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Background: Conventional laparoscopic cholecystectomy (CLC) with carbon dioxide pneumoperitoneum may cause major cardiovascular changes. The aim of this study was to evaluate the effect of
carbon dioxide pneumoperitoneum and positional changes on haemodynamics and cardiac function in
patients assigned randomly to CLC or gasless laparoscopic cholecystectomy (GLC).
Methods: Fifty patients with American Society of Anesthesiologists physical status I and II were randomly
allocated to CLC (28 patients) or GLC (22). Left ventricular end-diastolic and end-systolic diameters,
fractional shortening and cardiac output were determined by transoesophageal echocardiography.
Measurements were performed before (phase 1) and 10 and 30 min (phases 2 and 3 respectively)
after pneumoperitoneum or abdominal wall traction, and after desufflation or release of abdominal wall
traction (phase 4) in supine, Trendelenburg and reverse Trendelenburg positions.
Results: Mean diastolic diameter, systolic diameter, mean arterial pressure and heart rate
were significantly higher, and fractional shortening was significantly lower, with carbon dioxide
pneumoperitoneum than with the gasless procedure during phases 2 and 3. There were no significant
differences in cardiac output between the two groups.
Conclusion: Carbon dioxide pneumoperitoneum was associated with increased preload and afterload
in patients undergoing laparoscopic cholecystecomy. It also decreased heart performance (fractional
shortening), but did not affect cardiac output.
Introduction
Surgery
Three surgeons experienced in both procedures performed
all operations. CLC was performed using carbon dioxide
pneumoperitoneum at a pressure of 12 mmHg, with
two 10-mm ports and two 5-mm ports. In the gasless
group, two curved steel needles were inserted into the
subcutaneous space and attached to a mechanical arm
fixed to the operating table (Laparotensor ; Lucini, Milan,
Italy). A minilaparotomy (15 mm) was performed through
Copyright 2004 British Journal of Surgery Society Ltd
Published by John Wiley & Sons Ltd
849
Data collection
Primary outcome measures included left ventricular enddiastolic and end-systolic diameters, fractional shortening
and CO, which were determined by transoesophageal
echocardiography (TOE). Secondary outcome measures
were MAP and heart rate. TOE was performed by insertion
of a 5-MHz two-element annular, monoplane probe
(TN100047; Vingmed, Horten, Norway). Echocardiography included examination of the transgastric short-axis
view at the mid-papillary level, mitral annulus diameter
at diastole and mitral flow curves at the mitral annular
level. All images were recorded on to videotape by
one investigator and later analysed by the same person,
who was blinded to the treatment received. Fractional
shortening of the left ventricle of the heart (diastolic
diameter systolic diameter/diastolic diameter) and CO
were calculated. CO was calculated by multiplying the
time velocity integral of the mitral flow (TVI) by the
cross-sectional area of the mitral ostium (A) and the heart
rate (HR): CO = TVI A HR. Data were collected
after induction of anaesthesia, but before carbon dioxide
insufflation or abdominal wall traction (phase 1), 10 and
30 min after carbon dioxide insufflation or abdominal
wall traction (phases 2 and 3 respectively), and 10 min
after exsufflation or release of wall traction (phase 4).
All measurements were performed with the patient in the
supine, 20 Trendelenburg and 20 reverse Trendelenburg
positions. A 5-min stabilization period was allowed between
each change in position.
Statistical analysis
The sample size was calculated assuming an expected
difference in mean fractional shortening of 01, expected
standard deviation 010, = 005 and power = 090. A
sample size of 46 patients was calculated to be sufficient to
detect these differences.
Results are reported as mean(s.d.). Statistical analysis was
performed using the Jandel Sigmastat version 2.0 statistical
package (SPSS, Chicago, Illinois, USA). Demographic
data were compared using the unpaired Students t-test.
Three-way ANOVA was used to compare differences
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850
Results
Diastolic diameter
Diastolic diameter was significantly higher in the CLC
group than in the GLC group during operation, allowing
Table 1
Randomized
(n = 54)
Missing
data (n = 2)
CLC
Phase
Phase
Phase
Phase
Allocated
to GLC
(n =24)
Analysed
CLC
(n =28)
Analysed
GLC
(n =22)
S
27
24
24
27
1
2
3
4
GLC (n = 22)
19 : 11
49(11)
24(8)
86(32)
15 : 7
48(11)
26(2)
102(36)
R
27
14
10
26
GLC
Phase
Phase
Phase
Phase
S
20
22
21
18
1
2
3
4
T
19
21
21
19
R
20
20
20
18
50
40
30
20
T
Phase 1
CLC (n = 28)
T
27
28
25
24
Missing
data (n =2)
Demographic data
Sex ratio (M : F)
Age (years)
Body mass index (kg/m2 )
Operating time (min)
Allocated to
CLC
(n =30)
Fig. 1
T
Phase 2
T
Phase 3
Phase 4
Fig. 2
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CLC
GLC
40
30
20
10
Phase 1
851
Fractional shortening
T
Phase 2
Phase 3
CLC
GLC
06
05
04
03
02
Fig. 3
Phase 2
Phase 3
Phase 4
Fig. 4
Systolic diameter
During operation systolic diameter was significantly higher
in patients who had carbon dioxide pneumoperitoneum
than in those who had a gasless procedure, allowing for the
effects of differences in positions and phases (F = 1129,
P < 0001, three-way ANOVA) (Fig. 3). During surgery
changes in position did not significantly affect systolic
diameter in the two groups and no significant changes in
systolic diameter were recorded comparing phase 2 with
phase 3.
Phase 1
Phase 4
CLC
GLC
80
70
60
50
40
30
T
Phase 1
T
Phase 2
T
Phase 3
Phase 4
Fig. 5
Fractional shortening
Fractional shortening was significantly lower during CLC
(phases 2 and 3) than during GLC, allowing for the
effects of differences in positions and phases (F = 756,
P = 0006, three-way ANOVA) (Fig. 4). Further analysis
revealed significantly decreased fractional shortening in
the reverse Trendelenburg position in the CLC group
compared with the gasless group (F = 412, P = 0017)
whereas no differences were registered in the supine or
Trendelenburg positions.
Cardiac output
Heart rate
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852
Discussion
CLC
GLC
90
80
70
60
50
40
Phase 1
Phase 2
Phase 3
Phase 4
Fig. 6
During operation (phases 2 and 3) the MAP was significantly higher with carbon dioxide pneumoperitoneum than
during gasless procedures, allowing for the effects of positional changes and time (F = 1900, P < 0001, three-way
ANOVA) (Fig. 7). The two groups showed the same pattern of changes, irrespective of phase: a significant increase
from supine to Trendelenburg position and a significant
decrease from Trendelenburg to reverse Trendelenburg
position.
CLC
GLC
120
100
80
60
40
20
T
Phase 1
T
Phase 2
T
Phase 3
Phase 4
Fig. 7
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Acknowledgements
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