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Intraocular Pressure During Robotic-assisted Laparoscopic Procedures Utilizing Steep Trendelenburg Positioning

Mondzelewski, Todd J. MD*; Schmitz, Joseph W. MD*; Christman, Matthew S. MD; Davis, Kimberly D. MD, FACS; Lujan, Eugenio MD§; L’Esperance, James O. MD; Auge, Brian K. MD, FACS

doi: 10.1097/IJG.0000000000000302
Original Studies

Purpose: To determine the effect of steep Trendelenburg (sTBURG) surgical positioning on intraocular pressure (IOP) during robotic-assisted laparoscopy (RAL) in subjects without previously identified ocular disease.

Design: Prospective cohort study.

Participants and Controls: Eighteen patients undergoing RAL with sTBURG and 21 controls undergoing open and laparoscopic cases in horizontal positioning.

Materials and Methods: Research data derived from an approved Naval Medical Center, San Diego, CA, IRB protocol. A study group undergoing RAL utilizing sTBURG (group 1) was compared with a control group undergoing open surgery in the horizontal position (group 2), and laparoscopic cases in the horizontal position (group 3). An ophthalmologic examination including Snellen visual acuity, IOP, Humphrey Visual Field (HVF) 24-2 with standard Swedish Interactive Thresholding Algorithm, time domain optical coherence tomography (OCT), retinal nerve fiber layer (RNFL) analysis, pachymetry, and dilated fundus examination was conducted preoperatively and at 1 month postoperatively. IOP was measured intraoperatively at discrete time-points.

Main Outcome Measures: IOP values, change in OCT RNFL thickness, HVF mean deviation, and HVF pattern standard deviation.

Results: Baseline IOP (mm Hg) was similar, 13.7±3.2 for group 1 versus 15.3±3.2 for group 2 and 14.1±2.4 for group 3 (P=0.55). The IOP plateau from 60 minutes until case conclusion occurred at 29.9 mm Hg (95% confidence interval, 27.4-32.5), 19.9 mm Hg (95% confidence interval, 17.6-22.3), and 22.8 mm Hg (95% confidence interval, 20.2-25.4) for group 1, group 2, and group 3, respectively. There were no significant changes in OCT RNFL thickness, HVF mean deviation, and HVF pattern standard deviation.

Conclusions: Significant elevations of IOP are experienced during robotic surgery utilizing sTBURG positioning in patients with healthy eyes, and we recommend a multidisciplinary approach in determining potential risk to those with known ocular disease who are candidates for these procedures.

Departments of Urology


§Anesthesiology, Naval Medical Center San Diego, San Diego, CA

Department of Ophthalmology, Naval Medical Center Portsmouth, VA

Copyright: This work was prepared as part of the authors' official duties. Title 17 U.S.C. 105 provides that ‘Copyright protection under this title is not available for any work of the United States Government.’ Title 17 U.S.C. 101 defines a United States Government work as a work prepared by a military service member or employee of the United States Government as part of that person’s official duties.

The views expressed in this manuscript are those of the authors and by no means reflect the official position of the United States Navy, Department of Defense, or the United States Government.

Disclosure: The authors declare no conflict of interest.

Reprints: Todd J. Mondzelewski, MD, Department of Ophthalmology, 34800 Bob Wilson Drive, Naval Medical Center San Diego, San Diego, CA 92134 (e-mail:

Received January 8, 2013

Accepted May 8, 2015

Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.