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February 1998
A Comparison of Gasless Mechanical and Conventional Carbon Dioxide Pneumoperitoneum Methods for Laparoscopic Cholecystectomy.
Kiovusalo AM, Kellokumpu I, Scheinin M, Tikkanen I,M�kisalo K, Lindgren L;Anesth Analg 1998; 86: 153-8.
[ see abstract below ]
The laparoscopic approach to cholecystectomy is often chosen for patients in poorer physical condition because they may not be able to tolerate the "stresses" of cholecystectomy by laparotomy. What is generally not widely appreciated is that the conventional laparoscopic approach to
cholecystectomy achieved with carbon dioxide pneumoperitoneum is associated with significant physiologic disturbances.
CO2 is absorbed into the circulation resulting in hypercarbia and respiratory acidosis, which can be treated by increased minute volumes of ventilation. Pneumoperitoneum causes intraabdominal distention, increased intraabdominal pressure and decreased pulmonary dynamic compliance. The combination of low compliance with increased volume of ventilation may result in increased peak airway pressures. Furthermore, decreased urine output has been reported during laparoscopic procedures. This may be related to increased concentrations of plasma renin activity resuslting from increased intraabdominal pressure and compression of renal vessels. The use of room temperature CO2 contributes to patient cooling, with peripheral vasoconstriction and potential postoperative shivering.
Because of this list of detrimental effects, an alternative to conventional pressure pneumoperitoneum (CPP) may be of interest. These authors studied 26 consecutive ASA 1 or 2 patients undergoing elective laparoscopic cholecystectomy. They were randomly assigned to either a technique using CPP with intra-abdominal pressure 12 to 13 mm or to a technique which used a mechanical retractor to elevate the abdominal wall upward by 10 to 15 cm with a force of 12-15 ug/kg. No CO2 was used in the
retractor group, and one surgeon performed all operations. Anesthesia for all patients consisted of propofol induction with alfentanil boluses before induction and before incision, and maintenance with desflurane, alfentanil infusion, oxygen and atracurium. The two patient groups were comparable in
age, weight, ASA physical status and use of intraoperative fluids.
Arterial blood pressure increased significantly in the CPP group during the first 15 minutes of insufflation but remained at baseline levels in the retractor group. Heart rate response was also more marked in the CPP group. CVP was found to increase by 146% in the CPP group during the
first 5 minutes of insufflation but remained at baseline in the retractor group. CVP was significantly higher in the CPP group throughout the operation and until one hour postoperatively.
Minute volume ventilation needed to be increased during the first 15 minutes in CPP group to maintain
normal carbia; no changes required in the retractor group pulmonary dynamic decreased significantly in the first 5 minutes of insufflation in the CPP group remained at that level throughout the operation and returned to baseline at deflation: there were no changes in pulmonary compliance in the
retractor group. Urine output within the first 30 minutes of the operation was 0.38 + 0.71 ml/kg in CPP and 1.14 + 0.92 ml/kg in the retractor group 11 patients in CPP and 4 in retractor group required manitol to maintain the urinary output criterion of 1 ml/kg/hr.
Plasma renid activity concentrations increased significantly only in the CPP group beginning in the first 15 minutes of insufflation and staying at that level throughout the operation. Norepinephrine concentrations increased significantly in both groups. The increases in norepinephrine and epinephrine concentrations were small, which maybe related to the opioid based anesthesia which was used. Core temperatures decreased in the CPP group and remained baseline in the retractor group.
Summarizing these results, retractor-facilitated laparoscopic cholecystectomy was found to cause significantly less physiologic perturbation as assessed by these multiple factors. Why is it not more widely used? The authors suggest that it takes experience to obtain a clear view with the gasless technique. This may result in somewhat longer operation times, as in this study: 85 + 25 minutes in CPP vs 108 + 28 minutes in retractor group. Perhaps this technique can be used in patients who are at risk to suffer adverse events associated with CO2 inflation, such as patients with cardiac, pulmonary and renal diseases. Certainly this study will remind us to reeducate our surgeons about the physiologic hazards of the conventional CO2 laparoscopic cholecystectomy approach.
Return to the Current Literature Review Front Page, or read the abstract:
ABSTRACT
Carbon dioxide (CO2) insufflation with increased intrabdominal pressure (IAP) has adverse hemodynamic, pulmonary, and renal effects. To avoid these problems, an abdominal wall lift method with a retractor was used to provide the surgical view without CO2 insufflation.
Twenty-six patients undergoing elective laparscopic cholecystectomy were randomly allocated to either the gasless, retractor group, or conventional CO2 pneumoperitoneum group (CPP). Hemodynamic data, ventilatory variables, urine output, urine oxygen tension, and blood samples for determining stress hormones were collected throughout the perioperative period.
Patients in the retractor group had lower mean arterial pressure, heart rate, and central venous pressure (P < 0.001). They also had higher pulmonary dynamic compliance and needed a lower minute volume of ventilation to achieve normocarbia (P < 0.001). Urine output and oxygen tension in urine were higher (P < 0.05) with the retractor method than with CPP. Increase in plasma renin activity (P < 0.05) and decrease in core temperature (P < 0.001) were smaller with the gasless method than with CPP.
The gasless method for laparscopic cholecystectomy might be beneficial, especially in patients with compromised cardiorespiratory or renal function.
Implications: Totally gasless laparscopic cholecystectomy was compared with conventional pressure pneumoperitoneum with CO2 insufflation. The gasless method resulted in more stable hemodynamics and pulmonary function, as well as higher urine, output than conventional pressure pneumoperitoneum. No changes in renal oxygenation was seen with the gasless method, compared with conventional pressure pneumoperitoneum.
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