Low vs Standard Pressures in Gynecologic Laparoscopy: a Systematic Review

Abstract

Background:The optimal intraperitoneal pressure during laparoscopy is not known. Recent literature found benefits of using lower pressures, but the safety of doing abdominal surgery with low peritoneal pressures needs to be assessed. This systematic review compares low with standard pneumoperitoneum during gynecologic laparoscopy.Database:We searched Medline, Embase, and the Cochrane Library for randomized controlled trials comparing intraperitoneal pressures during gynecologic laparoscopy. Two authors reviewed references and extracted data from included trials. Risk ratios, mean differences, and standard mean differences were calculated and pooled using RevMan5. Of 2251 studies identified, three were included in the systematic review, for a total of 238 patients. We found a statistically significant but modest diminution in postoperative pain of 0.38 standardized unit based on an original 10-point scale (95% confidence interval [CI], –0.67 to –0.08) during the immediate postoperative period when using low intraperitoneal pressure of 8 mm Hg compared with ≥12 mm Hg and of 0.50 (95% CI, –0.80 to –0.21) 24 hours after the surgery. Lower pressures were associated with worse visualization of the surgical field (risk ratio, 10.31; 95% CI, 1.29–82.38). We found no difference between groups over blood loss, duration of surgery, hospital length of stay, or the need for increased pressure.Conclusion:Low intraperitoneal pressures during gynecologic laparoscopy cannot be recommended on the behalf of this review because improvement in pain scores is minimal and visualization of the surgical field is affected. The safety of this intervention as well as cost-effectiveness considerations need to be further studied.

Deep neuromuscular block to optimize surgical space conditions during laparoscopic surgery: a systematic review and meta-analysis

“…2 Lowering the IAP might decrease postoperative pain and the risk of laparoscopy-related complications. 3 However, lowpressure pneumoperitoneum impairs the quality of the surgical field, which can increase the risk of intraoperative complications or conversion to open surgery. 3 The quality of the working space is determined by nonmodifiable factors (i.e.…”

“…3 However, lowpressure pneumoperitoneum impairs the quality of the surgical field, which can increase the risk of intraoperative complications or conversion to open surgery. 3 The quality of the working space is determined by nonmodifiable factors (i.e. patients' obesity, previous pregnancies, or previous abdominal surgery) and by modifiable factors, such as anaesthesia-related factors, IAP, and body position.…”

Effects of Deep Versus Moderate Neuromuscular Blockade in Laparoscopic Gynecologic Surgery on Postoperative Pain and Surgical Conditions: Protocol for a Randomized Controlled Trial (Preprint)

“…A recent systematic review did not confirm this reported increase in operating time or blood loss with lower pressure; however, it did raise questions regarding whether the benefit of the observed reduction in postoperative pain could offset the decrease in the quality of surgical conditions [4]. The authors reported an association between lower pressure and increased risk of poorer surgical field visibility (RR 10.31; 95% CI 1.29-82.38).…”

Impact of different intraoperative CO2 pressure levels (8 and 15 mmHg) during laparoscopic hysterectomy performed due to benign uterine pathologies on postoperative pain and arterial pCO2: a prospective randomised controlled clinical trial

“…However, these findings cannot be generalised to gynaecological laparoscopic interventions due to differences in positioning and type of surgical interventions. The few studies that have assessed the use of LP laparoscopy in gynaecological surgery report an overall trend toward reduced postoperative pain levels, but sample sizes were small and inhomogeneous, and distinct outcomes in different pain domains are sparse and rather contradictory . Considering this lack of conclusive data, no sufficient evidence exists for the use of LP laparoscopy in gynaecological interventions in terms of effects on distinct postoperative pain outcomes, laparoscopy‐induced systemic physiological alterations, and safety (intra‐ and postoperative complications).…”

“…The few studies that have assessed the use of LP laparoscopy in gynaecological surgery report an overall trend toward reduced postoperative pain levels, but sample sizes were small and inhomogeneous, and distinct outcomes in different pain domains are sparse and rather contradictory. [15][16][17][18] Considering this lack of conclusive data, no sufficient evidence exists for the use of LP laparoscopy in gynaecological interventions in terms of effects on distinct postoperative pain outcomes, laparoscopy-induced systemic physiological alterations, and safety (intra-and postoperative complications). This study was conducted to compare the use of two different CO 2 pressure levels (15 and 8 mmHg) in patients undergoing laparoscopic hysterectomy for benign uterine pathologies in terms of distinct postoperative pain scores, vegetative laparoscopy-induced alterations, arterial CO 2 pressure (pCO 2 ) levels, safety, and surgical parameters.…”