title: Haemostatic changes in laparoscopic cholecystectomy: a comparison between upper and lower limb measurements.
abstract: BACKGROUND
  The use of pnuemoperitonium to create the working environment for laproscopic cholecystectomy results in an increase in intraabdominal pressure, which exceeds the pressure of the venous-return from the legs. The resulting venous stasis may increase the risk of thrombosis formation and deep vein thrombosis in the lower limbs. However, there is no information as to whether the venous stasis will also exacerbate the coagulabililty of blood flowing out of the lower limbs.
  
  
  OBJECTIVE
  The aim of the study is to find evidence of haemostatic activation in the blood draining the lower limbs, which experience venous stasis as a result of the laparoscopic cholecystectomy (LC) procedure.
  
  
  METHODS
  In this study, we prospectively studied 25 patients who underwent LC for uncomplicated cholelithiasis; 20 were female and 5 were male, aged between 17 to 65 years. LC was carried out according to a standard procedure. After general anesthesia, the patients were laid in a 30 degrees anti-Trendelenburg position, and pnuemoperitonium was maintained during the procedure with abdominal pressure of 12 mm Hg. The mean operating time was 55 minutes (range 25 to 118 min).Blood samples were collected simultaneously from the antecubetal fossa (the upper limb) and the dorsum of the foot (the lower limb), on 4 different occasions: i. preoperative; ii. after the induction of anesthesia, and before the inflation of the abdomen; iii. at the end of surgery, before deflation of the abdomen, and iv. 24 hours after surgery. LABORATORY ASSAYS: Prothrombin time, activated partial thromboplastin time, thrombin time, and plasma fibrinogen, Plasma Protein S (total and free), Protein C, Antithrombin, tissue plasminogen activator, and plasminogen activator inhibitor (PAI-I). Platelet function was assessed by the platelet function analyser (PFA100).
  
  
  RESULTS
  No significant differences were noted in all measured haemostatic parameters, including PFA100 closure times, when comparing the measurements that were taken simultaneously in the upper and lower limbs' blood. Plasma fibrinogen increased significantly 24 hours after surgery, and antithrombin levels dropped slightly, immediately after surgery, but recovered preoperative levels 24 hours after surgery. Coagulation inhibitors (total and free protein S and protein C), and fibrinolytic parameters did not show any significant fluctuations throughout the study intervals.
  
  
  CONCLUSIONS
  The finding of this study is of no significant activation of coagulation in the blood flowing out of the lower limbs at the time of venous stasis, adds to the criteria of safety of the current surgical procedure used in LC, including reverse Trendelenburg position and pneumoperitoneum that unavoidably produce significant stasis in the lower limbs.
authors.affiliation: Department of Surgery and the Coagulation Laboratory, College of Medicine and King Khalid University Hospital, King Saud University, Riyadh, Saudi Arabia.
authors.forename: Gamal
authors.initials: G
authors.lastname: Khairy
authors.forename: Abeer
authors.initials: A
authors.lastname: Al Ghumlas
authors.forename: Abdullah
authors.initials: A
authors.lastname: Al Dohayan
authors.forename: Abdel Galil Mohammad Abdel
authors.initials: AG
authors.lastname: Gader
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001780:Blood Coagulation Tests; D017081:Cholecystectomy, Laparoscopic; D002769:Cholelithiasis / Q000601:surgery; D005260:Female; D005528:Foot / Q000098:blood supply*; D006487:Hemostasis / Q000502:physiology*; D006801:Humans; D007866:Leg / Q000098:blood supply*; D008297:Male; D008875:Middle Aged