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. 2022 Mar 15;3(3):CD009569.
doi: 10.1002/14651858.CD009569.pub4.

Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery

Xudong Yang  1 , Yao Cheng  2 , Nansheng Cheng  3 , Jianping Gong  2 , Lian Bai  4 , Longshuan Zhao  1 , Yilei Deng  1
Affiliations

Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery

Xudong Yang et al. Cochrane Database Syst Rev. .

Abstract

Background: This is the second update of a Cochrane Review first published in 2013 and last updated in 2017. Laparoscopic surgery is now widely performed to treat various abdominal diseases. Currently, carbon dioxide is the most frequently used gas for insufflation of the abdominal cavity (pneumoperitoneum). Although carbon dioxide meets most of the requirements for pneumoperitoneum, the absorption of carbon dioxide may be associated with adverse events. Therefore, other gases have been introduced as alternatives to carbon dioxide for establishing pneumoperitoneum.

Objectives: To assess the safety, benefits, and harms of different gases (e.g. carbon dioxide, helium, argon, nitrogen, nitrous oxide, and room air) used for establishing pneumoperitoneum in participants undergoing laparoscopic abdominal or gynaecological pelvic surgery.

Search methods: We searched CENTRAL, Ovid MEDLINE, Ovid Embase, four other databases, and three trials registers on 15 October 2021 together with reference checking, citation searching, and contact with study authors to identify additional studies.

Selection criteria: We included randomised controlled trials (RCTs) comparing different gases for establishing pneumoperitoneum in participants (irrespective of age, sex, or race) undergoing laparoscopic abdominal or gynaecological pelvic surgery under general anaesthesia.

Data collection and analysis: We used standard methodological procedures expected by Cochrane.

Main results: We included 10 RCTs, randomising 583 participants, comparing different gases for establishing pneumoperitoneum: nitrous oxide (four trials), helium (five trials), or room air (one trial) was compared to carbon dioxide. All the RCTs were single-centre studies. Four RCTs were conducted in the USA; two in Australia; one in China; one in Finland; one in Iran; and one in the Netherlands. The mean age of the participants ranged from 27.6 years to 49.0 years. Four trials randomised participants to nitrous oxide pneumoperitoneum (132 participants) or carbon dioxide pneumoperitoneum (128 participants). None of the trials was at low risk of bias. The evidence is very uncertain about the effects of nitrous oxide pneumoperitoneum compared to carbon dioxide pneumoperitoneum on cardiopulmonary complications (Peto odds ratio (OR) 2.62, 95% CI 0.78 to 8.85; 3 studies, 204 participants; very low-certainty evidence), or surgical morbidity (Peto OR 1.01, 95% CI 0.14 to 7.31; 3 studies, 207 participants; very low-certainty evidence). There were no serious adverse events related to either nitrous oxide or carbon dioxide pneumoperitoneum (4 studies, 260 participants; very low-certainty evidence). Four trials randomised participants to helium pneumoperitoneum (69 participants) or carbon dioxide pneumoperitoneum (75 participants) and one trial involving 33 participants did not state the number of participants in each group. None of the trials was at low risk of bias. The evidence is very uncertain about the effects of helium pneumoperitoneum compared to carbon dioxide pneumoperitoneum on cardiopulmonary complications (Peto OR 1.66, 95% CI 0.28 to 9.72; 3 studies, 128 participants; very low-certainty evidence), or surgical morbidity (5 studies, 177 participants; very low-certainty evidence). There were three serious adverse events (subcutaneous emphysema) related to helium pneumoperitoneum (3 studies, 128 participants; very low-certainty evidence). One trial randomised participants to room air pneumoperitoneum (70 participants) or carbon dioxide pneumoperitoneum (76 participants). The trial was at high risk of bias. There were no cardiopulmonary complications, serious adverse events, or deaths observed related to either room air or carbon dioxide pneumoperitoneum. AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effects of nitrous oxide, helium, and room air pneumoperitoneum compared to carbon dioxide pneumoperitoneum on any of the primary outcomes, including cardiopulmonary complications, surgical morbidity, and serious adverse events. The safety of nitrous oxide, helium, and room air pneumoperitoneum has yet to be established, especially in people with high anaesthetic risk.

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Conflict of interest statement

XY: none.

YC: none.

NC: none.

JG: none.

LB: none.

LZ: none.

YD: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
Trial sequential analysis of nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum for cardiopulmonary complications. Analysis was performed with an event rate of 2.9% (Pc) in the control group, a risk ratio reduction of 20%, alpha 5%, beta 20%, and observed diversity 0%. The accrued sample size was so small that the trial sequential boundaries could not be drawn. The cumulative Z‐curve did not cross the naive 5% statistical boundaries (red horizontal lines). The results showed that the observed diversity‐adjusted required information size was 3781 participants, corresponding to 5.4% of the total sample size in the included trials. Accordingly, the meta‐analysis did not support or refute an intervention effect as data were too few.
5
5
Trial sequential analysis of nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum for surgical morbidity. Analysis was performed with an event rate of 2.8% (Pc) in the control group, a risk ratio reduction of 20%, alpha 5%, beta 20%, and observed diversity 0%. The cumulative Z‐curve did not cross the naive 5% statistical boundaries (red horizontal lines). The results showed that the observed diversity adjusted required information size was 3919 participants, corresponding to 5.3% of the total sample size in the included trials. Accordingly, the meta‐analysis did not support or refute an intervention effect as data were too few.
6
6
Trial sequential analysis of helium pneumoperitoneum versus carbon dioxide pneumoperitoneum for cardiopulmonary complications. Analysis was performed with an event rate of 3.0% (Pc) in the control group, a risk ratio reduction of 20%, alpha 5%, beta 20%, and observed diversity 0%. The cumulative Z‐curve did not cross the naive 5% statistical boundaries (red horizontal lines). The results showed that the observed diversity adjusted required information size was 3651 participants, corresponding to 3.5% of the total sample size in the included trials. Accordingly, the meta‐analysis did not support or refute an intervention effect as data were too few.
7
7
Trial sequential analysis of helium pneumoperitoneum versus carbon dioxide pneumoperitoneum for serious adverse events. Analysis was performed with an event rate of 2.3% (Pc) in the control group, a risk ratio reduction of 20%, alpha 5%, beta 20%, and observed diversity 0%. The cumulative Z‐curve did not cross the naive 5% statistical boundaries (red horizontal lines). The results showed that the observed diversity adjusted required information size was 4793 participants, corresponding to 2.7% of the total sample size in the included trials. Accordingly, the meta‐analysis did not support or refute an intervention effect as data were too few.
1.1
1.1. Analysis
Comparison 1: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 1: Cardiopulmonary complications
1.2
1.2. Analysis
Comparison 1: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 2: Procedure‐related general complications
1.3
1.3. Analysis
Comparison 1: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 3: Pain scores (cm) (first postoperative day)
1.4
1.4. Analysis
Comparison 1: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 4: Analgesia requirements
1.5
1.5. Analysis
Comparison 1: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 5: Cardiopulmonary changes
1.6
1.6. Analysis
Comparison 1: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 6: Cardiopulmonary parameters
2.1
2.1. Analysis
Comparison 2: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 1: Cardiopulmonary complications
2.2
2.2. Analysis
Comparison 2: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 2: Pneumoperitoneum‐related serious adverse events
2.3
2.3. Analysis
Comparison 2: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 3: Pain scores (cm) (first postoperative day)
2.4
2.4. Analysis
Comparison 2: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 4: Analgesia requirements (morphine mg)
2.5
2.5. Analysis
Comparison 2: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 5: Number of participants requiring analgesia
2.6
2.6. Analysis
Comparison 2: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 6: Cardiopulmonary parameters
3.1
3.1. Analysis
Comparison 3: Room air pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 1: Cardiopulmonary complications
3.2
3.2. Analysis
Comparison 3: Room air pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 2: Pneumoperitoneum‐related serious adverse events
3.3
3.3. Analysis
Comparison 3: Room air pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 3: Pain scores (cm) (first postoperative day)
3.4
3.4. Analysis
Comparison 3: Room air pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 4: Hospital costs (CNY)
3.5
3.5. Analysis
Comparison 3: Room air pneumoperitoneum versus carbon dioxide pneumoperitoneum, Outcome 5: Cardiopulmonary parameters
4.1
4.1. Analysis
Comparison 4: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 1: Cardiopulmonary complications
4.2
4.2. Analysis
Comparison 4: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 2: Procedure‐related general complications
4.3
4.3. Analysis
Comparison 4: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 3: Pneumoperitoneum‐related serious adverse events
4.4
4.4. Analysis
Comparison 4: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 4: Mortality
5.1
5.1. Analysis
Comparison 5: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 1: Cardiopulmonary complications
5.2
5.2. Analysis
Comparison 5: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 2: Procedure‐related general complications
5.3
5.3. Analysis
Comparison 5: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 3: Pneumoperitoneum‐related serious adverse events
5.4
5.4. Analysis
Comparison 5: Nitrous oxide pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 4: Mortality
6.1
6.1. Analysis
Comparison 6: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 1: Cardiopulmonary complications
6.2
6.2. Analysis
Comparison 6: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 2: Procedure‐related general complications
6.3
6.3. Analysis
Comparison 6: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 3: Pneumoperitoneum‐related serious adverse events
6.4
6.4. Analysis
Comparison 6: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (worst/best‐case scenario analysis for missing data), Outcome 4: Mortality
7.1
7.1. Analysis
Comparison 7: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 1: Cardiopulmonary complications
7.2
7.2. Analysis
Comparison 7: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 2: Procedure‐related general complications
7.3
7.3. Analysis
Comparison 7: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 3: Pneumoperitoneum‐related serious adverse events
7.4
7.4. Analysis
Comparison 7: Helium pneumoperitoneum versus carbon dioxide pneumoperitoneum (best/worst‐case scenario analysis for missing data, Outcome 4: Mortality
See this image and copyright information in PMC

Update of

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