|Year : 2017 | Volume
| Issue : 2 | Page : 189-192
Laparoscopic cholecystectomy in hepatic patients
Emad M Elsageer MD 1, Ahmad M Atiya1, Tohamy A Tohamy2
1 Assistant Professor G.S, ElMinia University Hospital, Minia, Egypt
2 Lecturer in G.S, ElMinia University Hospital, Minia, Egypt
|Date of Submission||30-Dec-2016|
|Date of Acceptance||30-Jan-2017|
|Date of Web Publication||13-Apr-2017|
Emad M Elsageer
General surgery Department, ElMinia University Hospital, Minia
Source of Support: None, Conflict of Interest: None
The aim of this study was to compare low-pressure with high-pressure pneumoperitoneum laparoscopic cholecystectomy in hepatic patients.
Patients and methods
This prospective study included 40 consecutive patients with calcular gall bladder and hepatitis C who were admitted in The Department of General Surgery, Minia University Hospital, between July 2016 and December 2016. We classified them into two groups, group I (high pressure) and group II (low pressure).
In group I, aspartate aminotransferase (AST), alanine aminotransferase (ALT), γ-glutamyltransferase, and lactate dehydrogenase (LDH) were significantly increased 24 h postoperatively. AST and ALT were elevated three-fold, and AST, ALT, and LDH reached levels over upper normal limits after 24 h postoperatively. However, in group II patients the elevation of enzyme levels did not reach two-fold and remained within the normal limits. On comparing the two groups, the elevation of AST, ALT, and LDH was significant for group I (P=0.0001). Moreover, elevation of γ-glutamyltransferase was significant (P=0.041), whereas alkaline phosphatase level changes were nonsignificant.
We conclude that pneumoperitoneum 14 mmHg pressure decreased blood flow to the liver with increased postoperative serum enzyme levels, and pneumoperitoneum 10 mmHg pressure is superior to 14 mmHg pressure pneumoperitoneum in laparoscopic cholecystectomy. Therefore, we recommend this low-pressure pneumoperitoneum in hepatic patients.
Keywords: cholecystectomy, laparoscopic, pneumoperitoneum
|How to cite this article:|
Elsageer EM, Atiya AM, Tohamy TA. Laparoscopic cholecystectomy in hepatic patients. Egypt J Surg 2017;36:189-92
| Introduction|| |
The Egyptian Demographic Health Survey, a cross-sectional survey including hepatitis C virus (HCV) biomarkers, was conducted in 2008 on a large nationally representative sample . It estimated HCV prevalence among individuals in the age group of 15–59 years to be 14.7% . Accordingly, Egypt has the highest HCV prevalence in the world ,,. This unparalleled level of exposure to this infection appears to reflect a national level epidemic. It has been postulated that the epidemic has been caused by extensive iatrogenic transmission during the era of parenteral antischistosomal therapy mass-treatment campaigns ,. Today, HCV infection and its complications are among the leading public health challenges in Egypt . The diverse HCV studies conducted among different general population subgroups, regardless of the design or methodology, consistently report a very high HCV prevalence, as high as 41% in some studies .
Worldwide, laparoscopic cholecystectomy is most often performed by pumping CO2 into the abdominal cavity. To provide good exposure of the surgical field, generally 10–15 mmHg pressure ranges are used during pneumoperitoneum creation ,,,.
Junghans et al.  demonstrated in a pig model that intra-abdominal pressure greater than 12 mmHg may induce a reduction in splanchnic and hepatic perfusion.
Morino et al.  evaluated the effects of pneumoperitoneum on hepatic function in patients treated with laparoscopic procedures. The cholecystectomies were performed with pneumoperitoneum at 10 and 14 mmHg and found that all patients had a postoperative increase in aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels. They suggested that patients with severe hepatic failure should probably not be subjected to prolonged laparoscopic procedures. In another recent study, Sakorafas et al.  demonstrated a statistically significant increase in ALT and AST in the laparoscopic cholecystectomy group at 14 mmHg of CO2 pressure.
| Patients and methods|| |
This prospective study included 40 patients with compensated hepatitis C-positive tests who were planned for elective laparoscopic cholecystectomy in El-Minia University Hospital from June 2016 to December 2016. Patients were classified carefully into two groups in an attempt to obtain the same range of age, sex, and weight of selected patients between the two groups. Group I patients were operated upon using pneumoperitoneum 14 mmHg pressure, and group II was operated upon using pneumoperitoneum 10 mmHg pressure. Informed written consent was obtained from all patients. Patients with decompensated liver were excluded from the study.
The same team of surgeons operated all patients, using the same anesthetic protocol. Midazolam hydrochloride was used as a premedication 45 min preoperatively at a dose of 0.7 mg/kg. Preoxygenation was carried out for 2 min, and then anesthesia was induced with fentanyl citrate (1–1.5 µg/kg) and propofol (2–2.5 mg/kg) and vecuronium (0.1 mg/kg) as a muscle relaxant. Maintenance of anesthesia was carried out with sevoflurane (2–2.5 vol.%) with oxygen-in-air mixture (0.50 ratio). Mechanical ventilation was used, and end-tidal carbon dioxide was maintained on 35–38 mmHg.
Heart rate, mean arterial pressure, oxygen saturation, and end-tidal carbon dioxide were all recorded three times first at preinsufflation, and then 10 min after insufflation, and lastly 10 min after desufflation. Anesthetic time and surgery time were recorded.
Serum AST, ALT, γ-glutamyltransferase (GGT), lactate dehydrogenase (LDH), and alkaline phosphatase levels were all recorded preoperatively and at 1 and 24 h postoperatively.
The enzyme levels were evaluated at 1 and 2 weeks of follow-up.
| Results|| |
This study included 40 patients, 18 female and 12 male, who were planned for elective laparoscopic cholecystectomy in El-Minia University Hospital. [Table 1] shows the sex, age, and weight of patients and the duration of surgery time. There was no difference between the two groups as regards demographic data or time of surgery.
There was no morbidity or mortality in any of the studied patients. In group I, AST, ALT, GGT, and LDH were significantly increased 24 h postoperatively, especially AST and ALT, which were elevated three-fold, and AST, ALT, and LDH reached levels over upper normal limits after 24 h postoperatively. However, in group II patients the elevation of enzyme levels did not reach two-fold and remained within the normal limits. On comparing the two groups, the elevation of AST, ALT, and LDH was significant for group I (P=0.0001). Moreover, elevation in GGT was significant (P=0.041), whereas alkaline phosphatase level changes were nonsignificant ([Table 2]).
On follow-up visits, all elevated enzymes returned to normal levels.
| Discussion|| |
With advancement of medical practice in present era, the introduction of laparoscopic surgeries has changed dramatically the management of gall bladder disease and establishing the laparoscopic cholecystectomy as the method of choice for the treatment of uncomplicated cholelithiasis .
Surgeons have traditionally relied on creating a pneumoperitoneum of up to 14–15 mmHg by insufflating carbon dioxide gas into the peritoneal cavity at the time of insertion of ports. This has the desired effect of raising the abdominal wall away from the viscera, giving room to visualize the gall bladder and surrounding organs, allowing manipulation of instruments, and also allowing the intestine to fall away from the subhepatic space when the patient is positioned properly . However, pneumoperitoneum with carbon dioxide gas at the pressures commonly used has been shown to be associated with unique and specific side effects ,,,,.
Egypt has the highest prevalence of HCV in the world, estimated nationally at 14.7% .
In our study, we operated on 40 compensated virus C-positive patients and compared the effects of low-pressure versus high-pressure pneumoperitoneum on hepatic enzyme levels and we found that, in group I (the high-pressure group), AST, ALT, GGT, and LDH were significantly increased 24 h postoperatively. AST and ALT were elevated three-fold and AST, ALT, and LDH reached levels over upper normal limits after 24 h postoperatively. However, in group II patients (the low-pressure group) the elevation of enzyme levels did not reached two-fold and remained within the normal limits. On comparing the two groups, the elevation of AST, ALT, and LDH was significant for group I (P=0.0001). Moreover, elevation in GGT was significant (P=0.041), whereas alkaline phosphatase level changes were nonsignificant. These results are in agreement with worldwide studies.
Several previous studies reported the effects of pneumoperitoneum on splanchnic and liver perfusion ,. Meierhenrich et al.  demonstrated that induction of CO2 pneumoperitoneum with an IAP of 12 mmHg is associated with an increase in hepatic perfusion in healthy adults. The authors do not have a definite explanation for these findings. Another study conducted by Sato et al.  compared hepatic blood flow and function in patients undergoing laparoscopic cholecystectomy with an intra-abdominal pressure of 9–12 mmHg and concluded that laparoscopic cholecystectomy might impair hepatic function because of the high pressure.
Standard pressure pneumoperitoneum is associated with significant changes in liver and renal function tests as compared with low-pressure pneumoperitoneum .
Operating time was about 2 min longer (very low-quality evidence) in the low-pressure group than in the standard pressure group . This is in agreement with our results in which our operating time was about two and a half minutes longer in the low pressure group than in the standard pressure group.
The safety of low pressure pneumoperitoneum has to be established .
| Conclusion|| |
We conclude that low-pressure pneumoperitoneum is better to be used, especially in patients with hepatitis, which is a very common disease in Egypt. Further studies will be conducted to evaluate the effect of high-pressure versus low-pressure pneumoperitoneum in more advanced hepatic patients and on a long-term outcome.
Financial support and sponsorship
Conflicts of interest
There is no conflict of interest.
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[Table 1], [Table 2]