Intravenous or inhalational anaesthesia for abdominal surgery assisted by a computerized surgical robot

This review assessed anaesthesia provided for computerized robotic assisted surgery in the abdomen via the veins or by breathing into the lungs (inhalation).

Review question

What are the advantages and disadvantages of using anaesthesia delivered via the veins compared with anaesthesia delivered by the lungs for robotic assisted abdominal surgery with a focus on managing pain, nausea and vomiting, adverse effects and associated costs?

Background

Computerized robotic assisted surgery in the abdomen is associated with reduced bleeding and less surgical trauma because incisions are small. With rapidly increasing use of computerized robotic assisted surgery has come the need to re-evaluate the two main types of anaesthesia administration. Robotic surgery demands different positioning of the patient during the procedure and introduction of carbon dioxide gas into the abdominal cavity to create a better overview. These factors may affect the functioning heart and lungs and may alter pressure in the brain and in the eyes, with accompanying risk of adverse effects.

Study characteristics

The evidence is current to May 2016 and was provided by three small randomized controlled trials involving 170 males who had their prostate removed. These studies took place in hospitals in Korea and Turkey. We looked for differences in pain and postoperative nausea and vomiting (PONV) and changes in pressure inside the eyes between patients receiving anaesthetic via the veins or by inhalation.

Study funding sources

Studies were funded by the institution, or the funding sources were not stated.

Key results

Postoperative pain was no different between the two types of anaesthesia. Anaesthesia delivered through the veins reduced PONV at one to six hours after prostate surgery compared with anaesthesia provided via inhalation. One study showed that anaesthesia delivered through the veins prevented an increase in pressure inside the eyes during surgery compared with inhalational anaesthesia. We cannot conclude whether this means that anaesthesia provided via the veins reduces ocular complications, as no patients in this small study developed these complications.

Quality of the evidence

The quality of the evidence was considered low, as included studies were small and provided an unclear description of methods. All participants in these studies were men who were undergoing robotic assisted laparoscopic removal of the prostate. An ongoing trial includes men and women undergoing abdominal robotic surgery, also with a focus on the quality of recovery. Additional studies are needed.

Authors' conclusions: 

It is unclear which anaesthetic technique is superior - TIVA or inhalational - for transabdominal robotic assisted surgery in urology, gynaecology and gastroenterology, as existing evidence is scarce, is of low quality and has been generated from exclusively male patients undergoing robotic radical prostatectomy.

An ongoing trial, which includes participants of both genders with a focus on quality of recovery, might have an impact on future evidence related to this topic.

Read the full abstract...
Background: 

Rapid implementation of robotic transabdominal surgery has resulted in the need for re-evaluation of the most suitable form of anaesthesia. The overall objective of anaesthesia is to minimize perioperative risk and discomfort for patients both during and after surgery. Anaesthesia for patients undergoing robotic assisted surgery is different from anaesthesia for patients undergoing open or laparoscopic surgery; new anaesthetic concerns accompany robotic assisted surgery.

Objectives: 

To assess outcomes related to the choice of total intravenous anaesthesia (TIVA) or inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016 Issue 5), Ovid MEDLINE (1946 to May 2016), Embase via OvidSP (1982 to May 2016), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) via EBSCOhost (1982 to May 2016) and the Institute for Scientific Information (ISI) Web of Science (1956 to May 2016). We also searched the International Standard Randomized Controlled Trial Number (ISRCTN) Registry and Clinical trials gov for ongoing trials (May 2016).

Selection criteria: 

We searched for randomized controlled trials (RCTs) including adults, aged 18 years and older, of both genders, treated with transabdominal robotic assisted laparoscopic gynaecological, urological or gastroenterological surgery and focusing on outcomes of TIVA or inhalational anaesthesia.

Data collection and analysis: 

We used standard methodological procedures of Cochrane. Study findings were not suitable for meta-analysis.

Main results: 

We included three single-centre, two-arm RCTs involving 170 participants. We found one ongoing trial. All included participants were male and were undergoing radical robotic assisted laparoscopic radical prostatectomy (RALRP). The men were between 50 and 75 years of age and met criteria for American Society of Anesthesiologists physical classification scores (ASA) I, ll and III.

We found evidence showing no clinically meaningful differences in postoperative pain between the two types of anaesthetics (mean difference (MD) in visual analogue scale (VAS) scores at one to six hours was -2.20 (95% confidence interval (CI) -10.62 to 6.22; P = 0.61) in a sample of 62 participants from one study. Low-quality evidence suggests that propofol reduces postoperative nausea and vomiting (PONV) over the short term (one to six hours after surgery) after RALRP compared with inhalational anaesthesia (sevoflurane, desflurane) (MD -1.70, 95% CI -2.59 to -0.81; P = 0.0002).

We found low-quality evidence suggesting that propofol may prevent an increase in intraocular pressure (IOP) after pneumoperitoneum and steep Trendelenburg positioning compared with sevoflurane (MD -3.90, 95% CI -6.34 to -1.46; P = 0.002) with increased IOP from baseline to 30 minutes in steep Trendelenburg. However, it is unclear whether this surrogate outcome translates directly to clinical avoidance of ocular complications during surgery. No studies addressed the secondary outcomes of adverse effects, all-cause mortality, respiratory or circulatory complications, cognitive dysfunction, length of stay or costs. Overall the quality of evidence was low to very low, as all studies were small, single-centre trials providing unclear descriptions of methods.

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