The Effects of Different Pressure Pneumoperitoneum on the Pulmonary Mechanics and Surgical Satisfaction in the Laparoscopic Cholecystectomy

Objectives. Inspiratory, hemodynamic and metabolic changes occur in laparoscopic surgery depending on pneumoperitoneum and patient position. This study aims to evaluate the effects of intra-abdominal pressure increase based on CO2 pneumoperitoneum in laparoscopic operations on hemodynamic parameters and respiratory dynamics and satisfaction of surgeon and operative view.
Materials and Methods. A total of 116 consecutive, prospective, ASA class I–III cases aged 18–70 years undergoing laparoscopic cholecystectomy were enrolled in this study. Data of 104 patients were analysed. Patients were divided into two groups as the group Low Pressure (<12 mmHg) (Group LP) (n=53) and the group Standard Pressure (>13 mmHg) (Group SP) (n=51). In this study administration of general anesthesia used total intravenous anaesthesia in both groups. All groups had standard and TOF monitorization applied. The anaesthesia methods used in both groups were recorded. Before, during and after peritoneal insufflation, the peroperative ventilation parameters and hemodynamic parameters were recorded. The adequacy of pneumoperitoneum, gastric and the operative view were evaluated by the operating surgeon and recorded.
Results. The peripheral oxygen saturation showed no significant difference between the low and standard pressure pneumoperitoneum in view of tidal volume, respiratory rate, end tidal CO2, mean and peak inspiratory pressure, and minute ventilation values. In terms of hemodynamics, when values just after intubation and before extubation were compared, it was observed that in the LP group systolic, diastolic and mean blood pressure values were higher. In terms of heart rate, no significant difference was observed in determined periods between groups. There was no significant difference between the groups in terms of surgical satisfaction and vision.
Conclusion. Low pressure pneumoperitoneum provides effective respiratory mechanics and stable hemodynamics for laparoscopic cholecystectomy. It also provides the surgeon with sufficient space for hand manipulations. Anaesthetic method, TIVA and neuromuscular blockage provided good surgery vision with low pressure pneumoperitoneum.

1. Bittner R. The standard of laparoscopic cholecystectomy. Langenbecks Arch Surg. 2004; 389: 157–163. DOI: 10.1007/s00423-004-0471-1. PMID: 15188083

2. Gin E., Lowen D., Tacey M., Hodgson R. Reduced Laparoscopic Intraabdominal Pressure During Laparoscopic Cholecystectomy and Its Effect on Post-operative Pain: a Double-Blinded Randomised Control Trial. J Gastrointest Surg. 2021 Feb 9. DOI: 10.1007/s11605-021-04919-0. PMID: 33565010

3. Raval A.D., Deshpande S., Koufopoulou M., Rabar S., Neupane B., Iheanacho I., Bash L.D., Horrow J., Fuchs-Buder T. The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: a systematic review and network meta-analysis of randomized controlled trials. Surg Endosc. 2020; 34 (7): 2878–2890. DOI: 10.1007/s00464-020-07527-2. PMID: 32253560

4. Halldestam I., Enell E.L., Kullman E., Borch K. Development of symptoms and complications in individuals with asymptomatic gallstones. The British Journal of Surgery. 2004; 91 (6): 734–8. DOI: 10.1002/bjs.4547. PMID: 15164444

5. Attili A.F., De Santis A., Capri R., Repice A.M., Maselli S. The natural history of gallstones: The GREPCO experience. The GREPCO group. Hepatology. 1995; 21 (3): 655–660. DOI: 10.1002/hep.1840210309. PMID: 7875663

6. NIH. NIH consensus statement on gallstones and laparoscopic cholecystectomy. http://consensus.nih.gov/1992/1992GallstonesLaparoscopy090html.htm 1992

7. Gurusamy K.S., Samraj K., Davidson B.R. Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. The Cochrane Cochrane Database of Systematic Reviews 2009: 2; 1–50. DOI: 10.1002/14651858.CD007060.pub2. PMID: 19370671.

8. Russell R.C. General surgery: Biliary surgery. BMJ. 1993; 307 (6914): 1266–9. DOI: 10.1136/bmj.307.6914.1266. PMID: 8281063.

9. Dexter S.P.L, Martin I.G., Marton J., McMahon M.J. Long operation and the risk of complications from laparoscopic cholecystectomy. The British Journal of Surgery. 1997; 84: (4): 464–466. PMID: 9112893.

10. Sarli L., Costi R. Prospective randomized trial of lowpressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. The British Journal of Surgery 2000; 87 (9): 1161–1165. DOI: 10.1046/j.1365-2168.2000.01507.x. PMID: 10971421

11. Goel A., Gupta S., Bhagat T.S., Garg P. Comparative Analysis of Hemodynamic Changes and Shoulder Tip Pain Under Standard Pressure Versus Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy. Euroasian J Hepatogastroenterol. 2019; 9 (1): 5–8. DOI: 10.5005/jp-journals-10018-1287. PMID: 31988859

12. Beylacq L., Bordes M., Semjen F., Cross A.-M. The I-gel, a single-use supraglottic airway device with a non-inflatable cuff and an esophageal vent: an observational study in children. Acta Anaesthesiol Scand 2009; 53: 376–379. DOI: 10.1111/j.1399-6576.2008.01869.x. PMID: 19243322.

13. Williams M.T., Rice I., Ewen S.P., Elliott S.M. A comparison of the effect of two anaesthetic techniques on surgical conditions during gynaecological laparoscopy. Anaesthesia. 2003; 58 (6): 574–578. DOI: 10.1046/j.1365-2044.2003.03150.x. PMID: 12846625

14. Khaitan L., Apelgren K., Hunter J., Traverso L.W. A report on the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) outcomes initaitive. Surg Endosc. 2003; 17: 65–70. DOI: 10.1007/s00464-002-8844-4. PMID: 12469242

15. Kelly M.D. Laparoscopic retrograde (fundus first) cholecystectomy. BMC Surgery. 2009; 9: 19–27. DOI: 10.1111/j.1528-1167.2009.02291.x. PMID: 19761450.

16. Singla S., Mittal G., Mittal R. Pain Management after Laparoscopic Cholecystectomy-A Randomized Prospective Trial of Low Pressure and Standard Pressure Pneumoperitoneum. J Clin Diagn Res. 2014; 8 (2): 92–94. PMID: 24701492. DOI: 10.7860/JCDR/2014/7782.4017

17. Perrakis E., Vezakis A., Velimezis G., Savanis G., Deverakis S., Antoniades J., Sagkana E. Randomized comparison between different insufflation pressures for laparoscopic cholecystectomy. Surgical Laparoscopy Endoscopy &Percutaneous Techniques. 2003; 13: (4): 245–249. DOI: 10.1097/00129689-200308000-00004. PMID: 12960786

18. Ibraheim O.A., Samarkandi A.H., Alshehry H., Faden A., Farouk E.O. Lactate and acid base changes during laparoscopic cholecystectomy Middle East Journal of Anesthesiology. 2006; 18: (4): 757–768. PMID: 16749570.

19. Barczynski M., Herman R.M. A prospective randomized trial on comparison of low pressure (LP) and standard-pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy. Surgical Endoscopy 2003; 17 (4): 533–538. DOI: 10.1007/s00464-002-9121-2. PMID: 12582754.

20. Barrio J., Errando C.L., García-Ramón J., Sellés R., San Miguel G., Gallego J. Influence of depth of neuromuscular blockade on surgical conditions during low-pressure pneumoperitoneum laparoscopic cholecystectomy: A randomized blinded study. J Clin Anesth. 2017; 42: 26–30. DOI: 10.1016/j.jclinane.2017.08.005. PMID: 28803124

21. Gerges F.J., Kanazi G.E., Jabbour-Khoury S.I. Anesthesia for laparoscopy: a review. J Clinl Anesth. 2006; 18 (1): 67–78. DOI: 10.1016/j.jclinane.2005.01.013. PMID: 16517337

22. Odeberg-Wernerman S. Laparoscopic surgery – effects on circulatory and respiratory physiology: an overview. Eur J Surg Suppl. 2000; 585: 4–11. PMID: 10885548

23. Makinen M.T., Yli-Hankala A. Respiratory compliance during laparoscopic hiatal and hernia repair. Can J Anaesth. 1998; 45 (9): 865–870. DOI: 10.1007/BF03012221. PMID: 9818110.

24. Luiz T., Huber T., Hartung H.J. Ventilatory changes during laparoscopic cholecystectomy. Anaesthesist. 1992; 41 (9): 520–526. DOI: 10.1007/BF03012221. PMID: 9818110.

25. Kendall A.P., Bhatt S., Oh T.E. Pulmonary consequences of carbondioxide insufflation for laparoscopic cholecystectomies. Anaesthesia. 1995; 50 (4): 286–289.

26. Makinen M-T., Yli-Hankala A. The effect of laparoscopic cholecystectomy on respiratory compliance as determined by continuous spirometry. J. Clin Anesth. 1996; 8: 119–122. DOI: 10.1111/j.1365-2044.1995.tb04600.x. PMID: 7747841.

27. Rishimani A.S., Gautam S.C. Hemodynamic and Respiratory Changes During Laparoscopic Cholecystectomy with High and Reduced Intraabdominal Pressure. Surgical Laparoscopy and Endoscopy. 1996; 6: (3): 201–204. PMID: 8743363.

28. Joris J., Noirot D.P., Legrand M.J., Jacquet N.J., Lamy M.L. Hemodynamic changes during laparoscopic cholcystectomy. Anesth Analg. 1993; 76: 1067–1071. PMID: 8743363.

29. Marshall R.L., Jepson P.R.J., Devie I.T, Scott B. Circulatory effects of peritoneal insufflation with nitrousoxide. Br J Anaesth. 1992; 44: 1183–1187. DOI: 10.1093/bja/44.11.1183. PMID: 4647113.

30. Dubois Phileppe E., Putz L., Jamart J., Marotta M.-L.; Gourdin M., Donnez O. Deep neuromuscular block improves surgical conditions during laparoscopic hysterectomy: A randomised controlled trial. European Journal of Anaesthesiology. 2014; 31: (8): 430–436. DOI: 10.1097/EJA.0000000000000094. PMID: 24809482.

31. Martini C.H., Boon M., Bevers R.F., Aarts L.P., Dahan A. Evaluation of surgical conditions during laparoscopic surgery in patients with moderate vs deep neuromuscular block. Br J Anaesth. 2014; 112 (3): 498–505. DOI: 10.1093/bja/aet377. PMID: 24240315.

32. Koo B.W., Oh A.Y., Seo K.S., Han J.W., Han H.S., Yoon Y.S. Randomized Clinical Trial of Moderate Versus Deep Neuromuscular Block for LowPressure Pneumoperitoneum During Laparoscopic Cholecystectomy. World J Surg. 2016; 40 (12): 2898–2903. DOI: 10.1007/s00268-016-3633-8. PMID: 27405749

33. Staehr-Rye A.K., Rasmussen L.S., Rosenberg J., Juul P., Gätke M.R. Optimized surgical space during low-pressure laparoscopy with deep neuromuscular blockade. Dan Med J. 2013; 60 (2): 579. PMID: 23461992.

34. Ibraheim O.A., Samarkandi A.H., Alshehry H., Faden A., Farouk E.O. Lactate acid base changes during laparoscopic cholecystectomy. Mej Anesth. 2006; 18 (4): 757–768. PMID: 16749570.

35. Hasukic S. Postoperative changes in liver function tests randomized comparison of low- and high-pressure laparoscopic cholecystectomy. Surg Endosc. 2005; 19 (11): 1451–1455. DOI: 10.1007/s00464-005-0061-5. PMID: 16206003.