Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital, Milan, Italy; Department of Health Sciences, University of Milan, Milan, Italy; Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy.
Br J Anaesth. 2023 Oct;131(4):764-774. doi: 10.1016/j.bja.2023.06.066. Epub 2023 Aug 3.
Robotic-assisted surgery has improved the precision and accuracy of surgical movements with subsequent improved outcomes. However, it requires steep Trendelenburg positioning combined with pneumoperitoneum that negatively affects respiratory mechanics and increases the risk of postoperative respiratory complications. This narrative review summarises the state of the art in ventilatory management of these patients in terms of levels of positive end-expiratory pressure (PEEP), tidal volume, recruitment manoeuvres, and ventilation modes during both urological and gynaecological robotic-assisted surgery. A review of the literature was conducted using PubMed/MEDLINE; after completing abstract and full-text review, 31 articles were included. Although different levels of PEEP were often evaluated within a protective ventilation strategy, including higher levels of PEEP, lower tidal volume, and recruitment manoeuvres vs a conventional ventilation strategy, we conclude that the best PEEP in terms of lung mechanics, gas exchange, and ventilation distribution has not been defined, but moderate PEEP levels (4-8 cm HO) could be associated with better outcomes than lower or highest levels. Recruitment manoeuvres improved intraoperative arterial oxygenation, end-expiratory lung volume and the distribution of ventilation to dependent (dorsal) lung regions. Pressure-controlled compared with volume-controlled ventilation showed lower peak airway pressures with both higher compliance and higher carbon dioxide clearance. We propose directions to optimise ventilatory management during robotic surgery in light of the current evidence.
机器人辅助手术提高了手术动作的精度和准确性，从而改善了手术结果。然而，它需要陡峭的特伦德伦伯格体位，同时结合气腹，这会对呼吸力学产生负面影响，并增加术后呼吸并发症的风险。本叙述性综述总结了在泌尿外科和妇科机器人辅助手术中，这些患者的通气管理的最新技术，包括呼气末正压（PEEP）水平、潮气量、复张手法和通气模式。使用 PubMed/MEDLINE 进行文献回顾；完成摘要和全文审查后，纳入了 31 篇文章。尽管在保护性通气策略中经常评估不同的 PEEP 水平，包括更高水平的 PEEP、更低的潮气量和复张手法与常规通气策略相比，但我们的结论是，尚未确定最佳的 PEEP 水平，以达到最佳的肺力学、气体交换和通气分布，但适度的 PEEP 水平（4-8 cm HO）可能与更好的结果相关，而不是更低或最高的水平。复张手法改善了术中动脉氧合、呼气末肺容积和通气分布到依赖（背部）肺区。与容量控制通气相比，压力控制通气显示出更低的峰气道压力，同时具有更高的顺应性和更高的二氧化碳清除率。根据当前的证据，我们提出了优化机器人手术期间通气管理的方向。
