Prospective Study
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 21, 2018; 24(11): 1278-1284
Published online Mar 21, 2018. doi: 10.3748/wjg.v24.i11.1278
Low-pressure pneumoperitoneum with abdominal wall lift in laparoscopic total mesorectal excision for rectal cancer: Initial experience
Ping-Tian Xia, Maimaiti Yusofu, Hai-Feng Han, Chun-Xiao Hu, San-Yuan Hu, Wen-Bin Yu, Shao-Zhuang Liu
Ping-Tian Xia, Maimaiti Yusofu, Hai-Feng Han, Chun-Xiao Hu, San-Yuan Hu, Wen-Bin Yu, Shao-Zhuang Liu, Department of General Surgery, Qilu Hospital of Shandong University, Jinan 250012, Shandong Province, China
Author contributions: Xia PT, Hu SY, Yu WB and Liu SZ designed the study, analyzed the data and wrote the paper; Yusofu M, Yu WB and Liu SZ performed the surgery and treated the patients; Han HF and Hu CX collected and analyzed the patient data; Hu SY and Liu SZ approved the final manuscript.
Supported by the Special Found for Taishan Scholar Project of Shandong Province, China.
Institutional review board statement: The study was reviewed and approved by the Ethics Committee of Scientific Research of Shandong University Qilu Hospital.
Informed consent statement: In this study, all involved participants or their legal guardian provided informed written consent before surgery.
Conflict-of-interest statement: No authors of this paper have conflicting interests.
Data sharing statement: No additional data are available.
CONSORT 2010 statement: The guidelines of the CONSORT 2010 Statement have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Shao-Zhuang Liu, MD, PhD, Attending Doctor, Postdoc, Department of General Surgery, Qilu Hospital of Shandong University, 107#, Wenhua Xi Road, Jinan 250012, Shandong Province, China. liushaozhuang@sdu.edu.cn
Telephone: +86-531-86920598 Fax: +86-531-86920598
Received: January 11, 2018
Peer-review started: January 11, 2018
First decision: January 25, 2018
Revised: January 30, 2018
Accepted: February 9, 2018
Article in press: February 9, 2018
Published online: March 21, 2018
Processing time: 64 Days and 4.9 Hours
ARTICLE HIGHLIGHTS
Research background

Pneumoperitoneum with carbon dioxide (CO2) is the conventional method of creating a workspace in laparoscopic surgery. Standard-pressure pneumoperitoneum (SPP; 12-15 mmHg) has been reported to result in lower respiratory compliance, increased paw airway pressure, enhanced venous stasis, reduced portal venous pressure and impaired cardiac function.

Low-pressure pneumoperitoneum (LPP) and abdominal wall lift (AWL) have been proposed as alternative approaches to SPP to avoid adverse cardiopulmonary effects. However, the operative field with these techniques is less optimal with increased technical difficulties.

Research motivation

In order to obtain adequate visualization, we combined LPP with AWL and initially used this technique in a case of laparoscopic single-site cholecystectomy, and the surgery was performed successfully. For laparoscopic colorectal surgery which requires sufficient exposure of the lower abdomen, a head-down or Trendelenburg position is necessary. SPP combined with this kind of position significantly influences patients’ cardiopulmonary function. Therefore, we decided to find out whether LPP with AWL technique can take the place of SPP in laparoscopic total mesorectal excision (TME) for rectal cancer.

Research objectives

In this study we designed and performed laparoscopic TME for rectal cancer using LPP with AWL, and evaluated the safety and feasibility. The outcomes of this study will guide the application of the new technique in laparoscopic TME and other surgeries in the future.

Research methods

From November 2015 to July 2017, 26 patients underwent laparoscopic TME for rectal cancer using LPP (6-8 mmHg) with subcutaneous AWL in Qilu Hospital of Shandong University, Jinan, China. Clinical data regarding patients’ demographics, intraoperative monitoring indices, operation-related indices and pathological outcomes were prospectively collected and analyzed.

Research results

Laparoscopic TME was performed in 26 cases (14 anterior resection and 12 abdominoperineal resection) successfully without conversion to open or laparoscopic surgery with SPP. Intraoperative monitoring showed stable heart rate, blood pressure and paw airway pressure. The number of lymph nodes retrieved, the completeness of TME, and the circumferential and mean distance to the distal margin were comparable with those reported in studies using SPP. There was no positive circumferential or distal resection margin. No local recurrence was observed during a median follow-up period of 11.96 ± 5.55 mo (range: 5-23 mo). Our preliminary experience indicated that LPP with AWL was safe and provided a satisfactory workspace for TME.

Research conclusions

LPP combined with AWL is safe and feasible for laparoscopic TME. The technique can provide satisfactory exposure of the operative field and result in stable operative monitoring indexes. It should be considered as an alternative approach to SPP in patients undergoing laparoscopic TME.

Research perspectives

Further studies are required to confirm the superiority of LPP with AWL over SPP in preservation of cardiopulmonary function, especially in patients with American Society of Anesthesiologists III and IV status. A prospective clinical trial study should be the best method for the future research.