Clinical Outcomes Using Low-Pressure Pneumoperitoneum during Robotic-Assisted Gynecologic Procedures

From the 2018 HVPAA National Conference

Jian Qun Huang (NYU Langone Health), Makoto Tokiwa (NYU Langone Health), Alyson Grant (NYU Langone Health), Sudheer Jain (NYU Langone Health), Laura Prunty (NYU Langone Health), Alan Arslan (NYU Langone Health)

Background

Robotic gynecologic procedures require insufflation of carbon dioxide during laparoscopy which increases intra-abdominal pressure and has been associated with postoperative pain. Robotic gynecologic procedures can be performed at low pressure pneumoperitoneum.

Objectives

To investigate whether decreased insufflation pressure during robotic assisted gynecologic surgery has an influence on intraoperative and postoperative parameters.

Methods

Retrospective cohort study of women undergoing robotic procedures for benign gynecologic conditions at a single University Hospital from March 2014 to 43 August 2015. A total of 301 consecutive patients were included in this study. The first 101 subjects were operated at standard insufflation pressure of 15 mmHg, the following 100 patients were operated at the insufflation pressure of 12 mmHg and the next 100 patients were operated at the insufflation pressure of 10 mmHg. The primary outcomes of interest were postoperative pain scores (first reported and maximum pain levels) and the length of stay (recovery time) in a post-anesthesia care unit. The secondary outcomes of interest were intraoperative respiratory parameters.

Results

There were no statistically significant differences in baseline characteristics in terms of age, weight, height, body mass index, race, ethnicity, and type of surgical procedures between the three comparison groups. Compared to 12 mmHg, 10 mmHg group had a lower first reported pain score (mean, 5.4 vs. 4.4, respectively, p<0.02), 54 maximum reported pain score (mean, 7.0 vs. 5.4, respectively, p><0.0001), and faster 55 recovery period (mean, 467 vs 351 min, respectively, p><0.05). Compared to 15 mmHg 56 insufflation group, patients in 10 mmHg insufflation group had a lower first reported pain 57 score (mean, 5.9 vs. 4.4, respectively, p><0.0001), maximum reported pain score (mean, 58 7.3 vs. 5.4, respectively, p><0.0001), lower mid-insufflation peak inspiratory pressure 59 (mean, 31.1 vs 27.9 cmH2O, respectively, p ><0.0001), plateau airway pressure (mean, 60 29.4 vs 26.6 mmHg, respectively, p = 0.0003), and tidal volume (mean, 579.2 vs 526.9 61 ml, respectively, p ><0.0001). 62 CONCLUSION: Performing robotic-assisted gynecologic surgery at lower insufflation 63 pressure is associated with lower patient-reported pain scores, faster postoperative 64 recovery time and improved intraoperative respiratory parameters.><0.0001), maximum reported pain score (mean, 7.3 vs. 5.4, respectively, p<0.0001), lower mid-insufflation peak inspiratory pressure (mean, 31.1 vs 27.9 cmH2O, respectively, p <0.0001), plateau airway pressure (mean, 29.4 vs 26.6 mmHg, respectively, p = 0.0003), and tidal volume (mean, 579.2 vs 526.9 ml, respectively, p <0.0001).

Conclusion

Performing robotic-assisted gynecologic surgery at lower insufflation pressure is associated with lower patient-reported pain scores, faster postoperative recovery time and improved intraoperative respiratory parameters.

Implications for the Patient

Preoperatively, operating at lower pressure will improve respiratory parameters that would aid in improving anesthesia procedures for patients. Postoperatively,  lowering pain scores will aid both regulating hospital patient flow and patient experience as patients will be in less pain and be able to spend less time in the hospital.