Subcutaneous Emphysema and Postoperative Complications in Robot-Assisted Gastrectomy: Impact of a Lower-Pressure...

Subcutaneous emphysema (SE) after minimally invasive surgery is common, but its clinical significance in robot-assisted gastrectomy remains unclear. We evaluated postoperative SE and explored the effect of a lower-pressure insufflation strategy.

We retrospectively reviewed 97 patients who underwent curative-intent robot-assisted gastrectomy for gastric cancer. SE on immediate postoperative abdominal radiographs was classified as negative or positive. Outcomes were compared between SE groups and between a standard-pressure period (10 mmHg) and a lower-pressure period (6-8 mmHg). Operative time was dichotomized using a 480-min cutoff based on ROC analysis for CD grade ≥ II complications. AUCs were compared using the DeLong method. A supplementary analysis included the case number.

SE occurred in 37 of 97 patients (38.1%). CD grade ≥ II complications were more frequent in the SE-positive than in the SE-negative group (29.7% vs. 8.3%). In the primary parsimonious multivariable model, SE positivity and prolonged operative time were associated with CD grade ≥ II complications. Adding SE to operative time increased the AUC numerically, but not significantly (DeLong p = 0.52). Compared with the standard-pressure period, the lower-pressure period showed a lower SE incidence, fewer CD grade ≥ II complications, and a shorter operative time. In a supplementary analysis, prolonged operative time remained significant, whereas case number was not, and the association with SE was attenuated.

Postoperative SE was common and may represent a marker of intraoperative physiologic or technical stress. A lower-pressure insufflation strategy coincided with lower SE incidence and fewer clinically relevant complications. These findings are hypothesis-generating.