Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy
Abstract
Background
A pneumoperitoneum of 12 to 16 mmHg 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 patients undergoing laparoscopic cholecystectomy.
Search methods
We searched The Cochrane Hepato‐Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until November 2008 for identifying randomised trials using search strategies.
Selection criteria
Only randomised clinical trials, irrespective of language, blinding, or publication status were considered for the review.
Data collection and analysis
Two authors independently identified trials and independently extracted data on mortality, morbidity, conversion to open cholecystectomy, pain, analgesic requirement, operating time, hospital stay, patient satisfaction, additional measures to increase vision, and cardiopulmonary parameters. We calculated the risk ratio (RR), mean difference (MD), or standardised mean difference (SMD) with 95% confidence intervals (CI) using both the fixed‐effect and the random‐effects models with RevMan 5 based on available case‐analysis.
Main results
Fifteen trials randomised 690 patients to low pressure (n = 336) and standard pressure (n = 354). All the trials were of high risk of bias. There was no difference in the mortality, morbidity, or conversion to open cholecystectomy between the groups. The intensity of pain was lower in the low pressure group at various time points. The incidence of shoulder pain was lower in the low pressure group (RR 0.53; 95% CI 0.31 to 0.90). The analgesic consumption was also lower. The operating time was similar between the groups (MD 2.30 minutes; 95% CI 0.42 to 4.18). Because of the high risk of bias due to incomplete outcome data in seven trials, it was not possible to conclude about the safety of low pressure pneumoperitoneum.
Authors' conclusions
Low pressure pneumoperitoneum appears effective in decreasing pain after laparoscopic cholecystectomy. The safety of low pressure pneumoperitoneum has to be established.
Plain language summary
Low pressure pneumoperitoneum appears effective in decreasing pain in laparoscopic cholecystectomy, but the safety has to be established
For key‐hole removal of the gallbladder, carbon‐dioxide is injected into the abdomen. A pressure of 12 to 16 mmHg of pressure is used for the surgery. Several physiological parameters related to heart and lung (cardiopulmonary changes) occur during insufflation of abdomen. While these changes can be tolerated by normal individuals, patients with poor heart or lung function may not tolerate the changes. Lowering the pressure of the insufflated gas might decrease the ability of the surgeon to view the surgical field. In this systematic review, 15 trials randomised 690 patients to low pressure (n = 336) and standard pressure (n = 354). All the trials were of high risk of bias. There was no difference in the mortality, post‐operative complications, or conversion to open cholecystectomy between the groups. The intensity of overall pain was lower in the low pressure group at various time points. The incidence of shoulder pain was lower in the low pressure group. The analgesic consumption was also lower. The operating time did not differ between the groups. Because the data on all the patients were not available in seven trials, it was not possible to conclude about the safety of low pressure pneumoperitoneum. In conclusion, low pressure pneumoperitoneum appears effective in decreasing pain after laparoscopic cholecystectomy, but its safety has to be established.
