Outcome analysis of low pressure versus high pressure pneumoperitoneum laparoscopic cholecystectomy: a randomized clinical study

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


Background: Laparoscopic cholecystectomy is established as gold standard for management of cholelithiasis. Intraoperative pneumoperitoneum affects the postoperative outcomes. The current stress is on increasing patient safety. Hence, this prospective study was undertaken to compare the effect of low pressure pneumoperitoneum (LPP <10 mm Hg) versus high pressure pneumoperitoneum (HPP > 14 mm Hg) on postoperative pain and ileus.

Methods: 120 patients undergoing laparoscopic cholecystectomy were randomized into the LPP (<10mm Hg) group (n=60) and the HPP (>14 mm Hg) group (n=60). Total duration of surgery, intra-operative gas consumption, occurrence of bile spillage during operation, shoulder pain and abdominal pain in postoperative period, additional requirement of analgesia in postoperative period and postoperative ileus were assessed.

Results: There was no significant difference in terms of operative duration, consumption of CO2 gas, intraoperative bile spillage, total hospital stay and tolerance to early feeding. The incidence of shoulder pain was higher in patients who underwent HPP laparoscopic cholecystectomy (p<0.05). There was early recovery and early return of bowel activity in LPP which was statistically significant.

Conclusions: Low-pressure pneumoperitoneum is feasible and safe and results in reduced postoperative shoulder tip pain and near-equal operative time with early return of bowel activity compared with high-pressure pneumoperitoneum.


High-pressure pneumoperitoneum, Laparoscopic cholecystectomy, Low-pressure pneumoperitoneum, Postoperative shoulder pain, Post-operative ileus

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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;16(6):383-6.

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.

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

Cunnife MG, McAnena OJ, Dar MA, Flyn CJ. prospective randomized trial of intraoperative bupivacaine irrigation for management of shoulder-tip pain after laparoscopic cholecystectomy. Surg Laparoscopy. Am J Surg. 1998;176;258-61.

Dobbs FF, Kumar V, Alexander JI, Hull MGR. Pain after laparoscopy related to posture and ring versus clip sterilization. Br J Obstect Gynaecol. 1987;94:262-6.

Tsimoyiannis EC, Semm K. Das pospeviskopische (laparoskopische) Schmerzsyndrom. Geburtbilfe Frauenbeil. 1980;40:635-43.

Rosenthal RJ, Friedman RL, Kahn AM, Martz J, Thiagarajah S, Cohen D, Shi Q, Nussbaum M. Reasons for intracranial hypertension and hemodynamic instability during acute elevations of intra-abdominal pressure: observations in a large animal model. J Gastrointest Surg. 1998 Sep-Oct;2(5):415-2.

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.

Davidas D, Birbs K, Vezakis A, Mcmohan MJ. Routine low-pressure pneumoperitoneum during laparoscopic cholecystectomy. Surg Endosc. 1999:13:87-9.

Barczynski M, Herman RM. The usefulness of low pressure pneumoperitoneum in laparoscopic surgery. Folia Med Cracow. 2002;43:43-50. (Abstract)

Vezakis A, Davides D, Gibson JS, Moore MR, Shah H, Larvin M, et al. Randomized comparison between laparoscopic cholecystectomy and gasless laparoscopic cholecystectomy. Surg Endosc. 1999;13:890-3.

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

Perrakis E, Vezakis A, Velimexis G, Savanis G, Deverakis S, Antoniades J, et al. Randomized comparison between different insufflation pressure for laparoscopic cholecystectomy. Surg Laparo Endosc Percutan Tech. 2003;13:245-9.

Dexter SP, Vucevic M, Gibson J, McMahon MJ. Hemodynamic consequences of high and low pressure capnoperitoneum during laparoscopic cholecystectomy. Surg Endosc. 1999;13:376-81.

Sarli L, Costi R, Sansebastiano G, Trivelli M, Roncoroni L. Prospective randomized trial of low pressure pneumoperitoneum for the reduction of shoulder tip pain following laparoscopy. Br J Surg. 2000;87:1161-5.

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 in laparoscopic cholecystectomy, a prospective randomized clinical trial. Surg Endosc. 2009 (5):1044-7.

Vijayaraghavan N, Sistla SC, Kundra P, Ananthanarayan PH, Karthikeyan VS, Ali SM, Sasi SP, Vikram K, 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.

Kandil TS, El Hefnawy E. Shoulder pain following laparoscopic cholecystectomy: factors affecting the incidence and severity. J Laparoendosc Adv Surg Tech A. 2010 Oct;20(8):677-82.

Yasir M, Mehta KS, Banday VH, Aiman A, Masood I, Iqbal B. Evaluation of post-operative shoulder tip pain in low pressure versus standard pressure pneumoperitoneum during laparoscopic cholecystectomy. Surgeon. 2012 Apr;10(2):71-4.

Topcu HO, Cavkaytar S, Kokanalı K, Guzel AI, Islimye M, Doganay M. A prospective randomized trial of postoperative pain following different insufflation pressures during gynecologic laparoscopy. Eur J Obstet Gynecol Reprod Biol. 2014 Nov;182:81-5.

Singla S, Mittal G, Raghav, Mittal RK Pain management after laparoscopic cholecystectomy-a randomized prospective trial of low pressure and standard pressure pneumoperitoneum. J Clin Diagn Res. 2014 Feb;8(2):92-4.

Bustorff-Silva J, Perez CA, Atkinson JB, Raybould HE. Effects of intraabdominally insufflate carbon dioxide and elevated intraabdominal pressure on postoperative gastrointestinal transit: an experimental study in mice. J Pediatr Surg. 1999 Oct;34(10):1482-5.

Augestad KM, Delaney CP. Postoperative ileus: impact of pharmacological treatment, laparoscopic surgery and enhanced recovery pathways. World journal of gastroenterology: WJG. 2010 May 7;16(17):2067.