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Koc et al. Mini-invasive Surg 2018;2:7 I http://dx.doi.org/10.20517/2574-1225.2017.33 Page 5 of 13

RARP has extremely low complication rates in terms of postoperative bleeding. This success may be the
result of elevated intra-abdominal pressure by CO insufflation, excellent vision quality and thin dissection
2
opportunities.

Veress needle injuries
In Veress technique, the needle should be placed at the horizontal plane at a 45° angle for umbilical access.
In obese patients, the needle should be placed at 45° to 90° angle to prevent vascular injury.

A meta-analysis revealed that vascular injury might be seen at a mean rate of 0.044% during laparoscopic
[33]
access . In management of the vascular injuries related with the Veress needle, we should target to the
specific situation. If a nonexpanding small hematoma exists, it may be outlined by clips and monitored
during the course of the surgery. If the hematoma is found as expanded in reinspection at the end of the
surgery, the hematoma should be opened to explore the bleeding site.

Trocar injury
The major vascular injury incidence related with Veress needles and trocars is approximately 0.1%. A study
carried out by US Food and Drug Administration reported totally 32 deaths out of 629 trocar injuries, from
1993 to 1996. Of the deaths, 81% of the deaths were due to the major vascular injuries and the remaining
19% were the result of bowel injuries.

Most of the trocar injuries are nonfatal vascular injuries followed by nonfatal visceral injuries emerging as
[34]
bowel or abdominal wall hematomas . Among the vascular injuries, the most commonly injured vessels
are the aorta, inferior vena cava, iliac vessels and epigastric vessels (due to lateral trocars) [35,36] .

[37]
In RARP, vascular injuries most frequently occur during the trocar insertion and lymphadenectomy .
They can also occur during neurovascular bundle dissection, and during the handling of the dorsal vein
complex or the lateral pedicles. Bipolar coagulation and clipping are very effective to control bleeding. If
[38]
the bleeding persists, the vessel should be tied with straight needle suturing through the abdominal wall .

During lymphadenectomy, direct contact should be avoided between the energy-based instruments and
vessels. Some reports exist about the failure of the insulation of laparoscopic instruments that results in
[27]
burning by the direct electrocautery electricity passage through the vessels . A direct cut to the iliac
vessels may also occur. Compression is the first step of the treatment. Then pneumoperitoneum should be
increased to 20 mmHg. In venous injuries, this action would stop the bleeding and allow repair. In arterial
[39]
bleedings, rolled gauze sponges should be utilized as a tamponade to stop the bleeding .
Patient positioning and compartment syndrome
Patient positioning
Proper patient positioning has a critical role in any surgical procedure. It is necessary for adequate
exposure and access, and also reduces the iatrogenic injuries as compartment syndrome and peripheral
nerve damage.

Intraoperative physiologic changes include increased intraocular pressure, central venous pressure,
intracranial and pulmonary venous pressure, and decreased functional residual capacity and pulmonary
compliance. Lung functions may be compromised prominently if the patient is too tightly taped to
[40]
the table . Prolonged Trendelenburg position may result in pooling of the venous blood in upper
extremities. Subsequently, head and neck edema may be seen and also re-intubation may be required due
to laryngeal edema and posterior ischemic optic neuropathy (PION) even after minimally invasive radical
prostatectomy [41,42] . Orbital stretching or direct compression from facedown prone positioning may also
cause permanent vision loss.