Individualized Positive End-Expiratory Pressure and Postoperative Pulmonary Outcomes in Laparoscopic and Robotic Abdominal-Pelvic Surgery: A Systematic Review and Meta-Analysis

Postoperative pulmonary complications remain clinically important after laparoscopic and robot-assisted abdominal-pelvic surgery, where pneumoperitoneum, altered respiratory mechanics, obesity, and procedure-specific positioning can promote lung collapse.This systematic review and meta-analysis evaluated whether individualized intraoperative positive end-expiratory pressure (PEEP), selected using patient-specific physiological or imaging responses, improves postoperative pulmonary outcomes compared with fixed or conventional PEEP.Randomized controlled trials involving adults undergoing eligible minimally invasive abdominal-pelvic procedures were identified through PubMed, Scopus, and Google Scholar and were included when they reported postoperative pulmonary or direct lung-aeration outcomes after extubation.Data were synthesized narratively, with random-effects meta-analysis performed for clinically compatible outcomes, and methodological quality was evaluated using a Cochrane risk-of-bias framework.Across the included evidence, individualized PEEP was generally associated with fewer postoperative pulmonary complications, fewer early postoperative oxygenation problems, and better postoperative lung-aeration measures, whereas binary atelectasis outcomes were more heterogeneous.Favorable findings were observed across driving-pressure-, compliance-, electrical-impedance-tomography-, and lung-ultrasound-guided approaches, although variation in outcome definitions, assessment times, and trial methods limits conclusions regarding the optimal titration strategy.Current evidence suggests that patient-specific PEEP selection may improve postoperative pulmonary outcomes, although larger, standardized trials are needed to determine the most effective titration strategy.