Ronney Abaza, MD, on robotic surgery at ultralow pressures

In this video, Ronney Abaza, MD, FACS, discusses his experience doing robotic surgery at ultralow pressures. Abaza is a robotic urologic surgeon at Central Ohio Urology Group in Columbus, Ohio.

Video Transcript:

The last thing that I'll mention that I'm really excited about, and have been for several years now, is the concept of doing robotic surgery at ultralow pressures. So, rather than filling up the belly with gas and stretching these people's bellies out for an hour or 2 at 12 mm Hg or 15 mm Hg, for years now, I've been doing robotic surgery at the lowest pressure possible. For the vast majority of these surgeries, you don't need to have a pressure of 12 mm Hg, 15 mm Hg, or even 10 mm Hg. All of my pelvic surgery, whether it's prostate or bladder, I do all of these surgeries at a pneumo pressure routinely of 6 mm Hg. On the skinnier guys, we turn the pneumo down to 5 Hg. Most recently, and I think a lot of people are going to be shocked by this, might think I'm crazy, but most recently, we've even had skinny enough patients where we turn the pneumo device off, meaning that we're doing their prostatectomy at a pneumo pressure of 0 mm Hg.

Now some people will think that's crazy. They'll say, "Well, how can you do that?" Remember that the robotic arms are fixed in space, so when you turn off the pneumo it's not like the belly collapses; the belly wall will still be held up by those robotic instruments going through the belly wall. But instead of it being filled because of the gas, the arms are what are holding the belly wall up. On a skinny enough patient, we can do the entire operation with 0 gas pressure in that patient's abdomen. Now, some people are going to say, "Well, doesn't it bleed a lot like open surgery used to bleed?" Honestly, in my experience, I've not seen that. I've done these prostatectomies at a pneumo pressure of 0 mm Hg, and they don't seem to bleed like the original open surgery that we did where we used to have transfusions and whatever. It might blow some people's mind that you would do a prostatectomy at 0 mm Hg, but the benefit to the patient is that with no gas circulating through their abdomen, no gas going in and out, circulating the entire time, that's going to dry out their belly less, and again, they're not going to be stretched out at all. It's actually closest to physiologic pressure.

I like to remind my colleagues in surgery who are skeptical of using low pressure, I always ask them the question, I say, "What is the physiologic pressure in your belly right now?" It's 0 mm Hg. It's atmospheric pressure. There's no additional pressure inside your abdomen compared to the outside atmosphere, in the normal steady state that all of us are used to and living in. So, whenever we fill the belly with gas, even 5 or 6 mm Hg, that's an abnormal situation for that patient for 2 hours. Now we have turned the pressure down to the minimum that we can do the operation, and sometimes we can do it at 0 mm Hg, and that's again, closest to the normal physiologic pressure.

When we did the randomized study of pneumo 15 vs pneumo of 6 for prostatectomy—we published this in the Journal of Urology a couple years ago, so people can go back and read that—in that randomized trial, we have level 1 evidence showing that patients have less pain and faster return of bowel function when you work at low pressure.¹ So, I encourage my colleagues to try it if they haven't tried it. But again, the idea here is that I specialize in robotic surgery. I do so much of it that I like to try new things, figure out what things work, and then share that with my colleagues and encourage them to give it a try.

This transcript was AI generated and edited by human editors for clarity.

Reference

1. Abaza R, Ferroni MC. Randomized Trial of Ultralow vs Standard Pneumoperitoneum during Robotic Prostatectomy. J Urol. 2022;208(3):626-632. doi:10.1097/JU.0000000000002729