Comparative Evaluation of High Pressure Carbon Dioxide with Low Pressurecarbon Dioxide for Hemodynamic Changes and Pain Symptoms
Inlaparoscopic Cholecystectomy
M Sandeep raj, Biren Prasad Padhy*, Jamohan Mishra
DepartmentofSurgery,IMSandSUMHospital, SOA deemed to be University Bhubaneswar, Orissa,India
Corresponding Author
Biren Prasad Padhy, DepartmentofSurgery,IMSandSUMHospital, SOA deemed to be University Bhubaneswar, Orissa,India
Email id- [email protected]
Abstract
Introduction: Hemodynamic changes and pain symptoms are influenced byvolume and pressure of CO2 in laparoscopic cholecystectomy (LC). The studyaimed to compare the above parameters in the low pressure (<8mm Hg) andstandard pressure (12-14mmHg)LC.
Methods:Arandomised,doubleblindstudywasdoneon80patientscategorised into 2 groups.Group A encompassed patients undergoing Lowpressure LC (<8mm Hg). In group B, Standard pressure LC (12-14mmHg) wasdone. Blood pressure, liver enzymes and pain was assessed in different timeintervals.SPSS21wasused toanalyse thedata.
Results: Difference in both systolic and diastolic pressure of Group A andGroup B was seen to be statistically significant. ALP was the only liver enzymeshowed significant difference between the groups at p =0.032. Abdominal andshoulder tip pain exhibited significant difference amongst the group even at 24hours atpvalue at0.037and0.027respectively.
Conclusions:Itconcludesthat lower pressure pneumoperitoneumseemstohave significant effects
on blood pressure; both systolic and diastolic,
liverenzymesandshoulderpainascomparedtostandardpressurepneumoperitoneuminpatients undergoingLC.
Keywords:LaparoscopicCholecystectomy,Pneumoperitoneum,CO2pressure,systolicbloodpress ure,diastolicbloodpressure.
Introduction
Carbondioxide(Co2)atacertainpressureisutilisedtoenablebettervisualisation in laproscopic cholecystectomy (LC).Off late, gall stones are awidely encountered condition in the biliary tract, with a prevalence of 10% Cholecystectomy was the commonly employed conventional surgical procedureto treat gallstone.1,2 Now a days, LC is regarded as thestandard technique totreat3. Initially proposed by Dubois in 1988, it has now evolved into the moreadvancedformwiththeaidofmonitorsandvideosystem.Itisthemostcommonly employed technique by surgeons and has also demonstrated patientcompliance.
LC offers the advantage of shorter healing time, small sized cuts, reduced postsurgical torment and faster recovery to normal physical activities. To ensurebetter outcomes, surgical area has to
be clearly seen during the procedure4.Pneumoperitoneum is the adapted strategy to achieve this
effect, where in
CO2diffusestheperitoneumwhilemaintainingsteadypressure.Theportsareevacuated under thesame pressure5.
The standard pressure levels employed in creation of peritoneum is 12 – 14 mmHg. But is correlated with complications arising due to reverse trendelenburgposition and carbon– di –
oxide transmission to peritoneum such as
reductionoflungcapacity,arterialbloodgasesconcentrationalteration,hemodynamicsideeffects,alte redliverenzymesandrenalcompromise6,7.Inordertoovercome these difficulties, pressure is lowered to 7- 10 mm Hg as against theconventional level. This has showed better results in
elderly patients and
thosewithcompromisedcardiovascularorrespiratoryconditions8.But,thiscompromises the clear vision of LC site. Hence, this comparative study wasconducted to evaluate hemodynamic changes and abdominal pain in high andlow pressure Co2 amongstpatientsundergoing L
MaterialsandMethods:
Studydesignandconsent:Thepresentstudyemployedaconcurrentrandomised parallel design, double blinded clinical trial conducted on 80 casesin IMS and SUM hospital. The study was
conducted from August
2018toAugust2020.Informedconsentofallparticipantswereobtained,afterexplaining the risks and benefits of the study. Institutional ethical clearance wasobtainedfromtheparentinstitution inwhich thestudywas conducted.
Eligibility criteria: Patients in the age range of 20 – 70 years, including bothgenders were recruited based on eligibility criteria. Consenting patients withsymptomaticcholelithiasiswereincluded.Patientpresentingwithrippedgallbladder,bileductsto nes,existingco-morbidities,previoushistoryofabdominal surgery, pregnant females, diagnosed malignancy, Body Mass Indexscore less than 19 or greater than 30, Grade 3 and Grade 4 levels of fatty liverwereexcluded.
Groups: Patients were categorised into two groups. Group A were patientsadministered with Co2 pressure of 7– 10 mm Hg and Group B with 12– 14mm Hg .
Procedure: A pre-surgical checkup and investigations was done in all patients.Surgical procedure of four port laproscopic cholecystectomy was performedunder general anesthesia.
The first port was constructed using the Veress needleunder 12 mm Hg pressure. In Group A pressure was lowered to 10 mm Hg andin Group B, it was elevated to 14 mmHg. Vitals of blood pressure and heartrate was constantly monitored. End tidal Co2 was recorded at predeterminedtime intervals of ; prior to Co2 insufflation, during insufflations, during surgery,at exsufflation and before anesthesia reversal. Diclofenac sodium (75mg IM)wasadministeredpostoperativelyforanalgesicpurpose.Subjectsweremotivatedtobegineatingaf ter 8post-operatively.
Outcome: Post –operative and Shoulder tip pain was evaluated by VisualAnalogue scores at time periods of 1, 3, 6, 12 and 24 hours. Liver enzyme andhemodynamicchangeswere also assessed.
Statisticalanalysis:DatawasanalysedusingSPSSversion21.0(IBM;Chicago). Chi square test and
independent t test was applied to test significantdifferences between the groups. P value of lesser than 0.5 was considered to bestatistically significant.
Results
The present study evaluated 80 patients undergoing LC. The mean age of GroupA and Group B patients were 42.79 + 2.24 and 44.08 + .97 respectively, with nosignificant difference between them at p =0.58.A clear female predilection wasnoted with88.33%inGroup A and 91.01%in Group Bpatients.
Comparative assessment of systolic blood pressure revealed a higher pressure inthe Group A cases at 1,3 and 6 hours post operatively,when charted againstGroup Bpatientsatp<0.001.(Table 1; Figure1and Figure2).
Liver function evaluation showed significant differences between preoperativeand postoperative time period in both groups. Intra group comparison showedsignificant differences, with ALT and AST reaching a remarkable higher scoresin the lower Co2 pressure group as compared to
high CO2 pressure. (Table
2).Whencomparingbetweenthetwogroups,onlyALPenzymeshowedsignificantdifferencebetweent hem (Table2a)
Both shoulder tip pain and abdominal pain was lesser in the lower CO2 pressuregroup.(Table 3). Long term complications was reported in neither of the groups.Overall, Group B exhibited better effectiveness in terms of blood pressure, liverenzymes andpainevaluation.
Table1:Comparativeevaluationof Bloodpressureforthe two groups
TimeIntervals Group A Group B P value
SystolicPressure Prior surgery – at admission
127.73 +1.63 121.54 +0.96 0.78(NS)
Duringsurgery 118.00 +1.07 116.07 +0.50 0.45(NS) 1hourpostsurgery 124.27 +0.95 112.87 +0.42 <0.001**
3hourpostsurgery 121.93 +0.69 109.13 +1.29 <0.001**
6hourpostsurgery 126.65 +0.58 110.56 +0.68 <0.001**
Diastolicpressure Prior surgery – at admission
77.61 +0.83 75.86 +0.68 0.10(NS)
Duringsurgery 75.90 +1.09 71.87 +0.55 0.64(NS)
1hourpostsurgery 73.14 +0.68 71.59 +0.49 <0.001**
3hourpostsurgery 72.77 +0.79 68.17+0.99 <0.001**
6hourpostsurgery 72.86 +1.02 67.10 +0.37 <0.001**
**=Highly significant;* =Significant; NS= NothingSignificant
Table2:Comparativeevaluation of LiverFunction tests forthetwogroups
Liver Function test
Group A Group B
Post- operative
Pre- operative
P value Post- operative
Pre- operative
P value
AST 39.6 +
12.1
23.7 +5.3 0.002* 46.8 + 31.04
22.3 +8.2 <0.001**
ALT 33.85 +
11.3
21.8 +9.6 0.02* 35.3 + 14.32
19.7 +8.9 <0.001**
ALP 176.01 +
63.3
182.01 + 59.8
0.73(NS) 156.49 + 59.71
171.8 + 61.32
<0.01*
BILLT 0.6 +0.3 0.7 +0.4 0.03* 0.71 + 0.01
0.57 + 0.47
0.02*
BILLD 0.4 +0.05 0.3 +0.05 0.02* 0.4 +0.15 0.34 + 0.12
0.01*
**=Highly significant;* =Significant; NS= NothingSignificant
Table2a:Comparativeevaluationofintergroupliverfunctiontestassessedpostoperatively
LiverFunctiontest GroupA GroupB Pvalue
AST 39.6 +12.1 46.8 +31.04 0.63(NS)
ALT 33.85 +11.3 35.3 +14.32 0.24(NS)
ALP 176.01 +63.3 156.49 +59.71 0.032*
BILLT 0.6 +0.3 0.71 +0.01 0.56(NS)
BILLD 0.4 +0.05 0.4 +0.15 0.79(NS)
**=Highlysignificant; *=Significant;NS =NothingSignificant
Table3:Comparativeevaluationof abdominalandshouldertippainbetweentwogroups
VASscore Group A Group B P value
Abdominalpain
1 hr 1.12+0.46 1.89 +0.30 0.04*
3 hr 1.48 +0.71 2.52 +0.07 0.03*
6 hr 2.93 +0.90 2.25+1.76 0.57(NS)
12 hr 2.20 +0.25 0.92 +0.36 <0.001**
80 78 76 74 72 70 68 66 64
GROUPA GROUPB
62
60 Priorsurgery–
During atadmission surgery
1hourpost 3hourpost 6 hour postsurgery surgery surgery 130
125
120
115
110
GROUPA GROUPB 105
100
95 Priorsurgery – atadmissi
on
During surgery
1hourpost 3hourpost 6 hourpost surgery surgery surgery
24 hr 5.03 +0.34 2.84 +0.45 0.037*
Shouldertippain
1 hr 0.91+0.68 1.52 +0.57 0.021*
3 hr 1.78 +0.50 2.21 +0.46 0.011*
6 hr 2.35 +0.56 1.95 +1.67 0.048*
12 hr 2.57 +0.69 0.76 +0.46 <0.001**
24 hr 4.68 +0.91 2.97 +0.84 0.027*
**=Highlysignificant; *=Significant;NS =NothingSignificant
Figure1:LinegraphforcomparativeevaluationofSystolicBloodpressurebetweenthegroups
Figure2:LinegraphforcomparativeevaluationofDiastolicBloodpressurebetweenthegroup s
Discussion:
LCdemonstratessustainedmaintenanceofbodyfunctionsasagainstopensurgrical procedure.
Advantages of reduced hospital stay, fewer post-
operativecomplicationincidencesanddecreasedtreatmentcost.Furthermore,painexperienced is of lower intensity in laparoscopic procedure. Laparoscopy iswidelyemployedintherecenttimes,withlaparoscopiccholecystectomyaccountingtoone8. Better visibility of the surgical site is of prime importance for obtaining bettersurgicaloutcomes.CO2isusedforbettersurgicalperformance,withitsconcentration directly
influencing the surgical site. Though higher
concentrationsuggestsbettervisualisation,itisalsoassociatedwithcertaincomplications9.
LC brings in potential changes in the hemodynamic system, such as alteredmean blood pressure and liver enzyme levels. Pathophysiological changes areprinicipallymanifestedinthecardiovascularsystembroughtaboutbyinsufflationsofCO210.Con sideringtheprobabilityofhemodynamicmodificationwhileCO2infsufflation,aneffortwasmadeto assessthedifferencebetweenlow andhigh pressurepneumoperitoneumforLC.
ThecurrentstudyshowedbothsystolicanddiastolicbloodpressurewerereportedtobehigherintheGr oupApatientsat1,3and6hours.A.R.Mohammadzade et al11 had similar findings with significant difference betweenhis 60 patients, with mean systolic BP having lower values in low pressuregroup,butwere not extendedtodiastolicbloodpressure.On thecontrary,Kanweret al12 demonstrated no significant differences in blood pressure in hispatients,administered with14 and 10mmHgof CO2pressure.
Liver enzymes increases in LC and is considered as one of the complications.Both the groups showed an enhanced enzyme level when compared pre and postoperatively.However,ALPwastheonlyenzymetohavesignificantdifference
between the high and low pressure groups. These were in concordance with thestudy of A. R.
Mohammadzadeet al11. Shoulder tip pain was remarkably lesserin the low pressure group in all time periods assessed postoperatively. Literatureevidence documents similar findings in the studies of Sarlietal, Yasir M etal,BhattacharjeeHK, ApoorvaGoeletal.13-16.
Conclusion
The present study hypothesises that lower pressure pneumoperitoneum performssuperiortohigherpressurepneumoperitoneumintermsofregulatedbloodpressure,liveren zymesandlesserpainpostoperatively
References
1. Johansson M. Management of acute cholecystitis in the laparoscopic era: Results of aprospective,randomizedclinicaltrial.JournalofGastrointestinalSurgery.2003;7(5):642- 45.
2. Sauerland S. Early versus delayed-interval laparoscopic cholecystectomy for acutecholecystitis:a metaanalysis. SurgicalEndoscopy. 2006;20(11):1780-83.
3. EsmatME,ElsebaeMM,NasrMMetal(2006)Combinedlowpressurepneumoperitoneuma ndintraperitonealinfusionofnormalsalineforreducingshoulder tip pain following laparoscopic cholecystectomy. World J Surg 30:1969–1973.
4. Uen Y, Chen Y, Kuo C, Wen K. Randomized trial of low-pressure carbon dioxide- elicitedpneumoperitoneumversusabdominalwallliftingforlaparoscopiccholecystectomy .Journal of ChineseMedical Association.2007;70(8):324-30.
5. Chok K, Yuen W, Lau H, Fan S. Prospective randomized trial on low-pressure versusstandard-pressurepneumo-
peritoneuminoutpatientlaparoscopiccholecystectomy.SurgicalLaparoscopy,Endoscopy
&PercutaneousTechniques. 2006;16(6):383-86.
6. KocM,ErtanT,TezMetal(2005)Randomizedprospectivecomparisonofpostoperativepain inlowversus-highpressurepneumoperitoneum.ANZJSurg75:693–696.
7. Catani M, GuerricchioR, De MilitoR et al (2004) "Low- pressure"laparoscopiccholecystectomy in high risk patients (ASA III and IV): our experience. ChirItal56(1):71–80.
8. JorisJ,CigariniI,LegrandM,JacquetN.Metabolicandrespiratorychangesaftercholec ystectomy performed via laparotomy or laparoscopy. British Journal ofAnaesthesia.1992;69(4):341-45.
9. Kondoh M, Morisaki H, Yorozu T, Shigematsu T. Does increasing end-tidal carbondioxide during laparoscopic cholecystectomy matter?. Journal of Anesthesia.1996;10(1):76-79.
10. Umar A, Mehta KS, Mehta N. Evaluation of Hemodynamic Changes Using DifferentIntra-
AbdominalPressuresforLaparoscopicCholecystectomy.IndianJSurg.2013;75:284-9.
11. R. Mohammadzadeand F. Esmaili.. Comparing Hemodynamic Symptoms and theLevel of Abdominal Pain inHigh- Versus Low-Pressure Carbon Dioxide in PatientsUndergoingLaparoscopicCholecystectomy.IndianJSurg(February2018)80(1):3 0–35.
12. KanwarDB,KamanL,NedounsejianeM,MedhiB,VermaGR,BlaI,etal.Comparative study of low pressure versus standard pressure pneumoperitoneum inlaparoscopiccholecystectomy-
Arandomizedcontrolledtrial.TropGastroenterol.2009;30:171-4.
13. SarliL,CostiR,etal.Prospectiverandomizedtrialoflow-pressurepneumoperitoneum for reduction of shoulder-tip pain following laparoscopy.Br J Surg2000;87(9):1161-1165.
14. YasirM,MehtaKS,etal.Evaluationofpostoperativeshouldertippaininlowpressureversuss tandardpressurepneumoperitoneumduringlaparoscopiccholecystectomy.Surgeon2012;
10(2):71-74.
15. Bhattacharjee HK, Jalaludeen A, et al. Impact of standard-pressure and low- pressurepneumoperitoneumonshoulderpainfollowinglaparoscopiccholecystectomy:ara ndomisedcontrolled trial. SurgEndosc2017;31(3):1287-1295.
16. ApoorvGoel, Shalabh Gupta, Tripta S Bhagat, PrakharGarg.Comparative Analysisof Hemodynamic Changes and Shoulder Tip Pain Under Standard Pressure VersusLow- pressurePneumoperitoneuminLaparoscopicCholecystectomy.EuroasianJournalof Hepato-Gastroenterology, Volume9Issue1(January-June2019)
