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Global and Regional Respiratory Mechanics During Robotic-Assisted Laparoscopic Surgery: A Randomized Study

Brandão, Julio C. MD, PhD*,†; Lessa, Marcos A. MD, PhD*,‡; Motta-Ribeiro, Gabriel PhD*; Hashimoto, Soshi MD, PhD*; Paula, Luis Felipe PhD*; Torsani, Vinicius PhD§; Le, Linh MSc*; Bao, Xiaodong MD*; Eikermann, Matthias MD; Dahl, Douglas M. MD; Deng, Hao MD, MPH*; Tabatabaei, Shahin MD*; Amato, Marcelo B. P. MD§; Vidal Melo, Marcos F. MD, PhD*

doi: 10.1213/ANE.0000000000004289
Critical Care and Resuscitation: Original Clinical Research Report

BACKGROUND: Pneumoperitoneum and nonphysiological positioning required for robotic surgery increase cardiopulmonary risk because of the use of larger airway pressures (Paws) to maintain tidal volume (Vt). However, the quantitative partitioning of respiratory mechanics and transpulmonary pressure (Pl) during robotic surgery is not well described. We tested the following hypothesis: (1) the components of driving pressure (transpulmonary and chest wall components) increase in a parallel fashion at robotic surgical stages (Trendelenburg and robot docking); and (2) deep, when compared to routine (moderate), neuromuscular blockade modifies those changes in Pls as well as in regional respiratory mechanics.

METHODS: We studied 35 American Society of Anesthesiologists (ASA) I-II patients undergoing elective robotic surgery. Airway and esophageal balloon pressures and respiratory flows were measured to calculate respiratory mechanics. Regional lung aeration and ventilation was assessed with electrical impedance tomography and level of neuromuscular blockade with acceleromyography. During robotic surgical stages, 2 crossover randomized groups (conditions) of neuromuscular relaxation were studied: Moderate (1 twitch in the train-of-four stimulation) and Deep (1–2 twitches in the posttetanic count).

RESULTS: Pneumoperitoneum was associated with increases in driving pressure, tidal changes in Pl, and esophageal pressure (Pes). Steep Trendelenburg position during robot docking was associated with further worsening of the respiratory mechanics. The fraction of driving pressures that partitioned to the lungs decreased from baseline (63% ± 15%) to Trendelenburg position (49% ± 14%, P < .001), due to a larger increase in chest wall elastance (Ecw; 12.7 ± 7.6 cm H2O·L−1) than in lung elastance (El; 4.3 ± 5.0 cm H2O·L−1, P < .001). Consequently, from baseline to Trendelenburg, the component of Paw affecting the chest wall increased by 6.6 ± 3.1 cm H2O, while Pls increased by only 3.4 ± 3.1 cm H2O (P < .001). Pl and driving pressures were larger at surgery end than at baseline and were accompanied by dorsal aeration loss. Deep neuromuscular blockade did not change respiratory mechanics, regional aeration and ventilation, and hemodynamics.

CONCLUSIONS: In robotic surgery with pneumoperitoneum, changes in ventilatory driving pressures during Trendelenburg and robot docking are distributed less to the lungs than to the chest wall as compared to routine mechanical ventilation for supine patients. This effect of robotic surgery derives from substantially larger increases in Ecw than Els and reduces the risk of excessive Pls. Deep neuromuscular blockade does not meaningfully change global or regional lung mechanics.

From the *Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts

Department of Anesthesia, Critical Care and Pain Medicine, UNIFESP, São Paulo, Brazil

Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Fiocruz, Rio de Janeiro, Brazil

§Cardio-Pulmonary Department, Pulmonary Division, Heart Institute (Incor), University of São Paulo, Sao Paulo, Brazil

Department of Urology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts.

Published ahead of print 26 July 2019.

Accepted for publication April 4, 2019.

Funding: This work was funded by Merck & Co.

Conflicts of Interest: See Disclosures at the end of the article.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website.

J. C. Brandão and M. A. Lessa contributed equally to this work and share first authorship.

Clinical Trials Number: NCT02025075. URL:

Reprints will not be available from the authors.

Address correspondence to Marcos A. Lessa, MD, PhD, Laboratory of Cardiovascular Investigation, Oswaldo Cruz Institute, Fiocruz Foundation, Avenida Brasil 4365, Rio de Janeiro, Brazil 21045-900. Address e-mail to

Copyright © 2019 International Anesthesia Research Society
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