Table 5.

Risks to patients undergoing abdominal or pelvic robotic surgery and management goals

Cardiovascular	•Decreased venous return with pneumoperitoneum •Decreased mesenteric perfusion with pneumoperitoneum Reverse Trendelenburg: • Decreased venous return • Hypotension • Increased DVT risk	•Consider preoperative consult for patients with congenital or other significant heart disease •Slow insufflation in patients who are more preload dependent Optimal volume status • in steep Trendelenberg, avoid too much crystalloid • in reverse Trendelenberg, ensure adequate volume repletion Maintain adequate MAP with pressors as needed Adequate DVT prophylaxis
Respiratory	Trendelenburg positioning: • Hypercapnia (decreased ventilation from FRC, ERV; CO2 insufflation) • Hypoxemia (atelectasis and decreased ventilation)	•Use lowest peritoneal insufflation pressure needed to provide surgical visualization •Pressure-controlled ventilation, optimize PEEP and other ventilation settings to achieve adequate ventilation
Airway	Trendelenburg positioning: • Airway edema • Subcutaneous emphysema	• Check proper ETT positioning after being placed in steep Trendelenburg/reverse •Consider performing cuff leak test before extubation •Judicious fluid administration, consider using goal- directed fluid administration, to decrease edema risk.
Nervous system	Trendelenburg: • Raised ICP • Raised IOP • Visual changes/loss Reverse Trendelenburg: • Hypotension • Decreased cerebral perfusion	•Check that there is no equipment causing external pressure on eyes, head/neck •Maintain adequate MAP for cerebral and ocular perfusion •Consider neurologic consult for patients at risk for increased ICP or IOP
Positioning	•Nerve injuries •Compartment syndrome •Limited access to airway, extremities	Team effort: • Obtain adequate arterial and venous access before positioning • Adequate padding of all pressure points • Decrease sliding/skidding risk: antiskid bedding and cross-torso straps • Use smallest degree and shortest duration of Trendelenburg/reverse Trendelenburg positioning required for surgical success

Abbreviations: ERV, expiratory reserve volume; FRC, functional residual capacity; ICP, itracranial pressure; IOP, intraoccular pressure ; MAP, mean arterial pressure; PEEP, positive end expiratory pressure.