Low-pressure Pneumoperitoneum Research Articles

Recovery and immune function after low pressure pneumoperitoneum during robot-assisted radical prostatectomy: a randomised controlled trial.

To compare the effectiveness of low intra-abdominal pressure (IAP) facilitated by deep neuromuscular block (NMB) to standard practice in improving the quality of recovery, preserving immune function, and enhancing parietal perfusion during robot-assisted radical prostatectomy (RARP). In this blinded, randomised controlled trial, 96 patients were randomised to the experimental group with low IAP (8 mmHg) facilitated by deep NMB (post-tetanic count 1-2) or the control group with standard IAP (14 mmHg) and moderate NMB (train-of-four 1-2). Recovery was measured using the 40-item Quality of Recovery questionnaire and 36-item Short-Form Health survey. Immune function was evaluated by plasma damage-associated molecular patterns, cytokines, and ex vivo lipopolysaccharide-stimulated cytokine production. Parietal peritoneum perfusion was measured by analysing the recordings of indocyanine-green injection. Quality of recovery was not superior in the experimental group (n = 46) compared to the control group (n = 50). All clinical outcomes, including pain scores, postoperative nausea and vomiting, and hospital stay were similar. There were no significant differences in postoperative plasma concentrations of damage-associated molecular patterns, cytokines, and ex vivo cytokine production capacity. The use of low IAP resulted in better parietal peritoneum perfusion. Despite better perfusion of the parietal peritoneum, low IAP facilitated by deep NMB did not improve the quality of recovery or preserve immune function compared to standard practice in patients undergoing RARP.

Comparative analysis of low versus normal pressure pneumoperitoneum in laparoscopic gynecological surgeries: a randomized control trial

Comparative analysis of low versus normal pressure pneumoperitoneum in laparoscopic gynecological surgeries: a randomized control trial

A comparative study of low-pressure pneumoperitoneum versus standard-pressure pneumoperitoneum in laparoscopic cholecystectomy in tertiary care center

Background: Laparoscopic cholecystectomy is the gold standard management of symptomatic cholelithiasis. We try to use low-pressure pneumoperitoneum (LPP) to study the effect of pneumoperitoneum in the duration of surgery, field of visualization with providing sufficient work space for surgeon, and post-operative shoulder pain and hospital stay in laparoscopic cholecystectomy. Aims and Objectives: The aims and objectives of the study are to compare outcomes in LPP versus standard-pressure pneumoperitoneum (SPP) with respect to duration of surgery, CO2 consumption, field of visualization, and surgical difficulties to convert SPP or open cholecystectomy and post-operative shoulder pain and hospital stay. Materials and Methods: The prospective randomized study was conducted in tertiary care center, Government Medical College, Banda, Uttar Pradesh from July 2021 to October 2022. All consented 100 patients after randomization were allotted into two groups. Results: In our study, the mean duration of surgery surgical difficulties to convert open and standard pressure and difficulty in field visualization insignificant is more in LPP as compared to SPP but CO2 consumption, post-operative shoulder pain, and mean hospital stay is less in LPP as compared to SPP. Conclusion: Laparoscopic cholecystectomy in LPP is safe and feasible. Field visualization, conversion rate, and duration of surgery are affected non-significantly because depend on the expertise of surgeon but shoulder pain, CO2 consumption, and hospital stay are less in LPP.

Comparative Study of Clinical Outcome of Low Pressure Versus Standard Pressure Pneumoperitoneum in Laparoscopic Cholecystectomy at Birat Medical College Teaching Hospital (BMCTH)

Introduction: Laparoscopic cholecystectomy at standard pressure pneumoperitoneum ( 12-15 mmHg of Co2) is standard of practice among surgeons. The increase in intraabdominal pressure by insufflation of carbon dioxide during laparoscopy brings certain changes in function of cardiopulmonary systems and also leads to postoperative pain due to stretching of the diaphragm.
 Objective: To minimise this impact on human physiology there is increasing effort of performing laparoscopic cholecystectomy at low pressure pneumoperitoneum (8mm Hg) however its safety has not been established. This study aims to compare outcomes of laparoscopic cholecystectomy at low pressure pneumoperitoneum versus standard pressure pneumoperitoneum in people undergoing laparoscopic cholecystectomy in terms of intraoperative time, postoperative pain including shoulder tip pain and length of hospital stay.Methodology: This descriptive randomised prospective study was conducted from Feb 2023 to Aug 2023 in the department of general surgery, BMCTH in patients diagnosed with symptomatic gallstone disease meeting inclusion criteria and willing for laparoscopic cholecystectomy. All patients were prospectively randomized into two groups randomly by the lottery method. A convenient sampling method was used. Group A odd number patients underwent surgery under low pressure (LPPLC group), Group B patients at standard pressure pneumoperitoneum (SPPLC).
 Results:A total of 145 patients (114 female and 31 male) with mean age 44.99 years of presentation. 73 patients underwent surgery under LPPLC group and 72 under SPPLC group. Mean pain recorded as per VAS score at 6, 12, 24 and 36 hours postoperatively showed no significant difference in pain among two groups with p value 0.972,0.121,0.212,0.072 respectively. Shoulder tip pain and additional need of analgesia was significantly less in LPPLC group, p value 0.002 and 0.015 respectively. No significant difference was observed in terms of operating time p value 0.151.Conversion between two groups p value 0.494 suggested no significant difference between two group.
 Conclusion:LPPLC is feasible, safe and can be considered over SPPLC. LPPLC is non inferior to SPPLC in terms of postoperative pain including shoulder tip pain and additional need of analgesia.

INCIDENCE OF SHOULDER-TIP PAIN IN LAP. CHOLECYSTECTOMY NORMAL VERSUS LOW-PRESSURE PNEUMOPERITONEUM

Open cholecystectomy can lead to several post-operative complications. However, with the advent of minimal access surgery, these complications have decreased to a large extent. Nowadays, laparoscopic cholecystectomy is considered the gold standard for cholelithiasis. Similar to other surgeries, some post-operative complications are linked to laparoscopic surgery. One such complication is shoulder-tip pain. This study aimed to compare the intensity of post-op shoulder-tip pain after laparoscopic cholecystectomy at low pressure (10mmHg or less than 10mmHg) and standard pressure (12-14mmHg). Two groups of 30 patients each were made in this prospective randomized study. Group A patients underwent low-pressure pneumoperitoneum cholecystectomy (10mmHg or less than 10mmHg), while group B underwent standard-pressure pneumoperitoneum cholecystectomy (12-15mmHg). According to the verbal pain intensity score, post-op shoulder-tip pain was reduced in Group A compared to Group B at 6, 12, and 24 postoperative hours. This study showed that using low-pressure pneumoperitoneum in laparoscopic cholecystectomy reduces the intensity of post-operative shoulder pain and the need for analgesia.

Low-pressure pneumoperitoneum—why and how

Low-pressure pneumoperitoneum—why and how

Effect of low-pressure pneumoperitoneum on pain and inflammation in laparoscopic cholecystectomy: a randomized controlled clinical trial

ObjectiveWe aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers.BackgroundThe standard of care pneumoperitoneum set pressure in laparoscopic cholecystectomy is set to 12–14 mmHg, but many societies advocate to operate at the lowest pressure allowing adequate exposure of the operative field. Many trials have described the benefits of operating at a low-pressure pneumoperitoneum in terms of lower post operative pain, and better hemodynamic stability. But only few describe the effects on inflammatory markers and cytokines.MethodsA prospective, double-blinded, randomised, controlled clinical trial, including patients who underwent elective laparoscopic cholecystectomy. Patients randomised into low-pressure (8–10 mmHg) vs. standard-pressure (12–14 mmHg) with an allocation ratio of 1:1. Perioperative variables were collected and analysed.Resultsone hundred patients were allocated, 50 patients in each study arm. Low-pressure patients reported lower median pain score 6-hour post operatively (5 vs. 6, p-value = 0.021) in comparison with standard-pressure group. Eight out of 10 inflammatory markers demonstrated better results in low-pressure group in comparison with standard-pressure, but the effect was not statistically significant. Total operative time and surgery difficulty was not significantly different between the two groups even in the hands of inexperienced surgeons.Conclusionlow-pressure laparoscopic cholecystectomy is associated with less post operative pain and lower rise of inflammatory markers. It is feasible with comparable complications to the standard of care. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022).

Low- versus standard- pneumoperitoneum in patients undergoing robot-assisted radical prostatectomy: a randomised, triple-blinded study.

To investigate the effectiveness and impact of low-pressure pneumoperitoneum (Pnp) on postoperative quality of recovery (QoR) and surgical workspace (SWS) in patients with prostate cancer undergoing robot-assisted radical prostatectomy (RARP). A randomised, triple-blinded trial was conducted in a single centre in Denmark from March 2021 to January 2022. A total of 98 patients with prostate cancer undergoing RARP were randomly assigned to either low-pressure Pnp (7 mmHg) or standard-pressure Pnp (12 mmHg). Co-primary outcomes were postoperative QoR measured via the QoR-15 questionnaire on postoperative Day 1 (POD1), POD3, POD14, and POD30, and SWS assessed intraoperatively by a blinded assessor (surgeon) via a validated SWS scale. Data analysis was performed according to the intention-to-treat principle. Patients who underwent RARP at low Pnp pressure demonstrated better postoperative QoR on POD1 (mean difference = 10, 95% confidence interval [CI] 4.4-15.5), but no significant differences were observed in the SWS (mean difference = 0.25, 95% CI -0.02 to 0.54). Patients allocated to low-pressure Pnp experienced statistically higher blood loss than those in the standard-pressure Pnp group (mean difference = 67 mL, P = 0.01). Domain analysis revealed significant improvements in pain (P = 0.001), physical comfort (P = 0.007), and emotional state (P = 0.006) for patients with low-pressure Pnp. This trial was registered at ClinicalTrials.gov, NCT04755452, on 16/02/2021. Performing RARP at low Pnp pressure is feasible without compromising the SWS and improves postoperative QoR, including pain, physical comfort, and emotional state, compared to the standard pressure.

Effects of extremely low-pressure pneumoperitoneum on postoperative recovery after single site robot-assisted cholecystectomy: a randomized controlled trial.

A robotic platform has enabled extremely low-pressure pneumoperitoneum (ELPP, 4 mmHg) to reduce surgical insults to human physiology during a minimally invasive surgery. The objective of this study was to investigate the effect of ELPP in single-site robotic cholecystectomy (SSRC) on postoperative pain, shoulder pain, and physiological changes during surgery compared to a standard pressure pneumoperitoneum (SPP, 12-14 mmHg). A total of 182 patients who underwent an elective cholecystectomy were randomized into an ELPP SSRC group (n = 91) and an SPP SSRC group (n = 91). Postoperative pain was assessed at 6, 12, 24, and 48 h after surgery. The number of patients complaining of shoulder pain was observed. Intraoperative changes of ventilatory parameters were also measured. Postoperative pain scores (p = 0.038, p < 0.001, p < 0.001, and p = 0.015 at 6, 12, 24, and 48 h after surgery, respectively) and the number of patients with shoulder pain (p <0.001) were significantly lower in the ELPP SSRC group than in the SPP SSRC group. Intraoperative changes in peak inspiratory pressure (p < 0.001), plateau pressure (p < 0.001), EtCO2 (p < 0.001), and lung compliance (p < 0.001) were also less in the ELPP SSRC group. The ELPP during robotic cholecystectomy could significantly relieve postoperative pain and shoulder pain. In addition, the ELPP can reduce changes in lung compliance during surgery and the demand for postoperative analgesics, thereby improving the quality of life of patients during early stages of postoperative rehabilitation.

The Effect of Low-Pressure Pneumoperitoneum with Active Evacuation on the Severity of Shoulder Pain in Patients Undergoing Laparoscopic Cholecystectomy

The Effect of Low-Pressure Pneumoperitoneum with Active Evacuation on the Severity of Shoulder Pain in Patients Undergoing Laparoscopic Cholecystectomy

Comparative evaluation of high versus low pressure pneumoperitoneum in causing acute kidney injury during laparoscopic cholecystectomy

Objective: Aim of our study is to monitor low- and high-pressure pneumoperitoneum effects and find optimum intra-abdominal pressure that is safe to avoid or minimise acute kidney injury. Material &amp; Methods: This study was conducted at Fatima Memorial hospital from May 2022 to November 2022. A total of 80 patients were segregated into two groups of 40 each. Group A had laparoscopic cholecystectomy with 15 mmHg pneumoperitoneum pressure while Group B had 20 mmHg pneumoperitoneum pressure. Patients were monitored postoperatively for creatinine and urine output changes at 8 hours, 24 hours and 72 hours interval. Results: Post operative creatinine rise and fall in urine output was statistically significant between both group indicating 15 mmHg pneumoperitoneum is safer for laparoscopic cholecystectomy to avoid AKI. Operation time, inflation time and blood loss were statistically significant and remain the key factors in predicting AKI after laparoscopic cholecystectomy. Conclusion: AKI is a common but transient condition that can arise after laparoscopic cholecystectomy. It can be minimized by keeping intra-abdominal pressure ≤15mmHg. Operation time, inflation time and perioperative blood loss can predict AKI perioperatively.

The effect of different pressures of pneumoperitoneum on the optic nerve sheath diameter – A prospective study

Abstract Background and Aims: Increased intra-abdominal pressure (IAP) and carbon dioxide gas during pneumoperitoneum leads to various systemic changes involving cardiovascular, respiratory, and cerebral physiology. In our study, we aimed to investigate the effect of standard (13–15 mmHg) and low (6–8 mmHg) pressure pneumoperitoneum on optic nerve sheath diameter (ONSD) using ultrasound, which is a reflection of intracranial pressure (ICP). Patient hemodynamics, surgery duration and surgeons’ comfort, and ease of performing surgery at low-pressure pneumoperitoneum were studied as secondary objectives. Materials and Methods: In this prospective double-blind randomized study, 75 patients of the American Society of Anesthesiologists physical status grades I and II, of both genders undergoing elective laparoscopic surgery, were allocated into two groups – S (standard IAP 13–15 mmHg) and L (low IAP 6–8 mmHg). ONSD acquired at different time points: before induction of anesthesia (T1), 5 min after intubation (T2), 5 min after the creation of pneumoperitoneum (T3), 5 min before desufflation (T4), and 5 min before extubation (T5). ONSD of 5 mm is taken as the cutoff value to correlate raised ICP. Continuous variables were analyzed by the Student’s t-test, and categorical data were assessed by the Chi-square test. Results: There was a significant increase in ONSD with insufflation in both the groups; however, T3 is higher than the cutoff value (&gt;5 mm) in Group S. The ONSD values at T1 (baseline) and at T2 (after intubation) were comparable between the groups, with P = 0.1855 and P = 0.8988, respectively. With pneumoperitoneum, the increase in ONSD (T3) is significantly higher in Group S than in Group L with P = 0.0022, attributing to the high IAP in Group S. Conclusion: Laparoscopic surgery with low-pressure pneumoperitoneum can be a safe approach, particularly in individuals at risk of raised ICP.

To study the low-pressure pneumoperitoneum laparoscopic cholecystectomy

Aim: The aim of this study to determine the low-pressure pneumoperitoneum laparoscopic cholecystectomy.Materials and methods: This research comprised a total of 80 patients who were hospitalised for elective laparoscopic cholecystectomy. patients undergoing open cholecystectomy after conversion. The research did not include patients with acute inflammation or any other choledocholithiasis or gallstone-related complications. Every patient was asked for written informed permission after being told about the research.Results: The most prevalent presenting symptom (85%) was pain in the right upper quadrant. All of the patients had cholelithiasis confirmed by ultrasonography but no symptoms of inflammation. The majority of the patients (80%) had numerous gallbladder stones. The gallbladder was normal in 40 instances (50%), distended in 24 cases (30%), and constricted in 16 cases (20%) intraoperatively, cholesterosis was present in 10 cases (12.5%), and biliary sludge was found in 16 cases (20%). There were no severe intraoperative complications. There was no conversion to normal pressure laparoscopic cholecystectomy or open cholecystectomy. The average surgical time was 35.85±5.85 minutes. The visual analogue scale pain ratings for postoperative shoulder tip pain were 4.5±0.33, 2.4±0.12, and 0.22±0.04, respectively, at 5, 10, and 24 hours. In 91.25% of the patients, oral feeds were begun on the first postoperative day. On the 0th postoperative day, 95% of the patients were ambulating. The average length of stay after surgery was 1.2±0.51 days. On average 6 months of follow-up, no serious problems were notedConclusion: Experienced surgeons may safely use low-pressure pneumoperitoneum to perform laparoscopic cholecystectomy with a lower risk of early postoperative problems, such as shoulder tip discomfort. Only the lengthier learning curve holds it back from being optimal for general usage; in certain circumstances, its reduced intraoperative impact on hemodynamics makes it a worthwhile alternative.

PJY05 - Low vs. High pressure pneumoperitoneum and associated risk of paralytic ileus in patients undergoing robotic-assisted laparoscopic radical cystectomy and intra-corporeal robotic urinary diversion

PJY05 - Low vs. High pressure pneumoperitoneum and associated risk of paralytic ileus in patients undergoing robotic-assisted laparoscopic radical cystectomy and intra-corporeal robotic urinary diversion

PE24 - A simple stitch to aid dorsal vein complex ligation with subsequent completion of robot assisted radical prostatectomy at sustained low-pressure pneumoperitoneum

PE24 - A simple stitch to aid dorsal vein complex ligation with subsequent completion of robot assisted radical prostatectomy at sustained low-pressure pneumoperitoneum

SC152 - Low-pressure pneumoperitoneum improves post-operative outcomes reducing complications in major urologic surgery

SC152 - Low-pressure pneumoperitoneum improves post-operative outcomes reducing complications in major urologic surgery

Lower vs standard pressure pneumoperitoneum in robotic-assisted radical prostatectomy: a systematic review and meta-analysis.

Robotic-assisted laparoscopic radical prostatectomy (RARP) has been traditionally performed at a pneumoperitoneum insufflation pressure of 12-15mmHg. This meta-analysis and systematic review aims to assess the current evidence comparing lower to standard pressure pneumoperitoneum in RARP. Systematic searches of MEDLINE, COCHRANE, SCOPUS and EMBASE were performed to identify articles published up until November 2021 comparing lower pressure with standard pressure pneumoperitoneum in RARP. Standard pressure was defined as > 12mmHg and lower pressure ≤ 12mmHg. Estimated blood loss, length of operation, length of hospital stay, post-operative ileus, 30-day readmissions, Clavien-Dindo complications and rate of positive surgical margins were extracted as endpoints of interest. Our searches identified 165 abstracts of which 4 articles with 1319 patients were eligible. Cumulative analysis demonstrated reduced length of stay when a lower pressure was used: WMD -0.23 (-0.45 to -0.02) days (p = 0.03) as well as a reduced rate of post-operative ileus: OR 0.41 (0.22 to 0.77) (p = 0.006). There was no significant increase in length of operation WMD -1.79 (-15.96 to 12.38) (p = 0.8), estimated blood loss WMD -2.89 (-29.41 to 23.62) (p = 0.83), 30-day readmissions or positive surgical margins OR 1.04 (0.78 to 1.38) (p = 0.81) and RD -0.01 (-0.04 to 0.01) (p = 0.3) when using a lower pressure. We have demonstrated reduced length of stay and rates of post-operative ileus, when performing RARP at a lower pressure without a significant increase in length of operation, estimated blood loss, positive surgical margins or complications. The recommendation to use lower pressure pneumoperitoneum is moderate to weak and more randomised control trials are required to validate these results.

Comparison of pharmacologic therapies alone versus operative techniques in combination with pharmacologic therapies for postoperative analgesia in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial

BackgroundLaparoscopic cholecystectomy (LC) causes moderate pain. Various operative analgesic techniques and pharmacologic treatments can reduce postoperative pain. This single-center, single-surgeon randomized controlled study aimed to assess the efficacy of combined operative analgesic techniques and pharmacologic analgesia in decreasing pain in patients undergoing LC. Materials and methodsFifty-nine patients scheduled for LC were assigned into two groups. In the pharmacologic analgesia (P) group (n = 29), patients were treated with pharmacologic intervention, including preoperative celecoxib (200 mg), intraoperative acetaminophen (1 g), and dexamethasone (8 mg). In the operative analgesic treatments with pharmacologic analgesia (OP) group (n = 30), patients were treated with both operative analgesic techniques and pharmacologic analgesia, including low-pressure pneumoperitoneum, intraperitoneal normal saline irrigation, and aspiration of intraperitoneal carbon dioxide. The area under the curve (AUC) of pain score for postoperative 24 h was assessed at 0, 2, 6, and 24 h post-operation. The analgesic requirements and sleep quality at postoperative day 1 were assessed. ResultsThe AUC/24 h of pain scores at rest and on cough were lower in the OP group (p < 0.001 and p = 0.001, respectively). The pain scores at rest were lower in the OP group at postoperative 2, 6, and 24 h (p = 0.001, p = 0.001, and p = 0.048, respectively). The pain scores on cough were lower in the OP group at postoperative 2 and 6 h (p = 0.004 and p = 0.008, respectively). Analgesic requirements were comparable. The sleep quality score at postoperative day 1 was higher in the OP group (56 ± 18 vs. 67 ± 15, absolute difference, 10; 95% confidence interval, 2 to 19; p = 0.017). ConclusionsCombined operative analgesic therapies and pharmacologic analgesia compared to pharmacologic analgesia alone decreased pain scores and increased sleep quality in patients undergoing LC.

The effectiveness of extremely low-pressure pneumoperitoneum on pain reduction after robot-assisted cholecystectomy

BackgroundThe robot-assisted cholecystectomy could provide a sufficient surgical field with the extremely low-pressure pneumoperitoneum (ELPP; 4 mmHg) by the robot arm lifting the abdominal wall upward. This study aimed to investigate the effect of ELPP on the postoperative outcomes in benign gallbladder disease. MethodsA retrospective study was designed to compare the postoperative pain in addition with operation time, estimated blood loss, length of hospital stay, and complication of three types of cholecystectomy for benign gallbladder disease: 75 ELPP single site robot-assisted cholecystectomy (SSRC), 114 standard-pressure pneumoperitoneum (SPP) SSRC and 110 SPP conventional laparoscopic cholecystectomy (CLC). ResultsThere was no difference in whole operation time between ELPP SSRC and SPP SSRC group (p = 0.159). Postoperative pain score was significantly less in ELPP SSRC group as compared to SPP SSRC or SPP CLC group at 6, 12, and 24 h postoperatively (p = 0.004, p = 0.004, and p = 0.013 respectively). The incidence of shoulder pain was also significantly lower in ELPP SSRC group (p < 0.001). The rate of postoperative complication and length of stay were not different among the three groups. ConclusionsThis study shows that ELPP technique using robot is feasible without increasing postoperative complications in the process of cholecystectomy and the use of the ELPP can reduce postoperative pain and shoulder pain compared to the use of the SPP.

Effects of Low and Standard Intra-Abdominal Pressure on Postoperative Pain in Laparoscopic Cholecystectomy

Objective: To analyze the effects of low and standard intra-abdominal pressure on post-operative pain in laparoscopic cholecystectomy.&#x0D; Study Design: Comparative prospective study.&#x0D; Place and Duration of the Study: Department of General Surgery, Pak Emirates Military Hospital Rawalpindi, from Nov 2019 to Feb 2020.&#x0D; Methodology: The study comprised 53 patients who underwent Laparoscopic Cholecystectomy and were selected for the study. They were randomly divided into two groups by third-party randomization. The first group was operated on under low pneumatic pressure, i.e. 8-12 mmHg and the second group was operated on under high pneumatic pressure, i.e. (≥15 mmHg). The complaint of post-operative pain was evaluated using a visual analogue scale (VAS) in the next 12 hours.&#x0D; Results: The group that was operated under high pneumatic pressure showed a higher occurrence of post-operative pain (50.9%) than the group that operated under low pneumatic pressure. On the Visual Analogue Scale, 80.0% of patients with high pneumatic pressure showed a pain of score four or more which is very high compared to the other group (p &lt;0.05).&#x0D; Conclusion: The patients operated for laparoscopic cholecystectomy under low-pressure pneumoperitoneum would suffer from less post-operative abdominal pain, which needs less analgesia and leads to early hospital discharge.