Journal: Acta Anaesthesiol Scand 51(8):1068-1078, 2007. 34 References
Reprint: Dept of Surgery, Diakonessenhuis, Bosboomstraat 1, 34582 KE Utrecht, the Netherlands (F Keus, MD)
Faculty Disclosure: Abstracted by L. Easley, who has nothing to disclose.
Pulmonary function differences between laparoscopic cholecystectomy (LC) and small-incision cholecystectomy (SIC) have been studied in only a few, technically oriented, randomized trials, which have reported inconsistent outcomes, involve small numbers of patients and seem to incorporate some important methodological shortcomings. This large single-center randomized trial was performed to evaluate pulmonary function in patients randomized between LC and SIC by measuring flow-volume curves and blood gases in a blind fashion. Patients referred to the surgical outpatient clinic with symptomatic cholecystolithiasis were eligible for inclusion in the trial.
The principal outcome measures of this paper are pulmonary function and related aspects. A random number table was used to generate the allocation sequence, with allocation concealment guaranteed by sealed envelopes. To avoid bias during the perioperative recovery, all patients were subjected to a standard anesthesia regime. Analgesics in the postoperative period were supplied according to a standard scheme. The supply of analgesics for pain minimization was objectified using a visual analogue scale (VAS) ruler. For LC, an open introduction was performed in all patients, regardless of previous abdominal surgery. The SIC approach involved a transverse incision of no more than 8 cm over the right musculus rectus abdominis.
Pulmonary function tests were performed immediately preoperatively, on the first postoperative day and at the 6-week outpatient check-up. During the tests, the best flow-volume curve of three attempts was taken for analysis. The maximal vital capacity forced expiratory volume in 1 sec, forced vital capacity (FVC), maximum expiratory flow when 25%, 50%, and 75% of the FVC has been exhaled, peak expiratory flow (PEF) and forced inspiratory volume in 1 sec were documented. Arterial blood gas analyses were performed preoperatively, 24-hr postoperatively, and during recovery. During this period, 366 patients visiting the authors’ outpatient clinic for symptomatic cholecystolithiasis fulfilled the inclusion criteria, gave informed consent and were initially included in the trial. Of these, 257 patients were left for analysis after exclusions. An overall 20% postoperative reduction in pulmonary function was documented, as well as complete return to baseline at the 6-week follow-up. Although there are statistically significant differences between the two techniques for the parameters PO2, PCO2 and pH, these had no influence on discharge from recovery.
The acceptance of LC as the technique of choice appears to have little foundation. The authors’ findings of a comparable clinical outcome for LC and SIC are in line with other data. Although more pain medication was given to the SIC group, this was only in the immediate postoperative period and had no apparent clinical significance. These findings should be generally applicable in general surgical practice. This study concurs with historical data, demonstrating a temporary decrease in pulmonary function in all forms of upper abdominal surgery, laparoscopic or open. This study demonstrates that SIC is comparable with LC in terms of the decrease in pulmonary function and blood gas analysis, and suggests that, from an anesthesiological approach to perioperative management, pulmonary and analgesic arguments indicate that these techniques are interchangeable when performed in an ASA PS 1 and 2 population. |
