Comparison of Carbon Dioxide Absorption Rates in Gynecologic Laparoscopy with a Valveless versus Standard Insufflation System: Randomized Controlled Trial

Abstract

The primary objective was to compare carbon dioxide (CO 2 ) absorption rates in patients undergoing gynecologic laparoscopy with a standard versus valveless insufflation system (AirSeal; ConMed, Utica, NY) at intraabdominal pressures (IAPs) of 10 and 15 mm Hg. Secondary objectives were assessment of surgeons' visualization of the operative field, anesthesiologists' ability to maintain adequate end-tidal CO 2 (etCO 2 ), and patients' report of postoperative shoulder pain. Design: A randomized controlled trial using an equal allocation ratio into 4 arms: standard insufflation/IAP 10 mm Hg, standard insufflation/IAP 15 mm Hg, valveless insufflation/IAP 10 mm Hg, and valveless insufflation/IAP 15 mm Hg. Setting: Single tertiary care academic institution. Patients: Women ≥ 18 years old undergoing nonemergent conventional or robotic gynecologic laparoscopic surgery. Interventions: A standard or valveless insufflation system at IAPs of 10 or 15 mm Hg. Measurements and Main Results: One hundred thirty-two patients were enrolled and randomized with 33 patients per group. There were 84 robotic cases and 47 conventional laparoscopic cases. CO 2 absorption rates (mL/kg*min) did not differ across groups with mean rates of 4.00 § 1.3 in the valveless insufflation groups and 4.00 § 1.1 in the standard insufflation groups. The surgeons' rating of overall visualization of the operative field on a 10-point Likert scale favored the valveless insufflation system (median visualization, 9.0 § 2.0 cm and 9.5 § 1.8 cm at 10 and 15 mm Hg, respectively) over standard insufflation (7.0 § 3.0 cm and 7.0 § 2.0 cm at 10 and 15 mm Hg, respectively; p <.001). The anesthesiologists' ability to maintain adequate etCO 2 was similar across groups (p = .417). Postoperative shoulder pain scores were low overall with no significant difference across groups (p >.05). Conclusion: CO 2 absorption rates, anesthesiologists' ability to maintain adequate etCO 2 , and postoperative shoulder pain did not differ based on insufflation system type or IAP. Surgeons' rating of visualization of the operative field was significantly improved when using the valveless over the standard insufflation system.

Low-Pressure Laparoscopy Using the AirSeal System versus Standard Insufflation in Early-Stage Endometrial Cancer: A Multicenter, Retrospective Study (ARIEL Study)

“…Moreover, as already shown by Sroussi et al, the pain control was lower overall in the AirSeal group compared to the standard insufflation group, in both the general population and the obese subgroup [ 6 ]. On the other hand, our study and those available in the literature are in contrast with the recent randomized study by Madueke-Laveaux et al [ 16 ], which did not report statistically significant advantages of the valveless system in terms of CO2 absorption rates and post-operative pain control in women who underwent laparoscopic surgery for benign conditions. However, the study involved a healthy, younger, and non-obese population with a lower rate of associated co-morbidity when compared to other already published experiments [ 6 , 11 ].…”

“…In randomized experiments in urology, the system improved visualization and reduced cardiopulmonary damage compared to standard insufflation [ 12 , 13 , 14 ]. The AirSeal platform has been evaluated in general gynecologic surgery, mainly in cases of benign disease [ 15 , 16 ]. However, data from a gynecologic oncologic setting are still lacking.…”

Prospective randomized controlled trial on comparison of standard CO2 pressure pneumoperitoneum insufflator versus AirSeal®

“…The result may be attributed to insufficient sample and lack of power to evaluate this variable in this study. In a RCT using an equal allocation ratio across 4 arms (standard insufflation vs. valveless insufflation with an intra-abdominal pressure of 10 mmHg or 15 mmHg) in 33 patients per group, no difference in patients postoperative shoulder pain was reported [34].…”

“…This is also an important feedback that may impact the decision to use AirSeal® in more complex surgical procedures. Maduueke-Laveaux et al [34] assessed surgeon's visualization of the operative field with valveless versus standard insufflation system in a randomized controlled trial. Surgeons reported improved visualization of the operative field using valveless insufflation system over standard insufflation (p < 0.001), and this was most significant when performing complex robotic gynecologic surgeries that require more electrocautery.…”

Impact of AirSeal® insufflation system on respiratory and circulatory dynamics during laparoscopic abdominal surgery

“…Several studies to date have compared the AirSeal ® with conventional CO 2 insufflation systems and demonstrated the advantages of the former including reduced CO 2 use [ 2 ], lower intraperitoneal pressure [ 3 , 4 ], shortened operative time [ 5 ], improved visualization of the operative field [ 6 ], and less postoperative shoulder pain [ 4 ] than conventional insufflation systems.…”