Safe and optimal pneumoperitoneal pressure for transperitoneal laparoscopic renal surgery in infant less than 10 kg, looked beyond intraoperative period: A prospective randomized study. Issue 5 (October 2016)

• Record Type: Journal Article
• Authors: Sureka, Sanjoy K.; Patidar, Nitesh; Mittal, Varun; Kapoor, Rakesh; Srivastava, Aneesh; Kishore, Kamal; Dhiraj, Sanjay; Ansari, M.S.
• Is Part Of: Journal of pediatric urology. Volume 12:Issue 5(2016)
• Page Start: 281.e1
• Page End: 281.e7
• Publication Date: 2016-10
• Subjects: Infants -- Pneumoperitoneal pressure -- Laparoscopy; Pediatric urology -- Periodicals; Urologic Diseases -- Periodicals; Urogenital Diseases -- Periodicals; Urologic Surgical Procedures -- Periodicals; Child; Infant; Urologie pédiatrique -- Périodiques; Appareil urinaire -- Maladies -- Périodiques; Pédiatrie; Urologie; Pediatric urology; Périodique électronique (Descripteur de forme); Ressource Internet (Descripteur de forme); Electronic journals; Periodicals; Electronic journals; 618.926
• DOI: 10.1016/j.jpurol.2016.01.014
• Languages: English
• ISSNs: 1477-5131

Abstract

Summary: Objective: A safe and optimal pneumoperitoneal pressure (PP) for laparoscopic renal surgery in infants is difficult to define. In a broad sense, a safe and optimal PP should cause least intraoperative and postoperative physiological stress for the infants and should be optimal for surgeon's technical feasibility. Unfortunately, the safe and optimal PP in infant for transperitoneal laparoscopic surgery has not been established by well validated study. To determine safe and optimal PP for laparoscopic renal surgery (LRS) in infants less than 10 kg. Method: In a prospective and randomized setting, between July 2008 and June 2014, 46 infants of <10 kg (Group I, n = 23, PP = 6–8 mmHg and Group II, n = 23, PP = 9–10 mmHg) who underwent LRS, were analyzed. Hemodynamic, respiratory, and blood gas changes were measured at four points: before CO2 insufflation (T0 ), 10 min after insufflation (T1 ), before desufflation (T2 ) and 10 min after desufflation (T3 ). Any required adjustments of ventilator parameters were noted. Time to resume feeding and postoperative pain at 1, 6, and 12 h, including requirement for postoperative rescue analgesia, were assessed. Technical feasibility with allocated PP was evaluated by means of successful completion of surgery, duration of surgery, and intraoperative complications. Results: At T1 and T2, changes in hemodynamic and respiratory parameters were significantly higher in Group II. At T3, most of the parameters statistically restored back to baseline in Group I but not so in Group II. Required adjustments in ventilatory parameters were 14 vs. 25 times in Group I vs. Group II ( p = 0.007, R = 0.552). Mean postoperative pain score, requirement for analgesia, and time to resume feeding were significantly greater in Group II. Surgeries were successfully completed in all the patients in both groups, with comparable duration of surgery and similar intraoperative complications (Table). Conclusion: It was found that hemodynamic and respiratory changes were more pronounced with higher pneumoperitoneal pressure in infants for renal laparoscopic surgery. With a PP of 6–8 mmHg, intraoperative accessibility is optimal, and physiological changes are minimal. Interestingly, we found that infants with PP of 6–8 mmHg enjoy smooth and early postoperative recovery. There was no direct objective criterion to assess level of difficulty with allocated PP, which may be considered a limitation of the present study. Pneumoperitoneal pressure of 6–8 mmHg appears to be a safe and optimal range for transperitoneal laparoscopic renal surgery in infants. Table Comparison of intraoperative and postoperative parameters in two groups. Variables Group I Group II Sig. Mean ± SD Mean ± SD p HR_T1 123.39 ± 15.31 128.95 ± 13.00 0.015 MBP_T1 77.56 ± 6.75 82.34 ± 5.44 0.02 PH_T1 7.32 ± 0.032 7.24 ± 0.039 0.000 PCO2 _T1 37.88 ± 2.830 45.71 ± 6.59 0.001 PIP_T1 20.08 ± 1.69 21.65 ± 1.92 0.005 ETCO2 _T1 34.80 ± 3.50 38.00 ± 2.16 0.001 HR_T2 119.82 ± 11.70 128.21 ± 12.047 0.032 MBP_T2 74.77 ± 5.50 80.30 ± 5.48 0.003 PH_T2 7.30 ± 0.02 7.22 ± 0.02 0.000 PCO2 _T2 36.43 ± 2.80 42.60 ± 3.31 0.001 Base excess_T2 6.48 ± 1.49 7.8783 ± 1.58966 0.045 Peak airway pressure_T2 19.60 ± 1.20 20.90 ± 1.92 0.05 ETCO2 _T2 33.91 ± 2.39 37.13 ± 2.049 0.015 MBP_T3 69.41 ± 3.81 73.97 ± 3.25 0.025 PH_T3 7.33 ± 0.03 7.25 ± 0.030 0.001 PCO2 _T3 34.08 ± 3.32 37.69 ± 2.42 0.017 ETCO2 _T3 30.47 ± 1.83 33.34 ± 2.29 0.008 Pain at postop hour 1 3.87 ± 0.679 6.78 ± 1.25 0.001 Pain at postop hour 6 1.43 ± 0.92 3.73 ± 1.48 0.03 Pain at postop hour 12 0.9 ± 0.52 1.5 ± 0.78 0.05 No. of doses of rescue analgesia 6 18 0.02 Time to resume feeding in hours 6.80 ± 2.28 8.95 ± 1.62 0.002 ETCO2 = end tidal CO2 ; HR = heart rate; MBP = mean blood pressure, PIP = peak inspiratory pressure.