Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy

Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy Kengo Hayashi, Noriyuki Inaki, Yusuke Sakimura, Takahisa Yamaguchi, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-2722291/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 19 Jun, 2023 Read the published version in Journal of Robotic Surgery → Version 1 posted 5 You are reading this latest preprint version Abstract Subcutaneous emphysema (SE), a complication of robotic gastrectomy (RG), occurs when the gas used to establish pneumoperitoneum escapes and enters the soft tissue. SE typically does not result in major clinical problems, but massive SE can have life-threatening consequences. Hence, developing adequate preventive methods against postoperative SE is essential. We aimed to determine whether an existing protective device, the LAP PROTECTOR™ (LP), can be used to reduce the incidence of SE after RG. We analyzed the data of 194 patients who underwent RG at our hospital between August 2016 and December 2022. Since September 2021 (the 102nd patient), we have used the LP (FF0504; Hakko Medical, Hongo, Tokyo, Japan) at the trocar site, as this was expected to reduce the incidence of SE. The primary endpoint of this study was the efficacy of the LP in reducing the incidence of clinically relevant SE (defined as SE extending into the cervical area) a day after RG. Univariate analysis revealed that sex, body mass index (BMI), and LP usage differed significantly between patients with and without postoperative SE. Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15–0.72, P < 0.001), high BMI (OR: 0.13, 95% CI: 1.23–4.45, P = 0.009), and LP usage (OR: 0.11, 95% CI: 0.04–0.3, P < 0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE. Placing an LP at the trocar site may be a safe and effective method of preventing SE after RG. robotic gastrectomy subcutaneous emphysema postoperative complication LAP PROTECTOR pneumoperitoneum da Vinci surgical system Figures Figure 1 Figure 2 Figure 3 Introduction Robotic surgery is becoming increasingly popular due to several technical advantages, including three-dimensional high-definition vision controlled by the operators, articulated robotic arms providing better ergonomics, and tremor filtration. The increased availability of robotic surgery has expanded the surgical options available for eligible patients. Subcutaneous emphysema (SE) is a rare complication after robotic surgery that can sometimes have serious consequences. At present, the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) is one of the most popular surgical robots available. One of the key features of this system is lifting the abdominal wall using trocars, helping to maintain a wide operative field. However, lifting the abdominal wall in this manner can create a small gap between the abdominal wall and the trocars, allowing the gas used to create pneumoperitoneum to enter the subcutaneous space through this gap, leading to the development of postoperative SE. SE can cause crepitus, insufflation problems, pneumothorax, pneumomediastinum, hypercarbia, acidosis, changes in lung compliance, cardiac arrhythmia, sinus tachycardia, and hypertension. In some cases, SE can also cause life-threatening complications, such as abdominal compartment syndrome or CO 2 embolism [ 1 – 6 ]. Additionally, patients typically undergo robotic gastrectomy (RG) in the reverse Trendelenburg position, which can cause SE to spread toward the cervical area. SE in the upper chest and neck is extremely uncomfortable for the patient and can lead to severe upper airway obstruction and fatal respiratory failure [ 7 ]. Therefore, it is important to develop appropriate methods to reduce the incidence of SE. Previous studies have identified several operative factors associated with an increased incidence of SE. However, few studies have reported concrete preventive measures to reduce the risk of SE [ 1 , 8 , 9 ]. Therefore, in this study, we aimed to determine whether protecting the cross section of the abdominal wall with existing protective devices can reduce the incidence of SE after RG. Materials And Methods Patients This retrospective cohort study analyzed the data of 194 consecutive patients who underwent RG for gastric cancer at the Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital (Ishikawa, Japan) between August 2016 and December 2022. For all recruited patients, we collected the following data: patient characteristics (age, sex, and body mass index [BMI]), clinical stage of gastric cancer, surgical procedure used, usage of the LAP PROTECTOR (LP) (FF0504; Hakko Medical, Hongo, Tokyo, Japan), overall surgery duration and surgical console time, usage of drainage tubes, amount of blood loss, and postoperative hospitalization. The chest radiograph on postoperative day 1 was also evaluated for patients who developed SE. SEs that reached the cervical area were considered clinically relevant, and the primary endpoint of this study was the incidence of clinically relevant SE. Surgical Indication And Procedures We performed RGs with appropriate lymph node dissection, depending on the clinical stage of cancer [ 10 ]. Gastric cancer at any stage was regarded as an indication for RG. A qualified surgeon from the Japanese Society for Endoscopic Surgery either performed or assisted with the RGs. All RGs were performed with the da Vinci Si or Xi surgical system equipped with four articulating robotic arms: one central arm for a 30° rigid endoscope, a first arm for Maryland bipolar forceps, a second arm for fenestrated bipolar forceps, and a third arm for Cadiere forceps [ 11 , 12 ]. We used a robotic vessel-sealing system equipped with an articulated joint (Vessel Sealer, Intuitive Surgical Inc., Sunnyvale, CA, USA). The patient was positioned with a 12° head-up tilt. To maintain pneumoperitoneum, the valveless AirSeal® system (SurgiQuest Inc., Milford, CT, USA) was used for insufflation at a relatively low pressure (10 mm Hg). Starting in September 2021 (the 102nd patient), we used the aforementioned LP system to protect the abdominal section at the trocar sites. The LP was expected to reduce the occurrence of postoperative SE. This LP was originally developed to protect and extend the incision wound, and the device is equipped with two flexible rings that are covered and connected with a silicone rubber membrane. The inner diameter of the LP is 1–2 cm; therefore, it allows the 8-mm trocar of the da Vinci system to pass through it. We applied a 2 − 0 silk thread on the intra-abdominal side to pull the LP out through the abdominal wall after the surgery was completed, preventing the LP from falling into the abdominal cavity (Fig. 1 a, b). After creating a route for trocar insertion in the abdomen, we inserted the LP with Pean forceps and placed a trocar (Fig. 2 a). The LP was wrapped with a sterilized rubber band, preventing leakage of gas through the gap between the LP and the trocar (Fig. 2 b, d). Statistical analysis All categorical variables are expressed as numbers (percentages), and continuous variables are expressed as medians (ranges). Differences in categorical and continuous variables were evaluated using Fisher’s exact test and the Mann–Whitney U test, as appropriate. Logistic regression analysis was performed to identify independent factors associated with the incidence of SE. Statistical significance was set at P < 0.05. All statistical analyses were performed using the EZR statistical software version 1.55 (Easy R; Saitama Medical Center, Jichi Medical University, Saitama, Japan) based on the R statistical software version 4.1.2 and R commander (R Foundation for Statistical Computing, Vienna, Austria). Results Table 1 summarizes the characteristics and outcomes of the 194 patients included in this study. The LP was used in 93 cases (48%), and SE extending into the cervical area occurred in 41 cases (21%). We divided the patients into two groups depending on the presence or absence of SE (Table 2 ). When the patient background and perioperative data for groups that were either positive or negative for SE were compared, we determined no significant differences in age, the American Society of Anesthesiologists physical status (ASA-PS), clinical stage, surgical procedure, surgery time, console time, drain placement, blood loss, postoperative hospitalization, and complications. The Clavien–Dindo (CD) system was used to grade surgical complications, with a grade II or higher set as the positive threshold. Univariately significant between-group differences were detected in the following explanatory variables: sex (P = 0.003), BMI (P < 0.001), and LP usage (P < 0.001). Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15–0.72, P < 0.001), a high BMI (OR: 0.13, 95% CI: 1.23–4.45, P = 0.009), and LP usage (OR: 0.11, 95% CI: 0.04–0.3, P < 0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE (Table 3 ). Table 1 Patient characteristics and surgical data Variables N = 194 Age (years) 69 (35–86) Sex Male 125 (64) Female 69 (36) BMI (kg/m 2 ) 22.6 (14.3–30.7) ASA-PS 1 61 (31) 2 118 (60) 3 15 (8) Clinical stage I 138 (71) IIA/B 28 (14) III 27 (14) IV 1 (1) Procedure Distal 135 (70) Proximal 20 (10) Total 38 (19) Pylorus preserving 1 (1) LAP PROTECTOR™ + 93 (48) - 101 (52) Surgery time (min) 305 (139–724) Console time (min) 255 (93–623) Drain + 169 (87) - 25 (13) SE + 41 (21) - 153 (79) Blood loss (g) 10 (0–500) Postoperative hospitalization (days) 11 (5–84) Data are presented as median (interquartile range) or n (%). Table 2 Patient characteristics and surgical data grouped by the presence or absence of SE Variables SE + N = 41 SE – N = 153 P Age (years) 71 (39–85) 69 (35–86) 0.744 Sex 0.003 Male 18 (44) 107 (70) Female 23 (56) 46 (30) BMI (kg/m 2 ) 21.7 (14.3–29.1) 22.9 (16.8–30.7) < 0.001 ASA-PS 0.855 1 13 (32) 48 (31) 2 24 (58) 94 (61) 3 4 (10) 11 (7) Clinical stage 0.234 I 26 (63) 112 (73) IIA/B 7 (17) 21 (14) III 7 (17) 20 (13) IV 1 (2) 0 (0) Procedure 0.114 Distal 26 (63) 109 (71) Proximal 2 (4) 18 (12) Total 13 (32) 25 (16) Pyrolus preserving 0 (0) 1 (1) LAP PROTECTOR™ < 0.001 + 7 (17) 86 (56) - 34 (83) 67 (43) Surgery time (min) 309 (183–576) 305 (139–724) 0.292 Console time (min) 255 (126–522) 256 (93–623) 0.407 Drain 0.43 + 34 (83) 135 (88) - 7 (17) 18 (12) Blood loss (g) 10 (0–500) 10 (0–330) 0.251 Postoperative hospitalization (days) 12 (9–37) 11 (5–84) 0.125 Complications CD grade II or higher 7 (14.6) 19 (13) 0.809 Data are presented as median (interquartile range) or n (%). ASA-PS: American Society of Anesthesiologists physical status; CD: Clavien–Dindo. Table 3 Logistic regression analysis for preventive factors of clinically relevant Se SE Univariable Multivariable OR 95% CI P value OR 95% CI P value Sex Male 0.33 0.15–0.72 0.003 0.22 0.09–0.52 < 0.001 Female 1 1 BMI ≥25 0.15 0.01–0.63 0.002 0.13 1.23–4.45 0.009 <25 1 1 Surgery time ≥300 1.8 9.83–4.02 0.115 2.21 0.97–5.02 0.058 <300 1 1 LAP PROTECTOR™ + 0.16 0.05–0.40 < 0.0001 0.11 0.04–0.30 < 0.001 - 1 1 Discussion In this study, male sex, high BMI, and LP usage were all associated with a lower incidence of SE after RG. Placing the LP at the trocar site provided the lowest OR (0.11) and was the most effective factor in reducing SE incidence. Previous studies have reported old age and a long operative duration as risk factors for severe SE; however, these factors were not significantly associated with postoperative SE in our study [ 1 , 3 , 8 ]. To the best of our knowledge, this is the first study to repurpose existing protective devices to reduce the incidence of SE after RG. SE is a rare complication of laparoscopic surgery, with an overall incidence of 0.43–2.3% [ 1 ]. However, the true incidence may have been considerably underestimated. McAllister et al [ 13 ] reported that the 24-hour postoperative computed tomography scans of patients who underwent laparoscopic cholecystectomy revealed grossly undetectable but clinical SE in 56% of cases. Similarly, Worrell, Saggar, and colleagues recognized SE in up to 99% of all laparoscopic cases based on radiographic findings and computed tomography scans [ 1 , 9 , 13 – 16 ]. The reported life-threatening complications and high incidence of clinically relevant SE (21%), including two abdominal infections caused by SE in our study, indicate that this complication deserves immediate consideration [ 1 – 6 ]. SE occurs due to the de novo generation or infiltration of air below the dermal layers [ 14 ]. The trocar acts as a fulcrum for the robotic arm to move as a class 1 lever and force multiplier (Fig. 3 a). The pivot point acts as the fascial entry site, and the port site can be dilated. When instruments are manipulated during robotic surgery, the surgeon lacks sensation and cannot appreciate the force exerted by the trocar on the abdominal wall. Therefore, a certain degree of blunt dissection may occur at the port site without the surgeon’s realization. Furthermore, the da Vinci system allows the abdominal wall to be lifted with trocars during surgery, which increases the pressure at the trocar site. This pressure can cause the gap between the trocars and abdominal wall to yield, allowing the entry of pneumoperitoneal air into the subcutaneous space (Fig. 3 b). Therefore, protecting the abdominal wall at the trocar site is crucial for preventing SE after surgery. The surgical risk factors for SE include the following: high-flow insufflation, high intra-abdominal pressure (> 15 mmHg), multiple attempts at the abdominal entry, lack of a snug fit between the skin/abdominal wall and trocars, use of > 5 trocars, use of the laparoscope as a lever, use of the trocars as a fulcrum, laparoscope with a long arm, structural weakness caused by repetitive movements, improper cannula placement, and prolonged operative time (> 3.5 hours) [ 1 ]. The da Vinci surgical system not only uses the long arm of the laparoscope as a lever but also uses the trocars as a fulcrum. Therefore, the potential preventive measures for SE include avoiding a high intra-abdominal pressure, avoiding the use of additional trocars, and minimizing surgical time as much as possible. However, reducing the intra-abdominal pressure can often cause difficulties in maintaining a good surgical field. Additionally, it is difficult to complete the RG procedure within 3.5 hours, especially because surgical difficulty varies among patients. Because RG is standardized to be performed with five ports, other means must be considered for minimizing the risk of SE. The valveless insufflation system, AirSeal®, is becoming increasingly popular in robotic surgery because it maintains a stable-pressure pneumoperitoneum and performs continuous smoke evacuation [ 17 , 18 ]. However, the use of this device is also known to increase the risk of SE [ 15 ]. In this study, an LP was used in all cases, and the incidence of SE was significantly decreased. Therefore, using an LP at the trocar site is beneficial for decreasing the incidence of SE while using AirSeal®, even in long surgeries. The LP used in this study was originally developed for protecting and expanding the incision wound. However, we started using an LP in RG because of its protective effects on the abdominal wall. Although LPs are available in several sizes and types, we found the LP to be suitable for the trocars in the da Vinci surgical system. During surgery, the LP is crimped to the cross section of the abdominal wall and confers a protective effect. Therefore, we hypothesized that it would also prevent leakage of air into the subcutaneous space through the trocar insertion site. However, after introducing the LP to cover the trocar sites, we still noticed air leakage through the gap between the trocars and LP because of a slight difference in diameter between the devices (Fig. 3 c). Owing to concerns related to lowered body temperature and increased CO 2 consumption, we wrapped sterilized rubber bands around the LP and trocars to prevent air leakage (Fig. 3 d). This practice not only prevented SE but also allowed the LP to effectively protect the incision. In addition, LPs were broken intraoperatively in some cases. If an LP is torn into two pieces, it can easily fall into the abdominal cavity. Therefore, a 2 − 0 silk thread was applied on the intra-abdominal side to prevent losing a damaged LP into the abdominal cavity. The thread was also useful for LP removal. In seven cases, SE occurred despite using an LP. This may be due to either intraoperative LP breakage or pneumoperitoneum without an LP at the entry site when placing a drainage tube or during reconstruction. However, even including those cases, the effectiveness of the LP for preventing SE remained significant. This study has a few limitations. First, this was a retrospective single-center study, which limits the generalizability of its findings. Second, the LP device was originally developed for other purposes, and was not intended for use at the trocar site. Consequently, using a device specifically designed for use at the trocar site may be better at reducing the incidence of SE. Nevertheless, we did not experience any unforeseen problems in any of the 93 consecutive cases where we used the LP. In conclusion, placing an LP device at the trocar site can be a safe and effective method for preventing SE after RG. Nevertheless, further studies are needed to evaluate the safety of this procedure. Declarations Funding This research received no specific grant from any funding agency. Competing interests Drs Kengo Hayashi, Noriyuki Inaki, Yusuke Sakimura, Takahisa Yamaguchi, Yoshinao Obatake, Shiro Terai, Hirotaka Kitamura, Shinichi Kadoya, and Hiroyuki Bando have no conflicts of interest to disclose. Author Contributions All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Kengo Hayashi. The first draft of the manuscript was written by Kengo Hayashi, and all authors read and approved the final manuscript. Acknowledgements We thank Editage for English language editing. Ethics approval This study was performed in accordance with the principles of the World Medical Association’s Declaration of Helsinki (ethical principles for medical research involving human subjects). This study was approved by the ethics committee of Ishikawa Prefectural Central Hospital (approval no. 2077). Consent to participate Each patient enrolled in this study provided written informed consent for the surgery and for the use of clinical data in research. Consent to publish The authors affirm that human research participants provided informed consent for publication of the images in Figure 2. References Ott DE (2014) Subcutaneous emphysema—beyond the pneumoperitoneum. JSLS 18:1-7. https://doi.org/10.4293/108680813X13693422520882 Shah SB, Dubey M, Meghana D (2020) An algorithm for management of intraoperative subcutaneous emphysema during robotic surgery. Saudi J Anaesth 14:269-270. https://doi.org/10.4103/sja.SJA_711_19 Tan PL, Lee TL, Tweed WA (1992) Carbon dioxide absorption and gas exchange during pelvic laparoscopy. Can J Anaesth 39:677-681. https://doi.org/10.1007/BF03008229 Lehmann LJ, Lewis MC, Goldman H, Marshall JR (1995) Cardiopulmonary complications during laparoscopy: two case reports. South Med J 88:1072-1075. https://doi.org/10.1097/00007611-199510000-00015 Celik H, Cremins A, Jones KA, Harmanli O (2013) Massive subcutaneous emphysema in robotic sacrocolpopexy. JSLS 17:245-248. https://doi.org/10.4293/108680813X13654754535151 Capone J, De Ranieri A, Knezevic NN, Lukić IK, Candido K, Gluncic V (2019) Massive upper body and cervicofacial subcutaneous emphysema following robotic myomectomy. Case Rep Anesthesiol 2019:5861705. https://doi.org/10.1155/2019/5861705. Dumont SW, Farag A (2008) Life threatening subcutaneous emphysema. Anaesthesia 63:212-213. https://doi.org/10.4103/0019-5049.179469 Murdock CM, Wolff AJ, Van Geem T (2000) Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol 95:704-709. https://doi.org/10.1016/s0029-7844(00)00781-x Saggar VR, Singhal A, Singh K, Sharma B, Sarangi R (2008) Factors influencing development of subcutaneous carbon dioxide emphysema in laparoscopic totally extraperitoneal inguinal hernia repair. J Laparoendosc Adv Surg Tech A 18:213-216. https://doi.org/10.1089/lap.2007.0089 Japanese Gastric Cancer Association (2021) Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 24:1-21. https://doi.org/10.1007/s10120-020-01042-y Uyama I, Kanaya S, Ishida Y, Inaba K, Suda K, Satoh S (2012) Novel integrated robotic approach for suprapancreatic D2 nodal dissection for treating gastric cancer: technique and initial experience. World J Surg 36:331-337. https://doi.org/10.1007/s00268-011-1352-8 Suda K, Nakauchi M, Inaba K, Ishida Y, Uyama I (2016) Robotic surgery for upper gastrointestinal cancer: current status and future perspectives. Dig Endosc 28:701-713. https://doi.org/10.1111/den.12697 McAllister JD, D'Altorio RA, Snyder A (1991) CT findings after uncomplicated percutaneous laparoscopic cholecystectomy. J Comput Assist Tomogr 15:770-772. https://doi.org/10.1097/00004728-199109000-00008 Kukuruza K, Aboeed A (2022) Subcutaneous emphysema. StatPearls, StatPearls Publishing LLC, St. Petersburg, FL Fukui S, Kagebayashi Y, Iemura Y, Matsumura Y (2022) Severe subcutaneous emphysema caused by small injury to the abdominal wall during robot-assisted laparoscopic radical prostatectomy. Urol Case Rep 40:101904. https://doi.org/10.1016/j.eucr.2021.101904 Worrell JB, Cleary DT (2002) Massive subcutaneous emphysema and hypercarbia: complications of carbon dioxide absorption during extraperitoneal and intraperitoneal laparoscopic surgery—case studies. AANA J 70:456-461 Luketina R, Luketina TLH, Antoniou SA, Köhler G, Könneker S, Manzenreiter L, Wundsam H, Koch OO, Knauer M, Emmanuel K (2021) Prospective randomized controlled trial on comparison of standard CO(2) pressure pneumoperitoneum insufflator versus AirSeal®. Surg Endosc 35:3670-3678. https://doi.org/10.1007/s00464-020-07846-4 Razdan S, Ucpinar B, Okhawere KE, Badani KK (2023) The role of AirSeal in robotic urologic surgery: a systematic review. J Laparoendosc Adv Surg Tech A 33:21-31. https://doi.org/10.1089/lap.2022.0153 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 19 Jun, 2023 Read the published version in Journal of Robotic Surgery → Version 1 posted Editorial decision: Accepted 11 Jun, 2023 Reviewers invited by journal 24 Apr, 2023 Editor assigned by journal 26 Mar, 2023 Submission checks completed at journal 22 Mar, 2023 First submitted to journal 22 Mar, 2023 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-2722291","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":185671511,"identity":"e6671bfb-142a-46bc-a443-fe375bbc5a38","order_by":0,"name":"Kengo Hayashi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6UlEQVRIiWNgGAWjYHACNgYGHhDNfABISMiQooUtAaSFh0gtYMBjACYJqpdvP/zsAYOMXR7/7J7Pr27UWPAwsB8+ugGfFoMzaeYGDDzJxRJ3zm6zzjkGdBhPWtoNvFokGMwkGHiYExtu5G4zzmEDapHgMcOrRX4G+zeglvrE+Tdynhnn/CNCC8MNHpAthxM33MhhfpzbRoQWgzM55QYJPMeLDW+kmTHn9knwsBHyi3z78W0PPvZU58ndSH78OedbnRw/++Fj+B0GAok9DAlAik0CxGHDrxYGfoC1MH8gTvUoGAWjYBSMNAAAjU5DqMooKQYAAAAASUVORK5CYII=","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Kengo","middleName":"","lastName":"Hayashi","suffix":""},{"id":185671512,"identity":"a223a03a-7249-445e-928d-a723779bcf83","order_by":1,"name":"Noriyuki Inaki","email":"","orcid":"","institution":"Kanazawa University Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Noriyuki","middleName":"","lastName":"Inaki","suffix":""},{"id":185671513,"identity":"f2c1f039-a49a-4ee9-9214-21b80c97661a","order_by":2,"name":"Yusuke Sakimura","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yusuke","middleName":"","lastName":"Sakimura","suffix":""},{"id":185671514,"identity":"045a7060-2b43-4205-a638-925d22d4fa62","order_by":3,"name":"Takahisa Yamaguchi","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Takahisa","middleName":"","lastName":"Yamaguchi","suffix":""},{"id":185671515,"identity":"db414e87-32ee-4136-88b1-30e01aa0a630","order_by":4,"name":"Yoshinao Obatake","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Yoshinao","middleName":"","lastName":"Obatake","suffix":""},{"id":185671516,"identity":"23aa2d73-d7d8-4171-8c38-5e88cf27a5b6","order_by":5,"name":"Shiro Terai","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shiro","middleName":"","lastName":"Terai","suffix":""},{"id":185671517,"identity":"6e9d9809-ecaa-4d29-9fe0-7969a9c2e747","order_by":6,"name":"Hirotaka Kitamura","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hirotaka","middleName":"","lastName":"Kitamura","suffix":""},{"id":185671518,"identity":"8bb2982d-9e2a-49a7-b821-6d3304315a7a","order_by":7,"name":"Shinichi Kadoya","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Shinichi","middleName":"","lastName":"Kadoya","suffix":""},{"id":185671519,"identity":"3d95314b-899e-4bc9-a1c0-c5696fc16ec5","order_by":8,"name":"Hiroyuki Bando","email":"","orcid":"","institution":"Ishikawa Prefectural Central Hospital","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Hiroyuki","middleName":"","lastName":"Bando","suffix":""}],"badges":[],"createdAt":"2023-03-22 09:44:24","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-2722291/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-2722291/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s11701-023-01651-6","type":"published","date":"2023-06-19T21:16:46+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":34784345,"identity":"9a7c74f4-9b80-4ab7-b291-fb10cc6fed6d","added_by":"auto","created_at":"2023-03-24 16:04:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":4526727,"visible":true,"origin":"","legend":"\u003cp\u003e(a) A 2-0 silk thread was applied on the intra-abdominal side to assist with easy device removal after completion of the intra-abdominal procedure. (b) Pean forceps were used to introduce the LP into the abdomen\u003c/p\u003e","description":"","filename":"Fig.1.png","url":"https://assets-eu.researchsquare.com/files/rs-2722291/v1/da1daffe19fef102acba87b2.png"},{"id":34784346,"identity":"a19566b0-6c70-4079-a827-6d75f82ce2a1","added_by":"auto","created_at":"2023-03-24 16:04:34","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":6672906,"visible":true,"origin":"","legend":"\u003cp\u003e(a) The LP was introduced into the abdominal cavity with Pean forceps. (b) A rubber band was wrapped around the LP to prevent air leakage. (c) The rubber band was wrapped several times depending on the size of the band. (d) Operative view following completed LP setting\u003c/p\u003e","description":"","filename":"Fig.2.png","url":"https://assets-eu.researchsquare.com/files/rs-2722291/v1/a1f6313ea7aabb46b577c2c3.png"},{"id":34784347,"identity":"f4aa9827-ccff-46c2-87cb-c54986e18c21","added_by":"auto","created_at":"2023-03-24 16:04:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":3074916,"visible":true,"origin":"","legend":"\u003cp\u003e(a) The trocar acts as a fulcrum for the robotic arm to move as a class 1 lever; blunt dissection occurs at the trocar site. (b) Blunt dissection and a lifting trocar can yield a gap between the trocars and abdominal wall, thus allowing entry of pneumoperitoneal air into the subcutaneous space. (c) Air leakage occurred through the gap between the trocars and LP due to a slight difference in diameter between the devices. (d) Air leakage was prevented by wrapping LP and trocars with sterilized rubber bands\u003c/p\u003e","description":"","filename":"Fig.3.png","url":"https://assets-eu.researchsquare.com/files/rs-2722291/v1/fa9c9ee5e9f7738f55922e59.png"},{"id":44732029,"identity":"b7ff6178-b188-464a-9302-be50d8973f0f","added_by":"auto","created_at":"2023-10-16 21:50:44","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5805903,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-2722291/v1/f5831414-cfd6-45cd-bcef-eb780ceed070.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy","fulltext":[{"header":"Introduction","content":"\u003cp\u003eRobotic surgery is becoming increasingly popular due to several technical advantages, including three-dimensional high-definition vision controlled by the operators, articulated robotic arms providing better ergonomics, and tremor filtration. The increased availability of robotic surgery has expanded the surgical options available for eligible patients. Subcutaneous emphysema (SE) is a rare complication after robotic surgery that can sometimes have serious consequences. At present, the da Vinci surgical system (Intuitive Surgical, Sunnyvale, CA, USA) is one of the most popular surgical robots available. One of the key features of this system is lifting the abdominal wall using trocars, helping to maintain a wide operative field. However, lifting the abdominal wall in this manner can create a small gap between the abdominal wall and the trocars, allowing the gas used to create pneumoperitoneum to enter the subcutaneous space through this gap, leading to the development of postoperative SE.\u003c/p\u003e \u003cp\u003eSE can cause crepitus, insufflation problems, pneumothorax, pneumomediastinum, hypercarbia, acidosis, changes in lung compliance, cardiac arrhythmia, sinus tachycardia, and hypertension. In some cases, SE can also cause life-threatening complications, such as abdominal compartment syndrome or CO\u003csub\u003e2\u003c/sub\u003e embolism [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Additionally, patients typically undergo robotic gastrectomy (RG) in the reverse Trendelenburg position, which can cause SE to spread toward the cervical area. SE in the upper chest and neck is extremely uncomfortable for the patient and can lead to severe upper airway obstruction and fatal respiratory failure [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Therefore, it is important to develop appropriate methods to reduce the incidence of SE.\u003c/p\u003e \u003cp\u003ePrevious studies have identified several operative factors associated with an increased incidence of SE. However, few studies have reported concrete preventive measures to reduce the risk of SE [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Therefore, in this study, we aimed to determine whether protecting the cross section of the abdominal wall with existing protective devices can reduce the incidence of SE after RG.\u003c/p\u003e"},{"header":"Materials And Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study analyzed the data of 194 consecutive patients who underwent RG for gastric cancer at the Department of Gastroenterological Surgery, Ishikawa Prefectural Central Hospital (Ishikawa, Japan) between August 2016 and December 2022. For all recruited patients, we collected the following data: patient characteristics (age, sex, and body mass index [BMI]), clinical stage of gastric cancer, surgical procedure used, usage of the LAP PROTECTOR (LP) (FF0504; Hakko Medical, Hongo, Tokyo, Japan), overall surgery duration and surgical console time, usage of drainage tubes, amount of blood loss, and postoperative hospitalization. The chest radiograph on postoperative day 1 was also evaluated for patients who developed SE. SEs that reached the cervical area were considered clinically relevant, and the primary endpoint of this study was the incidence of clinically relevant SE.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSurgical Indication And Procedures\u003c/h3\u003e\n\u003cp\u003eWe performed RGs with appropriate lymph node dissection, depending on the clinical stage of cancer [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Gastric cancer at any stage was regarded as an indication for RG. A qualified surgeon from the Japanese Society for Endoscopic Surgery either performed or assisted with the RGs. All RGs were performed with the da Vinci Si or Xi surgical system equipped with four articulating robotic arms: one central arm for a 30\u0026deg; rigid endoscope, a first arm for Maryland bipolar forceps, a second arm for fenestrated bipolar forceps, and a third arm for Cadiere forceps [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. We used a robotic vessel-sealing system equipped with an articulated joint (Vessel Sealer, Intuitive Surgical Inc., Sunnyvale, CA, USA). The patient was positioned with a 12\u0026deg; head-up tilt. To maintain pneumoperitoneum, the valveless AirSeal\u0026reg; system (SurgiQuest Inc., Milford, CT, USA) was used for insufflation at a relatively low pressure (10 mm Hg).\u003c/p\u003e \u003cp\u003eStarting in September 2021 (the 102nd patient), we used the aforementioned LP system to protect the abdominal section at the trocar sites. The LP was expected to reduce the occurrence of postoperative SE. This LP was originally developed to protect and extend the incision wound, and the device is equipped with two flexible rings that are covered and connected with a silicone rubber membrane. The inner diameter of the LP is 1\u0026ndash;2 cm; therefore, it allows the 8-mm trocar of the da Vinci system to pass through it. We applied a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 silk thread on the intra-abdominal side to pull the LP out through the abdominal wall after the surgery was completed, preventing the LP from falling into the abdominal cavity (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003ea, b). After creating a route for trocar insertion in the abdomen, we inserted the LP with Pean forceps and placed a trocar (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). The LP was wrapped with a sterilized rubber band, preventing leakage of gas through the gap between the LP and the trocar (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb, d).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eAll categorical variables are expressed as numbers (percentages), and continuous variables are expressed as medians (ranges). Differences in categorical and continuous variables were evaluated using Fisher\u0026rsquo;s exact test and the Mann\u0026ndash;Whitney U test, as appropriate. Logistic regression analysis was performed to identify independent factors associated with the incidence of SE. Statistical significance was set at P\u0026thinsp;\u0026lt;\u0026thinsp;0.05. All statistical analyses were performed using the EZR statistical software version 1.55 (Easy R; Saitama Medical Center, Jichi Medical University, Saitama, Japan) based on the R statistical software version 4.1.2 and R commander (R Foundation for Statistical Computing, Vienna, Austria).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarizes the characteristics and outcomes of the 194 patients included in this study. The LP was used in 93 cases (48%), and SE extending into the cervical area occurred in 41 cases (21%). We divided the patients into two groups depending on the presence or absence of SE (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e). When the patient background and perioperative data for groups that were either positive or negative for SE were compared, we determined no significant differences in age, the American Society of Anesthesiologists physical status (ASA-PS), clinical stage, surgical procedure, surgery time, console time, drain placement, blood loss, postoperative hospitalization, and complications. The Clavien\u0026ndash;Dindo (CD) system was used to grade surgical complications, with a grade II or higher set as the positive threshold. Univariately significant between-group differences were detected in the following explanatory variables: sex (P\u0026thinsp;=\u0026thinsp;0.003), BMI (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and LP usage (P\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15\u0026ndash;0.72, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), a high BMI (OR: 0.13, 95% CI: 1.23\u0026ndash;4.45, P\u0026thinsp;=\u0026thinsp;0.009), and LP usage (OR: 0.11, 95% CI: 0.04\u0026ndash;0.3, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and surgical data\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eN\u0026thinsp;=\u0026thinsp;194\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (35\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e125 (64)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (36)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.6 (14.3\u0026ndash;30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-PS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e61 (31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e118 (60)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e138 (71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIA/B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135 (70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20 (10)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (19)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePylorus preserving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAP PROTECTOR\u0026trade;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (48)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e101 (52)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e305 (139\u0026ndash;724)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e255 (93\u0026ndash;623)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e169 (87)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSE\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e41 (21)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e153 (79)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (0\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospitalization (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (5\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"2\"\u003eData are presented as median (interquartile range) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient characteristics and surgical data grouped by the presence or absence of SE\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSE\u0026thinsp;+\u0026thinsp;N\u0026thinsp;=\u0026thinsp;41\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSE \u0026ndash; N\u0026thinsp;=\u0026thinsp;153\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71 (39\u0026ndash;85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e69 (35\u0026ndash;86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.744\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e0.003\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e18 (44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e107 (70)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e23 (56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.7 (14.3\u0026ndash;29.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.9 (16.8\u0026ndash;30.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASA-PS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003e0.855\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e48 (31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24 (58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (61)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinical stage\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.234\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e112 (73)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIIA/B\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (14)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIII\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20 (13)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 (2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"4\" rowspan=\"5\"\u003e \u003cp\u003e0.114\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDistal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26 (63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e109 (71)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProximal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (4)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (32)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (16)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePyrolus preserving\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLAP PROTECTOR\u0026trade;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86 (56)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67 (43)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurgery time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e309 (183\u0026ndash;576)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e305 (139\u0026ndash;724)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConsole time (min)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e255 (126\u0026ndash;522)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e256 (93\u0026ndash;623)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.407\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDrain\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003e0.43\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e34 (83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e135 (88)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (12)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlood loss (g)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10 (0\u0026ndash;500)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10 (0\u0026ndash;330)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePostoperative hospitalization (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (9\u0026ndash;37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11 (5\u0026ndash;84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.125\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComplications CD grade II or higher\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7 (14.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e19 (13)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.809\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented as median (interquartile range) or n (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eASA-PS: American Society of Anesthesiologists physical status; CD: Clavien\u0026ndash;Dindo.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis for preventive factors of clinically relevant Se\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"7\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e SE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003eUnivariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c7\" namest=\"c5\"\u003e \u003cp\u003eMultivariable\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e95% CI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eP value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.15\u0026ndash;0.72\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.09\u0026ndash;0.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.01\u0026ndash;0.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.23\u0026ndash;4.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e0.009\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSurgery time\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.83\u0026ndash;4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.115\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.97\u0026ndash;5.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.058\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;300\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"7\" nameend=\"c7\" namest=\"c1\"\u003e \u003cp\u003e\u003cb\u003eLAP PROTECTOR\u0026trade;\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e+\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.05\u0026ndash;0.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.0001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.04\u0026ndash;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this study, male sex, high BMI, and LP usage were all associated with a lower incidence of SE after RG. Placing the LP at the trocar site provided the lowest OR (0.11) and was the most effective factor in reducing SE incidence. Previous studies have reported old age and a long operative duration as risk factors for severe SE; however, these factors were not significantly associated with postoperative SE in our study [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. To the best of our knowledge, this is the first study to repurpose existing protective devices to reduce the incidence of SE after RG.\u003c/p\u003e \u003cp\u003eSE is a rare complication of laparoscopic surgery, with an overall incidence of 0.43\u0026ndash;2.3% [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. However, the true incidence may have been considerably underestimated. McAllister et al [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] reported that the 24-hour postoperative computed tomography scans of patients who underwent laparoscopic cholecystectomy revealed grossly undetectable but clinical SE in 56% of cases. Similarly, Worrell, Saggar, and colleagues recognized SE in up to 99% of all laparoscopic cases based on radiographic findings and computed tomography scans [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. The reported life-threatening complications and high incidence of clinically relevant SE (21%), including two abdominal infections caused by SE in our study, indicate that this complication deserves immediate consideration [\u003cspan additionalcitationids=\"CR2 CR3 CR4 CR5\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSE occurs due to the de novo generation or infiltration of air below the dermal layers [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. The trocar acts as a fulcrum for the robotic arm to move as a class 1 lever and force multiplier (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea). The pivot point acts as the fascial entry site, and the port site can be dilated. When instruments are manipulated during robotic surgery, the surgeon lacks sensation and cannot appreciate the force exerted by the trocar on the abdominal wall. Therefore, a certain degree of blunt dissection may occur at the port site without the surgeon\u0026rsquo;s realization. Furthermore, the da Vinci system allows the abdominal wall to be lifted with trocars during surgery, which increases the pressure at the trocar site. This pressure can cause the gap between the trocars and abdominal wall to yield, allowing the entry of pneumoperitoneal air into the subcutaneous space (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eb). Therefore, protecting the abdominal wall at the trocar site is crucial for preventing SE after surgery.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe surgical risk factors for SE include the following: high-flow insufflation, high intra-abdominal pressure (\u0026gt;\u0026thinsp;15 mmHg), multiple attempts at the abdominal entry, lack of a snug fit between the skin/abdominal wall and trocars, use of \u0026gt;\u0026thinsp;5 trocars, use of the laparoscope as a lever, use of the trocars as a fulcrum, laparoscope with a long arm, structural weakness caused by repetitive movements, improper cannula placement, and prolonged operative time (\u0026gt;\u0026thinsp;3.5 hours) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The da Vinci surgical system not only uses the long arm of the laparoscope as a lever but also uses the trocars as a fulcrum. Therefore, the potential preventive measures for SE include avoiding a high intra-abdominal pressure, avoiding the use of additional trocars, and minimizing surgical time as much as possible. However, reducing the intra-abdominal pressure can often cause difficulties in maintaining a good surgical field. Additionally, it is difficult to complete the RG procedure within 3.5 hours, especially because surgical difficulty varies among patients. Because RG is standardized to be performed with five ports, other means must be considered for minimizing the risk of SE. The valveless insufflation system, AirSeal\u0026reg;, is becoming increasingly popular in robotic surgery because it maintains a stable-pressure pneumoperitoneum and performs continuous smoke evacuation [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. However, the use of this device is also known to increase the risk of SE [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. In this study, an LP was used in all cases, and the incidence of SE was significantly decreased. Therefore, using an LP at the trocar site is beneficial for decreasing the incidence of SE while using AirSeal\u0026reg;, even in long surgeries.\u003c/p\u003e \u003cp\u003eThe LP used in this study was originally developed for protecting and expanding the incision wound. However, we started using an LP in RG because of its protective effects on the abdominal wall. Although LPs are available in several sizes and types, we found the LP to be suitable for the trocars in the da Vinci surgical system. During surgery, the LP is crimped to the cross section of the abdominal wall and confers a protective effect. Therefore, we hypothesized that it would also prevent leakage of air into the subcutaneous space through the trocar insertion site. However, after introducing the LP to cover the trocar sites, we still noticed air leakage through the gap between the trocars and LP because of a slight difference in diameter between the devices (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ec). Owing to concerns related to lowered body temperature and increased CO\u003csub\u003e2\u003c/sub\u003e consumption, we wrapped sterilized rubber bands around the LP and trocars to prevent air leakage (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ed). This practice not only prevented SE but also allowed the LP to effectively protect the incision. In addition, LPs were broken intraoperatively in some cases. If an LP is torn into two pieces, it can easily fall into the abdominal cavity. Therefore, a 2\u0026thinsp;\u0026minus;\u0026thinsp;0 silk thread was applied on the intra-abdominal side to prevent losing a damaged LP into the abdominal cavity. The thread was also useful for LP removal. In seven cases, SE occurred despite using an LP. This may be due to either intraoperative LP breakage or pneumoperitoneum without an LP at the entry site when placing a drainage tube or during reconstruction. However, even including those cases, the effectiveness of the LP for preventing SE remained significant.\u003c/p\u003e \u003cp\u003eThis study has a few limitations. First, this was a retrospective single-center study, which limits the generalizability of its findings. Second, the LP device was originally developed for other purposes, and was not intended for use at the trocar site. Consequently, using a device specifically designed for use at the trocar site may be better at reducing the incidence of SE. Nevertheless, we did not experience any unforeseen problems in any of the 93 consecutive cases where we used the LP.\u003c/p\u003e \u003cp\u003eIn conclusion, placing an LP device at the trocar site can be a safe and effective method for preventing SE after RG. Nevertheless, further studies are needed to evaluate the safety of this procedure.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDrs Kengo Hayashi, Noriyuki Inaki, Yusuke Sakimura, Takahisa Yamaguchi, Yoshinao Obatake, Shiro Terai, Hirotaka Kitamura, Shinichi Kadoya, and Hiroyuki Bando have no conflicts of interest to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by Kengo Hayashi. The first draft of the manuscript was written by Kengo Hayashi, and all authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank Editage for\u0026nbsp;English\u0026nbsp;language editing.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was performed in accordance with the principles of the World Medical Association\u0026rsquo;s Declaration of Helsinki (ethical principles for medical research involving human subjects).\u0026nbsp;This study was approved by the ethics committee of Ishikawa Prefectural Central Hospital (approval no. 2077).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach patient enrolled in this study provided written informed consent for the surgery and for the use of clinical data in research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors affirm that human research participants provided informed consent for publication of the images in Figure 2.\u003c/p\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOtt DE (2014) Subcutaneous emphysema\u0026mdash;beyond the pneumoperitoneum. JSLS 18:1-7. https://doi.org/10.4293/108680813X13693422520882\u003c/li\u003e\n\u003cli\u003eShah SB, Dubey M, Meghana D (2020) An algorithm for management of intraoperative subcutaneous emphysema during robotic surgery. Saudi J Anaesth 14:269-270. https://doi.org/10.4103/sja.SJA_711_19\u003c/li\u003e\n\u003cli\u003eTan PL, Lee TL, Tweed WA (1992) Carbon dioxide absorption and gas exchange during pelvic laparoscopy. Can J Anaesth 39:677-681. https://doi.org/10.1007/BF03008229\u003c/li\u003e\n\u003cli\u003eLehmann LJ, Lewis MC, Goldman H, Marshall JR (1995) Cardiopulmonary complications during laparoscopy: two case reports. South Med J 88:1072-1075. https://doi.org/10.1097/00007611-199510000-00015\u003c/li\u003e\n\u003cli\u003eCelik H, Cremins A, Jones KA, Harmanli O (2013) Massive subcutaneous emphysema in robotic sacrocolpopexy. JSLS 17:245-248. https://doi.org/10.4293/108680813X13654754535151\u003c/li\u003e\n\u003cli\u003eCapone J, De Ranieri A, Knezevic NN, Lukić IK, Candido K, Gluncic V (2019) Massive upper body and cervicofacial subcutaneous emphysema following robotic myomectomy. Case Rep Anesthesiol 2019:5861705. https://doi.org/10.1155/2019/5861705.\u003c/li\u003e\n\u003cli\u003eDumont SW, Farag A (2008) Life threatening subcutaneous emphysema. Anaesthesia 63:212-213. https://doi.org/10.4103/0019-5049.179469\u003c/li\u003e\n\u003cli\u003eMurdock CM, Wolff AJ, Van Geem T (2000) Risk factors for hypercarbia, subcutaneous emphysema, pneumothorax, and pneumomediastinum during laparoscopy. Obstet Gynecol 95:704-709. https://doi.org/10.1016/s0029-7844(00)00781-x\u003c/li\u003e\n\u003cli\u003eSaggar VR, Singhal A, Singh K, Sharma B, Sarangi R (2008) Factors influencing development of subcutaneous carbon dioxide emphysema in laparoscopic totally extraperitoneal inguinal hernia repair. J Laparoendosc Adv Surg Tech A 18:213-216. https://doi.org/10.1089/lap.2007.0089\u003c/li\u003e\n\u003cli\u003eJapanese Gastric Cancer Association (2021) Japanese gastric cancer treatment guidelines 2018 (5th edition). Gastric Cancer 24:1-21. https://doi.org/10.1007/s10120-020-01042-y\u003c/li\u003e\n\u003cli\u003eUyama I, Kanaya S, Ishida Y, Inaba K, Suda K, Satoh S (2012) Novel integrated robotic approach for suprapancreatic D2 nodal dissection for treating gastric cancer: technique and initial experience. World J Surg 36:331-337. https://doi.org/10.1007/s00268-011-1352-8\u003c/li\u003e\n\u003cli\u003eSuda K, Nakauchi M, Inaba K, Ishida Y, Uyama I (2016) Robotic surgery for upper gastrointestinal cancer: current status and future perspectives. Dig Endosc 28:701-713. https://doi.org/10.1111/den.12697\u003c/li\u003e\n\u003cli\u003eMcAllister JD, D\u0026apos;Altorio RA, Snyder A (1991) CT findings after uncomplicated percutaneous laparoscopic cholecystectomy. J Comput Assist Tomogr 15:770-772. https://doi.org/10.1097/00004728-199109000-00008 \u003c/li\u003e\n\u003cli\u003eKukuruza K, Aboeed A (2022) Subcutaneous emphysema. StatPearls, StatPearls Publishing LLC, St. Petersburg, FL\u003c/li\u003e\n\u003cli\u003eFukui S, Kagebayashi Y, Iemura Y, Matsumura Y (2022) Severe subcutaneous emphysema caused by small injury to the abdominal wall during robot-assisted laparoscopic radical prostatectomy. Urol Case Rep 40:101904. https://doi.org/10.1016/j.eucr.2021.101904\u003c/li\u003e\n\u003cli\u003eWorrell JB, Cleary DT (2002) Massive subcutaneous emphysema and hypercarbia: complications of carbon dioxide absorption during extraperitoneal and intraperitoneal laparoscopic surgery\u0026mdash;case studies. AANA J 70:456-461\u003c/li\u003e\n\u003cli\u003eLuketina R, Luketina TLH, Antoniou SA, K\u0026ouml;hler G, K\u0026ouml;nneker S, Manzenreiter L, Wundsam H, Koch OO, Knauer M, Emmanuel K (2021) Prospective randomized controlled trial on comparison of standard CO(2) pressure pneumoperitoneum insufflator versus AirSeal\u0026reg;. Surg Endosc 35:3670-3678. https://doi.org/10.1007/s00464-020-07846-4\u003c/li\u003e\n\u003cli\u003eRazdan S, Ucpinar B, Okhawere KE, Badani KK (2023) The role of AirSeal in robotic urologic surgery: a systematic review. J Laparoendosc Adv Surg Tech A 33:21-31. https://doi.org/10.1089/lap.2022.0153\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"robotic gastrectomy, subcutaneous emphysema, postoperative complication, LAP PROTECTOR, pneumoperitoneum, da Vinci surgical system","lastPublishedDoi":"10.21203/rs.3.rs-2722291/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-2722291/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eSubcutaneous emphysema (SE), a complication of robotic gastrectomy (RG), occurs when the gas used to establish pneumoperitoneum escapes and enters the soft tissue. SE typically does not result in major clinical problems, but massive SE can have life-threatening consequences. Hence, developing adequate preventive methods against postoperative SE is essential. We aimed to determine whether an existing protective device, the LAP PROTECTOR\u0026trade; (LP), can be used to reduce the incidence of SE after RG. We analyzed the data of 194 patients who underwent RG at our hospital between August 2016 and December 2022. Since September 2021 (the 102nd patient), we have used the LP (FF0504; Hakko Medical, Hongo, Tokyo, Japan) at the trocar site, as this was expected to reduce the incidence of SE. The primary endpoint of this study was the efficacy of the LP in reducing the incidence of clinically relevant SE (defined as SE extending into the cervical area) a day after RG. Univariate analysis revealed that sex, body mass index (BMI), and LP usage differed significantly between patients with and without postoperative SE. Logistic regression analysis revealed that male sex (odds ratio [OR]: 0.22, 95% confidence interval [CI]: 0.15\u0026ndash;0.72, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001), high BMI (OR: 0.13, 95% CI: 1.23\u0026ndash;4.45, P\u0026thinsp;=\u0026thinsp;0.009), and LP usage (OR: 0.11, 95% CI: 0.04\u0026ndash;0.3, P\u0026thinsp;\u0026lt;\u0026thinsp;0.001) were preventive factors independently associated with a lower incidence of clinically relevant SE. Placing an LP at the trocar site may be a safe and effective method of preventing SE after RG.\u003c/p\u003e","manuscriptTitle":"Using LAP PROTECTOR™ to prevent subcutaneous emphysema after robotic gastrectomy","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2023-03-24 16:04:29","doi":"10.21203/rs.3.rs-2722291/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Accepted","date":"2023-06-11T21:38:12+00:00","index":"","fulltext":""},{"type":"reviewersInvited","content":"","date":"2023-04-24T09:59:59+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2023-03-26T21:30:17+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2023-03-22T15:32:42+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Robotic Surgery","date":"2023-03-22T09:33:13+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-robotic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jors","sideBox":"Learn more about [Journal of Robotic Surgery](http://link.springer.com/journal/11701)","snPcode":"11701","submissionUrl":"https://submission.nature.com/new-submission/11701/3","title":"Journal of Robotic Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"d338b9fd-e583-45d7-9748-87172dc778da","owner":[],"postedDate":"March 24th, 2023","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2023-10-16T21:34:56+00:00","versionOfRecord":{"articleIdentity":"rs-2722291","link":"https://doi.org/10.1007/s11701-023-01651-6","journal":{"identity":"journal-of-robotic-surgery","isVorOnly":false,"title":"Journal of Robotic Surgery"},"publishedOn":"2023-06-19 21:16:46","publishedOnDateReadable":"June 19th, 2023"},"versionCreatedAt":"2023-03-24 16:04:29","video":"","vorDoi":"10.1007/s11701-023-01651-6","vorDoiUrl":"https://doi.org/10.1007/s11701-023-01651-6","workflowStages":[]},"version":"v1","identity":"rs-2722291","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-2722291","identity":"rs-2722291","version":["v1"]},"buildId":"DiO0y1XJrWGSkZWLOoVa_","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}