Mechanical ventilation is essential for surgery under general anesthesia, but it introduces cyclical organ motion that complicates surgical precision and increases the risk of pulmonary complications for some thoracic and abdominal surgeries. Ventilator-induced lung inflation produces rhythmic displacement of the diaphragm, chest wall, and intra-abdominal organs, creating an inherently unstable operative field. Clinicians may need to use one-lung ventilation (OLV) during thoracic surgery and carbon dioxide pneumoperitoneum during laparoscopic abdominal surgery (which reduces the level of induced movement). Under both circumstances, altered respiratory mechanics, impaired gas exchange, and motion artifacts challenge the balance between surgical exposure and lung protection (1).

Thoracic surgery often requires OLV to improve visualization and access. However, this technique substantially increases mechanical stress on the ventilated lung. Redistribution of tidal volume to a single lung results in higher regional strain, elevated transpulmonary pressures, and heterogeneous ventilation. These factors contribute to atelectasis and ventilator-induced lung injury (VILI). Hypoxemia is a well-recognized complication of OLV, occurring in approximately 5% of cases despite modern anesthetic management. In addition to impairing gas exchange, respiratory motion persists during OLV due to diaphragmatic excursion and transmitted chest wall movement. This motion can disrupt fine surgical maneuvers and compromise operative accuracy. In addition, studies have demonstrated that both ventilated and nonventilated lungs are susceptible to inflammatory injury during OLV, especially when lung-protective strategies are not used (2).

Abdominal laparoscopic surgery presents distinct mechanical challenges primarily due to the creation of pneumoperitoneum, a state in which carbon dioxide is insufflated into the abdominal cavity to expand the operative workspace. This intentional elevation of intra-abdominal pressure displaces the diaphragm toward the head, reduces functional residual capacity, and increases chest wall elastance. These physiological changes elevate airway pressures and decrease lung compliance, thereby altering respiratory mechanics during mechanical ventilation. While pneumoperitoneum can reduce the magnitude of organ excursion by mechanically limiting diaphragmatic movement, it simultaneously increases overall system stiffness and pressure transmission to the thoracic cavity. As a result, respiratory mechanics may become less predictable, increasing the risk of perioperative pulmonary complications (3). The combined effects of pneumoperitoneum and ventilation are particularly relevant in laparoscopic and robotic surgery, where even small motion artifacts can compromise image guidance accuracy and instrument precision.

Respiratory motion also interferes with advanced surgical technologies, including image-guided navigation and robotic automation. Cyclic organ displacement reduces targeting accuracy and may necessitate intermittent apnea or reduced tidal volumes, both of which can compromise oxygenation. Conversely, excessive tidal volumes or inadequate positive end-expiratory pressure (PEEP) can exacerbate VILI by promoting volutrauma, especially in patients undergoing prolonged surgery or open lung ventilation (4).

To mitigate these risks, lung-protective ventilation has become central to intraoperative management during thoracic and abdominal surgery. Strategies include using low tidal volumes, individualized PEEP, and recruitment maneuvers to minimize overdistension while maintaining adequate oxygenation (3). Volume-controlled ventilation is often preferred intraoperatively to ensure consistent tidal delivery despite changing compliance during pneumoperitoneum or surgical manipulation. Deep neuromuscular blockade reduces spontaneous respiratory effort and abdominal wall tone further, contributing to a more stable operative field. These approaches collectively aim to reduce motion-induced surgical difficulty, protect lung function, and improve postoperative outcomes.

References

1. Campos JH, Feider A. Hypoxia During One-Lung Ventilation-A Review and Update. J Cardiothorac Vasc Anesth. 2018;32(5):2330-2338. doi:10.1053/j.jvca.2017.12.026

2. Lohser J, Slinger P. Lung Injury After One-Lung Ventilation: A Review of the Pathophysiologic Mechanisms Affecting the Ventilated and the Collapsed Lung. Anesth Analg. 2015;121(2):302-318. doi:10.1213/ANE.0000000000000808

3. Nguyen TK, Nguyen VL, Nguyen TG, et al. Lung-protective mechanical ventilation for patients undergoing abdominal laparoscopic surgeries: a randomized controlled trial. BMC Anesthesiol. 2021;21(1):95. Published 2021 Mar 30. doi:10.1186/s12871-021-01318-5

4. O’Gara B, Talmor D. Perioperative lung protective ventilation. BMJ. 2018;362:k3030. Published 2018 Sep 10. doi:10.1136/bmj.k3030