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

the increase in partial pressure of CO (PaCO ). If the patient has already an increased ICP caused by various
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reasons or there is a risk of cerebral ischemia inducing with pneumoperitoneum and applying Trendelenburg
position may cause no toleration due to ICP increase and severe cerebrovascular complications.

COMPLICATIONS AND MANAGEMENT
Pathophysiological changes during laparoscopy and robotic surgery has been already discussed. Most of
these effects are well tolerated if a proper anesthetic care is provided in healthy patients. But even in healthy
patients undesired consequences may be experienced. In order to prevent serious morbidity and mortality
management of complications should be taken seriously and a coordinated crisis plan should be ready to be
executed. Patients should be properly monitored to understand the current situation, to maintain stability
and to avoid the complications with the necessary interventions on time. Standard monitoring includes
electrocardiogram, non-invasive blood pressure, pulse oximetry, end tidal CO concentration and urine
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output. Also in major surgery, hemodynamically unstable patients or in patients with cardiovascular disease
intra-arterial blood pressure may be monitored by arterial cannulation [21,28] .

Cardiovascular complications
Cardiovascular complications related to laparoscopy begin to emerge with CO insufflation. Hypotension,
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hypertension, arrhythmias and cardiac arrest may be encountered during laparoscopy. As the
Trendelenburg position has the risk of increasing the risk of these complications, it may be wise to create
[12]
the pneumoperitoneum in horizontal position rather than down-tilted . CO insufflation and positional
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changes should be applied gradually as sudden changes may affect hemodynamic stability. Monitoring
IAP is also mandatory, because it is one of the main reasons of changes on hemodynamics. Keeping the
IAP low may allow avoiding many complications related to carboperitoneum. IAP > 15 mmHg increases
cardiovascular risk as inferior vena cava is compressed and eventually preload decreases. Additionally
atropine might be administrated before the initiation of pneumoperitoneum or it may be kept ready for
[12]
administration to prevent the brady-arrhythmias related to vagal reflex . Acid-base homeostasis is instable
in laparoscopic surgery because of the CO insufflated and the decrease in pulmonary compliance. It is
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essential to monitor pH levels and PaCO in order to keep the patient in normocapnic range and in ideal
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pH level, as it effects the cardiovascular efficiency and stability. If the patient has a cardiovascular disease
the anesthetist should avoid using cardio-depressant drugs. If there is an increase in MAP due to increase
in SVR, instead of increasing the concentration of inhalation anesthetics (which may cause myocardial
depression, especially in patients with cardiovascular disease) administrating vasodilating agents reducing
specifically preload or afterload should be considered [21,28] . However studies report that even in cases which
pneumoperitoneum is combined with steep Trendelenburg position (such as RALRP) a deterioration
of cardiac function was not present and patients usually tolerate the changes well [3,29] . However, the
position and pneumoperitoneum may aggravate mitral deficiency, so it must be kept in mind if a mitral
[29]
deficiency exists . If a cardiovascular complication is thought to be aggravated or caused by the position
or pneumoperitoneum, first IAP should be decreased and if it does not work, CO insufflation should be
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ceased, gas should be evacuated and position should be reversed to horizontal state. Venous gas embolism is
a complication possible to occur during laparoscopic or robotic surgery that may have fatal consequences. It
may occur during CO insufflation or during surgical procedure especially if venous structures are involved.
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During insufflation if the Veress needle is inserted directly into vascular structures results may be much
more catastrophic. If the structural integrity of a major vein is disrupted, the risk of gas embolism increases.
But it does not have to be a major vein. During transection the dorsal venous complex in RALRP operations
subclinical CO gas embolism can be observed as reported in literature [30,31] . The symptoms vary in a wide
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range; while most of gas embolisms are subclinical and can not be detected by standard monitoring, some
might cause catastrophic consequences such as cardiovascular collapse [11,23,30,31] . As it is a life-threatening
matter, the anesthetist should be vigilant. In the presence of a gas embolism insufflation should be ceased