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

Effect of Different Doses of Esketamine on Postoperative Recovery in Patients Undergoing Gynecologic Laparoscopic Surgery, a Randomized, Double-Blind, Single-Center Clinical Study

Purpose

This study aimed to explore the effect of preoperative different doses of esketamine on postoperative recovery in patients undergoing gynecologic laparoscopic surgery.

Methods

A total of 99 women scheduled for gynecologic laparoscopic surgery under general anesthesia were enrolled and randomized. Three minutes before surgical incision, patients in the three groups were intravenously administered 0.25 mg/kg esketamine, 0.5 mg/kg esketamine, and an equivalent dose of saline, respectively. The primary outcome was the Quality of Recovery-15 (QoR-15) score assessed on 1 day (pod1), 3 days (pod3), and 7 days postoperatively (pod7). Secondary outcomes encompassed the VAS score, MAP, HR, frequency of rescue analgesia and length of hospital stay.

Results

Compared with group C, QoR-15 score was significantly improved in group E1 and E2 on pod1, while the rest VAS score was significantly decreased at 6h postoperatively (F =19.164, P < 0.001; F = 6.059, P = 0.034). On pod1, the VAS scores at rest and movement in group E2 were significantly lower than those in group C (P = 0.007, P = 0.038). There was a significant decrease in resting VAS scores in the E2 group compared with group C on pod3 (P = 0.021). Compared with group C, the QoR-15 score in group E2 increased on pod7 (P = 0.008), but there was no clinical difference. There was no significant difference in MAP and HR among the three groups at each time point (F = 0.758, P = 0.471; F = 0.232, P = 0.794). There was a significant difference in the number of postoperative rescue analgesia among the three groups (P = 0. 023).

Conclusion

Preoperative single small dose of esketamine can improve the quality of recovery 24h after gynecologic laparoscopic surgery patients, decrease the number of rescue analgesia, and may contribute to the rapid recovery of patients. And 0.5 mg/kg esketamine seems to be better.

Non-programmed rehospitalizations after cholecystectomy

Cholecystectomy is one the most frequent procedures in digestive surgery. While the operation is generally associated with low rates of morbidity and mortality, frequency of occurrence can vary considerably according to surgical indication, time elapsed between symptom appearance and surgical intervention, anatomical area under treatment, and the experience of the different centers. Rehospitalization after cholecystectomy remains potentially problematic in numerous units, due in part to the ongoing development of day hospital treatment and short-term hospitalization. The objective of this update is to assess not only the rate, causes and risk factors of non-programmed hospitalizations subsequent to cholecystectomy, but also the available ways and means of prevention and management in the patient's best interests.

The Impact of Intraoperative CO 2 Pneumoperitoneum Pressure in Gastrointestinal Surgery: A Systematic Review

INTRODUCTION

Pneumoperitoneum is widely used in gastrointestinal surgery, particularly for laparoscopic or robotic procedures, with suggested advantages associated with low pressure. While existing data predominantly focuses on laparoscopic cholecystectomy, the assessment of intra-abdominal pressures in other gastrointestinal surgeries remains unexplored.

METHODS

This study conducted an electronic literature search for randomized control trials comparing low-pressure pneumoperitoneum to standard or high-pressure counterparts.

RESULTS

Out of 26 articles meeting inclusion criteria, encompassing 2077 patients, 15 demonstrated positive associations with low-pressure pneumoperitoneum. No significant difference in postoperative pain was found in the remaining papers. Methodological variations, diverse outcome reporting, and a prevalent high risk of bias precluded meta-analysis.

CONCLUSIONS

The study highlights substantial outcome variability, urging cautious interpretation of aggregated results. Despite positive associations in specific cases, insufficient evidence was found to support the superiority of low-pressure pneumoperitoneum. The study recommends future research employing validated patient-reported outcome measures and standardized reporting to help guide the development of evidence-based guidelines and optimize patient care in abdominal surgeries.

Effect of controlled hyperventilation on post-laparoscopic cholecystectomy shoulder pain: a prospective randomized controlled trial

OBJECTIVE

This study investigated whether intraoperative controlled hyperventilation could reduce the incidence and severity of post-laparoscopic shoulder pain.

METHODS

In this prospective, randomized, double-blind controlled trial, 150 patients undergoing elective laparoscopic cholecystectomy were randomly assigned to either controlled hyperventilation (n = 75) or conventional ventilation (n = 75) groups. The hyperventilation group received mechanical ventilation with a tidal volume of 10 mL/kg and respiratory rate adjusted to maintain end-tidal CO2 between 30 and 35 mmHg, while the control group received conventional ventilation (tidal volume 8 mL/kg, end-tidal CO2 35-45 mmHg). The primary outcome was the incidence and severity of shoulder pain during the first 48 postoperative hours. Secondary outcomes included intraoperative parameters, gas exchange values, surgical site pain, and patient satisfaction.

RESULTS

The hyperventilation group demonstrated significantly lower shoulder pain incidence (36.0% vs. 60.0%, P = 0.003), shorter pain duration (4.13 ± 6.25 vs. 9.24 ± 7.82 h, P < 0.001), and consistently lower pain intensity scores at all time points up to 48 h postoperatively. The intervention group also showed shorter operation time (50.01 ± 12.04 vs. 80.32 ± 34.23 min, P < 0.001), lower pneumoperitoneum pressure requirements (11.73 ± 1.19 vs. 33.72 ± 19.47 mmHg, P < 0.001), and improved patient satisfaction (73.33% vs. 42.67%, P < 0.001). No significant differences were observed in postoperative complications, time to first flatus, or length of hospital stay.

CONCLUSION

Intraoperative controlled hyperventilation effectively reduces the incidence and severity of shoulder pain following laparoscopic cholecystectomy, while improving surgical conditions and patient satisfaction. This simple intervention provides a safe and cost-effective approach to enhancing postoperative outcomes in laparoscopic surgery.

The Impact of Acupuncture on Pain Intensity, Nausea, and Vomiting for Laparoscopic Cholecystectomy: A Meta-analysis Study

BACKGROUND

Acupuncture may have some potential in pain relief after laparoscopic cholecystectomy, and this meta-analysis aims to explore the impact of acupuncture on pain intensity, nausea and vomiting for patients undergoing laparoscopic cholecystectomy.

METHODS

PubMed, EMbase, Web of science, EBSCO, Cochrane library databases, CNKI, VIP, and Wangfang were systematically searched, and we included randomized controlled trials (RCTs) assessing the effect of acupuncture on pain control for laparoscopic cholecystectomy.

RESULTS

Five RCTs and 366 patients were included in the meta-analysis. Overall, compared with control intervention for laparoscopic cholecystectomy, acupuncture was associated with significantly reduced pain scores at 6 hours [mean difference (MD)=-0.86; 95% CI=-1.37 to -0.34; P =0.001, 2 RCTs) and pain scores at 8 to 10 hours (MD=-0.71; 95% CI=-1.13 to -0.28; P =0.001, 2 RCTs), decreased incidence of nausea (odds ratio=0.10; 95% CI=0.03-0.34; P =0.0003, 3 RCTs), and vomiting (odds ratio=0.11; 95% CI=0.01-0.85; P =0.03, 3 RCTs), but demonstrated no obvious impact on pain scores at 12 to 24 hours (MD=-0.38; 95% CI=-1.02 to 0.27; P =0.25, 2 RCTs).

CONCLUSIONS

Acupuncture may be effective to reduce pain intensity, nausea, and vomiting for laparoscopic cholecystectomy.

Post-laparoscopic Shoulder Pain Management: A Narrative Review

PURPOSE OF REVIEW

Post-laparoscopic shoulder pain (PLSP) can slow patient recovery and extend hospital stays, making its management crucial for patients undergoing laparoscopic surgery. Current consensus guidelines say little about how to prevent or manage PLSP. In this context, a multimodal approach to PLSP management that maybe extend beyond the pharmaceutical interventions currently employed. A variety of devices comprising both invasive and noninvasive approaches are available to patients, serving as adjuvants to analgesics. In this review, we explore the potential causes of PLSP. Additionally, by searching relevant databases and reviewing existing literature, we provide a comprehensive summary of current PLSP management strategies excluding analgesics.

RECENT FINDINGS

A total of 30 articles were reviewed. The review identified a number of different treatments for PLSP, including trendelenburg position, discharge of residual gas, pulmonary recruitment manoeuvre, low-pressure pneumoperitoneum and phrenic nerve block, among others. However, the inconsistencies in the study designs resulted in disparate conclusions. While the current studies provide valuable insights, there is a clear need for further research in this area.

Comparison of gallbladder extraction via the subxiphoid port and the supraumbilical port during laparoscopic cholecystectomy: a prospective randomized clinical trial

BACKGROUND

Postoperative pain after laparoscopic cholecystectomy (LC) is the most frequent postoperative complaint. To date, gallbladder extraction via the subxiphoid port (SXP) versus the supraumbilical port (SUP) is still controversial. Thus, the authors performed this randomized controlled trial to compare postoperative pain between the SXP and SUP for LC.

METHOD

From June 2021 to June 2023, patients who met the inclusion criteria were randomly assigned to two groups. The perioperative data of both groups were recorded and compared.

RESULTS

A total of 253 patients were enrolled in the analysis. There were 126 in the SXP group and 127 in the SUP group. There was no significant difference between the two groups in terms of the duration of gallbladder extraction, whether the incision was extended, the least rate of pain, the average rate of pain, the right-now rate of pain, postoperative pain on the 5th, 7th, and 14th days, postoperative complications and Vancouver Scar scale. However, the SUP group had a lower the worst rate of pain (4.24±2.45 vs. 4.91±2.45, P=0.031) and 3 days of pain (3.35±1.57 vs. 3.75±1.52, P=0.045) than did the SXP group. The influence of pain on general activity (4.51±2.90 vs. 3.76±2.92, P=0.041), mood (3.62±2.66 vs. 2.92±2.36, P=0.028), walking ability (4.40±3.01 vs. 3.66±2.76, P=0.044), and enjoyment of life (3.19±2.68 vs. 2.32±2.34, P=0.007) in the SXP was more severe than that in the SUP.

CONCLUSION

The extraction of the gallbladder via the SUP is superior to that via the SXP because the early postoperative 24 h pain and pain on the third day are mild and do not increase the duration of gallbladder extraction or the risk of infection or hernia.

Protective effect of a novel smoke evacuation device during laparoscopic surgery: An experimental proof-of-concept study

BACKGROUND

Surgical smoke generated by energy devices poses health risks to medical staff. During laparoscopic surgery, the smoke aggregating around the camera obstructs the visual field, forcing surgeons to interrupt surgery, and may increase surgical risk. We propose a proximal smoke evacuation method to improve surgical quality by effectively eliminating surgical smoke.

METHODS

A smoke evacuation device was designed to attach to a laparoscopic electrode and create a channel for smoke to be suctioned directly from near the tip of the electrode (proximal evacuation). An animal study was conducted to collect videos of electrocautery with proximal (device) evacuation, distal (trocar) evacuation, and no evacuation. We used a computer vision-based model to compare in-screen smoke density and image quality between different evacuation pathways.

RESULTS

Compared with distal and no evacuation, proximal evacuation had significantly lower estimated in-screen smoke density and higher image quality (p < 0.001). The pneumoperitoneum pressure remained above 8 mmHg throughout the procedure with proper suction pressure setting. A total of 62 trials performed by 15 surgeons produced consistent results, supporting the core findings of this study. On average, proximal evacuation can eliminate 85.47% of the smoke around operative fields within 10 s.

CONCLUSIONS

Proximal smoke evacuation is capable of maintaining a clean surgical field and high image quality during laparoscopic surgery. The device can help avoid interrupting surgeries to wait for the smoke to clear or clean the camera lens.

Low vs. conventional intra-abdominal pressure in laparoscopic colorectal surgery: a prospective cohort study

PURPOSE

Low intraabdominal pressure (IAP) during laparoscopy is associated with improved post-operative outcomes across a variety of surgical specialties. A prospective cohort study was undertaken to assess post-operative outcomes in patients undergoing laparoscopic colorectal surgery (LCRS) with low (8mmHg) versus conventional (15mmHg) IAP.

METHODS

A prospective real-world observational study of patients undergoing LCRS in a single-centre, between June 2020 and June 2023 was performed. Operative procedures for diverse colonic pathology such as diverticular disease, inflammatory bowel disease (IBD), and colorectal cancers (CRC) were included. The evaluated primary outcomes were post-operative pain, return of gastrointestinal motility, and length of hospital stay. Secondary outcomes were the overall safety profile including intra- and post-operative complications and morbidity. Outcomes of interest were investigated using multivariate analysis.

RESULTS

A total of 120 patients were included of which 69 (57.5%) were male. Median age and BMI of the cohort was 67 years (51-75 years) and 27 kg/m2 (24-32 kg/m2), respectively. 61 (50.8%) patients were categorised as an ASA grade 3. Two (1.7%) patients had diverticular disease; 31 (25.9%) had IBD, and 87 (72.4%) were operated on for colonic malignancy. Low IAP (8mmHg) was used in 53 (44.2%) cases, whilst the remainder (55.8%) had IAP set at 15mmHg (conventional). Low-pressure surgery was associated with improved intraoperative lung compliance (p < 0.001) and peak inspiratory pressures up to 6 h (p < 0.001); reduced analgesic requirement (p ≤ 0.028), and decreased postoperative pain both at rest (p = 0.001) and on exertion (p < 0.001). Moreover, low IAP was associated with an earlier time to pass flatus postoperatively (p = 0.047) with no significant difference in length of hospital stay (p = 0.574). Additionally, no significant difference was observed between the groups for outcomes including median operating time (p = 0.089), conversion to open surgery (p = 0.056), overall complication rate (p = 0.102), and 90-day mortality (p = 0.381).

CONCLUSION

Low IAP use during LCRS is feasible with a comparable safety profile to conventional laparoscopy. Intra-operative respiratory physiology is improved with reduced postoperative pain and analgesic requirement, and earlier time to pass flatus. Future rationally designed; well-powered, randomised trials are needed to understand the benefits of low intra-peritoneal pressure during laparoscopic colorectal resections.

Comparison of the therapeutic effects of different pneumoperitoneum pressures on laparoscopic transabdominal preperitoneal hernia repair: a randomized controlled trail

PURPOSE

To compare the indicators, postoperative pneumoretroperitoneum-related complications, and postoperative recovery of laparoscopic preperitoneal inguinal hernia repair under different CO2 pneumoperitoneum pressures.

METHODS

The total of 187 adult patients with primary inguinal hernia who successfully underwent transabdominal preperitoneal prosthesis (TAPP) from September 2021 to September 2023 in the Department of General Surgery, Haimen People's Hospital affiliated to Nantong University, were collected. These patients were randomly divided into low abdominal pressure group (group A: pneumoperitoneum pressure = 8 mmHg), sub-low abdominal pressure group (group B: pneumoperitoneum pressure = 10 mmHg), moderate abdominal pressure group (group C: pneumoperitoneum pressure = 12 mmHg), and standard pressure group (group D: pneumoperitoneum pressure = 14 mmHg), with 40 patients each.

RESULTS

The operation time in group C (43.90 ± 9.75) was significantly lower than group A (51.98 ± 12.65, p 0.001), group B (46.70 ± 10.59, p 0.001), and was higher than that in group D without significant statistical differences (38.15 ± 7.98, P = 0.05). The peritoneal suturing time in group C (5.03 ± 1.07) was significantly higher than group A (4.23 ± 0.70, p 0.001), group B (4.55 ± 0.85, p = 0.03), and was significantly lower than that in group D (6.95 ± 1.96, p 0.001).

CONCLUSION

Selecting sub-low abdominal pressure (12 mmHg) can help to have a shorter operation time, with less blood loss, and it did not add pneumoretroperitoneum-related complications. Changing the pneumoperitonium pressure during different phases of the surgery is also an optimal option.

Comparison of low-pressure and standard-pressure pneumoperitoneum laparoscopic cholecystectomy in patients with cardiopulmonary comorbidities: a double blinded randomized clinical trial

BACKGROUND

The benefits of low-pressure laparoscopic cholecystectomy (LPLC) in patients with cardiopulmonary comorbidities remain unclear. This study aimed to explore the feasibility and pulmonary effects of LPLC in patients with cardiopulmonary comorbidities.

METHODS

This was a multicenter, parallel, double-blind, randomized controlled trial. Eligible patients included patients with cardiac or pulmonary comorbidities, who were randomly assigned (1:1) to undergo LPLC (10 mmHg) or standard-pressure laparoscopic cholecystectomy (SPLC) (14 mmHg). The primary outcome was postoperative partial pressure of carbon dioxide (CO2). Surgical safety variables, patient recovery, pulmonary function parameters, and surgeon comfort were also compared between groups.

RESULTS

This study enrolled 144 participants, with 124 participants extracted for the final analysis (62 in LPLC and 62 in SPLC group, respectively). The median postoperative PaCO2 was similar in the LPLC (43.3 mmHg) and SPLC (43.0 mmHg) groups (p = 0.988). Pulmonary parameters including postoperative pH, PaCO2, HCO3, and lactate levels were similar between the two groups. Postoperative base excess was significantly higher in the LPLC group (- 0.6 mmol/L [- 6.9 ~ 7.5] vs. -1.9 mmol/L [- 6.6 ~ 5.4]; p = 0.031). There was no between-group difference regarding intraabdominal operative time, rate of intraoperative bile spillage, blood loss, surgeon comfort during surgery, and conversion rate. Moreover, postoperative major complication rates, the median time to the first flatus, postoperative hospital stay, or mean postoperative visual analog scale score for pain were similar in both groups.

CONCLUSIONS

This study found no reduction of partial pressure of CO2 with LPLC compared with SPLC for patients with cardiopulmonary comorbidities. LPLC with a pneumoperitoneum pressure of 10 mmHg may be safe and feasible for these patients when performed by experienced surgeons, although it does not improve pulmonary parameters.

REGISTRATION

The trial is retrospectively registered at ClinicalTrials.gov (NCT04670952) on December 17, 2020.

Pain management after laparoscopic cholecystectomy: A systematic review and procedure-specific postoperative pain management (PROSPECT) recommendations

Laparoscopic cholecystectomy can be associated with significant postoperative pain that is difficult to treat. We aimed to evaluate the available literature and develop updated recommendations for optimal pain management after laparoscopic cholecystectomy. A systematic review was performed using the procedure-specific postoperative pain management (PROSPECT) methodology. Randomised controlled trials and systematic reviews published in the English language from August 2017 to December 2022 assessing postoperative pain after laparoscopic cholecystectomy using analgesic, anaesthetic or surgical interventions were identified from MEDLINE, Embase and Cochrane Databases. From 589 full text articles, 157 randomised controlled trials and 31 systematic reviews met the inclusion criteria. Paracetamol combined with NSAIDs or cyclo-oxygenase-2 inhibitors should be given either pre-operatively or intra-operatively, unless contraindicated. In addition, intra-operative intravenous (i.v.) dexamethasone, port-site wound infiltration or intraperitoneal local anaesthetic instillation are recommended, with opioids used for rescue analgesia. As a second-line regional technique, the erector spinae plane block or transversus abdominis plane block may be reserved for patients with a heightened risk of postoperative pain. Three-port laparoscopy, a low-pressure pneumoperitoneum, umbilical port extraction, active aspiration of the pneumoperitoneum and saline irrigation are recommended technical aspects of the operative procedure. The following interventions are not recommended due to limited or no evidence on improved pain scores: single port or mini-port techniques, routine drainage, low flow insufflation, natural orifice transluminal endoscopic surgery (NOTES), infra-umbilical incision, i.v. clonidine, nefopam and regional techniques such as quadratus lumborum block or rectus sheath block. Several interventions provided better pain scores but are not recommended due to risk of side effects: spinal or epidural anaesthesia, gabapentinoids, i.v. lidocaine, i.v. ketamine and i.v. dexmedetomidine.

Systemic lidocaine versus erector spinae plane block for improving quality of recovery after laparoscopic cholecystectomy: A randomized controlled trial

STUDY OBJECTIVE

To compare intravenous lidocaine, ultrasound-guided erector spinae plane block (ESPB), and placebo on the quality of recovery and analgesia after laparoscopic cholecystectomy.

DESIGN

A prospective, triple-arm, double-blind, randomized, placebo-controlled non-inferiority trial.

SETTING

A single tertiary academic medical center.

PATIENTS

126 adults aged 18-65 years undergoing elective laparoscopic cholecystectomy.

INTERVENTIONS

Patients were randomly allocated to one of three groups: intravenous lidocaine infusion (1.5 mg/kg bolus followed by 2 mg/kg/h) plus bilateral ESPB with saline (25 mL per side); bilateral ESPB with 0.25% ropivacaine (25 ml per side) plus placebo infusion; or bilateral ESPB with saline (25 ml per side) plus placebo infusion.

MEASUREMENTS

The primary outcome was the 24-h postoperative Quality of Recovery-15 (QoR-15) score. The non-inferiority of lidocaine versus ESPB was assessed with a margin of -6 points and 97.5% confidence interval (CI). Secondary outcomes included 24-h area under the curve (AUC) for pain scores, morphine consumption, and adverse events.

MAIN RESULTS

124 patients completed the study. Median (IQR) 24-h QoR-15 scores were 123 (117-127) for lidocaine, 124 (119-126) for ESPB, and 112 (108-117) for placebo. Lidocaine was non-inferior to ESPB (median difference  -1, 97.5% CI: -4 to ∞). Both lidocaine (median difference 9, 95% CI: 6-12, P < 0.001) and ESPB (median difference 10, 95% CI: 7-13, P < 0.001) were superior to placebo. AUC for pain scores and morphine use were lower with lidocaine and ESPB versus placebo (P < 0.001 for all), with no significant differences between lidocaine and ESPB. One ESPB patient reported a transient metallic taste; no other block-related complications occurred.

CONCLUSIONS

For patients undergoing laparoscopic cholecystectomy, intravenous lidocaine provides a non-inferior quality of recovery compared to ESPB without requiring specialized regional anesthesia procedures. Lidocaine may offer a practical and accessible alternative within multimodal analgesia pathways.

Association between postoperative shoulder pain and left-side laparoscopic urologic surgery: a single-center retrospective cohort study

PURPOSE

Postoperative shoulder pain is a common problem after laparoscopic surgery. This study aimed to investigate the association between operative side and postoperative shoulder pain following urologic laparoscopic surgery performed in the lateral recumbent position.

METHODS

This was a retrospective cohort study conducted at a single tertiary care center. A total of 506 patients who underwent urologic laparoscopic surgery (including adrenalectomy, radical nephrectomy, partial nephrectomy, and pyeloplasty) between January 2010 and December 2019 were included. Patients who underwent total nephroureterectomy or resection of other organs were excluded. The primary outcome was the incidence of postoperative shoulder pain. A multivariable logistic regression analysis investigated the association between the operative side and postoperative shoulder pain.

RESULTS

Among the 506 included patients, there were an equal number of surgeries on the left and right sides. Eighty-eight patients had postoperative shoulder pain. The incidence of postoperative shoulder pain in the left-side group was significantly higher than that in the right-side group (21.3% [54/253] versus 13.4% [34/253], crude odds ratio = 1.75, 95% confidence interval [CI] 1.07-2.89). After adjustment for potential confounders (age, sex, body mass index, operation duration, operative technique, epidural block, peripheral nerve block, American Society of Anesthesiologists physical status classification, and intraoperative rocuronium dose), the left operative side was found to be associated with postoperative shoulder pain (adjusted odds ratio = 1.89, 95% CI 1.15-3.09).

CONCLUSION

The left operative side is associated with an increased incidence of postoperative shoulder pain after urologic laparoscopic surgery performed in the lateral recumbent position.

Low-pressure versus standard-pressure pneumoperitoneum in minimally invasive colorectal surgery: a systematic review, meta-analysis, and meta-regression analysis

BACKGROUND

We aimed to assess the efficacy and safety of low-pressure pneumoperitoneum (LPP) in minimally invasive colorectal surgery.

METHODS

A PRISMA-compliant systematic review/meta-analysis was conducted, searching PubMed, Scopus, Google Scholar, and clinicaltrials.gov for randomized-controlled trials assessing outcomes of LPP vs standard-pressure pneumoperitoneum (SPP) in colorectal surgery. Efficacy outcomes [pain score in post-anesthesia care unit (PACU), pain score postoperative day 1 (POD1), operative time, and hospital stay] and safety outcomes (blood loss and postoperative complications) were analyzed. Risk of bias2 tool assessed bias risk. The certainty of evidence was graded using GRADE.

RESULTS

Four studies included 537 patients (male 59.8%). LPP was undertaken in 280 (52.1%) patients and associated with lower pain scores in PACU [weighted mean difference: -1.06, 95% confidence interval (CI): -1.65 to -0.47, P = 0.004, I 2  = 0%] and POD1 (weighted mean difference: -0.49, 95% CI: -0.91 to -0.07, P = 0.024, I 2  = 0%). Meta-regression showed that age [standard error (SE): 0.036, P < 0.001], male sex (SE: 0.006, P < 0.001), and operative time (SE: 0.002, P = 0.027) were significantly associated with increased complications with LPP. In addition, 5.9%-14.5% of surgeons using LLP requested pressure increases to equal the SPP group. The grade of evidence was high for pain score in PACU and on POD1 postoperative complications and major complications, and blood loss, moderate for operative time, low for intraoperative complications, and very low for length of stay.

CONCLUSIONS

LPP was associated with lower pain scores in PACU and on POD1 with similar operative times, length of stay, and safety profile compared with SPP in colorectal surgery. Although LPP was not associated with increased complications, older patients, males, patients undergoing laparoscopic surgery, and those with longer operative times may be at risk of increased complications.

Comparison of low versus high (standard) intraabdominal pressure during laparoscopic colorectal surgery: systematic review and meta-analysis

BACKGROUND

To evaluate outcomes of low with high intraabdominal pressure during laparoscopic colorectal resection surgery.

METHODS

A systematic search of multiple electronic data sources was conducted, and all studies comparing low with high (standard) intraabdominal pressures were included. Our primary outcomes were post-operative ileus occurrence and return of bowel movement/flatus. The evaluated secondary outcomes included: total operative time, post-operative haemorrhage, anastomotic leak, pneumonia, surgical site infection, overall post-operative complications (categorised by Clavien-Dindo grading), and length of hospital stay. Revman 5.4 was used for data analysis.

RESULTS

Six randomised controlled trials (RCTs) and one observational study with a total of 771 patients (370 surgery at low intraabdominal pressure and 401 at high pressures) were included. There was no statistically significant difference in all the measured outcomes; post-operative ileus [OR 0.80; CI (0.42, 1.52), P = 0.50], time-to-pass flatus [OR -4.31; CI (-12.12, 3.50), P = 0.28], total operative time [OR 0.40; CI (-10.19, 11.00), P = 0.94], post-operative haemorrhage [OR 1.51; CI (0.41, 5.58, P = 0.53], anastomotic leak [OR 1.14; CI (0.26, 4.91), P = 0.86], pneumonia [OR 1.15; CI (0.22, 6.09), P = 0.87], SSI [OR 0.69; CI (0.19, 2.47), P = 0.57], overall post-operative complications [OR 0.82; CI (0.52, 1.30), P = 0.40], Clavien-Dindo grade ≥ 3 [OR 1.27; CI (0.59, 2.77), P = 0.54], and length of hospital stay [OR -0.68; CI (-1.61, 0.24), P = 0.15].

CONCLUSION

Low intraabdominal pressure is safe and feasible approach to laparoscopic colorectal resection surgery with non-inferior outcomes to standard or high pressures. More robust and well-powered RCTs are needed to consolidate the potential benefits of low over high pressure intra-abdominal surgery.

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.

Low Pneumoperitoneum Pressure Reduces Gas Embolism During Laparoscopic Liver Resection: A Randomized Controlled Trial

OBJECTIVE

To compare the effect of low and standard pneumoperitoneal pressure (PP) on the occurrence of gas embolism during laparoscopic liver resection (LLR).

BACKGROUND

LLR has an increased risk of gas embolism. Although animal studies have shown that low PP reduces the occurrence of gas embolism, clinical evidence is lacking.

METHODS

This parallel, dual-arm, double-blind, randomized controlled trial included 141 patients undergoing elective LLR. Patients were randomized into standard ("S," 15 mm Hg; n = 70) or low ("L," 10 mm Hg; n = 71) PP groups. Severe gas embolism (≥ grade 3, based on the Schmandra microbubble method) was detected using transesophageal echocardiography and recorded as the primary outcome. Intraoperative vital signs and postoperative recovery profiles were also evaluated.

RESULTS

Fewer severe gas embolism cases (n = 29, 40.8% vs n = 47, 67.1%, P = 0.003), fewer abrupt decreases in end-tidal carbon dioxide partial pressure, shorter severe gas embolism duration, less peripheral oxygen saturation reduction, and fewer increases in heart rate and lactate during gas embolization episodes was found in group L than in group S. Moreover, a higher arterial partial pressure of oxygen and peripheral oxygen saturation were observed, and fewer fluids and vasoactive drugs were administered in group L than in group S. In both groups, the distensibility index of the inferior vena cava negatively correlated with central venous pressure throughout LLR, and a comparable quality of recovery was observed.

CONCLUSIONS

Low PP reduced the incidence and duration of severe gas embolism and achieved steadier hemodynamics and vital signs during LLR. Therefore, a low PP strategy can be considered a valuable choice for the future LLR.

Additional low-pressure pulmonary recruitment for reducing post-laparoscopic shoulder pain in gynecologic laparoscopy: a randomized controlled trial

OBJECTIVE

To evaluate the effectiveness of additional low-pressure pulmonary recruitment in reducing postoperative shoulder pain.

METHODS

A double-blind randomized controlled trial was conducted at Srinagarind Hospital between May 2021 and October 2021. Forty patients who underwent laparoscopic gynecologic surgery were randomized into either an intervention group that received additional low-pressure pulmonary recruitment (30 cmH2O) (n=20) or a control group (n=20). Shoulder pain was evaluated using a numerical rating scale from 0 to 10, 24, and 48 hours after the operation.

RESULTS

The mean±standard deviation of shoulder pain at 24 hours after the operation of both the intervention and control groups were 2.10±2.27 and 1.45±1.73 points, respectively. The shoulder pain at 48 hours after the operation of the intervention and control groups were 1.15±1.46 and 0.85±1.73 points, respectively. There were no statistical differences in the mean difference between the two groups at 24 and 48 hours after operation (P=0.49; 95% confidence interval [CI], -0.61 to 1.91 and P=1.00; 95% CI, -0.96 to 1.56, respectively). No statistically significant differences were observed in additional analgesic medications used in either group, such as intravenous morphine or oral acetaminophen.

CONCLUSION

Additional low-pressure pulmonary recruitment to reduce shoulder pain after laparoscopic surgery for benign gynecologic diseases did not show a significant benefit compared to the control group, especially when administering postoperative around-the-clock analgesia.

Research hotspots and trends in postlaparoscopic shoulder pain from 2003 to 2023: A bibliometric analysis

The incidence of postlaparoscopic shoulder pain has recently increased and has attracted increasing attention from clinical workers, but no study has performed bibliometric and visual analysis of the relevant literature. This study used bibliometric and visual analysis to conduct a comprehensive and systematic evaluation of postlaparoscopic shoulder pain to help researchers understand the latest global trends and hotspots and provide a reference for caregivers to carry out PLSP care interventions and research. Related studies on postlaparoscopic shoulder pain from 2003 to 2023 were retrieved from the Web of Science Core Collection. We analysed current research trends and hotspots in this field using VOSviewer and CiteSpace. A total of 2451 authors from 352 institutions in 50 countries published 464 studies related to postlaparoscopic shoulder pain. The United States was the country with the most publications and worked closely with other countries. Donmez Turgut was the researcher with the most published articles, while Bisgaard T had the most citations per article. The Journal of Surgical Endoscopy was cited most frequently, totalling 356 times. Through keyword significance analysis, we found that relieving postlaparoscopic shoulder pain in patients through integrated care interventions was an emerging research hotspot. This bibliometric and visual analysis provides a comprehensive review of studies related to postlaparoscopic shoulder pain. The current global research trend and hotspot is to alleviate postlaparoscopic shoulder pain through integrated care interventions, but the advantages of this approach are not outstanding. However, further research and global collaboration are still needed. Our findings can help researchers understand the current status of postlaparoscopic shoulder pain research and identify new directions for future research.

Moderate Intra-Abdominal Pressure Levels in Robot-Assisted Radical Prostatectomy Seem to Have No Negative Impact on Clinical Outcomes

Introduction: Radical prostatectomy is increasingly performed laparoscopically with robot assistance (RALRP). RALRP, as with all laparoscopic procedures, requires a pneumoperitoneum, which might result in peritoneal inflammatory response reactions and postoperative pain. The aim of this retrospective single-centre study was to analyse the effects of a pneumoperitoneum during RARLP on clinical outcomes. Methods: All patients who underwent robot-guided prostatectomy in our clinic were included, with the exception of patients who were converted to open prostatectomy. C-reactive protein was used as a marker for the primary outcome, namely the postoperative inflammatory response. Intra-abdominal pressure (IAP) was evaluated as a potential factor influencing inflammation. In addition, the waist-hip ratio was used to estimate the amount of visceral adipose tissue, and the administration of dexamethasone was considered as a factor influencing inflammation. The Visual Analogue Scale (VAS) was used to determine postoperative pain. Patients were consecutively recruited between 1 September 2020 and 31 March 2022. Results: A total of 135 consecutive patients were included. The median waist-hip ratio was 0.55. The median duration of the pneumoperitoneum was 143 min. The median values of the average and maximum IAP values were 10 mmHg and 15 mmHg, respectively. The mean CRP of the first postoperative day was 6.2 mg/dL. The median VAS pain level decreased from 2 to 1 from the first to the third postoperative day. On the first postoperative day, 16 patients complained of shoulder pain. In addition, 134 patients were given some form of opioid pain treatment following surgery. Conclusion: We could not identify any relevant associations between the duration and IAP of the pneumoperitoneum and the indirect markers of inflammation or indicators of pain, or between the latter and the amount of visceral adipose tissue. In addition, we found no significant effect of the administration of dexamethasone on postoperative inflammation. The results point to a noninferior tolerability of moderate pressure during the procedure compared to the commonly utilised higher pressure, yet this must be confirmed in randomised controlled trials.

Underneath Images and Robots, Looking Deeper into the Pneumoperitoneum: A Narrative Review

Laparoscopy offers numerous advantages over open procedures, minimizing trauma, reducing pain, accelerating recovery, and shortening hospital stays. Despite other technical advancements, pneumoperitoneum insufflation has received little attention, barely evolving since its inception. We explore the impact of pneumoperitoneum on patient outcomes and advocate for a minimally invasive approach that prioritizes peritoneal homeostasis. The nonlinear relationship between intra-abdominal pressure (IAP) and intra-abdominal volume (IAV) is discussed, emphasizing IAP titration to balance physiological effects and surgical workspace. Maintaining IAP below 10 mmHg is generally recommended, but factors such as patient positioning and surgical complexity must be considered. The depth of neuromuscular blockade (NMB) is explored as another variable affecting laparoscopic conditions. While deep NMB appears favorable for surgical stillness, achieving a balance between IAP and NMB depth is crucial. Temperature and humidity management during pneumoperitoneum are crucial for patient safety and optical field quality. Despite the debate over the significance of temperature drop, humidification and the warming of insufflated gas offer benefits in peritoneal homeostasis and visual clarity. In conclusion, there is potential for a paradigm shift in pneumoperitoneum management, with dynamic IAP adjustments and careful control of insufflated gas temperature and humidity to preserve peritoneal homeostasis and improve patient outcomes in minimally invasive surgery.

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

BACKGROUND

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

STUDY DESIGN

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

RESULTS

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

CONCLUSIONS

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

A Prospective Cohort Analysis of the Prevalence and Predictive Factors of Delayed Discharge After Laparoscopic Cholecystectomy in Italy: The DeDiLaCo Study

BACKGROUND

The concept of early discharge ≤24 hours after Laparoscopic Cholecystectomy (LC) is still doubted in Italy. This prospective multicentre study aims to analyze the prevalence of patients undergoing elective LC who experienced a delayed discharge >24 hours in an extensive Italian national database and identify potential limiting factors of early discharge after LC.

METHODS

This is a prospective observational multicentre study performed from January 1, 2021 to December 31, 2021 by 90 Italian surgical units.

RESULTS

A total of 4664 patients were included in the study. Clinical reasons were found only for 850 patients (37.7%) discharged >24 hours after LC. After excluding patients with nonclinical reasons for delayed discharge >24 hours, 2 groups based on the length of hospitalization were created: the Early group (≤24 h; 2414 patients, 73.9%) and the Delayed group (>24 h; 850 patients, 26.1%). At the multivariate analysis, ASA III class ( P <0.0001), Charlson's Comorbidity Index (P=0.001), history of choledocholithiasis (P=0.03), presence of peritoneal adhesions (P<0.0001), operative time >60 min (P<0.0001), drain placement (P<0.0001), pain ( P =0.001), postoperative vomiting (P=0.001) and complications (P<0.0001) were independent predictors of delayed discharge >24 hours.

CONCLUSIONS

The majority of delayed discharges >24 hours after LC in our study were unrelated to the surgery itself. ASA class >II, advanced comorbidity, the presence of peritoneal adhesions, prolonged operative time, and placement of abdominal drainage were intraoperative variables independently associated with failure of early discharge.

Low-Pressure Pneumoperitoneum During Laparoscopic Sleeve Gastrectomy: a Safety and Feasibility Analysis

PURPOSE

Laparoscopy is advised under the lowest possible intra-peritoneal pressure. The aim of this study is to analyze the safety/feasibility of low pneumoperitoneum pressure (LPP) during laparoscopic sleeve gastrectomy (LSG).

MATERIALS AND METHODS

All primary LSGs who completed a 3-month follow-up were included. Re-do operations and LSGs performed with concomitant procedures were excluded. All LSGs were performed by the senior author. Upon trocar insertions, pressure was set to 10 mmHg, and the procedure was started. The pressure was increased step-wise, according to the senior author's assessment of the quality of exposure. Doing so, three pressure groups were formed: groups 1 (10 mmHg), 2 (11-13 mmHg), and 3 (14 mmHg). All data was retrieved from our database. Statistical analysis was performed using one-way ANOVA/Tukey's HSD test/Chi-square test. P values < 0.05 were regarded as significant.

RESULTS

Between February 2018 and October 2022, 708 consecutive/primary LSGs were studied. No mortality/conversion/thromboembolic event was observed. Groups 1, 2, and 3 comprised 376 (53.1%), 243 (34.3%), and 89 (12.6%) patients, respectively. Demographics, initial weight, duration of surgery, history for abdominoplasty, drain output, length of stay, and %total weight loss were evenly distributed among groups. Among 16 bleeding episodes, 14 occurred in the LPP group (p = 0.019). Including the only leak and stenosis, 8/9 of Clavien-Dindo 3b + 4 complications were observed in the LPP group (p = 0.092).

CONCLUSIONS

LSG with LPP is feasible in about half of the patients. However, almost all potentially life-threatening complications occurred in the LPP group where a significantly higher rate of bleeding was observed. Our findings suggest caution for routinely using LPP during LSG.

Port Site Consequences After Laparoscopic Cholecystectomy Using an Open Versus Closed Approach of Pneumoperitoneum

Introduction: Laparoscopic surgery is the standard method for cholecystectomy, and pneumoperitoneum is performed either in a closed or open technique. However, exposure to the consequences of the port site may increase the patient's morbidity. Therefore, this study was conducted to compare both approaches in terms of complications at the port site of each procedure and potential risk factors.

Methods: A prospective study was conducted in the department of surgery, in hospitals affiliated with Kirkuk and Diyala governorates in Iraq, from January 2019 to March 2022. The participating patients (200) were electively divided into two groups, each group comprising 100 patients. The pneumoperitoneum was established in the first group by an open technique (Hasson) while in the second group it was by using a closed technique (Veress needle). A comparison was made between the two techniques for intraoperative and postoperative complications that may have occurred due to port insertion up to 18 weeks.

Results: According to the results, the highest percentage was for the following: females (84.0%), ages between 50 and 59 years (43.5%), and body mass index (BMI) range 25-30 kg/m² (49.0%). No significant difference was observed between those variables for the two surgical techniques (p-value > 0.05). No death was recorded in the study. Consequences at the port site were observed in 10.5% of patients, the majority reported in the open approach (8.5%) as follows: bleeding (3.0%), hematoma (2.0%), wound infection (1.5%), hernia (1.5%), and vascular injury (0.5%).

Conclusions: Thus, we concluded that port site complications are lowest in closed laparoscopic surgery which was not shown to be statistically significant but values showed less complications. Furthermore, samples could be used to gain a good statistical significance.