Hemodynamic consequences of high- and low-pressure capnoperitoneum during laparoscopic cholecystectomy

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.

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.

Intraoperative metabolic changes associated with cytoreductive surgery and hyperthermic intraperitoneal chemotherapy

BACKGROUND

Cytoreductive surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) causes considerable hemodynamic, respiratory, and metabolic changes during the perioperative period.

OBJECTIVES

To evaluate metabolic changes associated with this procedure. Understanding perioperative factors and their association with morbidity may improve the perioperative management of patients undergoing this treatment.

METHODS

A retrospective review of a prospectively maintained database was performed. All consecutive unselected patients who underwent CRS plus HIPEC between January 2018 and December 2020 (n = 219) were included.

RESULTS

The mean age was 58 ± 11.7 years and 167 (76.3%) were female. The most frequent histology diagnosis was serous ovarian carcinoma 49.3% (n = 108) and colon carcinoma 36.1% (n = 79). Mean peritoneal cancer index was 14.07 ± 10.47. There were significant variations in pH, lactic acid, sodium, potassium, glycemia, bicarbonate, excess bases, and temperature (p < 0.05) between the pre-HIPEC and post-HIPEC periods. The closed HIPEC technique resulted in higher levels of temperature than the open technique (p < 0.05). Age, potassium level post-HIPEC potassium level, and pre-HIPEC glycemia were identified as prognostic factors for morbidity in multivariate analysis.

CONCLUSION

The administration of HIPEC after CRS causes significant changes in internal homeostasis. Although the closed technique causes a greater increase in temperature, it is not related to higher morbidity rates. The patient's age, post-HIPEC potassium level, and pre-HIPEC glycemia are predictive factors for morbidity.

Low-pressure versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy: a systematic review and meta-analysis of randomized controlled trials

Introduction

It has been previously demonstrated that the rise of intra-abdominal pressures and prolonged exposure to such pressures can produce changes in the cardiovascular and pulmonary dynamic which, though potentially well tolerated in the majority of healthy patients with adequate cardiopulmonary reserve, may be less well tolerated when cardiopulmonary reserve is poor.

Nevertheless, theoretically lowering intra-abdominal pressure could reduce the impact of pneumoperitoneum on the blood circulation of intra-abdominal organs as well as cardiopulmonary function. However, the evidence remains weak, and as such, the debate remains unresolved. The aim of this systematic review and meta-analysis was to demonstrate the current knowledge around the effect of pneumoperitoneum at different pressures levels during laparoscopic cholecystectomy.

Materials and methods

This systematic review and meta-analysis were reported according to the recommendations of the 2020 updated Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines, and the Cochrane handbook for systematic reviews of interventions.

Results

This systematic review and meta-analysis included 44 randomized controlled trials that compared different pressures of pneumoperitoneum in the setting of elective laparoscopic cholecystectomy. Length of hospital, conversion rate, and complications rate were not significantly different, whereas statistically significant differences were observed in post-operative pain and analgesic consumption. According to the GRADE criteria, overall quality of evidence was high for intra-operative bile spillage (critical outcome), overall complications (critical outcome), shoulder pain (critical outcome), and overall post-operative pain (critical outcome). Overall quality of evidence was moderate for conversion to open surgery (critical outcome), post-operative pain at 1 day (critical outcome), post-operative pain at 3 days (important outcome), and bleeding (critical outcome). Overall quality of evidence was low for operative time (important outcome), length of hospital stay (important outcome), post-operative pain at 12 h (critical outcome), and was very low for post-operative pain at 1 h (critical outcome), post-operative pain at 4 h (critical outcome), post-operative pain at 8 h (critical outcome), and post-operative pain at 2 days (critical outcome).

Conclusions

This review allowed us to draw conclusive results from the use of low-pressure pneumoperitoneum with an adequate quality of evidence.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00464-022-09201-1.

NK. Study of Hemodynamic Effects of Preoperative Single-Bolus Dexmedetomidine in Elective Laparoscopic Surgeries

Objective:

To observe the hemodynamic effects of a single bolus dose of dexmedetomidine in patients undergoing elective laparoscopic surgeries.

Methods:

A total of 60 adult patients were randomized into two groups of 30 each. Group D patients were given 1 µg/kg dexmedetomidine in 50 mL of saline as a single-dose infusion over 10 min before induction. Group S patients were given a 50-mL 0.9% NS slow infusion over 10 min. Groups D and S patients were premedicated 10 min prior to surgery. Baseline vital and hemodynamic parameters were monitored during the perioperative period.

Conclusion:

Premedicating with a single bolus of 1 µg/kg IV dexmedetomidine has been proven safe and effective in maintaining perioperative hemodynamic stability, although few developed bradycardia and hypotension, which were managed without any adverse outcome. Furthermore, dexmedetomidine effectively reduced the incidence of shivering.

The effect of different pressures of pneumoperitoneum on the dimensions of internal jugular vein – A prospective double-blind, randomised study

Background and Aims:

During laparoscopic surgeries, pneumoperitoneum increases intraabdominal pressure (IAP) which can increase the central venous pressure (CVP), and significant haemodynamic changes. In this study, we evaluated the effect of two different pressures of pneumoperitoneum, standard (13-15 mmHg), and low (6-8 mmHg) on the cross-sectional area (CSA) of the internal jugular vein (IJV) using ultrasonography, haemodynamic changes and duration of surgery. Surgeon’s comfort and feasibility of performing laparoscopic surgeries with low pressure pneumoperitoneum was also studied.

Methods:

This prospective, double-blind, randomised study included 148 patients of American Society of Anesthesiologists physical status class I and II undergoing laparoscopic surgeries. They were allocated into two groups: group S (standard) (number (n) = 73) had the IAP maintained between 13-15 mmHg; group L (low) had an IAP of 6-8 mmHg (n = 75). CSA of right IJV was measured before induction of anaesthesia (T1), 5 min after intubation (T2), 5 min after pneumoperitoneum (T3), before desufflation (T4) and 5 min prior to extubation (T5). Chi-square test, and Student’s paired and unpaired t test were used for statistical analysis.

Results:

The increase in IJV CSA at T3 when compared to T2 was statistically significant in both the groups (P < 0.001). On desufflation, the change in IJV CSA showed significant decrease in T5 value than T4 value in both the groups (P < 0.001). However, the percentage change in the IJV CSA was more in group S (35.4%) than group L (21.2%).

Conclusion:

CSA of IJV increased significantly even with lower IAP of 6-8 mmHg. Laparoscopic surgery can be performed conveniently even at low IAP.

The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials

Background

Laparoscopic cholecystectomy involves using intra-abdominal pressure (IAP) to facilitate adequate surgical conditions. However, there is no consensus on optimal IAP levels to improve surgical outcomes. Therefore, we conducted a systematic literature review (SLR) to examine outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy.

Methods

An electronic database search was performed to identify randomized controlled trials (RCTs) that compared outcomes of low, standard, and high IAP among adults undergoing laparoscopic cholecystectomy. A Bayesian network meta-analysis (NMA) was used to conduct pairwise meta-analyses and indirect treatment comparisons of the levels of IAP assessed across trials.

Results

The SLR and NMA included 22 studies. Compared with standard IAP, on a scale of 0 (no pain at all) to 10 (worst imaginable pain), low IAP was associated with significantly lower overall pain scores at 24 h (mean difference [MD]: − 0.70; 95% credible interval [CrI]: − 1.26, − 0.13) and reduced risk of shoulder pain 24 h (odds ratio [OR] 0.24; 95% CrI 0.12, 0.48) and 72 h post-surgery (OR 0.22; 95% CrI 0.07, 0.65). Hospital stay was shorter with low IAP (MD: − 0.14 days; 95% CrI − 0.30, − 0.01). High IAP was not associated with a significant difference for these outcomes when compared with standard or low IAP. No significant differences were found between the IAP levels regarding need for conversion to open surgery; post-operative acute bleeding, pain at 72 h, nausea, and vomiting; and duration of surgery.

Conclusions

Our study of published trials indicates that using low, as opposed to standard, IAP during laparoscopic cholecystectomy may reduce patients’ post-operative pain, including shoulder pain, and length of hospital stay. Heterogeneity in the pooled estimates and high risk of bias of the included trials suggest the need for high-quality, adequately powered RCTs to confirm these findings.

Electronic supplementary material

The online version of this article (10.1007/s00464-020-07527-2) contains supplementary material, which is available to authorized users.

[Perioperative management for CRS and HIPEC : Anesthesiological aspects]

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are therapeutic options for the treatment of intra-abdominal neoplasms. Following the resection of all visible tumor areas by CRS, microscopic tumor areas are treated with HIPEC. This procedure increases the quality of life and survival. The CRS with HIPEC is a complex surgical procedure in which the mainly younger and often otherwise healthy patients undergo several pathophysiological changes during the operation. The main concern of the anesthesiologist is the massive volume loss, volume shift and metabolic alterations. Patients with a high comorbidity should undergo preoperative optimization to reduce the perioperative morbidity and mortality especially by protracted interventions.

Pulse Pressure Variation Can Predict the Hemodynamic Response to Pneumoperitoneum in Dogs: A Retrospective Study

Pneumoperitoneum may induce important hemodynamic alterations in healthy subjects. Pulse pressure variation (PPV) is a hemodynamic parameter able to discriminate preload dependent subjects. Anesthesia records of dogs undergoing laparoscopy were retrospectively evaluated. The anesthetic protocol included acepromazine, methadone, propofol and isoflurane administered with oxygen under mechanical ventilation. The hemodynamic parameters were considered five minutes before (BASE) and ten minutes after (P10) the pneumoperitoneum. Based on the cardiac index (CI) variation, at P10, dogs were classified as sensitive (S group, CI ≤ 15%) and non-sensitive (NO-S group). Data were analyzed with the ANOVA test and the ROC curve (p < 0.05). Fifty-five percent of dogs (S) had a reduction of CI ≥ 15% at P10 (2.97 ± 1.4 L/min/m²) compared to BASE (4.32 ± 1.62 L/min/m²) and at P10 in the NO-S group (4.51 ± 1.41 L/min/m²). PPV at BASE was significantly higher in the S group (22.4% ± 6.1%) compared to the NO-S group (10.9% ± 3.3%). The ROC curve showed a threshold of PPV > 16% to distinguish the S and NO-S groups. PPV may be a valid predictor of the hemodynamic response to pneumoperitoneum in dogs. A PPV > 16% can identify patients that may require fluid administration before the creation of pneumoperitoneum.

Effects of different intraabdominal pressure levels on oxidative stress markers in laparoscopic cholecystectomy

OBJECTIVE

To evaluate the effect of laparoscopic cholecystectomy performed under different intraabdominal pressure on oxidative stress markers.

MATERIAL AND METHODS

This prospective, randomized, controlled study examined 90 consecutive healthy patients who underwent elective laparoscopic cholecystectomy with the diagnosis of symptomatic cholelithiasis. The patients were divided into three groups, 30 patients in each. Group 1 included patients who underwent laparoscopic cholecystectomy at a CO₂ pneumoperitoneum pressure of 7 mmHg, Group 2 patients who underwent laparoscopic cholecystectomy at a CO₂ pneumoperitoneum pressure of 10 mmHg, and Group 3 patients who underwent laparoscopic cholecystectomy at a CO₂ pneumoperitoneum pressure of 13 mmHg. Blood samples were collected preoperatively, perioperatively, and postoperatively for measurement of the serum levels of ischemia modified albumin and an analysis of total antioxidant status and total oxidant status. Intra-group comparisons were made.

RESULTS

Group 1 experienced a significant increase in the postoperative ischemia modified albumin values compared to preoperative ischemia modified albumin values (p=0.013). Group 2 experienced a significant decrease in the perioperative total antioxidant status values compared to preoperative and postoperative total antioxidant status values (p=0.009). Group 3 experienced a significant increase in the perioperative total oxidant status and oxidative stress index values compared to preoperative values (p<0.001). Group 3 experienced a significant increase in the perioperative and postoperative ischemia modified albumin values compared to preoperative values (p<0.001).

CONCLUSION

Increased levels of oxidative stress markers were detected in patients who underwent laparoscopic cholecystectomy at a high intraabdominal pressure level.

Spinal/epidural block as an alternative to general anesthesia for laparoscopic appendectomy: a prospective randomized clinical study

Introduction

Laparoscopic appendectomy (LA) has been generally performed under general anesthesia. Laparoscopic appendectomy is rarely performed under regional anesthesia because of pneumoperitoneum-related problems.

Aim

To compare spinal/epidural anesthesia (SEA) and general anesthesia (GA) during LA with respect to perioperative and postoperative adverse events and postoperative pain.

Material and methods

Fifty patients, aged 18–65, who underwent LA, were randomly allocated to two groups: the GA (n = 25) and SEA (n = 25) groups. Perioperative and postoperative adverse events, postoperative pain level, and patient satisfaction were compared between the groups.

Results

None of the patients needed conversion to an open procedure or conversion from SEA to GA. In the SEA group we encountered shoulder pain in 6 (24%) patients, abdominal discomfort/pain in 4 (16%) patients, anxiety in 4 (16%) patients, and hypotension in 2 (8%) patients intraoperatively. Also, post-spinal headache was observed in 5 (20%) patients in the SEA group. Postoperative right shoulder pain was significantly higher in the GA group compared to the SEA group (32% vs. 8%; p = 0.037). In the SEA group the incidence of urinary retention and in the GA group the incidence of postoperative nausea and vomiting (PONV) were higher, but these differences were not statistically significant. The postoperative surgical pain level was significantly lower in the SEA group (p < 0.001).

Conclusions

Spinal/epidural anesthesia is effective and safe in ASA I healthy patients undergoing LA. Less postoperative pain, PONV and shoulder pain are the advantages of SEA compared to GA.

[Perioperative management for CRS and HIPEC : Anesthesiological aspects]

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are therapeutic options for the treatment of intra-abdominal neoplasms. Following the resection of all visible tumor areas by CRS, microscopic tumor areas are treated with HIPEC. This procedure increases the quality of life and survival. The CRS with HIPEC is a complex surgical procedure in which the mainly younger and often otherwise healthy patients undergo several pathophysiological changes during the operation. The main concern of the anesthesiologist is the massive volume loss, volume shift and metabolic alterations. Patients with a high comorbidity should undergo preoperative optimization to reduce the perioperative morbidity and mortality especially by protracted interventions.

Effect of intraperitoneal CO2 concentration on postoperative pain after laparoscopic cholecystectomy

Purpose

This study set out to identify the association between the intraperitoneal CO₂ concentrations and postoperative pain by dividing the participants into a control group and 2 experimental groups receiving irrigation (1 L and 2 L), and directly measuring their intraperitoneal CO₂ concentrations with a CO₂ gas detector.

Methods

A total of 101 patients, American Society of Anesthesiologists physical status classification I and II patients aged 18-65 years were enrolled in the study. Group 1 did not receive irrigation with normal saline, while groups 2 and 3 were administered irrigation with 1 L and 2 L of normal saline, respectively, after laparoscopic cholecystectomy. Intraperitoneal CO₂ concentrations were measured with a CO₂ gas detector through the port, and postoperative pain was assessed on a visual analogue scale at 6, 12, and 24 hours after surgery.

Results

The intraperitoneal CO₂ concentrations were 1,016.0 ± 960.3 ppm in group 1, 524.5 ± 383.2 ppm in group 2, and 362.2 ± 293.6 ppm in group 3, showing significantly lower concentrations in groups 2 and 3. Postoperative pain was significantly lower in group 3 at 6 hours after surgery, and in groups 2 and 3 at 12 hours after the surgery. However, there was no significant difference between the 3 groups in postoperative pain 24 hours after the surgery.

Conclusion

This study found a causal relationship between the amount of normal saline used for irrigation and the intraperitoneal CO₂ concentrations in that irrigation with normal saline reduces pain on the day of the surgery.

Low-pressure capnoperitoneum reduces stress responses during pediatric laparoscopic high ligation of indirect inguinal hernia sac: A randomized controlled study

BACKGROUND

We aimed to evaluate the effect of different capnoperitoneum pressures on stress responses in pediatric laparoscopic inguinal hernia repair.

METHODS

In this prospective randomized controlled study, 68 children with indirect inguinal hernia who underwent high ligation of hernia sac were randomly divided into 3 groups: high-pressure group (12 mm Hg, HP group, n = 26); low-pressure group (8 mm Hg, LP group, n = 20); open operation group (OP group, n = 22). Heart rate (HR), blood pressure, and end-tidal CO2 (PetCO2) were recorded, as well as the levels of adrenocorticotropic hormone (ACTH) and cortisol (COR) were measured by ELISAs before operation, during operation, and after operation, respectively.

RESULTS

After establishing capnoperitoneum, HR, blood pressure, and PetCO2 were significantly increased in the HP group compared with the OP and LP groups (P < 0.05). Comparing the intraoperatively measured ACTH and COR concentrations of the HP group to the LP group, we noted higher values in the first (P < 0.05). There was no significant difference in the postoperative concentrations of ACTH and COR among the HP, LP, and OP groups.

CONCLUSIONS

Laparoscopic surgery under LP capnoperitoneum or open operation may reduce stress responses and are superior to HP capnoperitoneum.

Combined spinal-epidural anesthesia in laparoscopic appendectomy: a prospective feasibility study

Purpose

Laparoscopic appendectomy (LA) is routinely performed under general, not regional anesthesia. This study assessed the feasibility, efficacy, and side effects of combined spinal-epidural anesthesia (CSEA) in LA.

Methods

Thirty-three American Society of Anesthesiologist (ASA) physical status classification grade I patients underwent LA under CSEA. CSEA was performed using the needle-through-needle technique at the L₃–L₄ interspace. Preoperative and postoperative adverse events related to CSEA, patient satisfaction, and postoperative pain levels were recorded.

Results

LA under CSEA was performed successfully in 33 patients (84.6%). Peroperatively, right shoulder pain was observed in 8 patients (24.1%), abdominal discomfort in 6 (18.2%), anxiety in 5 (15.2%), hypotension in 2 (6.1%) and nausea-vomiting in 1 (3%). In the first 24 hours after LA, headache, urinary retention, right shoulder pain, and postoperative nausea/vomiting (PONV) occurred in 18.1%, 12.1%, 9.1%, and 0% of patients, respectively. In the first 6 hours postoperation, no patients had operation-site pain that required analgesic treatment. Thirty-one patients (94%) evaluated their satisfaction with the procedure as good or moderate.

Conclusion

CSEA is an efficient and suitable anesthesia technique in LA for ASA physical status classification grade I healthy patients. CSEA is associated with good postoperative pain control and the absence of PONV and intubation-associated complications.

Which intraperitoneal insufflation pressure should be used for less postoperative pain in transperitoneal laparoscopic urologic surgeries?

Purpose

To determine whether using different intraperitoneal insufflation pressures for transperitoneal laparoscopic urologic surgeries decreases postoperative pain.

Materials and Methods

76 patients who underwent transperitoneal laparoscopic upper urinary tract surgery at different insufflation pressures were allocated into the following groups: 10mmHg (group I, n=24), 12mmHg (group II, n=25) and 14mmHg (group III, n=27). These patients were compared according to age, gender, body mass index (BMI), type and duration of surgery, intraoperative bleeding volume, postoperative pain score and length of hospital stay. A visual analog scale (VAS) was used for postoperative pain.

Results

Demographic characteristics, mean age, gender, BMI and type of surgeries were statistically similar among the groups. The mean operation time was higher in group I than group II and group III but this was not statistically significant (P=0.810). The mean intraoperative bleeding volume was significantly higher in group I compared with group II and group III (P=0.030 and P=0.006). The mean length of postoperative hospital stays was statistically similar among the groups (P=0.849). The mean VAS score at 6h was significantly reduced in group I compared with group III (P=0.011). At 12h, the mean VAS score was significantly reduced in group I compared with group II and group III (P=0.009 and P<0.001). There was no significant difference in the mean VAS scores at 24h among three groups (P=0.920).

Conclusion

Lower insufflation pressures are associated with lower postoperative pain scores in the early postoperative period.

Laparoscopic cholecystectomy under spinal-epidural anesthesia vs. general anaesthesia: a prospective randomised study

Purpose

Laparoscopic cholecystectomy (LC) is usually performed under the general anesthesia (GA). Aim of the study is to investigate the availability, safety and side effects of combined spinal/epidural anesthesia (CSEA) and comparison it with GA for LC.

Methods

Forty-nine patients who have a LC plan were included into the study. The patients were randomly divided into GA (n = 25) and CSEA (n = 24) groups. Intraoperative and postoperative adverse events, postoperative pain levels were compared between groups.

Results

Anesthesia procedures and surgeries for all patients were successfully completed. After the organization of pneumoperitoneum in CSEA group, 3 patients suffered from shoulder pain (12.5%) and 4 patients suffered from abdominal discomfort (16.6%). All these complaints were recovered with IV fentanyl administration. Only 1 patient developed hypotension which is recovered with fluid replacement and no need to use vasopressor treatment. Postoperative shoulder pain was significantly less observed in CSEA group (25% vs. 60%). Incidence of postoperative nausea and vomiting (PONV) was less observed in CSEA group but not statistically significant (4.2% vs. 20%). In the group of CSEA, 3 patients suffered from urinary retention (12.5%) and 2 patients suffered from spinal headache (8.3%). All postoperative pain parameters except 6th hour, were less observed in CSEA group, less VAS scores and less need to analgesic treatment in CSEA group comparing with GA group.

Conclusion

CSEA can be used safely for laparoscopic cholecystectomies. Less postoperative surgical field pain, shoulder pain and PONV are the advantages of CSEA compared to GA.

Cardiopulmonary effects associated with head-down position in halothane-anesthetized ponies with or without capnoperitoneum

OBJECTIVE

To compare the cardiopulmonary effects of the head-down position, with or without capnoperitoneum, in halothane-anesthetized horses.

STUDY DESIGN

Prospective randomized study.

ANIMALS

Five ponies (four mares, one stallion; bodyweight 302 ± 38.4 kg [mean ± SD]) were used.

METHODS

The ponies were anesthetized with xylazine, guiafenesin, ketamine, and maintained with halothane/oxygen and lungs were ventilated to 40 ± 2 mm Hg (5.3 ± 0.3 kPa) end-tidal CO₂ tension. After baseline cardiopulmonary measurements, ponies were kept in horizontal position for 30 minutes, then tilted head-down 30° to the horizontal position for 60 minutes, and then returned to a horizontal position for final measurements. Capnoperitoneum (intra-abdominal pressure: 12 mm Hg [1.6 kPa]) was introduced after baseline cardiopulmonary measurements, until 5 minutes before the final measurements (treatment INS). Ponies in the control treatment (CON) did not receive capnoperitoneum. Cardiopulmonary data were collected every 10 minutes following the baseline measurements until recovery.

RESULTS

In the head-down position, in both treatments, significant decreases were observed in PaO₂, and significant increases were observed in PaCO₂, right atrial blood pressure, arterial to end-tidal CO₂ gradient, calculated V_d/V_t and Q˙_s/Q˙_t ratios. During the head-down position, in CON there was decreased cardiac index, and in INS, there were decreases in arterial plasma pH and increases in mean systemic arterial and airway pressures. Treatment INS developed ventilation-perfusion mismatch earlier in the study, and had longer recovery times compared to CON.

CONCLUSION

Cardiac index and systemic blood pressure appeared to be preserved in INS during the head-down position, but ventilation-perfusion mismatch appeared earlier with head-down position and capnoperitoneum.

CLINICAL RELEVANCE

Healthy ponies tolerate capnoperitoneum at 12 mm Hg (1.6 kPa) intra-abdominal pressure when tilted head down 30° to the horizontal position.

Dexmedetomidine in Attenuation of Haemodynamic Response and Dose Sparing Effect on Opioid and Anaesthetic Agents in Patients undergoing Laparoscopic Cholecystectomy- A Randomized Study

INTRODUCTION

Perioperative procedures are stressful and lead to haemodynamic instability with potentially devastating consequences. Dexmedetomidine is found to have many of the desired characteristics that are required in perioperative period.

AIM

To evaluate the ability of pre and intraoperative dexmedetomidine to attenuate stress induced haemodynamic responses, quantifying the anaesthetic agents sparing as well as its cost-effectiveness in patients undergoing laparoscopic cholecystectomy.

MATERIALS AND METHODS

The present single blind randomized study was conducted with 120 ASA I and II consented patients who underwent laparoscopic cholecystectomy. Patients were randomly divided into 2 groups (i.e., group D and group N). Prior to induction, group D received 1 μg/kg of Dexmedetomidine and group N received Normal saline infusion over 20 minutes. Group D also received maintenance Dexmedetomidine intraoperatively. Bispectral index and minimum alveolar concentration monitoring was done in both the groups. Haemodynamic parameters were noted till 100 minutes post laryngoscopy. Opioid and anaesthetic agent consumptions were also noted and cost analysis was done. Medcalc-Version 12.5.0.0 software was used for statistics and p <0.05 was considered significant.

RESULTS

Dexmedetomidine attenuated the stress induced haemodynamics responses and produced stable, relatively non fluctuating haemodynamics throughout. The Minimum Alveolar Concentration (MAC) requirement and the consumptions of Fentanyl and Isoflurane were significantly less in the Dexmedetomidine group (p<0.0001). However, despite anaesthetic dose sparing effect the anaesthetic technique was not cost-effective.

CONCLUSION

Dexmedetomidine is effective in attenuating haemodynamic responses in laparoscopic surgery and having dose sparing effect on Fentanyl, Propofol and Isoflurane. However, overall this technique is not cost-effective.

Recommendations on the use of deep neuromuscular blockade by anaesthesiologists and surgeons. AQUILES (Anestesia QUIrúrgica para Lograr Eficiencia y Seguridad) Consensus

INTRODUCTION

Neuromuscular blockade enables airway management, ventilation and surgical procedures. However there is no national consensus on its routine clinical use. The objective was to establish the degree of agreement among anaesthesiologists and general surgeons on the clinical use of neuromuscular blockade in order to make recommendations to improve its use during surgical procedures.

METHODS

Multidisciplinary consensus study in Spain. Anaesthesiologists experts in neuromuscular blockade management (n=65) and general surgeons (n=36) were included. Delphi methodology was selected. A survey with 17 final questions developed by a dedicated scientific committee was designed. The experts answered the successive questions in two waves. The survey included questions on: type of surgery, type of patient, benefits/harm during and after surgery, impact of objective neuromuscular monitoring and use of reversal drugs, viability of a multidisciplinary and efficient approach to the whole surgical procedure, focussing on the level of neuromuscular blockade.

RESULTS

Five recommendations were agreed: 1) deep neuromuscular blockade is very appropriate for abdominal surgery (degree of agreement 94.1%), 2) and in obese patients (76.2%); 3) deep neuromuscular blockade maintenance until end of surgery might be beneficial in terms of clinical aspects, such as as immobility or better surgical access (86.1 to 72.3%); 4) quantitative monitoring and reversal drugs availability is recommended (89.1%); finally 5) anaesthesiologists/surgeons joint protocols are recommended.

CONCLUSIONS

Collaboration among anaesthesiologists and surgeons has enabled some general recommendations to be established on deep neuromuscular blockade use during abdominal surgery.

The effect of pneumoperitoneum on the cross-sectional areas of internal jugular vein and subclavian vein in laparoscopic cholecystectomy operation

Background

Increased central venous pressure secondary to an increase in intraabdominal pressure has been reported during laparoscopic surgery. However, no study has yet determined the effect of pneumoperitoneum on cross-sectional area (CSA) of central veins by ultrasonography during laparoscopic cholecystectomy. Herein, we aimed to quantify changes in CSAs of internal jugular (IJV) and subclavian veins (SCV) by ultrasonography during this surgery.

Methods

This study included 60 ASA I-II patients scheduled for laparoscopic cholecystectomy surgery under general anesthesia. Pneumoperitoneum was performed with CO₂ at 12 mmHg. The CSAs of right IJV and right SCV were measured using a 6 Mhz ultrasonography transducer in supine and neutral positions before anesthesia induction (T1), 5 min after connecting to mechanical ventilator (T2), 5 min after creation of pneumoperitoneum (T3), at the end of pneumoperitoneum (T4), and 5 min after desufflation and before extubation (T5) both at end-expiration and end-inspiration.

Results

The comparison of IJV CSA at inspiration showed significant increase in T3 value compared to T2 value (p < 0.001). Similarly the expiratory measurements of IJV CSA demonstrated significant increase in T3 value compared to T2 value (p < 0.001). The comparison of inspiratory CSA measurements of SCV showed significantly increased in T3 (p = 0.009) than T2 value. In expiratory measurements there was a significant increase in T3 (p = 0.032) value compared to T2. All measurements of IJV and SCV SCAs both end-inspiration and end-expiration T5 values significantly decreased compared to T4 values (p < 0.001).

Conclusions

Pneumoperitoneum with an intraabdominal pressure of 12 mmHg produces significant increases in IJV and SCV CSAs during laparoscopic cholecystectomy procedure. We believe that this finding may enhance our understanding of pneumoperitoneum-induced hemodynamic changes and facilitate catheterization attempts.

Trial registration

Date of registration 21/07/2016, ISRCTN Registry ( No:ISRCTN15164056, registered retrospectively).

Effects of low and standard intra-abdominal pressure on systemic inflammation and immune response in laparoscopic adrenalectomy: A prospective randomised study

BACKGROUND:

The advantages of laparoscopic adrenalectomy (LA) over open adrenalectomy are undeniable. Nevertheless, carbon dioxide (CO₂) pneumoperitoneum may have an unfavourable effect on the local immune response. The aim of this study was to compare changes in the systemic inflammation and immune response in the early post-operative (p.o.) period after LA performed with standard and low-pressure CO₂ pneumoperitoneum.

MATERIALS AND METHODS:

We studied, in a prospective randomised study, 51 patients consecutively with documented adrenal lesion who had undergone a LA: 26 using standard-pressure (12-14 mmHg) and 25 using low-pressure (6-8 mmHg) pneumoperitoneum. White blood cells (WBC), peripheral lymphocyte subpopulation, human leucocyte antigen-DR (HLA-DR), neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein (CRP) were investigated.

RESULTS:

Significantly higher concentrations of neutrophil elastase, IL-6 and IL-1 and CRP were detected p.o. in the standard-pressure group of patients in comparison with the low-pressure group (P < 0.05). A statistically significant change in HLA-DR expression was recorded p.o. at 24 h, as a reduction of this antigen expressed on the monocyte surface in patients from the standard group; no changes were noted in low-pressure group patients (P < 0.05).

CONCLUSIONS:

This study demonstrated that reducing the pressure of the pneumoperitoneum to 6-8 mmHg during LA reduced p.o. inflammatory response and averted p.o. immunosuppression.

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.

10 cm H2O PEEP application in laparoscopic surgery and cerebral oxygenation: a comparative study with INVOS and FORESIGHT

INTRODUCTION

In the present study, changes in hemodynamic parameters and cerebral oxygen saturation (rSO2) associated with 10 cm H2O PEEP application were investigated, which is assumed beneficial for the respiratory functions and oxygenation during laparoscopic cholecystectomy (LC) applied at 30° head-up left side position. Data gathered via two devices, namely INVOS and FORESIGHT, were compared.

METHODS

After both the ethics committee approval from the hospital and patients' written consents were obtained, patients undergoing elective laparoscopic surgery (only ASA I-II) were randomly divided into two groups (Clinical trials protocol NCT02071550). Sensors of INVOS and FORESIGHT devices were placed on the right side at the forehead region. In total, 11 evaluation periods were formed, namely pre-induction (1st period), post-induction (2nd period), abdominal insufflation outset (3rd period), post-insufflation at 5-min intervals (4th, 5th, 6th, 7th, and 8th period), at the end of insufflation (9th period), at the end of operation (10th period), and at the end of anesthesia (11th period). While one of the groups did not receive PEEP (ZEEP group), the other group received 10 cm H2O along with abdominal insufflation (PEEP group). Demographic data, hemodynamic values, and rSO2 values were recorded for both groups at all 11 periods.

RESULTS

A total of 44 patients in two groups, each group containing 22 individuals, were included in the study. Systolic, diastolic, and mean arterial pressures, etCO2 and SO2 values, and demographic data were found to be similar in both groups. Heart rate was observed to be higher in the PEEP group starting with the PEEP administration. INVOS rSO2 values were found similar in both groups. However, FORESIGHT rSO2 values were found to be higher in the PEEP group compared to the ZEEP group. No patient had cerebral desaturation in both groups throughout the study.

DISCUSSION

Application of PEEP with 10 cm H2O during abdominal insufflation could increase the rSO2 value and heart rate in patients undergoing laparoscopic cholecystectomy. However, all changes observed were within normal limits. FORESIGHT device yielded more compatible results with hemodynamic data compared to INVOS.

Experience of Laparoscopic Cholecystectomy Under Thoracic Epidural Anaesthesia: Retrospective Analysis of 96 Patients

OBJECTIVE

Although the traditional anaesthesia method for laparoscopic cholecystectomy has been general anaesthesia, regional anaesthesia techniques are also successfully used today. In this paper, we aimed to report our experiences with thoracic epidural anaesthesia, including complications, postoperative analgesia, technical difficulties and side effects.

METHODS

Between December 2009 and November 2012, 90 patients undergoing laparoscopic cholecystectomy were retrospectively analysed. Demographic data, American Society of Anesthesiologists (ASA) scores, comorbidities, duration of operations, medications and doses used for sedation were reviewed.

RESULTS

The gender distribution of patients were recorded as 15 males (15%) and 81 females (85%). The patients had an average age of 46.74±13.28, an average height of 162.50±5.57 cm and a mean weight of 73.57±12.48 kg. ASA classifications were distributed as follows: ASA I: 63 (65%) patients, ASA II 28 (29%) patients and ASA III: 5 patients. We recorded 3 patients with chronic obstructive pulmonary disease (COPD), 14 patients with diabetes mellitus (DM) and 22 patients with hypertension who got their diagnosis in the perioperative visit. During the operation, three patients had bradycardia (heart rate 50 min(-1)), and atropine was applied. Ephedrine and fluid resuscitation had been applied to 3 patients for the treatment of intraoperative hypotension. Midazolam, ketamine hydrochloride and propofol were administered to patients for sedation during the operations. Thoracic epidural anaesthesia was performed at the level of T7 -9 intervertebral space with the patients in the sitting position. Patients were given oxygen by a face mask at a rate of 3-4 L min(-1). The pneumoperitoneum was created by giving carbon dioxide at the standard pressure of 12 mmHg into the abdominal cavity in all patients. If needed, postoperative analgesia was provided by epidural local anaesthetic administration.

CONCLUSION

Thoracic epidural anaesthesia can be applied as an alternative to general anaesthesia for laparoscopic cholecystectomy.

Cardiorespiratory effects of balancing PEEP with intra-abdominal pressures during laparoscopic cholecystectomy

BACKGROUND

Applying appropriate positive end-expiratory pressure (PEEP) to corresponding intra-abdominal pressure (IAP) can improve gas exchange during capnoperitoneum without any hemodynamic effects.

MATERIALS AND METHODS

A total of 75 patients were randomly allocated to group 0PEEP (n=25), group 5PEEP (n=25), and group 10PEEP (n=25) according to the level of PEEP, in whom capnoperitoneum was created with IAP of 14, 8, and 14 mm Hg, respectively. Hemodynamic and respiratory parameters were recorded up to 30 minutes after capnoperitoneum.

RESULTS

In 0PEEP group, mean end-tidal carbon dioxide demonstrated significant rise 2 minutes after capnoperitoneum and plateaued at about 15 minutes but remained at high level for up to 30 minutes when compared with the 5PEEP and 10PEEP groups (P<0.05). Correspondingly, the mean PaCO2 (48.0±4.1 mm Hg) for the 0PEEP group was higher at 30 minutes when compared with 5PEEP (37.8±2.7 mm Hg) and 10PEEP (37.2±3.9 mm Hg) groups. The oxygenation was better preserved in 5PEEP and 10PEEP groups with significantly higher PaO2/Fio2 ratio. Heart rate, mean arterial pressure, and cardiac output remained stable throughout the study in all the 3 groups.

CONCLUSIONS

Application of appropriate PEEP corresponding to the IAP helped maintain CO2 elimination and improved oxygenation without any hemodynamic disturbance in patients undergoing laparoscopic cholecystectomy.

Neuromuscular blockade for optimising surgical conditions during abdominal and gynaecological surgery: a systematic review

BACKGROUND

The level of neuromuscular blockade (NMB) that provides optimal surgical conditions during abdominal surgery has not been well established. The aim of this systematic review was to evaluate current evidence on the use of neuromuscular blocking agents in order to optimise surgical conditions during laparoscopic procedures and open abdominal surgery.

METHODS

A wide search was performed in PubMed, Cochrane library and Embase with systematic approach including PRISMA recommendations. Individual risk of bias was assessed and systematic data extraction were performed.

RESULTS

Fifteen studies with data from 998 patients were included. There is good evidence that the use of deep NMB compared with moderate NMB is associated with optimised surgical conditions during laparoscopic cholecystectomy, hysterectomy and nephrectomy/prostatectomy. In laparoscopic cholecystectomy during low pressure pneumoperitoneum, deep NMB marginally improves the surgical conditions. However, to ensure acceptable surgical conditions, it may be necessary to increase the intra-abdominal pressure in up to half of the patients regardless of level of NMB. There is good evidence that moderate NMB improves surgical conditions in some cases during open radical retropubic prostatectomy. However, good and excellent surgical conditions may be achievable even without NMB. There is good evidence to recommend deep NMB in laparoscopic cholecystectomy, nephrectomy and prostatectomy to improve surgical conditions. There is insufficient evidence to recommend an ideal level of NMB creating optimal surgical condition during laparotomy.

CONCLUSION

Use of deep NMB in certain laparoscopic procedures may improve surgical conditions. In open abdominal surgery, use of NMB may optimise surgical conditions under certain circumstances.

Advancing frontiers in anaesthesiology with laparoscopy

The introduction of laparoscopy in the surgeon's armamentarium was in fact a "revolution in the history of surgery". Since this technique involves insufflation of carbon dioxide it produces several pathophysiological changes which have to be understood by the anaesthesiologist who can modify the anaesthesia technique accordingly. Advantages of laparoscopy include reduced pain, small scars and early return to work. Certain complications specific to laparoscopic surgery are due to carboperitoneum and increased intra-abdominal pressure. Venous air embolism, although very rare, can be lethal if not managed promptly. Other complications include subcutaneous emphysema, haemodynamic compromise and arrhythmias. Although associated with minimal postoperative morbidity, postoperative pain, nausea and vomiting can be quite problematic. The limitations of laparoscopy have been overcome by the introduction of robotic surgery. There are important implications for the anaesthesiologist during robotic surgeries which have to be practiced accordingly. Robotic surgery has a learning curve for both the surgeon and the anaesthesiologist. The robot is bulky, and cannot be disengaged after docking. Therefore it is important that the anaesthetized patient remains immobile throughout surgery and anaesthesia is reversed only after the robot has been disengaged at the end of surgery. Advances in laparoscopy and robotic surgery have modified anaesthetic techniques too.

Association between duration of carbon dioxide pneumoperitoneum during laparoscopic abdominal surgery and hepatic injury: a meta-analysis

BACKGROUND

The aim of this study is to accurately assess whether the duration of intraoperative carbon dioxide pneumoperitoneum (CDP) is associated with the induction of hepatic injury.

METHODS

We conducted a systematic review of PubMed, Embase, and Cochrane Library databases (through February 2014) to identify case-match studies that compared high-pressure CDP with low-pressure CDP or varied the duration of CDP in patients who underwent abdominal surgery. The outcome of interest was postoperative liver function (ALT, AST, TB).

RESULTS

Eleven comparative studies involving 2,235 participants were included. Overall, levels of ALT, AST, and TB (on postoperative days 1, 3, and 7) were significantly elevated in the study groups. However, the results of the subanalyses of those who underwent laparoscopic colorectal cancer resection (LCR) versus open colorectal cancer resection (OCR) and those who underwent laparoscopic gastric bypass (LGBP) versus open gastric bypass (OGBP) were inconsistent.

CONCLUSIONS

The current evidence suggests that the duration of CDP during laparoscopic abdominal surgery may be associated with hepatic injury. Additional large-scale, randomized, controlled trials are urgently needed to further confirm this.

Hemodynamic effect and safety of intermittent sequential pneumatic compression leg sleeves in patients with congestive heart failure

BACKGROUND

Pneumatic leg sleeves are widely used after prolonged operations for prevention of venous stasis. In healthy volunteers they increase cardiac function. We evaluated the hemodynamic effects and safety of intermittent sequential pneumatic compression (ISPC) leg sleeves in patients with chronic congestive heart failure (CHF).

METHODS AND RESULTS

We studied 19 patients with systolic left ventricular dysfunction and CHF. ISPC leg sleeves, each with 10 air cells, were operated by a computerized compressor, exerting 2 cycles/min. Hemodynamic and echocardiographic parameters were measured before, during, and after ISPC activation. The baseline mean left ventricular ejection fraction was 29 ± 9.2%, median 32%, range 10%-40%. Cardiac output (from 4.26 to 4.83 L/min; P = .008) and stroke volume (from 56.1 to 63.5 mL; P = .029) increased significantly after ISPC activation, without a reciprocal increase in heart rate, and declined after sleeve deactivation. Systemic vascular resistance (SVR) decreased significantly (from 1,520 to 1,216 dyne-s/cm5; P = .0005), and remained lower than the baseline level throughout the study. There was no detrimental effect on diastolic function and no adverse clinical events, despite increased pulmonary venous return.

CONCLUSIONS

ISPC leg sleeves in patients with chronic CHF do not exacerbate symptoms and transiently improve cardiac output through an increase in stroke volume and a reduction in SVR.

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.

Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy

BACKGROUND

A pneumoperitoneum of 12 to 16 mm Hg is used for laparoscopic cholecystectomy. Lower pressures are claimed to be safe and effective in decreasing cardiopulmonary complications and pain.

OBJECTIVES

To assess the benefits and harms of low pressure pneumoperitoneum compared with standard pressure pneumoperitoneum in people undergoing laparoscopic cholecystectomy.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013 to identify randomised trials,using search strategies.

SELECTION CRITERIA

We considered only randomised clinical trials, irrespective of language, blinding, or publication status for inclusion in the review.

DATA COLLECTION AND ANALYSIS

Two review authors independently identified trials and independently extracted data. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) using both fixed-effect and random-effects models with RevMan 5 based on available case analysis.

MAIN RESULTS

A total of 1092 participants randomly assigned to the low pressure group (509 participants) and the standard pressure group (583 participants) in 21 trials provided information for this review on one or more outcomes. Three additional trials comparing low pressure pneumoperitoneum with standard pressure pneumoperitoneum (including 179 participants) provided no information for this review. Most of the trials included low anaesthetic risk participants undergoing elective laparoscopic cholecystectomy. One trial including 140 participants was at low risk of bias. The remaining 20 trials were at high risk of bias. The overall quality of evidence was low or very low. No mortality was reported in either the low pressure group (0/199; 0%) or the standard pressure group (0/235; 0%) in eight trials that reported mortality. One participant experienced the outcome of serious adverse events (low pressure group 1/179, 0.6%; standard pressure group 0/215, 0%; seven trials; 394 participants; RR 3.00; 95% CI 0.14 to 65.90; very low quality evidence). Quality of life, return to normal activity, and return to work were not reported in any of the trials. The difference between groups in the conversion to open cholecystectomy was imprecise (low pressure group 2/269, adjusted proportion 0.8%; standard pressure group 2/287, 0.7%; 10 trials; 556 participants; RR 1.18; 95% CI 0.29 to 4.72; very low quality evidence) and was compatible with an increase, a decrease, or no difference in the proportion of conversion to open cholecystectomy due to low pressure pneumoperitoneum. No difference in the length of hospital stay was reported between the groups (five trials; 415 participants; MD -0.30 days; 95% CI -0.63 to 0.02; low quality evidence). Operating time was about two minutes longer in the low pressure group than in the standard pressure group (19 trials; 990 participants; MD 1.51 minutes; 95% CI 0.07 to 2.94; very low quality evidence).

AUTHORS' CONCLUSIONS

Laparoscopic cholecystectomy can be completed successfully using low pressure in approximately 90% of people undergoing laparoscopic cholecystectomy. However, no evidence is currently available to support the use of low pressure pneumoperitoneum in low anaesthetic risk patients undergoing elective laparoscopic cholecystectomy. The safety of low pressure pneumoperitoneum has to be established. Further well-designed trials are necessary, particularly in people with cardiopulmonary disorders who undergo laparoscopic cholecystectomy.

Pain management after laparoscopic cholecystectomy-a randomized prospective trial of low pressure and standard pressure pneumoperitoneum

BACKGROUND

Abdominal pain and shoulder tip pain after laparoscopic cholecystectomy are distressing for the patient. Various causes of this pain are peritoneal stretching and diaphragmatic irritation by high intra-abdominal pressure caused by pneumoperitoneum . We designed a study to compare the post operative pain after laparoscopic cholecystectomy at low pressure (7-8 mm of Hg) and standard pressure technique (12-14 mm of Hg). Aim : To compare the effect of low pressure and standard pressure pneumoperitoneum in post laparoscopic cholecystectomy pain . Further to study the safety of low pressure pneumoperitoneum in laparoscopic cholecystectomy.

SETTINGS AND DESIGN

A prospective randomised double blind study.

MATERIALS AND METHODS

A prospective randomised double blind study was done in 100 ASA grade I & II patients. They were divided into two groups -50 each. Group A patients underwent laparoscopic cholecystectomy with low pressure pneumoperitoneum (7-8 mm Hg) while group B underwent laparoscopic cholecystectomy with standard pressure pneumoperitoneum (12-13 mm Hg). Both the groups were compared for pain intensity, analgesic requirement and complications.

STATISTICAL ANALYSIS

Demographic data and intraoperative complications were analysed using chi-square test. Frequency of pain, intensity of pain and analgesics consumption was compared by applying ANOVA test.

RESULTS

Post-operative pain score was significantly less in low pressure group as compared to standard pressure group. Number of patients requiring rescue analgesic doses was more in standard pressure group . This was statistically significant. Also total analgesic consumption was more in standard pressure group. There was no difference in intraoperative complications.

CONCLUSION

This study demonstrates the use of simple expedient of reducing the pressure of pneumoperitoneum to 8 mm results in reduction in both intensity and frequency of post-operative pain and hence early recovery and better outcome.This study also shows that low pressure technique is safe with comparable rate of intraoperative complications.

Low-pressure versus standard-pressure pneumoperitoneum for laparoscopic cholecystectomy: a systematic review and meta-analysis

BACKGROUND

The feasibility and safety of low-pressure pneumoperitoneum in laparoscopic cholecystectomy remain unclear.

METHODS

A meta-analysis of randomized controlled trials comparing low-pressure with standard-pressure pneumoperitoneum was performed.

RESULTS

A total of 1,263 patients were included. Low-pressure pneumoperitoneum was associated with significantly decreased postoperative pain. The requirement for increased pressure was significantly greater in the low-pressure group (risk ratio = 6.16; P < .001). Operative time was similar, with only a slight statistical significance (weighted mean difference = 2.07; P < .001). Length of hospital stay was shorter in the low-pressure group (weighted mean difference = -.27; P = .01). No significant differences were found in surgical complications or conversion to open surgery.

CONCLUSIONS

Low-pressure pneumoperitoneum is feasible and safe and results in reduced postoperative pain and near-equal operative time compared with standard-pressure pneumoperitoneum. More studies are required to investigate the potential benefits of the reduced length of hospital stay.

A prospective randomized study of systemic inflammation and immune response after laparoscopic nissen fundoplication performed with standard and low-pressure pneumoperitoneum

BACKGROUND

The aim of this study was to compare changes in the systemic inflammation and immune response in the early postoperative (p.o.) period after laparoscopic Nissen fundoplication (LNF) was performed with standard-pressure and low-pressure carbon dioxide pneumoperitoneum.

MATERIALS AND METHODS

We studied 68 patients with documented gastroesophageal reflux disease and who underwent a LNF: 35 using standard-pressure (12 to 14 mmHg) and 33 low-pressure (6 to 8 mmHg) pneumoperitoneum. White blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein were investigated.

RESULTS

A significantly higher concentration of neutrophil elastase, IL-6 and IL-1, and C-reactive protein was detected postoperatively in the standard-pressure group of patients in comparison with the low-pressure group (P<0.05). A statistically significant change in human leukocyte antigen-DR expression was recorded p.o. at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from standard group; no changes were noted in low-pressure group patients (P<0.05).

CONCLUSIONS

This study demonstrated that reducing the pressure of the pneumoperitoneum to 6 to 8 mm Hg during LNF is reduced p.o. inflammatory response and avoided p.o. immunosuppression.

Optimizing working space in laparoscopy: CT measurement of the effect of pre-stretching of the abdominal wall in a porcine model

BACKGROUND

Determinants of working space in minimal access surgery have not been well studied. Using computed tomography (CT) to measure volumes and linear dimensions, we are studying the effect of a number of determinants of CO2 working space in a porcine laparoscopy model. Here we report the effects of pre-stretching of the abdominal wall.

METHODS

Earlier we had noted an increase in CO2 pneumoperitoneum volume at repeat insufflation with an intra-abdominal pressure (IAP) of 5 mmHg after previous stepwise insufflation up to an IAP of 15 mmHg. We reviewed the data of this serendipity group; data of 16 pigs were available. In a new group of eight pigs, we also explored this effect at repeat IAPs of 10 and 15 mmHg. Volumes and linear dimensions of the CO2 pneumoperitoneum were measured on reconstructed CT images and compared between the initial and repeat insufflation runs.

RESULTS

Previous stepwise insufflation of the abdomen with CO2 up to 15 mmHg significantly (p < 0.01) increased subsequent working-space volume at a repeat IAP of 5 mmHg by 21 %, 7 % at a repeat IAP of 10 mmHg and 3 % at a repeat IAP of 15 mmHg. The external anteroposterior diameter significantly (p < 0.01) increased by 0.5 cm (14 %) at repeat 5 mmHg. Other linear dimensions showed a much smaller change. There was no statistically significant correlation between the duration of the insufflation run and the volume increase after pre-stretching at all IAP levels.

CONCLUSIONS

Pre-stretching of the abdominal wall allows for the same surgical-field exposure at lower IAPs, reducing the negative effects of prolonged high-pressure CO2 pneumoperitoneum on the cardiorespiratory system and microcirculation. Pre-stretching has important scientific consequences in studies addressing ways of increasing working space in that its effect may confound the possible effects of other interventions aimed at increasing working space.