Published online Mar 21, 2018. doi: 10.3748/wjg.v24.i11.1278
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
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.
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.
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.
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.
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.
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.
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.