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A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study

  • Oscar Diaz-Cambronero
  • Blas Flor Lorente
  • Guido Mazzinari
  • Maria Vila Montañes
  • Nuria García Gregorio
  • Daniel Robles Hernandez
  • Luis Enrique Olmedilla Arnal
  • Maria Pilar Argente Navarro
  • Marcus J. Schultz
  • Carlos L. Errando
  • for the IPPColLapSe study group
Article
  • 78 Downloads

Abstract

Background

While guidelines for laparoscopic abdominal surgery advise using the lowest possible intra-abdominal pressure, commonly a standard pressure is used. We evaluated the feasibility of a predefined multifaceted individualized pneumoperitoneum strategy aiming at the lowest possible intra-abdominal pressure during laparoscopic colorectal surgery.

Methods

Multicenter prospective study in patients scheduled for laparoscopic colorectal surgery. The strategy consisted of ventilation with low tidal volume, a modified lithotomy position, deep neuromuscular blockade, pre-stretching of the abdominal wall, and individualized intra-abdominal pressure titration; the effect was blindly evaluated by the surgeon. The primary endpoint was the proportion of surgical procedures completed at each individualized intra-abdominal pressure level. Secondary endpoints were the respiratory system driving pressure, and the estimated volume of insufflated CO2 gas needed to perform the surgical procedure.

Results

Ninety-two patients were enrolled in the study. Fourteen cases were converted to open surgery for reasons not related to the strategy. The intervention was feasible in all patients and well-accepted by all surgeons. In 61 out of 78 patients (78%), surgery was performed and completed at the lowest possible IAP, 8 mmHg. In 17 patients, IAP was raised up to 12 mmHg. The relationship between IAP and driving pressure was almost linear. The mean estimated intra-abdominal CO2 volume at which surgery was performed was 3.2 L.

Conclusion

A multifaceted individualized pneumoperitoneum strategy during laparoscopic colorectal surgery was feasible and resulted in an adequate working space in most patients at lower intra-abdominal pressure and lower respiratory driving pressure.

ClinicalTrials.gov (Trial Identifier: NCT03000465).

Keywords

Laparoscopy Colorectal surgery Neuromuscular blockade 

Notes

Acknowledgements

We acknowledge the support of surgery, anesthesia, and administrative staff at the Hospital Universitario y Politecnico La Fe in Valencia, the Hospital General de Castellon in Castellon, and the Hospital Universitario Gregorio Marañon in Madrid, Spain, during this study and a special mention to David Hervás from Data Science and Biostatistics IISLaFe for the assistance with the data analysis.

IPPColLapSe study collaborators group members: Salvador Pous Ph.D. (salvadorpous@hotmail.com), Cristina Ballester Ph.D. (cris7balle@yahoo.es), Matteo Frasson Ph.D. (dr.frasson.matteo@gmail.com), Alvaro García-Granero Ph.D. (alvarogggt@hotmail.com), Carlos Cerdán Santacruz M.D. (carloscerdansantacruz@hotmail.com), Eduardo García-Granero Ph.D. (eggranero@telefonica.net), Luis Sanchez Guillen M.D. (drsanchezguillen@gmail.com), Anabel Marqués Marí Ph.D. (amarquesmari@gmail.com), David Casado Rodrigo M.D. (dcasador@hotmail.com), Joan Gibert Gerez M.D. (jgibertgerez@me.com), Rebeca Cosa Rodríguez M.D. (rebecacosa@hotmail.com), Mª de los Desamparados Moya Sanz M.D. (desampa.moya@gmail.com), Marcos Rodriguez Martín M.D. (marcosrodmar@hotmail.com), Jaime Zorrilla Ortúzar M.D. (jzorrillaortuzar@gmail.com), José María Pérez-Peña M.D. (jppena@salud.madrid.org), Maria Jose Alberola Estellés M.D. (majoni2000@yahoo.es), Begoña Ayas Montero Ph.D. (bego_ayas@hotmail.com), Salome Matoses Jaen M.D. (smatosesj@gmail.com), Sandra Verdeguer Ph.D. (sandraverdeguer@hotmail.com), Michiel. Warlé M.D. (Michiel.Warle@radboudumc.nl), David Cuesta Frau Ph.D. (dcuesta@disca.upv.es.)

Author contributions

O.D.C: Study design, acquisition, analysis and interpretation of data, drafting and revision of paper. B.F.L: Study design, acquisition, analysis and interpretation of data, drafting and revision of paper. G.M: Study design, analysis and interpretation of data, drafting and revision of paper. M.V.M: Study design, acquisition and interpretation of data, and revision of paper. N.G.G: Study design, acquisition and interpretation of data, and revision of paper. D.R.H: Study design, acquisition and interpretation of data, and revision of paper. L.E.O.A: Study design, acquisition and interpretation of data, and revision of paper. M.P.A.N: Study design, interpretation of data, and revision of paper. M.J.S: Analysis and interpretation of data, drafting and revision of paper. C.L.E.O: Study design, analysis and interpretation of data, drafting and revision of paper.

Funding

Support was provided solely from institutional and/or departmental sources.

Compliance with Ethical Standards

Disclosures

Oscar Diaz-Cambronero (oscardiazcambronero@gmail.com) has received speakers’ fees and honoraria from Merck Sharp & Dohme for lectures (approximately amount: 8.000 euros) and also received a research grant from Merck Sharp & Dohme of 80.000 euros not related to this study. Blas Flor Lorente (blasflor@hotmail.com) has received speakers’ fees and honoraria from Merck Sharp & Dohme for lectures (approximately amount: 3.000 euros). Guido Mazzinari (gmazzinari@gmail.com) declares no competing interests. Maria Vila Montañes (mvilamontanes@yahoo.es) declares no competing interests. Nuria Garcia Gregorio (nuriagcia6@gmail.com) declares no competing interests. Daniel Robles Hernandez (drobher@gmail.com) declares no competing interests. Luis Enrique Olmedilla Arnal (lolmedilla@gmail.com) declares no competing interests. Maria Pilar Argente Navarro (argente_marnav@gva.es) has received speakers’ fees and honoraria for lectures from Merck Sharp & Dohme (approximately amount: 1.000 euros). Marcus J. Schultz (marcus.j.schultz@gmail.com) declares no competing interests. Carlos L. Errando (errando013@gmail.com) has received speakers’ fees and honoraria for lectures from Merck Sharp & Dohme. (approximately amount: 1.000 euros).

Supplementary material

464_2018_6305_MOESM1_ESM.docx (1.8 mb)
Supplementary material 1 (DOCX 1806 KB)

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Copyright information

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Authors and Affiliations

  • Oscar Diaz-Cambronero
    • 1
  • Blas Flor Lorente
    • 2
  • Guido Mazzinari
    • 3
  • Maria Vila Montañes
    • 1
  • Nuria García Gregorio
    • 1
  • Daniel Robles Hernandez
    • 4
  • Luis Enrique Olmedilla Arnal
    • 5
  • Maria Pilar Argente Navarro
    • 1
  • Marcus J. Schultz
    • 6
    • 7
  • Carlos L. Errando
    • 8
  • for the IPPColLapSe study group
  1. 1.Department of Anesthesiology & Perioperative Medicine Research GroupHospital Universitario y Politécnico la Fe. Valencia EspañaValenciaSpain
  2. 2.Colorectal SurgeryHospital Universitario y Politecnico la FeValenciaSpain
  3. 3.Department of AnesthesiologyHospital de ManisesValenciaSpain
  4. 4.Department of AnesthesiologyHospital General Universitario de CastellonCastellón de la PlanaSpain
  5. 5.Department of AnesthesiologyHospital General Universitario Gregorio MarañonMadridSpain
  6. 6.Department of Intensive Care & Laboratory of Experimental Intensive Care and Anesthesiology (L·E·I·C·A)Academic Medical CenterAmsterdamThe Netherlands
  7. 7.Mahidol-Oxford Tropical Medicine Research Unit (MORU)Mahidol UniversityBangkokThailand
  8. 8.Department of AnesthesiologyConsorcio Hospital General Universitario de ValenciaValenciaSpain

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