The European Association for Endoscopic Surgery clinical practice guideline on the pneumoperitoneum for laparoscopic surgery.
BACKGROUND
The pneumoperitoneum is the crucial element in laparoscopic surgery. Different clinical problems are associated with this procedure, which has led to various modifications of the technique. The aim of this guideline is to define the scientifically proven standards of the pneumoperitoneum.


METHODS
Based on systematic literature searches (Medline, Embase, and Cochrane), an expert panel consensually formulated clinical recommendations, which were graded according to the strength of available literature evidence.


CONCLUSIONS
Preoperatively, all patients should be assessed for the presence of cardiac, pulmonary, hepatic, renal, or vascular comorbidity. Presupposing appropriate perioperative measures and surgical technique, there is no reason to contraindicate pneumoperitoneum in patients with peritonitis or intraabdominal malignancy. During laparoscopy, monitoring of end tidal CO2 concentration is mandatory. The available data on closed- (Veress needle) and open-access techniques do not allow us to principally favor the use of either technique. Using 2 to 5-mm instead of 5 to 10-mm trocars improves cosmetic result and postoperative pain marginally. It is recommended to use the lowest intraabdominal pressure allowing adequate exposure of the operative field, rather than using a routine pressure. In patients with limited cardiac, pulmonary, or renal function, abdominal wall lifting combined with low-pressure pneumoperitoneum might be an alternative. Abdominal wall lifting devices have no clinically relevant advantages compared to low-pressure (5-7 mmHg) pneumoperitoneum. In patients with cardiopulmonary diseases, intra- and postoperative arterial blood gas monitoring is recommended. The clinical benefits of warmed, humidified insufflation gas are minor and contradictory. Intraoperative sequential intermittent pneumatic compression of the lower extremities is recommended for all prolonged laparoscopic procedures. For the prevention of postoperative pain a wide range of treatment options exists. Although all these options seem to reduce pain, the data currently do not justify a general recommendation.
Neudecker
J
J
Department of Surgery, Charité Campus Mitte, Humboldt-University of Berlin, Schumannstrasse 20/21, 10117 Berlin, Germany.
Sauerland
S
S
Neugebauer
E
E
Bergamaschi
R
R
Bonjer
H J
HJ
Cuschieri
A
A
Fuchs
K-H
KH
Jacobi
Ch
Ch
Jansen
F W
FW
Koivusalo
A-M
AM
Lacy
A
A
McMahon
M J
MJ
Millat
B
B
Schwenk
W
W
D000075202:Contraindications; D004724:Endoscopy / Q000009:adverse effects / Q000592:standards*; D005060:Europe; D005260:Female; D006801:Humans; D007327:Insufflation / Q000009:adverse effects / Q000379:methods; D007431:Intraoperative Complications / Q000517:prevention & control; D008991:Monitoring, Physiologic; D010538:Peritonitis / Q000175:diagnosis; D011028:Pneumoperitoneum, Artificial / Q000009:adverse effects / Q000592:standards*; D011183:Postoperative Complications / Q000517:prevention & control; D020250:Postoperative Nausea and Vomiting / Q000517:prevention & control; D011247:Pregnancy; D011248:Pregnancy Complications / Q000601:surgery; D011262:Pregnancy Trimester, Second; D011300:Preoperative Care / Q000379:methods; D012955:Societies, Medical / Q000458:organization & administration / Q000592:standards