title: Abdominal wall lift versus positive-pressure capnoperitoneum for laparoscopic cholecystectomy: randomized controlled trial.
abstract: OBJECTIVE
  To compare intraoperative cardiac function, postoperative cognitive recovery, and surgical performance of laparoscopic cholecystectomy with abdominal wall lift (AWL) versus positive-pressure capnoperitoneum (PPCpn).
  
  
  BACKGROUND
  AWL has been proposed as an alternative approach to PPCpn to avoid adverse cardio-respiratory changes. However, the workspace obtained with the AWL is less optimal than PPCpn and previous studies documenting delayed postoperative recovery of consciousness following PPCpn have not assessed mental alertness despite its importance.
  
  
  METHODS
  Forty operations were randomized into AWL and PPCpn. A standard anesthetic protocol was followed. Cardiac indices were measured with an esophageal Doppler machine. An auditory vigilance test was used to measure alertness level following extubation. All operations were videotaped and human reliability assessment techniques were used to identify surgical errors.
  
  
  RESULTS
  There was a significant reduction in cardiac output during the first 20 minutes following CO2 insufflation in the PPCpn group, whereas in the AWL group it did not exhibit any significant change. Patients in AWL arm had better vigilance scores at 90 and 180 minutes following extubation compared with the PPn group (P < 0.05). Significantly more surgical errors were observed during surgery with AWL than with PPCpn (7.1 +/- 1.1; versus 2.9 +/- 0.4; P = 0.001).
  
  
  CONCLUSIONS
  The AWL approach avoids fall in cardiac output associated with PPCpn during laparoscopic surgery and is associated with a more rapid recovery of postoperative cognitive function compared with PPCpn. However, AWL increases the level of difficulty in the execution of the operation.
authors.affiliation: Department of Surgery and Molecular Oncology, Ninewells Hospital and Medical School, Dundee, Scotland.
authors.forename: Afshin
authors.initials: A
authors.lastname: Alijani
authors.forename: George B
authors.initials: GB
authors.lastname: Hanna
authors.forename: Alfred
authors.initials: A
authors.lastname: Cuschieri
mesh_terms: D034861:Abdominal Wall / Q000601:surgery*; D017081:Cholecystectomy, Laparoscopic / Q000379:methods*; D005260:Female; D006439:Hemodynamics; D006801:Humans; D008297:Male; D008875:Middle Aged; D011028:Pneumoperitoneum, Artificial / Q000379:methods