Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy

  • Review
  • Intervention

Authors

  • Kurinchi Selvan Gurusamy,

    Corresponding author
    1. Royal Free Hospital and University College School of Medicine, University Department of Surgery, London, UK
    • Kurinchi Selvan Gurusamy, University Department of Surgery, Royal Free Hospital and University College School of Medicine, 9th Floor, Royal Free Hospital, Pond Street, London, NW3 2QG, UK. kurinchi2k@hotmail.com.

    Search for more papers by this author
  • Kumarakrishnan Samraj,

    1. John Radcliffe Hospital, Department of General Surgery, Oxford, UK
    Search for more papers by this author
  • Brian R Davidson

    1. Royal Free Hospital and University College School of Medicine, University Department of Surgery, London, UK
    Search for more papers by this author

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.

摘要

背景

比較使用低壓和標準壓氣腹術於腹腔鏡膽囊切除術

腹腔鏡膽囊切除術一般使用的腹腔充氣壓力為12 16 mmHg之間。有人宣稱低壓可以安全有效的減少心肺併發症和疼痛。

目標

評估低壓氣腹對照標準壓氣腹用於接受腹腔鏡膽囊切除術病人的利弊。

搜尋策略

我們搜尋截至2008年11月的The Cochrane HepatoBiliary Group Controlled Trials Register, The Cochrane Library的Cochrane Central Register of Controlled Trials (CENTRAL)、 MEDLINE、EMBASE和ience Citation Index Expanded,利用搜尋策略以找出為隨機試驗。

選擇標準

本次文獻回顧只考慮隨機臨床試驗,不受語言、盲法或發表狀況的限制。

資料收集與分析

兩位作者獨立確定試驗,獨立摘錄有關死亡率、發病率、轉為開腹膽囊切除術、疼痛、止痛要求,手術時間,、住院天數、病人滿意度,內視鏡視野的額外措施和心肺參數等資料。我們以能獲得的個案分析為基礎,使用RevMan 5以固定效果模式和隨機效果模式分析,計算風險比率 (RR) ,平均差(MD),標準平均差(SMD),及其95% 信賴區間(CI)。

主要結論

共有15個隨機試驗,690 位病人參與,低壓組(n = 336)和標準壓組 (n = 354)。 所有試驗具有較高的偏誤風險。 2組在死亡率、發病率、或轉為開腹膽囊切除術等方面沒有顯著差異。在不同時間點,低壓組的疼痛強度較低。低壓組的肩膀疼痛的發生率較低 (RR 0.53; 95% CI 0.31 0.90)。止痛藥消耗量也較低。2組的手術時間相似(MD 2.30 分鐘 95% CI 0.42 4.18)。 由於7個試驗的結果資料不完整,導致偏誤風險較高,所以我們無法對低壓腹部充氣的安全性做出總結。

作者結論

低壓氣腹似乎有效減輕腹腔鏡膽囊切除術後的疼痛,低壓腹部充氣的安全性仍然需要被驗證。

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

至於鎖孔摘除膽囊為了經由鑰匙孔大小,需要在腹腔內注射二氧化碳。手術一般使用壓力為12 16 mmHg之間。腹腔充氣時會出現幾種和心肺有關的生理參數的變化。正常人可以忍受這些變化,但是心肺功能較弱的病人無法忍受這些變化。降低充入氣體的壓力則可能會降低外科醫生觀察手術區域的能力。本次系統性文獻回顧一共有 15個隨機試驗,共690位病人低壓組(n = 336)和標準壓組 (n = 354)。所有試驗具有較高的偏誤風險。2組在死亡率、術後併發症、或轉為開腹膽囊切除術等方面沒有顯著差異。在各個時間點,低壓組的疼痛強度較低。低壓組的肩膀疼痛的發生率較低。止痛劑消耗量也較低。2組的手術時間沒有差異。因為沒有從7個試驗中獲取和病人相關的資料,我們無法對低壓氣腹的安全性做出總結。總之,低壓氣腹似乎可以減輕腹腔鏡膽囊切除術後的疼痛,但安全性仍需要被驗證。

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.

Ancillary