title: Safe and optimal pneumoperitoneal pressure for transperitoneal laparoscopic renal surgery in infant less than 10 kg, looked beyond intraoperative period: A prospective randomized study.
abstract: OBJECTIVE
  A safe and optimal pneumoperitoneal pressure (PP) for laparoscopic renal surgery in infants is difficult to define. In a broad sense, a safe and optimal PP should cause least intraoperative and postoperative physiological stress for the infants and should be optimal for surgeon's technical feasibility. Unfortunately, the safe and optimal PP in infant for transperitoneal laparoscopic surgery has not been established by well validated study. To determine safe and optimal PP for laparoscopic renal surgery (LRS) in infants less than 10 kg.
  
  
  METHODS
  In a prospective and randomized setting, between July 2008 and June 2014, 46 infants of <10 kg (Group I, n = 23, PP = 6-8 mmHg and Group II, n = 23, PP = 9-10 mmHg) who underwent LRS, were analyzed. Hemodynamic, respiratory, and blood gas changes were measured at four points: before CO2insufflation (T0), 10 min after insufflation (T1), before desufflation (T2) and 10 min after desufflation (T3). Any required adjustments of ventilator parameters were noted. Time to resume feeding and postoperative pain at 1, 6, and 12 h, including requirement for postoperative rescue analgesia, were assessed. Technical feasibility with allocated PP was evaluated by means of successful completion of surgery, duration of surgery, and intraoperative complications.
  
  
  RESULTS
  At T1and T2, changes in hemodynamic and respiratory parameters were significantly higher in Group II. At T3, most of the parameters statistically restored back to baseline in Group I but not so in Group II. Required adjustments in ventilatory parameters were 14 vs. 25 times in Group I vs. Group II (p = 0.007, R = 0.552). Mean postoperative pain score, requirement for analgesia, and time to resume feeding were significantly greater in Group II. Surgeries were successfully completed in all the patients in both groups, with comparable duration of surgery and similar intraoperative complications (Table).
  
  
  CONCLUSIONS
  It was found that hemodynamic and respiratory changes were more pronounced with higher pneumoperitoneal pressure in infants for renal laparoscopic surgery. With a PP of 6-8 mmHg, intraoperative accessibility is optimal, and physiological changes are minimal. Interestingly, we found that infants with PP of 6-8 mmHg enjoy smooth and early postoperative recovery. There was no direct objective criterion to assess level of difficulty with allocated PP, which may be considered a limitation of the present study. Pneumoperitoneal pressure of 6-8 mmHg appears to be a safe and optimal range for transperitoneal laparoscopic renal surgery in infants.
authors.affiliation: Department of Urology and Renal Transplant, SGPGIMS, Lucknow, India. Electronic address: drsksureka@gmail.com.
authors.forename: Sanjoy K
authors.initials: SK
authors.lastname: Sureka
authors.affiliation: Department of Urology and Renal Transplant, SGPGIMS, Lucknow, India. Electronic address: drnitesh80@yahoo.co.in.
authors.forename: Nitesh
authors.initials: N
authors.lastname: Patidar
authors.affiliation: Department of Urology and Renal Transplant, SGPGIMS, Lucknow, India. Electronic address: varunshonu@yahoo.in.
authors.forename: Varun
authors.initials: V
authors.lastname: Mittal
authors.affiliation: Department of Urology and Renal Transplant, SGPGIMS, Lucknow, India. Electronic address: rkapoor@sgpgi.ac.in.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Kapoor
authors.affiliation: Department of Urology and Renal Transplant, SGPGIMS, Lucknow, India. Electronic address: aneesh892012@gmail.com.
authors.forename: Aneesh
authors.initials: A
authors.lastname: Srivastava
authors.affiliation: Department of Anesthesia, SGPGIMS, Lucknow, India. Electronic address: kamalkishore2@rediffmail.com.
authors.forename: Kamal
authors.initials: K
authors.lastname: Kishore
authors.affiliation: Department of Anesthesia, SGPGIMS, Lucknow, India. Electronic address: sdhiraaj@sgpgi.ac.in.
authors.forename: Sanjay
authors.initials: S
authors.lastname: Dhiraj
authors.affiliation: Department of Urology and Renal Transplant, SGPGIMS, Lucknow, India. Electronic address: ansarimsa@hotmail.com.
authors.forename: M S
authors.initials: MS
authors.lastname: Ansari
mesh_terms: D001835:Body Weight; D006801:Humans; D007223:Infant; D007432:Intraoperative Period; D010535:Laparoscopy / Q000379:methods*; D009392:Nephrectomy / Q000379:methods*; D010537:Peritoneum; D011028:Pneumoperitoneum, Artificial / Q000379:methods*; D011446:Prospective Studies; D016037:Single-Blind Method
keywords: Infants; Laparoscopy; Pneumoperitoneal pressure