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Arslan et al. Mini-invasive Surg 2018;2:4 I http://dx.doi.org/10.20517/2574-1225.2017.31 Page 7 of 10

found that 6.6% of 334 patients had positioning injuries. These injuries resolved at least within 1 month
[56]
but some persisted beyond 6 months . As well as positional effects caused by prolonged lithotomy and
Trendelenburg, use of pneumatic compression stockings, intravenous fluid restriction for improvement
of surgical view, hypotension and administration of vasoactive medication compromises the proper
perfusion of lower extremity, thus increases the risk of compartment syndrome, especially in the lower
extremities [57,58] . Compartment syndrome of the upper extremities is relatively rare in the literature,
[58]
however it is possible especially if higher amounts of intravenous fluid replacement is present .
[58]
Galyon et al. reported a patient with compartment syndrome in three limbs including both lower
extremities and left upper extremity after a robotic cystoprostatectomy which lasted about 6 h, and for
[58]
treatment fasciotomy was performed to all affected extremities . In order to avoid this serious complication
pressure points of the patient must be carefully assessed and materials absorbing the pressure must be
placed between the body and operating table. Also repositioning of the extremities every 2 h was found to be
[59]
beneficial avoiding compartment syndrome .
Emergency situations
Due to the positions applied to patients and surgical equipment limiting the access to patients, critical
interventions such as cardiopulmonary resuscitation or conversion to open surgery may delay. This
may lead to lethal consequences. Life threatening emergencies like cardiopulmonary arrest require
immediate attention and intervention. Especially in robotic surgery this may be a critical issue, as before
the anesthesiology team could start a resuscitation, robot must be undocked. Simulating this situation
[60]
and having an emergency plan can improve the time of preparation and intervention. O’Sullivan et al.
experienced a respiratory complication during a robotic sacrocolpopexy. The patient had a decreased sPO
2
and increased airway pressure, thus an emergency undocking of the robotic arms was required. After this
complication they reported that they created an emergency undocking protocol, which indicates the roles
[60]
[61]
of each member of the crew in emergency situations . Also Huser et al. reported that proper training
with repeating simulations improved the time for resuscitation in simulations. To be able to react to a life-
threatening emergency swiftly, having a similar training and an emergency protocol may be useful.

CONCLUSION
Minimal invasive surgery is being increasingly more popular. The application of laparoscopic and robotic
surgery is now more common. In urology, laparoscopy and robotic surgery may be applied in various
operations including uro-oncological surgery. Minimally invasive surgery provides patients many benefits,
however robotic and laparosopic surgery also has a risk of many significant and unique complications
related to these procedures. Pneumoperitoneum and specific patient positions such as steep Trendelenburg
position have important physiological effects on cardiovascular, pulmonary, ocular, renal and neurological
systems which may cause serious complications. In order to detect, manage or prevent these complications
properly these physiological effects must be thoroughly comprehended. All personnel in the operating
theatre should be prepared to all possible complications related to surgical procedure and anesthesia. With
proper interventions, careful monitoring and preventive precautions, these complications may be avoided or
at least their impact may be minimized.

DECLARATIONS
Authors’ contributions
Conception or design of the work: Özgök A, Arslan ME
Data collection: Arslan ME
Data analysis and interpretation: Özgök A, Arslan ME
Drafting the article: Arslan ME
Critical revision of the article: Özgök A