Abdominal wall retraction during laparoscopic cholecystectomy

Laparoscopic cholecystectomy has represented a potentially more morbid procedure than open cholecystectomy. Some of this morbidity has been due to complications associated with pneumoperitoneum. We have developed a technique that employs abdominal wall retraction during laparoscopic cholecystectomy and allows access to the right upper part of the abdomen without maintenance of pneumoperitoneum. Among 151 patients who underwent laparoscopic cholecystectomy using abdominal wall retraction there were no recognized adverse effects. Abdominal wall retraction enables the surgeon to minimize the risk of serious complications associated with pneumoperitoneum during laparoscopic cholecystectomy.

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Resumen En su estado actual, la colecistectomía laparoscópica representa un procedimiento potencialmente más mórbido que la colecistectomia abierta. Parte de la morbilidad de la colecistectomía laparoscópica se debe a las complicaciones asociadas con el neumoperitoneo. Nuestro grupo ha establecido una nueva técnica que emplea la retracción abdominal por medio de un alambre de Kirchner, a través de la pared abdominal, durante la colecistectomia laparoscópica, el cual permite el acceso al sector superior derecho del abdomen sin necesidad de mantener neumoperitoneo. Ciento cincuenta y un pacientes fueron sometidos a colecistectomia laparoscópica utilizando la retracción de la pared abdominal, sin detectar efectos adversos. La retracción de la pared abdominal permite al cirujano minimizar el riesgo de las complicaciones graves que se asocian con el neumoperitoneo en el curso de una colecistectomia laparoscópica.

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Résumé A l'heure actuelle, la morbidité de la cholécystectomie laparoscopique est plus élevée que la cholécystectomie traditionnelle. Un certain nombre des complications sont en rapport avec le pneumopéritoine. Nous avons développé une nouvelle technique de suspension de la paroi abdominale qui permet un accès facile à l'hypochondre droit sans avoir besoin de maintenir le pneumopéritoine pendant la cholécystectomie laparoscopique. Nous avons employé cette technique chez 151 patients ayant eu une chlécystectomie laparoscopique sans enregistrer d'effet secondaire néfaste. La suspension de la paroi abdominale permet de minimiser le risque de complications secondaires au pneumopéritoine pendant la cholécystectomie par voie laparoscopique.

     

Comparison between CO2 insufflation and abdominal wall lift in laparoscopic cholecystectomy

Background: Abdominal wall lift (AWL) was developed mainly in Japan to avoid insufflation-related complications and to improve cost performance. AWL, however, has been criticized for its poor visibility in obese patients, the complexity of preparing the lifting instruments, and increased inflammatory reactions. As experience with AWL has increased, proponents of the procedure have come to believe that AWL is simple enough to qualify as a standard method of laparoscopic surgery even in obese patients. Postoperatively, issues such as pain, changes in body temperature, and time before returning to work do not appear to be much different from those after CO₂ insufflation.     

Conventional pneumoperitoneum compared with abdominal wall lift for laparoscopic cholecystectomy

We have compared, in a randomized study, conventional carbon dioxide pneumoperitoneum with abdominal wall lift in 25 patients undergoing laparoscopic cholecystectomy. Intra-abdominal pressure (IAP) (11 (SD 2) mm Hg vs 2.7 (9) mm Hg) (P < 0.01) and total amount of carbon dioxide used (40 (23) litre vs 9 (7) litre) (P < 0.001) were significantly less with abdominal wall lift. Pulmonary compliance was significantly greater (P < 0.01) in the abdominal wall lift group throughout operation. During the first 15 min of insufflation, arterial pressures were lower with abdominal wall lift (P < 0.05). In the conventional pneumoperitoneum group, femoral vein pressure increased (P < 0.01) and remained elevated for 3 h in the recovery room. Postoperative drowsiness was of significantly longer duration in the conventional pneumoperitoneum group than in the abdominal wall lift group (98 (46) min vs 13 (34) min) (P < 0.01). Postoperative nausea and vomiting and right shoulder pain occurred more often in patients with conventional pneumoperitoneum (P < 0.05). We conclude that the benefits of abdominal wall lift may be attributed to avoiding excessive carbon dioxide and high IAP.      

Laparoscopic cholecystectomy using abdominal wall retraction

Background: Disadvantages related to CO₂ pneumoperitoneum have led to development of the abdominal wall retractor (AWR), a device designed to facilitate laparoscopic surgery without conventional pneumoperitoneum (15 mmHg CO₂). We investigated the effects of the AWR on hemodynamics and gas exchange in humans. We also investigated whether the use of an AWR imposed extra technical difficulties for the surgeon. A pilot study revealed that cholecystectomy without low-pressure pneumoperitoneum was technically impossible. Methods: A prospective randomized controlled trial: Twenty patients undergoing laparoscopic cholecystectomy were randomly allocated into group 1: AWR with low-pressure pneumoperitoneum (5 mmHg), or group 2: conventional pneumoperitoneum (15 mmHg). Results: Surgery using the AWR lasted longer, 72 ± 16 min (mean ± SD) vs 50 ± 18 min compared with standard laparoscopic cholecystectomy. There were no differences between the groups with respect to hemodynamic parameters, although a small reduction of the cardiac output was observed using conventional pneumoperitoneum (from 3.9 ± 0.7 to 3.2 ± 1.1 l/min) and an increase during AWR (from 4.2 ± 0.9 to 5.2 ± 1.5 l/min). Peak inspiratory pressures were significantly higher during conventional pneumoperitoneum compared to AWR. A slight decrease in pH accompanied by an increase in CO₂ developed during pneumoperitoneum and during the use of the AWR. In both groups arterial PO₂ decreased. Conclusions: The results indicate that the view was impaired during use of the AWR and therefore its use was difficult and time-consuming. Possible advantages of this devices' effects on hemodynamics and ventilatory parameters could not be confirmed in this study.     

二氧化碳气腹下行胆囊切除术对胃粘膜二氧化碳分压及pH的影响

目的：探讨腹腔镜二氧化碳气腹对胃粘膜二氧化碳分压（i-PCO2)及胃粘膜pH(i-pH)的影响。方法：选择20例二氧化碳气腹下胆囊切除术病人。采用胃管法，分别于气腹前，气腹20、40分钟，排气后30分钟抽取胃液3－5ml。分析胃液PCO2及PO2，同时在气腹前、后各时点监测动脉血PaCO2,PaO2,pH,HCO3^-和BE，并代入Henderson-Hasseibach公式，计算i-pH。结果：i-PCO2在气腹20分钟腹前有显著性升高（P＜0．05）（气腹40分钟，排气后30分钟与气腹前比较显著升高（P＜0．01），气腹20、40分钟，排气后，30分钟i-pH均较气腹前明显降低（P＜0．01）。气腹40分钟时，i-PCO2最高，而i-pH为最低。胃粘膜氧分压（i-PO2)气腹前、后无明显变化，PaCO3气腹40分钟、排气后30分钟均显著高于气腹前（P＜0．01），动脉血pH、BE气腹后各时点均较气腹前降低（P＜0．01）。动脉血PaO2,HCO3^-气腹前后变化不明显（P＞0．05）。结论：二氧化碳气腹下胃粘膜有缺血低灌注现象。随着气腹时间延长，胃粘膜低灌注，酸中毒的症状加重。     

Comparison between intraperitoneal CO2 insufflation and abdominal wall lift on QT dispersion and rate-corrected QT dispersion during laparoscopic cholecystectomy

This study compared the effect of intraperitoneal CO2 insufflation with abdominal wall lift on RR interval, QT interval, the rate-corrected QT (QTc) interval, QT dispersion (QTD), and the rate-corrected QTD (QTcD) using computerized measurement during laparoscopic cholecystectomy. Thirty patients scheduled for laparoscopic cholecystectomy were randomly assigned to 2 groups: intraperitoneal CO2 insufflation (CO2 group) or abdominal wall lift (lift group). A 12-lead electrocardiogram was monitored to measure parameters. The RR interval, QT interval, and QTc interval did not change significantly during the study in both groups. The QTD and QTcD in the CO2 group increased significantly during CO2 insufflation, and were significantly higher than those of the lift group. Statistically significant increases of QTD and QTcD, which are associated with an increased risk of arrhythmias and cardiac events, occur during CO2 insufflation, and QTD and QTcD in the CO2 group were significantly higher than those of the lift group.     

Comparison of pneumoperitoneum and abdominal wall lifting as to hemodynamics and surgical stress response during laparoscopic cholecystectomy

Background: Impairments in hemodynamics during pneumoperitoneum (PP) have been noted. This study compared changes in hemodynamics and surgical stress response with PP and abdominal wall lifting (AWL) during laparoscopic cholecystectomy. Methods: Twenty patients with symptomatic cholecystolithiasis were assigned to PP (n= 10) or AWL (n= 10). Cardiac output (CO), stroke volume (SV), and ejection fraction (%EF) were measured by transesophageal echocardiography. Clearances of para-aminohippurate (C_PAH) and sodium thiosulfate (C_STS) were determined as measures of renal function. Levels of interleukin-6, C-reactive protein, white cell count, and neutrophil elastase were evaluated as indicators of surgical stress. Results: In the PP group, CO, SV, and %EF were depressed significantly during pneumoperitoneum. Immediately after and 15 min after insufflation, the C_PAH and C_STS were decreased by 78.0% and 73.8%, respectively. None of the hemodynamic parameters changed significantly in the AWL group. Surgical stress response was not different significantly between the two groups. Conclusions: In contrast to pneumoperitoneum, AWL did not alter cardiac function or renal hemodynamics. AWL may be useful in patients with cardiovascular or renal disorders.     

Effect of CO(2) pneumoperitoneum on ventilation-perfusion relationships during laparoscopic cholecystectomy

BACKGROUND: Previous studies have shown that pneumoperitoneum transiently reduces venous admixture as assessed by a calculation based on the shunt formula, and increases arterial oxygen tension (PaO(2)) in patients without heart or lung disease. The aim of the present study was to further explore the relationship between ventilation-perfusion (V(A)/Q) before and during pneumoperitoneum by using the multiple inert gas technique. METHODS: Nine patients without heart or lung disease (ASA I), with a mean age of 42 years, scheduled for laparoscopic cholecystectomy were included. After premedication and induction of anaesthesia, radial artery and pulmonary artery catheters were introduced percutaneously. The V(A)Q relationships were evaluated by the multiple inert gas elimination technique before and during pneumoperitoneum to obtain a direct measure of the pulmonary shunt. RESULTS: Induction of pneumoperitoneum decreased the pulmonary shunt from 5.8 (4.5) to 4.1 (3.2)% (P<0.05) and increased PaO(2) from 21.7 (5.9) to 24.7 (4.8) kPa (P<0.01). During surgery, the shunt increased from 3.2 (2.8) to 5.2 (3.4)% to the same level as before pneumoperitoneum induction. No area with low V(A)Q was seen. Dead space ventilation amounted to 20.0 (1.2)% in the supine position and did not change during the investigation. CONCLUSIONS: In patients without heart or lung disease, pneumoperitoneum at an intra-abdominal pressure level of 11-13 mmHg causes a transient reduction of the pulmonary shunt. The mechanisms underlying the present finding remain to be elucidated.     

Routine low-pressure pneumoperitoneum during laparoscopic cholecystectomy

BACKGROUND: Pneumoperitoneum at 15 mmHg results in dangerous hemodynamic disturbances in some patients. The use of low-pressure insufflation may make laparoscopic surgery safer. METHODS: Data were collected prospectively from a consecutive series of patients who had undergone an elective laparoscopic cholecystectomy (LC) by the same surgeon, during the years 1993-94 (group 1, 77 patients) and 1996 (group 2, 50 patients). The groups were similar with respect to age, sex, body mass index (BMI), American Society of Anesthesiologists (ASA) grade, existence of abdominal scars due to previous surgery, and severity of gallbladder disease. Patients underwent LC with a mean intraabdominal pressure of 10.56 mmHg in group 1 and 7 mmHg in group 2, respectively. RESULTS: The mean operative time was 75 min and 78 min in groups 1 and 2, respectively (NS). Insertion of an additional cannula was required more frequently (24% versus 14%; NS) in group 2. There were no conversions in either group. The morbidity rate and the postoperative hospital stay were similar for both groups. CONCLUSIONS: LC can be performed routinely at low intraabdominal pressure, which may contribute to the safety and comfort of the procedure.     

腹腔镜胆囊切除术CO2气腹对脉搏血氧饱和度的影响

目的:观察腹腔镜胆囊切除术(laparoscop ic cholecystectomy,LC)CO2气腹对脉搏血氧饱和度的影响。方法:按照美国麻醉医师协会体格情况分级(ASA)标准,选择ASAⅠ~Ⅱ级600例患者全麻下行LC,在围手术期对脉搏血氧饱和度(SpO2)进行连续监测。结果:CO2充气后3m in SpO2明显下降(P<0.01),放气后恢复到术前水平。结论:CO2气腹对脉搏血氧饱和度存在一定程度的影响,因此CO2气腹压力不宜过大,应限制在10~12mm Hg为宜,对老年患者伴有心、肺功能不全及肥胖者更要加强麻醉管理,加强SpO2、呼气末二氧化碳分压(PETCO2)监测。     

全麻下腹腔镜胆囊切除术二氧化碳气腹对呼吸循环影响的临床研究

择期腹腔镜胆囊切除术（ＬＣ）手术患者１００例，全部采用气管内插管全麻，分别于气腹前、气腹后５、１０、２０分钟测定心率（ＨＲ）、收缩期血压（ＳＢＰ）、脉博氧饱和度（ＳｐＯ２）、呼吸道压力（Ｐａｗ）、呼气终末ＣＯ２分压（ＰｅｔＣＯ２）。结果表明，气腹５、１０分钟后，ＨＲ、ＳＢＰ、Ｐａｗ、ＰｅｔＣＯ２显著增高（Ｐ＜０．０１），ＳｐＯ２显著下降（Ｐ＜０．０５）；随着机体的自身调节作用，２０分钟后，各指标与气腹前相比明显好转（Ｐ＞０．０５）。本文通过上述参数的观察，认为ＣＯ２气腹使腹内正压增加，膈肌上升，胸腔受到物理性压迫以及手术期间呼吸性酸中毒、缺氧、反应性交感神经刺激而致呼吸循环发生变化。故应强调术中呼吸循环的监测，尤其对有心肺疾病的患者；同时，应将腹内正压控制在１５～２０ｋＰａ［１］。     

Lactate and acid base changes during laparoscopic cholecystectomy

BACKGROUND: The observation of hemodynamic and metabolic impairment related to CO2 pneumoperitoneum and postoperative mesenteric ischemia reports following laparoscopic procedures have raised concern about local and systemic effects of increase intraabdominal pressure during laparoscopic procedures. The present study aims to evaluate the metabolic and acid base responses of using high pressure versus low pressure pneumoperitonium in patients undergoing laparoscopic cholecystectomy in a prospective randomized clinical trial. PATIENTS AND METHOD: 20 ASA I-II patients scheduled for elective laparoscopic cholecystectomy were randomly allocated to one of two study groups; high pressure pneumoperitoneum 12-14mmHg (HPP, n=10) versus low pressure pneumoperitoneum 6-8mmHg (LPP, n=10) undergoing laparoscopic cholecystectomy. Arterial blood gases and lactate levels were determined after induction of anesthesia (before pneumoperitonium), then after 10 min, then 30 min after insufflations and at the end of surgery and 1 hour postoperatively. Nurses in recovery unit reported pain assessment starting postoperatively until 3 hours on a 10mm VAS (0-10). Statistical significant was established at P<0.05. RESULT: Bicarbonate was significantly (P>0.0412) lower in high pressure group at 30 min and 60 min after insufflations. In high pressure group lactate levels increased significantly as compared to low pressure group, (at 30 minutes after the establishment of abdominal pneumatic inflation P<0.006 and remained significantly increased (P<0.001) until the end of surgery and one hour thereafter) (P<0.001). The mean postoperative pain score during second hour (VAS) at HPP group was 7.4 +/- 1.17 which is significantly (P < or = 0.006) higher than pain score in LPP group 5.0 +/- 1.886. Shoulder tip pain was reported in 3 patients in the high pressure group and only one patient in the lower pressure group. Conclusion: High-pressure pneumoperitonium causes statistically significant elevation in the arterial lactate level intraoperatively until one hour post operatively. It also causes higher pain score and shoulder tip pain.     

Randomized comparison of conventional carbon dioxide insufflation and abdominal wall lifting for laparoscopic cholecystectomy

BACKGROUND: Gasless laparoscopy using abdominal wall lifting (AWL) has been developed in an attempt to avoid the adverse effects of carbon dioxide pneumoperitoneum that may occur in conventional laparoscopy. However, lifting has been criticized for its poor operative space and surgical invasiveness. This study compared the AWL method with conventional CO2 pneumoperitoneum for laparoscopic cholecystectomy with respect to operation performance, postoperative course, and stress response. PATIENTS AND METHODS: During a 6-month period, 95 patients with symptomatic gallstones were randomly assigned to receive laparoscopic cholecystectomy with conventional CO2 pneumoperitoneum (CO2 group; N = 47) or the AWL method (AWL group; N = 48). Operative results and operative time were recorded. Cardiopulmonary functions were assessed, and arterial blood gases were analyzed during surgery. Urinary cortisol, vanillylmandelic acid, metanephrines, and nitrogen loss; serum complement 3, C-reactive protein, and interleukin-6; postoperative pain; and the presence of nausea and vomiting were assessed for 48 hours after surgery. Postoperative time to recovery of flatus, tolerance of a full oral diet, and full activity were also determined. RESULTS: Only three significant differences were found. First, intraoperative ventilatory function deteriorated significantly less in the AWL group. Second, arterial blood gas determinations and capnography showed a greater decrease in intraoperative arterial pH and compliance with CO2 retention and an increase in peak airway pressure in the CO2 group (P < 0.05), reflecting poorer ventilatory performance. Third, preparation time and total operating time were significantly greater with the AWL method (P < 0.05). CONCLUSIONS: Although AWL required a longer operation time, our results suggest that the technique may still have value in high-risk patients with cardiorespiratory diseases.     

Randomized comparison between low-pressure laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy

Background: Laparoscopic cholecystectomy using low-pressure pneumoperitoneum (8 mmHg) minimizes adverse hemodynamic effects, reduces postoperative pain, and accelerates recovery. Similar claims are made for gasless laparoscopy using abdominal wall lifting. The aim of this study was to compare gasless laparoscopic cholecystectomy to low-pressure cholecystectomy with respect to postoperative pain and recovery. Methods: Thirty-six patients were randomized to low-pressure or gasless laparoscopic cholecystectomy using a subcutaneous lifting system (Laparotenser). Results: The characteristics of the patients were similar in the two groups. The procedure was completed in all patients in the low-pressure group, but two patients in the gasless group were converted to pneumoperitoneum. There were no significant differences in postoperative pain and analgesic consumption, but patients in the gasless group developed shoulder pain more frequently (50% vs 11%, p < 0.05). Gasless operation took longer to perform (95 vs 72.5 min, p= 0.01). Conclusions: Gasless and low-pressure laparoscopic cholecystectomy were similar with respect to postoperative pain and recovery. The gasless technique provided inferior exposure and the operation took longer, but the technique may still have value in high-risk patients with cardiorespiratory disease. Received: 10 August 1998/Accepted: 12 February 1999     

Retained abdominal gallstones during laparoscopic cholecystectomy

BACKGROUND: Although gallbladder perforation with spillage of bile and gallstones is quite common, the approach to retained gallstones in the abdomen still is controversial. METHODS: Laparoscopic cholecystectomy (LC) was performed on 580 patients with gallstones. In 101 (17%) patients, gallbladder perforations occurred during surgery, and in 43 (7%) patients, stone(s) were spilled into the peritoneal cavity. In 24 (4%) patients, gallstone(s) were not cleared entirely from the peritoneal cavity. These patients were invited to return for physical examination and biochemical tests. To investigate the retained abdominal gallstone(s) computed tomography was performed. RESULTS: Twenty-two patients were investigated. After a median follow-up period of 121 months, retained abdominal gallstone(s) were shown in 2 patients by computed tomography. Biochemical tests were normal except in 1 patient with chronic hepatitis. All of the patients were happy with their surgical results. CONCLUSIONS: This study revealed no harm caused by retained abdominal gallstone(s) during LC after long-term follow-up evaluation.     

腹腔镜胆囊切除术中气腹后中心静脉压的变化

目的观察腹腔镜下胆囊切除术中气腹后中心静脉压的变化情况,探讨其临床意义。方法无其他因素影响中心静脉压的30例病例行腹腔镜下胆囊切除术,观察二氧化碳气腹前、中、后中心静脉压的变化情况。结果二氧化碳气腹后中心静脉压明显升高,但仍在正常范围内,停止气腹后,中心静脉压快速恢复至术前水平。结论行腹腔镜下胆囊切除术时,二氧化碳气腹后的中心静脉压增加对循环系统功能影响不明显,仍在机体代偿范围,无常规检测的必要。     

不同麻醉对腹腔镜胆囊切除术患者二氧化碳气腹时脑氧合的影响

目的 观察不同麻醉对腹腔镜胆囊切除术患者二氧化碳气腹时脑氧合的影响。方法 腹腔镜胆囊切除术患者60例，ASAⅠ级或Ⅱ级，随机分为3组（n=20）：异氟醚组（Ⅰ组）、硬膜外复合异氟醚组（Ⅱ组）和硬膜外复合异丙酚组（Ⅲ组）。分别于气腹前即刻、气腹10、30min取桡动脉血和颈内静脉球部静脉血行血气分析，记录动脉血氧分压（PaO2）、动脉血二氧化碳分压（PaCO2）、动脉血氧饱和度（SaO2）、血红蛋白（Hb）浓度、颈内静脉血氧分压（PjvO2）和颈内静脉血氧饱和度（SjvO2）。根据Fick公式分别计算脑动脉和颈内静脉血氧含量及脑动静脉血氧含量差（Da-jvO2）。结果 与气腹前即刻比较，Ⅰ组、Ⅱ组气腹10、30min时SjvO2升高、Da-jvO2降低（P〈0．01）;与Ⅲ组比较，气腹10、30min时Ⅰ组、Ⅱ组SjvO2升高、Da-jvO2降低（P〈0.05）;与Ⅱ组比较，气腹10、30 min时Ⅰ组SjvO2升高、Da-jvO2降低（P〈0．05）。结论 硬膜外复合异丙酚静脉麻醉可改善术中脑组织的氧合，是腹腔镜手术患者较适宜的麻醉方法。     

Swan-Ganz catheter-induced tricuspid regurgitation during pneumoperitoneum for laparoscopic cholecystectomy

The occurrence of Swan-Ganz (S-G) catheter-induced tricuspid regurgitation (TR) was investigated using transesophageal echocardiography in four patients who underwent laparoscopic cholecystectomy with 12-mmHg pneumoperitoneum. Before pneumoperitoneum, TR was not detected in any of the four patients, despite the presence of an inserted S-G catheter; however, it was detected after completion of 12-mmHg pneumoperitoneum in one of the four patients. This TR was diminished after depneumoperitoneum and the employment of a retraction method by which the intra-abdominal pressure became equal to the atmospheric pressure. This TR was not recognized after the removal of the S-G catheter during 12-mmHg pneumoperitoneum in the same patient. There is a possibility that the S-G catheter induces TR during 12-mmHg pneumoperitioneum.