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We hypothesized that deep neuromuscular blockade (NMB) with low-pressure pneumoperitoneum (PP) would improve respiratory mechanics and reduce biotrauma compared to moderate NMB with high-pressure PP in a steep Trendelenburg position. Seventy-four women undergoing robotic gynecologic surgery were randomly assigned to two equal groups. Moderate NMB group was maintained with a train of four count of 1–2 and PP at 12 mmHg. Deep NMB group was maintained with a post-tetanic count of 1–2 and PP at 8 mmHg. Inflammatory cytokines were measured at baseline, at the end of PP, and 24 h after surgery. Interleukin-6 increased significantly from baseline at the end of PP and 24 h after the surgery in moderate NMB group but not in deep NMB group (Pgroup*time = 0.036). The peak inspiratory, driving, and mean airway pressures were significantly higher in moderate NMB group than in deep NMB group at 15 min and 60 min after PP (Pgroup*time = 0.002, 0.003, and 0.048, respectively). In conclusion, deep NMB with low-pressure PP significantly suppressed the increase in interleukin-6 developed after PP, by significantly improving the respiratory mechanics compared to moderate NMB with high-pressure PP during robotic surgery.

Robotic surgery has revolutionized postoperative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks given the change in physiological parameters that accompany its utilization. A recent internal review found a 7% decrease in postoperative ileus rates when utilizing a pneumoperitoneum of 12 mmHg over the standard 15 mmHg in robotic assisted radical prostatectomies (RARP). The purpose of this study is to prospectively evaluate the utility of lower pressure pneumoperitoneum by comparing 8 mmHg and 12 mmHg during RARP. Patients were randomly assigned to undergo robotic assisted radical prostatectomy at a pneumoperitoneum pressure of 12 mmHg or 8 mmHg. The primary outcome was development of postoperative ileus and secondary outcomes were length of operation, estimated blood loss and positive surgical margin status. A total of 201 patients were analyzed; 96 patients at 8 mmHg and 105 patients at 12 mmHg. The groups were adequately matched as there were no differences between demographic parameters or medical comorbidities. There was a decrease in postoperative ileus rates with lower pneumoperitoneum pressures; 2% at 8 mmHg and 4.8% at 12 mmHg. There were no clinically significant differences in estimated blood loss, total length of operative time and positive margin status. Lower pressure pneumoperitoneum during robotic assisted radical prostatectomy is non-inferior to higher pressure pneumoperitoneum levels and the experienced surgeon may safely perform this operation at 8 mmHg to take advantage of the proposed benefits.

Рак предстательной железы является актуальной проблемой у мужчин старших возрастных групп, при этом сопутствующий преморбидный фон данной категории пациентов зачастую приводит к развитию послеоперационных осложнений при применении стандартного оперативного метода. В статье приведены результаты применения пневмоперитонеума низкого давления с лифтингом передней брюшной стенки при лапароскопической радикальной простатэктомии у пациентов пожилого возраста с локализованной формой рака предстательной железы. Убедительно показано, что использование этой методики позволяет обеспечить удовлетворительное операционное поле, получить стабильные показатели операционного мониторинга и при этом уменьшить длительность самого оперативного пособия, а также уменьшить длительность госпитализации и частоту встречаемости послеоперационных осложнений., Prostate cancer is an actual problem among males of older age groups, while the concomitant pre-morbid background of this category of patients often leads to the development of postoperative complications using the standard surgical method. The article presents the results of using low-pressure pneumoperitoneum with anterior abdominal wall lifting for laparoscopic radical prostatectomy in elderly patients with a localized form of prostate cancer. Convincingly shown that the use of low-pressure techniques pneumoperitoneum with lifting anterior abdominal wall ensures satisfactory operating field, obtains stable indicators of operational monitoring and allow to reduce the duration of the operation, as well as reduce the duration of hospitalization and incidence of postoperative complications., Успехи геронтологии, Выпуск 5 2021, Pages 934-939

Objectives: Despite the advantages of laparoscopic cholecystectomy (LC), postoperative pain remains a major complaint for many patients. In this study, in patients undergoing LC, the application of LC via incisional bupivacaine and low inflation pressure, alone or combined, and a comparison of the effects on postoperative pain has been purposed. Methods: Patients were randomly assigned into the following 4 groups: the standard pressure (SP) group (n = 30); patients with an intraabdominal insufflation pressure of 12 mmHg, where bupivacaine application was not performed at the trocar locations. The SP+local anesthetic (LA) (SP+LA) group (n = 30); patients with an intraabdominal insufflation pressure of 12 mmHg, where bupivacaine application was performed at the trocar locations. The low pressure (LP) group (n = 30); patients with an intraabdominal insufflation pressure of 8 mmHg, where bupivacaine application was not performed at the trocar locations. The (LP+LA) group (n = 30); patients with an intraabdominal insufflation pressure of 8 mmHg, where bupivacaine application was performed at the trocar locations. Postoperative pain was evaluated using the visual analogous scale (VAS). Results: When the relationships between the VAS scores, gender, age, and American Society of Anesthesiologists classification were evaluated, no significant relationships between the groups were observed (p > 0.05). A significant relationship between the groups was detected with regards to the VAS scores, 1st analgesic application, 2nd analgesic application, and patients’ satisfaction (p < 0.05). Conclusions: The combination of low insufflation pressure with intrafacial preincisional local anesthetic infiltration in post-LC pain palliation is thought to be more effective and applicable.

Feasibility of low-pressure pneumoperitoneum is feasible in expert hand. Its efficacy within enhanced recovery programmes and its safety need to be demonstrated in future studies

Introduction: General anesthesia-related side effects are more common in the presence of chronic obstructive pulmonary disease (COPD). Regional anesthesia techniques should be considered in these patients to reduce the risks. In this study, we aimed to retrospectively review our experience of laparoscopic cholecystectomy with thoracic epidural anesthesia, which we carried out in the COPD group. Materials and Methods: A total of 34 patients who underwent laparoscopic cholecystectomy operation under thoracic epidural anesthesia in our general surgery clinic between 2014 and 2018 were enrolled in this study. All patients had COPD with American Society of Anesthesiologist (ASA) III-IV. Results: All patients were successfully operated with low CO2 pneumoperitoneum (10 mmHg) under thoracic epidural anesthesia. Of all patients, 21 (61.8%) of them were male, and 13 (38.2%) of them were female with a mean age of 64 years (range: 52–76). Thirty-one (91.2%) of the patients had ASA III and 3 (8.8%) of them had ASA IV status. Analgesic was needed in 13 (38.2%) patients at the 6th hour and three (8.8%) patients at the 12th hour, while no analgesic was needed in any patients at the 24th hour. The most common complaint in the perioperative period was right shoulder pain by 35.2% (n=12). In addition, nausea occurred in 29.4% (n=10) of the patients; abdominal discomfort, or pain was noted in nine (26.5%) patients. In the per-op period, three (8.8%) patients developed hypotension and two patients (5.9%) bradycardia. In the post-op period, any complain was not observed in 14 (41.2%) patients, while 11 (32.5%) patients had nausea/vomiting, shoulder pain in four (11.8%), and abdominal discomfort was seen in four (11.8%). When pre- and post-op respiratory function tests were compared, no adverse effect was seen due to thoracic epidural anesthesia. Conclusion: COPD patients who are at a high risk of general anesthesia can be operated under regional anesthesia without experiencing respiratory system complications and with less post-op pain.

To analyze an efficacy of FT-protocol in patients with acute cholecystitis.Prospective randomized study included 102 patients (45 of main group (FT) and 57 of control groups). Patients did not differ by TG13 severity index. The protocol included information, antibiotic prophylaxis, restriction of drainage, intraperitoneal anesthesia with long-term anesthetics, low pressure pneumoperitoneum, antiemetics in the presence of risk factors, early activation and feeding of the patient. Pain was assessed by VAS immediately after surgery, and 2, 6 and 12-24 hours postoperatively.Surgery time was similar in both groups. Need for anesthesia and pain severity were significantly lower in the FT group. A total absence of pain (VAS 0-1) on the 1FT protocol in AC reduce postoperative pain, dyspepsia, shoulder pain and in-hospital stay with equal number of postoperative complications.Цель исследования - изучить результаты применения протокола раннего послеоперационного восстановления у пациентов с ОХ. Материал и методы. В проспективное рандомизированное мультицентровое исследование включены 102 пациента, 45 основной и 57 контрольной группы. Пациенты не отличались по возрасту, полу, давности заболевания, сопутствующей патологии. Протокол включал информирование, антибиотикопрофилактику, ограничение дренажей, инфильтрационную анестезию (ложе желчного пузыря, поддиафрагмальное пространство, троакарные раны), минипневмоперитонеум, электрохирургическое воздействие минимальной мощности, антиэметики при наличии 1 фактора риска и более, ранняя активизация (2 ч) и кормление больного (6 ч после операции). Боль оценивалась по ВАШ непосредственно после операции, через 2, 6 и 12-24 ч после операции. Критериями выписки были отсутствие осложнений на УЗИ, лейкоцитоза, лихорадки, боли, диспепсии и желание пациента. Осложнения оценивались по шкале Clavien-Dindo. Результаты. Продолжительность операции в группах не отличалась. Потребность в обезболивании и болевой синдром во всех временных интервалах были достоверно ниже в основной группе. Полное отсутствие боли (0-1 балл по ВАШ) отметили 8 (17,7%) пациентов основной и 2 (3,5%) контрольной группы (р=0,038). Френикус-симптом развился у 4 (8,9%) основной и 22 (38,6%) контрольной группы (р=0,001). Послеоперационная тошнота развилась в контрольной группе 40,5% против 13% основной (р=0,05). Время появления стула в группах не отличалось. Средний койко-день в основной группе составил 1,29±0,7 сут, в контрольной группе - 2,7±1,6 (р0,0001). Досуточное послеоперационное пребывание отмечено 24 (53,5%) в основной и 5 (8,9%) контрольной групп. Было 2 осложнения в основной группе IIIA степени (подпеченочный абсцесс и гематома послеоперационной раны) и 3 осложнения в контрольной группе (серома послеоперационной раны (IIIA), холедохолитиаз (IIIB) и инфаркт головного мозга (IV) - развившиеся в стационаре). Летальности и повторных госпитализаций не было. Выводы. Применение алгоритмов фаст-трек при остром холецистите позволило уменьшить послеоперационный болевой синдром, диспепсию, частоту развития френикус-симптома и сократить койко-день при равном количестве послеоперационных осложнений.

Postoperative shoulder pain remains a significant problem after laparoscopy. Pneumoperitoneum with insufflation of carbon dioxide (CO2) is thought to be the most important cause. Reduction of pneumoperitoneum pressure may, however, compromise surgical visualisation. Recent studies indicate that the use of deep neuromuscular blockade (NMB) improves surgical conditions during a low-pressure pneumoperitoneum (8 mmHg).The aim of this study was to investigate whether low-pressure pneumoperitoneum (8 mmHg) and deep NMB (posttetanic count 0 to 1) compared with standard-pressure pneumoperitoneum (12 mmHg) and moderate NMB (single bolus of rocuronium 0.3 mg kg with spontaneous recovery) would reduce the incidence of shoulder pain and improve recovery after laparoscopic hysterectomy.A randomised, controlled, double-blinded study.Private hospital in Denmark.Ninety-nine patients.Randomisation to either deep NMB and 8 mmHg pneumoperitoneum (Group 8-Deep) or moderate NMB and 12 mmHg pneumoperitoneum (Group 12-Mod). Pain was assessed on a visual analogue scale (VAS) for 14 postoperative days.The primary endpoint was the incidence of shoulder pain during 14 postoperative days. Secondary endpoints included area under curve VAS scores for shoulder, abdominal, incisional and overall pain during 4 and 14 postoperative days; opioid consumption; incidence of nausea and vomiting; antiemetic consumption; time to recovery of activities of daily living; length of hospital stay; and duration of surgery.Shoulder pain occurred in 14 of 49 patients (28.6%) in Group 8-Deep compared with 30 of 50 (60%) patients in Group 12-Mod. Absolute risk reduction was 0.31 (95% confidence interval 0.12 to 0.48; P = 0.002). There were no differences in any secondary endpoints including area under the curve for VAS scores.Deep NMB and low-pressure pneumoperitoneum (8 mmHg) reduced the incidence of shoulder pain after laparoscopic hysterectomy in comparison to moderate NMB and standard-pressure pneumoperitoneum (12 mmHg).Clinicaltrials.gov identifier: NCT01722097.

INTRODUCTION AND OBJECTIVE:Laparoscopic and robotic surgery have revolutionized post-operative outcomes across surgical specialties. However, the use of pneumoperitoneum comes with known risks give...

Low-impact laparoscopic (LIL) cholecystectomy is an innovative surgical protocol that combines the use of mini-laparoscopic instruments (3-mm ports) under a low- and stable-pressure pneumoperitoneum (8 mmHg), with the aim of minimizing the surgical invasiveness and the risks related to CO2 insufflation on the peritoneal environment. In day-surgery settings, LIL may contribute to increase the surgical success due to several potential benefits in terms of postoperative pain intensity and time to full recovery. In 14 consecutive patients requiring cholecystectomy for uncomplicated cholelithiasis, LIL was carried out uneventfully. No conversion, intra-operative or postoperative complications occurred. All patients were discharged the same day of surgery. Postoperative pain was well tolerated with no need of prolonged opioid therapy. Technical aspects and indications for LIL cholecystectomy are detailed.

Contains fulltext : 171946.pdf (Publisher’s version ) (Closed access) 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.

Limited studies examined the effects of pneumoperitoneum during robot-assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45 degrees, proving how the combination of steep Trendelenburg, lower pressure pneumoperitoneum and the extreme surgeon's experience allows to safely perform RARP using a low-impact surgery. Background: Limited studies examined effects of pneumoperiotneum during robot-assisted radical prostatectomy (RARP) and with AirSeal. The aim of this study was to assess the effect on hemodynamics of a lower pressure pneumoperitoneum (8 mmHg) with AirSeal, during RARP in steep Trendelenburg 45 degrees (ST). Materials and Methods: This is an institutional review board-approved, prospective, interventional, single-center study including patients treated with RARP at OLV Hospital by one extremely experienced surgeon (July 2015-February 2016). Intraoperative monitoring included: arterial pressure, central venous pressure, cardiac output, heart rate, stroke volume, systemic vascular resistance, intrathoracic pressure, airways pressures, left ventricular end-diastolic and end-systolic areas/volumes and ejection fraction, by transesophageal echocardiography, an esophageal catheter, and FloTrac/Vigileo system. Measurements were performed after induction of anesthesia with patient in horizontal (T0), 5 minutes after 8 mmHg pneumoperitoneum (TP), 5 minutes after ST (TT1) and every 30 minutes thereafter until the end of surgery (TH). Parameters modification at the prespecified times was assessed by Wilcoxon and Friedman tests, as appropriate. All analyses were performed by SPSS v. 23.0. Results: A total of 53 consecutive patients were enrolled. The mean patients age was 62.6 +/- 6.9 years. Comorbidity was relatively limited (51% with Charlson Comorbidity Index as low as 0). Despite the ST, working always at 8 mmHg with AirSeal, only central venous pressure and mean airways pressure showed a statistically significant variation during the operative time. Although other significant hemodynamic/respiratory changes were observed adding pneumoperitoneum and then ST, all variables remained always within limits safely manageable by anesthesiologists. Conclusion: The combination of ST, lower pressure pneumoperitoneum and extreme surgeon's experience enables to safely perform RARP. (C) 2017 Elsevier Inc. All rights reserved.

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.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.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.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.CTRI/2016/02/006590.

Background: With the establishment of laparoscopic cholecystectomy as gold standard for management of cholelithiasis, the current stress is on increasing patient safety. Hence, this study was undertaken to compare the effect of low pressure pneumoperitoneum (LPP 14mm Hg) in a prospective randomized manner on intraoperative safety, assessing the working space and safety by seeing contact of parietal peritoneum to underlying viscera during secondary port insertion.Methods: 120 patients undergoing laparoscopic cholecystectomy were randomized into the LPP (14mm Hg) group (n=60) prospectively. Available working space assessed directly, safety by contact of parietal peritoneum to underlying viscera during secondary port insertion and operative difficulty assessed by visualization, dissection and grasping, total duration of surgery; intra-operative gas consumption, and bile spillage were assessed.Results: There was no significant difference in terms of available working space, operative duration, consumption of carbon dioxide, surgeon’s operative difficulty and intraoperative bile spillage. Out of 180 secondary ports inserted, there was evident contact of 20 (11.1%) secondary ports in high pressure groups and 14 (7.7%) secondary ports in low pressure group, which is suggestive of adequate exposure and working space available for surgery at both pressures.Conclusions: Low-pressure cholecystectomy did not compromise intraoperative safety and should be the standard of care in day care surgery.

This paper describe a case of hereditary spherocytosis in a child who required laparoscopic splenectomy. A 3-year-old female child, who had been diagnosed as having hereditary spherocytosis with splenomegaly, underwent a laparoscopic splenecotmy. The patient was placed in a complete decubitus position. The table was flexed to separate the left subcostal margin and iliac crest. A 4-mm laparoscope and other instruments required for 3-mm trocar were used. Good exposure of the laparoscopic visual field was obtained under 6-8mmHg low pressure pneumoperitoneum which was established to secure the laparoscopic visual field. There were no anesthetic complications even though there was continual air leakage observed during the pneumoperitoneum due to a lack of a cuff trachea tube. Hemodynamics, end-tidal CO2, and transcutaneous O2 saturation were carefully monitored during the operation, especially as the patient in this case was a child. The endoscopic linear stapler was applied across the splenic hilum, and the stumps of the splenic hilar vessels were additionally ligated by endoloop. Specimen extraction was performed by placing the spleen in a nylon bag for instrumental splenic fragmentation with a morecerator. The operating time was 176min, and postoperative hospital stay was 9 days. Laparoscopic splenectomy in children is considered to be a safe and effective extension of minimally invasive surgery.

Background. The purpose of this study was to determine the effect of pneumoperitoneum on the implantation of tumor at trocar sites. Methods. GW-39 human colon cancer cell suspension (0.5 ml of 2.5% rmvv) was injected into the peritoneal cavity of golden Syrian hamsters through a 1 cm midline incision. Four 5 mm trocars were inserted through the anterior abdominal wall, and the midline incision was then closed. The animals were randomized to receive pneumoperitoneum (n = 62) or no pneumoperitoneum (n = 60) for 10 minutes. Tumor implantations at trocar sites and midline wound incisions were documented grossly and histologically 8 weeks later. Results. Tumor was identified in 86% (49 of 57) of control animals and 95% (52 of 55) of the experimental group (p = 0.20). Implants increased with pneumoperitoneum at the midline incision from 44% to 71% (p < 0.01) and at trocar sites from 41% to 64% (p < 0.00001). Conclusions. Pneumoperitoneum significantly increased tumor implantation at trocar sites and midline incisions.

Contains fulltext : 118759.pdf (Publisher’s version ) (Closed access) Nowadays, laparoscopic donor nephrectomy (LDN) has become the gold standard to procure live donor kidneys. As the relationship between donor and recipient loosens, it becomes of even greater importance to optimize safety and comfort of the surgical procedure. Low-pressure pneumoperitoneum has been shown to reduce pain scores after laparoscopic cholecystectomy. Live kidney donors may also benefit from the use of low pressure during LDN. To evaluate feasibility and efficacy to reduce post-operative pain, we performed a randomized blinded study. Twenty donors were randomly assigned to standard (14 mmHg) or low (7 mmHg) pressure during LDN. One conversion from low to standard pressure was indicated by protocol due to lack of progression. Intention-to-treat analysis showed that low pressure resulted in a significantly longer skin-to-skin time (149 +/- 86 vs. 111 +/- 19 min), higher urine output during pneumoperitoneum (23 +/- 35 vs. 11 +/- 20 mL/h), lower cumulative overall pain score after 72 h (9.4 +/- 3.2 vs. 13.5 +/- 4.5), lower deep intra-abdominal pain score (11 +/- 3.3 vs. 7.5 +/- 3.1), and a lower cumulative overall referred pain score (1.8 +/- 1.9 vs. 4.2 +/- 3). Donor serum creatinine levels, complications, and quality of life dimensions were not significantly different. Our data show that low-pressure pneumoperitoneum during LDN is feasible and may contribute to increase live donors' comfort during the early post-operative phase.

The aim of this study was to compare changes in the systemic inflammation and immune response in the early postoperative (p.o.) period after laparoscopic Nissen fundoplication (LNF) was performed with standard-pressure and low-pressure carbon dioxide pneumoperitoneum.We studied 68 patients with documented gastroesophageal reflux disease and who underwent a LNF: 35 using standard-pressure (12 to 14 mmHg) and 33 low-pressure (6 to 8 mmHg) pneumoperitoneum. White blood cells, peripheral lymphocytes subpopulation, human leukocyte antigen-DR, neutrophil elastase, interleukin (IL)-6 and IL-1, and C-reactive protein were investigated.A significantly higher concentration of neutrophil elastase, IL-6 and IL-1, and C-reactive protein was detected postoperatively in the standard-pressure group of patients in comparison with the low-pressure group (P0.05). A statistically significant change in human leukocyte antigen-DR expression was recorded p.o. at 24 hours, as a reduction of this antigen expressed on monocyte surface in patients from standard group; no changes were noted in low-pressure group patients (P0.05).This study demonstrated that reducing the pressure of the pneumoperitoneum to 6 to 8 mm Hg during LNF is reduced p.o. inflammatory response and avoided p.o. immunosuppression.

Since April 1991, we have studied 160 patients who had had a successful laparoscopic cholecystectomy. Nine patients who presented with chronic cholecystitis with severe local adhesion and who were also considered to require a longer operative time were selected as suitable candidates for this procedure. They were successfully treated under a zero- to four-mmHg low-pressured pneumoperitoneum procedure combined with total abdominal wall lifting using a disposable, flexible vinyl tube retractor. This method enabled exactly the same clear laparoscopic vision as is possible in the routinely-used high-pressure pneumoperitoneum even in the marginal portions of the abdominal cavity. Moreover, it facilitated early reinsufflation after the cauterization-produced smoke was exhausted, which minimized the operative time and reduced the surgeon's anxiety concerning the maintenance of a sufficiently airtight condition. We believe that this low-pressure pneumopeqitoneum procedure also benefits the poor-risk patient who has restricted cardiopulmonary function, especially during advanced laparoscopic surgery which requires a longer operative and anesthetic time.

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.

CLINICAL BOTTOM LINE For keyhole removal of the gallbladder, an inert gas, usually carbon dioxide, is injected into the abdomen. Generally, a pressure of 12 mm Hg to 16 mm Hg is used for surgery. During insufflation of the abdomen, several physiological parameters change related to the heart and lung. Lowering the pressure might decrease cardiopulmonary complications and reduce postoperative pain; however, lower pressure may not provide a clear surgical field, which presents safety concerns. Although a clear surgical field is of importance during the surgical procedure, reduced cardiopulmonary complications, as well as reduced postoperative pain, use of analgesics, and shoulder pain will all be important during the perioperative period; recovery; and later, when the patient is at home. A systematic review was undertaken to determine whether there were any differences in the effects of using low pressure pneumoperitoneum compared with standard pressure pneumoperitoneum in patients undergoing laparoscopic cholecystectomy.