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Abdominal lift for laparoscopic cholecystectomy

  1. Kurinchi Selvan Gurusamy*,
  2. Rahul Koti,
  3. Brian R Davidson

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 31 AUG 2013

Assessed as up-to-date: 19 FEB 2013

DOI: 10.1002/14651858.CD006574.pub4


How to Cite

Gurusamy KS, Koti R, Davidson BR. Abdominal lift for laparoscopic cholecystectomy. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD006574. DOI: 10.1002/14651858.CD006574.pub4.

Author Information

  1. Royal Free Campus, UCL Medical School, Department of Surgery, London, UK

*Kurinchi Selvan Gurusamy, Department of Surgery, Royal Free Campus, UCL Medical School, Royal Free Hospital,, Rowland Hill Street, London, NW3 2PF, UK. kurinchi2k@hotmail.com.

Publication History

  1. Publication Status: New search for studies and content updated (conclusions changed)
  2. Published Online: 31 AUG 2013

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary

Background

Laparoscopic cholecystectomy (key-hole removal of the gallbladder) is now the most often used method for treatment of symptomatic gallstones. Several cardiopulmonary changes (decreased cardiac output, pulmonary compliance, and increased peak airway pressure) occur during pneumoperitoneum, which is now introduced to allow laparoscopic cholecystectomy. These cardiopulmonary 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 (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, and Science Citation Index Expanded until February 2013.

Selection criteria

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

Data collection and analysis

We calculated the risk ratio (RR), rate ratio (RaR), or mean difference (MD) with 95% confidence intervals (CI) based on intention-to-treat analysis with both the fixed-effect and the random-effects models using the Review Manager (RevMan) software.

Main results

For abdominal wall lift with pneumoperitoneum versus pneumoperitoneum, a total of 130 participants (all with low anaesthetic risk) scheduled for elective laparoscopic cholecystectomy were randomised in five trials to abdominal wall lift with pneumoperitoneum (n = 53) versus pneumoperitoneum only (n = 52). One trial which included 25 people did not state the number of participants in each group. All five trials had a high risk of bias. There was no mortality or conversion to open cholecystectomy in any of the participants in the trials that reported these outcomes. There was no significant difference in the rate of serious adverse events between the two groups (two trials; 2/29 events (0.069 events per person) versus 2/29 events (0.069 events per person); rate ratio 1.00; 95% CI 0.17 to 5.77). None of the trials reported quality of life, the proportion of people discharged as day-patient laparoscopic cholecystectomies, or pain between four and eight hours after the operation. There was no significant difference in the operating time between the two groups (four trials; 53 participants versus 54 participants; 13.39 minutes longer (95% CI 2.73 less to 29.51 minutes longer) in the abdominal wall lift with pneumoperitoneum group and 100 minutes in the pneumoperitoneum group).

For abdominal wall lift versus pneumoperitoneum, a total of 774 participants (the majority with low anaesthetic risk) scheduled for elective laparoscopic cholecystectomy were randomised in 18 trials to abdominal wall lift without pneumoperitoneum (n = 332) versus pneumoperitoneum (n = 358). One trial which included 84 people did not state the number in each group. All the trials had a high risk of bias. There was no mortality in any of the trials that reported this outcome. There was no significant difference in the proportion of participants with serious adverse events (six trials; 5/172 (weighted proportion 2.4%) versus 2/171 (1.2%); RR 2.01; 95% CI 0.52 to 7.80). There was no significant difference in the rate of serious adverse events between the two groups (three trials; 5/99 events (weighted number of events per person = 0.346 events) versus 2/99 events (0.020 events per person); rate ratio 1.73; 95% CI 0.35 to 8.61). None of the trials reported quality of life or pain between four and eight hours after the operation. There was no significant difference in the proportion of people who underwent conversion to open cholecystectomy (11 trials; 5/225 (weighted proportion 2.3%) versus 7/235 (3.0%); RR 0.76; 95% CI 0.26 to 2.21). The operating time was significantly longer in the abdominal wall lift group than in the pneumoperitoneum group (16 trials; 6.87 minutes longer (95% CI 4.74 minutes to 9.00 minutes longer) in the abdominal wall lift group versus 75 minutes in the pneumoperitoneum group). There was no significant difference in the proportion of people discharged as laparoscopic cholecystectomy day-patients (two trials; 15/31 (weighted proportion 48.5%) versus 9/31 (29%); RR 1.67; 95% CI 0.85 to 3.26).

Authors' conclusions

Abdominal wall lift with or without pneumoperitoneum does not seem to offer an advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in people with low anaesthetic risk. Hence it cannot be recommended routinely. The safety of abdominal wall lift is yet to be established. More research on the topic is needed because of the risk of bias in the included trials and because of the risk of type I and type II random errors due to the few participants included in the trials. Future trials should include people at higher anaesthetic risk. Furthermore, such trials should include blinded assessment of outcomes.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary

Abdominal wall lift for people undergoing gallbladder removal by a key-hole operation

Key-hole removal of the gallbladder (laparoscopic cholecystectomy) is currently the preferred treatment for people with symptoms related to gallstones in the gallbladder. This is generally performed by distending the tummy (abdomen) using carbon dioxide gas (pneumoperitoneum) so that there is adequate space for instruments and to visualise the structures within the abdomen. This enables the surgeons to identify and divide the appropriate structures. However, distending the abdominal wall can result in various physiological changes that affect the functioning of the heart or lungs. These changes are more pronounced at higher pressures of the gas used to distend the abdomen. They are generally tolerated well in people with a low risk of anaesthetic problems. However, those with pre-existing illnesses may not tolerate this distension of the abdomen well. So, an alternate method of enabling the surgeons to visualise the structures in the abdomen and to use instruments by lifting up the abdominal wall using special devices (abdominal wall lift) has been suggested for people undergoing laparoscopic cholecystectomy. We reviewed all the relevant information from randomised trials (a type of study which provides the best information on whether one treatment is better than the other, if conducted properly) in the literature to find out if abdominal wall lift is better than distending the abdomen using carbon dioxide gas. We adopted methods to identify all the possible studies and used methods that decrease the errors in data collection.

Abdominal wall lift with pneumoperitoneum versus pneumoperitoneum
A total of 130 participants (all with low anaesthetic risk) were included in five trials which compared abdominal wall lift combined with very low pressure pneumoperitoneum and standard pneumoperitoneum. All five trials had a high risk of bias (introducing the possibility of overestimating benefits or underestimating the harms of abdominal wall lift). No-one died as a result of surgery. There was no significant difference in the rate of serious complications related to the surgery. None of the trials reported quality of life, the proportion of people discharged as laparoscopic cholecystectomy day-patients, or pain between four and eight hours after the operation. None required conversion of key-hole surgery to an open operation using a larger incision. There was no significant difference in the operating time between the two groups.

Abdominal wall lift versus pneumoperitoneum
A total of 774 participants (the majority with low anaesthetic risk) who underwent planned laparoscopic cholecystectomy were included in 18 trials which compared abdominal wall lift and standard pneumoperitoneum. All the trials had a high risk of bias. No-one died as a result of the surgery. There was no significant difference in the rate of serious complications related to surgery. None of the trials reported quality of life or pain between four and eight hours after the operation. There was no significant difference in the rate of serious adverse events, the proportion of people who underwent an open operation using a larger incision, or the proportion discharged on the same day of surgery. The operating time was about seven minutes longer on average if the operation was performed using abdominal wall lift rather than pneumoperitoneum.

In summary, abdominal wall lift does not seem to offer an advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in people with low anaesthetic risk. Abdominal wall lift may increase costs by increasing the operating time. Hence it cannot be recommended routinely. The safety of abdominal wall lift is yet to be established. More randomised clinical trials on the topic are needed since the possibility of arriving at erroneous conclusions due to bias and due to the play of chance was high because of the design of the trials. Future trials should include people at high risk during anaesthesia. Furthermore, such trials should employ blinded assessments of outcome measures.