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["Low-pressure" laparoscopic cholecystectomy in high risk patients (ASA III and IV): our experience]
Marco Catani1, Renato Guerricchio, Ritanna De Milito
1Dipartimento di Chirurgia Paride Stefanini, Università La Sapienza di Roma.
Insights
Low-pressure pneumoperitoneum (6.5-8 mm Hg) is feasible for laparoscopic cholecystectomy in high-risk patients. This technique minimizes adverse cardiovascular effects compared to standard insufflation pressures.
Area of Science:
- Minimally Invasive Surgery
- Surgical Anesthesiology
- Gastrointestinal Surgery
Context:
- Laparoscopic cholecystectomy typically uses 12-15 mm Hg insufflation pressure.
- Carbon dioxide pneumoperitoneum significantly impacts cardiovascular and respiratory function.
- High-risk patients (ASA III/IV) with poor cardiac reserve are vulnerable to these effects.
Purpose:
- To assess the feasibility of performing laparoscopic cholecystectomy at reduced insufflation pressures (6.5-8 mm Hg).
- To evaluate the impact of low-pressure pneumoperitoneum on cardiovascular and respiratory variables in high-risk surgical patients.
Summary:
- Thirteen high-risk patients (10 ASA III, 3 ASA IV) underwent laparoscopic cholecystectomy with 6.5-8 mm Hg insufflation pressure and 10-degree anti-Trendelenburg position.
- Minimal increases in heart rate and mean arterial blood pressure were observed compared to standard pressures.
- No conversions or complications occurred; moderate increases in PaCO2 and a stable end-tidal CO2 gradient were noted.
Impact:
- Low-pressure pneumoperitoneum is a feasible and safer alternative for laparoscopic cholecystectomy in high-risk populations.
- This approach effectively minimizes adverse hemodynamic effects associated with peritoneal insufflation.
- The findings support the adoption of reduced insufflation pressures to improve patient safety in specific surgical contexts.
Abstract:
The insufflation pressure used for laparoscopic cholecystectomy is usually 12-15 mm Hg, and a pneumoperitoneum with carbon dioxide has a significant effect on both cardiovascular and respiratory function. These effects are transient in young, healthy patients, but may be dangerous in ASA III and IV patients with a poor cardiac reserve. This study was designed to assess the feasibility of performing laparoscopic cholecystectomy at 6.5-8 mm Hg insufflation pressure in "high-risk" patients. Thirteen patients, 10 ASA III and 3 ASA IV, with cholelithiasis, were included in this study The insufflation pressure was 6.5-8 mm Hg, with a 10 degrees anti-Trendelenburg position. The cardiovascular and blood gas variables studied were: mean arterial blood pressure, heart rate, respiratory rate, and end-tidal CO2 pressure. The authors reported no conversions and no intra- or postoperative complications. During insufflation heart rate and mean arterial blood pressure increased minimally if compared with laparoscopic cholecystectomy at 12-15 mm Hg. Pa CO2 increased after insufflation (+5 mm Hg), and the end-tidal CO2 pressure gradient was moderate (3.5 mm Hg) and unchanged during surgery. A low-pressure pneumoperitoneum is feasible for laparoscopic cholecystectomy and minimizes the adverse haemodynamic effects of peritoneal insufflation.
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