• Oscar Diaz-Cambronero, Blas Flor Lorente, Guido Mazzinari, Maria Vila Montañes, Nuria García Gregorio, Daniel Robles Hernandez, Luis Enrique Olmedilla Arnal, Maria Pilar Argente Navarro, Marcus J Schultz, Carlos L Errando, and IPPColLapSe study group.
• Department of Anesthesiology & Perioperative Medicine Research Group, Hospital Universitario y Politécnico la Fe. Valencia España, Avinguda de Fernando Abril Martorell 106, 46026, Valencia, Spain. perioperativemedicine@iislafe.es.
• Surg Endosc. 2019 Jan 1; 33 (1): 252-260.

BackgroundWhile guidelines for laparoscopic abdominal surgery advise using the lowest possible intra-abdominal pressure, commonly a standard pressure is used. We evaluated the feasibility of a predefined multifaceted individualized pneumoperitoneum strategy aiming at the lowest possible intra-abdominal pressure during laparoscopic colorectal surgery.MethodsMulticenter prospective study in patients scheduled for laparoscopic colorectal surgery. The strategy consisted of ventilation with low tidal volume, a modified lithotomy position, deep neuromuscular blockade, pre-stretching of the abdominal wall, and individualized intra-abdominal pressure titration; the effect was blindly evaluated by the surgeon. The primary endpoint was the proportion of surgical procedures completed at each individualized intra-abdominal pressure level. Secondary endpoints were the respiratory system driving pressure, and the estimated volume of insufflated CO2 gas needed to perform the surgical procedure.ResultsNinety-two patients were enrolled in the study. Fourteen cases were converted to open surgery for reasons not related to the strategy. The intervention was feasible in all patients and well-accepted by all surgeons. In 61 out of 78 patients (78%), surgery was performed and completed at the lowest possible IAP, 8 mmHg. In 17 patients, IAP was raised up to 12 mmHg. The relationship between IAP and driving pressure was almost linear. The mean estimated intra-abdominal CO2 volume at which surgery was performed was 3.2 L.ConclusionA multifaceted individualized pneumoperitoneum strategy during laparoscopic colorectal surgery was feasible and resulted in an adequate working space in most patients at lower intra-abdominal pressure and lower respiratory driving pressure. ClinicalTrials.gov (Trial Identifier: NCT03000465).

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