Respiratory changes: Pneumoperitoneum can lead to upward diaphragmatic displacement, reduce lung volume and compliance, increase airway resistance, increase ventilation/perfusion (V/Q) mismatch, cause hypoxia/hypercarbia and increase risk of regurgitation. Increase in minute ventilation by 15–25 % offsets this problem. If surgery is prolonged, it is advisable to do arterial blood gas analysis to know the acidosis status of the patient [9–13].

Cardiovascular changes [8, 14–18]: Pneumoperitoneum can show biphasic changes in cardiac output, increased systemic vascular resistance, raised mean arterial pressure (MAP), compression of IVC and reduced venous return. To maintain the haemodynamic stability, patient should be preloaded with crystalloid fluid before pneumoperitoneum, and creation of pneumoperitoneum should be gradual. During creation of pneumoperitoneum, it leads to increase vagal tone, bradycardia and hypotension, which can be treated by injection atropine.

Renal effects [8, 19]: Pneumoperitoneum is also responsible for the reduction of renal blood flow, reduced glomerular filtration rate and reduced urine output. These are the unfavourable effects for the donor kidney. To counteract these effects, it is always better to keep MAP >100 mmHg and administer diuretics just prior to onset of pneumoperitoneum (intravenous injection of 10 mg frusemide). Urine output monitoring is also required every half hourly to monitor the effect of pneumoperitoneum on renal function.

The other effects of pneumoperitoneum are decreased mesenteric circulation, increased intracranial pressure, increased intraocular pressure [20] and fall in body temperature and should be taken into consideration.

Decreased venous return from lower limbs, decreased venous peak flow rate in the femoral vein, increased femoral venous pressure and reduced venous pulsatility contribute to the development of venous thromboembolism (VTE) and deep-vein thrombosis (DVT). For all indications and all ages, reported incidence of DVT is 50 per 100,000 patients. The incidence of DVT rarely occurs before 20 years, but the incidence increases with age. The incidence of DVT, in patients over 70 years, is 200 per 100,000 [21]. For urological laparoscopic procedures, postoperative VTE has been reported in 0.13–1.3 % [22, 23]. DVT and VTE are important preventable complications that put the patients at risk of pulmonary embolism, recurrent VTE and post-thrombotic syndrome [24]. Usually, urological laparoscopic surgery carries the minimal risk of VTE as per available data on literature. Among the many risk factors, age over-exceeding 40 years, previous VTE, obesity, varices and oestrogen use are especially relevant for surgical patients. Recently, the approach to the problem has become increasingly evidence-based, and some relevant medical professional societies worldwide have recommendation and clinical practice guidelines. According to their recommendation, there are four levels of risk emerged, and preventive strategies need to be applied [25]. As a policy, we ensure that early mobilization, compression elastic stocking and sometimes low molecular weight heparin (LMWH) are the main tools for DVT prophylaxis.