Anesthetic Management for Robotic Bariatric Surgery

  • Veronica Neves Fialho Queiroz
  • Rafael Takamitsu Romero
  • Flavio Takaoka


Perioperative care of obese patients presents special challenges to anesthesiologists, mainly due to these patients’ comorbid conditions, such as diabetes, cardiovascular disease, obstructive sleep apnea (OSA), musculoskeletal disorders, and some forms of neoplasia. Bariatric surgery is the only evidence-based, durable treatment for this disease (Colquitt et al., Cochrane Database Syst Rev (2):CD003641, 2009).

Robotic surgery has recently gained relevance in the field of bariatric surgery. Robotic bariatric surgery (RBS), compared with traditional laparoscopy, has similar or lower complication rates, provides superior imaging and freedom of movement, and results in reduced hospital length of stay, decreased postoperative pain and enhanced postoperative recovery (Fourman and Saber, Surg Obes Relat Dis 8(4):483–8, 2012; Bindal et al., J Minim Access Surg 11(1):16–21, 2015) with lower incidence of wound infections (Acquafresca et al., Ann Surg Innov Res 9:9, 2015).

The physiology and anatomy of bariatric patients demand a tailored approach from both the anesthesiologist and the perioperative team. The interaction of a multi-disciplinary team is key to achieving good outcomes and a low rate of complications (Lindauer et al., BMC Anesthesiol 14:125, 2014).


Anesthesia Morbid obesity 


  1. 1.
    Lindauer B, Steurer MP, Müller MK, Dullenkopf A. Anesthetic management of patients undergoing bariatric surgery: two year experience in a single institution in Switzerland. BMC Anesthesiol. 2014;14:125.CrossRefGoogle Scholar
  2. 2.
    Reisin E, Frohlich ED. Cardiovascular and respiratory pathophysiological alterations. Arch Intern Med. 1981;141(4):431–4. Scholar
  3. 3.
    D’Ávila melo SM, Melo VA, Menezes filho RS, Santos FA. Effects of progressive increase in body weight on lung function in six groups of body mass index. Rev Assoc Med Bras (1992). 2011;57(5):509–15.CrossRefGoogle Scholar
  4. 4.
    Sinha AC, Singh PM. Controversies in perioperative anesthetic management of the morbidly obese: I am a surgeon, why should I care? Obes Surg. 2015;25(5):879–87.CrossRefGoogle Scholar
  5. 5.
    Magnani JW, Hylek EM, Apovian CM. Obesity begets atrial fibrillation: a contemporary summary. Circulation. 2013;128(4):401–5.CrossRefGoogle Scholar
  6. 6.
    Rasmussen JJ, Fuller WD, Ali MR. Sleep apnea syndrome is significantly underdiagnosed in bariatric surgical patients. Surg Obes Relat Dis. 2012;8(5):569–73. Scholar
  7. 7.
    Opperer M, Cozowicz C, Bugada D, Mokhlesi B, Kaw R, Auckley D, et al. Does obstructive sleep apnea influence perioperative outcome? A qualitative systematic review for the society of anesthesia and sleep medicine task force on preoperative preparation of patients with sleep-disordered breathing. Anesth Analg. 2016;122:1321–34. Scholar
  8. 8.
    Hai F, Porhomayon J, Vermont L, Frydrych L, Jaoude P, El-Solh AA. Postoperative complications in patients with obstructive sleep apnea: a meta-analysis. J Clin Anesth. 2014;26:591–600. Scholar
  9. 9.
    Kaw R, Chung F, Pasupuleti V, Mehta J, Gay PC, Hernandez AV. Meta-analysis of the association between obstructive sleep apnea and postoperative outcome. Br J Anaesth. 2012;109:897–906. Scholar
  10. 10.
    Gaddam S, Gunukula SK, Mador MJ. Post-operative outcomes in adult obstructive sleep apnea patients undergoing non-upper airway surgery: a systematic review and meta-analysis. Sleep Breath. 2014;18:615–33. Scholar
  11. 11.
    Kaw R, Bhateja P, Paz Y, Mar H, Hernandez AV, Ramaswamy A, et al. Postoperative complications in patients with unrecognized obesity hypoventilation syndrome undergoing elective noncardiac surgery. Chest. 2016;149:84–91. Scholar
  12. 12.
    Chung F, Chau E, Yang Y, Liao P, Hall R, Mokhlesi B. Serum bicarbonate level improves specificity of STOP-bang screening for obstructive sleep apnea. Chest. 2013;143:1284–93. Scholar
  13. 13.
    de Divitiis O, Fazio S, Petitto M, Maddalena G, Contaldo F, Mancini M. Obesity and cardiac function. Circulation. 1981;64(3):477–82. Scholar
  14. 14.
    Kenchaiah S, Evans JC, Levy D, et al. Obesity and the risk of heart failure. N Engl J Med. 2002;347(5):305–13.CrossRefGoogle Scholar
  15. 15.
    Lukosiute A, Karmali A, Cousins JM. Anaesthetic preparation of obese patients: current status on optimal work-up. Curr Obes Rep. 2017;6(3):229–37.CrossRefGoogle Scholar
  16. 16.
    Purnell JQ, Selzer F, Smith MD, et al. Metabolic syndrome prevalence and associations in a bariatric surgery cohort from the Longitudinal Assessment of Bariatric Surgery-2 study. Metab Syndr Relat Disord. 2014;12(2):86–94.CrossRefGoogle Scholar
  17. 17.
    Mechanick JI, Youdim A, Jones DB, Timothy Garvey W, Hurley DL, Molly McMahon M, Heinberg LJ, et al. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2013;9(2):159–91. Scholar
  18. 18.
    Xie X, Pan L, Ren D, Du C, Guo Y. Effects of continuous positive airway pressure therapy on systemic inflammation in obstructive sleep apnea: a meta-analysis. Sleep Med. 2013;14:1139–50. Scholar
  19. 19.
    Jayaraman L, Sinha A, Punhani D. A comparative study to evaluate the effect of intranasal dexmedetomidine versus oral alprazolam as a premedication agent in morbidly obese patients undergoing bariatric surgery. J Anaesthesiol Clin Pharmacol. 2013;29:179–82.CrossRefGoogle Scholar
  20. 20.
    Ivry M, Goitein D, Welly W, Berkenstadt H. Melatonin premedication improves quality of recovery following bariatric surgery – a double blind placebo controlled prospective study. Surg Obes Relat Dis. 2017;13(3):502–6.CrossRefGoogle Scholar
  21. 21.
    Baltayian S. A brief review: anesthesia for robotic prostatectomy. J Robot Surg. 2008;2:59–66.CrossRefGoogle Scholar
  22. 22.
    Lemmens HJ. Perioperative pharmacology in morbid obesity. Curr Opin Anaesthesiol. 2010;23(4):485–91.CrossRefGoogle Scholar
  23. 23.
    Kristensen MS. Airway management and morbid obesity. Eur J Anaesthesiol. 2010;27:923–7. Scholar
  24. 24.
    Wadhwa A, Singh PM, Sinha AC. Airway management in patients with morbid obesity. Int Anesthesiol Clin. 2013;51(3):26–40.CrossRefGoogle Scholar
  25. 25.
    Pouwels S, Smeenk FW, Manschot L, Lascaris B, Nienhuijs S, Bouwman RA, Buise MP. Perioperative respiratory care in obese patients undergoing bariatric surgery: implications for clinical practice. Respir Med. 2016;117:73–80.CrossRefGoogle Scholar
  26. 26.
    Pelosi P, Gregoretti C. Perioperative management of obese patients. Best Prac Res Clin Anaesthesiol. 2010;24:211–25.CrossRefGoogle Scholar
  27. 27.
    Herling SF, Dreijer B, Wrist Lam G, Thomsen T, Møller AM. Total intravenous anaesthesia versus inhalational anaesthesia for adults undergoing transabdominal robotic assisted laparoscopic surgery. Cochrane Database Syst Rev. 2017; (4). Art. no.: CD011387.
  28. 28.
    McLarney JT, Rose GL. Anesthetic implications of robotic gynecologic surgery. J Gynecol Endosc Surg. 2011;2(2):75–8. Scholar
  29. 29.
    Baete S, Vercruysse G, Vander Laenen M, et al. The effect of deep versus moderate neuromuscular block on surgical conditions and postoperative respiratory function in bariatric laparoscopic surgery: a randomized, double blind clinical trial. Anesth Analg. 2017;124(5):1469–75.CrossRefGoogle Scholar
  30. 30.
    Jain AK, Dutta A. Stroke volume variation as a guide to fluid administration in morbidly obese patients undergoing laparoscopic bariatric surgery. Obes Surg. 2010;20(6):709–15.CrossRefGoogle Scholar
  31. 31.
    Pösö T, Winsö O, Aroch R, Kesek D. Perioperative fluid guidance with transthoracic echocardiography and pulse-contour device in morbidly obese patients. Obes Surg. 2014;24(12):2117–25.CrossRefGoogle Scholar
  32. 32.
    Charghi R, Backman S, Christou N, Rouah F, Schricker T. Patient controlled i.v. Analgesia is an acceptable pain management strategy in morbidly obese patients undergoing gastric bypass surgery. A retrospective comparison with epidural analgesia. Can J Anaesth. 2003;50(7):672–8.CrossRefGoogle Scholar
  33. 33.
    Feld JM, Laurito CE, Beckerman M, Vincent J, Hoffman WE. Non-opioid analgesia improves pain relief and decreases sedation after gastric bypass surgery. Can J Anaesth. 2003;50(4):336–41.CrossRefGoogle Scholar
  34. 34.
    Ortiz VE, Vidal-melo MF, Walsh JL. Strategies for managing oxygenation in obese patients undergoing laparoscopic surgery. Surg Obes Relat Dis. 2015;11(3):721–8.CrossRefGoogle Scholar
  35. 35.
    Fernandez-bustamante A, Hashimoto S, Serpa neto A, Moine P, Vidal melo MF, Repine JE. Perioperative lung protective ventilation in obese patients. BMC Anesthesiol. 2015;15:56.CrossRefGoogle Scholar
  36. 36.
    Stankiewicz-rudnicki M, Gaszynski W, Gaszynski T. Assessment of ventilation distribution during laparoscopic bariatric surgery: an electrical impedance tomography study. Biomed Res Int. 2016;2016:7423162.CrossRefGoogle Scholar
  37. 37.
    Aldenkortt M, Lysakowski C, Elia N, Brochard L, Tramèr MR. Ventilation strategies in obese patients undergoing surgery: a quantitative systematic review and meta-analysis. Br J Anaesth. 2012;109(4):493–502.CrossRefGoogle Scholar
  38. 38.
    Perilli V, Sollazzi L, Bozza P, et al. The effects of the reverse trendelenburg position on respiratory mechanics and blood gases in morbidly obese patients during bariatric surgery. Anesth Analg. 2000;91(6):1520–5.CrossRefGoogle Scholar
  39. 39.
    Castro DS, Leão P, Borges S, Gomes L, Pacheco M, Figueiredo P. Sugammadex reduces postoperative pain after laparoscopic bariatric surgery: a randomized trial. Surg Laparosc Endosc Percutan Tech. 2014;24(5):420–3.CrossRefGoogle Scholar
  40. 40.
    Ahmad S, Nagle A, Mccarthy RJ, Fitzgerald PC, Sullivan JT, Prystowsky J. Postoperative hypoxemia in morbidly obese patients with and without obstructive sleep apnea undergoing laparoscopic bariatric surgery. Anesth Analg. 2008;107(1):138–43.CrossRefGoogle Scholar
  41. 41.
    Colquitt JL, Picot J, Loveman E, Clegg AJ. Surgery for obesity. Cochrane Database Syst Rev. 2009;(2):CD003641. Review. Update in: Cochrane Database Syst Rev. 2014;8:CD003641. PubMed [citation].
  42. 42.
    Fourman MM, Saber AA. Robotic bariatric surgery: a systematic review. Surg Obes Relat Dis. 2012;8(4):483–8.CrossRefGoogle Scholar
  43. 43.
    Bindal V, Bhatia P, Dudeja U, et al. Review of contemporary role of robotics in bariatric surgery. J Minim Access Surg. 2015;11(1):16–21.CrossRefGoogle Scholar
  44. 44.
    Acquafresca PA, Palermo M, Rogula T, Duza GE, Serra E. Most common robotic bariatric procedures: review and technical aspects. Ann Surg Innov Res. 2015;9:9.CrossRefGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  • Veronica Neves Fialho Queiroz
    • 1
    • 2
  • Rafael Takamitsu Romero
    • 1
  • Flavio Takaoka
    • 1
    • 2
  1. 1.Department of AnesthesiaHospital Israelita Albert EinsteinSão PauloBrazil
  2. 2.Hospital 9 de JulhoSão PauloBrazil

Personalised recommendations