Subcutaneous Emphysema and Postoperative Complications in Robot‐Assisted Gastrectomy: Impact of a Lower‐Pressure Insufflation Strategy

ABSTRACT Introduction 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. Methods 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. Results 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. Conclusion 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.