Objective: To compare intraoperative cardiac function, postoperative cognitive recovery, and surgical performance of laparoscopic cholecystectomy with abdominal wall lift (AWL) versus positive-pressure capnoperitoneum (PPCpn).
Summary Background Data: AWL has been proposed as an alternative approach to PPCpn to avoid adverse cardio-respiratory changes. However, the workspace obtained with the AWL is less optimal than PPCpn and previous studies documenting delayed postoperative recovery of consciousness following PPCpn have not assessed mental alertness despite its importance.
Methods: Forty operations were randomized into AWL and PPCpn. A standard anesthetic protocol was followed. Cardiac indices were measured with an esophageal Doppler machine. An auditory vigilance test was used to measure alertness level following extubation. All operations were videotaped and human reliability assessment techniques were used to identify surgical errors.
Results: There was a significant reduction in cardiac output during the first 20 minutes following CO2 insufflation in the PPCpn group, whereas in the AWL group it did not exhibit any significant change. Patients in AWL arm had better vigilance scores at 90 and 180 minutes following extubation compared with the PPn group (P < 0.05). Significantly more surgical errors were observed during surgery with AWL than with PPCpn (7.1 ± 1.1; versus 2.9 ± 0.4; P = 0.001).
Conclusions: The AWL approach avoids fall in cardiac output associated with PPCpn during laparoscopic surgery and is associated with a more rapid recovery of postoperative cognitive function compared with PPCpn. However, AWL increases the level of difficulty in the execution of the operation.
Positive-pressure capnoperitoneum (PPCpn) is the conventional method of exposure in laparoscopic surgery. This positive intra-abdominal pressure (10-12 mm Hg) is associated with a variable but significant reduction in cardiac output1 that may be detrimental in high-risk patients with poor cardiac reserve. The adverse cardiovascular effects of PPCpn are important, as up to 45% of patients undergoing laparoscopic cholecystectomy are in the high-risk category (American Society of Anaesthesiologists grade 3 and above), and over 20% have established cardiovascular disease.2 In a nationwide audit,3 cardiac morbidity was identified as an independent risk factor for mortality after laparoscopic cholecystectomy.
Recovery of physical fitness and cognitive functions determine the period of short-term disability before return to normal physical/mental activity following surgery. The level of patients' alertness following surgery is a determining factor in the restoration of early postoperative independence, and early discharge from hospital. Delay in mental recovery following laparoscopic surgery may detract from the benefits of reduced access trauma. The reported research on delayed postanesthetic recovery following PPCpn has not included studies on mental alertness.4 This is a serious limitation, as cognitive function is crucial to safe independent activity of patients recovering from surgery.
Abdominal wall lift (AWL) is an alternative approach to PPCpn that avoids the cardiac changes associated with a raised intra-abdominal pressure. To date, a variety of AWL systems have been used in a wide range of surgical procedures.5 In AWL, intra-abdominal workspace is created by elevating the anterior abdominal wall with a mechanical lift device. However, the exposure of the operative field and workspace obtained with the abdominal wall lift technique are less optimal than those provided by PPCpn. This imposes as extra level of difficulty to the execution of the operation. The present trial was designed to compare the patients' cardiac function and postoperative cognitive recovery and the surgical performance using a lifting device compared with laparoscopic exposure by PPCpn.