Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Anesthesia for laparoscopic and abdominal robotic surgery in adults

Girish P Joshi, MB, BS, MD, FFARCSI
Section Editor
Stephanie B Jones, MD
Deputy Editor
Marianna Crowley, MD


The laparoscopic approach has become a standard of care for many abdominal surgical procedures. Compared with laparotomy, laparoscopy can reduce postoperative pain, result in shorter recovery time, allow smaller incisions, and reduce the postoperative stress response. Laparoscopy requires insufflation of intraperitoneal or extraperitoneal gas, usually carbon dioxide (CO2), to create space for visualization and surgical maneuvers.

Robotic surgery is usually performed laparoscopically and is commonly used for gynecologic and urologic surgery.

Anesthetic concerns for patients undergoing laparoscopic and robotic surgery differ from those for patients undergoing open abdominal surgery. They include the physiologic effects of the pneumoperitoneum, absorption of CO2, and positioning required for surgery. In addition, some laparoscopic procedures take longer than the open alternative.

This topic will discuss the anesthetic management of patients having laparoscopic and robotic abdominal surgery. Advantages and disadvantages of laparoscopy and robotic surgery, technical aspects of these techniques, and surgical complications are discussed separately. (See "Robot-assisted laparoscopy" and "Complications of laparoscopic surgery" and "Instruments and devices used in laparoscopic surgery" and "Laparoscopic cholecystectomy".)


Laparoscopy requires creation of a pneumoperitoneum by insufflation of gas, usually carbon dioxide (CO2), to open space in the abdomen for visualization and allow surgical manipulation. CO2 insufflation can be performed blindly using a Veress needle or by placement of a port under direct vision through a small subumbilical incision. The gas source is connected to the needle or port; intraabdominal pressure (IAP) is monitored as gas is insufflated, aiming for a pressure ≤15 mmHg to minimize physiologic effects. For laparoscopic prostatectomy, which is performed in steep Trendelenburg position, the European Association for Endoscopic Surgery recommends IAP below 12 mmHg [1].

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Nov 06, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Neudecker J, Sauerland S, Neugebauer E, et al. The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 2002; 16:1121.
  2. Joshi GP, Cunningham AJ. Anesthesia for laparoscopic and robotic surgery. In: Clinical Anesthesia, 7th ed, Barash PG, Cullen BF, Steolting RK, et al. (Eds), Lippincott, Williams & Wilkins, Philadelphia 2013. p.1257.
  3. Meininger D, Westphal K, Bremerich DH, et al. Effects of posture and prolonged pneumoperitoneum on hemodynamic parameters during laparoscopy. World J Surg 2008; 32:1400.
  4. Kalmar AF, Foubert L, Hendrickx JF, et al. Influence of steep Trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy. Br J Anaesth 2010; 104:433.
  5. Lestar M, Gunnarsson L, Lagerstrand L, et al. Hemodynamic perturbations during robot-assisted laparoscopic radical prostatectomy in 45° Trendelenburg position. Anesth Analg 2011; 113:1069.
  6. Hein HA, Joshi GP, Ramsay MA, et al. Hemodynamic changes during laparoscopic cholecystectomy in patients with severe cardiac disease. J Clin Anesth 1997; 9:261.
  7. Harris SN, Ballantyne GH, Luther MA, Perrino AC Jr. Alterations of cardiovascular performance during laparoscopic colectomy: a combined hemodynamic and echocardiographic analysis. Anesth Analg 1996; 83:482.
  8. Kraut EJ, Anderson JT, Safwat A, et al. Impairment of cardiac performance by laparoscopy in patients receiving positive end-expiratory pressure. Arch Surg 1999; 134:76.
  9. Safran D, Sgambati S, Orlando R 3rd. Laparoscopy in high-risk cardiac patients. Surg Gynecol Obstet 1993; 176:548.
  10. McLaughlin JG, Scheeres DE, Dean RJ, Bonnell BW. The adverse hemodynamic effects of laparoscopic cholecystectomy. Surg Endosc 1995; 9:121.
  11. O'Malley C, Cunningham AJ. Physiologic changes during laparoscopy. Anesthesiol Clin North America 2001; 19:1.
  12. Gutt CN, Oniu T, Mehrabi A, et al. Circulatory and respiratory complications of carbon dioxide insufflation. Dig Surg 2004; 21:95.
  13. Myre K, Rostrup M, Buanes T, Stokland O. Plasma catecholamines and haemodynamic changes during pneumoperitoneum. Acta Anaesthesiol Scand 1998; 42:343.
  14. Joris JL, Noirot DP, Legrand MJ, et al. Hemodynamic changes during laparoscopic cholecystectomy. Anesth Analg 1993; 76:1067.
  15. Carmichael DE. Laparoscopy-cardiac considerations. Fertil Steril 1971; 22:69.
  16. Zuckerman RS, Heneghan S. The duration of hemodynamic depression during laparoscopic cholecystectomy. Surg Endosc 2002; 16:1233.
  17. Hirvonen EA, Poikolainen EO, Pääkkönen ME, Nuutinen LS. The adverse hemodynamic effects of anesthesia, head-up tilt, and carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy. Surg Endosc 2000; 14:272.
  18. Nguyen NT, Wolfe BM. The physiologic effects of pneumoperitoneum in the morbidly obese. Ann Surg 2005; 241:219.
  19. Meininger D, Zwissler B, Byhahn C, et al. Impact of overweight and pneumoperitoneum on hemodynamics and oxygenation during prolonged laparoscopic surgery. World J Surg 2006; 30:520.
  20. Giebler RM, Kabatnik M, Stegen BH, et al. Retroperitoneal and intraperitoneal CO2 insufflation have markedly different cardiovascular effects. J Surg Res 1997; 68:153.
  21. Kadam PG, Marda M, Shah VR. Carbon dioxide absorption during laparoscopic donor nephrectomy: a comparison between retroperitoneal and transperitoneal approaches. Transplant Proc 2008; 40:1119.
  22. Ng CS, Gill IS, Sung GT, et al. Retroperitoneoscopic surgery is not associated with increased carbon dioxide absorption. J Urol 1999; 162:1268.
  23. Wolf JS Jr, Monk TG, McDougall EM, et al. The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery. J Urol 1995; 154:959.
  24. Mullett CE, Viale JP, Sagnard PE, et al. Pulmonary CO2 elimination during surgical procedures using intra- or extraperitoneal CO2 insufflation. Anesth Analg 1993; 76:622.
  25. Schrijvers D, Mottrie A, Traen K, et al. Pulmonary gas exchange is well preserved during robot assisted surgery in steep Trendelenburg position. Acta Anaesthesiol Belg 2009; 60:229.
  26. Rajan GR, Foroughi V. Mainstem bronchial obstruction during laparoscopic fundoplication. Anesth Analg 1999; 89:252.
  27. Chang CH, Lee HK, Nam SH. The displacement of the tracheal tube during robot-assisted radical prostatectomy. Eur J Anaesthesiol 2010; 27:478.
  28. Wu CY, Yeh YC, Wang MC, et al. Changes in endotracheal tube cuff pressure during laparoscopic surgery in head-up or head-down position. BMC Anesthesiol 2014; 14:75.
  29. Hatipoglu S, Akbulut S, Hatipoglu F, Abdullayev R. Effect of laparoscopic abdominal surgery on splanchnic circulation: historical developments. World J Gastroenterol 2014; 20:18165.
  30. Kawanaka H, Akahoshi T, Kinjo N, et al. Laparoscopic Splenectomy with Technical Standardization and Selection Criteria for Standard or Hand-Assisted Approach in 390 Patients with Liver Cirrhosis and Portal Hypertension. J Am Coll Surg 2015; 221:354.
  31. Nguyen NT, Perez RV, Fleming N, et al. Effect of prolonged pneumoperitoneum on intraoperative urine output during laparoscopic gastric bypass. J Am Coll Surg 2002; 195:476.
  32. Chiu AW, Chang LS, Birkett DH, Babayan RK. The impact of pneumoperitoneum, pneumoretroperitoneum, and gasless laparoscopy on the systemic and renal hemodynamics. J Am Coll Surg 1995; 181:397.
  33. Schäfer M, Krähenbühl L. Effect of laparoscopy on intra-abdominal blood flow. Surgery 2001; 129:385.
  34. Halverson A, Buchanan R, Jacobs L, et al. Evaluation of mechanism of increased intracranial pressure with insufflation. Surg Endosc 1998; 12:266.
  35. Closhen D, Treiber AH, Berres M, et al. Robotic assisted prostatic surgery in the Trendelenburg position does not impair cerebral oxygenation measured using two different monitors: A clinical observational study. Eur J Anaesthesiol 2014; 31:104.
  36. 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.
  37. Grosso A, Scozzari G, Bert F, et al. Intraocular pressure variation during colorectal laparoscopic surgery: standard pneumoperitoneum leads to reversible elevation in intraocular pressure. Surg Endosc 2013; 27:3370.
  38. 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.
  39. Das W, Bhattacharya S, Ghosh S, et al. Comparison between general anesthesia and spinal anesthesia in attenuation of stress response in laparoscopic cholecystectomy: A randomized prospective trial. Saudi J Anaesth 2015; 9:184.
  40. Sinha R, Gurwara AK, Gupta SC. Laparoscopic cholecystectomy under spinal anesthesia: a study of 3492 patients. J Laparoendosc Adv Surg Tech A 2009; 19:323.
  41. Bessa SS, Katri KM, Abdel-Salam WN, et al. Spinal versus general anesthesia for day-case laparoscopic cholecystectomy: a prospective randomized study. J Laparoendosc Adv Surg Tech A 2012; 22:550.
  42. Agrawal M, Verma AP, Kang LS. Thoracic epidural anesthesia for laparoscopic cholecystectomy using either bupivacaine or a mixture of bupivacaine and clonidine: A comparative clinical study. Anesth Essays Res 2013; 7:44.
  43. Lim Y, Goel S, Brimacombe JR. The ProSeal laryngeal mask airway is an effective alternative to laryngoscope-guided tracheal intubation for gynaecological laparoscopy. Anaesth Intensive Care 2007; 35:52.
  44. Mukadder S, Zekine B, Erdogan KG, et al. Comparison of the proseal, supreme, and i-gel SAD in gynecological laparoscopic surgeries. ScientificWorldJournal 2015; 2015:634320.
  45. Viira D, Myles PS. The use of the laryngeal mask in gynaecological laparoscopy. Anaesth Intensive Care 2004; 32:560.
  46. Saraswat N, Kumar A, Mishra A, et al. The comparison of Proseal laryngeal mask airway and endotracheal tube in patients undergoing laparoscopic surgeries under general anaesthesia. Indian J Anaesth 2011; 55:129.
  47. Taylor E, Feinstein R, White PF, Soper N. Anesthesia for laparoscopic cholecystectomy. Is nitrous oxide contraindicated? Anesthesiology 1992; 76:541.
  48. Muir JJ, Warner MA, Offord KP, et al. Role of nitrous oxide and other factors in postoperative nausea and vomiting: a randomized and blinded prospective study. Anesthesiology 1987; 66:513.
  49. Lonie DS, Harper NJ. Nitrous oxide anaesthesia and vomiting. The effect of nitrous oxide anaesthesia on the incidence of vomiting following gynaecological laparoscopy. Anaesthesia 1986; 41:703.
  50. Fernández-Guisasola J, Gómez-Arnau JI, Cabrera Y, del Valle SG. Association between nitrous oxide and the incidence of postoperative nausea and vomiting in adults: a systematic review and meta-analysis. Anaesthesia 2010; 65:379.
  52. Brodsky JB, Lemmens HJ, Collins JS, et al. Nitrous oxide and laparoscopic bariatric surgery. Obes Surg 2005; 15:494.
  53. Akca O, Lenhardt R, Fleischmann E, et al. Nitrous oxide increases the incidence of bowel distension in patients undergoing elective colon resection. Acta Anaesthesiol Scand 2004; 48:894.
  54. Kopman AF, Naguib M. Laparoscopic surgery and muscle relaxants: is deep block helpful? Anesth Analg 2015; 120:51.
  55. Martini CH, Boon M, Bevers RF, et al. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth 2014; 112:498.
  56. Dubois PE, Putz L, Jamart J, et al. Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: a randomised controlled trial. Eur J Anaesthesiol 2014; 31:430.
  57. Staehr-Rye AK, Rasmussen LS, Rosenberg J, et al. Surgical space conditions during low-pressure laparoscopic cholecystectomy with deep versus moderate neuromuscular blockade: a randomized clinical study. Anesth Analg 2014; 119:1084.
  58. Chassard D, Berrada K, Tournadre J, Boulétreau P. The effects of neuromuscular block on peak airway pressure and abdominal elastance during pneumoperitoneum. Anesth Analg 1996; 82:525.
  59. Gertler R, Joshi GP. Modern understanding of intraoperative mechanical ventilation in normal and diseased lungs. Adv Anesth 2010; 28:15.
  60. Güldner A, Kiss T, Serpa Neto A, et al. Intraoperative protective mechanical ventilation for prevention of postoperative pulmonary complications: a comprehensive review of the role of tidal volume, positive end-expiratory pressure, and lung recruitment maneuvers. Anesthesiology 2015; 123:692.
  61. Serpa Neto A, Hemmes SN, Barbas CS, et al. Protective versus Conventional Ventilation for Surgery: A Systematic Review and Individual Patient Data Meta-analysis. Anesthesiology 2015; 123:66.
  62. Meininger D, Byhahn C, Mierdl S, et al. Positive end-expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum. Acta Anaesthesiol Scand 2005; 49:778.
  63. Choi EM, Na S, Choi SH, et al. Comparison of volume-controlled and pressure-controlled ventilation in steep Trendelenburg position for robot-assisted laparoscopic radical prostatectomy. J Clin Anesth 2011; 23:183.
  64. Joshi GP. The role of carbon dioxide in facilitating emergence from inhalation anesthesia: then & now. Anesth Analg 2012; 114:933.
  65. Hager H, Reddy D, Mandadi G, et al. Hypercapnia improves tissue oxygenation in morbidly obese surgical patients. Anesth Analg 2006; 103:677.
  66. Fleischmann E, Herbst F, Kugener A, et al. Mild hypercapnia increases subcutaneous and colonic oxygen tension in patients given 80% inspired oxygen during abdominal surgery. Anesthesiology 2006; 104:944.
  67. Kim MS, Kim NY, Lee KY, et al. The impact of two different inspiratory to expiratory ratios (1:1 and 1:2) on respiratory mechanics and oxygenation during volume-controlled ventilation in robot-assisted laparoscopic radical prostatectomy: a randomized controlled trial. Can J Anaesth 2015; 62:979.
  68. Joshi GP. Intraoperative fluid restriction improves outcome after major elective gastrointestinal surgery. Anesth Analg 2005; 101:601.
  69. Miller TE, Raghunathan K, Gan TJ. State-of-the-art fluid management in the operating room. Best Pract Res Clin Anaesthesiol 2014; 28:261.
  70. Apfel CC, Heidrich FM, Jukar-Rao S, et al. Evidence-based analysis of risk factors for postoperative nausea and vomiting. Br J Anaesth 2012; 109:742.
  71. Gan TJ, Diemunsch P, Habib AS, et al. Consensus guidelines for the management of postoperative nausea and vomiting. Anesth Analg 2014; 118:85.
  72. Diemunsch P, Joshi GP, Brichant JF. Neurokinin-1 receptor antagonists in the prevention of postoperative nausea and vomiting. Br J Anaesth 2009; 103:7.
  73. Woldu SL, Weinberg AC, Bergman A, et al. Pain and analgesic use after robot-assisted radical prostatectomy. J Endourol 2014; 28:544.
  74. Leitao MM Jr, Malhotra V, Briscoe G, et al. Postoperative pain medication requirements in patients undergoing computer-assisted (“Robotic”) and standard laparoscopic procedures for newly diagnosed endometrial cancer. Ann Surg Oncol 2013; 20:3561.
  75. Poulakis V, Skriapas K, de Vries R, et al. Quality of life after laparoscopic and open retroperitoneal lymph node dissection in clinical Stage I nonseminomatous germ cell tumor: a comparison study. Urology 2006; 68:154.
  76. Magheli A, Knoll N, Lein M, et al. Impact of fast-track postoperative care on intestinal function, pain, and length of hospital stay after laparoscopic radical prostatectomy. J Endourol 2011; 25:1143.
  77. Joshi GP, Schug SA, Kehlet H. Procedure-specific pain management and outcome strategies. Best Pract Res Clin Anaesthesiol 2014; 28:191.
  78. Maund E, McDaid C, Rice S, et al. Paracetamol and selective and non-selective non-steroidal anti-inflammatory drugs for the reduction in morphine-related side-effects after major surgery: a systematic review. Br J Anaesth 2011; 106:292.
  79. Ong CK, Seymour RA, Lirk P, Merry AF. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg 2010; 110:1170.
  80. Srinivasa S, Kahokehr AA, Yu TC, Hill AG. Preoperative glucocorticoid use in major abdominal surgery: systematic review and meta-analysis of randomized trials. Ann Surg 2011; 254:183.
  81. Waldron NH, Jones CA, Gan TJ, et al. Impact of perioperative dexamethasone on postoperative analgesia and side-effects: systematic review and meta-analysis. Br J Anaesth 2013; 110:191.
  82. ERAS Compliance Group. The Impact of Enhanced Recovery Protocol Compliance on Elective Colorectal Cancer Resection: Results From an International Registry. Ann Surg 2015; 261:1153.
  83. Joshi GP, Bonnet F, Kehlet H, PROSPECT collaboration. Evidence-based postoperative pain management after laparoscopic colorectal surgery. Colorectal Dis 2013; 15:146.
  84. Joshi GP. Complications of laparoscopy. Anesthesiol Clin North America 2001; 19:89.
  85. Coelho JC, Campos AC, Costa MA, et al. Complications of laparoscopic fundoplication in the elderly. Surg Laparosc Endosc Percutan Tech 2003; 13:6.
  86. Pareek G, Hedican SP, Gee JR, et al. Meta-analysis of the complications of laparoscopic renal surgery: comparison of procedures and techniques. J Urol 2006; 175:1208.
  87. Fischer B, Engel N, Fehr JL, John H. Complications of robotic assisted radical prostatectomy. World J Urol 2008; 26:595.
  88. Coelho RF, Palmer KJ, Rocco B, et al. Early complication rates in a single-surgeon series of 2500 robotic-assisted radical prostatectomies: report applying a standardized grading system. Eur Urol 2010; 57:945.
  89. Lasser MS, Renzulli J 2nd, Turini GA 3rd, et al. An unbiased prospective report of perioperative complications of robot-assisted laparoscopic radical prostatectomy. Urology 2010; 75:1083.
  90. Siu W, Seifman BD, Wolf JS Jr. Subcutaneous emphysema, pneumomediastinum and bilateral pneumothoraces after laparoscopic pyeloplasty. J Urol 2003; 170:1936.
  91. Stern JA, Nadler RB. Pneumothorax masked by subcutaneous emphysema after laparoscopic nephrectomy. J Endourol 2004; 18:457.
  92. Murdock CM, Wolff AJ, Van Geem T. Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol 2000; 95:704.
  93. Hall D, Goldstein A, Tynan E, Braunstein L. Profound hypercarbia late in the course of laparoscopic cholecystectomy: detection by continuous capnometry. Anesthesiology 1993; 79:173.
  94. Phillips S, Falk GL. Surgical tension pneumothorax during laparoscopic repair of massive hiatus hernia: a different situation requiring different management. Anaesth Intensive Care 2011; 39:1120.
  95. Hawasli A. Spontaneous resolution of massive laparoscopy-associated pneumothorax: the case of the bulging diaphragm and review of the literature. J Laparoendosc Adv Surg Tech A 2002; 12:77.
  96. Ueda K, Ahmed W, Ross AF. Intraoperative pneumothorax identified with transthoracic ultrasound. Anesthesiology 2011; 115:653.
  97. Joris JL, Chiche JD, Lamy ML. Pneumothorax during laparoscopic fundoplication: diagnosis and treatment with positive end-expiratory pressure. Anesth Analg 1995; 81:993.
  98. Venkatesh R, Kibel AS, Lee D, et al. Rapid resolution of carbon dioxide pneumothorax (capno-thorax) resulting from diaphragmatic injury during laparoscopic nephrectomy. J Urol 2002; 167:1387.
  99. Harkin CP, Sommerhaug EW, Mayer KL. An unexpected complication during laparoscopic herniorrhaphy. Anesth Analg 1999; 89:1576.
  100. Day CJ, Parker MR, Cloote AH. Pneumothorax during fundoplication. Can J Anaesth 1995; 42:556.
  101. Derouin M, Couture P, Boudreault D, et al. Detection of gas embolism by transesophageal echocardiography during laparoscopic cholecystectomy. Anesth Analg 1996; 82:119.
  102. Hong JY, Kim JY, Choi YD, et al. Incidence of venous gas embolism during robotic-assisted laparoscopic radical prostatectomy is lower than that during radical retropubic prostatectomy. Br J Anaesth 2010; 105:777.
  103. Hong JY, Kim WO, Kil HK. Detection of subclinical CO2 embolism by transesophageal echocardiography during laparoscopic radical prostatectomy. Urology 2010; 75:581.
  104. Kim CS, Kim JY, Kwon JY, et al. Venous air embolism during total laparoscopic hysterectomy: comparison to total abdominal hysterectomy. Anesthesiology 2009; 111:50.
  105. Magrina JF. Complications of laparoscopic surgery. Clin Obstet Gynecol 2002; 45:469.
  106. Mathews PV, Perry JJ, Murray PC. Compartment syndrome of the well leg as a result of the hemilithotomy position: a report of two cases and review of literature. J Orthop Trauma 2001; 15:580.
  107. Ikeya E, Taguchi J, Ohta K, et al. Compartment syndrome of bilateral lower extremities following laparoscopic surgery of rectal cancer in lithotomy position: report of a case. Surg Today 2006; 36:1122.
  108. American Society of Anesthesiologists Task Force on Prevention of Perioperative Peripheral Neuropathies. Practice advisory for the prevention of perioperative peripheral neuropathies: an updated report by the American Society of Anesthesiologists Task Force on prevention of perioperative peripheral neuropathies. Anesthesiology 2011; 114:741.