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Page 6 of 10 Arslan et al. Mini-invasive Surg 2018;2:4 I http://dx.doi.org/10.20517/2574-1225.2017.31

CO gas reserved by subcutaneous emphysema may cause hypercarbia, so increased ventilation might be
2
necessary to cope with the increased end tidal CO concentrations.
2
Pneumothorax and pneumomediastinum
There are multiple ways for a pneumothorax to occur during laparoscopic surgery. Either a real
pneumothorax may occur due to high airway peak pressures causing a congenital bulla to rupture or
insufflated CO may infiltrate thoracic cavity. Insufflated CO may create a capno-thorax or capno-
2
2
mediastinum (pneumothorax or pneumomediastinum caused by pure CO that has been insufflated)
2
through congenital or acquired (injuries caused by surgery) diaphragmatic defects, as a result of CO
2
dissecting through retroperitoneum or by the extension of subcutaneous emphysema up to pleura or
[7]
mediastinum . Mostly the cases are asymptomatic and conservative treatment and close observation is
sufficient. However increase in peak airway pressures, hypoxemia, hypotension and even cardiac arrest may
be present according to the severity of this complication [7,32] . If cardiopulmonary functions are compromised,
releasing of pneumoperitoneum and placing a chest tube must be considered. Usually a chest tube insertion
[44]
is sufficient . However thoracic complications after laparoscopic urologic procedures are rare and most of
the cases are subclinical, thus a routine postoperative chest radiography was not found to be necessary [44,45] .

Renal complications
Due to high IAP in laparoscopic surgeries renal perfusion and glomerular filtration rate decreases thus
[46]
causing oliguria . In multiple studies on animals and humans effects of pneumoperitoneum on renal
physiology were examined and the reasons, which were found responsible for this complication, are IAP
applying direct compression on renal vascular structures, activation of renin-angiotensin-aldosterone,
increase of anti-diuretic hormone and low cardiac output [47-49] . To prevent oliguria sufficient hydration of
the patient before and during the operation must be provided and urine output must be observed especially
in prolonged and major surgeries. Also using low-dose dopamine at 2 mcg/kg/min and nicardipine at
0.5 mcg/kg/min was found useful to protect kidneys from hypoperfusion and renal dysfunction [50,51] .

Neurologic complications
As previously discussed neurologic complications may occur due to laparoscopic and robotic surgeries
as a reason of increase in ICP, cerebral hypoperfusion or hypoxemia. High risk patients with a previous
cerebrovascular disorder should be carefully assessed preoperatively. Near infrared spectroscopy may be
used to monitor cerebral oxygen levels. Pneumoperitoneum and Trendelenburg position both increases
ICP [13,24,25] . High ICP may cause transient or permanent neurologic deficits such as motor paralysis or paresis.
In two case reports transient neurologic deficits including quadriplegia and hemiparesis were reported and
both patients had full recovery [52,53] .

Ocular complications and edema
Trendelenburg position increases intra-ocular pressure. This may cause temporary or permanent loss in
vision. Ischemic optic neuropathy, which is a rare complication, was reported after robotic and laparoscopic
[55]
[54]
radical prostatectomy . Corneal abrasions may occur because of chemosis or exposure keratopathy . Eye
patchings and transparent occlusive dressings are recommended to prevent corneal abrasions. Prolonged
operations in Trendelenburg position may cause facial, periorbital, conjunctival, pharyngeal and laryngeal
edema. Edema of the upper airways might cause serious consequences after extubation. If facial edema or
conjunctival edema is observed, there is a chance that laryngeal edema might also exist. Therefore if there is
[11]
a suspicion of upper airway edema, an endotracheal leak test should be done before extubation .
Positional injuries and compartment syndrome
Patient positioning is an important preparation for the operation. Improper positioning may cause nerve
[12]
injuries and compartment syndrome, furthermore it may compromise cardiopulmonary function .
[56]
Mills et al. investigated positioning injuries associated with robotic surgery in their institution and