Article based on the webinar Innovation and Challenging Dogmas with Robotic Urologic Surgery featuring Dr. Ronney Abaza
Challenging Surgical Dogmas: The Case for Ultra-Low Pneumo Pressure in Robotic Urology
- Published: 5/19/2025
- 5 min
For decades, robotic-assisted surgery inherited the principles of laparoscopy, including the belief that an insufflated abdomen is necessary for successful procedures. Early adopters of robotics borrowed the standard 15 mmHg pressure used in laparoscopy without questioning whether it was truly needed. Like many surgeons, I followed this norm—until a pivotal study in 2016 changed my approach entirely.
Breaking Tradition: How a Study Redefined My Practice
While comparing AirSeal® insufflation with a standard insufflator, I decided to challenge conventional wisdom. Instead of the usual 15 mmHg pressure, I started at just 6 mmHg—expecting to increase it as needed.
The results were astonishing: 100 consecutive prostatectomies were successfully completed at 6 mmHg, with significantly improved patient outcomes.
Patients experienced:
- Less post-operative pain
- Reduced groin discomfort
- Elimination of pneumoscrotum
- Nearly zero incidence of shoulder pain
- Faster return to normal bowel function
Seeing these benefits, I adopted 6 mmHg as my standard for prostate surgeries. Over time, I pushed the boundaries even further—eventually performing procedures at zero insufflation pressure.
Debunking the Bleeding Concern
One of the biggest concerns about lower pneumo pressure is potential increased bleeding. Many surgeons worry that reducing pressure will lead to excessive venous bleeding, particularly during procedures like robotic prostatectomy. However, I can confidently say this concern is largely unfounded.
In my experience performing robotic prostatectomies at a pneumo pressure of zero, venous bleeding has not been an issue. When I first attempted zero-pressure cases, I expected bleeding similar to open prostatectomy, where cutting through the dorsal venous complex leads to significant hemorrhage. But this didn’t happen. Patients had minimal bleeding, no transfusions, and all went home the same day.
For those hesitant to lower their pneumo pressure, there’s always an option to temporarily increase it during moments of heightened concern. Turning pressure up to 12 mmHg for a few minutes during a critical phase still provides benefits, since the total time at high pressure is what impacts post-operative pain and recovery.
A Case for Ultra-Low Pressure
Physiologically, the human abdomen is naturally at zero pressure—the same as atmospheric pressure. Traditional insufflation forces an unnatural increase, affecting patient pain levels, ventilation, and recovery. By using the lowest possible pressure, we bring surgical conditions closer to normal physiology.
Over the last few years, I’ve performed over 3,000 prostatectomies at 6 mmHg or lower, including some at zero pressure. Patients have consistently had better outcomes, less pain, and faster discharge times.
In a randomized study published in 2022 comparing 6 mmHg vs. 15 mmHg, results confirmed:
- Improved ventilation for obese patients
- Faster recovery and fewer complications
- Near elimination of post-op ileus and readmissions
A Call for Change in Robotic Surgery
Robotic surgery offers stable abdominal conditions without relying on excessive insufflation. Unlike laparoscopy, the robotic arms suspend the abdominal wall, maintaining working space even at lower pressures. This means we no longer need to default to 15 mmHg, a pressure borrowed from a technique that is fundamentally different.
While zero-pressure surgery is still in its experimental phase, my ongoing cases prove that it’s possible. As robotic techniques evolve, it's time we challenge outdated assumptions and adopt strategies that prioritize patient recovery and comfort—starting with rethinking insufflation pressure.
For surgeons hesitant to drop pressure immediately, the best approach is:
- Start low—try 6 mmHg instead of 15
- Monitor patient response—adjust pressure only if needed
- Use AirSeal® to maintain stable insufflation and visibility
For surgeons interested in seeing ultra-low-pressure techniques in action, my YouTube channel features full-length cases. The data speaks for itself: lower pressures mean better outcomes.