Abdominal lift for laparoscopic cholecystectomy

  • Review
  • Intervention

Authors


Abstract

Background

Laparoscopic cholecystectomy is the main method of treatment of symptomatic gallstones. Several cardiopulmonary changes (decreased cardiac output, pulmonary compliance, and increased peak airway pressure) occur during pneumoperitoneum. These changes may not be tolerated in individuals with poor cardiopulmonary reserve.

Objectives

To assess the benefits and harms of abdominal wall lift compared to 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 in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until January 2007.

Selection criteria

We included all randomised clinical trials comparing abdominal wall lift (with or without pneumoperitoneum) and pneumoperitoneum.

Data collection and analysis

We calculated the relative risk (RR), weighted mean difference (WMD) or standardised mean difference (SMD) with 95% confidence intervals (CI) based on intention-to-treat analysis with both the fixed-effect and the random-effects model using RevMan Analysis.

Main results

Abdominal wall lift with pneumoperitoneum versus pneumoperitoneum
A total of 156 participants (all with low anaesthetic risk) who underwent elective laparoscopic cholecystectomy were randomised in six trials to abdominal wall lift with pneumoperitoneum (n = 65) versus pneumoperitoneum only (n = 66). One trial which included 25 patients did not state the number of patients in each group. All six trials were of high risk of bias. The cardiopulmonary changes were less in abdominal wall lift than pneumoperitoneum. There was no difference in the morbidity and pain between the groups.

Abdominal wall lift versus pneumoperitoneum
A total of 550 participants (the majority with low anaesthetic risk) who underwent elective laparoscopic cholecystectomy were randomised in fourteen trials to abdominal wall lift without pneumoperitoneum (n = 268) versus pneumoperitoneum (n = 282). Two of these fourteen trials were of low risk of bias. The cardiopulmonary changes were less in abdominal wall lift than with pneumoperitoneum. There was no difference in the morbidity and pain between the groups. The operating time was prolonged in abdominal wall lift compared with pneumoperitoneum (WMD 7.74, 95% CI 1.37 to 14.12).

Authors' conclusions

1. Abdominal wall lift seems safe and decreases the cardiopulmonary changes associated with laparoscopic cholecystectomy.

2. Abdominal wall lift does not seem to offer advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in patients with low anaesthetic risk and may increase costs by increasing the operating time. Hence it cannot be recommended routinely. More research on the topic is needed.

Plain language summary

Abdominal wall lift decreases cardiopulmonary changes, does not influence the morbidity and, increases operating time in laparoscopic cholecystectomy. It cannot be recommended routinely

Several physiological parameters related to heart and lung (cardiopulmonary changes) occur during insufflation of abdomen (tummy) with key-hole surgery. While these changes can be tolerated by normal individuals, patients with poor heart or lung function may not tolerate the changes. These changes in physiological parameters related to heart and lung are decreased by using special instruments to lift the front wall of the abdomen so that key-hole surgery can be performed without gas insufflation. In this systematic review of 20 trials including 706 patients (six trials including 156 patients used gas at very low pressures), it is shown that the technique of lifting the front wall of the tummy is associated with increased operating time (8 minutes) without reducing surgical complications. It cannot be recommended as a routine in patients with mild or no systemic disease. So, it cannot be recommended routinely in patients with low anaesthetic risk.

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