Natural-orifice transluminal endoscopic surgery: Low-pressure pneumoperitoneum is sufficient and is associated with an improved cardiopulmonary response (PressurePig Study)

Background and aims: The aim of this randomized trial in the acute porcine model was to compare the quality of transgastric peritoneoscopy with the use of low-pressure versus standard-pressure pneumoperitoneum and to evaluate the respective associated cardiopulmonary changes. Methods: For transgastric peritoneoscopy, carbon dioxide was insufflated via the endoscope for a constant intraperitoneal pressure of 6mmHg or 12mmHg in 9 pigs each. The quality of transgastric peritoneoscopy was rated on a visual analog scale (0mm, min.; 100mm, max.) by the endoscopist, who was blinded to the intraperitoneal pressure. The cardiac index and global end-diastolic volume index (GEDVI, reflecting preload) were measured every 3 minutes by transpulmonary thermodilution. The following were also recorded: heart rate, mean arterial pressure (MAP), systemic vascular resistance index (SVRI, reflecting afterload), peak inspiratory pressure (PIP), pH, PCO and PO Results: The quality of transgastric peritoneoscopy with the use of low-pressure pneumoperitoneum was not inferior to that obtained using standard-pressure pneumoperitoneum (87.0mm vs. 87.3mm; P<0.05). In both groups we observed a statistically significant rise in MAP and SVRI. The increase in SVRI was less pronounced during low-pressure peritoneum (P=0.042), indicating a reduced stress response in comparison to standard-pressure peritoneum. There were no relevant differences between the groups in relation to cardiac index, GEDVI, and heart rate. An intra-abdominal pressure of 6mmHg also led to better oxygenation (P=0.031 for difference in PObetween the two groups) due to lower peak inspiratory pressure (P<0.001 for difference). There were only slight differences between the groups with regard to pH and PCO Conclusions: Pneumoperitoneum of 1216mmHg is used for standard laparoscopy. For NOTES, low-pressure pneumoperitoneum is sufficient and is associated with an improved cardiopulmonary response compared to standard-pressure pneumoperitoneum.