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 Table of Contents  
ORIGINAL ARTICLE
Year : 2019  |  Volume : 5  |  Issue : 1  |  Page : 63-68

Comparative Evaluation of Haemodynamic and Capnographic Changes in Laparoscopic Cholecystectomy and Open Cholecystectomy: Prospective, Randomized Clinical Study


1 Associate Professor, Dept. of Anaesthesiology, IGIMS, Patna, India
2 Professor, Dept. of Anaesthesiology, IGIMS, Patna, India
3 PG Student, Dept. of Anaesthesiology, IGIMS, Patna, India
4 Senior Resident, Dept. of Anaesthesiology, IGIMS, Patna, India

Date of Web Publication20-Nov-2020

Correspondence Address:
Vinod Kumar Verma
Professor, Dept. of Anaesthesiology, IGIMS, Patna
India
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Source of Support: None, Conflict of Interest: None


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How to cite this article:
Kumar A, Verma VK, Jha RK, Kumar R, Hussain M. Comparative Evaluation of Haemodynamic and Capnographic Changes in Laparoscopic Cholecystectomy and Open Cholecystectomy: Prospective, Randomized Clinical Study. J Indira Gandhi Inst Med Sci 2019;5:63-8

How to cite this URL:
Kumar A, Verma VK, Jha RK, Kumar R, Hussain M. Comparative Evaluation of Haemodynamic and Capnographic Changes in Laparoscopic Cholecystectomy and Open Cholecystectomy: Prospective, Randomized Clinical Study. J Indira Gandhi Inst Med Sci [serial online] 2019 [cited 2021 Jan 18];5:63-8. Available from: http://www.jigims.co.in/text.asp?2019/5/1/63/301081




  Introduction: Top


The overall mortality following open cholecystectomy is very low but is followed by a higher morbidity, especially in elderly patients. After open cholecystectomy, there is post-operative impairment in pulmonary functions, increase in acute phase reactions, severe pain, discomfort, bowel distension, paralytic ileus and prolonged convalescence in the post-operative period. Although laparoscopy was first described at the beginning of 20th century, therapeutic laparoscopic surgical procedures have only recently become well established being somewhat ignored until the late 1960s. In the late 1980s, laparoscopic cholecystectomy was described and has become well established[1],[2] because of the advantages like greater cosmetic value, less hospital stay and cost-effectiveness.

For laparoscopy, creation of pneumoperitoneum and very often changing of patient position are required. The pneumoperitoneum and the patient positions required for laparoscopy induce pathophysiologic changes that complicate anaesthetic management. Many studies have confirmed that CO2 pneumoperitoneum during laparoscopy causes significant haemodynamic changes such as increase in MABP, SVR and decrease in cardiac output. Therefore understanding of pathophysiologic consequences of increased intra-abdominal pressure and Hypercapnia are important for the anaesthesiologists who must ideally prevent or adequately respond to these changes. They must also evaluate and prepare the patient pre-operatively in light of these disturbances. During laparoscopic cholecystectomy pneumoperitoneum is produced to facilitate surgery. The most preferred gas commonly used for producing pneumoperitoneum is carbon-dioxide (CO2). As CO2 is rapidly absorbed in the blood and eliminated through respiration, it enables rapid reversal of clinical signs by treatment, if an open venous channel leads to CO2 embolism. Thus laparoscopic cholecystectomy has some inherent complications due to increase in intra-abdominal pressure, carbon dioxide absorption from the peritoneal cavity and frequent changes of position. These are associated with severe pulmonary, haemodynamic and acid base changes. These haemodynamic effects of laparoscopy in the head-up position is still seen to be well tolerated by healthy persons[3] (ASA I, II). But in elderly patients with multiple co-morbid conditions, the paediatric age group, the morbidly obese, pregnant women and the critically ill (ASA III, IV) the risks associated with general anaesthesia can be compounded by the physiologic changes induced by pneumoperitoneum and patient positions.

Various studies have demonstrated an increase in heart rate during laparoscopic surgery may be due to absorption of carbon dioxide from peritoneal cavity. Pneumoperitoneum related increased IAP results in activation of the sympathetic system with catecholamine's release and the renin-angiotensin system with vasopressin release. An increase in intra-abdominal pressure (IAP) with decrease in venous return may also cause a compensatory increase in heart rate. Laparoscopic cholecystectomy also results in multiple benefits compared with open procedures4. So laparoscopic cholecystectomy is gaining popularity over open cholecystectomy. The present study was conducted to compare the haemodynamic and capnographic changes in laparoscopic cholecystectomy and open cholecystectomy.


  Material and Method: Top


After approval from the institutional ethical committee of Indira Gandhi Institute of Medical Sciences, Patna and written informed consent from the patients, this Prospective, Parallel group, randomized clinical study was conducted. The study was registered with Clinical Trial Registry-India (CTRI/2017/12/010789). Sixtypatients, thirty in each group aged 18 -60 years, ASA I and II, BMI < 30 kg/m2 undergoing laparoscopic cholecystectomies and open cholecystectomies under general anesthesia, were randomly divided into two groups, Group- I (laparoscopic cholecystectomy) and Group-II (open cholecystectomy), using computer generated randomization list. Patients having cardio respiratory, renal, metabolic disorders or uncontrolled systemic illness and patients in whom laparoscopic cholecystectomy may need to be converted to open cholecystectomy were not included in the study. Sample size had been estimated based on an alpha error of 0.05 and a power of 80%. All patients received oral lorazepam 1 mg and ranitidine 150 mg night before surgery. Following overnight fast patients were taken for operation. In the operation theatre intravenous access were made with 18G canula and Ryle's tube inserted. Cardiac monitor was attached and pre-operative pulse rate, mean arterial pressure (MAP), oxygen saturation (SpO2) recorded and continuous ECG in lead II attached and recorded. Inj. Fentanyl 2 microgram/kg body weight was given intravenously (IV) immediately before starting anaesthesia. Following pre-oxygenation with 100% oxygen for three minutes, anaesthesia was induced with propofol 2 mg/kg body weight of patient. Neuromuscular blocking has been done with vecuronium 0.1 mg/kg body weight of patient. After adequate neuromuscular blocking trachea has been intubated with appropriate size of endotracheal tube. Capnograph was attached with ETT and pre- insufflation EtCO2 in laparoscopic cholecystectomy and pre-incision EtCO2 in open cholecystectomy was recorded. Anaesthesia was maintained with oxygen, nitrous oxide, Isoflurane and intermittent bolus dose of vecuronium. During insufflation of CO2 surgeon had been asked to insufflate the peritoneum slowly i.e. flow rate of CO2 had been 1 litre/minute to 2 litre/minute and maximum intraabdominal pressure allowed was 15 mm of Hg16-18. Minute volume was adjusted to keep the EtCO2 within normal limit. For better pain relief 75 mg diclofenac sodium was given slow IV during operation. Position of the patient during operation kept at head up position with right side up tilt by 15o& Intra-abdominal pressure (IAP) kept at 15mm of Hg[24]. Following monitoring were done intra-operatively:- Pulse rate, NIBP( Mean arterial pressure), ECG in lead II, SpO2, EtCO2. These parameters were monitored continuously and recorded every 15 minutes interval for one hour, and then every 30 minutes till the end of the procedure. After operation was completed pneumoperitoneum was evacuated as completely as possible. All patients were reversed with inj. glycopyrrolate (0.01 mg/kg) and inj. neostigmine (0.05 mg/kg) i.v., after closure of abdomen. After patients were awake and vital parameters within acceptable range Ryle's tube suction was done and removed. Then patients were extubated after oro-pharyngeal suction. In the post-operative period all the vital parameters except EtCO2 were recorded up to two hours.


  Statistical Analysis: Top


The results thus obtained in each group (group I and group II) were tabulated and analysed statistically using students t- test and results of two groups were compared. Data is presented as mean±SD. Probability value (P - value) were seen from the statistical table. Significance of P- values are follows:-P > 0.05 : Not statistically significant, P < 0.05 : Statistically significant, P < 0.01 : Highly statistically significant.


  Result: Top


Demographic data of patients under study in different groups are shown in [Table 1] and [Table 2]. P values calculated using student's t- test. All values are mean ± standard deviation (SD). This table shows age (in years) and body weight (in kg) in both thegroups. There was no statistically significant difference in respect to age and body weight as P value > 0.05. There was no significant difference in sex distribution between group I and group II, as P value > 0.05 by chi square test.
Table 1: [n = 30]
Bar diagrams representing the observations of Table 1


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Table 2: Sex Distribution
Bar diagrams representing the observations of Table 2


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Table 3: Comparison of pulse rate between group I and group II in different points of peri-operative times and their statistical analysis
Bar diagrams representing the observations of Table 3


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Table 4: Comparison of mean arterial pressure between group I and group II at different points of time and their statistical analysis
Table 4 Bar diagrams representing the observations of


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Table 5: Comparison of EtCO2 changes between group I and group II at different point of times
Table 5 Bar diagrams representing the observations of EtCO2


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There was no statistically significant difference between pre-operative pulse rate in between group I and group II (P value > 0.05 by student's t- test). In 15 minutes, 30 minutes, 45 minutes, 60 minutes per operatively group I patients showed greater rise in pulse rate than group II patients and the differences in between both the groups were statistically highly significant (P value < 0.01 by student's t- test). After 2 hours post operatively there was decrease in pulse rate almost to the pre-operative values in both the groups and there was no statistically significant difference between post- operative pulse rate in between group I and group II (P value > 0.05).

There was no statistically significant difference between pre- operative mean arterial pressure between group I and group II (P value > 0.05). Per- operatively at 15 minutes, 30 minutes, 45 minutes and 60 minutes the rise in mean arterial pressure was more in group I. The differences in between both groups were statistically highly significant (P < 0.01). Post -operatively after 2 hours the mean arterial pressure in both the groups attained almost the pre operative values. There was no statistically significant difference between group I and group II (P value > 0.05).

Data shows there was no statistically significant difference in between group I and group II pre-operatively immediately after intubation (P value > 0.05). But per- operatively 15 minutes, 30 minutes, 45 minutes and 60 minutes there was greater rises in EtCO2 in group I patients with minimum rise in group II patients and the differences between the two groups were statistically highly significant (P value < 0.01).

ARRHYTHMIA: In this study no significant arrhythmia was noted. Sinus tachycardia was observed in all patients of group I. but only in few patients of group II. In laparoscopic cholecystectomy group (group I) occasional premature ventricular ectopic occurred in 2 patients, just after creation of pneumoperitoneum which subsided without any treatment. No notable ST - T changes observed in E. C. G. monitor in both groups. Sao2 were within normal limit and comparable in both the groups throughout the period of surgery.


  Discussion: Top


Laparoscopic surgery was first described in the beginning of 20th century but it became well established when Steptoe in 1967 described the laparoscopic technique in pelvic surgery. Since then considerable development has been seen in the field of laparoscopic surgical technique. From the early days of laparoscopic surgery quest have been made to venture into suitable monitoring techniques in the anaesthetic management for laparoscopic surgery. In present day scenario EtCO2 monitoring is considered a standard monitoring technique in the field of general anaesthesia and it also provides useful information regarding pathophysiological changes occurring in laparoscopic surgery. The present study was taken up with the noble intention to compare the haemodynamic as well as capnographic changes occurring during laparoscopic cholecystectomy and open cholecystectomy. In our study all the patients randomly allocated in both groups. Regarding age, sex and weight there was no significant difference in between the two groups (P > 0.05) (ref. [Table 1] and [Table 2]). The number of patients in each group were equal (n = 30). All patients were either ASA physical status of I or II; ASA III, IV patients not taken in study. So impact of age, sex, weight, ASA physical status, if any, was equal in both the groups. In our study, the comparison of pulse rate between the two groups showed statistically highly significant rise in pulse rate in group I (P < 0.01) at 15, 30, 45 and 60 minutes per operatively after the creation of pneumoperitoneum (ref. [Table 3]). These findings corroborate with the findings in the study conducted by N Kachru, U Saha in 2001[22] where they found significant rise in pulse rate from baseline within 30 minutes of CO2 insufflation. Berg K et al. in 1997[20] also found rise in pulse rate after insufflation of CO2 during laparoscopic cholecystectomy. However, the finding in our study differs from the study conducted by Girardis M et al in 1996[19] where they found no significant rise in pulse rate during pneumoperitoneum. pressure.. In our study the comparison of mean arterial pressure between two groups showed that statistically highly significant rise in MAP occurred in group I at 15, 30, 45 and 60 minutes (ref. [Table 4]). This finding is supported by Dexter SP et al in 2000[21] where they found increase in MAP on insufflation of CO2 in both high (15mm of Hg) and low (7 mm of Hg) intra abdominal pressure. In these studies consistent increase in MAP were reported by the researcher in different time intervals from insufflation. However Girardis M et al in 1996[19] reported only transient increase in MAP after CO2 insufflation. Though the haemodynamic changes observed in group I were statistically significant but were not clinically alarming and no treatments were required in these patients. The changes in the parameters also decreased after desufflation and attained almost the baseline within 2 hours post operatively. No patient in our study suffered dangerous arrhythmia during the surgery. Alterations in Cardiovascular function during laparoscopy depend on the interaction of several patient and surgical factors including increased intra-abdominal pressure (IAP), patient position, CO2 absorption, ventilatory strategy and surgical technique and duration of operation. Peritoneal insufflation to IAP higher than 10 mmHg induces signification alterations of haemodynamic parameters13, 14. In our study during laparoscopic cholecystectomy (group I patients) IAP was kept at 15 mmHg, 15° head up with right side up tilt position was maintained and pneumoperitoneum was created with insufflation of CO2. Hence the increased haemodynamic alterations observed in group I patients of our study resulted from increased IAP, patient position and CO2 absorption. Galizia et al. 2001[23] studied haemodynamic changes during open and laparoscopic cholecystectomy and concluded that CO2 pneumoperitoneum caused a significant impairment in cardiac function. On comparison of the EtCO2 changes between the two groups in our study, we found that persistent statistically highly significant rise in EtCO2 levels in group I patients (P Value <0.01) (Refer [Table 7]) at 15, 30, 45 and 60 minutes after insufflation of CO2 but the values did not exceed the upper limit of normal. This finding is supported by the studies conducted by N. Kachru, U Saha in 2001[22] where they observed significant rise in EtCO2 at 30 minutes from insufflation. Similar observations were made in the studies conducted by Berg K et al in 1997[20]. In the above studies persistent increase in EtCO2 levels were noted after insufflation of the peritoneum. Respiratory changes during laparoscopic procedures are the important factors to cause increase in PaCO2 ensuring arterial and tissue acidosis[5]. Ventilation is impaired by increased IAP produced by pneumoperitoneum. The elevation of the diaphragm results in decreased FRC, TLC and pulmonary compliance[7]. There is mismatching in ventilation and perfusion and the physiological dead space is increased6. Capnometry and capnography were of great help in prevention of hypercarbia and End tidal CO2 (EtCO2) is generally considered to provide reliable information of PaCO2 during laparoscopy. In our study capnography was used to monitor EtCO2 and minute volume was adjusted during controlled ventilation to keep the EtCO2 within normal range. However, the EtCO2 was higher in group I patients than in group II during different periods of time during operation. This may be attributed to the respiratory changes due to increased IAP produced by pneumoperitoneum and absorption of CO2.


  Conclusion: Top


From the present study it is observed that laparoscopic cholecystectomy causes more severe physiological alterations than open cholecystectomy intra- operatively. There is significant increase in pulse rate, mean arterial pressure and EtCO2 even in ASA I and II patients. Though these physiological alterations generally do not need any intervention. Yet it makes continuous intra- operative monitoring mandatory. Thus it is desired that continuous haemodynamic and ECG monitoring, pulse oximetry and capnographic monitoring should be done in laparoscopic cholecystectomy.



 
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