Authors: Denise M D Özdemirvan Brunschot Kees C J H M van Laarhoven GertJan Scheffer Sjaak Pouwels Kim E Wever Michiel C Warlé
Publish Date: 2015/08/15
Volume: 30, Issue: 5, Pages: 2049-2065
Abstract
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 standardpressure pneumoperitoneumQuality assessment showed that the overall quality of evidence was moderate to low Postoperative pain scores were reduced by the use of lowpressure pneumoperitoneum With appropriate perioperative measures the use of lowpressure pneumoperitoneum does not seem to have clinical advantages as compared to standard pressure on cardiac and pulmonary function Although there are indications that lowpressure pneumoperitoneum is associated with less liver and kidney injury when compared to standardpressure pneumoperitoneum this does not seem to have clinical implications for healthy individuals The influence of lowpressure 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 lowpressure 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 lowpressure 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 lowpressure pneumoperitoneum during laparoscopy is weak and more studies are requiredBased on experiments in dogs by Georg Kelling Hans Christian Jacobaeus was the first to perform a laparoscopic procedure in humans in 1910 1 2 Insufflation of air into the peritoneal cavity created working space between the abdominal wall and the intraabdominal organs Until the 1960s the physiological consequences of increased intraabdominal pressure by gas insufflation were poorly understood In 1966 Kurt Semm introduced an automatic insufflation device capable of monitoring intraabdominal pressure thereby improving the safety of laparoscopy 3 Today intraabdominal pressure is traditionally set at a routine pressure of 12–15 mmHg 4 Bearing in mind the potential negative impact of pneumoperitoneum PNP on cardiopulmonary function and the positive impact on postoperative pain international guidelines recommend that the use of “the lowest intraabdominal pressure allowing adequate exposure of the operative field rather than a routine pressure” should be used 5 In literature lowpressure PNP is generally defined as an intraabdominal pressure of 6–10 mmHg 6 7 8 9 However in daily clinical practice usually the intraabdominal pressure is set at 12–14 mmHg and for gynecological laparoscopic procedures sometimes even higher pressures are used In this systematic review we will address the risks and benefits of low versus standardpressure PNP
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