Comparison of Valve-less and Standard Insufflation on Pneumoperitoneum-Related Complications in Robotic Partial Nephrectomy: A Prospective Randomized Trial

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Data on the effects of valve-less insufflation (AirSeal) on the development of pneumoperitoneum-related complications, namely subcutaneous emphysema (SCE), are limited. We sought to compare the rates of SCE and other insufflation-related complications between AirSeal and standard insufflation systems as well as identify potential risk factors for development of SCE in patients undergoing robotic partial nephrectomy.


A prospective randomized controlled trial was conducted during a 1.5 year period to compare insufflation-related complications in partial nephrectomy surgery by a single surgeon. Thirty-one patients were recruited for each group: AirSeal insufflation at 12 mmHg, AirSeal at 15 mmHg, and standard insufflation at 15 mmHg. Primary outcome assessed was rate of SCE. Secondary outcomes included rates of pneumothorax, pneumomediastinum, shoulder pain scores, overall pain scores, pain medication usage, insufflation time, recovery room time, and length of hospital stay. Predictors for SCE were assessed with univariate and multivariate logistic models.


93 patients with similar baseline characteristics were randomized into the three insufflation groups. Incidence of subcutaneous emphysema was lower in the AirSeal 12mmHg group compared to standard (p=0.03). Shoulder pain was less in both AirSeal groups compared to standard, especially at 8 and 12 hours postoperatively. There was no difference between overall pain scores, morphine equivalent use, insufflation time, recovery room time, and length of hospital stay (all p>0.12). Univariate analysis shows positive smoking history (p=0.05) and insufflation with AirSeal at 12 mmHg (p=0.02) to be significant predictors for lower risk of developing SCE. When controlling for age, BMI, gender, smoking history, history of respiratory disease, and insufflation type, AirSeal at 12mmHg remained a significant predictor for decreased risk of SCE (p


Compared to standard insufflation, AirSeal insufflation at 12mmHg was associated with reduced risk of developing subcutaneous emphysema in robotic partial nephrectomy. Furthermore, shoulder pain seems to be less in both the AirSeal groups compared to standard insufflation.

Funding: Educational grant from Conmed for data collection