Association between intraabdominal pressure during gynaecologic laparoscopy and postoperative pain

Low-Impact Laparoscopy vs Conventional Laparoscopy for Appendectomy: A Prospective Randomized Trial

BACKGROUND

Low-impact laparoscopy (LIL), combining low-pressure insufflation and microlaparoscopy, is a surgical technique that is still not widely used and that has never been evaluated for the management of acute appendicitis. The aim of this study is to assess the feasibility of an LIL protocol, to compare postoperative pain, average length of stay, and in-hospital use of analgesics by patients who underwent appendectomy according to a conventional laparoscopy or an LIL protocol.

STUDY DESIGN

Patients presenting with acute uncomplicated appendicitis who were operated on between January 1, 2021, and July 10, 2022, were included in this double-blind, single-center, prospective study. They were preoperatively randomly assigned to a group undergoing conventional laparoscopy, ie with an insufflation pressure of 12 mmHg and conventional instrumentation, and an LIL group, with an insufflation pressure of 7 mmHg and microlaparoscopic instrumentation.

RESULTS

Fifty patients were included in this study, 24 in the LIL group and 26 in the conventional group. There were no statistically significant differences between the 2 patient groups, including weight and surgical history. The postoperative complication rate was comparable between the 2 groups (p = 0.81). Pain was reported as significantly lower according to the visual analog scale 2 hours after surgery among the LIL group (p = 0.019). For patients who underwent surgery according to the LIL protocol, the study confirms a statistically significant difference for theoretical and actual length of stay, ie -0.77 days and -0.59 days, respectively (p < 0.001 and p = 0.03). In-hospital use of analgesics was comparable between both groups.

CONCLUSIONS

In uncomplicated acute appendicitis, the LIL protocol could reduce postoperative pain and average length of stay compared to conventional laparoscopic appendectomy.

Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis

BACKGROUND

Guidelines do not provide clear recommendations with regard to the use of low intra-abdominal pressure (IAP) during laparoscopic surgery. The aim of this meta-analysis is to assess the influence of low versus standard IAP during laparoscopic surgery on the key-outcomes in perioperative medicine as defined by the StEP-COMPAC consensus group.

MATERIALS AND METHODS

We searched the Cochrane Library, PubMed, and EMBASE for randomized controlled trials comparing low IAP (<10 mmHg) with standard IAP (10 mmHg or higher) during laparoscopic surgery without time, language, or blinding restrictions. According to the PRISMA guidelines, two review authors independently identified trials and extracted data. Risk ratio (RR), and mean difference (MD), with 95% CIs were calculated using random-effects models with RevMan5. Main outcomes were based on StEP-COMPAC recommendations, and included postoperative complications, postoperative pain, postoperative nausea and vomiting (PONV) scores, and length of hospital stay.

RESULTS

Eighty-five studies in a wide range of laparoscopic procedures (7349 patients) were included in this meta-analysis. The available evidence indicates that the use of low IAP (<10 mmHg) leads to a lower incidence of mild (Clavien-Dindo grade 1-2) postoperative complications (RR=0.68, 95% CI: 0.53-0.86), lower pain scores (MD=-0.68, 95% CI: -0.82 to 0.54) and PONV incidence (RR=0.67, 95% CI: 0.51-0.88), and a reduced length of hospital stay (MD=-0.29, 95% CI: -0.46 to 0.11). Low IAP did not increase the risk of intraoperative complications (RR=1.15, 95% CI: 0.77-1.73).

CONCLUSIONS

Given the established safety and the reduced incidence of mild postoperative complications, lower pain scores, reduced incidence of PONV, and shorter length of stay, the available evidence supports a moderate to strong recommendation (1a level of evidence) in favor of low IAP during laparoscopic surgery.

Comparison of the effect of general anesthesia and spinal anesthesia technique combined with general anesthesia on intraabdominal volume during gynecological laparoscopy

PURPOSE

We aimed to investigate the effect of spinal anesthesia which will be performed simultaneously with general anesthesia on the site of operation with the same pressure.

MATERIAL AND METHOD

This study was conducted as a randomized, prospective clinical study on 40 patients who were randomly divided into two groups. Twenty women underwent general anesthesia (Group GA) and 20 women underwent spinal anesthesia with general anesthesia (Group SGA). For all cases, preoperative height, weight, waist circumference, body mass index (kg/m² ), the distance between both spina iliaca anterior superior, the distance of the intersection of both ribs with an imaginary line drawn over the anterior axillary line, suprapubic bone-umbilical, umbilical-xiphoid, and suprapubic bone-xiphoid distance from the midline of the abdomen were measured. Moreover, while the patient was lying in the neutral position on the operating table, the height of the highest point of the abdomen to the operating table was also measured. These measurements were repeated at intra-abdominal pressure (IAP) 14 and 25 mmHg. The amount of intra-abdominal insufflated CO₂ was also recorded at IAP 14 and 25 mmHg.

RESULTS

When the intra-abdominal insufflation volumes of both groups were compared at 14 and 25 mmHg, respectively, there was no statistical difference (p: 0.54, p: 0.40). When 14 and 25 mmHg were compared in all cases, a statistically significant difference was observed in other measurements except in xiphoid-umbilical distance (p < 0.05).

CONCLUSION

We found that spinal anesthesia combined with GA had no effect on the abdominal volume and anthropometric measurements in laparoscopic procedures.

Proposal of a Novel Index of Abdominal Compliance and the Association With Postoperative Pain After Laparoscopic Inguinal Hernia Repair

BACKGROUND

In laparoscopic surgery, low pneumoperitoneum pressure is reported to reduce pain, which suggests that easing abdominal expansion is crucial for less postoperative pain. However, although abdominal compliance (AC) is associated with the degree of abdominal expansion, the role of AC in pain by pneumoperitoneum is unknown. In this study, we devised a novel index as a surrogate of AC to evaluate the association between AC and postoperative pain in laparoscopic inguinal hernia repair.

MATERIALS AND METHODS

We reviewed 83 patients who underwent elective transabdominal preperitoneal repair from 2019 to 2021 at Heisei Memorial Hospital. Insufflation pressure was set to low pressure (8 mm Hg). The abdominal compliance index [ACI; insufflated intra-abdominal volume (L)/body surface area (m2)] was utilized to evaluate the association between AC and postoperative pain.

RESULTS

ACI was evaluated in 30 patients. Median ACI was 1.53 (1.00 to 2.48) L/m2. Although there was no difference in the average body constitution, the high ACI group (n=15) had significantly higher intra-abdominal volume at 8 mm Hg pressure, compared with the low ACI group (n=15) (3.1 vs. 2.1 L, P<0.0001). The high ACI group had significantly higher pain than the low ACI group on the day of surgery (2.0 vs. 1.0, P=0.006) and the day after (0.8 vs. 0.3, P=0.007). In addition, 46.7% of the patients in the high ACI group experienced pneumoperitoneum-associated pain, whereas patients in the low ACI group experienced incision pain only. Additional analgesics were administered in 53.3% of the high ACI group, compared with 33.3% in the low ACI group.

CONCLUSIONS

AC was suggested to be a vital factor of postoperative pain after laparoscopic inguinal hernia repair. Patients with high AC may be susceptible to higher pain by pneumoperitoneum, even in low-pressure settings.

Effects of Additional Intraoperative Administration of Sufentanil on Postoperative Pain, Stress and Inflammatory Responses in Patients Undergoing Laparoscopic Myomectomy: A Double-Blind, Randomized, Placebo-Controlled Trial

Purpose

Although pain after laparoscopic surgery is assumed to be minor, many women still suffer from unexpected postoperative pain. Thus, we aimed to assess whether additional intraoperative administration of sufentanil could help to improve postoperative pain and related agitation, stress, and inflammation response in patients undergoing laparoscopic myomectomy.

Patients and Methods

Forty female patients with uterine myoma scheduled for laparoscopic myomectomy under general anesthesia were randomized to receive sufentanil (group T, n=20) or normal saline (group C, n=20) 1h before the end of the surgery. The postoperative pain, agitation, stress, inflammation, and adverse effects were measured.

Results

As the primary outcome, the visual analog scale (VAS) pain score was significantly reduced in group T as compared with group C at each measured time point in a post-anesthesia care unit (PACU), VAS 5 min (31.5 ± 2.7 vs 40.6 ± 5.6) (P<0.001), VAS 30 min (36.5 ± 4.5 vs 46.0 ± 2.9) (P<0.001), VAS 1h (37.8 ± 4.0 vs 48.6 ± 5.5) (P<0.001). The secondary outcomes, including the sedation agitation scale (SAS) scores, plasma concentrations of epinephrine and norepinephrine, and the levels of plasma interleukin-6 (IL-6), interleukin-8 (IL-8), and tumor necrosis factor-alpha (TNF-α) in group T were remarkably lower than those in group C (P < 0.001). The cough cases in group T also showed a significant reduction in comparison with group C (P < 0.05). In addition, the anesthetic recovery time, including the spontaneous breathing recovery time and extubation time, were not significantly different between the two groups, as were the cases of respiratory depression and postoperative delirium (P > 0.05).

Conclusion

For patients undergoing laparoscopic myomectomy, administration of sufentanil 1 h before the end of surgery shows excellent analgesic and sedative effects, alleviated postoperative stress and inflammatory responses, reduced incidence of cough, without prolonging anesthetic recovery time and increasing adverse reactions.

Pain Vision System for Evaluating Chronic Pain: A Comparison with VAS Scoring

Objective. To study the value of pain vision system in quantitative evaluation of chronic pain from the perspective of neuroelectrophysiology, as compared with VAS (visual analog scale). Methods. Seventy-one patients with chronic pain were randomly selected to receive pain treatments from August 1, 2018, to September 30, 2018, in the Pain Department of Li Zhuang Tongji Hospital. Among all patients, 26 had cervical spondylosis and 45 had lumbar disc herniation. Pain vision and visual analog scoring (VAS) were used to evaluate the degree of pain before and after treatment. The correlation between the pain vision system’s pain ratio (pain ratio) and the VAS score was analyzed. Results. Pain ratio and VAS scores were linearly correlated before and after treatment in patients with chronic pain (Pearson coefficient was 0.730 before treatment and 0.449 after treatment; P<0.001). Conclusions. The pain vision system can evaluate chronic pain well and quantify it in the form of pain degree, which is helpful for objective quantitative analysis of chronic pain. This trial is registered with ChiCTR1900026331.