A multifaceted individualized pneumoperitoneum strategy for laparoscopic colorectal surgery: a multicenter observational feasibility study
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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.
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.
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.
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).
KeywordsLaparoscopy Colorectal surgery Neuromuscular blockade
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. (email@example.com), Cristina Ballester Ph.D. (firstname.lastname@example.org), Matteo Frasson Ph.D. (email@example.com), Alvaro García-Granero Ph.D. (firstname.lastname@example.org), Carlos Cerdán Santacruz M.D. (email@example.com), Eduardo García-Granero Ph.D. (firstname.lastname@example.org), Luis Sanchez Guillen M.D. (email@example.com), Anabel Marqués Marí Ph.D. (firstname.lastname@example.org), David Casado Rodrigo M.D. (email@example.com), Joan Gibert Gerez M.D. (firstname.lastname@example.org), Rebeca Cosa Rodríguez M.D. (email@example.com), Mª de los Desamparados Moya Sanz M.D. (firstname.lastname@example.org), Marcos Rodriguez Martín M.D. (email@example.com), Jaime Zorrilla Ortúzar M.D. (firstname.lastname@example.org), José María Pérez-Peña M.D. (email@example.com), Maria Jose Alberola Estellés M.D. (firstname.lastname@example.org), Begoña Ayas Montero Ph.D. (email@example.com), Salome Matoses Jaen M.D. (firstname.lastname@example.org), Sandra Verdeguer Ph.D. (email@example.com), Michiel. Warlé M.D. (Michiel.Warle@radboudumc.nl), David Cuesta Frau Ph.D. (firstname.lastname@example.org.)
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.
Support was provided solely from institutional and/or departmental sources.
Compliance with Ethical Standards
Oscar Diaz-Cambronero (email@example.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 (firstname.lastname@example.org) has received speakers’ fees and honoraria from Merck Sharp & Dohme for lectures (approximately amount: 3.000 euros). Guido Mazzinari (email@example.com) declares no competing interests. Maria Vila Montañes (firstname.lastname@example.org) declares no competing interests. Nuria Garcia Gregorio (email@example.com) declares no competing interests. Daniel Robles Hernandez (firstname.lastname@example.org) declares no competing interests. Luis Enrique Olmedilla Arnal (email@example.com) declares no competing interests. Maria Pilar Argente Navarro (firstname.lastname@example.org) has received speakers’ fees and honoraria for lectures from Merck Sharp & Dohme (approximately amount: 1.000 euros). Marcus J. Schultz (email@example.com) declares no competing interests. Carlos L. Errando (firstname.lastname@example.org) has received speakers’ fees and honoraria for lectures from Merck Sharp & Dohme. (approximately amount: 1.000 euros).
- 1.Neudecker J, Sauerland S, Neugebauer E, Bergamaschi R, Bonjer HJ, Cuschieri A, Fuchs KH, Jacobi Ch, Jansen FW, Koivusalo AM, Lacy A, McMahon MJ, Millat B, Schwenk W (2002) The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery. Surg Endosc 16:1121–1143CrossRefPubMedGoogle Scholar
- 3.Gurusamy KS, Vaughan J, Davidson BR (2014) Low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy. Cochrane Database of Syst Rev 3:CD006930Google Scholar
- 5.Maddison L, Karjagin J, Tenhunen J, Starkopf J (2012) Moderate intra-abdominal hypertension is associated with an increased lactate-pyruvate ratio in the rectus abdominis muscle tissue: a pilot study during laparoscopic surgery. Ann Intensive Care 2(Suppl 1):S14CrossRefPubMedPubMedCentralGoogle Scholar
- 6.Malbrain ML, Viaene D, Kortgen A, De Laet I, Dits H, Van Regenmortel N, Schoonheydt K, Bauer M (2012) Relationship between intra-abdominal pressure and indocyanine green plasma disappearance rate: hepatic perfusion may be impaired in critically ill patients with intra-abdominal hypertension. Ann Intensive Care 2(Suppl 1):S19CrossRefPubMedPubMedCentralGoogle Scholar
- 18.Özdemir-van Brunschot DMD, Braat AE, van der Jagt MFP, Scheffer GJ, Martini CH, Langenhuijsen JF, Dam RE, Huurman VA, Lam D, d’Ancona FC, Dahan A, Warle MC (2018) Deep neuromuscular blockade improves surgical conditions during low-pressure pneumoperitoneum laparoscopic donor nephrectomy. Surg Endosc 32:245–251CrossRefPubMedGoogle Scholar
- 25.Serpa Neto A, Hemmes SN, Barbas CS, Beiderlinden M, Biehl M, Binnekade JM, Canet J, Fernandez-Bustamante A, Futier E, Gajic O, Hedenstierna G, Hollmann MW, Jaber S, Kozian A, Licker M, Lin WQ, Maslow AD, Memtsoudis SG, Reis Miranda D, Moine P, Ng T, Paparella D, Putensen C, Ranieri M, Scavonetto F, Schilling T, Schmid W, Selmo G, Severgnini P, Sprung J, Sundar S, Talmor D, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, Gama de Abreu M, Pelosi P, Schultz MJ, PROVE Network Investigators (2015) Protective versus conventional ventilation for surgery: a systematic review and individual patient data meta-analysis. Anesthesiology 123(1):66–78CrossRefPubMedGoogle Scholar
- 29.Kim MH, Lee KY, Lee KY, Min BS, Yoo YC (2016) Maintaining optimal surgical conditions with low insufflation pressures is possible with deep neuromuscular blockade during laparoscopic colorectal surgery: a prospective, randomized, double-blind, parallel-group clinical trial. Medicine 95:e2920CrossRefPubMedPubMedCentralGoogle Scholar
- 30.Serpa Neto A, Hemmes SN, Barbas CS, Beiderlinden M, Fernandez-Bustamante A, Futier E, Hollmann MW, Jaber S, Kozian A, Licker M, Lin WQ, Moine P, Scavonetto F, Schilling T, Selmo G, Severgnini P, Sprung J, Treschan T, Unzueta C, Weingarten TN, Wolthuis EK, Wrigge H, Gama de Abreu M, Pelosi P, Schultz MJ, PROVE Network investigators (2014) Incidence of mortality and morbidity related to postoperative lung injury in patients who have undergone abdominal or thoracic surgery: a systematic review and meta-analysis. Lancet Respir Med 2(12):1007–1015CrossRefPubMedGoogle Scholar
- 31.Cinnella G, Grasso S, Spadaro S, Rauseo M, Mirabella L, Salatto P, De Capraris A, Nappi L, Greco P, Dambrosio M (2013) Effects of recruitment maneuver and positive end-expiratory pressure on respiratory mechanics and transpulmonary pressure during laparoscopic surgery. Anesthesiology 118(1):114–122CrossRefPubMedGoogle Scholar
- 32.D’Antini D, Rauseo M, Grasso S, Mirabella L, Camporota L, Cotoia A, Spadaro S, Fersini A, Petta R, Menga R, Sciusco A, Dambrosio M, Cinnella G (2018) Physiological effects of the open lung approach during laparoscopic cholecystectomy: focus on driving pressure. Minerva Anestesiol 84(2):159–167PubMedGoogle Scholar
- 35.Mulier JP, Dillemans BRS, Crombach M, Missant C, Sels A (2009) On the abdominal pressure volume relationship. Internet J Anesthesiol 21:1Google Scholar