Discussion
intra-abdominal, pain
POST-OP COMPLICATION, INTRAOPERATIVE COMPLICATION, GALLBLADDER DISEASE, PNEUMOPERITONEUM
Until today, there is no consensus on the standard pressure to operate during laparoscopic surgeries, but majority of surgical societies agrees on “the lowest intra-abdominal pressure allowing adequate exposure of the operative field rather than a routine pressure” to be used [This trial has been designed to assess laparoscopic cholecystectomy operated at a low-pressure pneumoperitoneum with a set pressure between 8 and 10 mmHg compared to a standard of 12–14 mmHg. The study design added to its strength, validity and generalisability being a prospective, randomised, double-blinded controlled clinical trial. But the study was limited to patients with low-anaesthesia risk of ASA score I and II and non-complicated gallbladder disease.As the study was conducted at a teaching hospital, the difficulty of surgery could be assessed when operated by non-experienced surgeons in contrary to other trials that required low-pressure pneumoperitoneum surgeries to be operated by experienced surgeons. In our study sample, majority of the operations was done by non-experienced surgeons (senior residents), the distribution of surgeries done by residents was non-significantly different between the two groups. We found no correlation between the surgery difficulty and level of operator experience, indicating that low-pressure pneumoperitoneum surgery is feasible in the hands of non-experienced surgeons. Regarding the safety of low-pressure pneumoperitoneum, Mandal et al. found no significant increase in terms of difficulty of surgery, conversion rate, or post-op complication rate of low-pressure pneumoperitoneum when done in the hands of experienced surgeon. They found that the operative visual field was also not compromised [In this trial the total operative time, insufflation time and total hospital stay was similar across both groups. None of the patients had major intraoperative complication, 30-day mortality rate was zero in both groups, only 3 patients in the low-pressure group had a change from initial set pressure point, and 4 patients required re-admission within the 30-day period post-op, none of the reasons for readmission were significant nor resulted a long-term morbidity.The benefits of operating at a low-pressure pneumoperitoneum are many and reported in multiple clinical trials In observing the hemodynamic effects of reduced pressure pneumoperitoneum, the heart rate, mean arterial pressure and end tidal carbon dioxide is found to have variation intraoperatively. [The use of low-pressure pneumoperitoneum also demonstrated a reduced effect on derangement of hepatic blood flow The effect on immune response has been reported in few studies only, our trial was focused on ten inflammatory mediators affected by the stress of surgery. Schietroma et al. observed a significant decrease in interleukin IL-1, IL-6, and CRP. [This trial was limited to laparoscopic cholecystectomy, but in reviewing the literature we found that the beneficial effects of low-pressure pneumoperitoneum have been exploited to other surgeries. The PAROS and RECOVERY In conclusion, this clinical trial demonstrated a reduction of pain and inflammatory markers post laparoscopic cholecystectomy in patients operated at a low-pressure (8–10 mmHg) compared to a standard-pressure (12–14 mmHg), although the difference was not significant except for the 6-hour post-op pain scores. No significant difference could be observed between the two groups regarding total surgery time, also the difficulty of surgery was not significant even in the hands of non-experienced surgeons. Thereby we recommend a larger trial to confirm the benefits of low-pressure pneumoperitoneum to establish a new standard of care in laparoscopic cholecystectomy and other similar procedures utilising intra-abdominal insufflation, and to extend the benefits to high anaesthesia risk patients such as elderly.