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Impact of standard-pressure and low-pressure pneumoperitoneum on shoulder pain following laparoscopic cholecystectomy: a randomised controlled trial

Authors:
Hemanga Kumar Bhattacharjee at All India Institute of Medical Sciences
Hemanga Kumar Bhattacharjee
Azarudeen Jalaludeen
Azarudeen Jalaludeen
Azarudeen Jalaludeen
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Virinder Kumar Bansal at All India Institute of Medical Sciences
Virinder Kumar Bansal
Krishna Asuri at All India Institute of Medical Sciences
Krishna Asuri
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Abstract and Figures

Background: The incidence of shoulder pain (SP) following laparoscopic cholecystectomy (LC) varies between 21 and 80 %. A few randomised controlled trials and meta-analysis have shown lesser SP in LC performed under low-pressure carbon dioxide pneumoperitoneum (LPCP) than under standard-pressure carbon dioxide pneumoperitoneum (SPCP). However, the possible compromise in adequate exposure and effective working space during LPCP has negatively influenced its uniform adoption for LC. Materials and methods: All consecutive patients undergoing elective LC for gallstone disease who met the inclusion and exclusion criteria were enroled. Fourty patients were randomised to SPCP group (pressure of 14 mmHg) and 40 to LPCP group (pressure of 9-10 mmHg). Primary outcome measured was incidence of SP and its severity on visual analogue scale (VAS) at 4, 8, 24 h and 7 days after LC. Secondary outcomes measured were procedural time, technical difficulty, surgeons' satisfaction score on exposure and working space, intra-operative changes in heart rate and blood pressure, abdominal pain and analgesic requirement. Analyses were performed using Stata software. Results: There was no conversion to open surgery, bile duct injury or need to increase intra-abdominal pressure on either group. Twenty-three patients (57.5 %) in SPCP group and nine patients (22.5 %) in LPCP group had SP (p = 0.001). The severity of SP was significantly more in SPCP group at 8 and 24 h (p = 0.009 and 0.005, respectively). Both the groups had similar procedural time, surgeons' satisfaction score, intra-operative changes in heart rate and blood pressure. Conclusion: The incidence and severity of SP following LC performed at LPCP are significantly less compared to that in SPCP. The safety, efficacy and surgeons' satisfaction appear to be comparable in both the groups. Hence, a routine practice of low-pressure carbon dioxide pneumoperitoneum may be recommended in selected group of patients undergoing laparoscopic cholecystectomy. Clinical trial registration number: CTRI/2016/02/006590.
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Impact of standard-pressure and low-pressure
pneumoperitoneum on shoulder pain following laparoscopic
cholecystectomy: a randomised controlled trial
Hemanga K. Bhattacharjee
1
•Azarudeen Jalaludeen
1
•Virinder Bansal
1
•
Asuri Krishna
1
•Subodh Kumar
1
•Rajeshwari Subramanium
2
•
Rashmi Ramachandran
2
•Mahesh Misra
1
Received: 16 March 2016 / Accepted: 9 July 2016 / Published online: 21 July 2016
ÓSpringer Science+Business Media New York 2016
Abstract
Background The incidence of shoulder pain (SP) follow-
ing laparoscopic cholecystectomy (LC) varies between 21
and 80 %. A few randomised controlled trials and meta-
analysis have shown lesser SP in LC performed under low-
pressure carbon dioxide pneumoperitoneum (LPCP) than
under standard-pressure carbon dioxide pneumoperitoneum
(SPCP). However, the possible compromise in adequate
exposure and effective working space during LPCP has
negatively influenced its uniform adoption for LC.
Materials and methods All consecutive patients undergo-
ing elective LC for gallstone disease who met the inclusion
and exclusion criteria were enroled. Fourty patients were
randomised to SPCP group (pressure of 14 mmHg) and 40
to LPCP group (pressure of 9–10 mmHg). Primary out-
come measured was incidence of SP and its severity on
visual analogue scale (VAS) at 4, 8, 24 h and 7 days after
LC. Secondary outcomes measured were procedural time,
technical difficulty, surgeons’ satisfaction score on expo-
sure and working space, intra-operative changes in heart
rate and blood pressure, abdominal pain and analgesic
requirement. Analyses were performed using Stata
software.
Results There was no conversion to open surgery, bile duct
injury or need to increase intra-abdominal pressure on
either group. Twenty-three patients (57.5 %) in SPCP
group and nine patients (22.5 %) in LPCP group had SP
(p=0.001). The severity of SP was significantly more in
SPCP group at 8 and 24 h (p=0.009 and 0.005, respec-
tively). Both the groups had similar procedural time, sur-
geons’ satisfaction score, intra-operative changes in heart
rate and blood pressure.
Conclusion The incidence and severity of SP following LC
performed at LPCP are significantly less compared to that
in SPCP. The safety, efficacy and surgeons’ satisfaction
appear to be comparable in both the groups. Hence, a
routine practice of low-pressure carbon dioxide pneu-
moperitoneum may be recommended in selected group of
patients undergoing laparoscopic cholecystectomy.
Clinical trial registration number CTRI/2016/02/006590.
Keywords Laparoscopic cholecystectomy Shoulder
pain Low-pressure pneumoperitoneum Standard-
pressure pneumoperitoneum Surgeons’ satisfaction
Presented at the SAGES 2016 Annual Meeting, March 16–19, 2016,
Boston, Massachusetts.
&Virinder Bansal
drvkbansal@gmail.com
Hemanga K. Bhattacharjee
dr_hkb75@yahoo.com
Azarudeen Jalaludeen
azrudn@gmail.com
Asuri Krishna
dr.asurikrishna@gmail.com
Subodh Kumar
subodh6@gmail.com
Rajeshwari Subramanium
drsrajeshwari@gmail.com
Rashmi Ramachandran
rashmiramachandran1@gmail.com
Mahesh Misra
mcmisra@gmail.com
1
Department of Surgical Disciplines, All India Institute of
Medical Sciences, New Delhi, India
2
Department of Anaesthesiology, All India Institute of
Medical Sciences, New Delhi, India
123
Surg Endosc (2017) 31:1287–1295
DOI 10.1007/s00464-016-5108-2
and Other Interventional Techniques
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... In terms of postoperative pain studies have demonstrated LPP has better pain score and lower incidence of shoulder pain than SPP in laparoscopic cholecystectomy [28] and it has been demonstrated use of deep NMB further reduces postoperative pain and incidence of shoulder pain. In our study however, we did not find any clinically significant difference in pain outcomes in terms of postoperative pain scores or incidence of shoulder pain. ...
... A standardization of reporting may be considered in future studies. The scoring used here was part of previous study from our institute and was standardized for laparoscopic cholecystectomy [28]. ...
Low-pressure pneumoperitoneum with deep neuromuscular blockade versus standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy for gallstone disease: a non-inferiority randomized control trial
Article
Full-text available
  • Nov 2023
Background Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. Methodology This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8-10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1-2] and Group B: SPP; 12-14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. Results Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. Conclusion LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
View
... In terms of postoperative pain studies have demonstrated LPP has better pain score and lower incidence of shoulder pain than SPP in laparoscopic cholecystectomy [28] and it has been demonstrated use of deep NMB further reduces postoperative pain and incidence of shoulder pain. In our study however, we did not find any clinically significant difference in pain outcomes in terms of postoperative pain scores or incidence of shoulder pain. ...
... A standardization of reporting may be considered in future studies. The scoring used here was part of previous study from our institute and was standardized for laparoscopic cholecystectomy [28]. ...
Low pressure pneumoperitoneum
Article
Full-text available
  • Nov 2023
  • SURG ENDOSC
Background Low-pressure pneumoperitoneum (LPP) is an attempt at improving laparoscopic surgery. However, it has the issue of poor working space for which deep neuromuscular blockade (NMB) may be a solution. There is a lack of literature comparing LPP with deep NMB to standard pressure pneumoperitoneum (SPP) with moderate NMB. Methodology This was a single institutional prospective non-inferiority RCT, with permuted block randomization of subjects into group A and B [Group A: LPP; 8–10 mmHg with deep NMB [ Train of Four count (TOF): 0, Post Tetanic Count (PTC): 1–2] and Group B: SPP; 12–14 mmHg with moderate NMB]. The level of NMB was monitored with neuromuscular monitor with TOF count and PTC. Cisatracurium infusion was used for continuous deep NMB in group A. Primary outcome measures were the surgeon satisfaction score and the time for completion of the procedure. Secondarily important clinical outcomes were also reported. Results Of the 222 patients screened, 181 participants were enrolled [F: 138 (76.2%); M: 43 (23.8%); Group A n = 90, Group B n = 91]. Statistically similar surgeon satisfaction scores (26.1 ± 3.7 vs 26.4 ± 3.4; p = 0.52) and time for completion (55.2 ± 23.4 vs 52.5 ± 24.9 min; p = 0.46) were noted respectively in groups A and B. On both intention-to-treat and per-protocol analysis it was found that group A was non-inferior to group B in terms of total surgeon satisfaction score, however, non-inferiority was not proven for time for completion of surgery. Mean pain scores and incidence of shoulder pain were statistically similar up-to 7 days of follow-up in both groups. 4 (4.4%) patients in group B and 2 (2.2%) in group A had bradycardia (p = 0.4). Four (4.4%) cases of group A were converted to group B. One case of group B converted to open surgery. Bile spills and gallbladder perforations were comparable. Conclusion LPP with deep NMB is non-inferior to SPP with moderate NMB in terms of surgeon satisfaction score but not in terms of time required to complete the procedure. Clinical outcomes and safety profile are similar in both groups. However, it could be marginally costlier to use LPP with deep NMB.
View
... Shoulder pain: Thirteen studies [10][11][12]19,20,23,24,27,29,32,34,[39][40][41][42] including 1036 patients reported shoulder pain outcomes. Of the 505 patients in the LAP group, 104 patients suffered shoulder pain. ...
... Analgesic use was reported in nine studies [10,12,17,22,23,32,36,39] including 646 patients. Of the 326 patients in the LAP group, 100 used analgesics. ...
Impact of low- and standard-abdominal pressure on post- operative pain during laparoscopic cholecystectomy: A systematic review and meta-analysis of randomized trials
Article
  • Mar 2023
Background: This study aimed to comprehensively evaluate the impact of low- and standard-abdominal pressure on intraoperative, postoperative, and survival outcomes of Laparoscopic Cholecystectomy (LC). Methods: A literature search of the databases, PubMed, Web of Science, Embase, and Cochrane Library was performed until April 30, 2021. Studies comparing low abdominal pressure and standard abdominal pressure for LC were included. Two reviewers independently screened the studies, extracted the data of interest, and assessed the risk of bias. Meta-analysis was performed using RevMan 5.3.
View
... Low pressure pneumoperitoneum 4] has been challenging the complications and feasibility of standard pressure pneumoperitoneum [5,6]. Clinical trials have compared low pressure vs. standard in terms of perioperative complications, post-operative pain, hospital length of stay, stress response and surgeon comfort [6,7]. In this trail we conducted a randomized comparison between low pressure and standard pressure pneumoperitoneum for laparoscopic cholecystectomy in terms of postoperative pain, inflammatory markers, timing of surgery and surgeon comfort. ...
Effect of low-pressure pneumoperitoneum on pain and inflammation in laparoscopic cholecystectomy: a randomized controlled clinical trial
Article
Full-text available
  • Sep 2023
  • BMC Res Notes
Objective We aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers. Background The 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. Methods A 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. Results one 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. Conclusion low-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).
View
... El riesgo relativo de presentar dolor fue de 2.7 (IC 95% 1.4, 5.0) con la presión alta. 25 Estos hallazgos sugieren que la fisiopatología del dolor está relacionada con la presión a la que es Otro ensayo clínico controlado, con 160 pacientes divididos en dos grupos, demostró que el grupo sometido a presiones menores de 10 mmHg (comparado con > de 10 mmHg) presentó menos frecuencia de dolor (7.5 vs 23.8%, p = 0.005) y disminución en la intensidad de dolor en una escala visual análoga de 0.28 ± 0.90 vs 1.31 ± 2.30, p = 0.001). No obstante, llama la atención que la incidencia total de dolor de hombros en ambos grupos fue sólo de 15%, lo cual indica que aun usando presiones mayores de 10 mmHg, son pocos los pacientes que presentaron dolor. ...
View
... 5,6 Clinical trials have compared low pressure vs. standard in terms of perioperative complications, post-operative pain, hospital length of stay, stress response and surgeon comfort. 6,7 In this trail we conducted a randomized comparison between low pressure and standard pressure pneumoperitoneum for laparoscopic cholecystectomy in terms of postoperative pain, in ammatory markers, timing of surgery and surgeon comfort. This trial adds to the literature the extensive study of in ammatory markers associated with stress of surgery, and the surgeon comfort level along with safety of the procedure with performed by non-experienced surgeons (senior residents). ...
Effect of Low-pressure Pneumoperitoneum on Pain and Inflammation in Laparoscopic Cholecystectomy: A Randomized Controlled Clinical Trial
Preprint
Full-text available
  • Mar 2023
Objective We aim to assess the effect of low-pressure pneumoperitoneum on post operative pain and ten of the known inflammatory markers. Background The 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. Methods A 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. Registered on ClinicalTrials.gov (NCT05530564/ September 7th, 2022). Results one 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. Conclusion low-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.
View
The Effect of Low-Pressure Pneumoperitoneum with Active Evacuation on the Severity of Shoulder Pain in Patients Undergoing Laparoscopic Cholecystectomy
Article
Full-text available
  • May 2023
Background and Objective: Although the pain severity following laparoscopic cholecystectomy is generally lower compared to the open method, but some patients may still experience abdominal and shoulder pain for several days after the laparoscopic procedure. Based on recent evidences, pneumoperitoneum using low-pressure carbon dioxide gas can reduce the pain. This study evaluated the feedback on shoulder pain severity from laparoscopic cholecystectomy patients experiencing CO2-pneumoperitoneum. Materials and Methods: 80 laparoscopic cholecystectomy cases were allocated for intervention (n = 40) and control groups (n = 40) randomly. Pneumoperitoneum was done by a direct trocar. Patients’ pain feedback was assessed using the visual pain scale after the surgery. SPSS 21 was used to analyze the collected data. Results: Shoulder pain frequency significantly differed between the two groups at 12 hours (P = 0.048) and 24 hours (P = 0.001) after the surgery. Regarding average shoulder pain severity, the groups showed significant differences after 2, 6, and 24 hours of surgery (P < 0.05). Moreover, pneumoperitoneum duration was different in the groups (P = 0.001). Conclusion: Based on these findings, low pressure of pneumoperitoneum with active evacuation compared to the standard pressure, efficiently reduced shoulder pain intensity. Thus, using low-pressure pneumoperitoneum in laparoscopic cholecystectomy is recommended to relieve postoperative pain. Keywords: Shoulder Pain, Pneumoperitoneum, Laparoscopy, Cholecystectomy, Evacuation
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Low intra-abdominal pressure in laparoscopic surgery: a systematic review and meta-analysis
Article
  • Apr 2023
  • Int J Surg
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. Material 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% confidence intervals (CI) 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: 85 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 -0.82-0.54) and PONV incidence (RR 0.67, 95%-CI 0.51-0.88), and a reduced length of hospital stay (MD -0.29, 95%-CI -0.46-0.11). Low IAP did not increase the risk of intra-operative complications (RR 1.15, 95%-CI 0.77-1.73). Conclusion: 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.
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Enhanced Recovery After Bariatric Surgery
Chapter
  • Feb 2023
Enhanced recovery after surgery (ERAS) represents the use of a standardized, multimodal perioperative care pathway aiming to achieve early recovery after surgery. ERAS pathways aim to optimize the patient preoperatively, minimize the surgical stress response, and expedite recovery to a normal physiological state via standardized, evidence-based protocols. Enhanced recovery after bariatric surgery (ERABS) has evolved rapidly in the last decade, culminating in the publication of a number of guidelines in the last five years recommending perioperative ERABS interventions, while the evidence to support these interventions is constantly expanding. The evidence base supporting ERABS protocol implementation is robust, with a number of randomized controlled trials and meta-analyses showing convincing evidence of benefits, including decreased length of stay, pain, and risk of postoperative nausea and vomiting, while confirming the safety of ERABS interventions. Implementation of enhanced recovery protocols can be challenging and is often incomplete, limiting their effectiveness. Progress is needed toward standardizing enhanced recovery protocols in bariatric surgery to ensure consistency in implementing the best practice among bariatric centers. In order to achieve this, protocols must be generalizable so that they can be used in a variety of settings. The development of ERABS protocols has been the driving force enabling significant change to everyday practice in bariatric surgery in the last decade and has demonstrated an impressive decrease in the use of resources and hospital stay. In this chapter, we present the rationale supporting ERABS interventions, the relevant guidelines published in the last five years, and an overview of protocol recommendations and discuss the evidence supporting the use of protocols as well as their limitations.
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Residual Pneumoperitoneum Volume and Postlaparoscopic Cholecystectomy Pain
Article
Full-text available
  • Oct 2014
Gasretention in the peritoneal cavity plays an important role in inducing postoperative pain after laparoscopy, which is inevitably retained in the peritoneal cavity. The aim of this study was to detect the relation between the volume of residual gas and severity of shoulder and abdominal pain. In this Prospective study 55 women who were referred for laparoscopic cholecystectomy, were evaluated for the effect of residual pneumoperitoneum on postlaparoscopic cholecystectomy pain intensity. The pneumoperitoneum was graded as absent, mild (1-5 mm), moderate (6-10 mm) and severe (> 11 mm). Patients were followed for postoperative abdominal and shoulder pain using visual analogue scale (VAS), postoperative analgesic requirements, presence of nausea and vomiting, time of unassisted ambulation, time of oral intake and time of return of bowel function in the recovery room and at 6, 12 and 24 hours after operation. At the end of the study, 17 patients (30.9%) had no residual pneumoperitoneum after 24 hours; which 23 (41.81%) had mild residual pneumoperitoneum, eight (14.54%) had moderate pneumoperitoneum and seven (12.72%) had severe pneumoperitoneum. Patients with no or mild residual pneumoperitoneum had significantly lower abdominal and shoulder pain scores than whom with moderate to severe pneumoperitoneum (P = 0.00) and need less meperidine requirements (P = 0.00). Patients did not have any significant difference in time of oral intake, return of bowel function, nausea and vomiting percentages. We conclude that volume of residual pneumoperitoneum is a contributing factor in the etiology of postoperative pain after laparoscopic cholecystectomy.
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Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy—a randomised controlled trial
Article
Full-text available
  • Jul 2009
  • Trop Gastroenterol
Standard pressure pneumoperitoneum for laparoscopic cholecystectomy employs a pressure range of 12-14 mm Hg. An emerging trend has been the use of low pressure pneumoperitoneum in the range of 7-10 mm Hg in an attempt to lower the impact of pneumoperitoneum on the human physiology while providing adequate working space. Our study proposes to compare the use of low pressure pneumoperitoneum with the use of standard pressure pneumoperitoneum. A randomised controlled trial consisting of 60 patients with symptomatic gallstone disease who underwent laparoscopic cholecystectomy, of which 30 patients were subjected to standard pressure pneumoperitoneum during the procedure and 30 patients to low pressure pneumoperitoneum. Both groups were comparable in all aspects. The mean operating time with low pressure pneumoperitoneum was 49.07 +/- 5.72 minutes and with standard pressure pneumoperitoneum was 46.43 +/- 6.92 minutes. There was no statistically significant change in blood pressure, heart rate, pain at 6 hours, need for additional analgesia or shoulder tip pain with the use of lower pressure pneumoperitoneum. Low pressure pneumoperitoneum benefits the patient in the form of lower intensity of postoperative pain but it does not positively impact intraoperative hemodynamics.
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Comparison of Standard-pressure and Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Double Blinded Randomized Controlled Study
Article
  • Apr 2014
With the safety of laparoscopic cholecystectomy (LC) having been established, the current stress is on reducing the postoperative morbidity associated with this procedure. Hence, this study was undertaken to compare the effect of low-pressure (8 mm Hg) (LPLC) versus standard-pressure (12 mm Hg) (SPLC) pneumoperitoneum on postoperative pain, respiratory and liver functions, the stress response, and the intraoperative surgeon comfort in patients undergoing LC. Patients undergoing LC (n=43) were randomized into the LPLC (8 mm Hg) group (n=22) and the SPLC (12 mm Hg) group (n=21). Postoperative pain, changes in liver function, peak expiration flow rate, C-reactive protein level, and intraoperative surgeon comfort were assessed. The postoperative pain scores (P=0.003, 0.000, 0.001, and 0.002 at 0, 4, 8, and 24 h), total analgesic requirement (P=0.001), and the number (total and good) of demands for analgesic in the first 24 hours (P=0.002 and 0.001) were lower in the LPLC group. The surgeon comfort in the LPLC group was significantly lesser (P=0.000). The liver function and peak expiration flow rate did not show any significant changes. C-reactive protein levels varied significantly only at 24 hours postoperatively (P=0.001). The use of low-pressure pneumoperitoneum (8 mm Hg) for LC is associated with a significantly lower postoperative pain. However, the use of this low-pressure pneumoperitoneum can jeopardize the surgeon's comfort.
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Low-pressure versus standard-pressure pneumoperitoneum for laparoscopic cholecystectomy: A systematic review and meta-analysis
Article
  • Jul 2014
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.
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Low vs Standard Pneumoperitoneum Pressure During Laparoscopic Hysterectomy: Prospective Randomized Trial
Article
  • Dec 2013
To compare the use of low (LPP - 8 mmHg) vs. standard pneumoperitoneum pressure (SPP - 12 mmHg) during mini-laparoscopic hysterectomy (MLH). Randomized controlled trial (Canadian Task Force Classification I). Tertiary care center. Consecutive forty-two women scheduled to undergo MLH for benign uterine disease. Women were randomly selected to undergo MLH using LPP (n=20) or SPP (n=22). MLH was performed with the use of 3-mm ancillary ports. Primary outcome was to evaluate changes in abdominal and shoulder-tip postoperative pain by use of a 100-mm visual analogue scale (VAS) at 1-, 3- and 24-hour postoperatively. All procedures were completed mini-laparoscopically without the need of increase intra-abdominal pressure or conversion to conventional laparoscopy or open surgery. Intra-operatively, one case of severe bradycardia occurred in the LPP group, while no intraoperative complications were registered in the SPP group (p=0.47). No postoperative complications were recorded (p>0.99). Abdominal pain was similar between groups at each time point. Incidence and intensity of shoulder-tip pain at 1-and 3-hour postoperatively was lower in the LPP in comparison to the SPP group (p<0.05), while no between-group differences were observed at 24-hour (p>0.05). Rescue analgesic requirement did not differ statistically between groups (20% in the LPP group vs. 41% in the SPP group; p=0.19, OR:2.7; 95%CI: 0.69, 11.08). In experienced hands the use of LPP is safe and feasible. During the execution of MLH, LPP is a simple method that offers advantages of less shoulder-tip pain in comparison with SPP.
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Surgical techniques to minimize shoulder pain after laparoscopic cholecystectomy. A systematic review
Article
  • Jan 2013
  • SURG ENDOSC
Background: Laparoscopic cholecystectomy (LC) is the treatment of choice for symptomatic cholecystolithiasis. Despite the many advantages over open surgery, many patients complain about referred pain to the shoulder during the postoperative course. The purpose of this review was to evaluate different intraoperative surgical methods to minimize shoulder pain (SP). Methods: A search of the literature was conducted using PubMed, Excerpta Medica Database (EMBASE), and Cochrane database of systematic reviews. Eligibility criteria were: randomized clinical trials or meta-analysis evaluating intraoperative surgical methods applied to minimize incidence or severity of SP after LC. Only papers published in English were included. Data extracted were year of publication, number of participants and allocation, nonsignificant or significant effect on incidence or severity of SP. Results: A total of 31 papers where included in the review. Seven, 8, and 12 papers investigated the effect of drains, abdominal wall lift (AWL), and low-pressure pneumoperitoneum respectively. Four papers investigated drain suction, active gas aspiration, low insufflation flow or N2O insufflation respectively. The interventions that overall showed a significant reduction on either the incidence or severity of SP were low-pressure pneumoperitoneum, low insufflation rate, and active gas aspiration. Conclusions: Drainage and AWL are not recommended to reduce SP after LC. Low-pressure pneumoperitoneum with carbon dioxide is the best documented intraoperative surgical method to minimize both the incidence and severity of SP after LC.
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Evaluation of post operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy
Article
  • Apr 2012
  • SURG-J R COLL SURG E
Insufflation of carbon dioxide during laparoscopic cholecystectomy leads to postoperative shoulder tip pain. The origin of shoulder pain is commonly assumed to be due to overstretching of the diaphragmatic muscle fibres owing to a high carbon dioxide pressure. To study the frequency and intensity of post operative shoulder tip pain in laparoscopic cholecystectomy and compare low and standard pressure pneumoperitoneum during laparoscopic cholecystectomy with respect to post operative shoulder tip pain. Patients admitted in the department of surgery for elective cholecystectomy were enrolled in the study. The patients were randomly allocated to two groups (group A and group B). In group A (n = 50), low pressure pneumoperitoneum (8 mm Hg) and in group B (n = 50), standard pressure pneumoperitoneum (14 mm Hg) was generated during laparoscopic cholecystectomy. Postoperative shoulder tip pain was assessed at 4, 8 and 24 h after operation by the Visual Analogue Scale of Pain. 14 patients (28%) in group B complained of post operative shoulder tip pain as compared to only 5 patients (10%) in group A. The mean intensity of post operative shoulder tip pain assessed by visual analogue scoring scale at 4, 8 and 24 h was less in group A as compared to group B, although statistical significance was seen only at 4 h. Analgesic requirements and the mean length of post operative stay in the hospital were also less in group A as compared to group B. Low pressure laparoscopic cholecystectomy (LPLC) significantly decreases the frequency and intensity of postoperative shoulder tip pain. LPLC decreases the demand for postoperative analgesics, decreases postoperative hospital stay and hence improves the quality of life in the early stage of postoperative rehabilitation.
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The combination of infiltrative bupivacaine with low-pressure laparoscopy reduces postcholecystectomy pain. A prospective randomized controlled study
Article
  • Feb 2012
To evaluate the efficacy of combined infiltrative bupivacaine with low intraperitoneal pressure insufflation in reducing the post-laparoscopic pain in patients undergoing laparoscopic cholecystectomy (LC). This randomized prospective single-blind study included 473 patients undergoing LC. The study took place at University Hospital Center Mother Teresa, Tirana, Albania between January 2006 to September 2009. The patients were divided in 4 groups: Group 1 (n=120) with intra-abdominal insufflation pressure 15 mm Hg and no infiltrative bupivacaine (HPNBG); Group 2 (n=122) with intra-abdominal insufflation pressure 15 mm Hg and with 5 ml infiltrative bupivacaine 0.5% in abdominal minincisions (HPBG); Group 3 (n=110) with intra-abdominal insufflation pressure under 10 mm Hg and no infiltrative bupivacaine (LPNBG); and Group 4 (n=121) with intra-abdominal insufflation pressure under 10 mm Hg and infiltrative bupivacaine (LPBG). There were statistically significant differences (p=0.003) between groups regarding incisional pain intensity, between LPBG and HPNBG (p=0.001), between LPBG and HPBG (p=0.037), between LPBG and LPNBG (p=0.001), as well the shoulder-tip pain intensity (p=0.001); between LPBG and HPNBG (p=0.001), between LPBG and HPBG (p=0.001), and between LPBG and LPNBG (p=0.031). We found statistically significant differences related to pain beginning time (ANOVA test, p=0.027); between LPBG and HPNBG (p=0.041), between LPBG and HPBG (p=0.031), and between LPBG and LPNBG (p=0.05). The combination of infiltrative bupivacaine with low intraperitoneal pressure insufflation shows to be more efficient in reducing the post-laparoscopic pain, compared with other regimens.
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Maneuvers to Decrease Laparoscopy-Induced Shoulder and Upper Abdominal Pain A Randomized Controlled Study
Article
  • Dec 2011
To evaluate the effectiveness of the pulmonary recruitment maneuver (PRM) and intraperitoneal normal saline infusion (INSI) in removing postlaparoscopic carbon dioxide from the abdominal cavity to decrease laparoscopy-induced abdominal or shoulder pain after surgery. Design, Setting, and A prospective, randomized, controlled trial was conducted at Taipei Veterans General Hospital, Taipei, Taiwan, from August 1, 2009, through June 30, 2010. One hundred fifty-eight women undergoing laparoscopic surgery for benign gynecologic lesions were randomly assigned to 3 groups: the PRM group (n = 53), the INSI group (n = 54), and the control group (n = 51). Postoperative maneuvers included PRM and INSI. Evaluation of pain, including abdominal pain and shoulder pain, was performed at 12, 24, and 48 hours postoperatively. The frequency of postoperative shoulder pain at 24 and 48 hours was significantly decreased in the INSI group compared with that of either the PRM or control group (40.7% and 24.1% in the INSI group vs 66.0% and 50.9% in the PRM group [P = .009 and .004, respectively] or vs 72.5% and 54.9% in the control group [both P < .001]). Both methods significantly reduced the frequency of upper abdominal pain compared with the control condition (73.6% in the PRM group at 24 hours [P = .03] or 72.2% at 24 hours [P .02] and 44.4% at 48 hours [P = .01] in the INSI group vs 90.2% at 24 hours and 68.6% at 48 hours in the control group). Both PRM and INSI could effectively reduce pain after laparoscopic surgery, but INSI might be better for both upper abdominal and shoulder pain.
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Shoulder Pain Following Laparoscopic Cholecystectomy: Factors Affecting the Incidence and Severity
Article
  • Oct 2010
  • J LAPAROENDOSC ADV S
Laparoscopic cholecystectomy (LC) has become the standard treatment for gall bladder disease. However, despite its low degree of invasiveness, many patients complain of postoperative pain and postoperative nausea/vomiting. This study was planned to evaluate different factors affecting the incidence and severity of postoperative shoulder-tip pain after LC. One hundred consecutive patients who were treated for gall bladder stone by LC at the Gastroenterology Surgical Center, Mansoura University, Mansoura, Egypt, during the period from October 2008 to January 2010, were randomized according to different pnemoperitonum pressures (8, 10, 12, and 14 mm Hg). Each group comprises 25 patients. There were 62 patients reported to have postoperative shoulder-tip pain during the first 12 hours after operation, which decreased to 9 patients on the 10th postoperative day. A significant difference was observed in the prevalence of pain at different pressures, 11% with low pressure and increased to 20% with high pressure. The incidence of shoulder-tip pain was significantly more in patients with a longer duration of the operation of >45 minutes at 12 hours (23 [76.7%] versus 39 [55.7%]; P = 0.04), at 24 hours (23 [76.7%] versus 29 [41.4%]; P = 0.009), and at 3 days postoperatively (19 [63.3%] versus 20 [28.6%]; P = 0.01). The volume of used gases during the operation had no effect on the incidence or severity of shoulder-tip pain after LC. Also, the use of intraoperative analgesics had no effect on the incidence or severity of shoulder-tip pain after LC. The origin of pain after LC is multifactorial. We recommend the use of the lower pressure technique during LC, and as patients with and without drains have similar incidence of postoperative shoulder pain, drains should not be used with the intention of preventing shoulder pain.
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