Original Article

JK-PRACTITIONER

Comparative evaluation of pulmonary function tests in Iaparoscopic and open cholecystectomy

Zahoor Ahmad Shah, Altaf Sultan Puri,Basharat Ahad, Iqbal Saleem Mir

Abstract :This prospective study was conducted in the Department of Anaesthesiology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar from 1997 to 2000 on 50 female patients (ASA I & II), in the age group of 25 to 50 years, weighing between 40 to 60 kgs and height between 150 to 165cms. The patients were divided into two equal groups. Group A - laparoscopic cholecystectomy (LPC) and group B - open cholecystectomy (OC). Pulmonary function test viz., vital capacity (VC), forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC and peak expiratory flow rate (PEFR) were measured preoperatively and at 24 hour and 48 hour in the postoperative period. The preoperative and postoperative values were compared within and in between the groups. In group A, the decrease in VC at 24 hour and 48 hour postoperatively was 24.74% and 16.03% respectively, while as in group B the decrease was 45.10% and 34.27% respectively. The decrease in FVC in group A at 24 hour and 48 hour postoperatively was 26.52% and 18% respectively, while as the decrease in group B was 46.37% and 35.5% respectively. In group A, the decrease in FEV1 at 24 hour and 48 hour postoperatively was 22.32% and 13.02% respectively, while as in group B, the decrease was 43.05% and 31.01% respectively. There was a significant increase (p < 0.001) in FEV1/FVC in both the groups postoperatively, suggesting a restrictive pattern of pulmonary impairment. PEFR after LPC significantly exceeded that after OC at 24 hour (p<0.05), while as the increase in PFR at 48 hour in group A was insignificant (p<0.70).
JK-Practitioner 2005;12(4):193-196

Authors affliations: Zahoor Ahmad Shah, Altaf Sultan Puri, Basharat Ahad Deptt. Of Anaesthesiology, SKIMS Iqbal Saleem Mir J&K Health Services

Accepted for Publication April 2005

Correspondence to : Dr. Zahoor Ahmad Shah, Associate Professor Department of Anaesthesiology & Critical Care Sher-i-Kashmir Institute of Medical Sciences, Post Bag 27, Srinagar, Kashmir, India, 190 011.

INTRODUCTION The first open cholecystectomy was performed by John Stough Bobbs in Indianapolis on June 15, 18671, and the first laparoscopic cholecystectomy was performed in Lyon by Phillipe Mouret in 19872. Although gallstones managed through a right upper quadrant incision has proved to be safe and efficient2, most patients experience significant postoperative impairment of pulmonary function, pain discomfort, ileus, and require prolonged convalescence. The major source of complication in open cholecystectomy is abdominal incision2. Upper abdominal procedures, including open cholecystectomy, produce significant impairment of pulmonary, mechanics independent of the effect of general anesthesia. Vital capacity (VC), which is critical for effective coughing, is reduced in the hours after surgery by as much as 40% - 50% of pre-operative values. Functional residual capacity (FRC) is reduced to 70% - 80% of pre-operative values 3. Gradual restoration of lung function begins on the second or third postoperative day. The site of the surgical, incision and transaction of abdominal muscles has been demonstrated to have a major impact on depression of pulmonary function after cholecystectomy4.5. The reduction in functional residual capacity (FRC) and vital capacity (VC) after abdominal surgery are primarily due to incision pain and reflex diaphragmatic dysfunction6. Laparoscopic cholecystectomy combines the benefits of completely removing the gall bladder, with additional benefits of reduced hospital stay, rapid return to normal activities, less pain and less post-operative ileus compared to open cholecystectomy 7-9. The aim of this study was to compare the changes in pulmonary function upto 48 hours in patients undergoing either laparoscopic cholecystectomy or open cholecystectomy via subcostal incision. MATERIALS AND METHODS Fifty healthy female patients (ASA physical status I and II), in the age group of 25-50 years, height between 150-165 cm, weighing between 40-60 Kgs scheduled for elective cholecystectomy were selected for the study.
Key words: Cholecystecbomy, Laparosopic, pulmonary function tests, restrictive pattern.

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Patient with previous history of thoracic or abdominal surgery, chronic obstructive pulmonary disease, obesity (BMI. > 29) and any deformity of thoracic cage were excluded from the study. Patients were randomly divided into two groups of 25 patients each Group A - laparoscopic cholecystectomy group. Group B - open cholecystectomy group. Patients were taught the technique of spirometry and pre-operative pulmonary function studies including vital

abdomen with CO2 in the Trendelenburg position with an automatic insufflator set at I l/m to a maximum pressure of 12 mmHg. Ventilation was adjusted to maintain ETC02 between 35 and 40 mmHg. Open cholecystectomy was performed via a subcostal incision. At the end of surgery, residual neuromuscular blockade was reversed by neostigmine 50 mg/kg iv in atropine 20 mg/kg iv. Patients were shifted to post- operative ward and analgesia (diclofenac sodium IM) was provided on, as and when required basis. Pulmonary function .tests

Table 1: Comparison of Vital Capacity (VC) in laparoscopic cholecystectomy (Group A) and open cholecystectomy (Group B) at 24 and 48 hrs postoperatively with pre-operative (POP) values. Group POP 24 hrs 48 hrs Group A 2.87 0.29 2.16 0.25* 2.4: 0.25 Group B 2.86 0.47 1.57 0.32* 1.88 0.41 Values are mean SD *p < 0.001 compared to POP (students t-test) . VC was significantly decreased at 24 and 48 hrs post-operatively in both the groups. The decrease in laparoscopic cholecystectomy group was 24.74% and 16.03% at 24 and 48 hrs post-op respectively whereas ill open cholecystectomy group the decrease was 45.1% and 34.27% at 24 and 48 hrs post-operatively respectively. capacity (VC), forced vital capacity (FVC), forced expiratory volume in first second (FEV1), FEV1/FVC and peak expiratory flow rate (PEFR) were performed on a spirometer (Vitalograph Buckingham MK, 18, ISW, UK). were carried in both groups of patients in the post-operative ward at 24 hrs and 48 hrs post-operatively in supine position with 30 head tilt upwards. The preoperative and postoperative values of pulmonary function tests were

Table 2: Comparison of Forced Vital Capacity (FVC) in laparoscopic cholecystectomy (Group A) and open cholecystectomy (Group B) at 24 and 48 hrs postoperatively with pre- I operative (POP) values. Group POP 24 hrs 48 hrs Group A 2.790.31 2.160.24* 2.410.26* Group B 2.760.48 1.570.32- 0 1.880.41* Values are meanSD . *p < 0.001 compared to POP (students t-test) FVC was significantly decreased at 24 and 48 hrs post-operatively in both the groups. The decrease in laparoscopic cholecystectomy group was 26.52% and 18% at 24 and 48 hrs post-op respectively whereas in open cholecystectomy group the decrease was 46.37% and 35.5% at 24 and 48 hrs post-operatively respectively. All measurements were made with the patients in the supine position with 30 head tilt upwards. Diazepam 10mg preoperatively was administered on the night before surgery patients were induced with sodium thiopentone 5mg/kg iv followed by suxamethonium 2mg/kg iv to facilitate endotracheal intubation and buprenorphine 4 mg/kg iv anesthesia was maintained using 66% N20 in 02, 0.5% halothane and muscle relaxation achieved with pancuronium bromide 80 mg/kg iv. Laparoscopic cholecystectomy was performed in the reverse Trendelenburgs position after insufflating the
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compared within and between the groups and the significance of difference in the two groups was evaluated and tabulated using students t-test. RESULTS The two groups were similar with respect to age weight, height and body mass index. Demographic profile Vital capacity was significantly decreased (P < 0.001) at 24 hour and 48 hour postoperatively in both the groups. (Table 1) Forced vital capacity decreased significantly (P < 0.001) at 24 hour and 48 hour postoperatively in both the

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groups . (Table 2) Forced expiratory volume in Is (FEV1) decreased significantly (P<0.001) at 24 hour and 48 hour postoperatively in both the groups FEV1 after laparoscopic cholecystectomy significantly exceeded that after open cholecystectomy at 24 hour (P < 0.001) and 48 hour (P < 0.01) postoperatively. In laparoscopic group the decrease in FEV1 at 24 hour and 48 hour postoperatively was 22.32% and 13.02% respectively while as in open cholecystectomy the decrease was 43.05% and 31.01% respectively. There was a statistically significant increase (P < 0.001) in FEV1/FVC in both the groups at 24 hour and 48 hour postoperatively, suggesting a restrictively pattern of pulmonary impairment postoperatively. Peak expiratory flow rate PEFR decreased significantly (P < 0.001 ) at 24 hour and 48 hour postoperatively in both the groups PEFR after laparoscopic cholecystectomy significantly exceeded that after open cholecystectomy at 24 hour (P < 0.05) postoperatively, while as the increase in PEFR at 48 hour in the laparoscopic group was insignificant (P < 0.70) compared to open cholecystectomy group in laparoscopic cholecystectomy group the decrease in PEFR at 24 hour and 48 hour postoperatively was 46.45% and 31..1.2% respectively, while as in open cholecystectomy group the decrease 49.87% and 29.73% respectively. DISCUSSION Alterations in pulmonary function after abdominal surgery and general anesthesia have been well studied.. General anesthesia produces impaired gas exchange as a result of decreased lung volumes, shunting and change in pulmonary mechanics. The effects of general anesthesia are short lived with a return to near baseline function within 24 hours of induction. The effects of upper abdominal operation on pulmonary function, however, is more pronounced and of longer duration, lasting upto at least ten days after surgery. Restrictive patter characterized by a 50% reduction in vital capacity (VC) and 30% decrease in tidal volume (TV) and functional residual capacity (FRC) occur after major abdominal surgeries. Forced expiratory volume in first second (FEV1) decreases probably as a result of decreased lung volume rather than the airway obstruction. A statistically significant decrease was observed in vital capacity at 24 hrs and 48 hrs between the two groups with lesser decrease in vital capacity in patients belonging to group A (laparoscopic cholecystectomy) compared to group B (open cholecystectomy) (Table-1). Similar observations were made by Johnson et al10, Coutere JG et al 11, Freeman JA et al 12 and Mealy K et al 13. Regarding forced vital capacity (FVC) a highly significant decrease (p < 0.001) in forced vital capacity (FVC) was found in both the groups in our study. The decrease was more in open cholecystectomy group than in laparoscopic cholecystectomy group. In laparoscopic group the decrease in forced vital capacity (FVC) at 24 hrs and 48 hrs postoperatively was 26.52% and 18% respectively, whereas in open cholecystectomy group the decrease was 46.37% and 35.5% respectively (Table 2). The results of our study are consistent with that of Diament et al 14, Latimer

RG15, Frazee et al 16 and Rademaker BM 17 Regarding forced expiratory volume in first second (FEV1) a highly statistically significant decrease (p < 0.001) in forced expiratory volume in first second (FEV1) in both the groups studied at 24 hr postoperatively forced expiratory volume in first second (FEV1) after laparoscopic cholecystectomy at 24 hrs and 48 hrs postoperatively. In laparoscopic group the decrease in forced expiratory volume in first second (FEV1) at 24 hrs and 48 hrs postoperatively were 22.32% and 1.3.02% respectively, whereas in open cholecystectomy group the decrease was 43.05% and 31..01.% respectively. Similar changes in forced expiratory volume in first second (FEV1) were reported by Rademaker BM et al 17, Putensen G 18, Couture JG 11. Postoperative pulmonary dysfunction has primarily been considered a restrictive process. The ratio FEV1/FVC helps to distinguish between obstructive and restrictive pattern. In patients with obstructive pattern i.e., air flow limitation the FEVl/FVC is reduced, but in patients with restrictive disease the ratio is normal or increased. In our study we noted a significant increase in FEVl/FVC in both groups. Similar changes in FEVl/FVC were reported by Freeman JA et al 12, Schauer PR et al 19, and Rademaker BM17. The decrease in peak expiratory flow rate (PEFR) was highly significant in both groups (p < 0.001). The decrease in peak expiratory flow rate (PEFR) was 46.45% and 31.12% in the laparoscopic group at 24 hrs and 48 hrs postoperatively, while as the decrease was 49.87% and 29.73% in the open cholecystectomy group at 24 hrs and 48 hrs postoperatively. When comparing the peak expiratory flow rate (PEFR) in both the groups the difference in peak expiratory flow rate (PEFR) was significant (p < 0.05) at 24 hrs whereas at 48 hrs postoperatively the difference was insignificant (p< 0.70). Our findings are in agreement with the findings of Scheur PR et al 19 and Redmaker BM17. The normal value of peak expiratory flow rate (PEFR) in healthy adults is 500 1/min. values of less than 200 l/min suggest impaired cough efficiency and strong likelihood of postoperative complications (30). In our study peak expiratory flow rate (PEFR) remained above 200 1/min in the laparoscopic group whereas in open cholecystectomy group peak expiratory flow rate (PEFR) recorded at 24 hrs postoperatively was 18137.49, whereas at 48 hrs peak expiratory flow rate (PEFR) was more than 200 1/m. this preservation of PEFR in laparoscopic group is one of the reasons for the decreased incidence pulmonary complications in patients undergoing laparoscopic cholecystectomy. The difference in respiratory function after laparoscopic and open cholecystectomy cannot be explained by duration of anesthesia or postoperative care. Several other mechanisms may be responsible for the marked depression of pulmonary function after upper abdominal surgery including surgical incision local abdominal pain20, and diaphragmatic dysfunction6. Abdominal muscles act during forced expiration and coughing 21. The site of surgical incision and transaction of
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the abdominal muscles has been demonstrated to have major impact on depressed pulmonary function after cholecystectomy 4,5. Since open cholecystectomy is associated with a long subcostal incision and transaction of rectus abdomens muscle it is evident that expiration is impaired. In contrast laparoscopic cholecystectomy requires only four small incisions for the insertion of trocars7. Thus laparoscopic cholecystectomy might be expected to decrease the pulmonary function less than a sub costal incision with muscle splitting 4 Diaphragmatic dysfunction after upper abdominal surgery is related to pain, an increase in abdominal wall tone and reflexes due to local reflexes of gall bladder 22. The local stimulation and irritation should be comparable in both the

laparoscopic and open cholecystectomy surgical candidates. Increased abdominal pressure associated with CO2 insufflation during laparoscopy on postoperative diaphragmatic function may have caused the significant decrease in vital capacity, forced vital capacity, forced expiration in first second (FEV1) in the laparoscopic group but this mechanism seems to be of less clinical importance since depression of respiratory function is less and recovery is improved compared to open cholecystectomy. Our study confirms improved perioperative respiratory performance with laparoscopic cholecystectomy in comparison with open cholecystectomy. The decreases in VC, FVC, FEVl and PEFR were all significantly improved with the laparoscopic procedure.

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