Laparoscopic Cholecystectomy and Postoperative Pain: Is it Affected by Intra-abdominal Pressure?

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.

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.

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 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.

Randomized controlled trial comparing the effects of usual gas release, active aspiration, and passive-valve release on abdominal distension in patients who have undergone laparoscopic cholecystectomy

INTRODUCTION

Residual, intra-abdominal CO₂ contributes to abdominal distension and pain after laparoscopic surgery. The study was designed to assess recovery after gas release in patients who have undergone laparoscopic cholecystectomy (LC).

METHODS

A total of 142 patients undergoing laparoscopic cholecystectomy were randomly divided into three groups: (i) group 1 (control group), gas release from the surgical wound without port release (n = 47); (ii) group 2, active gas aspiration via a subdiaphragmatic port (n = 48); and (iii) group 3, passive-valve release via a subdiaphragmatic port valve opening (n = 47). Abdominal distension and shoulder pain levels were assessed postoperatively.

RESULTS

The active aspiration group had significantly reduced postoperative abdominal distensions at 30 min, 4, and 24 h compared with the control group (50.0% vs 80.9%, 43.8% vs 76.6%, 33.3% vs 57.4%, respectively; P < 0.05). Similarly, the passive-valve release group had significantly reduced postoperative abdominal distensions at 4 and 24 h compared with the control group (51.1% vs 76.6%, 57.4% vs 36.2%; P < 0.05). Both intervention groups had significantly reduced postoperative shoulder pain at 4 and 24 h compared with the control group (P < 0.001). In addition, the postoperative ambulation times for the active aspiration group were significantly shorter than those for the control and passive-valve release groups (P < 0.001).

CONCLUSION

Releasing residual CO₂ from the intra-abdominal cavity at the end of laparoscopic cholecystectomy by either the active aspiration or passive-valve release technique is an effective way to reduce postoperative abdominal distension and shoulder pain.

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.

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.

Cholecystectomy for biliary dyskinesia: how did we get there?

BACKGROUND

The focus of biliary dyskinesia (BD) shifted within the last 30 years, moving from symptoms after cholecystectomy (CCY) to symptoms with morphological normal gallbladder, but low gallbladder ejection fraction.

METHODS

We searched the pubmed database to systematically review studies focusing on the diagnosis and treatment of gallbladder dysfunction.

RESULTS

Impaired gallbladder contraction can be found in about 20% of healthy controls and an even higher number of patients with various other disorders. Surgery for BD increased after introduction of laparoscopic CCY, with BD now accounting for >20% of CCY in adults and up to 60% in pediatric patients. The majority of cases reported were operated in the USA, which differs from surgical series for cholelithiasis. Postoperative outcomes do not differ between groups with abnormal or normal gallbladder function.

CONCLUSION

Functional gallbladder testing should not be seen as an indicator of relevant biliary tract disease or prognostic marker to identify patients who may benefit from operative intervention. Instead biliary dyskinesia should be considered as a part of a spectrum of functional disorders, which are generally managed conservatively. Small proof of concept studies have demonstrated effects of medical therapy on biliary dysfunction and should thus be never tested in appropriately designed trials.

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.

Successful interventional management of abdominal compartment syndrome caused by blunt liver injury with hemorrhagic diathesis

We report that a case of primary abdominal compartment syndrome (ACS), caused by blunt liver injury under the oral anticoagulation therapy, was successfully treated. Transcatheter arterial embolization (TAE) was initially selected, and the bleeding point of hepatic artery was embolized with N-Butyl Cyanoacylate (NBCA). Secondary, percutaneous catheter drainage (PCD) was performed for massive hemoperitoneum. There are some reports of ACS treated with TAE. However, combination treatment of TAE with NBCA and PCD for ACS has not been reported. Even low invasive interventional procedures may improve primary ACS if the patient has hemorrhagic diathesis or coagulopathy discouraging surgeon from laparotomy.

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.

Preoperative administration of intramuscular dezocine reduces postoperative pain for laparoscopic cholecystectomy

Postoperative pain is the most common complaint after laparoscopic cholecystectomy. This study was carried out to evaluate whether preoperative administration of intramuscular dezocine can provide postoperative analgesia and reduce postoperative opioid consumption in patients undergoing laparoscopic cholecystectomy. Patients (ASA I or II) scheduled for laparoscopic cholecystectomy were randomly assigned into intramuscular dezocine group (group 1) or intramuscular normal saline group (group 2). Dezocine and equal volume normal saline were administered intramuscularly 10 min before the induction of anesthesia. After operation, the severity of postoperative pain, postoperative fentanyl requirement, incidence and severity of side-effects were assessed. Postoperative pain and postoperative patient-controlled fentanyl consumption were reduced significantly in group 1 compared with group 2. The incidence and severity of side effects were similar between the two groups. Preoperative single-dose administration of intramuscular dezocine 0.1 mg/kg was effective in reducing postoperative pain and postoperative patient-controlled fentanyl requirement in patients undergoing laparoscopic cholecystectomy.

Peritrocal and intraperitoneal ropivacaine for laparoscopic cholecystectomy: a prospective, randomized, double-blind controlled trial

BACKGROUND

The goal of this study was to evaluate the effect of peritrocal, intraperitoneal, or combined peritrocal-intraperitoneal ropivacaine on the parietal, visceral, and shoulder tip pain after laparoscopic cholecystectomy.

METHODS

Eighty patients were randomly assigned to four groups. Group A received peritrocal and intraperitoneal saline. Group B received peritrocal saline and intraperitoneal ropivacaine. Group C received peritrocal ropivacaine and intraperitoneal saline. Group D received peritrocal and intraperitoneal ropivacaine. The parietal, visceral, and shoulder tip pain were assessed at 2, 4, 8, 12, 24, and 48 h postoperatively using a visual analog scale (VAS). The frequency of the patient pushing the button of the PCA and fentanyl use were also recorded.

RESULTS

In visceral pain, significantly lower VAS scores were observed in Group B from 2 to 4 h and in Group D from 2 to 8 h. In parietal pain, significantly lower VAS scores were observed in Group C from 4 to 24 h and in Group D from 2 to 12 h. In shoulder tip pain, significantly lower VAS scores were observed in Group B from 4 to 48 h and in Group D from 2 to 12 h. The fentanyl use and the frequency to push the button of the PCA were the highest in Group A and the lowest in Group D at every time point.

CONCLUSIONS

We conclude that peritrocal infiltration of ropivacaine significantly decreases parietal pain and intraperitoneal instillation of ropivacaine significantly decreases the visceral and shoulder tip pain. Their effects are additive with respect to the total pain.