 |
Publisher: Peytchinski Publishing Ltd.
ISSN: 1312-773X (Online)
Issue: 2026, vol. 32, issue4
Subject Area: Medicine
-
DOI: 10.5272/jimab.2026324.7148
Published online: 15 October 2026
Case report
J of IMAB. 2026 Oct-Dec;32(4):7148-7153
MASSIVE SUBCUTANEOUS EMPHYSEMA DURING ROBOT-ASSISTED RECTAL CANCER RESECTION: A CASE REPORT
Mirela Neykova1, 2
, Ozan-Iv Bayrak1, 2, Martin Ninov2, Petya Ivanova1, 2,
1) Department of Anaesthesiology, emergency and intensive medicine, Medical University - Varna, Bulgaria.
2) UMHAT "St. Marina ", Medical University - Varna, Bulgaria.
ABSTRACT:
Purpose. Robot-assisted surgery offers superior structural visualization and dexterity in fixed anatomical landmarks like the deep pelvis. However, prolonged high-pressure pneumoperitoneum and extreme positioning introduce unique anesthetic and soft-tissue ventilation challenges. The aim of our study was to analyze the clinical progression, risk factors, and the efficacy of vacuum-assisted surgical decompression in managing massive iatrogenic subcutaneous emphysema after robotic surgery.
Material/Methods. A 78-year-old male underwent an elective robot-assisted Hartmann's procedure and partial cystectomy. Continuous pneumoperitoneum and Trendelenburg position were maintained. Intraoperative soft-tissue gas tracking and progressive hypercapnia (EtCO2 ≥50 mmHg) were noted. Postoperatively, the patient was transferred to the ICU. Physical and X-ray examinations revealed extensive, bilateral subcutaneous emphysema spanning from the face down to the thighs, without evidence of pneumothorax. Immediate surgical decompression was performed via bilateral pectoral incisions, followed by the application of Negative Pressure Wound Therapy (NPWT).
Results. The implementation of infraclavicular incisions combined with NPWT led to rapid and controlled gas evacuation, preserving tissue viability and improving respiratory compliance. The patient was successfully extubated the next day; resolution of the tissue tension allowed removal of the vacuum dressings on the third postoperative day. Subtotal reduction of the emphysema was achieved by day four, enabling a safe transfer to the surgical ward.
Conclusions. Prolonged high-pressure pneumoperitoneum and wide retroperitoneal dissection during RAS represent crucial cumulative risk factors for massive subcutaneous emphysema. Infraclavicular decompression ("blowholes") combined with NPWT is a highly effective, safe, and expedited therapeutic strategy to ensure airway patency and facilitate early postoperative weaning.
Keywords: robot-assisted surgery, subcutaneous emphysema, pneumoperitoneum, negative pressure wound therapy,
- Download FULL TEXT /PDF 979 KB/
Please cite this article as: Neykova M, Bayrak O-I, Ninov M, Ivanova P. Massive Subcutaneous emphysema during robot-assisted rectal cancer resection: A case report. J of IMAB. 2026 Oct-Dec;32(4):7148-7153. [Crossref - 10.5272/jimab.2026324.7148]
Correspondence to: Mirela Neykova, MD, PhD, Saint Marina University Hospital; 1, Hr. Smirnenski Blvd., 9010, Varna; Medical University - Varna; 55, Marin Drinov Str., 9000, Varna, Bulgaria. E-mail: mirella_1619@abv.bg
REFERENCES:
1. Xue Y, Li S, Guo S, Kuang Y, Ke M, Liu X, et al. Evaluation of the advantages of robotic versus laparoscopic surgery in elderly patients with colorectal cancer. BMC Geriatr. 2023 Feb 20;23(1):105. [PubMed]
2. Tustumi F, Bolm L, Edelmuth RCL, Maegawa FAB, Andraus W, Herman P, et al. Global strategies for the diffusion of robotic surgery. Arq Bras Cir Dig. 2025; 38:e1908. [PubMed]
3. Reinisch A, Liese J, Padberg W, Ulrich F. Robotic operations in urgent general surgery: a systematic review. J Robot Surg. 2023 Apr;17(2):275–90. [PubMed]
4. Wang Y, Cao D, Chen SL, Li YM, Zheng YW, Ohkohchi N. Current trends in three-dimensional visualization and real-time navigation as well as robot-assisted technologies in hepatobiliary surgery. World J Gastrointest Surg. 2021 Sep 27;13(9):904–22. [PubMed]
5. Suryawanshi CM, Shah B, Khanna S, Ghodki P, Bhati K, Ashok K. Anaesthetic management of robot-assisted laparoscopic surgery. Indian J Anaesth. 2023 Jan;67(1):117–22. [PubMed]
6. Khan H, Dhillon K, Mahapatra P, Popat R, Zakieh O, Kim WJ, et al. Blood loss and transfusion risk in robotic-assisted knee arthroplasty: A retrospective analysis. Int J Med Robot Comput Assist Surg. 2021 Dec;17(6):e2308. [PubMed]
7. Niewinski P, Golusiński WJ. Current indications and patient selection for transoral robotic surgery in head and neck cancer-abriefreview. Contemp Oncol Poznan Pol. 2022; 26(2):91–6. [PubMed]
8. Reddy K, Gharde P, Tayade H, Patil M, Reddy LS, Surya D. Advancements in Robotic Surgery: A Comprehensive Overview of Current Utilizations and Upcoming Frontiers. Cureus. 2023 Dec 12;15(12):e50415. [PubMed]
9. Zanev A. The effect of TAP block in postoperative opiate consumption in inferior median laparotomy. Scr Sci Medica. 2024 Dec 9;55(2):2. [Crossref]
10. Jaradeh M, Curran B, Poulikidis K, Rodrigues A, Jeske W, Abdelsattar ZM, et al. Inflammatory cytokines in robot-assisted thoracic surgery versus video-assisted thoracic surgery. J Thorac Dis. 2022 Jun;14(6). [PubMed]
11. Cofran L, Cohen T, Alfred M, Kanji F, Choi E, Savage S, et al. Barriers to safety and efficiency in robotic surgery docking. Surg Endosc. 2022 Jan;36(1):206-15. [PubMed]
12. Ruan A, Kulkarni V. Anesthesia considerations for robotic thoracic surgery. Video-Assist Thorac Surg. 2020 Mar 15;5:6. [Crossref]
13. Sullivan MJ, Frost EAM, Lew MW. Anesthetic care of the patient for robotic surgery. Middle East J Anaesthesiol. 2008 Jun;19(5):967–82. [PubMed]
14. Hinrichs-Krapels S, Ditewig B, Boulding H, Chalkidou A, Erskine J, Shokraneh F. Purchasing high-cost medical devices and equipment in hospitals: a systematic review. BMJ Open. 2022 Sep 1;12(9):e057516. [PubMed]
15. Soomro NA, Hashimoto DA, Porteous AJ, Ridley CJA, Marsh WJ, Ditto R, et al. Systematic review of learning curves in robot‐assisted surgery. BJS Open. 2019 Nov 29;4(1):27–44. [PubMed]
16. Ng KT, Tsia AKV, Chong VYL. Robotic Versus Conventional Laparoscopic Surgery for Colorectal Cancer: A Systematic Review and Meta-Analysis with Trial Sequential Analysis. World J Surg. 2019 Apr;43(4):1146–61. [PubMed]
17. Kalmar AF, Foubert L, Hendrickx JFA, Mottrie A, Absalom A, Mortier EP, et al. Influence of steep Trendelenburg position and CO(2) pneumoperitoneum on cardiovascular, cerebrovascular, and respiratory homeostasis during robotic prostatectomy. Br J Anaesth. 2010 Apr;104(4):433–9. [PubMed]
18. Pozzi T, Coppola S, Catozzi G, Colombo A, Chioccola M, Duscio E, et al. Mechanical power during robotic-assisted laparoscopic prostatectomy: an observational study. J Clin Monit Comput. 2024;38(5):1135–43. [PubMed]
19. Ball L, Costantino F, Fiorito M, Amodio S, Pelosi P. Respiratory mechanics during general anaesthesia. Ann Transl Med. 2018 Oct;6(19):379. [PubMed]
20. Zanev A, Neykova M. Alveolar recruitment maneuver for robot-assisted laparoscopic surgery in trendelenburg positioning. J of IMAB. 2025 Jul-Sep;31(3):6305-6312. [Crossref]
21. Ott DE. Subcutaneous Emphysema--Beyond the Pneumoperitoneum. JSLS. 2014;18(1):1-7. [PubMed]
22. Ono A, Nakamura M, Hayashi T, Tsuru I, Izumi T, Kusakabe M, et al. Broad subcutaneous emphysema with airway obstruction during robot-assisted partial nephrectomy: A case report and literature review. IJU Case Rep. 2023 Nov 1;6(6):461-4. [Crossref]
23.Umano GR, Delehaye G, Noviello C, Papparella A. The "Dark Side" of Pneumoperitoneum and Laparoscopy. Minim Invasive Surg. 2021 May19;2021:5564745. [PubMed]
24. Janssen N, Laven IEWG, Daemen JHT, Hulsewé KWE, Vissers YLJ, de Loos ER. Negative pressure wound therapy for massive subcutaneous emphysema: a systematic review and case series. J Thorac Dis. 2022 Jan;14(1):43-53. [PubMed]
Received: 27 May 2026
Published online: 15 October 2026