Intraoperative safety of low pressure pneumoperitoneum cholecystectomy: a comparative study

Salil Mahajan, Manu Shankar, Vinod K. Garg, Vijender Gupta, Jaya Sorout


Background: With the establishment of laparoscopic cholecystectomy as gold standard for management of cholelithiasis, the current stress is on increasing patient safety. Hence, this study was undertaken to compare the effect of low pressure pneumoperitoneum (LPP <10mm Hg) versus high pressure pneumoperitoneum (HPP >14mm Hg) in a prospective randomized manner on intraoperative safety, assessing the working space and safety by seeing contact of parietal peritoneum to underlying viscera during secondary port insertion.

Methods: 120 patients undergoing laparoscopic cholecystectomy were randomized into the LPP (<10mm Hg) group (n=60) and the HPP (>14mm Hg) group (n=60) prospectively. Available working space assessed directly, safety by contact of parietal peritoneum to underlying viscera during secondary port insertion and operative difficulty assessed by visualization, dissection and grasping, total duration of surgery; intra-operative gas consumption, and bile spillage were assessed.

Results: There was no significant difference in terms of available working space, operative duration, consumption of carbon dioxide, surgeon’s operative difficulty and intraoperative bile spillage. Out of 180 secondary ports inserted, there was evident contact of 20 (11.1%) secondary ports in high pressure groups and 14 (7.7%) secondary ports in low pressure group, which is suggestive of adequate exposure and working space available for surgery at both pressures.

Conclusions: Low-pressure cholecystectomy did not compromise intraoperative safety and should be the standard of care in day care surgery.


High-pressure pneumoperitoneum, Laparoscopic cholecystectomy, Low-pressure pneumoperitoneum, Postoperative shoulder pain

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Chok KS, Yuen WK, Lau H, Fan ST. Prospective randomized trial on low-pressure versus standard-pressure pneumoperitoneum in outpatient laparoscopic cholecystectomy Surg Laparosc Endosc Percutan Tech. 2006 Dec;16(6):383-6.

Koc M, Ertan T, Tez M, Kocpinar MA, Kilic M, Gocmen E, Aslar AK. Randomized, prospective comparison of postoperative pain in low- versus high-pressure pneumoperitoneum. ANZ J Surg. 2005 Aug;75(8):693-6.

Esmat ME, Elsebae MM, Nasr MM, Elsebaie SB. Combined low-pressure pneumoperitoneum and intraperitoneal infusion of normal saline for reducing shoulder tip pain following laparoscopic cholecystectomy. World J Surg. 2006;30:1969-73.

Hasukiae S. Postoperative changes in liver function tests:randomized comparisons of low and high pressure laparoscopic cholecystectomy. Surg Endosc. 2005;19:1451-5.

Joris J, Cigarini I, Legrand M, Jacquet N, De Groote D, FranchimontP, et al. Metabolic and respiratory changes after cholecystectomy performed via laparotomy or laparoscopy. Br J Anaesth. 1992;63:341-5.

Baraka A, Jabbour S, Hammond R. End tidal carbon dioxide tension during laparoscopic cholecystectomy. Anaesthesia. 1994;49:403-6.

Compeau C, McLeod NT, Ternamian A. Laparoscopic entry: a review of Canadian general surgical practice. Canadian J Surg. 2011;54(5):315-20.

Catarci M, Carlini M, Gentileschi P, Santoro E. Major and minor injuries during the creation of pneumoperitoneum. A multicentre study on 12,919 cases Surg Endosc. 2001 Jun;15(6):566-9. Epub 2001 Apr 3.

Hashizume M, Sugimachi K. Needle and trocar injury during laparoscopic surgery in Japan Surgical Endoscopy. 1997;11(12):1198-201.

Wideochir Inne Tech Malo Inwazyjne. Intra-abdominal and abdominal wall haematoma from 5 mm port insertion site in laparoscopic cholecystectomy Wideochir Inne Tech Malo Inwazyjne. 2011 Sep;6(3):164-6.

Komuta K, Haraguchi M, Inoue K, Furui J, Kanematsu T. Herniation of the small bowel through the port site following removal of drains during laparoscopic surgery. Dig Surg. 2000;17(5):544-6.

Han NY, Sung DJ, Park BJ, Kim MJ, Cho SB, Kim YH. Imaging of complications associated with port access of abdominal laparoscopic surgery Abdom Imaging. 2014 Apr;39(2):398-410.

Corson SL, Chandler JG, Way LW. Survey of laparoscopic entry injuries provoking litigation. J Am Assoc Gynecol Laparosc. 2001 Aug;8(3):341-7.

Krishnakumar S, Tambe P. Entry Complications in Laparoscopic Surgery J Gynecol Endosc Surg. 2009 Jan-Jun;1(1):4-11.

Galizia G, Prizio G, Lieto E, Castellano P, Pelosio L, Imperatore V, et al. Hemodynamic and pulmonary changes during open, carbon dioxide pneumoperitoneum and abdominal wall-lifting cholecystectomy. A prospective, randomized study. Surgical Endoscopy. 2001;15(5):477-83.

Kanwer DB, Kaman L, Nedounsejiane M, Medhi B, Verma GR, Bala I. Comparative study of low pressure versus standard pressure pneumoperitoneum in laparoscopic cholecystectomy- a randomized controlled trial. Tropical Gastroenterology. 2009;30(3):171-4.

Sandhu T, Yamada S, Ariyakachon V, Chakrabandhu T, Chongruksut W, Ko-iam W. Low-pressure pneumoperitoneum versus standard pneumoperitoneum inlaparoscopic cholecystectomy, a prospective randomized clinical trial. Surg Endosc. 2009 (5):1044-7.

Vijayaraghavan N, Sistla SC, Kundra P, Ananthanarayan PH, Karthikeyan VS, Ali SM, et al. Comparison of standard-pressure and low-pressure pneumoperitoneum in laparoscopic cholecystectomy: a double blinded randomized controlled study. Surg Laparosc Endosc Percutan Tech. 2014;24(2):127-33.

Barczynski M, Herman RM. A prospective randomized trial on comparison of low pressure and standard pressure pneumoperitoneum for laparoscopic cholecystectomy. Surg Endosc. 2003;17:533-8.

Wallace DH, Serpell MG, Baxter JN, O’Dwyer PJ. Randomized trialof different insufflation pressures for laparoscopic cholecystectomy. Br J Surg. 1997;84:455-8.

Joshipura VP, Haribhakti SP, Patel NR, Naik RP, Soni HN, Patel B, et al. A prospective randomized, controlled study comparing low pressure versus high pressure pneumoperitoneum during laparoscopic cholecystectomy. Surg Laparosc Endosc Percutan Tech. 2009 Jun;19(3):234-40.