THE INTERNATIONAL JOURNAL OF MEDICAL ROBOTICS AND COMPUTER ASSISTED SURGERY REVIEW Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. Published online 6 November 2014 in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/rcs.1632
ARTICLE
Ocular complications in robotic surgery
Ioannis D. Gkegkes1 Andreas Karydis2 Stavros I. Tyritzis3,4 Christos Iavazzo5*
Abstract
1
Methods A systematic search was performed in both PubMed and Scopus databases.
First Department of Surgery, General Hospital of Attica ’KAT’, Athens, Greece
2
Bristol University Eye Hospital, Glaucoma DepartmentBristol, UK
3
Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
4
Centre of Minimally Invasive Urological Surgery, Athens Medical Centre, Athens, Greece
5
Gynaecological Oncology Department, Christie Hospital, Manchester, UK *Correspondence to: C. Iavazzo, 38 Seizani Street, Nea Ionia, Athens 14231, Greece. E-mail: [email protected]
Background The penetration of robotic technology in various surgical fields may increase ocular complications.
Results Eight articles were retrieved by the literature search. In total, 142 patients were included in the study. The most frequent complication was increased intra-ocular pressure. Corneal abrasion, ischaemic optic neuropathy and postoperative visual loss were also reported. The duration of operations was 1.7–9.9 h; mean intra-ocular pressure was 3.6–13.3 mmHg; estimated blood loss was 29.7–1200 ml; and administered intravenous fluids were 1.600–4.300 ml. Conclusions Meticulous preoperative ophthalmological assessment, restriction of intravenous fluids, ’rest stops’, eyelid taping and ocular dressings are the major protective measures suggested by the literature. Collaboration between the surgical team and the anaesthetist is also essential. Copyright © 2014 John Wiley & Sons, Ltd. Keywords ocular complications; robotic surgery; corneal abrasion; intra-ocular pressure; Trendelenburg position
Introduction
Accepted: 5 October 2014
Copyright © 2014 John Wiley & Sons, Ltd.
Robotic surgery is extensively applied in various surgical fields, including gynaecological and urological procedures. Its main advantages for the surgeon are improved dexterity, due to the existence of wristed instrumentation, highdefinition 3D vision, tremor filtration and improved ergonomics (1). Moreover, its learning curve is not as steep as for laparoscopy. Such advantages optimize the care offered to the patient. However, due to lack of experience, as it is a rather new method, it can be related to several risks and possible complications, such as urinary tract injury, bowel injury, neurovascular injury, anaesthetic risks and, among others, ocular complications (2–4). Peri-operative visual loss occurring during non-ocular surgery is a devastating event. In an older animal study, a combination of CO2 pneumoperitoneum and steep Trendelenburg position could cause an increase in intra-ocular pressure (5). Molloy (6) suggested a relationship between prolonged steep Tredelenburg and reduced ocular perfusion pressure, and challenged the accepted view that cerebral and ophthalmic
I. D. Gkegkes et al.
270
circulatory autoregulation prevents elevated compartment pressures and reductions in perfusion. The purpose of this review is to examine the possible ocular complications correlated to robotic-assisted surgical techniques and discuss their possible mechanisms, prevention and management.
Methods Data sources A systematic search was performed in PubMed (25 May 2014) and Scopus (25 May 2014). The search strategy adopted in both of these databases included the combination of the keywords (robot OR robotic OR tele-surgery) AND (ocular OR corneal OR intra-ocular pressure OR ischaemic neuropathy). The reference lists of the included articles were also searched.
Study selection criteria Papers reporting data on ocular complications of the robotic surgical technique, independently of the surgical specialty, were considered as eligible for this review. Studies written in languages other than English, German, French, Italian, Spanish and Greek were not included.
Reviews, conference papers, letters to the editor, short surveys and commentaries were excluded from our analysis.
Results A total of five articles were retrieved from the search in the PubMed and Scopus databases (7–11). Three additional studies were also identified as eligible for inclusion through the search of the reference list of relevant articles (12,13,22). The process of articles’ selection is depicted in Figure 1. The major characteristics of the included studies (study design, number of patients, patients’age, body mass index, type of operation performed, ocular complications presented, degree of inclination in the Trendelenburg position, duration of the operation, intra-ocular pressure measured, estimated blood loss, the quantity of intravenous fluids administered, need for transfusion and hospital stay) are presented in Table 1. In total, 142 patients were included, aged 31–74 years. Two of eight studies reported the data on body mass index (BMI) of the patients, which was in the range 20–43 kg/m2. Robot-assisted laparoscopic prostatectomy, robot-assisted laparoscopic hysterectomy, robotic sacral colpopexy and robot-assisted endoscopic thyroidectomy were reported in five, one, one and one study, respectively. The most frequent ocular complication was increased intra-ocular
Figure 1. Flow diagram of the detailed process of selection of articles for inclusion in our review Copyright © 2014 John Wiley & Sons, Ltd.
Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
Copyright © 2014 John Wiley & Sons, Ltd.
Retrospective study Prospective study
Retrospective study Case report
Prospective study
1
45
33
3
19
8
2
NM
NM
62
Median (range): 61.5 (37–74) NM
NM
NM
NM
Median (range): 28 (20–43)
NM
Median NM (range): 44 (31–63) Mean (SD): Mean (SD): 41.4 (6) 23.6 (3.7)
Mean (range): 66.15 (54–74) NM
RALP
RALP
RALP
RALP
RET
RALH
RSC
RALP
BMI Type of 2 (kg/m ) operation
Corneal abrasion Ischaemic optic neuropathy
Postoperative visual loss Increased IOP
Increased IOP
Corneal abrasion Increased IOP
Increased IOP
NM
45
25
6.5
NM
Median (range): 2.37 (1.75–3.5)
7.9–9.9
Mean (SD): 2.9 (0.645)
– NM
NM
NM
Mean (SD): 4.57 (0.03)
30
NM
23
Ocular Degree of Operation complications Trendelenburg time (h)
EBL (ml)
NM
NM
Mean (SD): 13.3 (0.58)‡
NM
Mean (SD): 3.6 (3)†
NM
NM
NM
NM
NM
NM
NM
Intravenous fluids (ml)
1200
NM
4300
NM
Median Median (range): (range): 2000 80 (45–155) (1600–3100)
NM
Mean (SD): 29.7 (11.1)
Median: 50
NM
Mean (range): Mean (SD): 13.2 (8–20) 364 (196)
IOP (mmHg)
Yes
NM
No
NM
No
No
No
NM
3
NM
NM
NM
NM
NM
NM
NM
Transfusions Hospital (yes/no) stay (days)
NM, not mentioned; BMI, body mass index; IOP, intraocular pressure; RALP, robot-assisted laparoscopic prostatectomy; RALH, robot-assisted laparoscopic hysterectomy, SD, standard deviation; RSC, robotic sacral colpopexy; RET, robot-assisted endoscopic thyroidectomy; EBL, estimated blood loss. ‡ On average at the end of steep Trendelenburg position than the preanesthesia induction value. † Higher than the previous measurements (p < 0.001).
USA (13)
USA (12)
USA (8)
Korea (11) Prospective comparative study USA (22) Abstract
USA (9)
USA (7)
31
Age of Publication No. of patient type patients (years)
Japan (10) Prospective study
Country/ reference
Table 1. Studies referring to ocular complications in robotic surgery
Ocular complications in robotic surgery
271
Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
272
pressure (five of eight studies), while corneal abrasion, ischaemic optic neuropathy and postoperative visual loss were present in two, one and one study, respectively. The inclination of Trendelenburg position was in the range 23–45°. The duration of the operations was in the range 1.75–9.9 h. Mean intraocular pressure varied in the range 3.6–13.3 mmHg. Estimated blood loss was in the range 29.7–1.200 ml. Only one of eight studies reported the necessity of blood transfusion; administered intravenous fluids were in the range 1.600–4.300 ml. The duration of the hospital stay after the operation was reported in one study (3 days).
Discussion The first two studies of ocular complications were presented in 2007 (12,13). Weber et al. (13) described the first and only case of ischaemic optic neuropathy after robot-assisted laparoscopic prostatectomy, in which, after a 3 month period, the patient presented a stable loss of bilateral inferior fields. Nevertheless, the main ocular complications include increased intra-ocular pressure and corneal abrasions. The pathophysiology behind the appearance of ocular complications during robotic surgery is quite complex. For the realization of robot-assisted operations, especially at the lesser pelvis, the steep Trendelenburg position (23–45°) is fundamental; the abdominal viscera are removed from the pelvic cavity and, with the assistance of gravity, a free operating field is created (10). The Trendelenburg position, as it does not represent a physiological condition for the human body, can result in a number of haemodynamic effects. Decrease of cardiac output, increase of central venous pressure and increase of the blood flow in the direction of the head are the main consequences of such a position, leading to an increase in intra-ocular pressure. In addition, the increased intra-ocular pressure and the prolonged placement in Trendelenburg position may be associated with an increased risk of developing glaucoma, particularly in patients predisposed to elevated intra-ocular pressure prior to the operation (20). Ophthalmology consultations could be recommended prior to robot-assisted operations that include a steep Trendelenburg position. These may include an optical coherence tomography that uses near-infrared light in order to visualize retinal thickness. This type of tomography could evaluate the glaucomatous damage, as reflected by death and thinning of the retina (21). Ganglion cell complex and retinal nerve fibre layer thicknesses are of particular importance in such an evaluation (19). Moreover, other studies have shown that transient elevation of intra-ocular pressure in adult eyes is a triggering glaucoma factor that results in increases in disc area and linear disc dimensions (LASIK Copyright © 2014 John Wiley & Sons, Ltd.
I. D. Gkegkes et al.
patients) (14). Furthermore, robot-assisted surgery at the neck may also result in increased intra-ocular pressure. In the case of robot-assisted endoscopic thyroidectomy, surgical manipulations of the great vessels of the neck (such as the jugular veins during the CO2 insufflation of the neck) can raise jugular venous pressure and further elevate intra-ocular pressure (11). Concerning the rare case of ischaemic optic neuropathy, it seems that this is a result of a steep Trendelenburg position in combination with excessive blood loss. Optic nerve damage is most likely the result of two different pathophysiological mechanisms, either due to decreased blood supply (ischaemia) from the arteries of the optic nerve, or due to venous stasis as consequence of reduced venous outflow (15). Ischaemic neuropathy, although rare, is a detrimental complication. To date, there are no literature data regarding the prevention of ischaemic neuropathy during robotic surgery. Another ophthalmologic complication that could occur during robotic surgery is ocular injury. The most common complications related to anaesthesia are corneal abrasions, which can be the result of the use of either eye or plastic tape exposure or oxygen toxicity, keratopathy and conjunctival oedema as a consequence of erroneous eye touching and due to increased administration of intravenous fluids (15). In the studies included in our review, it has been showed that ocular pressure is increased in a timedependent fashion in anaesthetized patients, especially when we examine the correlation with surgical and/or compromised patient positioning time. There is no supportive evidence that the ’rest stop’ can be beneficial as a preventative measure of ocular complications, and especially in cases of prolonged operations with severe blood loss. However, a rest stop will increase the operation time, as it involves undocking and redocking of the robot and repositioning of the patient. One could argue that elderly and/or obese patients could face more ocular complications when they are undergoing robotic procedures; however, such a conclusion could not be safely drawn from our review. A recent clinical trial showed that intra-ocular pressure increases after pneumoperitoneum and the steep Trendelenburg position, and that such an increase is less with propofol than with sevoflurane anaesthesia (16). However, again, such a correlation was not found in our review of the literature because of lack of such information. Elevated intra-ocular pressure and ischaemic damage to the optic nerve could possibly be prevented by the introduction of ’rest stops’ (intervals of reverse Trendelenburg positioning) during robotic surgery operations (9,17). The use of eye-occlusive dressings, ocular ointments, eye pads and protective goggles could avoid eye touching and keratopathy. Also, restriction of the intravenous fluids administered during steep Trendelenburg position could be considered another eye-protective Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
273
Ocular complications in robotic surgery
measure (18). However, when the presence of conjunctival or facial oedema is observed at the end of an operation, anaesthetists and surgeons should always be alert to synchronous presence of laryngeal oedema. For the prevention of such complications, restriction of intravenous fluids and optimization of the operative time are also considered essential (Table 2). In the literature, the application of temporary suturing of the eyelids (tarsorrhaphy) is another technique described in order to prevent mechanical injuries to the cornea (18). There is no evidence that tarsorrhaphy increases the IOP pressure. However, the trauma inflicted to the eyelids and the limited protection of the ocular surface make tarsorrhaphy a less-recommended and oldfashioned technique. For the reasons given above, some studies suggest preoperative assessment as well as intraoperative and postoperative management of such complications as part of a multidisciplinary approach (surgeon, anaesthesiologist, ophthalmologist), especially for patients with a history of either glaucoma or ocular hypertension and the presence of past ischaemic events (8,12). A number of limitations and weaknesses should be considered in the reading of the results of this review. First and foremost, the limited number of the studies and patients included make it difficult to arrive at safe conclusions. Moreover, a possible predictive factor, BMI, which increases the IOP secondary to increasing the intrathoracic pressure, was only recorded in two of the seven studies; similarly, another risk factor, the total volume of intravenous fluids administered, was only mentioned in two of the seven studies. Moreover, the rather novel robotic technique may increase complication rates due to learning curve issues for both surgeons and anaesthetists. Furthermore, it should be mentioned that the medicolegal system in some countries, e.g. the USA (where 75% of the robotic cases are done globally), may not record ocular complications systematically (19). Another limitation is the lack of high-powered, prospective randomized studies. Although we have reviewed the incidence of ocular complications in different types of robotic operation, one could argue that we should have compared our findings with the incidence of ocular complications during the same operations done laparoscopically in the Trendelenburg position. Table 2. Possible protective measures against ocular complications during robotic assisted operations Increased IOP Pre-operative assessment in patients with glaucoma or ocular hypertension Restriction of intravenous fluids Rest stops
IOP, intraocular pressure. Copyright © 2014 John Wiley & Sons, Ltd.
Corneal abrasions Eyelid taping Ocular ointments Protective goggles Bio-occlusive dressings Tarsorrhaphy (less recommended)
However, we argue against such a comparison, as the degree of the Trendelenburg position is different between the two approaches. Further studies need to be conducted in order to compare the standard laparoscopic technique with the robotic one for the same surgery for the outcome of ocular complications. Another question that should be answered is whether there is any practicality of applying ’rest stops’ in the case of tight operative time scenarios. Regarding the search strategy adopted, which was defined earlier, it could be considered restricted as a consequence of the exclusion of review articles, conference papers, letters to the editor, short surveys and commentaries. Last but not least, the restriction as far as the languages of the excluded articles could be thought as another weakness of the present study.
Conclusion With the continuous increase in the frequency of robotassisted operations that are performed, ocular complications may also be increasing. More clinical data on risk factors associated with ocular damage, and more well-designed studies, are needed to clarify the negative role of robotic surgery in this type of complication. Therefore, knowledge of the probable complications and the relative protective measures by both anaesthetists and surgeons is imposed for the peri-operative management of these patients. Collaboration between the surgical team and the anaesthetist is essential for a successful outcome.
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Funding No specific funding.
References 1. Cho JE, Nezhat FR. Robotics and gynecologic oncology: review of the literature. J Minim Invasive Gynecol 2009; 16: 669–681. 2. Cormier B, Nezhat F, Sternchos J, et al. Electrocautery-associated vascular injury during robotic-assisted surgery. Obstet Gynecol 2012; 120: 491–493. 3. Hakimi AA, Faleck DM, Sobey S, et al. Assessment of complication and functional outcome reporting in the minimally invasive prostatectomy literature from 2006 to the present. BJU Int 2012; 109: 26–30, discussion. Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
274 4. Pedraza R, Ragupathi M, Martinez T, et al. Robotic-assisted laparoscopic primary repair of acute iatrogenic colonic perforation: case report. Int J Med Robot 2012; 8: 375–378. 5. Lentschener C, Leveque JP, Mazoit JX, et al. The effect of pneumoperitoneum on intraocular pressure in rabbits with α-chymotrypsininduced glaucoma. Anesth Analg 1998; 86: 1283–1288. 6. Molloy BL. Implications for postoperative visual loss: steep Trendelenburg position and effects on intraocular pressure. J Am Assoc Nurse Anesth 2011; 79: 115–121. 7. Antosh DD, Whyte T, Ezzell A, et al. Incidence of corneal abrasions during pelvic reconstructive surgery. Eur J Obstet Gynecol Reprod Biol 2013; 166: 226–228. 8. Awad H, Santilli S, Ohr M, et al. The effects of steep Trendelenburg positioning on intraocular pressure during robotic radical prostatectomy. Anesth Analg 2009; 109: 473–478. 9. Borahay MA, Patel PR, Walsh TM, et al. Intraocular pressure and steep Trendelenburg during minimally invasive gynecologic surgery: is there a risk? J Minim Invasive Gynecol 2013; 20: 819–824. 10. Hoshikawa Y, Tsutsumi N, Ohkoshi K, et al. The effect of steep Trendelenburg positioning on intraocular pressure and visual function during robotic-assisted radical prostatectomy. Br J Ophthalmol 2014; 98: 305–308. 11. Kim JA, Kim JS, Chang MS, et al. Influence of carbon dioxide insufflation of the neck on intraocular pressure during robotassisted endoscopic thyroidectomy: a comparison with open thyroidectomy. Surg Endosc 2013; 27: 1587–1593. 12. Danic MJCM, Alexander G, et al. Anesthesia considerations for robotic-assisted laparoscopic prostatectomy: a review of 1500 cases. J Robotic Surg 2007; 1(2): 119–123.
Copyright © 2014 John Wiley & Sons, Ltd.
I. D. Gkegkes et al. 13. Weber EDCM, Lesser RL, et al. Posterior ischemic optic neuropathy after minimally invasive prostatectomy. J Neuroophthalmol 2007; 27(4): 285–287. 14. Poostchi A, Wong T, Chan KC, et al. Optic disc diameter increases during acute elevations of intraocular pressure. Invest Ophthalmol Vis Sci 2010; 51: 2313–2316. 15. Gainsburg DM. Anesthetic concerns for robotic-assisted laparoscopic radical prostatectomy. Minerva Anestesiol 2012; 78: 596–604. 16. Yoo YC, Shin S, Choi EK, et al. Increase in intraocular pressure is less with propofol than with sevoflurane during laparoscopic surgery in the steep Trendelenburg position. Can J Anaesth 2014; 61: 322–329. 17. Baig MN, Lubow M, Immesoete P, et al. Vision loss after spine surgery: review of the literature and recommendations. Neurosurg Focus 2007; 23: E15. 18. Grixti A, Sadri M, Watts MT. Corneal protection during general anesthesia for nonocular surgery. Ocul Surf 2013; 11: 109–118. 19. Awad H, Malik OS, Cloud AR, et al. Robotic surgeries in patients with advanced glaucoma. Anesthesiology 2013; 119(4): 954. 20. Awad H, Walker CM, Shaikh M, et al. Anesthetic considerations for robotic prostatectomy: a review of the literature. J Clin Anesth 2012; 24(6): 494–504. 21. Schuman JS, Puliafito CA, Fujimoto JG. Optical coherence tomography: its history, how it works, and what its images show. In Everyday OCT: A Handbook for Clinicians and Technicians, Schuman JS, Puliafito CA, Fujimoto JG (eds). Slack Inc.: Thorofare, NJ, 2006; 87–120. 22. Lee LA, Posner KL, Bruchas R, et al. Visual loss after prostatectomy [abstract]. Paper presented at the Annual Meeting of the American Society of Anesthesiologists, 18 October 2010, San Diego, CA.
Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
ARTICLE
Ocular complications in robotic surgery
Ioannis D. Gkegkes1 Andreas Karydis2 Stavros I. Tyritzis3,4 Christos Iavazzo5*
Abstract
1
Methods A systematic search was performed in both PubMed and Scopus databases.
First Department of Surgery, General Hospital of Attica ’KAT’, Athens, Greece
2
Bristol University Eye Hospital, Glaucoma DepartmentBristol, UK
3
Department of Molecular Medicine and Surgery, Section of Urology, Karolinska Institutet, Stockholm, Sweden
4
Centre of Minimally Invasive Urological Surgery, Athens Medical Centre, Athens, Greece
5
Gynaecological Oncology Department, Christie Hospital, Manchester, UK *Correspondence to: C. Iavazzo, 38 Seizani Street, Nea Ionia, Athens 14231, Greece. E-mail: [email protected]
Background The penetration of robotic technology in various surgical fields may increase ocular complications.
Results Eight articles were retrieved by the literature search. In total, 142 patients were included in the study. The most frequent complication was increased intra-ocular pressure. Corneal abrasion, ischaemic optic neuropathy and postoperative visual loss were also reported. The duration of operations was 1.7–9.9 h; mean intra-ocular pressure was 3.6–13.3 mmHg; estimated blood loss was 29.7–1200 ml; and administered intravenous fluids were 1.600–4.300 ml. Conclusions Meticulous preoperative ophthalmological assessment, restriction of intravenous fluids, ’rest stops’, eyelid taping and ocular dressings are the major protective measures suggested by the literature. Collaboration between the surgical team and the anaesthetist is also essential. Copyright © 2014 John Wiley & Sons, Ltd. Keywords ocular complications; robotic surgery; corneal abrasion; intra-ocular pressure; Trendelenburg position
Introduction
Accepted: 5 October 2014
Copyright © 2014 John Wiley & Sons, Ltd.
Robotic surgery is extensively applied in various surgical fields, including gynaecological and urological procedures. Its main advantages for the surgeon are improved dexterity, due to the existence of wristed instrumentation, highdefinition 3D vision, tremor filtration and improved ergonomics (1). Moreover, its learning curve is not as steep as for laparoscopy. Such advantages optimize the care offered to the patient. However, due to lack of experience, as it is a rather new method, it can be related to several risks and possible complications, such as urinary tract injury, bowel injury, neurovascular injury, anaesthetic risks and, among others, ocular complications (2–4). Peri-operative visual loss occurring during non-ocular surgery is a devastating event. In an older animal study, a combination of CO2 pneumoperitoneum and steep Trendelenburg position could cause an increase in intra-ocular pressure (5). Molloy (6) suggested a relationship between prolonged steep Tredelenburg and reduced ocular perfusion pressure, and challenged the accepted view that cerebral and ophthalmic
I. D. Gkegkes et al.
270
circulatory autoregulation prevents elevated compartment pressures and reductions in perfusion. The purpose of this review is to examine the possible ocular complications correlated to robotic-assisted surgical techniques and discuss their possible mechanisms, prevention and management.
Methods Data sources A systematic search was performed in PubMed (25 May 2014) and Scopus (25 May 2014). The search strategy adopted in both of these databases included the combination of the keywords (robot OR robotic OR tele-surgery) AND (ocular OR corneal OR intra-ocular pressure OR ischaemic neuropathy). The reference lists of the included articles were also searched.
Study selection criteria Papers reporting data on ocular complications of the robotic surgical technique, independently of the surgical specialty, were considered as eligible for this review. Studies written in languages other than English, German, French, Italian, Spanish and Greek were not included.
Reviews, conference papers, letters to the editor, short surveys and commentaries were excluded from our analysis.
Results A total of five articles were retrieved from the search in the PubMed and Scopus databases (7–11). Three additional studies were also identified as eligible for inclusion through the search of the reference list of relevant articles (12,13,22). The process of articles’ selection is depicted in Figure 1. The major characteristics of the included studies (study design, number of patients, patients’age, body mass index, type of operation performed, ocular complications presented, degree of inclination in the Trendelenburg position, duration of the operation, intra-ocular pressure measured, estimated blood loss, the quantity of intravenous fluids administered, need for transfusion and hospital stay) are presented in Table 1. In total, 142 patients were included, aged 31–74 years. Two of eight studies reported the data on body mass index (BMI) of the patients, which was in the range 20–43 kg/m2. Robot-assisted laparoscopic prostatectomy, robot-assisted laparoscopic hysterectomy, robotic sacral colpopexy and robot-assisted endoscopic thyroidectomy were reported in five, one, one and one study, respectively. The most frequent ocular complication was increased intra-ocular
Figure 1. Flow diagram of the detailed process of selection of articles for inclusion in our review Copyright © 2014 John Wiley & Sons, Ltd.
Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
Copyright © 2014 John Wiley & Sons, Ltd.
Retrospective study Prospective study
Retrospective study Case report
Prospective study
1
45
33
3
19
8
2
NM
NM
62
Median (range): 61.5 (37–74) NM
NM
NM
NM
Median (range): 28 (20–43)
NM
Median NM (range): 44 (31–63) Mean (SD): Mean (SD): 41.4 (6) 23.6 (3.7)
Mean (range): 66.15 (54–74) NM
RALP
RALP
RALP
RALP
RET
RALH
RSC
RALP
BMI Type of 2 (kg/m ) operation
Corneal abrasion Ischaemic optic neuropathy
Postoperative visual loss Increased IOP
Increased IOP
Corneal abrasion Increased IOP
Increased IOP
NM
45
25
6.5
NM
Median (range): 2.37 (1.75–3.5)
7.9–9.9
Mean (SD): 2.9 (0.645)
– NM
NM
NM
Mean (SD): 4.57 (0.03)
30
NM
23
Ocular Degree of Operation complications Trendelenburg time (h)
EBL (ml)
NM
NM
Mean (SD): 13.3 (0.58)‡
NM
Mean (SD): 3.6 (3)†
NM
NM
NM
NM
NM
NM
NM
Intravenous fluids (ml)
1200
NM
4300
NM
Median Median (range): (range): 2000 80 (45–155) (1600–3100)
NM
Mean (SD): 29.7 (11.1)
Median: 50
NM
Mean (range): Mean (SD): 13.2 (8–20) 364 (196)
IOP (mmHg)
Yes
NM
No
NM
No
No
No
NM
3
NM
NM
NM
NM
NM
NM
NM
Transfusions Hospital (yes/no) stay (days)
NM, not mentioned; BMI, body mass index; IOP, intraocular pressure; RALP, robot-assisted laparoscopic prostatectomy; RALH, robot-assisted laparoscopic hysterectomy, SD, standard deviation; RSC, robotic sacral colpopexy; RET, robot-assisted endoscopic thyroidectomy; EBL, estimated blood loss. ‡ On average at the end of steep Trendelenburg position than the preanesthesia induction value. † Higher than the previous measurements (p < 0.001).
USA (13)
USA (12)
USA (8)
Korea (11) Prospective comparative study USA (22) Abstract
USA (9)
USA (7)
31
Age of Publication No. of patient type patients (years)
Japan (10) Prospective study
Country/ reference
Table 1. Studies referring to ocular complications in robotic surgery
Ocular complications in robotic surgery
271
Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
272
pressure (five of eight studies), while corneal abrasion, ischaemic optic neuropathy and postoperative visual loss were present in two, one and one study, respectively. The inclination of Trendelenburg position was in the range 23–45°. The duration of the operations was in the range 1.75–9.9 h. Mean intraocular pressure varied in the range 3.6–13.3 mmHg. Estimated blood loss was in the range 29.7–1.200 ml. Only one of eight studies reported the necessity of blood transfusion; administered intravenous fluids were in the range 1.600–4.300 ml. The duration of the hospital stay after the operation was reported in one study (3 days).
Discussion The first two studies of ocular complications were presented in 2007 (12,13). Weber et al. (13) described the first and only case of ischaemic optic neuropathy after robot-assisted laparoscopic prostatectomy, in which, after a 3 month period, the patient presented a stable loss of bilateral inferior fields. Nevertheless, the main ocular complications include increased intra-ocular pressure and corneal abrasions. The pathophysiology behind the appearance of ocular complications during robotic surgery is quite complex. For the realization of robot-assisted operations, especially at the lesser pelvis, the steep Trendelenburg position (23–45°) is fundamental; the abdominal viscera are removed from the pelvic cavity and, with the assistance of gravity, a free operating field is created (10). The Trendelenburg position, as it does not represent a physiological condition for the human body, can result in a number of haemodynamic effects. Decrease of cardiac output, increase of central venous pressure and increase of the blood flow in the direction of the head are the main consequences of such a position, leading to an increase in intra-ocular pressure. In addition, the increased intra-ocular pressure and the prolonged placement in Trendelenburg position may be associated with an increased risk of developing glaucoma, particularly in patients predisposed to elevated intra-ocular pressure prior to the operation (20). Ophthalmology consultations could be recommended prior to robot-assisted operations that include a steep Trendelenburg position. These may include an optical coherence tomography that uses near-infrared light in order to visualize retinal thickness. This type of tomography could evaluate the glaucomatous damage, as reflected by death and thinning of the retina (21). Ganglion cell complex and retinal nerve fibre layer thicknesses are of particular importance in such an evaluation (19). Moreover, other studies have shown that transient elevation of intra-ocular pressure in adult eyes is a triggering glaucoma factor that results in increases in disc area and linear disc dimensions (LASIK Copyright © 2014 John Wiley & Sons, Ltd.
I. D. Gkegkes et al.
patients) (14). Furthermore, robot-assisted surgery at the neck may also result in increased intra-ocular pressure. In the case of robot-assisted endoscopic thyroidectomy, surgical manipulations of the great vessels of the neck (such as the jugular veins during the CO2 insufflation of the neck) can raise jugular venous pressure and further elevate intra-ocular pressure (11). Concerning the rare case of ischaemic optic neuropathy, it seems that this is a result of a steep Trendelenburg position in combination with excessive blood loss. Optic nerve damage is most likely the result of two different pathophysiological mechanisms, either due to decreased blood supply (ischaemia) from the arteries of the optic nerve, or due to venous stasis as consequence of reduced venous outflow (15). Ischaemic neuropathy, although rare, is a detrimental complication. To date, there are no literature data regarding the prevention of ischaemic neuropathy during robotic surgery. Another ophthalmologic complication that could occur during robotic surgery is ocular injury. The most common complications related to anaesthesia are corneal abrasions, which can be the result of the use of either eye or plastic tape exposure or oxygen toxicity, keratopathy and conjunctival oedema as a consequence of erroneous eye touching and due to increased administration of intravenous fluids (15). In the studies included in our review, it has been showed that ocular pressure is increased in a timedependent fashion in anaesthetized patients, especially when we examine the correlation with surgical and/or compromised patient positioning time. There is no supportive evidence that the ’rest stop’ can be beneficial as a preventative measure of ocular complications, and especially in cases of prolonged operations with severe blood loss. However, a rest stop will increase the operation time, as it involves undocking and redocking of the robot and repositioning of the patient. One could argue that elderly and/or obese patients could face more ocular complications when they are undergoing robotic procedures; however, such a conclusion could not be safely drawn from our review. A recent clinical trial showed that intra-ocular pressure increases after pneumoperitoneum and the steep Trendelenburg position, and that such an increase is less with propofol than with sevoflurane anaesthesia (16). However, again, such a correlation was not found in our review of the literature because of lack of such information. Elevated intra-ocular pressure and ischaemic damage to the optic nerve could possibly be prevented by the introduction of ’rest stops’ (intervals of reverse Trendelenburg positioning) during robotic surgery operations (9,17). The use of eye-occlusive dressings, ocular ointments, eye pads and protective goggles could avoid eye touching and keratopathy. Also, restriction of the intravenous fluids administered during steep Trendelenburg position could be considered another eye-protective Int J Med Robotics Comput Assist Surg 2015; 11: 269–274. DOI: 10.1002/rcs
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measure (18). However, when the presence of conjunctival or facial oedema is observed at the end of an operation, anaesthetists and surgeons should always be alert to synchronous presence of laryngeal oedema. For the prevention of such complications, restriction of intravenous fluids and optimization of the operative time are also considered essential (Table 2). In the literature, the application of temporary suturing of the eyelids (tarsorrhaphy) is another technique described in order to prevent mechanical injuries to the cornea (18). There is no evidence that tarsorrhaphy increases the IOP pressure. However, the trauma inflicted to the eyelids and the limited protection of the ocular surface make tarsorrhaphy a less-recommended and oldfashioned technique. For the reasons given above, some studies suggest preoperative assessment as well as intraoperative and postoperative management of such complications as part of a multidisciplinary approach (surgeon, anaesthesiologist, ophthalmologist), especially for patients with a history of either glaucoma or ocular hypertension and the presence of past ischaemic events (8,12). A number of limitations and weaknesses should be considered in the reading of the results of this review. First and foremost, the limited number of the studies and patients included make it difficult to arrive at safe conclusions. Moreover, a possible predictive factor, BMI, which increases the IOP secondary to increasing the intrathoracic pressure, was only recorded in two of the seven studies; similarly, another risk factor, the total volume of intravenous fluids administered, was only mentioned in two of the seven studies. Moreover, the rather novel robotic technique may increase complication rates due to learning curve issues for both surgeons and anaesthetists. Furthermore, it should be mentioned that the medicolegal system in some countries, e.g. the USA (where 75% of the robotic cases are done globally), may not record ocular complications systematically (19). Another limitation is the lack of high-powered, prospective randomized studies. Although we have reviewed the incidence of ocular complications in different types of robotic operation, one could argue that we should have compared our findings with the incidence of ocular complications during the same operations done laparoscopically in the Trendelenburg position. Table 2. Possible protective measures against ocular complications during robotic assisted operations Increased IOP Pre-operative assessment in patients with glaucoma or ocular hypertension Restriction of intravenous fluids Rest stops
IOP, intraocular pressure. Copyright © 2014 John Wiley & Sons, Ltd.
Corneal abrasions Eyelid taping Ocular ointments Protective goggles Bio-occlusive dressings Tarsorrhaphy (less recommended)
However, we argue against such a comparison, as the degree of the Trendelenburg position is different between the two approaches. Further studies need to be conducted in order to compare the standard laparoscopic technique with the robotic one for the same surgery for the outcome of ocular complications. Another question that should be answered is whether there is any practicality of applying ’rest stops’ in the case of tight operative time scenarios. Regarding the search strategy adopted, which was defined earlier, it could be considered restricted as a consequence of the exclusion of review articles, conference papers, letters to the editor, short surveys and commentaries. Last but not least, the restriction as far as the languages of the excluded articles could be thought as another weakness of the present study.
Conclusion With the continuous increase in the frequency of robotassisted operations that are performed, ocular complications may also be increasing. More clinical data on risk factors associated with ocular damage, and more well-designed studies, are needed to clarify the negative role of robotic surgery in this type of complication. Therefore, knowledge of the probable complications and the relative protective measures by both anaesthetists and surgeons is imposed for the peri-operative management of these patients. Collaboration between the surgical team and the anaesthetist is essential for a successful outcome.
Conflict of interest The authors have stated explicitly that there are no conflicts of interest in connection with this article.
Funding No specific funding.
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