LATEST INNOVATIONS &TRENDS IN MEDICAL SCIENCE - “SINGLE INSTITUTIONAL COMPARATIVE STUDY ON THE IMPACT OF THE STANDARD PRESSURE AND LOW PRESSURE PNEUMOPERITONEUM ON POST - OPERATIVE PAIN FOLLOWING LAPAROSCOPIC CHOLECYSTECTOMY - A STRATIFIED RANDOMIZED CONTROLLED TRIAL”

Abstract

Background and Objectives:GastroIntestinal surgery has undergone a revolution in the recent years by the introduction of laparoscopic techniques. The most common complaint following laparoscopic surgery, initially being recognized by gynaecologists during early experience with laparoscopic sterilization is shoulder pain. The concept of “Keyhole Surgery” created an immediate disparity between the potential of the new technique and training of surgeons to perform it. Now modern surgical methods are aimed at giving cure along with minimal invasive techniques with patient in mind and safety never being compromised. Cholelithiasis, which is one of the most common gastrointestinal disorders seen, was traditionally treated by conventional or open cholecystectomy. Currently laparoscopic cholecystectomy is the standard procedure as it is less painful, needs shorter recovery period and short hospital stay. Recovery after laparoscopic cholecystectomy depends upon several factors such as: Abdominal pain, Shoulder tip pain, Nausea, Vomiting and Fatigue. These side-effects are due to peritoneal stretching and diaphragmatic irritation caused by high intraabdominal pressure and by CO2. Among the causes for shoulder pains are: Stimulation of the sympathetic nervous system by hypercarbia, the residual pneumoperitoneum after the surgery, and rapid distention of the abdomen by carbon dioxide. Keeping this in mind, it was assumed that lower intraabdominal pressure will decrease these complications. Traditionally, the pressure used to create pneumoperitoneum is around 15mm Hg. There are a few studies done using low pressure pneumoperitoneum (less than 12 mm Hg) and showed decrease in pain post- operatively. But, all the studies are not equivocal in this respect. Further, the safety of low- pressure pneumoperitoneum is not established. There were no Stratified RCT studies conducted before on this topic. So, our aim was to compare impact of the Standard Pressure and Low-Pressure pneumoperitoneum technique on postoperative pain following conventional laparoscopic cholecystectomy Materials and methods: A stratified study to compare impact of the Standard Pressure and LowPressure pneumoperitoneum technique on post-operative pain following conventional laparoscopic cholecystectomy was performed 143 patients during the period of Jan 2018- Dec 2019. Individuals fulfilling the inclusion and exclusion criteria were assigned to 2 groups as per methodology. 1. Group: A patients will be undergoing laparoscopic cholecystectomy with low pressure pneumoperitoneum –LPP (7-8 mm Hg) while, 2. Group: B will be undergoing laparoscopic cholecystectomy with standard pressure pneumoperitoneum -SPP (12-14 mm Hg). The duration of surgery was carefully recorded using the wall mounted OT timers. The time of arrival in the postoperative ward was defined as 0 h postoperatively. Presence of shoulder pain, port site pain and / or diffuse abdominal pain was measured at 2, 4, 6, 12, 24, and 48 hours, respectively. Pain score VAS (Visual Analogue Score) according to scale was used to detect the intensity of the pain postoperatively. World Health Organization (WHO) analgesic step ladder was used as a frame work for providing symptomatic pain relief to the patients. Statistical analysis was done using standard tools. Mean of two groups were compared using independent t-test. Chi square test was used to analyse the significance of difference between frequency distribution of the data. P value < 0.05 was considered as statistically significant Results: Standard Pressure Pneumoperitoneum was done in 51% patients and Low Pressure Pneumoperitoneum was done in 49% patients. Majority of the patients belong to the age group of 28-37 years (39.2%). Surgeon visibility was good in 98.6% patients and poor in 1.4% patients. Bile spillage was seen in 7.7% patients. Postoperative mobilization was earlier in patients belonging to Low Pressure Pneumoperitoneum group. Post-operative opioid consumption was significantly lower in the Low Pressure group. There is no statistical significance among age, surgeon visibility and bile pillage