What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review.
BACKGROUND
Laparoscopic surgery has several advantages when compared to open surgery, including faster postoperative recovery and lower pain scores. However, for laparoscopy, a pneumoperitoneum is required to create workspace between the abdominal wall and intraabdominal organs. Increased intraabdominal pressure may also have negative implications on cardiovascular, pulmonary, and intraabdominal organ functionings. To overcome these negative consequences, several trials have been performed comparing low- versus standard-pressure pneumoperitoneum.


METHODS
A systematic review of all randomized controlled clinical trials and observational studies comparing low- versus standard-pressure pneumoperitoneum.


CONCLUSIONS
Quality assessment showed that the overall quality of evidence was moderate to low. Postoperative pain scores were reduced by the use of low-pressure pneumoperitoneum. With appropriate perioperative measures, the use of low-pressure pneumoperitoneum does not seem to have clinical advantages as compared to standard pressure on cardiac and pulmonary function. Although there are indications that low-pressure pneumoperitoneum is associated with less liver and kidney injury when compared to standard-pressure pneumoperitoneum, this does not seem to have clinical implications for healthy individuals. The influence of low-pressure pneumoperitoneum on adhesion formation, anastomosis healing, tumor metastasis, intraocular and intracerebral pressure, and thromboembolic complications remains uncertain, as no human clinical trials have been performed. The influence of pressure on surgical conditions and safety has not been established to date. In conclusion, the most important benefit of low-pressure pneumoperitoneum is lower postoperative pain scores, supported by a moderate quality of evidence. However, the quality of surgical conditions and safety of the use of low-pressure pneumoperitoneum need to be established, as are the values and preferences of physicians and patients regarding the potential benefits and risks. Therefore, the recommendation to use low-pressure pneumoperitoneum during laparoscopy is weak, and more studies are required.
Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands. Denise.Ozdemir-vanBrunschot@radboudumc.nl.
Denise M D
DM
Özdemir-van Brunschot
Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
Kees C J H M
KC
van Laarhoven
Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands.
Gert-Jan
GJ
Scheffer
Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
Sjaak
S
Pouwels
Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE), Radboud University Medical Center, Nijmegen, The Netherlands.
Kim E
KE
Wever
Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
Michiel C
MC
Warlé
D058186:Acute Kidney Injury / Q000453:epidemiology; D048550:Hepatic Insufficiency / Q000453:epidemiology; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D010149:Postoperative Pain / Q000453:epidemiology* / Q000503:physiopathology; D011028:Pneumoperitoneum, Artificial / Q000379:methods*; D011183:Postoperative Complications / Q000453:epidemiology*; D011312:Pressure
Laparoscopy; Low pressure; Pain; Perioperative conditions; Pneumoperitoneum