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Year : 2017  |  Volume : 11  |  Issue : 2  |  Page : 260-261

Why should a “gasless” oncologic robotic procedure be performed?

1 Department of Surgery, Oncology and Gastroenterology – Urology, University of Padova, Padua, Italy
2 Department of Anesthesia, Azienda Ospedaliera di Padova, Padua, Italy

Correspondence Address:
Fabrizio Dal Moro
epartment of Surgery, Oncology and Gastroenterology - Urology, University of Padova, Via Giustiniani, 2, 35126 Padova
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/sja.SJA_53_17

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Date of Web Publication27-Mar-2017

How to cite this article:
Moro FD, Mangano A. Why should a “gasless” oncologic robotic procedure be performed?. Saudi J Anaesth 2017;11:260-1

How to cite this URL:
Moro FD, Mangano A. Why should a “gasless” oncologic robotic procedure be performed?. Saudi J Anaesth [serial online] 2017 [cited 2023 Jan 31];11:260-1. Available from:


In this paper,[1] the authors describe a challenging approach during robot-assisted radical prostatectomy (RARP)performing the procedure without gas insufflation and using (after the “docking” of robot) a so-called “tenting of the abdominal wall.” They demonstrate that this technique reduces the peak airway pressure while maintaining an adequate intra-abdominal space.

This work is particularly interesting for both its anesthesiologic and oncologic impacts.

  1. During laparoendoscopy, carbon dioxide (CO2) insufflation into peritoneal (and extraperitoneal) cavities produces a wide range of pathophysiological hemodynamic changes. Vigilance in monitoring and diligence in management are essential to prevent complications because CO2 absorption may lead to hypercapnia and acidosis.

  2. Clearance of CO2 is related to adequate alveolar ventilation: CO2 absorbed through the peritoneum is eliminated by respiratory exchange in the lungs, and a rapid increase in CO2 levels may be compensated by hyperventilation of the lungs. While the patient is under general anesthesia, minute ventilation volumes must be increased to maintain normocarbia.

    There are some situations associated with an increased CO2 absorption, such as the extraperitoneal approach during RARP as we recently demonstrated.[2]

    Although the increase in PaCO2 is not fully compensated by hyperventilation, most healthy patients can easily adapt to the increase in end-tidal CO2. However, some are unable to tolerate the increased CO2 load during insufflation, and this condition may lead to myocardial depression and vasodilation. The patient counteracts these effects by centrally mediated sympathetic stimulation, which causes persistent increases in blood pressure and heart rate, increasing catecholamine concentrations.[3] In addition, the pneumoperitoneum, as a consequence of direct compression of the diaphragm, leads to a significant reduction in forced expiratory volume, peak expiratory flow, and forced vital capacity, with a consequent decrease in pulmonary compliance.[4]

    For all the points mentioned above, RARP is associated with various anesthesiologic challenges due to pneumoperitoneum and “tenting” can be helpful in improving ventilation and reducing complications of high peak airway pressure above all in men with an impaired cardiopulmonary function, such as in broncopneumopatic or cardiopatic patients.

    While in our department, we are used to performing completely gasless procedures during some robotic interventions, such as pyeloplasty and hysterosacropexy, it is not always possible to conclude all the steps of RARP because the risk of massive bleeding, above all during the dissection of Santorini venous complex or during complete nerve-sparing lateral dissection of the prostate: in these cases, sometimes, it is necessary to restart the CO2 insufflation until the closure of venous vessels.

  3. From the oncological point of view, there are some concerns about the possible role of gas insufflation during laparoscopic/robotic procedures to treat (urological) cancers in the seeding of neoplastic cells. Indeed, tumor spillage is a phenomenon observed after laparoscopic surgical manipulation for both benign and malignant diseases, and it is usually a result of dissemination and concomitant implantation of neoplastic cells on the peritoneal surface.[5]

In literature, port-site metastasis or peritoneal spread after laparoscopic surgery for urological malignancies is a rare occurrence accounting for 0.09% and 0.03% of the cases, respectively.[6] Although the etiology of this phenomenon is not clearly understood, different factors have been implicated, such as the aggressiveness and the type of tumor, host immune response and local processes, and (last, but not least) laparoscopic/robotic-related factors.

Although there is no doubt that a poor surgical technique with traumatic manipulation of cancer (surgical manipulation, tumor handling, morcellation, specimen removal methods,…) may violate the boundaries of the tumor, consequently promoting seeding, the mechanism involved in cancer cell wounds or peritoneal implantation is uncertain. One possible explanation is gas insufflation.[7]

The use of “gasless” laparoscopy/robotic technique, to reduce the risk of wound or peritoneal metastasis, has been suggested since the '90s;[8] however, further multicentric studies are needed to confirm or not the role of the pneumoperitoneum in cancer seeding.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Kakde AS, Wagh HD. An observational study: Effects of tenting of the abdominal wall on peak airway pressure in robotic radical prostatectomy surgery. Saudi J Anaesth 2017;11.[In press].  Back to cited text no. 1
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;41:466-72.  Back to cited text no. 2
Kanwer DB, Kaman L, Nedounsejiane M, Medhi B, Verma GR, Bala I. Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy – A randomised controlled trial. Trop Gastroenterol 2009;30:171-4.  Back to cited text no. 3
Hasukic S, Mesic D, Dizdarevic E, Keser D, Hadziselimovic S, Bazardzanovic M. Pulmonary function after laparoscopic and open cholecystectomy. Surg Endosc 2002;16:163-5.  Back to cited text no. 4
Thian YL, Tan KH, Kwek JW, Wang J, Chern B, Yam KL. Leiomyomatosis peritonealis disseminata and subcutaneous myoma – A rare complication of laparoscopic myomectomy. Abdom Imaging 2009;34:235-8.  Back to cited text no. 5
Ploumidis A, Panoskaltsis T, Gavresea T, Yiannou P, Yiannakou N, Pavlakis K. Tumor seeding incidentally found two years after robotic-assisted radical nephrectomy for papillary renal cell carcinoma. A case report and review of the literature. Int J Surg Case Rep 2013;4:561-4.  Back to cited text no. 6
Tsivian A, Sidi AA. Port site metastases in urological laparoscopic surgery. J Urol 2003;169:1213-8.  Back to cited text no. 7
Watson DI, Mathew G, Ellis T, Baigrie CF, Rofe AM, Jamieson GG. Gasless laparoscopy may reduce the risk of port-site metastases following laparascopic tumor surgery. Arch Surg 1997;132:166-8.  Back to cited text no. 8

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