CASE REPORT Hemiparesis after robotic laparoscopic radical cystectomy and ileal conduit formation in steep Trendelenburg position Ravindra Pandey • Rakesh Garg • V. Darlong • Jyotsna Punj • Chandralekha Received: 18 January 2011 / Accepted: 27 July 2011 Ó Springer-Verlag London Ltd 2011 Abstract Robotic surgery is becoming popular for min- imally invasive surgical procedures as robotic devices allow unprecedented control and precision. We report a case of robotic radical cystectomy with ileal conduit uri- nary diversion surgery having perioperative neurological complications related to prolonged surgery in the steep head-down position. There was a neurological deficit in the form of hemiparesis, which resolved with conservative management. We suggest that duration and positioning should be optimized for such prolonged surgery in the steep head-down position, and make some recommenda- tions. Moreover, in such surgeries great vigilance must be observed in the perioperative period. Keywords Robotic surgery Á Urinary bladder carcinoma Á Anaesthesia Á Hemiparesis Á Cerebral edema Introduction Conventional laparoscopic surgery is gradually being replaced by robotic surgery because of its benefit of unprecedented control and precision in minimally invasive procedures [1]. However, it is prudent to be aware of some unexpected complications associated with the procedure. Here, we report a case of transient hemiparesis following robotic radical cystectomy with ileal conduit formation. Case report A 65-year-old male, weighing 68 kg, diagnosed with uri- nary bladder (UB) carcinoma, was scheduled for robotic radical cystectomy with ileal conduit urinary diversion. Preanaesthetic evaluation of the patient revealed a pulse rate of 72 beats/min and blood pressure (BP) of 140/78 mmHg. Routine blood investigations including haemogram, liver, renal functions, chest X-ray and elec- trocardiogram (ECG) were within normal limits. In the operating room, ECG, non-invasive blood pres- sure (NIBP) and pulse oximeter were attached. After insertion of an epidural catheter in the L2–3 intervertebral space, anaesthesia was induced with intravenous fentanyl (100 lg), thiopentone (250 mg) and vecuronium (7 mg), and the lungs were ventilated with isoflurane (1–2%) in oxygen and nitrous oxide (50:50). Tracheal intubation was achieved with an 8-mm ID endotracheal tube. The right internal jugular vein (IJV) and left radial artery were cannulated. The patient was positioned in lithotomy and the upper limbs placed beside the torso, and shoulder braces were applied for support. Trocars were inserted after the creation of pneumoperitoneum. The patient was placed in steep Trendelenburg position (45°) for the entire surgical procedure. Anaesthesia was maintained on isoflurane (1–2%), keeping the minimum alveolar concentration at 1–1.2, and neuromuscular monitoring guided top-ups of vecuronium. Perioperative analgesia was maintained with infusion of 0.1% bupivacaine mixed with 2 lg/mL of fentanyl at 4–5 mL/h, administered epidurally with top-ups of intravenous fentanyl (0.5 lg/kg). The patient remained haemodynamically stable. Peak airway pressure ranged from 25 to 28 cmH 2 O, central venous pressure (CVP) ranged between 8 and 16 cmH 2 O and temperature remained *36°C. Total blood loss of 750 mL was R. Pandey Á R. Garg (&) Á V. Darlong Á J. Punj Á Chandralekha Department of Anaesthesiology and Intensive Care, All India Institute of Medical Sciences, Ansari Nagar, New Delhi 110029, India e-mail: drrgarg@hotmail.com 123 J Robotic Surg DOI 10.1007/s11701-011-0302-7