI and hematocrit level are independent factors associated with the risk of hyperviscosity during RALP in the STP with pneumoperitoneum.

Trial registration

Clinical Research Information Service, Republic of Korea, approval number: KCT0003295 on October 25, 2018.

Anesthetic considerations for urologic surgeries

Urologic surgeries are widely performed, and the cases have increased owing to the fact that the elderly population is growing. The narrow and limited surgical space is a challenge in performing most urologic surgeries. Additionally, the elderly population is exposed to the risk of perioperative complications; therefore, a comprehensive understanding and approach are required to provide optimized anesthesia during surgery. We have searched the literature on anesthesia for urologic surgeries and summarized the anesthetic considerations for urologic surgeries.

The effect of prolonged steep head-down laparoscopy on the optical nerve sheath diameter

Both the steep head-down position and pneumoperitoneum increase the intracranial pressure (ICP), and their combination for a prolonged period during laparoscopic radical prostatectomy (LRP) might influence the central nervous system homeostasis. Changes in optic nerve sheath diameter (ONSD) may reflect those in ICP. This study aims to quantify the change in ONSD in response to peritoneal CO₂ insufflation and steep Trendelenburg position during LRP. ONSD was measured by ultrasound in 20 patients undergoing LRP and ten awake healthy volunteers. In patients, ONSD was assessed at baseline immediately after induction of general anesthesia in supine position, 10 and 60 min from baseline in a 25° head-down position during pneumoperitoneum, and after deflation of pneumoperitoneum with the patient supine at 0° angle. ONSD in controls was assessed at baseline with the patient lying supine, after 10 and 60 min of 25° head-down position, and 10 min after repositioning at 0° angle. ONSD increased significantly in both patients and controls (p < 0.0001) without between-group differences. The mean increase was 10.3% (95% CI 7.7-12.9%) in patients versus 7.5% (95% CI 2.5-12.6%) in controls (p = 0.28), and didn't affect the time to recovery from anesthesia. In the studied patients, with a limited increase of end-tidal CO₂ and airway pressure, and low volume fluid infusion, the maximal ONSD was always below the cut-off value suspect for increased ICP. ONSD reflects the changes in hydrostatic pressure in response to steep Trendelenburg position, and its increase might be minimized by careful handling of general anesthesia.

Does the experience of the bedside assistant effect the results of robotic surgeons in the learning curve of robot assisted radical prostatectomy?

Introduction:

The success of the robot assisted radical prostatectomy (RARP) procedures depend on a successful team, however the literature focuses on the performance of a console surgeon. The aim of this study was to evaluate surgical outcomes of the surgeons during the learning curve in relation to the bedside assistant's experience level during RARP.

Materials and Methods:

We retrospectively reviewed two non - laparoscopic, beginner robotic surgeon's cases, and we divided the patients into two groups. The first surgeon completed the operations on 20 patients with a beginner bedside assistant in February - May 2009 (Group-1). The second surgeon completed operations on 16 patients with an experienced (at least 150 cases) bedside assistant in February 2015 - December 2015 (Group-2). The collected data included age, prostate volume, prostate specific antigen (PSA), estimated blood loss, complications and percent of positive surgical margins. In addition, the elapsed time for trocar insertion, robot docking, console surgery, specimen extraction and total anesthesia time were measured separately.

Results:

There were no significant differences between the groups in terms of age, comorbidity, prostate volume, PSA value, preoperative Gleason score, number of positive cores, postoperative Gleason score, pathological grade, protection rate of neurovascular bundles, surgical margin positivity, postoperative complications, length of hospital stay, or estimated blood loss. The robot docking, trocar placement, console surgery, anesthesia and specimen extraction times were significantly shorter in group 2 than they were in group 1 (17.75 ± 3.53 min vs. 30.20 ± 7.54 min, p ≤ 0.001; 9.63 ± 2.71 min vs. 14.40 ± 4.52 min, p = 0.001; 189.06 ± 27.70 min vs. 244.95 ± 80.58 min, p = 0.01; 230.94 ± 30.83 min vs. 306.75 ± 87.96 min, p = 0.002; 10.19 ± 2.54 min vs. 17.55 ± 8.79 min, p = 0.002; respectively).

Conclusion:

Although the bedside assistant's experience in RARP does not appear to influence the robotic surgeon's oncological outcomes during the learning curve, it may reduce the potential complications by shortening the total operation time.

Changes of intraocular pressure and ocular perfusion pressure during controlled hypotension in patients undergoing arthroscopic shoulder surgery: A prospective, randomized, controlled study comparing propofol, and desflurane anesthesia

PURPOSE

The aim of the present study is to evaluate the effects of deliberate hypotensive anesthesia on intraocular pressure (IOP) and ocular perfusion pressure (OPP) and compare the effects of propofol total intravenous anesthesia (TIVA) and desflurane anesthesia on IOP and OPP.

METHODS

A total of 50 patients undergoing arthroscopic shoulder surgery in the lateral decubitus position were randomized to receive desflurane or propofol anesthesia. Mean arterial pressure (MAP) was maintained in the range of 60-75 mm Hg during hypotensive anesthesia. IOP was measured using a handheld tonometer at 7 time points: before induction (T1, baseline); immediately after endotracheal intubation (T2); 10 minutes after position change to lateral decubitus (T3); 10, 30, and 50 minutes after the start of hypotensive anesthesia (T4-T6); and at the end of surgery (T7).

RESULTS

MAP decreased about 35% to 38% during hypotensive anesthesia. Compared to baseline values, the IOP at T6 in dependent and non-dependent eyes decreased by 0.43 and 2.74 mm Hg, respectively in desflurane group; 3.61 and 6.05 mm Hg, respectively in the propofol group. IOP of both eyes in the propofol group was significantly lower than in the desflurane group from T2 to T7. OPP of both eyes in both groups was significantly lower than at baseline, except at T2 in the desflurane group. OPP of both eyes in the propofol group was significantly higher than that in the desflurane group at T5 and T6.

CONCLUSIONS

Hypotensive anesthesia reduced IOP and OPP, but propofol TIVA maintained higher OPP than desflurane anesthesia. These findings suggest that propofol TIVA can help mitigate the decrease of OPP during hypotensive anesthesia.

The Evolution of Kidney Transplantation Surgery Into the Robotic Era and Its Prospects for Obese Recipients

Robotic-assisted kidney transplantation (RAKT) represents the most recent innovation in the evolution of kidney transplantation surgery. Vascular techniques enabling kidney transplantation have existed since the early 20th century and contributed to the first successful open kidney transplant procedure in 1954. Technical advances have since facilitated minimally invasive laparoscopic and robotic techniques in live-donor surgery, and subsequently for the recipient procedure. This review follows the development of surgical techniques for kidney transplantation, with a special focus on the advent of robotic-assisted transplantation because of its potential to facilitate transplantation of those deemed previously too obese to transplant by standard means. The different techniques, indications, advantages, disadvantages, and future directions of this approach will be explored in detail. Robot-assisted kidney transplantation may become the preferred means of transplanting morbidly obese recipients, although its availability to such recipients remains extremely limited and strategies targeting weight loss pretransplantation should never be abandoned in favor of a "RAKT-first" approach.

Effects of positive end-expiratory pressure on intraocular pressure and optic nerve sheath diameter in robot-assisted laparoscopic radical prostatectomy: A randomized, clinical trial

BACKGROUND

There has been no study of the effect of post end-expiratory pressure (PEEP) on intraocular or intracranial pressure during pneumoperitoneum with steep Trendelenburg positioning. We investigated the effects of 5 cmH2O of PEEP on intraocular pressure and optic nerve sheath diameter as a surrogate for intracranial pressure in robot-assisted laparoscopic radical prostatectomy.

METHODS

Fifty patients scheduled for robot-assisted laparoscopic radical prostatectomy were divided into a zero-PEEP (ZEEP) group and a 5 cmH2O of PEEP (PEEP) group. Intraocular pressure, optic nerve sheath diameter, and respiratory and hemodynamic parameters were measured before induction (T0), 10 minutes after induction of general anesthesia in the supine position before CO2 insufflation (T1), 5 minutes (T2), and 30 minutes (T3) after steep Trendelenburg positioning with pneumoperitoneum, after desufflation of pneumoperitoneum in the supine position (T4), and after 30 minutes in the recovery room postoperatively (T5).

RESULTS

There was no significant difference in intraocular pressure or optic nerve sheath diameter between the groups during the study. The partial pressure of arterial oxygen and dynamic lung compliance at T1, T2, T3, and T4 were significantly higher in the PEEP than in the ZEEP group. There was no difference in mean arterial pressure or heart rate between groups at any time.

CONCLUSION

Applying 5 cmH2O of PEEP did not increase intraocular pressure or optic nerve sheath diameter during pneumoperitoneum with steep Trendelenburg positioning in robot-assisted laparoscopic radical prostatectomy. These results suggest that low PEEP can be safely applied during surgery with pneumoperitoneum and steep Trendelenburg positioning in patients without preexisting eye disease and brain pathology.

Intraocular pressure change during laparoscopic sacral colpopexy in patients with normal tension glaucoma

INTRODUCTION AND HYPOTHESIS

The steep Trendelenburg position, high pneumoperitoneum pressure, and longer surgical time may lead to significantly increased intraocular pressure (IOP), which could result in unexpected eye disease complications, including perioperative visual loss (POVL). We monitored IOP to induce early laparoscopic sacral colpopexy (LSC) safely.

METHODS

This prospective study enrolled 39 patients with pelvic organ prolapse (POP), including 10 with eye diseases (6 with normal tension glaucoma and 4 with a narrow anterior chamber and normal range IOP). Enrolled patients underwent LSC under the same surgical settings involving a pneumoperitoneum of 10 mmHg and a Trendelenburg position of 15°. We measured IOP at seven time points during surgery and estimated IOP changes with time in patients with or without eye diseases.

RESULTS

All patients, with or without eye diseases, experienced significantly elevated IOP during LSC. There were no significant differences between these groups. The average maximal IOP reached 20 mmHg at the end of surgery, and recovered to baseline values with the patient in the supine position at the end of anesthesia. No patient had an IOP of >40 mmHg as a critical threshold during surgery, and no substantial clinical eye symptoms were seen after LSC.

CONCLUSIONS

Laparoscopic sacral colpopexy using an pneumoperitoneum of 10 mmHg and a Trendelenburg position of 15° during a 3-h surgical period could be performed within a safe range of IOP.

Evaluating the Variation of Intraocular Pressure With Positional Change During Colorectal Laparoscopic Surgery: Observational Study

Background

The incidence of perioperative visual loss following colorectal surgery in the US is quoted as 1.24 per 10,000. Raised intraocular pressure (IOP) during extreme Trendelenburg position leading to reduced optic nerve perfusion is thought to be a cause.

Objective

To assess the effect of the degree of Trendelenburg tilt and time spent in Trendelenburg on IOP during laparoscopic colorectal surgery.

Methods

Fifty patients undergoing laparoscopic colorectal surgery were recruited. A Tonopen XL applanation tonometer was used to take IOP measurements hourly during surgery, and each time the operating table was tilted. A correlation coefficient for the degree of Trendelenburg tilt and IOP was calculated for each patient. Group 1 included patients undergoing a right-sided colonic procedure, and Group 2 included all left-sided colonic operations.

Results

The mean age of Group 1 participants (n=25) was 69 years (SD 14), and Group 2 (n=25) was 63 years (SD 16; P>.05). The average length of surgery for Group 1 was 142 minutes (SD 48), and Group 2 was 268 minutes (SD 99; P≤.05). The mean maximum degree of Trendelenburg tilt in Group 1 was 10 (SD 7) and Group 2 was 19 (SD 6; P≤.05). The mean IOP increase was 9 mm Hg (SD 5) for Group 1 and 15 mm Hg (SD 5) in Group 2 (P≤.05). An overall correlation coefficient for the degree of Trendelenburg tilt and IOP change (n=48) was .78.

Conclusions

There is a strong correlation between IOP elevation during laparoscopic colorectal surgery and the degree of Trendelenburg tilt. This may be significant for patients undergoing prolonged surgery and especially those with glaucoma.

Survey of anesthesiologists' practices related to steep Trendelenburg positioning in the USA

BACKGROUND

Steep Trendelenburg during surgery has been associated with many position-related injuries. The American Society of Anesthesiology practice advisory recommends documentation, frequent position checks, avoiding shoulder braces, and limiting abduction of upper extremities to avoid brachial plexopathy. We conducted a web-based survey to assess anesthesiologists' practices, institutional policies, and complications encountered when using steep Trendelenburg.

METHODS

Two thousand fifty randomly selected active members of the American Society of Anesthesiology were invited via email to participate in a 9-item web-based survey. Results are reported as absolute numbers and proportions with 95% confidence interval (CI).

RESULTS

Survey response rate was 290 of 2050 (14.1%). 44.6% (95% CI, 38.9-50.3) of the respondents documented anesthesia start and finish, 73.9% (95% CI, 68.8-79) frequently checked positioning during surgery, 30.8% (95% CI, 25.4-36.2) reported using shoulder braces, 66.9% (95% CI, 61.5-72.3) tucked patients' arms to the side, 54.0% (95% CI, 48.2-59.8) limited fluid administration, and more than two-thirds did not limit the duration or inclination angle. Notably, 63/290 (21.7%) reported a complication and only 6/289 (2.1%) had an institutional policy. The most common complication was airway and face edema, second was brachial plexus injury, and third was corneal abrasions. Most institutional policies, when present, focused on limiting duration of steep Trendelenburg and communication with surgical team. Only 1/6 policies required avoiding use of shoulder braces.

CONCLUSION

Based on survey results, practices related to steep Trendelenburg varied among USA anesthesiologists. Differences included protective measures, documentation, positioning techniques, fluid management, and institutional guidelines. The singular commonality found among all respondents was lack of institutional policies. Survey results highlighted the need for institutional policies and more education.

Are you seeing this: the impact of steep Trendelenburg position during robot-assisted laparoscopic radical prostatectomy on intraocular pressure: a brief review of the literature

With the increasing popularity, frequency, and acceptance of the robotic-assisted laparoscopic radical prostatectomy procedure, an awareness of unique intra- and postoperative complications is heightened, including that of increases in intraocular pressure. The steep Trendelenburg positioning required for operative exposure has been shown to increase this value. While the literature is infrequent and undeveloped, certain anesthetic parameters including deep neuromuscular blockade, modified positioning, and the use of dexmedetomidine have been shown to have mild-to-modest decreases in intraocular pressure for baseline. In the four randomized control trials and four observational studies that were found via PubMed/Medline search, the aforementioned techniques demonstrate some preliminary evidence of operative considerations in this unique patient population. These modifications may prove to have even greater significance in patients with pre-existing ophthalmologic pathologies, such as glaucoma, which were excluded from the studies' analyses. This review summarizes the early literature obtained in this subject, with the intent of emphasizing the initial hypotheses and identifying areas for future study.

The Effect of Steep Trendelenburg Positioning on Retinal Structure and Function during Robotic-Assisted Laparoscopic Procedures

Purpose

Robotic-assisted laparoscopic radical prostatectomy (RALP) has become a standard treatment choice for localized prostate cancer. RALP requires a steep Trendelenburg position, which leads to a significant increase in intraocular pressure (IOP). This study evaluated the effect on the retinal structure and function in patients undergoing RALP.

Methods

Standard automated perimetry (SAP) and optical coherence tomography (OCT) were performed in 20 males scheduled for RALP at 1 month and 1 day before the operation and at 1 and 3 months after the operation. IOP measurements were made in the supine position at 5 min after intubation under general anesthesia (T1), at 6 discrete time points (5, 30, 60, 120, 180, and 240 min; T2-7), and at 5 min after returning to a horizontal supine position (T8). Serial retinal nerve fiber layer (RNFL) thicknesses and visual field progression were assessed using the guided progression analysis software program. RNFL thickness progression and visual field progression were evaluated by event analysis.

Results

Average IOP (mmHg) for each time point was as follows: T1 = 12.3 ± 2.6, T2 = 20.4 ± 4.2, T3 = 23.3 ± 3.8, T4 = 24.0 ± 3.2, T5 = 24.3 ± 3.4, T6 = 27.1 ± 7.2, T7 = 29.8 ± 8.7, and T8 = 20.1 ± 4.4. During RALP, IOP significantly increased. There was no progression of the visual field and RNFL thickness after surgery or any other ocular complications found.

Conclusions

Although IOP significantly increased during RALP, there were no significant changes in the retinal structure and function between the pre- and postoperation observations.

"HEADS UP" DIGITALLY ASSISTED SURGICAL VIEWING FOR RETINAL DETACHMENT REPAIR IN A PATIENT WITH SEVERE KYPHOSIS

PURPOSE

To describe the surgical approach with a screen-based "heads up" digital viewing technology for the successful repair of a retinal detachment in a patient with severe kyphosis.

METHODS

Case report.

RESULTS

An 89-year-old man with vision loss in the left eye from a macula-involving retinal detachment of 4 weeks was scheduled for pars plana vitrectomy and retinal detachment repair. The patient had severe thoracic kyphosis, causing a fixed spinal flexion that presented a significant challenge to traditional intraoperative positioning and management. Surgery was performed using the NGENUITY system for primary surgical viewing, the surgeon operating heads up, and the patient in Trendelenburg position. There were no intraoperative or postoperative complications. Visual acuity improved to 20/80 and the retina remained attached with 11 weeks of follow-up.

CONCLUSION

Heads up digitally assisted viewing technology may be useful or preferred for patients requiring vitreoretinal surgery in the setting of severe musculoskeletal limitations or other positioning challenges.

Joint consensus on abdominal robotic surgery and anesthesia from a task force of the SIAARTI and SIC

Minimally invasive surgical procedures have revolutionized the world of surgery in the past decades. While laparoscopy, the first minimally invasive surgical technique to be developed, is widely used and has been addressed by several guidelines and recommendations, the implementation of robotic-assisted surgery is still hindered by the lack of consensus documents that support healthcare professionals in the management of this novel surgical procedure. Here we summarize the available evidence and provide expert opinion aimed at improving the implementation and resolution of issues derived from robotic abdominal surgery procedures. A joint task force of Italian surgeons, anesthesiologists and clinical epidemiologists reviewed the available evidence on robotic abdominal surgery. Recommendations were graded according to the strength of evidence. Statements and recommendations are provided for general issues regarding robotic abdominal surgery, operating theatre organization, preoperative patient assessment and preparation, intraoperative management, and postoperative procedures and discharge. The consensus document provides evidence-based recommendations and expert statements aimed at improving the implementation and management of robotic abdominal surgery.

Variation in intraocular pressure caused by repetitive positional changes during laparoscopic colorectal surgery: a prospective, randomized, controlled study comparing propofol and desflurane anesthesia

Laparoscopic surgery is often prolonged and requires positional changes to facilitate surgical access. Previous studies reported intraocular pressure (IOP) changes in one fixed position. This study investigated the effect of desflurane and propofol anesthesia on IOP during repeated positional changes. A total of 46 patients undergoing laparoscopic colorectal surgery were randomized into desflurane or propofol groups. IOP was measured using a handheld tonometer at seven time points: before induction (baseline), after endotracheal intubation, after pneumoperitoneum, after the first Trendelenburg and right tilt position, after reverse Trendelenburg and right tilt position, after the second Trendelenburg and right tilt position and before endotracheal extubation. Trendelenburg positioning raised IOP in both groups. In the desflurane group, IOP at the first Trendelenburg position was 6.27 and 8.48 mmHg higher than baseline IOP in left and right eye, respectively; IOP at the second Trendelenburg position was 7 and 9.44 mmHg higher than baseline in left and right eye, respectively. In the propofol group, IOP at the first Trendelenburg position was 2.04 and 4.04 mmHg higher than baseline in left and right eyes, respectively. It was 3.04 and 4.87 mmHg higher than baseline in left and right eye, respectively, at the second Trendelenburg position. In the desflurane group, 56.52% patients exhibited high IOP (≥ 25 mmHg) compared with 13.04% in the propofol group at the second Trendelenburg position in the right eyes (P = 0.005). There was a positive correlation between IOP and peak inspiratory pressure (P < 0.001). Propofol anesthesia mitigated wide variations in IOP caused by repetitive positional changes during laparoscopic colorectal surgery.

Patient positioning for robot-assisted laparoscopic benign gynecologic surgery: A review

Robotic surgical platforms are now in widespread use in the practice of gynecology all over the world. The introduction of robotic surgery has required some modifications of patient positioning when compared to standard laparoscopic surgery. Optimal patient positioning is likely to be the most essential step of robotic surgery as it provides the technical feasibility to have adequate access to the pelvic structures for performing the surgery. It is prudent to pay attention to preventing patient shifting in Trendelenburg position because of tendency of sliding down toward the direction of the head. Inappropriate patient positioning is associated with inadequate exposure of the operative field as well as detrimental complications that may lead to long-term side effects. These issues can be reduced with use of proper or strategic positioning technique. The purpose of this review is to highlight important points to properly position patient for robot-assisted laparoscopic benign gynecologic surgery and protect patient from position-related injuries.

Anaesthetic issues in robotic-assisted minimally invasive surgery

Over the past decade there has been an exponential increase in the number of robotic-assisted surgical procedures performed in Australia and internationally. Despite this growth, there are no level I or II studies examining the anaesthetic implications of these procedures. Available observational studies provide insight into the significant challenges for the anaesthetist. Most anaesthetic considerations overlap with those of non-robotic surgery. However, issues with limited patient access and extremes of positioning resulting in physiological disturbances and risk of injury are consistently demonstrated concerns specific to robotic-assisted procedures.

Does Restrictive Fluid Strategy during Robotic Pelvic Surgeries Obtund Intraoperative Rise in Intraocular Pressure?

Background:

Robotic pelvic surgeries require steep Trendelenburg position which may result in rise in intraocular pressure (IOP).

Aim:

The aim of this study was to compare the changes that occur in IOP during robotic pelvic surgeries in steep Trendelenburg position with a restrictive intravenous fluid administration.

Settings and Design:

This prospective observational study was conducted in a tertiary care institution.

Subjects and Methods:

Twenty consenting patients scheduled for pelvic robotic gynecological surgeries were enrolled. All patients received general anesthesia following a standardized protocol. IOP was measured before induction of anesthesia, immediately after induction and intubation, at the end of surgery immediately after making the patient supine and immediately after extubation. Ringer's lactate was administered intravenously at a rate of 4 mL/kg/h targeting a mean arterial pressure of >65 mmHg and urine output of >0.5 mL/kg/h.

Statistical Analysis Used:

Paired t-test was used in this study.

Results:

There was a fall in IOP soon after induction from baseline which was not significant. Immediately, following intubation, there was a significant rise in IOP. At the end of surgery, though IOP remained high, it was not statistically significant. However, following extubation, IOP rose further and the difference from the baseline became statistically significant. Although there was a moderate increase in peak airway pressure and highest EtCO₂ levels during Trendelenburg from baseline values, the differences were statistically insignificant.

Conclusion:

During robotic pelvic surgeries, adopting a restrictive intravenous fluid strategy with the maintenance of normal end-tidal carbon dioxide levels could abate effects of steep Trendelenburg position on IOP.

Intraocular Pressure Changes during Laparoscopic Surgery in Trendelenburg Position in Patients Anesthetized with Propofol-based Total Intravenous Anesthesia Compared to Sevoflurane Anesthesia: A Comparative Study

Background:

Intraocular pressure (IOP) is increased during laparoscopic surgery with Trendelenburg position and may contribute to deleterious effects on optic nerve in susceptible patients.

Aims:

The primary objective of this study is to compare the effects of propofol-based total intravenous anesthesia (TIVA) with those of sevoflurane anesthesia on IOP in patients undergoing lower abdominal laparoscopic surgery in Trendelenburg position. Secondary objectives are to compare hemodynamic changes, mean arterial pressure (MAP), end-tidal CO₂, and peak inspiratory pressure changes.

Materials and Methods:

Sixty patients with physical status American Society of Anesthesiologists classes I and II were randomly allocated in two groups: Group A (propofol) and Group B (sevoflurane). IOP along with other parameters was measured at seven points including baseline (T0), 5 min after induction (T1), 5 min after CO₂ pneumoperitoneum in supine position (T2), 30 min after CO₂ pneumoperitoneum with Trendelenburg position (T3), 5 min after returning to supine position (T4), 5 min after CO₂ desufflation (T5), and 5 min after extubation (T6).

Results:

The change in IOP was different between the two groups. Maximum rise in IOP was seen at T3, and mean ± standard deviation IOP was 15.5 ± 0.9 mmHg and 19.8 ± 1.2 mmHg in Group A and Group B, respectively (P < 0.01). In Group A (propofol), IOP remained almost equal to the baseline value at T3 and the IOP difference was 0.3 ± 0.9 mmHg less than baseline (statistically insignificant, P > 0.05), while in Group B (sevoflurane), IOP increased significantly at T3 and the difference was 4.0 ± 1.2 mmHg (P < 0.001). The IOP was significantly greater (P < 0.01) from T2 to T6 in sevoflurane group than propofol group.

Conclusion:

Propofol-based TIVA is more effective than inhalational anesthesia with sevoflurane in attenuating the increase in IOP during laparoscopic surgery requiring CO₂ pneumoperitoneum with Trendelenburg position.

[SIGNIFICANT, TRANSIENT VISUAL DISTURBANCE AFTER LAPAROSCOPIC RADICAL PROSTATECTOMY]

Visual disturbance following non-ophthalmologic surgery under general anesthesia is rare but can be devastating both socially and medicolegally. Immediate salvage intervention as well as prevention is of utmost importance since this can be a serious blow to patient's functional outcome postoperatively. We experienced a case of temporary but significant visual disturbance right after transperitoneal laparoscopic radical prostatectomy for localized prostate cancer. We need to raise our levels of vigilance to this condition since it can be avoided and prevented with immediate therapeutic intervention and decent clinical awareness.