Surgical Endoscopy

, 23:1044 | Cite as

Low-pressure pneumoperitoneum versus standard pneumoperitoneum in laparoscopic cholecystectomy, a prospective randomized clinical trial

  • Trichak SandhuEmail author
  • Sirikan Yamada
  • Veeravorn Ariyakachon
  • Thiraphat Chakrabandhu
  • Wilaiwan Chongruksut
  • Wasana Ko-iam



Post-laparoscopic pain syndrome is well recognized and characterized by abdominal and particularly shoulder tip pain; it occurs frequently following laparoscopic cholecystectomy. The etiology of post-laparoscopic pain can be classified into three aspects: visceral, incision, and shoulder. The origin of shoulder pain is only partly understood, but it is commonly assumed that the cause is overstretching of the diaphragmatic muscle fibers owing to a high rate of insufflations. This study aimed to compare the frequency and intensity of shoulder tip pain between low-pressure (7 mmHg) and standard-pressure (14 mmHg) in a prospective randomized clinical trial.


One hundred and forty consecutive patients undergoing elective laparoscopic cholecystectomy were randomized prospectively to either high- or low-pressure pneumoperitoneum and blinded by research nurses who assessed the patients during the postoperative period. The statistical analysis included sex, mean age, weight, American Society of Anesthesiologists (ASA) grade, operative time, complication rate, duration of surgery, conversion rate, postoperative pain by using visual analogue scale, number of analgesic injections, incidence and severity of shoulder tip pain, and postoperative hospital stay. p < 0.05 was considered indicative of significance.


The characteristics of the patients were similar in the two groups except for the predominance of males in the standard-pressure group (controls). The procedure was successful in 68 of 70 patients in the low-pressure group compared with in 70 patients in the standard group. Operative time, number of analgesic injections, visual analogue score, and length of postoperative days were similar in both groups. Incidence of shoulder tip pain was higher in the standard-pressure group, but not statistically significantly so (27.9% versus 44.3%) (p = 0.100).


Low-pressure pneumoperitoneum tended to be better than standard-pressure pneumoperitoneum in terms of lower incidence of shoulder tip pain, but this difference did not reach statistical significance following elective laparoscopic cholecystectomy.


Laparoscopic cholecystectomy Pneumoperitoneum 


  1. 1.
    Alexander JL, Hull MGR (1987) Abdominal pain after laparoscopy: the value of a gas drain. Br J Obstet Gyn 94:267–269Google Scholar
  2. 2.
    Chamberlain G (1984) The recovery of gases insufflated at laparoscopy. Br J Obstet Gyn 1:367–370Google Scholar
  3. 3.
    Tsimoyiannis EC, Glantzounis G, Lekke ET, Siakas P, Jabaria M, Tszourou H (1998) Intraperitoneal normal saline and bupivacaine infusion for reduction of post-operative pain after laparoscopic cholecystectomy. Surg Laparos Endos 8:416–420CrossRefGoogle Scholar
  4. 4.
    Cunniffe MG, Anena OJ, Dar MA, Calleary J, Flynn N (1998) A prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain following laparoscopy. Am J Surg 176:258–261PubMedCrossRefGoogle Scholar
  5. 5.
    Wallace DH, Serpell MG, Bakter JN, O’ Dwyer PJ (1997) Randomized trial of different insufflation pressure for laparoscopic cholecystectomy. Br J Surg 84:455–458PubMedCrossRefGoogle Scholar
  6. 6.
    Barczynski M, Herman RM (2003) A prospective randomized trial on comparison of low-pressure (LP) and standard pressure (SP) pneumoperitoneum for laparoscopic cholecystectomy. Surg Endosc 17:533–538PubMedCrossRefGoogle Scholar
  7. 7.
    Pier A, Benedic M, Mann B, Buck V (1994) Das postlaparosko pische Schmerzsyndrom : Ergebnisre einer prospektiven, randomi sierten Studie. Chirurg 65:200–208PubMedGoogle Scholar
  8. 8.
    Dexter SP, Vucevic M, Gibson J, McMahon MJ (1999) Hemodynamic consequence of high and low pressure capnoperitoneum during laparoscopic cholecystectomy. Surg Endos 13:376–381CrossRefGoogle Scholar
  9. 9.
    Sandhu T (2003) Three port versus standard four-port laparoscopic cholecystectomy, a prospective randomized study. Surg Endosc 17:1434–1436CrossRefGoogle Scholar
  10. 10.
    Dubois F, Icard P, Berthelot G, Levard H (1990) Coelioscopic cholecystectomy: preliminary report of 36 cases. Ann Surg 211:60–62PubMedCrossRefGoogle Scholar
  11. 11.
    Koivusalo AM, Lindgren L (1999) Respiratory mechanics during laparoscopic cholecystectomy. Anesth Analg 89:800PubMedCrossRefGoogle Scholar
  12. 12.
    Stuttmann R, Vogt C, Eypasch E, Doehn M (1995) Haemodynamic changes during laparoscopic cholecystectomy in the high risk patient. Endosc Surg Allied Technol 3:174–179PubMedGoogle Scholar
  13. 13.
    Bisgaard T, Klarskov B, Kristiansen VB et al (1999) Multi-regional local anesthetic infiltration during laparoscopic cholecystectomy in patients receiving prophylactic multi-modal analgesia, a randomized, double-blinded, placebo-controlled study. Anesth Analg 89:1017–1024PubMedCrossRefGoogle Scholar
  14. 14.
    Joris J, Thiry E, Paris P, Weerts J, Lamy M (1995) Pain after laparoscopic cholecystectomy: characteristics and effect of intra peritoneal bupivacaine. Anesth Analg 81:379–384PubMedCrossRefGoogle Scholar
  15. 15.
    Ure BM, Troidl H, Spangenberger W et al (1994) Pain after laparoscopic cholecystectomy. Intensity and localization of pain and analysis of predictors in preoperative symptoms and intraoperative events. Surg Endosc 8:90–96PubMedCrossRefGoogle Scholar
  16. 16.
    Berberoglu M, Dilex ON, Ercan F, Kati I, Ozmen M (1998) The effect of CO2 insufflation rate on the postlaparoscopic shoulder pain. J Laparoendosc Adv Surg Tech A 8:273–277PubMedCrossRefGoogle Scholar
  17. 17.
    Sarli L, Costi R, Sansebastiano G, Trirelli M, Roncoroni L (2000) Prospective randomized trial of low-pressure pneumoperitoneum for reduction of shoulder-tip pain following laparoscopy. Br J Surg 87:1161–1165PubMedCrossRefGoogle Scholar
  18. 18.
    Sood J, Jayaraman L, Kumra VP, Chowbey PK (2006) Laparoscopic approach to pheochromocytoma: is a lower intraabdominal pressure helpful? Anesth Analg 102(2):637–641PubMedCrossRefGoogle Scholar
  19. 19.
    Beebe DS, Zhu S, Kumar MV et al (2002) The effect of insufflation pressure on CO2 pneumoperitoneum and embolism in piglets. Anesth Analg 94(5):1182–1187PubMedCrossRefGoogle Scholar
  20. 20.
    Schwarte LA, Scheeren TW, Lorenz C, De Bruyne F, Fournell A (2004) Moderate increase intraabdominal pressure attenuates gastric mucosal oxygen saturation in patients undergoing laparoscopy. Anesthesiology 100(5):1081–1087PubMedCrossRefGoogle Scholar
  21. 21.
    Neudecker J, Sauerland S, Neugebauer E et al (2002) The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 16:1121–1143PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2008

Authors and Affiliations

  • Trichak Sandhu
    • 1
    Email author
  • Sirikan Yamada
    • 1
  • Veeravorn Ariyakachon
    • 1
  • Thiraphat Chakrabandhu
    • 1
  • Wilaiwan Chongruksut
    • 1
  • Wasana Ko-iam
    • 1
  1. 1.Department of Surgery, Faculty of MedicineChiang Mai UniversityChiang MaiThailand

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