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incrementally. Today we can easily say that laparoscopic and robotic surgeries are the most common surgical
procedures . Despite its several advantages, it has some surgery and pneumoperitoneum related adverse
[1]
effects and hemodynamic complications.

Ischemia-reperfusion injury (IRI) is a pathological condition characterized by initial undersupply of blood
to an area or organ, and subsequent restoration of perfusion and concomitant reoxygenation. Interestingly,
this ischemia and reperfusion produce a robust inflammation and oxidative response, and lead to the injury
(“reperfusion injury”) of microvascular endothelium and renal tubular epithelium . IRI is a major cause of
[2,3]
acute organ dysfunction . CO pneumoperitoneum is mandatory for visualization during laparoscopic and
[4]
2
robotic surgeries. For that reason, it is very logical to infer that creating CO pneumoperitoneum may lead
2
tissue/organ ischemia during insufflation and reperfusion during desufflation, a kind of laparoscopy related
IRI . Schäfer and Krähenbühl demonstrated that pneumoperitoneum leads to a 10%-80% reduction in
[6]
[5]
the rate of blood flow to the intraabdominal organs, but they also reported the return of this reduction to
the normal range after desufflation . IRI is a risk factor for splanchnic organ injury and liver and kidney
[6]
are among the intraabdominal organs most severely affected . To reduce or avoid the complications related
[7]
to laparoscopy and robotics, several alternative approaches such as gasless laparoscopy, lower pressure
laparoscopy and ischemic preconditioning (IPC) are introduced. IRI is also a risk factor for acute kidney
injury in partial nephrectomy surgeries even performed via open, or laparoscopic/robotic assisted. We
know that partial nephrectomy is the treatment of choice for small, localized renal tumors , and it is
[8]
generally performed with occlusion of kidney vascular supply, leading to IRI. To reduce this kind of injury,
several methods are proposed and investigated in the literature such as early hilar unclamping , renal
[9]
hypothermia , segmental renal artery clamping , and selective branch microdissection (beyond the
[12]
[10]
[11]
scope of this review), and IPC .
[13]
IPC is a phenomenon. It was first introduced in 1986 by Murry et al. . In their study on dogs, they were
[1]
able to show reduced myocardial infarct size by IPC . Since then, in contrast to some small studies with
[1]
conflicting results, several studies demonstrating its protective effects on kidney have been published.
This article will provide an updated summary of the effects of IRI and protective mechanisms of IPC. We
will also discuss the animal studies and clinical evidence of IPC, remote and local IPC, laparoscopy/robotics
induced IRI. The last section will review the main topic, role of laparoscopic/robotic IPC. For this purpose,
an extensive search of literature in PubMed was performed. “Ischemia reperfusion injury” and “ischemic
preconditioning” key words were used. It was not restricted to any year but language was restricted to
English. All relevant studies to make an update on the topic were reviewed.

IRI AND PROTECTIVE MECHANISMS OF IPC
The inflammatory cascade that is triggered by ischemia and subsequent reperfusion plays the major role
in IRI. In their study Fan et al. have demonstrated that leukocyte activation, invasion, adhesion, and
[15]
impaction evidently occur in ischemic reperfusion kidney injury. This leads release of several substances
and mediators such as free radicals, lysosomal enzymes and various cytokines causing cell damage, which
is called IRI . To overcome this tissue injury many studies suggested the IPC. Underlying mechanisms of
[16]
action of the protective effect of this procedure have been studied in several trials. In their study Mahfoudh-
Boussaid et al. found that IPC reduced lipid peroxidation and showed elevated levels of endothelial nitric
[17]
oxide synthase, nitrite and hypoxia inducible transcription factor-1α. Kim et al. suggested the protective
[18]
effect of isositrate dehydrogenase in IPC. Chen et al. proposed the NF-kappa B as the key mediator for
[19]
reperfusion injury and showed that IPC significantly reduced the expressions of renal adhesion molecules
ICAM-1, P-selectin, and E-selectin. Fan et al. also believed that the reduction of adhesion molecules
[15]
is an important step in preventing IRI. Many other studies confirmed that the adhesion molecules have