Low-pressure Pneumoperitoneum in Laparoscopic Cholecystectomy: A Randomized Controlled Trial.

BACKGROUND/PURPOSE: To compare the changes in hepatic enzymes and comfort level of the surgeon in low-pressure pneumoperitoneum laparoscopic cholecystectomy (LPPLC, 7 mm Hg) with that of normal pressure pneumoperitoneum laparoscopic cholecystectomy (NPPLC, 14 mm Hg). METHODS: Eighty-two patients were randomly divided into 2 groups (LPPLC and NPPLC). Serum levels of bilirubin, serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, alkaline phosphatase, and lactate dehydrogenase were measured before the operation, at the time of reversal from anesthesia, 24 hours after the operation, and on day 7. Serious adverse events, intra-operative complications, surgeon's comfort level of dissection, operative time, conversion rates to an open procedure, or normal pressure pneumoperitoneum were recorded. RESULTS: Of the 41 patients randomized for LPPLC, 8 patients were converted to NPPLC due to difficulty in dissection and 1 converted to open in each group. There was statistically significant fall in mean serum bilirubin level in both the groups in the immediate postoperative period (P<0.05). Statistically significant increase in its level was observed after 24 hours in the NPPLC group only (P<0.05). Levels of mean serum serum glutamic-oxaloacetic transaminase, serum glutamic-pyruvic transaminase, and lactate dehydrogenase increased significantly (P<0.05) in immediate postoperative period and a further increase was observed after 24 hours (P<0.05) in the NPPLC group only. The comfort level of surgeon was found to be significantly better in the NPPLC group. CONCLUSIONS: LPPLC is a safe procedure, especially in the hands of an experienced surgeon with clinically insignificant systemic effects. But the comfort level of surgeon is better in normal pressure when compared with low pressure. In patients with deranged hepatic functions undergoing advanced laparoscopic procedures, it is advisable to start the surgery with low-pressure pneumoperitoneum. Pressure may be escalated further as per the surgeon's comfort.

Duodenal adenoma presenting as duodenojejunal intussusception.

Enteroenteric intussusceptions are rarely observed in adults. Most of these are associated with tumors. We operated a 25-year old female with suspected stricture in the third part of the duodenum. However during laparotomy, duodenojejunal intussusception was found along with an adenoma in the third part of the duodenum associated with a lax ligament of Treitz. The intussusception was reduced and the parts of the duodenum containing the adenoma were resected, followed by an end-to-end duodenojejunal anastomosis. To the best of our knowledge, this is the first reported case of tubulovillous adenoma in the third part of the duodenum presenting as intussusception in an adult.