Review of Outcomes of Low Verses Standard Pressure Pneumoperitoneum in Laparoscopic Surgery

BACKGROUND

Carbon dioxide pneumoperitoneum during laparoscopy changes cardiorespiratory physiology and contributes to post-op pain. We studied outcomes before and after implementing low-pressure pneumoperitoneum QI project.

METHODS

Forty-two patients were insufflated at standard pressures (15 mmHg) while 41 were insufflated using low (8-12 mmHg) during laparoscopic procedures. These variables were obtained from the patient chart: pain scores, intravenous morphine milligram equivalents (MME), peak inspiratory pressures (PIP), end-tidal CO₂ (EtCO₂), surgery duration, and patient demographics. The study was conducted after IRB approval.

RESULTS

Low-pressure pneumoperitoneum is feasible and the surgeon can increase to 10-12 mmHg as needed. The mean post-op IV MME was significantly decreased in the low-pressure group (11.75 ± 10.41) compared to the standard pressure group (17.36 ± 18.1) (t-test, P = .047). Mean peak inspiratory pressures during insufflation were significantly higher for procedures conducted at standard pressure (31.40 ± 4.82) compared to the 8 mmHg (24.68 ± 4.19) and 12 mmHg (27.33± 3.85) low pressure groups (one-way ANOVA, P < .0001). During insufflation, there was a significant increase in the average EtCO₂ in the standard pressure group (42.07 ± 5.60) compared to the 8 mmHg low pressure group (37.59 ± 5.05) (ANOVA, P = .0096). Constant flow insufflation was more likely to be performed at low pressure than demand mode (58% v. 33%).

CONCLUSION

Low pressure pneumoperitoneum decreases PIP pressure and CO2 absorption evidenced by lower ETCO2 intra-operatively. Patients have significant improvement in postoperative pain evidenced by decreased narcotics needed. Low pressure pneumoperitoneum using a constant flow insufflator is safe and results in improved patient outcomes.

Significance of umbilical trocar size and intra-abdominal pressure on postoperative pain after transabdominal preperitoneal repair for inguinal hernia

INTRODUCTION

Laparoscopic inguinal hernia repair is reported to be associated with lower postoperative pain than open repair. However, in the actual clinical setting, some patients experience relatively severe pain. This study aimed to elucidate surgical factors that affect pain after transabdominal preperitoneal (TAPP) repair.

METHODS

We evaluated 199 patients who underwent elective TAPP for inguinal hernia from 2014 to 2019 in Heisei Memorial Hospital. The umbilical trocar size was changed from 12 to 5 mm from October 2017. The pneumoperitoneum intra-abdominal pressure was changed from 10 to 8 mmHg from 2019. Postoperative pain scores and analgesics were compared between patients who were grouped according to trocar size and intra-abdominal pressure, as well as 80 patients who received open repair.

RESULTS

Patients with a 12 mm trocar had significantly higher pain than open repair patients (P < .0001). Patients with a 5 mm umbilical trocar and 8 mm Hg intra-abdominal pressure had significantly lower pain than a 12 mm trocar (P = .025) and did not significantly differ with pain after open repair. Analgesic use significantly decreased in patients using a 5 mm trocar than 12 mm (P = .002).

CONCLUSION

Umbilical trocar size and pneumoperitoneum intra-abdominal pressure were significantly associated with post-TAPP pain. Using a 5 mm umbilical trocar and 8 mm Hg intra-abdominal pressure achieved pain levels as comparatively low as open repair.

Analysis of risk factors of postlaparoscopic shoulder pain

AIM

Postlaparoscopic shoulder pain (SP), mainly caused by pneumoperitoneum with CO₂ , sometimes suffers patients. This study was aimed to analyze the backgrounds of SP after gynecologic laparoscopy to clarify the risk of SP.

METHODS

We analyzed answers of questionnaire about the degree of SP from 696 patients undergoing gynecologic laparoscopic surgery since 2014-2018. The questionnaire asks the degree of SP with numeric rating scale from 0 to 10, before and 3 days after operation. We defined cases in which postoperative score elevated more than three compared to preoperative score as SP(+). Analyzed backgrounds were age, parity, body mass index, operative method, operative duration and amount of hemorrhage. Statistics was performed by Fisher exact analysis as univariate analysis, and with logistic regression as multivariate analysis. All laparoscopic surgeries were performed under 10-12 mmHg in pressure of pneumoperitoneum with CO₂ .

RESULTS

Univariate analysis revealed categories 'less than 50 years old', and 'over 2 h' and 'over 3 h' in operative duration resulted significant high rate of SP(+). For these three factors, multivariate analysis resulted that "less than 50 years old' and 'over 3 h in operative duration' were significantly high.

CONCLUSION

This study suggests that 'less than 50 years' old and 'over 3 h in operative duration' were risk factors of postlaparoscopic SP. To protect from SP after laparoscopy, some countermeasures should be necessary especially for these patients.

Efficacy and Safety of Intraperitoneal Local Anesthetics in Laparoscopic Appendectomy: A Systematic Review and Meta-Analysis

Intraperitoneal local anesthetics have been increasingly used nowadays. However, they are not routinely given in laparoscopic appendectomy and a lot of controversies are found about their administration in this procedure. The goal of this study is to review effectiveness and safety of intraperitoneal local anesthetics in laparoscopic appendectomy. We conducted a computer search of four authentic databases. We included randomized controlled trials (RCTs) which compared intraperitoneal local anesthetics versus control group in laparoscopic appendectomy. Data were extracted from eligible studies and pooled in a meta-analysis model using RevMan software. We evaluated post-operative pain in different periods and safety outcomes including postoperative nausea and vomiting (PONV) and shoulder pain. Furthermore, we assessed the length of hospital stay and postoperative opioid consumption within 24 hours. Seven RCTs were included with a total of 579 patients in this review. Our analysis indicated a significant difference in postoperative pain at different durations preferring intraperitoneal local anesthetics compared to control. Moreover, intraperitoneal local anesthetics were significantly linked to fewer patients experienced PONV and shoulder pain respectively (RR= 0.28, 95% CI [0.16, 0.50], p < 0.0001), (RR= 0.32, 95% CI [0.17, 0.58], p = 0.0002). We found less hospital stay duration in intraperitoneal local anesthetics group after removal of the heterogeneity (MD= -0.39, 95% CI [-0.63, -0.16], p = 0.001). Intraperitoneal local anesthetics were significantly linked to less postoperative opioid consumption (SMD = -0.60, 95% CI [-0.96, -0.24], p = 0.001). Intraperitoneal local anesthetics can be routinely used in laparoscopic appendectomy as it is associated with less postoperative pain and reduction in different adverse events postoperatively.

Postoperative morphine consumption in children with sickle-cell disease

BACKGROUND

Effective pain control is a primary goal in the perioperative management of patients with sickle-cell disease. To understand analgesic requirements better, the authors compared postoperative morphine consumption and pain scores in sickle and non-sickle children who had undergone laparoscopic cholecystectomy.

METHODS

We reviewed the medical records of all sickle and non-sickle children referred to the Acute Pain Service of a tertiary care teaching hospital for patient-controlled analgesia (PCA) following laparoscopic cholecystectomy from 1996 to 2003. Data collected included postoperative morphine consumption, visual analogue pain scores, and perioperative outcome.

RESULTS

Total postoperative morphine consumption in sickle children (n = 12) (1.58 +/- 0.78 mg.kg(-1)) was more than double when compared with non-sickle children (n = 10) (0.65 +/- 0.32 mg.kg(-1)) (P < 0.005). Duration of PCA use among sickle children (51 +/- 25 h) was more than double when compared with non-sickle children (21 +/- 11 h) (P < 0.005). Sickle patients had greater pain scores in the initial 24 h after surgery (P < 0.05) and used more adjuvant analgesics (P < 0.05). Duration of postoperative hospital stay was 3.4 +/- 1.6 days and 1.5 +/- 0.5 days for sickle and non-sickle children, respectively (P < 0.005).

CONCLUSIONS

Sickle children self-administered more than double the amount of morphine, reported more intense pain, and remained hospitalized for more than twice as long as nonsickle children undergoing the same surgical procedure. These findings probably have a multifactorial origin, and might be attributable in part to alterations in pain perception, opioid pharmacokinetics, opioid tolerance, and psychosocial variables.

Effects of carbon dioxide pneumoretroperitoneum on free radical formation in remote organs and use of verapamil as an antioxidant

BACKGROUND AND PURPOSE

Pneumoretroperitoneum (Prp) acts as an ischemia/reperfusion (I/R) model. Ischemia/reperfusion (I/R) injury causes production of reactive oxygen species, which affect organs remote from the sites of I/R. The aim of this study was to assess the remote organ changes after Prp and to explore the effects of antioxidants.

MATERIALS AND METHODS

Eighteen adult rabbits were randomized to three groups, each consisting of six rabbits. Group I (control) underwent balloon dissection of the left retroperitoneal space without gas insufflation. In group II (Prp), carbon dioxide at 10 mm Hg was applied for 2 hours after the balloon dissection (ischemia period) and for 1 hour after desufflation (reperfusion period). In group III (Prp + antioxidant), 5 minutes before the experiment, verapamil at 0.2 mg/kg was given intravenously and the same procedure was employed as in group II. Hepatic, pulmonary, opposite kidney, and treated kidney malondialdehyde (MDA) and reduced glutathione (GSH) levels were evaluated to show response to Prp.

RESULTS

Pneumoretroperitoneum exerted oxidative stress on all tissues with an increase of MDA (P < 0.05) and a decrease of GSH (P < 0.05). The verapamil-treated group showed lower values of MDA (P < 0.05) and higher values of GSH (P < 0.05) than group II.

CONCLUSION

Pneumoretroperitoneum increased oxidative stress in all remote organs tested. Verapamil reduced the oxidative stress. We concluded that Prp should be employed carefully in patients with limited vital organ capacity. Verapamil administration may be considered for protection against tissue injury attributable to oxidative stress in these patients.

Pressure-related hemodynamic effects of CO2 pneumoperitoneum in a model of acute cardiac failure

BACKGROUND

The adverse effects related to CO2 pneumoperitoneum (PP) have been well documented. Although these effects in the state of cardiac failure have not been investigated, it appears to be common current clinical practice to use low-pressure PP in this clinical setting, assuming it to be safer.

OBJECTIVE

The aim of our study was to compare the hemodynamic changes with the application of conventional 15 mm Hg PP versus low-pressure 10 mm Hg PP in control and acute cardiac failure (ACF) animal models.

METHODS

We studied changes in cardiac output (CO), stroke volume (SV), and systemic vascular resistance (SVR), applying 10 mm Hg and 15 mm Hg CO2 PP in control and, following the pharmacological induction of acute cardiac failure, in 10 domestic pigs.

RESULTS

In control, the application of 10 mm Hg PP did not cause any significant hemodynamic changes compared to baseline parameters. The use of 15 mm Hg PP in the model with normal cardiac function, however, produced a significant change in the tested hemodynamic values: CO decreased from 3.8L/min to 2.8L/min (P =.0018); SV declined from 38 mL to 30 mL (P =.046); SVR increased from 1677 dyne.s.cm-5 to 2414 dyne.s.cm-5 (P =.049) compared to baseline. In the model of ACF induced by the intravenous infusion of sodium pentobarbital, the application of either 10 mm Hg or 15 mm Hg PP was found to have a similar hemodynamic trend: CO, 1.65 L/min vs. 1.41 L/min; SV, 23.2 L vs. 20.9 L; SVR, 2487 dyne.s.cm-5 vs. 2597 dyne.s.cm-5 (P = NS for all).

CONCLUSIONS

The application of low-pressure 10 mm Hg PP, compared to conventional 15 mm Hg PP, in the animal model of ACF does not appear to have any hemodynamic advantages.

Low-pressure laparoscopy may ameliorate intracranial hypertension and renal hypoperfusion

BACKGROUND

Increased abdominal pressure is associated with elevations in the intracranial pressure (ICP) and impaired renal function. These adverse effects are potentially important in clinical situations such as severe abdominal trauma and laparoscopic donor nephrectomy. It was hypothesized that the secondary elevation of ICP leads to release of vasoconstrictors, which may affect renal function by decreasing the renal blood flow (RBF). We investigated the effect of laparoscopy on ICP and renal blood flow in a porcine model.

MATERIALS AND METHODS

The abdominal pressure of swine (N = 5; 20-25 kg) was gradually increased from baseline to 5, 15, and 25 mm Hg by insufflation of nitrogen into the abdominal cavity. The ICP was measured using a Camino monitor, and RBF was simultaneously measured using a Transonic Doppler probe placed on the renal artery. Results were analyzed using repeated measures ANOVA and the paired t-test.

RESULTS

No significant change from baseline was observed in ICP and RBF when the abdominal pressure was 5 mm Hg. However, both ICP and RBF were affected by increasing the abdominal pressure to 15 and 25 mm Hg (P = 0.035 and 0.04 for ICP and P = 0.074 and 0.034 for RBF, respectively).

CONCLUSIONS

Low-pressure laparoscopy may reduce the adverse effects of pneumoperitoneum on ICP and RBF. It may be advisable to use low pressures in laparoscopic surgery, especially when changes in ICP or renal perfusion may have significant clinical implications.