Creation of pneumoperitoneum: noninvasive monitoring of clinical effects of elevated intraperitoneal pressure for the insertion of the first trocar

Low- versus standard- pneumoperitoneum in patients undergoing robot-assisted radical prostatectomy: a randomised, triple-blinded study

OBJECTIVE

To investigate the effectiveness and impact of low-pressure pneumoperitoneum (Pnp) on postoperative quality of recovery (QoR) and surgical workspace (SWS) in patients with prostate cancer undergoing robot-assisted radical prostatectomy (RARP).

PATIENTS AND METHODS

A randomised, triple-blinded trial was conducted in a single centre in Denmark from March 2021 to January 2022. A total of 98 patients with prostate cancer undergoing RARP were randomly assigned to either low-pressure Pnp (7 mmHg) or standard-pressure Pnp (12 mmHg). Co-primary outcomes were postoperative QoR measured via the QoR-15 questionnaire on postoperative Day 1 (POD1), POD3, POD14, and POD30, and SWS assessed intraoperatively by a blinded assessor (surgeon) via a validated SWS scale. Data analysis was performed according to the intention-to-treat principle.

RESULTS

Patients who underwent RARP at low Pnp pressure demonstrated better postoperative QoR on POD1 (mean difference = 10, 95% confidence interval [CI] 4.4-15.5), but no significant differences were observed in the SWS (mean difference = 0.25, 95% CI -0.02 to 0.54). Patients allocated to low-pressure Pnp experienced statistically higher blood loss than those in the standard-pressure Pnp group (mean difference = 67 mL, P = 0.01). Domain analysis revealed significant improvements in pain (P = 0.001), physical comfort (P = 0.007), and emotional state (P = 0.006) for patients with low-pressure Pnp. This trial was registered at ClinicalTrials.gov, NCT04755452, on 16/02/2021.

CONCLUSION

Performing RARP at low Pnp pressure is feasible without compromising the SWS and improves postoperative QoR, including pain, physical comfort, and emotional state, compared to the standard pressure.

Effect of low-pressure pneumoperitoneum on pain and inflammation in laparoscopic cholecystectomy: a randomized controlled clinical trial

OBJECTIVE

We aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers.

BACKGROUND

The standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12-14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines.

METHODS

A prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8-10 mmHg) vs. standard-pressure (12-14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed.

RESULTS

one hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs. 6, p-value = 0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons.

CONCLUSION

low-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022).

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.

Lower vs standard pressure pneumoperitoneum in robotic-assisted radical prostatectomy: a systematic review and meta-analysis

Robotic-assisted laparoscopic radical prostatectomy (RARP) has been traditionally performed at a pneumoperitoneum insufflation pressure of 12-15 mmHg. This meta-analysis and systematic review aims to assess the current evidence comparing lower to standard pressure pneumoperitoneum in RARP. Systematic searches of MEDLINE, COCHRANE, SCOPUS and EMBASE were performed to identify articles published up until November 2021 comparing lower pressure with standard pressure pneumoperitoneum in RARP. Standard pressure was defined as > 12 mmHg and lower pressure ≤ 12 mmHg. Estimated blood loss, length of operation, length of hospital stay, post-operative ileus, 30-day readmissions, Clavien-Dindo complications and rate of positive surgical margins were extracted as endpoints of interest. Our searches identified 165 abstracts of which 4 articles with 1319 patients were eligible. Cumulative analysis demonstrated reduced length of stay when a lower pressure was used: WMD - 0.23 (- 0.45 to - 0.02) days (p = 0.03) as well as a reduced rate of post-operative ileus: OR 0.41 (0.22 to 0.77) (p = 0.006). There was no significant increase in length of operation WMD - 1.79 (- 15.96 to 12.38) (p = 0.8), estimated blood loss WMD - 2.89 (- 29.41 to 23.62) (p = 0.83), 30-day readmissions or positive surgical margins OR 1.04 (0.78 to 1.38) (p = 0.81) and RD - 0.01 (- 0.04 to 0.01) (p = 0.3) when using a lower pressure. We have demonstrated reduced length of stay and rates of post-operative ileus, when performing RARP at a lower pressure without a significant increase in length of operation, estimated blood loss, positive surgical margins or complications. The recommendation to use lower pressure pneumoperitoneum is moderate to weak and more randomised control trials are required to validate these results.

Total Hysterectomy by Low-Impact Laparoscopy to Decrease Opioids Consumption: A Prospective Cohort Study

Our objective was to evaluate postoperative pain and opioid consumption in patients undergoing hysterectomy by low-impact laparoscopy and compare these parameters with conventional laparoscopy. We conducted a prospective study in two French gynecological surgery departments from May 2017 to January 2018. The primary endpoint was the intensity of postoperative pain evaluated by a validated numeric rating scale (NRS) and opioid consumption in the postoperative recovery unit on Day 0 and Day 1. Thirty-two patients underwent low-impact laparoscopy and 77 had conventional laparoscopy. Most of the patients (90.6%) who underwent low-impact laparoscopy were managed as outpatients. There was a significantly higher consumption of strong opioids in the conventional compared to the low-impact group on both Day 0 and Day 1: 26.0% and 36.4% vs. 3.1% and 12.5%, respectively (p = 0.02 and p < 0.01). Over two-thirds of the patients in the low-impact group did not require opioids postoperatively. Two factors were predictive of lower postoperative opioid consumption: low-impact laparoscopy (OR 1.38, 95%CI 1.13−1.69, p = 0.002) and a mean intraoperative peritoneum below 10 mmHg (OR 1.25, 95%CI 1.03−1.51). Total hysterectomy by low-impact laparoscopy is feasible in an outpatient setting and is associated with a marked decrease in opioid consumption compared to conventional laparoscopy.

Deep Neuromuscular Blockade Combined with Low Pneumoperitoneum Pressure for Nociceptive Recovery After Major Laparoscopic Gastrointestinal Surgery: Study Protocol for a Randomized Controlled Trial

Purpose

Patients undergoing major laparoscopic surgery often experience significant pain and postoperative nausea and vomiting (PONV). Deep neuromuscular block (NMB) improves surgical conditions and facilitates the application of low intra-abdominal pressure (IAP), which may be beneficial for these patients. This study is designed to determine the effects of deep NMB combined with low IAP, as compared to moderate NMB combined with standard IAP, on patients' nociceptive recovery after major laparoscopic gastrointestinal surgery.

Study Design and Methods

This single-center randomized controlled trial will include 220 patients scheduled for major laparoscopic gastrointestinal surgery (lasts for ≥ 90 minutes). Patients will be randomly assigned, with a 1:1 ratio, into a deep NMB + low IAP group (train of four = 0, post-tetanic count = 1-3, IAP = 8 mmHg) and a moderate NMB + standard IAP group (train of four = 1-3, IAP = 12 mmHg). If the surgical workspace is inadequate, the surgeons can request a step increase of 1 mmHg in IAP during 3-min intervals. The upper limit of IAP will be set at 15 mmHg. Postoperative recovery will be assessed using the postoperative quality recovery scale (PQRS). The primary outcome of this trial is the PQRS nociceptive recovery (including pain and PONV) at postoperative day (POD) 1. The secondary outcomes include recovery in other PQRS domains at POD 1, and recovery in all PQRS domains in a post-anesthesia care unit, at POD 3 in the surgical wards, at hospital discharge, and at postoperative 30 days. For the sample size estimation, 110 patients in each group (220 in total) would be needed to detect an absolute increase rate of 20% in the PQRS nociceptive domain in the deep NMB + low IAP group at POD 1.

Discussion

This study investigates the effects of deep NMB combined with low IAP on postoperative PQRS nociceptive recovery in patients undergoing major laparoscopic gastrointestinal surgery. We expect that this deep NMB + low IAP strategy would improve postoperative pain and PONV following major laparoscopic gastrointestinal surgery.

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2 : a prospective randomised controlled clinical trial

OBJECTIVE

To compare the effects of two different intraoperative CO₂ pressures (8 and 15 mmHg) during laparoscopic hysterectomy for benign uterine pathologies in terms of postoperative abdominal and shoulder pain, laparoscopy-mediated vegetative alterations, pain medication requirement, arterial CO₂ pressure (pCO₂ ), surgical parameters, and safety.

DESIGN

Prospective randomised controlled study.

SETTING

German university hospital.

POPULATION

Female patients undergoing laparoscopic hysterectomy for benign uterine pathologies.

METHODS

Patients were randomised to a standard pressure (SP; 15 mmHg, control) or low-pressure (LP; 8 mmHg, experimental) group.

MAIN OUTCOME MEASURES

Primary outcomes were postoperative abdominal and shoulder pain intensities, measured via numeric rating scale (NRS) and vegetative parameters (fatigue, nausea, vomiting, bloating) at 3, 24, and 48 hours postoperatively. Secondary outcomes were pain medication requirement (mg) and arterial pCO₂ (mmHg). Surgical parameters and intra- and postoperative complications were also recorded.

RESULTS

In total, 178 patients were included. Patients in the LP group (n = 91) showed significantly lower postoperative abdominal and shoulder pain scores, fewer vegetative alterations, lower pain medication requirements, a shorter postoperative hospitalization, and lower intra- and postoperative arterial pCO₂ values compared with the SP group (n = 87; P ≤ 0.01). No differences in intra- and postoperative complications were observed between groups.

CONCLUSIONS

Low-pressure laparoscopy seems to be an effective and safe technique for the reduction of postoperative pain and laparoscopy-induced metabolic and vegetative alterations following laparoscopic hysterectomy for benign indications.

TWEETABLE ABSTRACT

Low-pressure laparoscopy seems to be an effective and safe technique for reduction of pain following laparoscopic hysterectomy.

Comparison of two methods of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed and complication in urologic surgery

BACKGROUND

Nowadays, diverse approaches have been existed for laparoscopic procedures. The most common laparoscopic entry methods included close and direct entry laparoscopy and open (Hasson) laparoscopy. There is no evidence regarding the superiority in safety and initial speed for the use of open and optical laparoscopic entry. Therefore, the sight of current study was to evaluate comparative survey of two methods of laparoscopic trocar insertion (Hasson and VisiportTM) in terms of speed and complications in urologic surgery.

METHODS

This expertized base clinical trial study was conducted on 100 patients who underwent urological laparoscopy in Alzahra Hospital, Isfahan, Iran. These patients were randomly divided to two groups (n = 50). One group underwent open laparoscopy and another group Visiport optical trocar. Speed and Complications of urologic surgery was extracted from medical records. Independent T test was used for doing of analysis.

RESULTS

The mean age of patients in Hasson and Visiport laparoscopic group was 41.4 ± 11.2 and 41.6 ± 15 years old, respectively (p = 0.91). The mean time for initial trocar placement in patients who underwent Visiport trocar system and Hasson laparoscopic technique was 37.7 ± 15.59 and 95.4 ± 31.75 seconds. There was gratifying difference between two techniques of laparoscopic trocar insertion (Hasson and Visiport) in terms of speed (p = 0.000). In addition, complications were observed in 8% of patients who underwent Visiport trocar system. However, no complications were observed in Hasson laparoscopy group.

CONCLUSION

Visiport optical trocar technique is faster for initial trocar placement than open laparoscopy. However it is associated with complications compared to open laparoscopy. Therefore, there is evidence of benefit in terms of speed for initial trocar placement and harm based on complications in Visiport trocar system.

What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review

Background

Laparoscopic surgery has several advantages when compared to open surgery, including faster postoperative recovery and lower pain scores. However, for laparoscopy, a pneumoperitoneum is required to create workspace between the abdominal wall and intraabdominal organs. Increased intraabdominal pressure may also have negative implications on cardiovascular, pulmonary, and intraabdominal organ functionings. To overcome these negative consequences, several trials have been performed comparing low- versus standard-pressure pneumoperitoneum.

Methods

A systematic review of all randomized controlled clinical trials and observational studies comparing low- versus standard-pressure pneumoperitoneum.

Results and conclusions

Quality assessment showed that the overall quality of evidence was moderate to low. Postoperative pain scores were reduced by the use of low-pressure pneumoperitoneum. With appropriate perioperative measures, the use of low-pressure pneumoperitoneum does not seem to have clinical advantages as compared to standard pressure on cardiac and pulmonary function. Although there are indications that low-pressure pneumoperitoneum is associated with less liver and kidney injury when compared to standard-pressure pneumoperitoneum, this does not seem to have clinical implications for healthy individuals. The influence of low-pressure pneumoperitoneum on adhesion formation, anastomosis healing, tumor metastasis, intraocular and intracerebral pressure, and thromboembolic complications remains uncertain, as no human clinical trials have been performed. The influence of pressure on surgical conditions and safety has not been established to date. In conclusion, the most important benefit of low-pressure pneumoperitoneum is lower postoperative pain scores, supported by a moderate quality of evidence. However, the quality of surgical conditions and safety of the use of low-pressure pneumoperitoneum need to be established, as are the values and preferences of physicians and patients regarding the potential benefits and risks. Therefore, the recommendation to use low-pressure pneumoperitoneum during laparoscopy is weak, and more studies are required.

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases

BACKGROUND AND OBJECTIVE

to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar.

METHODS

sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes.

RESULTS

there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed.

CONCLUSIONS

high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Effects of elevated artificial pneumoperitoneum pressure on invasive blood pressure and levels of blood gases

BACKGROUND AND OBJECTIVE

to evaluate the clinical, hemodynamic, gas analysis and metabolic repercussions of high transient pressures of pneumoperitoneum for a short period of time to ensure greater security for introduction of the first trocar.

METHODS

sixty-seven patients undergoing laparoscopic procedures were studied and randomly distributed in P12 group: n=30 (intraperitoneal pressure [IPP] 12mmHg) and P20 group: n=37 (IPP of 20mmHg). Mean arterial pressure (MAP) was evaluated by catheterization of the radial artery; and through gas analysis, pH, partial pressure of oxygen (PaO2), partial pressure of CO2 (PaCO2), bicarbonate (HCO3) and alkalinity (BE) were evaluated. These parameters were measured in both groups at time zero before pneumoperitoneum (TP0); at time 1 (TP1) when IPP reaches 12mmHg in both groups; at time 2 (TP2) after five min with IPP=12mmHg in P12 and after 5min with IPP=20mmHg at P20; and at time 3 (TP3) after 10min with IPP=12mmHg in P12 and with return of IPP from 20 to 12mmHg, starting 10min after TP1 in P20. Different values from those considered normal for all parameters assessed, or the appearance of atypical organic phenomena, were considered as clinical changes.

RESULTS

there were statistically significant differences in P20 group in MAP, pH, HCO3 and BE, but within normal limits. No clinical and pathological changes were observed.

CONCLUSIONS

high and transient intra-abdominal pressure causes changes in MAP, pH, HCO3 and BE, but without any clinical impact on the patient.

Laparoscopic-assisted ovariectomy of tigers (Panthera tigris) with the use of the LigaSure device

Laparoscopic ovariectomy was performed in seven tigers with the use of a vessel-sealing device and a three-port technique. A comparison group of seven tigers that underwent traditional ovariohysterectomy was assembled with the use of a medical records search. Mean operative times for laparoscopic ovariectomy were compared to standard ovariohysterectomy, and mean combined laparoscopic incision length compared to standard ovariohysterectomy incision lengths. Significance was set at P < or = 0.05. Mean surgical time for laparoscopic ovariectomy (82 min, range 71-126 min) was significantly shorter than standard ovariohysterectomy surgical time (129 min, range 80-165 min, P = 0.007). Mean combined laparoscopic incision length (8.07 cm, range 3.80-9.50 cm) was significantly shorter than the mean incision length for standard ovariohysterectomy (13.57 cm, range 12.00-20.00 cm, P = 0.009). There were no clinically important complications observed in either group. Laparoscopic ovariectomy has a significantly shorter surgical time and combined incision length compared to standard ovariohysterectomy in tigers, and appears to be a safe and rapid sterilization method for tigers. Equipment cost and the necessity for advanced training may limit its use in some institutions. Further prospective evaluation is warranted to determine whether it is associated with decreased morbidity, mortality, or cost.

Comparison of two entry methods for laparoscopic port entry: technical point of view

Laparoscopic entry is a blind procedure and it often represents a problem for all the related complications. In the last three decades, rapid advances in laparoscopic surgery have made it an invaluable part of general surgery, but there remains no clear consensus on an optimal method of entry into the peritoneal cavity. The aim of this paper is to focus on the evolution of two used methods of entry into the peritoneal cavity in laparoscopic surgery.

Laparoscopic management of a large torted ovarian cyst in an adolescent virgin: a case report

We report a case of a torted mature cystic teratoma in a 23-year-old, sexually inactive, virgin female which necessitated immediate laparoscopy. The patient and her family stressed that the integrity of the hymen must be maintained at any cost, for cultural reasons. We opted out of our routine intravaginal preparation for laparoscopic surgery to honor the patient’s request to maintain the integrity of the hymen. Left salpingo-oophorectomy was accomplished, and the specimen was removed using a large nephrectomy endobag. Here, we describe techniques that are useful for this procedure, including the use of gauze attached to ovum forceps to manipulate the uterus through the rectum, and a review of the literature.

Hemodynamic effects of laparoscopic radiofrequency ablation of liver tumors versus laparoscopic hepatic ultrasound examination

STUDY OBJECTIVE

To compare the hemodynamic changes that occur during laparoscopic radiofrequency ablation of liver metastases with those occurring during laparoscopic ultrasound hepatic examination alone.

DESIGN

Prospective, observational study.

SETTING

Operating rooms of a university-affiliated hospital.

PATIENTS

40 ASA physical status 2 and 3 patients with liver metastases.

INTERVENTIONS

20 patients underwent laparoscopic radiofrequency ablation of liver tumors following laparoscopic ultrasound examination, and 20 had laparoscopic ultrasound examination alone. The anesthetic technique was standardized.

MEASUREMENTS

The primary endpoint of the study was the number of episodes of mean arterial pressure (MAP) < 70 mmHg. Secondary endpoints were significant differences between the groups in MAP, heart rate, cardiac index, ejection fraction (EF; both measured with thoracic bioimpedance), calculated systemic vascular resistance index (SVRI), and central venous pressure.

MAIN RESULTS

The number of episodes of MAP < 70 mmHg did not differ between groups: there were 9 episodes in the ultrasound alone group and 7 in the radiofrequency group (P = 0.668). Cardiac index, EF, and SVRI were similar between groups. Central venous pressure was slightly higher in the radiofrequency group [11.99 (10.8-13.2) mmHg vs. 10.3 (9.2-11.4) mmHg, P = 0.04].

CONCLUSIONS

Hemodynamic profiles were similar when comparing laparoscopic radiofrequency ablation of liver metastases with laparoscopic ultrasound hepatic examination alone.