Prospective randomized trial on low-pressure versus standard-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy

Low Pressure versus Standard Pressure Pneumoperitoneum in Laparoscopic Appendectomy: A Randomized Controlled Trial

BACKGROUND

The creation of pneumoperitoneum using higher pressure is believed to be associated with increased postoperative abdominal pain.

AIM

This study aimed to compare postoperative abdominal pain following low pressure laparoscopic appendectomy and standard pressure laparoscopic appendectomy.

METHODS

This was a prospective, double-blind, randomized controlled trial of 54 patients aged between 18 and 56 years with clinical and/or radiologic diagnosis of acute appendicitis. The patients were randomly allocated to two groups: low pressure laparoscopic appendectomy (n = 26) and standard pressure laparoscopic appendectomy (n = 28). The intra-abdominal pressure was kept in either low pressure (9 mm Hg) or standard pressure (13 mm Hg). Abdominal and shoulder pain scores were assessed using the visual analog scale at 6 hours and 3 days post procedure. Postoperative analgesia requirement, duration of surgery, complications, and hospital stay were recorded.

RESULTS

Both groups match for the demographic parameters. Three patients required conversion from low to standard pressure. There was no difference between the two groups in terms of abdominal pain (P = 0.86) and shoulder pain (P = 0.33), duration of surgery (P = 0.51), complications (P = 0.17), and length of hospital stay (P = 0.83).

CONCLUSION

The use of low pressure pneumoperitoneum did not reduce the incidence of abdominal pain in patients who had laparoscopic appendectomy. Patients with acute appendicitis can be treated with either low or normal pressure pneumoperitoneum depending on the experience of the surgeon.

A randomised clinical trial to study postoperative abdominal and shoulder tip pain following low and standard pressure laparoscopic cholecystectomy

Background

Laparoscopic cholecystectomy (LC) has become the gold standard for the management of symptomatic gallstone disease. The complications related to different pressure ranges of pneumoperitoneum have been studied widely with no definite conclusion till date. The current study was planned to determine the effect of standard versus low pressure laparoscopic cholecystectomy (LPLC) on postoperative abdominal and shoulder tip pain (STP).

Methods

The present randomised clinical trial included 84 patients divided into two groups: standard pressure laparoscopic cholecystectomy (SPLC) (13 mmHg) and LPLC (9 mmHg). The variables tested were abdominal pain at 3, 6, 12 and 24 h (by verbal rating scale), the incidence and intensity of STP, post-operative nausea and vomiting (PONV) and surgeon's comfort for the two techniques.

Results

The demographic characteristics of patients were similar in both groups. In LPP group, the postoperative abdominal pain at 6, 12 and 24 h was significantly less than SPLC; p = 0.02. Incidence of shoulder pain was significantly less in low pressure group (7.14%) compared with standard pressure (28.57%).

Conclusions

Low-pressure pneumoperitoneum (LPP) is safe and feasible surgery with reduced abdominal and STP.

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.

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.

Reduced Laparoscopic Intra-abdominal Pressure During Laparoscopic Cholecystectomy and Its Effect on Post-operative Pain: a Double-Blinded Randomised Control Trial

BACKGROUND

Laparoscopic surgery is regarded as the gold standard for the surgical management of cholelithiasis. To improve post-operative pain, low-pressure laparoscopic cholecystectomies (LPLC) have been trialed. A recent systematic review found that LPLC reduced pain; however, many of the randomised control trials were at a high risk of bias and the overall quality of evidence was low.

METHODS

One hundred patients undergoing elective laparoscopic cholecystectomy were randomised to a LPLC (8 mmHg) or a standard pressure laparoscopic cholecystectomy (12 mmHg) (SPLC) with surgeons and anaesthetists blinded to the pressure. Pressures were increased if vision was compromised. Primary outcomes were post-operative pain and analgesia requirements at 4-6 h and 24 h.

RESULTS

Intra-operative visibility was significantly reduced in LPLC (p<0.01) resulting in a higher number of operations requiring the pressure to be increased (29% vs 8%, p=0.010); however, there were no differences in length of operation or post-operative outcomes. Pain scores were comparable at all time points across all pressures; however, recovery room fentanyl requirement was more than four times higher when comparing 8 to 12 mmHg (12.5mcg vs 60mcg, p=0.047). Nausea and vomiting was also higher when comparing these pressures (0/36 vs 7/60, p=0.033). Interestingly, when surgeons estimated the operating pressure, they were correct in only 69% of cases.

CONCLUSION

Although pain scores were similar, there was a significant reduction in fentanyl requirement and nausea/vomiting in LPLC. Although LPLC compromised intra-operative visibility requiring increased pressure in some cases, there was no difference in complications, suggesting LPLC is safe and beneficial to attempt in all patients.

TRIAL REGISTRATION

Registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12619000205134).

Comparing postoperative pain in various pressure pneumoperitoneum of laparoscopic cholecystectomy: a double-blind randomized controlled study

Purpose

This study aims to evaluate the effect of different pneumoperitoneum pressures on postoperative pain, especially by subcategorizing the pressures into 3 groups during laparoscopic cholecystectomy (LC).

Methods

We conducted a prospective randomized, double-blinded study of 150 patients with benign and uncomplicated gallbladder disease. They were categorized into 3 groups. Each group (50 patients) underwent LC with different pneumoperitoneum methods: group VLP, very-low pressure (6–8 mmHg); group LP, low pressure (9–11 mmHg); and group SP, standard pressure (12–14 mmHg). The 3 groups were compared for pain intensity, duration, analgesic requirement, and complications.

Results

The characteristics of the patients were similar among all groups. Postoperative pain scores at each time point (1, 2, 4, 6, 12, 24, and 48 hours) were not significantly different among the 3 groups. Further, operation time, hospital stay, the number of analgesic consumption doses, and postoperative complications were not significantly different among the 3 groups.

Conclusion

This study demonstrates no difference in postoperative pain among various pneumoperitoneum pressures during LC. Therefore, routine use of lower-pressure pneumoperitoneum is not recommended unless in selected patients who require low-pressure pneumoperitoneum surgery.

Low-pressure versus standard pressure laparoscopic colorectal surgery (PAROS trial): a phase III randomized controlled trial

TRIAL DESIGN

This is a phase III, double-blind, randomized, controlled trial.

METHODS

In this trial, patients with laparoscopic colectomy were assigned to either low pressure (LP: 7 mmHg) or standard pressure (SP: 12 mmHg) at a ratio of 1 : 1. The aim of this trial was to assess the impact of low-pressure pneumoperitoneum during laparoscopic colectomy on postoperative recovery. The primary endpoint was the duration of hospital stay. The main secondary endpoints were postoperative pain, consumption of analgesics and postoperative morbidity.

RESULTS

Some 138 patients were enrolled, of whom 11 were excluded and 127 were analysed: 62 with LP and 65 with SP. Duration of hospital stay (3 versus 4 days; P = 0.010), visual analog scale (0.5 versus 2.0; P = 0.008) and analgesic consumption (level II: 73 versus 88 per cent; P = 0.032; level III: 10 versus 23 per cent; P = 0.042) were lower with LP. Morbidity was not significantly different between the two groups (10 versus 17 per cent; P = 0.231).

CONCLUSION

Using low-pressure pneumoperitoneum in laparoscopic colonic resection improves postoperative recovery, shortening the duration of hospitalization and decreasing postoperative pain and analgesic consumption. This suggests that low pressure should become the standard of care for laparoscopic colectomy.

TRIAL REGISTRATION

NCT03813797.

The Comparison of Postoperative Pain, Nausea, and Vomiting between Veress Needle Entry and Direct Trocar Entry Methods in Patients Undergoing Laparoscopic Cholecystectomy

BACKGROUND Postoperative pain, nausea, and vomiting are the most common side effects of laparoscopic cholecystectomy (LC). In the present study, we investigated the differences in postoperative pain, nausea, and vomiting between Veress needle and direct trocar entry methods among patients undergoing LC. METHODS 96 patients with gallstones were studied. They were randomly divided into two groups: the patients in the first group (n = 48) were insufflated 8.1 liters per minute CO2 gas by direct trocar port, and the patients in another group (n = 48) were insufflated 2.1 liters per minute CO2 gas by Veress needle. Pain intensity, nausea, and vomiting were assessed at 20 minutes, 4 hours, and 12 hours after the operations. RESULTS The duration of CO2 gas insufflation in Veress needle was 88.7 ± 10.7 seconds and indirect trocar was 16.6 ± 1.6 seconds. Visual analog scale (VAS) score significantly reduced in Veress needle compared with direct trocar (0.39 ± 0.98 vs. 1.68 ± 1.48) at 20 min after the operation, while there was no difference at 4 hours and 12 hours after the operation. The requirement and dose of pethidine injection were significantly lower in Veress needle than direct trocar. In addition, nausea and vomiting occurred in Veress needle less than direct trocar at 20 min, 4 hours, and 12 hours after LC. CONCLUSION Pain intensity just in the short term after LC in the group with CO2 gas insufflation in Veress needle was significantly less than the other group, while nausea and vomiting were significantly less during the whole follow-up periods in the group with CO2 gas insufflation in Veress needle.

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.

Comparing Hemodynamic Symptoms and the Level of Abdominal Pain in High- Versus Low-Pressure Carbon Dioxide in Patients Undergoing Laparoscopic Cholecystectomy

The laparoscopic cholecystectomy (LC) is the gold standard to treat gallstone. To view the surgical site in this type of operations better, carbon dioxide is used with a certain pressure. The current study aimed to compare the hemodynamic symptoms and the level of abdominal pain due to using high- and low-pressure carbon dioxide in patients undergoing LC. The current double-blind randomized clinical trial was conducted on 60 patients with the age range of 20-70 years old undergoing LC. The first and second groups experienced PaCO₂ of 7-10 and 12-14 mmHg, respectively. The hemodynamic symptoms, abdominal pain, shoulder-tip pain, nausea and vomiting after the surgery, and the mean of liver function tests were evaluated. Data were analyzed using T test, Chi-square test, and repeated measures ANOVA by SPSS 16. Information of 60 patients in two groups was analyzed. There was a significant difference between the groups regarding the mean of systolic blood pressure (P < 0.05). The mean of heart rate was significantly higher in the high-pressure group during surgery and 1 h after that (P < 0.05). The frequency of pain in shoulder-tip and abdomen was higher in the high-pressure group. Frequency of nausea and vomiting 12 h after the surgery between two groups was significant (P < 0.05). The mean of alkaline phosphatase was higher in the low-pressure group than the high-pressure group (P < 0.05). Considering the good performance and low side effects of low-pressure laparoscopic cholecystectomy compared to those of high-pressure, this method can be replaced by high-pressure in LC.

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.

Low vs Standard Pressures in Gynecologic Laparoscopy: a Systematic Review

BACKGROUND

The optimal intraperitoneal pressure during laparoscopy is not known. Recent literature found benefits of using lower pressures, but the safety of doing abdominal surgery with low peritoneal pressures needs to be assessed. This systematic review compares low with standard pneumoperitoneum during gynecologic laparoscopy.

DATABASE

We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing intraperitoneal pressures during gynecologic laparoscopy. Two authors reviewed references and extracted data from included trials. Risk ratios, mean differences, and standard mean differences were calculated and pooled using RevMan5. Of 2251 studies identified, three were included in the systematic review, for a total of 238 patients. We found a statistically significant but modest diminution in postoperative pain of 0.38 standardized unit based on an original 10-point scale (95% confidence interval [CI], -0.67 to -0.08) during the immediate postoperative period when using low intraperitoneal pressure of 8 mm Hg compared with ≥ 12 mm Hg and of 0.50 (95% CI, -0.80 to -0.21) 24 hours after the surgery. Lower pressures were associated with worse visualization of the surgical field (risk ratio, 10.31; 95% CI, 1.29-82.38). We found no difference between groups over blood loss, duration of surgery, hospital length of stay, or the need for increased pressure.

CONCLUSION

Low intraperitoneal pressures during gynecologic laparoscopy cannot be recommended on the behalf of this review because improvement in pain scores is minimal and visualization of the surgical field is affected. The safety of this intervention as well as cost-effectiveness considerations need to be further studied.

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.

Laparoscopic surgery and muscle relaxants: is deep block helpful?

It has been hypothesized that providing deep neuromuscular block (a posttetanic count of 1 or more, but a train-of-four [TOF] count of zero) when compared with moderate block (TOF counts of 1-3) for laparoscopic surgery would allow for the use of lower inflation pressures while optimizing surgical space and enhancing patient safety. We conducted a literature search on 6 different medical databases using 3 search strategies in each database in an attempt to find data substantiating this proposition. In addition, we studied the reference lists of the articles retrieved in the search and of other relevant articles known to the authors. There is some evidence that maintaining low inflation pressures during intra-abdominal laparoscopic surgery may reduce postoperative pain. Unfortunately most of the studies that come to these conclusions give few if any details as to the anesthetic protocol or the management of neuromuscular block. Performing laparoscopic surgery under low versus standard pressure pneumoperitoneum is associated with no difference in outcome with respect to surgical morbidity, conversion to open cholecystectomy, hemodynamic effects, length of hospital stay, or patient satisfaction. There is a limit to what deep neuromuscular block can achieve. Attempts to perform laparoscopic cholecystectomy at an inflation pressure of 8 mm Hg are associated with a 40% failure rate even at posttetanic counts of 1 or less. Well-designed studies that ask the question "is deep block superior to moderate block vis-à-vis surgical operating conditions" are essentially nonexistent. Without exception, all the peer-reviewed studies we uncovered which state that they investigated this issue have such serious flaws in their protocols that the authors' conclusions are suspect. However, there is evidence that abdominal compliance was not increased by a significant amount when deep block was established when compared with moderate neuromuscular block. Maintenance of deep block for the duration of the pneumoperitoneum presents a problem for clinicians who do not have access to sugammadex. Reversal of block with neostigmine at a time when no response to TOF stimulation can be elicited is slow and incomplete and increases the potential for postoperative residual neuromuscular block. The obligatory addition of sugammadex to any anesthetic protocol based on the continuous maintenance of deep block is not without associated caveats. First, monitoring of neuromuscular function is still essential and second, antagonism of deep block necessitates doses of sugammadex of ≥4.0 mg/kg. Thus, maintenance of deep block has substantial economic repercussions. There are little objective data to support the proposition that deep neuromuscular block (when compared with less intense block; TOF counts of 1-3) contributes to better patient outcome or improves surgical operating conditions.

A prospective randomized trial of postoperative pain following different insufflation pressures during gynecologic laparoscopy

OBJECTIVE

To determine the effects of different intra-abdominal pressure values on visceral pain following gynecologic laparoscopic surgery in the Trendelenburg position.

STUDY DESIGN

This randomized, controlled prospective trial was conducted at a tertiary education hospital and included 150 patients who underwent gynecologic laparoscopy with different abdominal insufflation pressures. There were 54 patients in the 8 mmHg low pressure group (LPG), 45 in the 12 mmHg standard pressure group (SPG), and 51 in the 15 mmHg high pressure group (HPG). We assessed mean age, body mass index (BMI), duration of surgery, analgesic consumption, length of hospital stay, amount of CO2 expended and volume of hemorrhage. Visceral pain and referred visceral pain were assessed 6, 12, and 24 h postoperatively using a visual analog scale (VAS).

RESULTS

There was no significant difference in age, BMI, analgesic consumption or length of hospital stay among groups. The mean operative time and total CO2 expended during surgery were higher in the LPG compared with the SPG and HPG. The mean intensity of postoperative pain assessed by the VAS score at 6 and 12 h was less in the LPG than in the SPG and HPG and was reduced significantly at 12 h. VAS scores at 24 h in the LPG and SPG were lower than in the HPG.

CONCLUSION

Pain is reduced by low insufflation pressure compared with standard and high insufflation pressure following gynecologic laparoscopic surgery in the Trendelenburg position. However, low insufflation pressure may result in longer operation times and increased hemorrhage.

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.

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.

Laparoscopic cholecystectomy under spinal anaesthesia: A prospective, randomised study

CONTEXT:

Spinal anaesthesia has been reported as an alternative to general anaesthesia for performing laparoscopic cholecystectomy (LC).

AIMS:

Study aimed to evaluate efficacy, safety and cost benefit of conducting laparoscopic cholecystectomy under spinal anaesthesia (SA) in comparison to general anaesthesia(GA)

SETTINGS AND DESIGN:

A prospective, randomised study conducted over a two year period at an urban, non teaching hospital.

MATERIALS AND METHODS:

Patients meeting inclusion criteria e randomised into two groups. Group A and Group B received general and spinal anaesthesia by standardised techniques. Both groups underwent standard four port laparoscopic cholecystectomy. Mean anaesthesia time, pneumoperitoneum time and surgery time defined primary outcome measures. Intraoperative events and post operative pain score were secondary outcome measure.

STATISTICAL ANALYSIS USED:

The Student t test, Pearson′s chi-square test and Fisher exact test.

RESULTS:

Out of 235 cases enrolled in the study, 114 cases in Group A and 110 in Group B analysed. Mean anaesthesia time appeared to be more in the GA group (49.45 vs. 40.64, P = 0.02) while pneumoperitoneum time and corresponding the total surgery time was slightly longer in the SA group. 27/117 cases who received SA experienced intraoperative events, four significant enough to convert to GA. No postoperative complications noted in either group. Pain relief significantly more in SA group in immediate post operative period (06 and 12 hours) but same as GA group at time of discharge (24 hours). No late postoperative complication or readmission noted in either group.

CONCLUSION:

Laparoscopic cholecystectomy done under spinal anaesthesia as a routine anaesthesia of choice is feasible and safe. Spinal anaesthesia can be recommended to be the anaesthesia technique of choice for conducting laparoscopic cholecystectomy in hospital setups in developing countries where cost factor is a major factor.

Responsiveness of quality of life instruments for the comparison of minimally invasive cholecystectomy procedures

BACKGROUND

Traditional metrics of postoperative outcomes (morbidity and mortality) are not useful to compare minimally invasive procedures with each other. Patient reported outcomes, such as quality of life (QOL) scores, offer an alternative approach. Compared with a large body of data in cancer treatment, the responsiveness of these instruments for minimally invasive surgery is not well described. To better define expected differences, we analyzed the reported QOL outcomes in randomized, controlled trials (RCTs) comparing single and four-port laparoscopic cholecystectomy.

METHODS

Searching Medline, Embase, Psychinfo, Scopus, and the Cochrane Library (1946 to Jan 2012), two independent reviewers identified RCTs comparing single with four-port cholecystectomy in adult patients using perioperative QOL assessments. The quality of the studies was assessed regarding trial design and QOL reporting. RevMan was used for mathematical analysis of the pooled outcome data using a random-effects model. Standardized mean difference estimation was utilized when pooling studies reporting different QOL tools. Statistical heterogeneity was assessed using χ(2) and I(2).

RESULTS

Of 743 citations, 37 RCTs were identified. Five studies with a total of 502 patients compared single with four-port cholecystectomy on QOL and were included. Pooled analysis was performed using preoperative and 1-month postoperative outcomes. At 1 month postoperatively, the reported effect size of perioperative QOL changes was up to 5 points (~1/2 SD) on the global SF 12 score. The largest difference in change of perioperative physical functioning was 9.9 points (~1 SD). No difference between the treatments was demonstrated.

CONCLUSIONS

Reporting of QOL may improve the comparison of minimally invasive surgical procedures. This systematic review reports clinically important changes and did not demonstrate a difference between treatments at 1 month postoperatively. The optimal timing and trial design for QOL tools in this setting needs to be defined further.

A multidisciplinary evidence-based guideline for minimally invasive surgery.: Part 1: entry techniques and the pneumoperitoneum

The Dutch Society for Endoscopic Surgery together with the Dutch Society of Obstetrics and Gynecology initiated a multidisciplinary working group to develop a guideline on minimally invasive surgery to formulate multidisciplinary agreements for minimally invasive surgery aiming towards better patient care and safety. The guideline development group consisted of general surgeons, gynecologists, an anesthesiologist, and urologist authorized by their scientific professional association. Two advisors in evidence-based guideline development supported the group. The guideline was developed using the "Appraisal of Guidelines for Research and Evaluation" instrument. Clinically important aspects were identified and discussed. The best available evidence on these aspects was gathered by systematic review. Recommendations for clinical practice were formulated based on the evidence and a consensus of expert opinion. The guideline was externally reviewed by members of the participating scientific associations and their feedback was integrated. Identified important topics were: laparoscopic entry techniques, intra-abdominal pressure, trocar use, electrosurgical techniques, prevention of trocar site herniation, patient positioning, anesthesiology, perioperative care, patient information, multidisciplinary user consultation, and complication registration. The text of each topic contains an introduction with an explanation of the problem and a summary of the current literature. Each topic was discussed, considerations were evaluated and recommendations were formulated. The development of a guideline on a multidisciplinary level facilitated a broad and rich discussion, which resulted in a very complete and implementable guideline.

A systematic review of interventions to facilitate ambulatory laparoscopic cholecystectomy

OBJECTIVES

  We aimed to perform a systematic review of the literature to identify interventions that may facilitate ambulatory laparoscopic cholecystectomy (LC).

METHODS

The PubMed and CENTRAL databases were interrogated for key MeSH headings. To be eligible for systematic review, trials were required to include outcome measures of postoperative pain, nausea or vomiting and time to discharge following LC. Interventions were subsequently assessed for the level of evidence and grade of recommendation given.

RESULTS

A total of 331 trials were identified, 68 of which met the predefined study inclusion criteria. Interventions which met Level I, Grade A recommendation included the administration of 8 mg i.v. dexamethasone, preoperative administration of analgesia including the use of non-steroidal anti-inflammatory or COX II inhibitors, intraoperative use of an anti-emetic, pre-incisional use of bupivacaine, administration of intraperitoneal bupivacaine on establishment of pneumoperitoneum, and avoidance of drains.

CONCLUSIONS

  High-quality evidence describing interventions that minimize barriers to ambulatory LC exists. Further studies will be required to determine the optimal combination of these interventions.

Impact of the patient's body position on the intraabdominal workspace during laparoscopic surgery

Background

The effects of the patient’s body position on the intraabdominal workspace in laparoscopic surgery were analyzed.

Methods

The inflated volume of carbon dioxide was measured after insufflation to a preset pressure of 15 mmHg for 20 patients with a body mass index (BMI) greater than 35 kg/m². The patients were anesthetized with full muscle relaxation. The five positions were (1) table horizontal with the legs flat (supine position), (2) table in 20° reverse Trendelenburg with the legs flat, (3) table in 20° reverse Trendelenburg with the legs flexed 45° upward at the hips (beach chair position), (4) table horizontal with the legs flexed 45° upward at the hips, and (5) table in 20° Trendelenburg with the legs flat. The positions were performed in a random order, and the first position was repeated after the last measurement. Repeated measure analysis of variance was used to compare inflated volumes among the five positions.

Results

A significant difference in inflated volume was found between the five body positions (P = 0.042). Compared with the mean inflated volume for the supine position (3.22 ± 0.78 l), the mean inflated volume increased by 900 ml for the Trendelenburg position or when the legs were flexed at the hips, and decreased by 230 ml for the reverse Trendelenburg position.

Conclusions

The Trendelenburg position for lower abdominal surgery and reverse Trendelenburg with flexing of the legs at the hips for upper abdominal surgery effectively improved the workspace in obese patients, even with full muscle relaxation.

A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy

BACKGROUND

The increase in intra-abdominal pressure by insufflation of carbon dioxide during laparoscopy brings certain changes in function of organ systems and also leads to postoperative pain. Degree of intra-abdominal pressure is directly related with such change. Laparoscopic cholecystectomy can be performed at low pressure pneumoperitoneum. However, available space for dissection is less than the high pressure pneumoperitoneum.

METHODS

Twenty-six patients for elective laparoscopic cholecystectomy were studied in a prospective, randomized, patient, and surgeon blinded manner. The intra-abdominal pressure was kept either in low pressure (8 mm Hg) or in high pressure (12 mm Hg). All patients underwent two dimensional echocardiography, pulmonary function test and color Doppler examination of lower limb vessels preoperatively and postoperatively. Arterial blood gas analysis and End Tidal CO2 monitored before insufflation, during surgery and after deflation. Pain score was measured by visual analog scale and surgeon's comfort level was recorded. Postoperative analgesia requirement, complications, and hospital stay were recorded. Student t test used for the statistical analysis.

RESULTS

Both groups match for the demographic parameters. Four patients required conversion to high pressure. Intraoperative pO2 level, postoperative pain, analgesic requirement, pulmonary function, and hospital stay were favoring low pressure pneumoperitoneum in a statistically significant manner. There was no difference between 2 groups for duration of surgery, intraoperative, and postoperative complications. However, the technical difficulties were graded more (statistically nonsignificant) with low pressure pneumoperitoneum.

CONCLUSIONS

An uncomplicated gall stone disease can be treated by low pressure laparoscopic cholecystectomy with reasonable safety by an experienced surgeon. Though surgeons experience more difficulty in dissection during low pressure pneumoperitoneum, it is significantly advantageous in terms of postoperative pain, use of analgesics, preservation of pulmonary function, and hospital stay.

Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy

BACKGROUND

A pneumoperitoneum of 12 to 16 mmHg 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 patients undergoing laparoscopic cholecystectomy.

SEARCH STRATEGY

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until November 2008 for identifying randomised trials using search strategies.

SELECTION CRITERIA

Only randomised clinical trials, irrespective of language, blinding, or publication status were considered for the review.

DATA COLLECTION AND ANALYSIS

Two authors independently identified trials and independently extracted data on mortality, morbidity, conversion to open cholecystectomy, pain, analgesic requirement, operating time, hospital stay, patient satisfaction, additional measures to increase vision, and cardiopulmonary parameters. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) using both the fixed-effect and the random-effects models with RevMan 5 based on available case-analysis.

MAIN RESULTS

Fifteen trials randomised 690 patients to low pressure (n = 336) and standard pressure (n = 354). All the trials were of high risk of bias. There was no difference in the mortality, morbidity, or conversion to open cholecystectomy between the groups. The intensity of pain was lower in the low pressure group at various time points. The incidence of shoulder pain was lower in the low pressure group (RR 0.53; 95% CI 0.31 to 0.90). The analgesic consumption was also lower. The operating time was similar between the groups (MD 2.30 minutes; 95% CI 0.42 to 4.18). Because of the high risk of bias due to incomplete outcome data in seven trials, it was not possible to conclude about the safety of low pressure pneumoperitoneum.

AUTHORS' CONCLUSIONS

Low pressure pneumoperitoneum appears effective in decreasing pain after laparoscopic cholecystectomy. The safety of low pressure pneumoperitoneum has to be established.