Title : Evaluating the role of pneumoperitoneum in surgical stress response: A randomized controlled trial
Abstract:
Background: Meta-analyses and large-scale studies have stated that minimally invasive surgery reduces surgical stress compared with open procedures; however, they also indicated that the physiologic effects of pneumoperitoneum may exacerbate neuroendocrine and inflammatory responses. Gasless laparoscopic cholecystectomy (GLC) avoids pneumoperitoneum by using abdominal wall lift, but comparative evidence with standard-pressure laparoscopic cholecystectomy (SPLC) remains limited.
Methods: This prospective, randomized study included 40 patients undergoing elective laparoscopic cholecystectomy, randomized equally to SPLC (12–14 mmHg CO?, n=20) or GLC (n=20). Surgical stress response was measured in terms of the biochemical markers (CRP, IL-6, ACTH, cortisol, Neutrophil-lymphocyte ratio) were measured preoperatively, 1 h and at 24 h postoperatively. Clinical outcomes included abdominal pain and shoulder pain (VAS at 2, 8, 14, 20, 24 h), postoperative nausea and vomiting (PONV), hospital stay, and intraoperative events (Blood pressure fluctuation, bradycardia, EtCO2 fluctuation).
Results: GLC demonstrated significantly lower CRP immediately (GLC: 20.25 ± 4.60 vs SPLC: 30.4 ± 5.25, p=0.01) and at 24 h (GLC: 12.80 ± 3.95 vs SPLC: 17.14 ± 4.90, p=0.02). IL-6 and cortisol were significantly lower in the GLC group at 1 h (p=0.04, p=0.03) with non-significant downward trends at 24 h. NLR was significantly reduced in GLC at both time points (p=0.02, p=0.04). ACTH rose similarly in both groups (p>0.1). Abdominal pain peaked at 8 h (p=0.72) and decreased; group differences between GLC and SPLC were not significant. Shoulder pain, PONV, and hospital stay were numerically lower in GLC (p>0.05). Hemodynamic instability was observed in SPLC group (Blood pressure fluctuation-2, bradycardia-2), though managed adequately, exclusively in patients with EtCO? fluctuations (p = 0.0077).
Conclusion: Gasless laparoscopic cholecystectomy significantly attenuates surgical stress response compared with standard-pressure laparoscopy as evidenced by significantly reduced CRP (p=0.01 at 1 h post op & p=0.02 at 24 h post op), IL-6 (p=0.04 at 1h post op), cortisol (p=0.03 at 1h post op), and NLR (p=0.02 at 1 h post op & p=0.04 at 24 h post op) responses while maintaining equivalent safety and clinical outcomes. The inherent nature of minimal invasive surgery causing reduced stress response in both groups, and absence of pneumoperitoneum further attenuates that. These findings suggest GLC offers physiologic advantages, by avoiding pneumoperitoneum-associated surgical stress, though larger multicentric studies are recommended.
