ANESTHESIOLOGICAL CHALLENGES IN ROBOTIC SURGERY

  2. 2025
  3. ANESTHESIOLOGICAL CHALLENGES IN ROBOTIC SURGERY

Plis M. O., Tsarev A. V.

ANESTHESIOLOGICAL CHALLENGES IN ROBOTIC SURGERY

Show/Download

About the author:

Plis M. O., Tsarev A. V.

Heading:

LITERATURE REVIEWS

Type of article:

Scientific article

Annotation:

Robotic surgery holds a leading position among modern minimally invasive methods, enabling complex surgical procedures to be performed with high precision. However, its use is accompanied by several anesthesiological difficulties. The Trendelenburg position and pneumoperitoneum lead to an increase in systemic vascular resistance, mean arterial pressure, and intracranial pressure, a decrease in lung compliance, and the development of hypercapnia and acidosis. In patients with concomitant pathologies (obesity, COPD, cardiovascular diseases), these changes become clinically significant and may complicate the course of anesthesia. Additional risks include endotracheal tube displacement, upper airway edema, rhabdomyolysis during prolonged lithotomy position, and hypothermia due to the duration of surgery. A significant problem is the limited intraoperative access to the patient after docking the robot, which requires careful fixation of all respiratory and vascular pathways during the preparation stage. The aim of the study was to summarize current literature data on physiological changes associated with robotic interventions and to identify the main strategies for their anesthesiological support. Analysis of the sources showed that safe performance of operations requires an individualized approach to anes- thesiological support: correction of ventilation modes, targeted control of infusion therapy, prevention of hypothermia, and extended intraoperative monitoring. Thus, timely detection and correction of potential complications caused by the patient's position, pneumoperitoneum, and the duration of the intervention are key factors in improving the safety and effectiveness of robotic surgery.

Tags:

anesthesia complications, anesthesiology, general anesthesia, hemodynamics, infusion therapy, intraoperative monitoring, perioperative period, pneumoperitoneum, robotic surgery, Trendelenburg position

Bibliography:

  1. Hottenrott S, Schlesinger T, Helmer P, Meybohm P, Alkatout I, Kranke P. Do Small Incisions Need Only Minimal Anesthesia?-Anesthetic Management in Laparoscopic and Robotic Surgery. J Clin Med. 2020;9(12):4058. DOI: 10.3390/jcm9124058.
  2. Walshaw J, Huo B, McClean A, Gajos S, Kwan JY, Tomlinson J, et al. Innovation in gastrointestinal surgery: the evolution of minimally invasive surgery - a narrative review. Front Surg. 2023;10:1193486. DOI: 10.3389/fsurg.2023.1193486.
  3. Erlinger S. A history of research into the physiology of bile, from Hippocrates to molecular medicine. Clin Liver Dis (Hoboken). 2022;20(1):33- 44. DOI: 10.1002/cld.1266.
  4. Vretzakis G, Bareka M, Aretha D, Karanikolas M. Regional anesthesia for laparoscopic surgery: a narrative review. J Anesth. 2014;28(3):429- 446. DOI: 10.1007/s00540-013-1736-z.
  5.  Wang D, Dong T, Shao Y, Gu T, Xu Y, Jiang Y. Laparoscopy versus open appendectomy for elderly patients, a meta-analysis and systematic review. BMC Surg. 2019;19(1):54. DOI: 10.1186/s12893-019-0515-7.
  6. Tameze Y, Low YH. Outpatient Robotic surgery: Considerations for the Anesthesiologist. Adv Anesth. 2022;40(1):15-32. DOI: 10.1016/j. aan.2022. 06.001.
  7. George EI, Brand TC, LaPorta A, Marescaux J, Satava RM. Origins of Robotic Surgery: From Skepticism to Standard of Care. JSLS. 2018;22(4):e2018.00039. DOI: 10.4293/JSLS.2018.00039.
  8. Duarte A, Katerenchuk V, Poeira R, Rocha P, Pissarra F, Canas M, et al. Anesthesia management for total robotic liver transplantation: Inaugural case series in Europe. Ann Hepatobiliary Pancreat Surg. 2025;29(1):88-94. DOI: 10.14701/ahbps.24-170.
  9. Sheetz KH, Claflin J, Dimick JB. Trends in the Adoption of Robotic Surgery for Common Surgical Procedures. JAMA Netw Open. 2020;3(1):e1918911. DOI: 10.1001/jamanetworkopen.2019.18911.
  10.  Maynou L, Pearson G, McGuire A, Serra-Sastre V. The diffusion of robotic surgery: Examining technology use in the English NHS. Health Policy. 2022;126(4):325-336. DOI: 10.1016/j.healthpol.2022.02.007.
  11. Barud M, Turek B, Dąbrowski W, Siwicka D. Anesthesia for robot-assisted surgery: a review. Anaesthesiol Intensive Ther. 2025;57(1):99-107. DOI: 10.5114/ait/203168.
  12.  Kubiak M, Doniec J, Grasso SV, Gumbs A, Mohammadi AN, Sędłak K, et al. Quality over quantity-current challenges of robotic surgery in Poland. J Robot Surg. 2025;19(1):258. DOI: 10.1007/s11701-025-02423-0.
  13. Lee JR. Anesthetic considerations for robotic surgery. Korean J Anesthesiol. 2014;66(1):3-11. DOI: 10.4097/kjae.2014.66.1.3.
  14. Mishra P, Gupta B, Nath A. Anesthetic considerations and goals in robotic pediatric surgery: a narrative review. J Anesth. 2020;34(2):286-293. DOI: 10.1007/s00540-020-02738-2.
  15. Newman RM, Umer A, Bozzuto BJ, Dilungo JL, Ellner S. Surgical Value of Elective Minimally Invasive Gallbladder Removal: A Cost Analysis of Traditional 4-Port vs Single-Incision and Robotically Assisted Cholecystectomy. J Am Coll Surg. 2016;222(3):303-308. DOI:10.1016/j.jamcollsurg.2015.12.016.
  16.  Alotaibi WM. Anesthesia experience of pediatric robotic surgery in a University Hospital. J Robot Surg. 2019;13(1):141-146. DOI: 10.1007/ s11701-018-0834-1.
  17.  Ashrafian H, Clancy O, Grover V, Darzi A. The evolution of robotic surgery: surgical and anaesthetic aspects. Br J Anaesth. 2017;119(1):i72-i84. DOI: 10.1093/bja/aex383.
  18. Finotti M, D’Amico F, Mulligan D, Testa G. A narrative review of the current and future role of robotic surgery in liver surgery and transplantation. Hepatobiliary Surg Nutr. 2023;12(1):56-68. DOI: 10.21037/hbsn-21-115.
  19. Wong DJ, Wong MJ, Choi GH, Wu YM, Lai PB, Goh BKP. Systematic review and meta-analysis of robotic versus open hepatectomy. ANZ J Surg. 2019;89(3):165-170. DOI: 10.1111/ans.14690.
  20. Herling SF, Dreijer B, Wrist Lam G, Thomsen T, Møller AM. Total intravenous anaesthesia versus inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic surgery. Cochrane Database Syst Rev. 2017;4(4):CD011387. DOI:10.1002/14651858.CD 011387.pub2.
  21.  Grossmann NC, Aschwanden FJ, Cornelius J, Malkmus C, Zahiti L, Viktorin P, et al. Impact of patient positioning during surgery on neuropathies after robot-assisted laparoscopic radical prostatectomy: a randomised controlled trial. BJU Int. 2025;135(5):802-809. DOI:10.1111/bju.16623.
  22.  Suryawanshi CM, Shah B, Khanna S, Ghodki P, Bhati K, Ashok KV. Anaesthetic management of robot-assisted laparoscopic surgery. Indian J Anaesth. 2023;67(1):117-122. DOI: 10.4103/ija.ija_966_22.
  23. Pathirana S, Kam P. Anaesthetic issues in robotic-assisted minimally invasive surgery. Anaesth Intensive Care. 2018;46(1):25-35. DOI:10.1177/0310057X1804600105.
  24.  Souki FG, Rodriguez-Blanco YF, Polu SR, Eber S, Candiotti KA. Survey of anesthesiologists’ practices related to steep Trendelenburg positioning in the USA. BMC Anesthesiol. 2018;18(1):117. DOI: 10.1186/s12871-018-0578-5.
  25. Mills JT, Burris MB, Warburton DJ, Conaway MR, Schenkman NS, Krupski TL. Positioning injuries associated with robotic assisted urological surgery. J Urol. 2013;190(2):580-584. DOI: 10.1016/j.juro.2013.02.3185.
  26. Yamasaki K, Fujii K, Kohjimoto Y, Matsuda K, Iwamoto H, Kawai M, et al. Lower extremity pain and/or numbness after laparoscopic surgery and robot-assisted surgery in the lithotomy position combined with the Trendelenburg position. J Anesth. 2024;38(6):821-827. DOI: 10.1007/s00540-024-03399-1.
  27.  Bjøro B, Ballestad I, Rustøen T, Fosmark MH, Bentsen SB. Positioning patients for robotic-assisted surgery: A qualitative study of operating room nurses’ experiences. Nurs Open. 2023;10(2):469-478. DOI: 10.1002/nop2. 1312.
  28. Bjøro B, Mykkeltveit I, Rustøen T, Candas Altinbas B, Røise O, Bentsen SB. Intraoperative peripheral nerve injury related to lithotomy positioning with steep Trendelenburg in patients undergoing robotic-assisted laparoscopic surgery - A systematic review. J Adv Nurs. 2020;76(2):490-503. DOI: 10.1111/jan.14271.
  29. Falcão LFDR, Battisti FPL, Oliveira Júnior IS, Ferez D. Alteração da função pulmonar em cirurgia laparoscópica com pneumoperitônio e elevação da parede abdominal. Braz J Anesthesiol. 2018;68(2):215-216. DOI: 10.1016/j.bjan.2017.08.004.
  30. Goel N, Chowdhury I, Dubey J, Mittal A, Pathak S. Quantitative rise in intraocular pressure in patients undergoing robotic surgery in steep Trendelenburg position: A prospective observational study. J Anaesthesiol Clin Pharmacol. 2020;36(4):546-551. DOI: 10.4103/joacp.JOACP_96_20.
  31. Kato T, Kurazumi T, Konishi T, Takko C, Ogawa Y, Iwasaki KI. Effects of -10° and -30° head-down tilt on cerebral blood velocity, dynamic cerebral autoregulation, and noninvasively estimated intracranial pressure. J Appl Physiol (1985). 2022;132(4):938-946. DOI: 10.1152/japplphysiol.00283. 2021.
  32.  Arvizo C, Mehta ST, Yunker A. Adverse events related to Trendelenburg position during laparoscopic surgery: recommendations and review of the literature. Curr Opin Obstet Gynecol. 2018;30(4):272-278. DOI: 10.1097/GCO.0000000000000471.
  33. Chen K, Wang L, Wang Q, Liu X, Lu Y, Li Y, et al. Effects of pneumoperitoneum and steep Trendelenburg position on cerebral hemodynamics during robotic-assisted laparoscopic radical prostatectomy: A randomized controlled study. Medicine (Baltimore). 2019;98(21):e15794. DOI: 10.1097/MD.0000000000015794.
  34.  Ozcan MF, Akbulut Z, Gurdal C, Tan S, Yildiz Y, Bayraktar S, et al. Does steep Trendelenburg positioning effect the ocular hemodynamics and intraocular pressure in patients undergoing robotic cystectomy and robotic prostatectomy?. Int Urol Nephrol. 2017;49(1):55-60. DOI:10.1007/s11255-016-1449-y.
  35.  Lebowitz P, Yedlin A, Hakimi AA, Bryan-Brown C, Richards M, Ghavamian R. Respiratory gas exchange during robotic-assisted laparoscopic radical prostatectomy. J Clin Anesth. 2015;27(6):470-475. DOI: 10.1016/j.jclinane.2015.06.001.
  36. Savarkar SD, Bakshi SG, Thosar RV, Sareen R. Shoulder soreness due to shoulder braces following robotic surgery in steep Trendelenburg position. Saudi J Anaesth. 2016;10(3):363-364. DOI: 10.4103/1658-354X.174909.
  37. Aceto P, Beretta L, Cariello C, Claroni C, Esposito C, Forastiere EM, et al. Joint consensus on anesthesia in urologic and gynecologic robotic surgery: specific issues in management from a task force of the SIAARTI, SIGO, and SIU. Minerva Anestesiol. 2019;85(8):871-885. DOI: 10.23736/S0375-9393.19.13360-3.
  38.  Ciccone MA, Hom MS, Morocco EB, Muderspach LI, Matsuo K. Prolonged intubation after robotic-assisted hysterectomy for endometrial cancer: Case reports. Gynecol Oncol Rep. 2018;25:106-108. DOI: 10.1016/j.gore.2018. 06.005.
  39. Xue S, Wang D, Tu HQ, Gu XP, Ma ZL, Liu Y, et al. The effects of robot-assisted laparoscopic surgery with Trendelenburg position on short- term postoperative respiratory diaphragmatic function. BMC Anesthesiol. 2024;24(1):92. DOI: 10.1186/s12871-024-02463-3.
  40. Oti C, Mahendran M, Sabir N. Anaesthesia for laparoscopic surgery. Br J Hosp Med (Lond). 2016;77(1):24-28. DOI: 10.12968/ hmed.2016.77.1.24.
  41.  Yu T, Cheng Y, Wang X, Tu B, Cheng N, Gong J, et al. Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery. Cochrane Database Syst Rev. 2017;6(6):CD009569. DOI: 10.1002/ 14651858.CD009569.pub3.
  42. Dal Moro F, Crestani A, Valotto C, Guttilla A, Soncin R, Mangano A, et al. Anesthesiologic effects of transperitoneal versus extraperitoneal approach during robot-assisted radical prostatectomy: results of a prospective randomized study. Int Braz J Urol. 2015;41(3):466-472. DOI:10.1590/S1677-5538.IBJU.2014.0199.
  43.  Bachh MD, Farooq N, Gillani YM. Metabolic effects of carbon dioxide insufflation during laparoscopic surgery: changes in pH, arterial partial pressure of carbon dioxide (PaCO₂) and end tidal carbon dioxide (EtCO₂). National Journal of Medical Research. 2022;12(01):3-6. DOI: 10.55489/njmr.12012022893.
  44.  Manici M, Aykanat İC, Simsek D, Tarim K, Gurkan Y, Canda AE. Anesthesiological and surgical perspectives on using 8 mmHg versus 12 mmHg pneumoperitoneum pressures during robotic radical prostatectomy: Results of a prospective randomized study. Robotik radikal prostatektomide 8 mmHg ve 12 mmHg pnömoperiton basınçlarının karşılaştırılması: Anesteziolojik ve cerrahi perspektiften prospektif randomize kontrollü çalışma. Ulus Travma Acil Cerrahi Derg. 2024;30(6):430-436. DOI: 10.14744/tjtes.2024.78617.
  45. Lee HJ, Chae JS, An SM, Oh HW, Kim YJ, Woo JH. Strategy to Reduce Hypercapnia in Robot-Assisted Radical Prostatectomy Using Transcutaneous Carbon Dioxide Monitoring: A Prospective Observational Study. Ther Clin Risk Manag. 2022;18:249-258. DOI: 10.2147/TCRM.S347690.
  46.  Lestar M, Gunnarsson L, Lagerstrand L, Wiklund P, Odeberg-Wernerman S. Hemodynamic perturbations during robot-assisted laparoscopic radical prostatectomy in 45° Trendelenburg position. Anesth Analg. 2011;113(5):1069-1075. DOI: 10.1213/ANE.0b013e3182075d1f.
  47. Kalmar AF, Foubert L, Hendrickx JF, Mottrie A, Absalom A, Mortier EP, et al. Influence of steep Trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy. Br J Anaesth. 2010;104(4):433-439. DOI: 10.1093/ bja/aeq018.
  48. Kopitkó C, Medve L, Gondos T, Soliman KMM, Fülöp T. Mediators of Regional Kidney Perfusion during Surgical Pneumo-Peritoneum Creation and the Risk of Acute Kidney Injury-A Review of Basic Physiology. J Clin Med. 2022;11(10):2728. DOI: 10.3390/jcm11102728.
  49. Høyer S, Mose FH, Ekeløf P, Jensen JB, Bech JN. Hemodynamic, renal and hormonal effects of lung protective ventilation during robot- assisted radical prostatectomy, analysis of secondary outcomes from a randomized controlled trial. BMC Anesthesiol. 2021;21(1):200. DOI: 10.1186/s12871-021-01401-x.
  50. Cheng ZJ, Wang YB, Chen L, Gong JP, Zhang W. Effects of Different Levels of Intra-Abdominal Pressure on the Postoperative Hepatic Function of Patients Undergoing Laparoscopic Cholecystectomy: A Systematic Review and Meta-Analysis. Surg Laparosc Endosc Percutan Tech. 2018;28(5):275-281. DOI: 10.1097/SLE.0000000000000525.
  51. Baksh SA, Muhammad S, Parvez U, Shirazi B, Khan MA. Impact of the Laparoscopic Approach on Liver Function Tests: Comparison of Elective Biliary and Non-biliary Procedures. Cureus. 2025;17(3):e81500. DOI: 10.7759/cureus.81500.

Publication of the article:

«Bulletin of problems biology and medicine», 2025 Issue 3,178, 88-96 pages, index UDC 616-089.8-089.5-06:007.52:004.896

DOI:

10.29254/2077-4214-2025-3-178-88-96

2025 Issue 3,178
anesthesia complications anesthesiology general anesthesia hemodynamics infusion therapy intraoperative monitoring perioperative period pneumoperitoneum robotic surgery Trendelenburg position
27.10.2025
Was this article helpful?
4
3

Leave a Reply

Your email address will not be published. Required fields are marked *


The reCAPTCHA verification period has expired. Please reload the page.