Resuscitation in the Era of Robotic Surgery: A Cross-Procedure Narrative Review and Proposed Protocol for Indian Practice

Abstract

Robotic surgery is expanding rapidly in India and globally, yet the docked configuration of robotic platforms creates mechanical, physiological, and human-factor obstacles to intraoperative resuscitation that standard advanced cardiovascular life support (ACLS) protocols do not contemplate. This narrative review synthesizes the determinants of cardiac arrest during docked robotic surgery and proposes a structured robotic arrest protocol (RAP) adapted for Indian practice. The dominant time cost in resuscitation is the undocking interval—averaging approximately 146 s in untrained teams—which delays high-quality chest compressions and defibrillation. Carbon dioxide pneumoperitoneum reduces chest-wall compliance and venous return; steep Trendelenburg position lowers left ventricular ejection fraction and impairs the hemodynamic efficacy of compressions. Procedure-specific risks include venous gas embolism in urogynecological surgery, shared-airway compromise in transoral robotic surgery, and carotid-sinus hypersensitivity in robotic-assisted breast-axillo-insufflation thyroidectomy. Human-factor risks include fixation error, console–bedside communication latency, and role ambiguity. The proposed RAP is built on three pillars: (i) early recognition with a standardized trigger word, (ii) parallel-process emergency undocking with venting of pneumoperitoneum, and (iii) immediate horizontal repositioning before ACLS, supported by defined role allocation, pre-brief safety checklists, and in situ multidisciplinary simulation. Adoption by Indian centers and incorporation into Indian Society of Anesthesiologists and Indian Resuscitation Council frameworks may reduce time to first compression and improve neurologically intact survival. As India scales robotic surgery, minimal access must not translate into minimal safety.