A 71-year-old man, posted for robotic-assisted laparoscopic prostatectomy, taught a roomful of people something that no textbook line ever quite lands the same way: a borderline cuff leak test can go either way, and even a reasonably read result doesn't guarantee what happens next at the bedside.
71-year-old male, 90 kg, diagnosed with carcinoma of the prostate, posted for robotic-assisted laparoscopic prostatectomy (RALP).
This patient walked into the room already carrying two separate risk profiles that don't talk to each other often enough — an airway that was borderline difficult before anyone even induced him, and a procedure that was about to spend hours quietly working against venous drainage from his head and neck.
Surgery lasted approximately 4.5 hours in steep Trendelenburg position. An intraoperative fluid-restrictive strategy was followed, in line with current recommendations for RALP to limit airway and facial edema. Hemodynamics stayed stable throughout, with blood pressure in the 130–140/90 mmHg range.
No issues were flagged intraoperatively. The case "looked clean" — which is exactly the problem with airway edema in steep Trendelenburg. It doesn't announce itself during the case. It announces itself afterward, when the head goes back down and the fluid that pooled for four and a half hours has nowhere obvious left to hide.
He was managed on the ventilator afterward, kept head-up, and was extubated later once airway edema had clinically resolved — the same safe pathway described for delayed extubation in the literature on this exact patient population.
This isn't a case about a missed or ignored warning sign. The surgery was fluid-restricted, the positioning was standard, the supine recovery period was observed, and the cuff leak test was performed and gave a borderline result — not a clear pass, not a clear fail. The team made a defensible call on an ambiguous number. The airway still failed about fifteen minutes later.
That gap is what stayed with me. A leak in the 100–150 mL range sits in a zone where the published literature itself disagrees on interpretation — some thresholds (110 mL, 130 mL) would call parts of that range reassuring, others would call the lower end of it concerning. This is precisely why current evidence describes the cuff leak test as a tool with excellent specificity but only moderate sensitivity: a passing or borderline result is genuinely useful for flagging patients at higher risk, but it cannot, by itself, rule out airway edema that is still actively progressing in the tissue. The guidance that follows from this is not "the team should have read the number differently" — it's that close post-extubation monitoring is required regardless of how the leak test reads, and matters most in exactly this kind of high-risk patient.
When the cuff leak volume falls in a borderline zone (roughly 100–150 mL by commonly cited thresholds), the result should not be treated as clearance to extubate and move on — especially in a patient with baseline difficult-airway features after prolonged steep Trendelenburg. Close observation should continue for at least 15–30 minutes after extubation, with re-intubation equipment immediately at hand, regardless of how the leak test was read at the time.
The post-case discussion covered four things worth carrying into the next steep-Trendelenburg case:
Conjunctival edema (CE) is one of the few signs of upper-body venous congestion you can actually see intraoperatively without any extra equipment. A 2019 retrospective study of 56 RALP patients found CE in 23.21% of cases — and of those who developed CE, 61.54% went on to have delayed extubation, a statistically significant association (p = 0.0008).1 The same study found that prolonged Trendelenburg time trended toward more delayed extubation, though this didn't reach statistical significance (p = 0.0842) — duration matters, but it isn't the whole story.
The practical takeaway raised in discussion: check the conjunctivae roughly every 15 minutes during a long Trendelenburg case, and treat visible CE as a trigger to consider a diuretic rather than a finding to simply note in the chart.
Worth flagging directly: clinicians use "positive" and "negative" inconsistently for this test. In most of the quantitative literature (Miller & Cole 1996; Jaber et al. 2003), a "positive" cuff leak test actually refers to a low leak volume (<110 mL) — positive for risk — while a "negative" test means an adequate leak and lower risk. This patient's leak, at 100–150 mL, straddled the commonly cited 110–130 mL threshold zone — a genuinely borderline number rather than a clearly reassuring one. The practical lesson isn't to distrust the test outright; it's to recognise that a borderline or even a clearly "good" volume doesn't override the rest of a patient's risk profile, and shouldn't be the only thing the extubation decision rests on.
For patients requiring central venous access who are also going into steep Trendelenburg, the discussion favored avoiding internal jugular cannulation where feasible and preferring the subclavian route — partly to avoid adding to head-and-neck venous congestion that the position is already creating, and partly to keep the access route undisturbed by the same swelling you're trying to monitor for.
Steep Trendelenburg raises intraocular pressure (IOP) and intracranial pressure (ICP), and in patients with a history suggestive of glaucoma or raised ICP, this carries a real risk of postoperative visual loss. A relevant ocular and neurological history should be taken before any pelvic surgery planned in steep Trendelenburg, and a modified, less steep ("Z") Trendelenburg position should be considered for patients identified as high-risk.
Current perioperative airway guidance continues to support extubation caution after prolonged steep Trendelenburg and pneumoperitoneum, particularly in patients with baseline difficult-airway features. Practical measures with reasonable supporting evidence include:
None of this is exotic. All of it was, in fact, already present in this case — the fluid restriction was followed, the position change before extubation was observed, the cuff leak test was performed and gave a borderline number that was read as acceptable. The lesson here isn't "do more" or "distrust every test." It's "an equivocal result deserves the same vigilance as a worrying one." The 15–30 minutes after extubation are not a formality to get through — they're the window where this kind of edema actually declares itself.
This case has been fully de-identified. No institutional or departmental identifiers are included. Details have been generalised where necessary to protect patient and staff confidentiality, consistent with HIPAA principles, India's Digital Personal Data Protection (DPDP) Act 2023, and NMC ethical guidelines. This content is for educational reflection only and does not represent the views of any institution, employer, or training program, and is not a substitute for independent clinical judgment.