Journal of Laparoendoscopic & Advanced Surgical Techniques

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1 : Effects of persistent CO insufflation during different laparoscopic inguinal hernioplasty: a prospective randomized controlled study Journal: Manuscript ID: LAP Manuscript Type: Full Reports (Standard) Date Submitted by the Author: 0-Mar-00 Complete List of Authors: Zhu, Qianlin; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of Anesthesiology Mao, Zhihai; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of General Surgery Yu, Buwei; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of Anesthesiology Jin, Jue; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of Anesthesiology Deng, Yunxin; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of Anesthesiology Zheng, Minhua; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of General Surgery Li, Jianwen; Ruijin Hospital Shanghai Jiaotong University School of Medicine, Department of General Surgery Keyword: Hernia, Perioperative/Complications Abstract: Objective To investigate the effects of CO insufflation on hemodynamic and respiratory function during laparoscopic inguinal hernioplasty and to evaluate the safety of transabdominal preperitoneal hernia repair (TAPP) and extraperitoneal hernia repair (TEP). Methods Forty patients with inguinal hernia were admitted for laparoscopic inguinal hernia repair in our study. The patients were randomly assigned to undergo TAPP (TAPP group, n = 0) or TEP (TEP group, n = 0). Hemodynamic and respiratory parameters including heart rate, blood pressure, end-tidal CO (Et CO) as well as blood gas parameters were observed and compared between the two groups. Results There was no significant difference between the two groups in terms of sex, age, ASA degree, BMI, type of hernia, operation time, hospital stay and postoperative pain score. In both groups, after minute of the operation, blood pressure, EtCO, PaCO and HCO- increased significantly, heart rate and ph decreased significantly (P<0.0). The above tendency became

2 Page of significant with the operation prolonged. All parameters recovered to normal level at the end of surgery. No significant difference was found between TAPP and TEP group. Conclusions Both TAPP and TEP procedures can result in CO accumulation, acidosis, increased blood pressure and decreased heart rate. But these effects were transient and can be well controlled by appropriate treatments during operation. The laparoscopic TAPP and TEP are safe for patients by proper perioperative management.

3 Page of HR Time (min) Figure: variations of HR between TEP and TAPP group TAPP TEP

4 Page of BP Time (min) Figure: variations of BP between TEP and TAPP group TAPP TEP

5 Page of EtCO Time (min) Figure: variations of EtCO between TEP and TAPP group TAPP TEP

6 Page of Effects of persistent CO insufflation during different laparoscopic inguinal hernioplasty: a prospective randomized controlled study Qianlin Zhu a *, Zhihai Mao b *, Buwei Yu a, Jue Jin a, Minhua Zheng b, Jianwen Li b# a b Department of Anesthesiology, Department of General Surgery, Shanghai Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, 000, China *Qianlin Zhu and Zhihai Mao contributed equally to this work #Corresponding author: Jianwen Li ( jian_wen_li@.com) [Abstract] Objective To investigate the effects of CO insufflation on hemodynamic and respiratory function during laparoscopic inguinal hernioplasty and to evaluate the safety of transabdominal preperitoneal hernia repair (TAPP) and extraperitoneal hernia repair (TEP). Methods Forty patients with inguinal hernia were admitted for laparoscopic inguinal hernia repair in our study. The patients were randomly assigned to undergo TAPP (TAPP group, n = 0) or TEP (TEP group, n = 0). Hemodynamic and respiratory parameters including heart rate, blood pressure, end-tidal CO (Et CO ) as well as blood gas parameters were observed and compared between the two groups. Results There was no significant difference between the two groups in terms of sex, age, ASA degree, BMI, type of hernia, operation time, hospital stay and postoperative pain score. In both groups, after minute of the operation, blood pressure, EtCO, PaCO and HCO - increased significantly, heart rate and ph decreased significantly (P<0.0). The above tendency became significant with the operation prolonged. All parameters recovered to normal level at the end of surgery. No significant difference was found between TAPP and TEP group. Conclusions Both TAPP and TEP procedures can result in CO accumulation, acidosis, increased blood pressure and decreased heart rate. But these effects were transient and can be well controlled by appropriate treatments during operation. The laparoscopic TAPP and TEP are safe for patients by proper perioperative management. Key words: TAPP; TEP; CO insufflation; hernia; prospective study Introduction

7 Page of Transabdominal preperitoneal (TAPP) and total extraperitoneal (TEP) hernia repair are clinically applied as two major laparoscopic techniques of tension-free hernia repair [, ]. The main difference between them is the space for a persistent CO insufflation: TAPP created it intraabdominally while TEP accomplished it extraperitoneally. CO absorption is a problem associated with laparoscopic surgery which usually causes significant pathophysiological changes during or after operation. The uptake of exogenous CO in laparoscopic cholecystectomy or gynecological surgery has been documented [, ] ; however, results from laparoscopic hernioplasty are scarce. In TEP technique for laparoscopic hernioplasty, there is significant insufflation of CO into extraperitoneal tissues, with the probability of even more CO absorption than TAPP technique [-]. Many adult patients requiring hernia repair have either chronic obstructive or restrictive lung disease which clinically decrease the elimination of additional CO loading during operation [], and are prone to occur with hypercapnia and acidosis. We observed the possible variations of patients caused by CO insufflation during laparoscopic hernioplasty and compared these two laparoscopic techniques with respect to parameters. The outcome may assist the clinical assessment for intraoperative risk and may be valuable when deciding which approach of laparoscopic hernioplasty would be more appropriate for each individual patient. Materials and methods Forty patients (ASA physical status I or II) with inguinal hernia who were scheduled for a laparoscopic hernioplasty were enrolled in this study. They were randomly assigned to have transabdominal preperitoneal hernioplasty (TAPP group,n=0) or total extraperitoneal hernioplasty (TEP group,n=0). The exclusion criteria were as follows: ) recurrent or bilateral hernia; ) previous history of low abdominal surgery; ) coexisting severe cardiovascular or pulmonary diseases; and ) any other contraindications for a laparoscopic surgery. Unwarmed CO was used for insufflation

8 Page of during both TAPP and TEP approach; the intracavitary pressure was kept at mm Hg in TEP approach and mmhg in TAPP approach. Anesthesia was induced with fentanyl and propofol by continuous infusion and atracurium was used for neuromuscular relaxation. After the tracheal intubation, the initial respiratory frequency was set at breaths/min with a ventilatory tidal volume of 0 to ml/kg body weight. The inspiration-expiration time ratio was :. with no inspiratory hold and no rebreathing. The airway pressure was restricted to be under 0 cmh O and the end-tidal CO concentration (EtCO ) was maintained below 0mmHg throughout the operation by adjustment of minute ventilation (Datex-Ohmeda, Finland). Intraoperative bradycardia (pulse<0 bpm) was treated by atropine 0.mg IV or isoprenaline if needed, while hypertension was treated with an infusion of 0.mg nicardipine, mg urapidil or mg labetalol selectively to maintain a systolic blood pressure less than 0 mmhg and the diastolic pressure less than 0 mmhg. After an over ventilation which allowed a satisfactory lung expansion and EtCO below 0mmHg, and the patients spontaneous breathing recovered completely, the patients were extubated. The demographics of patients including age, gender, ASA(American Society of Anesthesiology)degree, and body mass index (BMI), as well as operation time, length of stay (LOS) and VAS score were observed. Blood gases such as ph, HCO -, PaCO were analyzed at four time points (before and min after pneumoperitoneum, 0min during operation and after extubation). Heart rate (HR), blood pressure (BP) and EtCO were also monitored for defined time points every min since the beginning of operation. The SPSS.0 software package was used for statistical analysis. The results are presented as mean ± standard deviation and within-group analysis of variance (ANOVA) was used. Comparisons for variables were performed using chi-square test. All p values less than 0.0 were considered statistically significant. Results

9 Page of There was no statistical difference between TEP and TAPP group on gender, age, ASA degree, and BMI; as well as on operation time, LOS, and VAS scoring. No recurrence of patient s preexisting systemic diseases or any obvious operative complications were observed. (Table ) Table: demographics and clinical parameters of TEP and TAPP group TAPP(n=0) TEP(n=0) P value Gender (M/F) / 0/0.00 Age (yr).±. 0.±. 0. ASA (I/II) / / 0. BMI (kg/m ).±..±.0 0. Operation time (min).±..±. 0. LOS (d).±0..± VAS.0±..±. 0.0 A decrease of HR and an increase of BP were begun since the beginning of operation and data collected at min during operation showed a statistical difference with the baseline level before operation, the tendency of which is more significant along with the prolonging of procedure. However, data collected at min were similar to the baseline level which may imply the effectiveness of our drug administration. The variation of absolute values from TAPP group was larger than in TEP group, but no statistical difference was revealed between the two groups on these defined time intervals. (Figure&) The EtCO values increased in both TEP and TAPP group, and data collected at min during operation showed a statistical difference with the baseline level before operation, this variation is more obvious when the operation is prolonged. In both groups the EtCO value could reach towards 0mmHg or over at 0min during operation. The absolute variation of EtCO in TEP group is more significant than that in TAPP group but in accordance to the circulatory parameters listed above, no statistical difference could be revealed from between the two groups on the same defined time intervals. (Figure)

10 Page of HR Time (min) 0 0 BP Figure: variations of HR between TEP and TAPP group Time (min) Figure: variations of BP between TEP and TAPP group TAPP TEP TAPP TEP

11 Page 0 of Figure: variations of EtCO between TEP and TAPP group Since the beginning of operation, the blood gas analysis presented with a decrease of ph value, while the PaCO and HCO - increased synchronously. ph, PaCO and HCO - values at min during operation were statistically different compared with those collected before operation. The above trend was observed to be constantly existed during operation, but these parameters quickly recovered after extubation. Nevertheless, the actual values after operation were still statistically different compared with the preoperative level. The parameters in TEP group showed a larger variation than that in TAPP group, but the difference is not statistically significant between groups on whether during persistent insufflation or not, even after extubation. (Table ) HR BP EtCO PH EtCO Time (min) Table: Pathophysiological parameters of TEP and TAPP group Before CO insufflation min during operation 0min during operation TAPP TEP After extubation TEP.0±..±.00.±..0±. TAPP.0±..±..±..±. TEP 0.±.0 0.0±..±..±. TAPP 0.0±..0±..±..±. TEP.0±..0±.0.±. / TAPP.0±..±..0±. / TEP.0±0.0.±0.0.±0.0.±0.0 TAPP.0±0.0.±0.0.0±0.0.±0.0

12 Page of PaCO TEP.0±..±..±..±. TAPP.±..±..±..±. HCO TEP.±..0±..±..±. TAPP.0±..±..±..±.0 Discussion The pathophysiological changes caused by CO pneumoperitoneum has been enthusiastically discussed through recent years since the successful application of this novel technique to general surgery. Previous studies have demonstrated that a CO pneumoperitoneum would cause adverse effects to the cardiaovascular and pulmonary function of the patients. An increase of intraabdominal pressure (IAP) would enhance abdomino-cardiac reflex which stimulate the vagus nerve; compress the inferior vena cava and thus decrease the venous return; the distension of abdominal cavity further increase the peripheral vascular resistance, all of the above descriptions would clinically present with a higher BP and a slower HR. The absorption of CO through peritoneum or capillary vessels would accumulate to a gradually result in acidosis; the restriction of lung expansion would impair the normal expiration of residual CO and cause the EtCO to increase continuously. In this study, we noticed that the CO pneumoperitoneum during operation did have these impacts to the human body: increase of EtCO and PaCO, HCO - ; decrease of ph value; and fluctuation of HR and BP as illustrated above. Moreover, these variations were aggravated with the prolonging of surgery. Nevertheless, by adequate monitoring and administration throughout the perioperative period, these adverse effects could be minimized down to a safe extent. For example, fluctuation of HR and BP could return to stable status by proper drug administration; suitable regulation of mechanically ventilation by increasing respiratory rate and end-tidal volume may relieve the accumulation of CO ; an over ventilation before tracheal extubation allows a better distension of lung and sufficient oxygenation. Although data revealed some evidence for residual mild acidosis, the overall circulatory, pulmonary and blood chemistry parameters were recovered and patients had no associated complaints.

13 Page of As one of the most popular techniques for laparoscopic hernioplasty, TEP approach is a modified technique based on TAPP approach. Although both TEP and TAPP are favorable for their mild destruction to subcutaneous tissue, quick recovery, fewer surgical complications and lower recurrence rate, TEP better protects the peritoneum so that intraabdominal complications are avoided [,,, 0]. It is gradually replacing TAPP as the standard surgical therapy for inguinal hernia repair. However, as TEP should create a preperitoneal cavity for a relatively complicated surgical procedure, which would influence the body respiratory, circulatory and acid-base balance even more severe than TAPP approach does. Although references available have already performed a serial comparison between these two approaches and concluded that no statistically difference was discovered, the parameters for comparisons were mostly limited within clinical observations [-]. Few studied were focused on the impact of extraperitoneal CO insufflation towards human physiological environment. The influence of extraperitoneal insufflation to human body is mainly centralized on the massive CO absorption through subcutaneous tissue. A direct diffusion of carbon dioxide may cause subcutaneous emphysema, pneumomediastinum even pneumothorax [, ] ; and due to a localized high pressure, hypercapnia or acidosis is easily occurred during operation because the CO absorption is always more critical than normal pneumoperitoneum [, ]. We have observed a synchronous variation in both groups on EtCO, ph, PaCO, and HCO -, but no significant difference was summerized from between-group comparison and the absolute values implied a much more obvious impairment to pulmonary function in TEP group than in TAPP group. Since the insufflation during TEP would not have direct compression on intraabdominal organs, only a relatively smooth fluctuation of HR and BP was noticed because of the chemical stimulation towards cardiovascular system. The overall variation of HR and BP is smaller in TEP group than in TAPP group and the statistical comparison revealed no significant difference. Bannenberg et al [] once performed an experimental study which defined that extraperitoneal CO insufflation had less impairment to cardiovascular function than intraperitoneal pneumoperitoneum did, which was again confirmed by our study.

14 Page of Both TEP and TAPP approach for laparoscopic hernioplasty might cause pulmonary, cardiovascular or acid-base disorder. But their impairments were mostly transient and could be controlled by sufficient introperative management. An appropriate selection of the operation approach should not only base on hernia type but also put the patient s preoperative physical status into consideration. Nevertheless, through adequate anesthetic management and experienced surgical procedure, all of them are feasible and safe for patients. Reference. Reuben B, Neumayer L. Surgical management of inguinal hernia. Adv Surg 00, 0: -.. Papachristou EA, Mitselou MF, Finokaliotis ND. Surgical outcome and hospital cost analyses of laparoscopic and open tension-free hernia repair. Hernia 00, (): -.. Tan PL, Lee TL, Tweed EA. Carbon dioxide absorption and gas exchange during pelvic laparoscopy. Can J Anaesth ; :.. Debois P, Sabbe MB, Wouters P, Vandermeersch E,. Van Aken H. Carbon dioxide adsorption during laparoscopic cholecystectomy and inguinal hernia repair. Eur J Anaesth ; :.. Mullett CE, Viale JP, Sagnard PE, Miellet CC, Ruynat LG, Counioux HC, Motin JP, Boulez JP, Dargent DM, Annat GJ. Pulmonary CO elimination during surgical procedures using intra- or extraperitoneal CO insufflation. Anesth Analg, :.. Wolf JS Jr, Monk TG, McDougall EM, Shepherd DL, Folger WH, Monk TG. The extraperitoneal approach and subcutaneous emphysema are associated with greater absorption of carbon dioxide during laparoscopic renal surgery. J Urol, :.. Felix EL, Michas CA, Gonzalez MH Jr. Laparoscopic hernioplasty: TAPP vs TEP.

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