Not only surgical technique, but also anesthetic concerns
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LETTER TO EDITOR
Not only surgical technique, but also anesthetic concerns Fabrizio Dal Moro • Filiberto Zattoni
Received: 11 March 2013 / Accepted: 29 March 2013 Ó Springer-Verlag Berlin Heidelberg 2013
Dear Editor, We would like to congratulate Patel and Porter [1] on their experience of robotic partial nephrectomy for renal tumors using a retroperitoneal approach (RP). In this elegant study, they demonstrated that RP approach offers a feasible, reproducible option for dealing with surgical renal disease, comparable with transperitoneal (TP) kidney surgery. However, in the results, the authors reported a case of hypercapnia refracting to anesthesia’s efforts to increase minute ventilation and requiring a decrease in carbon dioxide (CO2) pressure. Patel and colleagues then did not mention this problem in the discussion. In our opinion, evaluating all the features of RP technique, a great attention has to be spent on the anesthetic concerns: this is an old issue, already known in retroperitoneoscopic surgery, but also a new topic, considering that in general, most of the robotic surgeons lack conventional laparoscopic experience. Although few data exist on the hemodynamic effects of robotic surgery in an extraperitoneally created cavity, experiences reported in the literature are controversial. If there are comparative experimental studies in dogs showing an earlier and
stronger tendency toward the development of hypercapnia and respiratory acidosis in the TP than in RP group [2], specific experiences in robotic surgery demonstrated that levels of partial pressure of CO2 during RP insufflation increase earlier reaching significant higher level than during TP insufflation [3]. Our experience (data not yet published) on comparison of TP and extraperitoneal robotic radical prostatectomy confirm an higher CO2 reabsorption in the second group, probably due to a much larger resorptive surface area created when gas is insufflated directly into extraperitoneal tissue. As suggested by Gascock et al. [4], direct intravascular uptake of CO2 may be facilitated by the disruption of microvascular and lymphatic channels during the development of a retroperitoneal/extraperitoneal cavity. In conclusion, we believe that when two different surgical techniques are compared, anesthetic concerns are to be carefully analyzed; in particular, in this field, the absorption of CO2 from the insufflation cavity could result in hypercapnia associated with sympathetic stimulation, which may increase heart rate, blood pressure, systemic vascular resistance, and cardiac output.
F. D. Moro (&) F. Zattoni Department of Surgical, Oncological and Gastroenterological Sciences, Urology, University of Padova, Via Giustiniani 2, Padova 35126, Italy e-mail: [email protected]
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World J Urol Conflict of interest All authors declare they have no actual or potential competing financial interest. The manuscript is original work, and all authors have given their consent for publication of the manuscript. The manuscript has been submitted sole
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