DEPARTMENT OF ANAESTHESIOLOGY

CHHATRAPATI SHAHUJI MAHARAJ MEDICAL UNIVERSITY,

(UPGRADED KING GEORGE MEDICAL UNIVERSITY)
LUCKNOW. (INDIA)

August, 2011

Certificate

This is to certify that the Research work entitled HAEMODYNAMIC CHANGES IN

MINIMAL INVASIVE SURGERY IN PAEDIATRIC PATIENTS has been under taken by the

candidate Dr Yogesh verma in this department.

It is further certified that the candidate has fulfilled the pre-requisites
necessary for the submission of the thesis.

Chief Supervisor:
(DR ANITA MALIK)
MD, DA
Professor
Department of Anaesthesiology,
CSMMU, Lucknow. U.P.

Co Supervisors:

(DR RAJNI KAPOOR )

RAJNI GUPTA)
MD
Professor

( DR
MD
Associate Professor

Department of Anaesthesiology,
CSMMU, Lucknow. U.P

Department of Anaesthesiology
CSMMU, Lucknow. U.P

(DR REETU VERMA)

MD
Lecturer
Department of Anaesthesiology
CSMMU, Lucknow, U.P

(DR JYOTSNA AGARWAL)

MD
Professor
Department of Anaesthesiology
CSMMU, Lucknow, U.P

( DR ASHISH WAKHLU)

MS, MCh
Professor,
Department of Paediatric surgery,
CSMMU, Lucknow, U.P

DEPARTMENT OF ANAESTHESIOLOGY
Chhatrapati Shahuji Maharaj Medical University
Lucknow
Certificate
August, 2011
This is to certify that the research work entitled,
HAEMODYNAMIC CHANGES IN MINIMAL INVASIVE
SURGERY IN PAEDIATRIC PATIENTS has been carried out
by the candidate Dr. Yogesh Verma, in the department.
This is further certified that the candidate has also fulfilled all the
pre-requisites necessary for the submission of this thesis.

Forwarded and recommended by

[Prof. J. Bogra]
M.D, D.A
Professor and Head
Department of Anaesthesiology
Chhatrapati Shahuji Maharaj Medical University
Lucknow

Acknowledgem
ent

This thesis arose in part out of the study that has been done since I came to the
Department Of Anaesthesiology, CSM Medical University. By that time, I have worked
with a great number of people whose contribution in assorted ways to this study and the
making of the thesis deserved special mention. It is a pleasure to convey my gratitude to
them all in my humble acknowledgment.
In the first place I would like to record my gratitude to Dr. Jaishri Bogra MD,
DA professor and head, Department of anaesthesiology, CSM Medical University for her
advice and guidance from the very early stage of this study as well as giving me
extraordinary experiences throughout the work. Above all and the most needed, she
provided me unflinching encouragement and support in various ways. I am indebted to
her more than she knows.
At the very outset, words are inadequate to express my deep
gratitude to my chief guide and supervisor, Dr. Anita Malik DA, MD
,Professor in department of anaesthesiology, Chhatrapati Shahuji
Maharaj Medical University,Lucknow, without whose inspiring guidance,
unstinted cooperation and exceptional attitude

this thesis could not

have seen light of day. I consider it my privilege to work under his

supervision.
Words are inadequate to express the depth of my gratitude for my respected coguide Dr. Rajni Kapoor ,MD, Professor, Department of Anaesthesiology, Chhatrapati
Shahuji Maharaj Medical University, lucknow for his co-operation, constructive
suggestions, encouragement right from the beginning, affection and masterly guidance
helped me to complete this work.

I am extremely grateful to my respected

co-guide Dr. Jyotsna Agarwal. MD,

professor, Department of Anaesthesiology, CSMMU for her advice, supervision, and

crucial contribution, which made her a backbone of this study and so to this thesis. Her
involvement with her originality has triggered and nourished my intellectual maturity that
will benefit from, for a long time to come.
At the very outset, words are inadequate to express my deep gratitude to my
respected co-guide Dr. Rajni Gupta, MD, Associate Professor, Department of
Anaesthesiology, Chhatrapati Shahuji Maharaj Medical University, lucknow, without
whose inspiring guidance, unstinted co-operation and exceptional attitude this thesis
would not have seen the light of the day. I consider privilege to work under his
supervision. He has always inspired me to work honestly .
I convey my heartful gratitude and my profound sense of regard to my respected
co-guide Dr. Reetu Verma, MD, Lecturer, Department of Anaesthesiology,
Chhatrapati Shahuji Maharaj Medical University, lucknow, under whom I have privileged
opportunity work. Without whose valuable guidance, constant encouragement and
indispensible suggestions it would have been impossible for me to accomplish this work.
I would like to acknowledge with extreme gratitude the intellectual and moral
support extended to me by respected co-guide Prof. Ashish Wakhlu, MS, MCh,
Professor Department of Paediatric surgery, Chhatrapati Shahuji Maharaj
Medical University,Lucknow. Her personal interest, constant encouragement and
constructive suggestions helped me to complete this work in the present form.
I am also thankful to seniors, colleagues and juniors for their
continuous co-operation and encouragement.
Where would I be without my family? My parents deserve special mention for
their inseparable support and prayers. My Father, Mr V.D.Verma, and my mother Mrs
Mukta Verma sincerely raised me with care and gentle love. Mrs Archana Verma, Mrs
Kavita Verma, and Miss Mohini , thanks for being my supportive and caring sisters.

and I am thankful my better half Dr. Archana for her love , care and support in my
life.
Parents are the first teachers, teachers are the second parents; with these words I
humbly acknowledge the affectionate and caring attitude of my teachers throughout my
work, and all praises to almighty GOD who enlightened me to carry out this study
successfully.
I would also like to thank Mr Varun and Mr Tarun of Arun Photostate for providing
the statistical analysis and have done real good job in presenting this work on paper.
Finally, I would like to thank everybody who was important to the successful
realization of thesis, as well as expressing my apology that I could not mention
personally one by one.

-Yogesh Verma

Contents
INTRODUCTION
AIM OF THE STUDY
REVIEW OF LITERATURE
Material and Methods
Observations
Discussion
Conclusion
Bibliography
SUMMARY (ENCLOSED SEPARATELY)

Introduction

In recent years, there has been a considerable improvement in

laparoscopic surgical techniques and equipments and this has led to an
increasing number of diagnostic and surgical procedures being done
laparoscopically not only in adults but also in paediatric patients. With

increasing experience in paediatric laparoscopic procedures, and

advances in miniaturised instrumentation, laparoscopys place in the
modern

paediatric

surgical

armamentarium

has

finally

become

accepted.
The many benefits reported after laparoscopy, which include smaller
incisions, reduced surgical stress and fluid shifts that may accompany
it, lesser postoperative pain, earlier oral intake, quicker mobilization,
faster

discharge,

respiratory

and

better
wound

cosmetic

effect,

complications,

reduced

postoperative

shortened

postoperative

convalescence, explain its success and the efforts to encourage its use.
Laparoscopic procedures may also be cost-effective due to the shorter
length of hospital stay although the initial equipment cost may be
higher.
With the success of laparoscopy, the demands and applicability of this
technique in children has a rising trend. As a result, the number of
children

requiring

laparoscopic

services

procedures

pneumoperitoneum

of
is

required

paediatric
increasing

for

anaesthesiologists
day

laparoscopy

by

induce

day.

for
The

physiologic

changes that complicate anaesthetic management. Knowledge of the

pathophysiologic consequences of increased intra-abdominal pressure
is important for the anaesthesiologist.
Physiological changes during laparoscopic surgery are mainly related
to the increased intraabdominal pressure (IAP) associated with CO2
insufflation of the abdomen, the patients postural modifications (headup or head-down) and CO2 absorption and its general effects.
Increases in IAP affect both ventilation and circulation. Increased IAP
induces a mechanical compression of the diaphragm that reduces
pulmonary compliance, vital capacity,

functional residual capacity

(FRC) and total lung volume. Pneumoperitoneum in children has a

major impact on cardiac volumes and function, mainly through the
effect on ventricular load conditions.
Although experimental and clinical data regarding the cardiorespiratory
effect of laparoscopic surgery with invasive and non invasive
monitoring

in

adult

have

been

established,

literature

on

cardiorespiratory changes in children is limited. The present study was

conducted to assess the hemodynamic changes during minimal
invasive surgeries in pediatric patients.

Review of
Literature

Minimally

invasive

surgery

use

indirect

visualisation,

instrumentation and aims to minimise the trauma of any interventional

process but still achieve a satisfactory therapeutic result. Laparoscopy
is the most widely studied minimally invasive procedure.
In 1999 Lobe et al. reported the first repair of oesophageal
atresia entirely thoracoscopically, which was accomplished on a 2-3 kg
neonate. Since then innumerable paediatric laparoscopic procedures
have

been

performed

with

development

of

better

technology,

equipment and resources. But these procedures are becoming more

and more challenging to the anaesthesiologist especially when dealing
with the younger paediatric age group.
The intra- abdominal pressure level is a major determinant of cardiorespiratory
changes during laparoscopy. The cardiovascular response to an increase in intraabdominal pressure involves changes in preload, systemic vascular resistance and
myocardial contractility.A decrease in cardiac output (CO) may occur as a result of
decreased venous return and an increase in systemic vascular resistance (SVR). The
reduction in preload is dependent on the degree of increase in abdominal pressure. In
adults, with minor increases in IAP (<15mmHg), there is an increase in venous return and
cardiac output resulting from the displacement of blood from the splanchnic venous
circulation. With intra-abdominal pressure of above 20mmHg, preload decreases while
systemic vascular resistance increases. These factors lead to a decrease in cardiac output.
The mean arterial pressure usually remains unchanged or even increases because of the
increase in systemic vascular resistance. In the paediatric patient similar changes in the
cardiovascular status have been seen at much lower IAP.

Sfez et al(1994) in their retrospective study showed that intraoperatively high

EtCO2 in 37% of cases , high arterial pressure in 10% cases while low in 3% of cases,
bradycardia

in 1%, hypoxia in 0.5% and one case of pneumothorax. In the

appendecectomy series, laparoscopy increased the duration of the procedure, and

therefore intraoperative opioids requirements. Arterial pressure was higher in this group,
irrespective to intraabdominal pressure and to EtCO2. No significant improvement in
postoperative analgesia was found. It was therefore recommended to pay special attention
to intraoperative anaesthetic and surgical management of children undergoing
laparoscopic surgery, particularly newborns and infants
Tobias and colleagues (1995) found minimal cardiovascular
changes in paediatric patients during laparoscopy in their study. An
increase in blood pressure was seen which probably resulted from an
increase in systemic vascular resistance related to the increased IAP
and the increased PaCO2. In a retrospective paediatric study, it was
found that arterial pressure increased only when IAP was higher than
6mmHg.
Hsingh et al (1995). concluded that the changes to EtCO2
during laparoscopy did not influence the hemodynamic stability in their
study. The younger children gave a faster reaction time of EtCO2
change after CO2 insufflation than do the older children which may be
related to the variation of physiological exhibition at different state of
development. Children enrolled were of age from 11 months to 13
years undergoing laparoscopic inguinal exploration. and were divided
into three groups based on age orientation: Group I comprised of 40
children with age from 11 months to 2 years; Group II comprised of 46
children with age between 2 to 5 yr; and Group III comprised of 40
children aged from 5 to 13 yr. All patients received endotracheal
Anaesthesia with halothane-N2O in 50% Oxygen and atracurium for

muscle relaxation. The intraabdominal pressure exerted by CO2 was 10

mmHg and the duration of pneumoperitoneum and laparoscopy was 15
min. they recorded airway pressure, EtCO2, body temperature, blood
pressure,

heart

rate,

heart

rhythm,

and

oxygen

saturation

simultaneously at 1 min interval before, during, and after laparoscopy.

The airway pressure and EtCO2 showed significant increases during
laparoscopy (15-18% and 18-20% respectively) in all cases, but the
percentage of increases were not significantly different among groups.
However, the EtCO2 change in terms of time lag were different in
between the groups: (1) the time lag from CO2 insufflation to the
emergence of EtCO2 change (latent period) was respectively 0.7 0.1
(mean SD) minutes in group I, 0.9 0.2 min in group II and 1.5 0.2
min in group III (p < 0.05); (2) the EtCO2 change from baseline to a
plateau (ascending period) was respectively 4.20.6 min in group I,
6.3 1.0 min in group II and 9.11.1 min in group III (p < 0.05); (3) the
EtCO2 decline from plateau to baseline after CO2 deflation (descending
period) was respectively 6.2 0.5 min in group I, 8.3 0.8 min in group
II and 12.0 1.3 min in group III (p < 0.05).The body temperature and
hemodynamics including blood pressure, heart rate, heart rhythm,
oxygen saturation were not significantly changed during laparoscopy in
all the groups.
Manner et al (1998) initiated the study to assess respiratory
mechanics such as lung compliance and peak airway pressure (PIP)
during laparoscopic surgery in paediatric patients. In their prospective
study ten consecutive patients with age between 1 to15 yrs scheduled
for laparoscopic procedure were enrolled. Anaesthesia was induced
and maintained with intravenous infusions of propofol and alfentanil.
Vecuronium was administered to maintain muscle relaxation. Postural

changes like head down tilt induced a mean decrease of 17% in lung
compliance, which was further decreased by 27% from the baseline
during insufflation of intraabdominal CO 2 .At the same time peak
airway pressure (PIP) increased by 19% and 32% from the baseline
during

trendelenburg

position

and

peritoneal

insufflation.

Lung

compliance and peak airway pressure (PIP) returned to their respective

baseline values after removal of CO2 from the peritoneal cavity. End
tidal CO2 increased from a baseline value of 4.3 kPa to 5.4 kPa during
surgery. They concluded that insufflation of CO 2 induces significant
increases in peak airway pressure with simultaneous decreases in lung
compliance.
Gueugniaud

and

colleagues

(1998)

studied

the

haemodynamic effects of pneumoperitoneum during laparoscopic

surgery in healthy infants by continuous oesophageal aortic blood flow
echo-doppler.The

intra-abdominal

pressure

was

maintained

at

10mmHg. They found that the induction of pneumoperitoneum

resulted in a significant decrease in aortic blood flow and stroke
volume, and a significant increase in systemic vascular resistance,
compared with controlled values. These changes had no clinically
deleterious effects in healthy infants and were completely reversed
after peritoneal decompression.
Bozkurt et al (1999) in their study enrolled patients, whose
ages ranged between 36 and 365 days weighing 2.713 kg, end-tidal
carbon dioxide was monitored. Intra-abdominal pressure was not
permitted to rise above 10mmHg. All patients were placed in the
supine position and a maximum of Trendelenburg allowed. Patients
were extubated and oxygen was given via a mask. Full monitoring
continued into the early postoperative period. Arterial blood samples

were obtained 5 min after intubation,15 min and 30 min after carbon
dioxide insuffation, 5 min after desufflation and after extubation. The
pH, PaO2, SaO2 and SpO2 decreased, and PaCO2 increased by
insufflation of carbon dioxide intraperitoneally, and improved following
deflation. The changes in base excess and bicarbonate were minimal,
statistically and clinically insignicant. The changes in pH and PaO2
during the study were statistically significant. The increase in PaCO2 at
30 min after pneumoperitoneum was statistically significant when
compared with values obtained 5 min after intubation. An infant with
primary biliary atresia (PBA) and prior bronchopneumonia showed
persistent hypercapnia following desufflation. Another infant with PBA
had an SpO2 of 92% when awake but better SpO2 values during
laparoscopy. SpO2 decrease (lowest90%) was observed in an infant
with pyloric stenosis when intra-abdominal pressure (IAP) rose to 10
mmHg. There were no statistically significant changes in heart rate and
systolic blood pressures.
de Agustn et al (1999), evaluated haemodynamic changes produced by
laparoscopic surgery in children. A transesophageal echocardiographic study was
performed on 13 patients ,7 males and 6 females, aged 10.8 2.7 years, before, during
and after peritoneal CO2 gas insufflation. A change on the Doppler waves pattern of the
infradiaphragmatic veins along with an increase in blood flow velocity were observed.
Pulmonary veins suffered minimal changes showing an increase on either the systolic
pressure and on atrial contraction. Diastolic retrograde flow in aorta reflected an increase
in peripheral vascular resistance. Cardiac output increased minimally. All haemodynamic
changes returned to basal after gas peritoneal desufflation. He concluded that
laparoscopic surgery could produce important cardiac derangements in children with
ventricular dysfunction or in patients presenting left ventricular outlet obstruction. In
these patients laparoscopic surgery might be precluded.

Sakka and colleagues (2000) performed a transoesophageal

echocardiographic assessment of haemodynamic changes during
laparoscopic herniorrhaphy in small children at two different levels of
IAP 6and 12mmHg, they found that the cardiac index (CI) decreased
significantly after increasing IAP to 12mmHg but this decrease did not
appear to be clinically important. Subsequent decrease in IAP to
6mmHg caused return of CI to baseline level and a further increase in
IAP to 12mmHg did not cause any reduction in CI.
Gentili et al(2000) used echocardiography to look at the
cardiac response to peritoneal insufflation in children and found
significant increase in left ventricular end diastolic volume and end
systolic volume. Ejection fraction was preserved and blood pressure
and heart rate increased. The peak and mean airway pressures also
increased. They examined cardiovascular changes associated with
intra-abdominal insufflation in 20 children , undergoing laparoscopic
surgery. Intra-abdominal pressure never exceeded 10 mmHg. Systolic
blood pressure, diastolic blood pressure, endtidal CO2, peak, and mean
airway

pressure

increased

during

intra-abdominal

insufflation.

Pneumoperitoneum was associated with increases in left ventricular

enddiastolic volume, left ventricular end-systolic volume and left
ventricular endsystolic meridional wall stress. In addition, before,
during and after intra-abdominal insufflation, left ventricular fractional
shortening

and

left

ventricular

ejection

fraction,

underwent

insignificant changes. Pneumoperitoneum in children has a major

impact on cardiac volumes and function, mainly through the effect on
ventricular load conditions. The sharp increase in intra-abdominal
pressure affects both preload and afterload, while systolic cardiac
performance remains unchanged.

Rowney
management

and
and

Aldridge
outcomes

(2000)
of

reported

their

first

the
51

anaesthetic
laparoscopic

fundoplications. They reviewed case records of the 50 patients (one

redo) with median age 6 years (5 months to 20 years). Median duration
of anaesthesia was 120 (60-300) min. During the procedure, the heart
rate and blood pressure increased by more than 20% over baseline in
18% and 12% cases, respectively. Median increase in EtCO2 was 1.0
(0.3-2.3)

kPa

[7.6

(2.3-18)

mmHg].

Postoperative

analgesia

requirement was oral or rectal analgesics in 89% of patients and

ceased within 48 hr of surgery in 95% patients. Median time to
discharge home from day of operation was 2 (1-9) days. They
concluded that laparoscopic fundoplication in children is well tolerated,
there is no requirement for routine postoperative high dependency
care and analgesic requirements are minimal.
Tobias (2002) reviewed the anaesthesia for minimal invasive
surgery in children and stated that specific modifications of the
anaesthetic technique may be necessary in children undergoing
minimally invasive surgery.
Baroncini

et

al

(2002)

concluded

in

their

study

that

pneumoperitoneum during laparoscopic surgery has a major impact on

cardiac volumes and function, mainly through the effect on ventricular
load conditions. The acute increase in IAP affects both preload and
afterload, while the systolic cardiac performance remains unchanged.
Heart rate, systolic blood pressure, diastolic blood pressure, arterial
oxygen saturation, end-tidal CO2, respiratory frequency, tidal volume
both inspiratory and expiratory, minute volume as well as peak and
mean inflating airway pressure and body temperature were monitored,
before and 10 minutes after CO2 insufflation, also before and 5

minutes after deflation in the peritoneal cavity. Intra-abdominal

pressure never exceeded 6mmHg. Intrasurgical measurements of the
parameters always remained within physiological range for each age
group. Heart rate was constantly within normal ranges without
undergoing statistically significant modifications during the different
moments of the surgical procedures. Systolic blood pressure and
Diastolic

blood

pressure,

always

remaining

within

physiological

parameters age-related to the patient, tended towards a statistically

significant rise during the whole pneumoperitoneum time. The mean
value of arterial oxygen saturation was completely steady during the
whole treatment. End-tidal CO2 showed a statistically significant rise
during pneumoperitoneum compared with the post-induction and preinsulation

parameters,

minutes

after

desufflation.

However,

normocarbia was maintained during the whole laparoscopic procedure.

Even if body temperature remained within physiological ranges, it
decreased progressively throughout the whole laparoscopic procedure.
Pneumoperitoneum was associated with increases in left ventricular
end-diastolic volume, left ventricular end-systolic volume and left
ventricular end-systolic meridional wall stress. Before, during and after
intra-abdominal insufflation, systolic function indexes, left ventricular
fractional

shortening

and

ejection

fraction,

underwent

slight,

insignificant changes. The EDV was recognised as a good indicator of

preload; the increase is mostly due to a drainage effect on the
splanchnic circulation, with an increase in venous return to the right
heart.
The overall cardiovascular changes associated with laparoscopic
surgery depend upon the intra-abdominal pressure attained, the
amount of CO2 absorbed, the patient's intravascular volume status,

the ventilatory technique, surgical conditions, and the anaesthetic

agents used. Patient positioning, hypercarbia, and the use of positive
pressure

ventilation

can further

compromise the

cardiovascular

function. Vagally mediated reflex bradycardia or even asystole can

occur during insufflation, especially in infants and small children. The
absorption of carbondioxide from the peritoneal cavity leads to an
increase in the end tidal CO2 (EtCO2) during laparoscopic surgery
which frequently requires an increase in the minute ventilation in
children to compensate for the hypercarbia.
Huettemann et al (2003) found that at an IAP of 12mmHg,
there

was

significant

septal

hypokinesia

in

paediatric

patients

undergoing laparoscopic surgery.

Halachmi
extraperitoneal

et

al

and

(2003)

investigated the impact of

intraperitoneal

CO2

insufflation

on

cardiopulmonary variables in children undergoing laparoscopic surgery

and concluded significant hemodynamic and respiratory changes
during pediatric laparoscopic surgeries. They reviewed retrospectively
the records of 62 patients who underwent laparoscopic urological
surgery. Data collection included respiratory rate (RR), peak airway
pressure (PAP), O2 saturation, end tidal CO2 (EtCO2), heart rate,
systolic

and

diastolic

blood

pressure,

electrocardiogram

and

insufflation pressure. All variables were recorded before and after CO2
insufflation. Of the patients 16 boys and 13 girls with a mean age SD
of 7.2 5.1 years underwent extraperitoneal surgeries, 14 partial or
total nephrectomy and 5 pyeloplasty. Mean retroperitoneal CO2
insufflation pressure was 12.1 1.5 mm Hg and mean operative time
was 3.6 1 hours. They operated 13 children on the right and 16 on
the left decubitus lateral position. Significant increase in EtCO2, RR and

PAP was recorded after CO2 insufflation in the extraperitoneal group.

Use of the left lateral position resulted in a significant increase in
EtCO2 (37.1 3.6 vs 40 3.8, p = 0.04) after CO2 insufflation
compared to the right decubitus lateral position. Transperitoneal
surgery was performed in 32 boys and 1 girl with a mean age of 3.8
4.1 years for cryptorchidism (32) and attempted pyeloplasty (1). Mean
intraabdominal CO2 insufflation pressure was 11 2.4 mm Hg and
mean operative time was 1.7 0.8 hours. A significant increase in RR
(16.5 3.1 vs 17.9 3.4, p = 0.0002) and PAP (13.2 4.8 vs 16.1
5.7, p <0.0001), and a decrease in O2 saturation (99.6 0.6 vs 98.7
7.1, p = 0.0003) and heart rate (116 19 vs 113 18, p = 0.019)
were recorded after CO2 insufflation. A similar effect on the respiratory
parameters was observed in both groups. Although there were no
apparent complications associated with either approach.
Bannister and colleague (2003) observed the pulmonary
effects of laparoscopically induced pneumoperitoneum in infants less
than 1 year of age undergoing surgical procedures under general
anaesthesia. Patients less than 1 year of age were enrolled in this
direct observational study. Anaesthetic technique included inhalation
induction using sevoflurane/O2/air and neuromuscular blockade. Infants
were ventilated using 1015 mlkg1 tidal volume at a respiratory rate
sufficient to achieve normocarbia. Peak inspiratory pressure, expiratory
tidal volume , end tidal carbon dioxide concentration

and dynamic

compliance were recorded at baseline, 5, 10 mmHg and maximal

insufflation pressure. Maximal insufflation pressure was limited to 12
mmHg for infants <5 kg, 15 mmHg for infants >5 kg. At steady state
maximal insufflation pressure, ventilator changes were implemented to
restore expiratory tidal volume and

end tidal carbon dioxide

concentration to within 10% of baseline. Each patient served as his

own control. At maximal insufflation pressure, average peak inspiratory
pressure increased 18%, average expiratory tidal volume decreased
33%, average end tidal carbon dioxide concentration increased 13%,
average dynamic compliance decreased 48%; O 2 saturation fell in 41%
of patients.
Mattioli et al(2003) performed a prospective nonrandomized
study aimed

at describing

the main cardiorespiratory

changes

produced by pneumoperitoneum in 33 pediatric patients operated on

by laparoscopic fundoplication. Patients were divided into two groups;
namely, group A and group B. Group A included 14 patients with
chronic respiratory symptoms, and group B included 19 children who
preoperatively mainly emphasized gastrointestinal symptoms. They
monitored intraoperative cardiorespiratory status, timed length of
surgery, and described intraoperative complications.They found No
significant cardiovascular changes occurred during carbon dioxide
insufflation. Partial oxygen saturation remained still in all the patients.
End tidal CO2, meanly higher in group A children, increased in all the
patients after pneumoperitoneum creation, but never exceeded 45
mmHg. Similarly, peak inspiratory pressure increased in all the
patients, but was always maintained within acceptable values.
De Waal et al (2003),evaluated the haemodynamic effects of
low-pressure

pneumoperitoneum

[intra-abdominal

pressure

(IAP)

5 mmHg] in young children (< 3 years),scheduled for laparoscopic

fundoplication for gastro-oesophageal reflux. Noninvasive thoracic
electrical bioimpedance cardiac index (CI), stroke volume index (SVI),
heart rate (HR), mean arterial pressure (MAP) and peak inspiratory
pressure (PIP) were recorded, together with EtCO 2 and PaCO2 at five

time points: before insufflation, 20, 35 and 70 min after start of CO2
insufflation and 12 min after desufflation. During insufflation, minute
ventilation

was

5 mmHg.During

not adjusted
insufflation,

and

the

EtCO2

IAP

was

increased

maintained

from

29 4

at
to

37 5 mmHg and PaCO2 increased from 31 4 to 39 5 mmHg . CI

increased from 2.39 0.86 to 2.92 0.94 lmin1m2 , HR increased
from 108 10 to 126 22 bmin1 (P < 0.01), MAP increased from
52 10 to 63 9 and PIP increased from 16 3 to 18 3 cm H2O.
There were no changes in SVI and arterial oxygen saturation.They
concluded that low-pressure CO2 pneumoperitoneum (with IAPs not
exceeding 5 mmHg) for laparoscopic fundoplication in infants and
children does not decrease their cardiac index
Merrill McHoney et al(2003), in their study characterised the
pattern of CO2 elimination during laparoscopic surgery in infants and
children as during pneumoperitoneum, younger children absorb
proportionately more CO2 than older individuals. These findings
suggest

that

small

children

warrant

close

monitoring

during

laparoscopy and during the immediate postoperative period.

Meininger et al(2005) evaluated the hemodynamic and
respiratory effects of pneumoperitoneum (PP) with an intra-abdominal
pressure (IAP) of 12 mmHg in children undergoing robot-assisted
laparoscopic fundoplication during total intravenous Anaesthesia. Ten
children, aged 816 years, American Society of Anaesthesiologists
physical

status

IIIII,

scheduled

for

robot-assisted

laparoscopic

fundoplication in the reverse Trendelenburg position were investigated.

Minute ventilation (MV), peak inspiratory pressure (PIP), IAP, heart rate
(HR), mean arterial blood pressure (MAP) were recorded, together with
pH, base excess, HCO3, EtCO2, PaCO2, and PaO2 at six time points:

before insufflation, 10, 30, 60, 90 minutes after creating PP and after
desufflation. The IAP was maintained at 12 mmHg. During insufflation
MAP increased significantly from 70.6 (9.0) to 84.8 (10.4) mmHg,
MV was increased from 4.6 (0.8) to 5.5 (0.9) lmin1, PIP increased,
PaO2 and pH decreased. EtCO2 increased from 33.1 (1.6) to 36.6
(1.6) mmHg together with PaCO2. Hemodynamic and respiratory
effects due to the intra-abdominal insufflation of CO2 with an IAP of 12
mmHg are well tolerated, and Anaesthesia with remifentanil, propofol
and mivacurium facilitates extubation immediately at the end of
surgery.
Lorenzoa AJ et al(2006), underwent prospective study recorded
data

respiratory

rate,

PAP,

O2

saturation,

EtCO2,

HR,

MAP,

electrocardiogram and insufflation pressure in consecutive series of

patient before, during and after CO2 insufflation at regular intervals of
1 to 2 minutes, with up to 23 measurements recorded for each
period.Mean retroperitoneal CO2 insufflation pressure was kept at 12
mm Hg. Significant differences (p <0.05) in average EtCO2, PAP and
MAP were noted after CO2 insufflation compared to baseline (prepneumoretroperitoneum) values. HR and temperature did not change.
At completion of the laparoscopic intervention physiological variables
exhibited a trend to return to baseline values.This prospective study
documents significant changes in systemic hemodynamic variables
that seem to be directly associated with the insufflation of CO2 during
pediatric retroperitoneal laparoscopic surgery.
Dave

and

Farhat

(2006)

reviewed

the current

pediatric

literature on the physiological changes secondary to transperitoneal or

retroperitoneal laparoscopic urological surgery in pediatric patients and

showed varying and often statistically significant respiratory and

hemodynamic changes with laparoscopy.
Ahmed et al (2009) studied effect of pneumoperitoneum during
laparoscopic surgery in patients below 5years of age. They concluded
that patients were stable other than expected fluctuation during
intubation and reversal and knowledge of pathophysiological changes
is essential to safely guide these children through potentially
deleterious intraoperative changes.
Hyo-Jin Byon1 et al (2010) studied Anaesthetic management
of video-assisted thoracoscopic surgery (VATS) in pediatric patients.
They

reviewed The medical records of 52 pediatric patients

undergoing VATS using general Anaesthesia and one-lung ventilation

(OLV) .

OLV was achieved with a Fogarty catheter (n = 23) or

endobronchial intubation (n = 7) in patients < 10 years of age (group

Y, n = 30), and using a double-lumen tube (n = 19) in children aged
between 10 and 16 years of age (group O, n = 22). And was observed:
A decrease in SpO2 less than 90% was observed in 40% of the group Y,
compared to none of the group O (P < 0.05). hypercarbia (ETCO2 > 50
mmHg) more frequently in group Y (40%) than in group O (0%; P <
0.05) . The study concluded that

the infants and younger children

presented with more intra-operative problems when compared with

older children.

Aim Of The Study

To study the haemodynamic changes (Heart Rate,

Systolic Blood Pressure, Diastolic Blood Pressure,
and Mean Arterial Pressure) in minimal invasive
surgery in paediatric patients.

Material and
Methods

After getting approval from ethical committee of Chhatrapati Shahuji Maharaj

Medical University (U.P.) the present prospective study entitled The haemodynamic
changes in minimal invasive surgery in paediatric patients

was conducted in

C.S.M.M.U. Lucknow .As minimal invasive surgery has recently been started in
paediatric patients ,the patients included in the study were neonate to 12 year of age
( ASA I,II ) undergoing

minimal invasive surgery admitted to paediatric surgery

department of C.SM.M.U. under general anaesthesia. Patients of raised intracranial

tension and hypovolumia were excluded from the study.
A thorough preanaesthetic check up of the patient was done 48 hours before the
surgery and proper consent was taken.
After premedication with intravenous atropine(0.01-0.02mg/kg),fentanyl (1-2
mcg/kg)the patients were induced with thiopentone

(4-6 mg/kg) and endotracheal

intubation was performed with succinylcholine (1-2mg/kg). Loading dose of atracurium

(0.5/kg) and maintenance of 0.1-0.2mg/kg was done with 02 and N2O. Nasogastric tube
was passed. Bilateral auscultation of chest was done after any change of patients
position. At the end of surgery myoneural blockade was reversed with neostigmine
(0.04-0.08mg/kg) and atropine(0.02 mg/kg) and patients were extubated .
.

Monitoring of the patient

Systolic B.P

Diastolic B.P

Mean Arterial Pressure

Heart Rate

Pulse Oxymetry

Etco2

CO2 Insufflation Pressure

Continuous ECG Monitoring

Time periods for monitoring

Before induction (baseline), after induction, before insufflations,
every 5 min after insufflation till 30 minutes, every 10 min till
desufflation, every 5 min after desufflation upto 15 min.
Change of position .
Statistical tools employed
Data collected was subjected to statistical analysis.
The statistical analysis was done using SPSS (Statistical Package
for Social Sciences) Version 15.0 statistical Analysis Software. The
values were represented in Number (%) and MeanSD.
The following Statistical formulas were used:
1. Mean: To obtain the mean, the individual observations were first
added together and then divided by the number of observation.
The operation of adding together or summation is denoted by the
sign .
The individual observation is denoted by the sign X, number
of observation denoted by n, and the mean by

2.

X
No. of observatio ns (n )

Standard Deviation: It is denoted by the Greek letter . If a

sample is more than 30 then.
(X X )2

n

When sample in less than 30 then.

( X X )2

n 1

3.

Paired "t" test: To compare the change in a parameter at two

different time intervals paired "t" test was used.

where:
dav is the mean difference, i.e. the sum of the differences of all
the data points (set 1 point 1 - set 2 point 2, ...) divided by the
number
ofpairs
SD is the standard deviation of the differences between all the
pairs
N is the number of pairs.
4.

Analysis of Variance: Analysis of Variance (ANOVA): The

ANOVA test was used to compare the within group and between
group variances amongst the study groups i.e. the three different
sealers. Analysis of variance of these three sealers at a particular

time interval revealed the differences amongst them. ANOVA

provided F" ratio, where a higher "F" value depicted a higher
inter-group difference.
Mean of Sum of Between Group Difference s
Mean of Sum of within Group Difference s

:F=
Sum
of
Squar
Differences

Mean

es

df

Square

Groups

N1

X=A/N1

X/Y

Within Groups

N2

Y=B/N2

Between

5.

Post-Hoc Tests (Tukey-HSD)

M=
treatment/
group
mean
n=
number per
treatment/
group
1. Calculate an analysis of variance (e.g., One-way betweensubjects ANOVA).

2. Select two means and note the relevant variables (Means, Mean
Square Within, and number per condition/group)
3. Calculate Tukey's test for each mean comparison
4. Check to see if Tukey's score is statistically significant with
Tukey's probability/critical value table taking into account
appropriate dfwithin and number of treatments.
6.

Level of significance: "p" is level of significance

p > 0.05

Not significant

p <0.05

Significant

p <0.01

Highly significant

p <0.001 Very highly significant

Results

The present study was carried out to study the haemodynamic

changes in minimal invasive surgery in pediatric patients. For this
purpose a total of 53 patients were enrolled in the study.

Table 1;Demographic Distribution (n=53)

S.No
.

Characteristic

1.

Mean AgeSD (Years)

2.

Male:Female

3.

Mean weightSD (kg)

4.

Procedure

5.

Statistic
3.263.43
45:8
10.876.57

Laparoscopic

39 (64.1%)

Thoracoscopic

14 (35.9%)

Position
Supine

5 (9.4%)

Lateral

15 (28.3%)

Trendelenberg

24 (45.3%)

Reverse
Trendelenberg

9 (17.0%)

Agewise distribution of subjects has been shown in Table 1 below:

Table 2a: Agewise Distribution of subjects

S.N
o.

Characteristic

No. of cases

Percentage

1.

0-1 months

15.1

2.

1 month-1 year

17

32.1

3.

1-5 years

13

24.5

4.

5-12 years

15

28.3

Age of patients ranged from 4 days to 11 years. Maximum

number of subjects (n=17; 32.1%) were between 1 month to 1 year of
age. There were 15 (28.3%) subjects aged between 5 to 12 years, 13
(24.5%) in agegroup 1-5 years, and only 8 (15.1%) were in the
agegroup 0-1 months. Mean age of patients was 3.263.43 years.

Gender wise distribution of patients has been shown in Table 2

below:

Table 2b: Genderwise Distribution of subjects

S.N
o.

Gender

No. of cases

Percentage

1.

Female

15.1

2.

Male

45

84.9

More than four-fifth (84.9%) subjects were males. There were 8

(15.1%) females. Male to female ratio of the study subjects was 5.63:1.

Weight wise distribution of patients has been shown in Table 3

below:
Table 3: Weight Distribution (kg)
N

Minimum

Maximum

Mean

Std. Deviation

53

2.80

27.00

10.87

6.57

The weight of patients varied from 2.80 to 27.00 kg with a mean

weight of 10.876.57 kg.

Table 4 shows the baseline hemodynamics of the patients:

Table 4: Baseline Hemodynamics
Parameter

Minimu
m

Maximu
m

Mean

Std.
Deviation

HR

53

100.0

171.0

130.4

15.9

SBP

53

79.0

134.0

95.8

10.2

DBP

53

53.0

80.0

63.5

5.9

MAP

53

61.7

98.0

75.1

7.2

SPO2

53

94.0

100.0

98.6

1.6

EtCO2

53

24.0

40.0

30.1

3.5

At baseline the heart rate of subjects varied from 100 to 171 bpm
with a mean value of 130.415.9 bpm.
The systolic blood pressure of children ranged from 79 to 134 mm
of Hg with a mean value of 95.810.2 mm of Hg.
Mean diastolic blood pressure of the children was 63.55.9 mm
of Hg with a range from 53 to 80 mm of Hg.
Mean MAP ranged from 61.7 to 98.0 mm of Hg with a mean of
75.17.2 mm of Hg.

The mean oxygen saturation was 98.61.6% with a range from

94 to 100%.
Mean EtCO2 was 30.13.5% with a range from 24 to 40%.
At baseline all the children were afebrile and in supine position.

Agewise Comparison of Baseline parameters

Table 5: Baseline Parameters in different age groups
SN

Parameter

Group A

Group B

Upto 1 Year
(n=25)

>1 Year (n=28)

Significance of
difference

Mean

SD

Mean

SD

HR

143.48

9.92

118.79

9.93

8.059

<0.001

SBP

87.52

5.42

103.21

7.33

2.695

0.010

DBP

59.68

3.65

67.00

5.41

1.606

0.114

MAP

71.05

6.61

78.67

5.74

2.818

0.007

SPO2

98.76

1.54

98.43

1.67

0.537

0.593

EtCO2

29.40

3.71

30.79

3.15

2.325

0.024

Mean heart rate was significantly higher in Group A as compared

to Group B. For rest of the parameters, Group B has higher mean value
as compared to Group A, however, the difference between two groups
was observed to be significant statistically for all the variables except
oxygen saturation. Mean oxygen saturation was higher in Group A as
compared to Group B but the difference was not significant statistically.
As baseline parameters showed a wide variability
between two groups, it was not feasible to study the agewise
differences in hemodynamic variables at different time
intervals in the absence of a matched profile at baseline which
is an essential for a crossover study. Hence in subsequent
results hemodynamic changes have been discussed collectively
for all age groups together.

STUDY OF CHANGE IN HEMODYNAMIC VARIABLES

Table 6: Change in Heart Rate at different time intervals

At different time
intervals
No.
Mean
SD

Baseline
AI
Insuff
5m
10m
15m
20m
25m
30m
40m
50m
60m
70m
80m
90m
100m
110m
120m
130m
140m
150m
160m
170m
180m

Corresponding values
at baseline
No.
Mean
SD
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
53
130.4
15.9
52
130.6
16.0
50
130.7
16.3
48
130.1
16.3
46
130.6
16.3
41
130.8
16.5
35
129.7
15.2
28
129.9
15.6
21
127.8
15.1
11
125.7
16.4
9
124.9
15.1
7
125.4
11.2
3
118.3
5.7
3
118.3
5.7

53
53
53
53
53
53
53
53
53
53
52
50
48
46
41
35
28
21
11
9
7
3
3

149.5
154.5
150.4
149.8
150.7
150.0
149.9
147.6
149.3
150.1
149.9
149.3
149.9
150.8
150.4
149.5
148.0
146.1
142.0
145.1
143.7
145.0
143.7

At desuf

53

130.4

15.9

53

5m desuf

53

130.4

15.9

10m desuf

53

130.4

15m desuf

53

130.4

(Paired t-test)

"t"

"p"

14.8
14.4
15.4
14.6
15.1
14.2
13.8
15.7
14.4
14.6
14.1
14.5
14.2
14.5
14.0
13.6
14.0
14.4
15.0
9.1
11.0
8.2
5.0

-16.536
-18.624
-14.776
-14.221
-16.132
-14.433
-14.544
-10.890
-12.535
-14.168
-12.073
-12.480
-13.275
-14.466
-15.965
-12.419
-11.198
-9.771
-4.835
-5.009
-6.251
-6.576
-9.285

<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
<0.001
0.001
0.001
0.001
0.022
0.011

140.8

14.6

-7.379

<0.001

53

136.8

14.5

-4.716

<0.001

15.9

53

134.6

15.1

-3.168

0.003

15.9

53

132.7

14.1

-1.825

0.074

At all time intervals except 15 min after desufflation the mean

heart rate was significantly higher as compared to baseline (p<0.05).

Table 7: Change in SBP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

53

95.8

10.2

AI

53

95.8

10.2

53

130.8

8.4

-25.583

<0.001

Insuff

53

95.8

10.2

53

142.0

9.3

-26.962

<0.001

5m

53

95.8

10.2

53

135.5

8.3

-24.937

<0.001

10m

53

95.8

10.2

53

132.3

6.7

-25.429

<0.001

15m

53

95.8

10.2

53

131.3

6.7

-23.677

<0.001

20m

53

95.8

10.2

53

130.3

6.3

-22.163

<0.001

25m

53

95.8

10.2

53

129.3

6.3

-24.657

<0.001

30m

53

95.8

10.2

53

129.1

6.9

-22.570

<0.001

40m

53

95.8

10.2

53

128.8

7.6

-21.841

<0.001

50m

53

95.8

10.2

53

127.9

6.2

-21.604

<0.001

60m

52

95.8

10.3

52

128.8

4.8

-24.202

<0.001

70m

50

95.6

10.4

50

127.7

6.9

-24.281

<0.001

80m

48

95.7

10.7

48

127.6

6.9

-20.619

<0.001

90m

46

95.3

10.7

46

128.1

7.2

-21.438

<0.001

100m

41

95.1

9.2

41

128.1

5.3

-23.878

<0.001

110m

35

95.2

9.0

35

127.4

4.7

-23.166

<0.001

120m

28

95.3

9.1

28

127.9

4.5

-21.354

<0.001

130m

21

94.9

9.9

21

127.0

5.1

-15.735

<0.001

140m

11

96.5

9.6

11

127.5

4.2

-9.637

<0.001

150m

96.9

7.9

129.3

3.1

-11.256

<0.001

160m

97.4

6.4

129.7

1.6

-14.528

<0.001

170m

96.3

5.7

129.0

2.6

-6.947

0.020

180m

96.3

5.7

128.3

3.2

-12.095

0.007

At desuf

53

95.8

10.2

53

115.5

6.5

-15.816

<0.001

5m desuf

53

95.8

10.2

53

111.3

6.5

-12.567

<0.001

10m desuf

53

95.8

10.2

53

108.5

6.6

-12.018

<0.001

15m desuf

53

95.8

10.2

53

107.2

6.7

-10.665

<0.001

(Paired t-test)

At all time intervals the mean SBP was significantly higher as

compared to baseline (p<0.05).

Table 8: Change in DBP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

53

63.5

5.9

AI

53

63.5

5.9

53

77.8

5.8

-14.356

<0.001

Insuff

53

63.5

5.9

53

81.2

5.7

-15.881

<0.001

5m

53

63.5

5.9

53

79.5

5.0

-17.125

<0.001

10m

53

63.5

5.9

53

78.9

4.4

-17.639

<0.001

15m

53

63.5

5.9

53

78.1

4.4

-15.593

<0.001

20m

53

63.5

5.9

53

77.7

3.8

-16.283

<0.001

25m

53

63.5

5.9

53

77.9

4.0

-17.256

<0.001

30m

53

63.5

5.9

53

77.6

4.2

-15.666

<0.001

40m

53

63.5

5.9

53

78.3

3.9

-16.659

<0.001

50m

53

63.5

5.9

53

77.2

3.6

-15.935

<0.001

60m

52

63.5

5.9

52

77.8

3.8

-17.992

<0.001

70m

50

63.3

6.0

50

78.2

5.0

-18.253

<0.001

80m

48

63.5

6.0

48

78.2

5.7

-14.697

<0.001

90m

46

63.2

5.9

46

78.4

10.4

-9.778

<0.001

100m

41

63.1

5.6

41

77.9

5.1

-14.104

<0.001

110m

35

63.1

5.7

35

77.0

3.5

-14.647

<0.001

120m

28

63.0

5.7

28

76.7

3.1

-11.834

<0.001

130m

21

62.4

6.2

21

76.0

3.2

-9.613

<0.001

140m

11

62.8

6.0

11

76.6

2.1

-6.976

<0.001

150m

62.7

5.6

77.9

4.1

-5.874

<0.001

160m

62.0

4.3

77.9

2.9

-9.760

<0.001

170m

60.3

5.0

77.0

4.0

-5.735

0.029

180m

60.3

5.0

76.3

3.8

-16.000

0.004

At desuf

53

63.5

5.9

53

73.1

4.1

-10.809

<0.001

5m desuf

53

63.5

5.9

53

72.2

4.1

-11.139

<0.001

10m desuf

53

63.5

5.9

53

70.4

3.6

-10.512

<0.001

15m desuf

53

63.5

5.9

53

70.2

4.2

-10.275

<0.001

(Paired t-test)

At all time intervals the mean DBP was significantly higher as

compared to baseline (p<0.05).

Table 9: Change in MAP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

53

75.1

7.2

AI

53

75.1

7.2

53

95.3

5.5

-19.354

<0.001

Insuff

53

75.1

7.2

53

100.4

6.5

-18.933

<0.001

5m

53

75.1

7.2

53

97.4

5.6

-20.543

<0.001

10m

53

75.1

7.2

53

96.5

4.6

-20.897

<0.001

15m

53

75.1

7.2

53

95.6

4.7

-18.672

<0.001

20m

53

75.1

7.2

53

95.1

4.2

-19.008

<0.001

25m

53

75.1

7.2

53

94.9

4.4

-20.040

<0.001

30m

53

75.1

7.2

53

94.3

5.1

-17.852

<0.001

40m

53

75.1

7.2

53

95.1

4.3

-20.112

<0.001

50m

53

75.1

7.2

53

94.0

3.8

-18.588

<0.001

60m

52

75.0

7.3

52

94.7

3.6

-21.078

<0.001

70m

50

74.9

7.4

50

94.7

5.0

-23.251

<0.001

80m

48

75.1

7.4

48

94.5

5.8

-16.355

<0.001

90m

46

74.8

7.5

46

93.1

6.2

-15.382

<0.001

100m

41

73.9

6.4

41

93.6

5.2

-17.635

<0.001

110m

35

73.8

6.4

35

93.2

3.9

-18.232

<0.001

120m

28

73.8

6.5

28

93.5

3.6

-16.547

<0.001

130m

21

73.2

7.1

21

92.2

4.0

-13.300

<0.001

140m

11

73.9

6.9

11

92.7

3.8

-9.002

<0.001

150m

73.7

6.4

88.3

5.5

-6.902

<0.001

160m

73.6

4.5

90.1

3.4

-7.205

<0.001

170m

72.3

5.2

92.1

5.3

-4.205

0.052

180m

72.3

5.2

92.8

2.1

-10.606

0.009

At desuf

53

75.1

7.2

53

85.8

5.2

-9.582

<0.001

5m desuf

53

75.1

7.2

53

85.3

4.7

-10.751

<0.001

10m desuf

53

75.1

7.2

53

83.1

4.6

-8.423

<0.001

15m desuf

53

75.1

7.2

53

82.4

4.2

-8.807

<0.001

(Paired t-test)

At all time intervals the mean MAP was significantly higher as

compared to baseline (p<0.05) except at 170 min.

Table 10: Change in Oxygen Saturation at different time

intervals
Corresponding values
at baseline
No.
Mean
SD

At different time
Intervals
No.
Mean
SD

"t"

"p"

Baseline

53

98.6

1.6

AI

53

98.6

1.6

53

99.2

1.2

-3.825

<0.001

Insuff

53

98.6

1.6

53

99.2

1.2

-4.078

<0.001

5m

53

98.6

1.6

53

99.0

1.4

-2.748

0.008

10m

53

98.6

1.6

53

99.0

1.3

-2.748

0.008

15m

53

98.6

1.6

53

99.1

1.2

-3.736

<0.001

20m

53

98.6

1.6

53

99.0

1.4

-2.518

0.015

25m

53

98.6

1.6

53

99.1

1.2

-2.789

0.007

30m

53

98.6

1.6

53

99.0

1.4

-2.440

0.018

40m

53

98.6

1.6

53

99.2

1.1

-3.718

<0.001

50m

53

98.6

1.6

53

99.0

1.5

-2.548

0.014

60m

52

98.6

1.6

52

99.1

1.3

-3.088

0.003

70m

50

98.5

1.6

50

99.0

1.3

-3.082

0.003

80m

48

98.5

1.6

48

99.1

1.4

-3.721

0.001

90m

46

98.4

1.7

46

99.1

1.4

-4.098

<0.001

100m

41

98.3

1.7

41

98.8

1.4

-2.504

0.016

110m

35

98.4

1.5

35

99.0

1.4

-2.487

0.018

120m

28

98.5

1.6

28

99.1

1.4

-3.014

0.006

130m

21

98.6

1.6

21

99.2

1.0

-2.467

0.023

140m

11

99.4

0.7

11

99.9

0.3

2,631

0.025

150m

99.3

0.7

99.9

0.3

-3.162

0.013

160m

99.3

0.8

99.9

0.4

-1.922

0.103

170m

99.3

0.6

100.0

0.0

-2.000

0.184

180m

99.3

0.6

100.0

0.0

-2.000

0.184

At desuf

53

98.6

1.6

53

98.5

2.3

0.216

0.830

5m desuf

53

98.6

1.6

53

98.9

1.0

-1.842

0.071

10m desuf

53

98.6

1.6

53

99.0

1.1

-2.748

0.008

15m desuf

53

98.6

1.6

53

99.2

1.0

-3.738

<0.001

(Paired t-test)

At all time intervals, mean oxygen saturation was higher as

compared to corresponding baseline values. The change from baseline
was significant at all time intervals except at 140, 160, 170, 180 min,
at desufflation and 5 min. after desufflation intervals.

Table 11: Change in End tidal CO2 at different time

intervals
Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

53

30.1

3.5

AI

53

30.1

3.5

53

34.2

3.8

-7.409

<0.001

Insuff

53

30.1

3.5

53

41.2

4.4

-15.576

<0.001

5m

53

30.1

3.5

53

43.8

4.1

-20.249

<0.001

10m

53

30.1

3.5

53

43.9

4.4

-17.903

<0.001

15m

53

30.1

3.5

53

43.5

3.9

-18.704

<0.001

20m

53

30.1

3.5

53

43.6

3.5

-23.945

<0.001

25m

53

30.1

3.5

53

43.6

2.9

-24.280

<0.001

30m

53

30.1

3.5

53

43.5

4.2

-18.866

<0.001

40m

53

30.1

3.5

53

43.2

4.0

-21.559

<0.001

50m

53

30.1

3.5

53

43.5

3.4

-24.082

<0.001

60m

52

30.2

3.5

52

43.6

3.3

-21.428

<0.001

70m

50

30.2

3.5

50

43.5

3.5

-20.129

<0.001

80m

48

30.4

3.4

48

43.8

3.1

-22.237

<0.001

90m

46

30.3

3.5

46

43.9

3.2

-21.090

<0.001

100m

41

30.2

3.1

41

43.5

3.2

-21.274

<0.001

110m

35

30.4

3.0

35

43.9

2.6

-19.399

<0.001

120m

28

30.6

3.2

28

43.3

3.1

-15.028

<0.001

130m

21

31.0

3.2

21

43.2

3.2

-11.412

<0.001

140m

11

31.1

3.4

11

41.6

5.1

-4.943

0.001

150m

31.3

3.7

41.1

5.6

-3.572

0.007

160m

31.9

2.5

41.3

4.6

-4.281

0.005

170m

30.3

2.1

43.7

4.9

-7.559

0.017

180m

30.3

2.1

44.0

3.6

-11.371

0.008

At desuf

53

30.1

3.5

53

34.7

3.8

-7.029

<0.001

5m desuf

53

30.1

3.5

53

34.2

3.0

-6.539

<0.001

10m desuf

53

30.1

3.5

53

33.3

3.3

-5.499

<0.001

15m desuf

53

30.1

3.5

53

32.1

2.5

-4.278

<0.001

(Paired t-test)

At all follow up intervals the mean End tidal CO2 levels were
significantly higher as compared to baseline..

TYPE OF SURGERY

Table 12: Comparison of Heart Rate in abdominal Laparoscopic

surgery and Thoracic laparoscopic surgery types at different
time intervals
abdominal
Laparoscopy
No.
Mean
SD

Thoracic laparoscpy
No.
Mean
SD

Baseline

39

131.77

15.71

14

126.71

AI

39

149.67

14.87

14

Insuff

39

154.64

13.83

5m

39

151.28

10m

39

15m

"t"

"p"

16.26

1.024

0.311

149.14

15.05

0.113

0.911

14

154.14

16.54

0.110

0.913

16.11

14

147.93

13.59

0.694

0.491

150.67

14.91

14

147.57

14.10

0.675

0.503

39

151.72

14.93

14

148.00

15.97

0.785

0.436

20m

39

151.18

13.52

14

146.79

16.01

0.993

0.325

25m

39

151.44

12.91

14

145.79

15.63

1.328

0.190

30m

39

149.33

14.98

14

142.93

17.30

1.318

0.193

40m

39

150.74

14.09

14

145.14

14.99

1.255

0.215

50m

39

151.44

14.86

14

146.21

13.49

1.154

0.254

60m

38

152.03

13.34

14

144.29

14.97

1.796

0.079

70m

36

151.25

14.12

14

144.21

14.71

1.564

0.124

80m

34

151.74

13.35

14

145.36

15.62

1.432

0.159

90m

32

152.88

13.89

14

146.21

15.42

1.448

0.155

100m

27

152.48

13.29

14

146.29

15.00

1.355

0.183

110m

23

149.96

12.47

12

148.58

16.18

0.279

0.782

120m

19

149.63

11.18

144.44

18.87

0.916

0.368

130m

15

147.07

13.20

143.67

18.14

0.480

0.637

140m

10

141.80

15.81

144.00

-0.133

0.897

150m

144.88

9.73

147.00

-0.206

0.843

160m

144.50

11.78

139.00

0.432

0.683

170m

146.00

11.31

143.00

0.217

0.864

180m

144.00

7.07

143.00

0.115

0.927

At desuf

39

141.36

14.56

14

139.29

14.98

0.454

0.652

5m desuf

39

137.46

14.93

14

135.14

13.70

0.509

0.613

10m desuf

39

135.31

15.24

14

132.50

15.20

0.592

0.557

15m desuf

39

132.97

14.12

14

131.93

14.51

0.236

0.814

Student "t"-test

No difference between two types of surgery was observed at any

time interval.

Table 13: Comparison of SBP Rate in abdominal Laparoscopic

surgery and Thoracic laparoscopic surgery types at different
time intervals
abdominal
Laparoscopy
No.
Mean
SD

Thoracic laparoscpy
No.
Mean
SD

Baseline

39

95.59

10.67

14

96.43

AI

39

128.97

8.13

14

Insuff

39

139.92

8.70

5m

39

133.74

10m

39

15m

"t"

"p"

9.10

-0.262

0.795

135.86

7.21

-2.794

0.007

14

147.64

8.90

-2.831

0.007

7.38

14

140.36

9.04

-2.709

0.009

131.15

5.85

14

135.50

8.02

-2.156

0.036

39

130.28

6.41

14

134.00

6.77

-1.835

0.072

20m

39

129.90

6.08

14

131.57

6.89

-0.853

0.398

25m

39

129.13

6.50

14

129.64

5.72

-0.262

0.794

30m

39

129.08

7.63

14

129.07

4.34

0.003

0.998

40m

39

128.95

7.32

14

128.57

8.67

0.158

0.875

50m

39

127.54

5.72

14

129.00

7.53

-0.753

0.455

60m

38

128.47

4.74

14

129.86

4.96

-0.922

0.361

70m

36

127.31

7.69

14

128.64

4.11

-0.615

0.541

80m

34

127.29

7.53

14

128.50

5.40

-0.543

0.590

90m

32

127.34

7.13

14

129.86

7.25

-1.094

0.280

100m

27

127.30

5.09

14

129.71

5.53

-1.401

0.169

110m

23

127.09

4.75

12

128.00

4.86

-0.536

0.596

120m

19

127.63

4.92

128.56

3.81

-0.495

0.625

130m

15

127.40

4.88

126.17

5.88

0.495

0.627

140m

10

127.60

4.40

127.00

0.130

0.899

150m

129.50

3.30

128.00

0.429

0.681

160m

129.83

1.72

129.00

0.448

0.673

170m

127.50

0.71

132.00

-5.196

0.121

180m

129.00

4.24

127.00

0.385

0.766

At desuf

39

115.77

6.73

14

114.57

5.76

0.592

0.557

5m desuf

39

111.10

6.00

14

111.86

7.89

-0.371

0.713

10m desuf

39

109.03

6.74

14

107.00

6.32

0.980

0.332

15m desuf

39

107.44

7.06

14

106.57

5.89

0.409

0.684

Student "t"-test

No difference between two types of surgery was observed at any

time interval.

Table 14: Comparison of DBP Rate in abdominal Laparoscopic

surgery and Thorasic laparoscpic surgery types at different
time intervals
abdominal
Laparoscopy
No.
Mean
SD

Thorasic laparoscpy
No.
Mean
SD

Baseline

39

63.67

5.97

14

63.21

AI

39

78.44

5.72

14

Insuff

39

81.95

5.60

5m

39

79.64

10m

39

15m

"t"

"p"

5.95

0.243

0.809

76.21

5.83

1.240

0.221

14

79.21

5.74

1.558

0.125

4.97

14

79.07

5.28

0.362

0.719

79.21

4.21

14

78.14

4.96

0.773

0.443

39

78.79

4.48

14

76.21

3.49

1.947

0.057

20m

39

77.92

3.30

14

77.00

4.93

0.783

0.437

25m

39

78.26

3.65

14

76.93

4.97

1.057

0.295

30m

39

78.18

4.22

14

76.00

3.78

1.700

0.095

40m

39

78.82

4.03

14

76.79

3.40

1.685

0.098

50m

39

77.21

3.42

14

77.00

4.24

0.181

0.857

60m

38

77.87

3.68

14

77.57

4.16

0.249

0.804

70m

36

77.92

4.77

14

79.00

5.82

-0.678

0.501

80m

34

78.32

6.37

14

77.79

3.53

0.296

0.768

90m

32

77.59

6.53

14

80.21

16.35

-0.783

0.438

100m

27

78.07

5.47

14

77.43

4.54

0.379

0.707

110m

23

77.83

2.35

12

75.50

4.68

1.971

0.057

120m

19

76.58

3.01

77.00

3.50

-0.329

0.745

130m

15

76.60

2.75

74.33

3.93

1.512

0.147

140m

10

76.70

2.16

76.00

0.309

0.765

150m

77.88

4.39

78.00

-0.027

0.979

160m

78.33

2.88

75.00

1.073

0.332

170m

77.00

5.66

77.00

<0.001

1.000

180m

78.50

0.71

72.00

7.506

0.084

At desuf

39

73.36

4.50

14

72.21

2.36

0.904

0.371

5m desuf

39

72.31

4.30

14

71.93

3.52

0.296

0.769

10m desuf

39

70.21

3.69

14

70.86

3.23

-0.584

0.562

15m desuf

39

70.05

4.03

14

70.79

4.69

-0.560

0.578

Student "t"-test

No
difference between two types of surgery was observed at any time
interval.

Table 15: Comparison of MAP in abdominal Laparoscopic

surgery and Thorasic laparoscpic surgery types at different
time intervals
abdominal
Laparoscopy

"t"

"p"

Thorasic laparoscpy

No.

Mean

SD

No.

Mean

SD

Baseline

39

75.15

7.58

14

74.86

6.31

0.131

0.896

AI

39

95.16

5.61

14

95.76

5.39

-0.346

0.731

Insuff

39

100.16

6.64

14

100.98

6.24

-0.399

0.691

5m

39

96.62

5.80

14

99.50

4.40

-1.691

0.097

10m

39

96.19

4.39

14

97.26

5.18

-0.748

0.458

15m

39

95.64

5.05

14

95.48

3.71

0.112

0.912

20m

39

95.02

3.88

14

95.19

5.27

-0.130

0.897

25m

39

95.04

4.44

14

94.50

4.44

0.393

0.696

30m

39

94.54

5.70

14

93.69

3.12

0.527

0.600

40m

39

95.53

4.28

14

94.05

4.16

1.119

0.268

50m

39

93.85

3.77

14

94.33

3.94

-0.403

0.689

60m

38

94.54

3.69

14

95.00

3.52

-0.408

0.685

70m

36

94.38

5.19

14

95.55

4.60

-0.736

0.465

80m

34

94.37

6.57

14

94.69

3.30

-0.172

0.864

90m

32

93.73

6.60

14

91.79

5.19

0.976

0.335

100m

27

93.81

5.35

14

93.21

5.09

0.346

0.731

110m

23

93.36

3.85

12

93.00

4.02

0.260

0.796

120m

19

93.21

3.84

94.19

3.15

-0.661

0.514

130m

15

92.44

4.16

91.61

4.05

0.418

0.681

140m

10

92.63

4.04

93.00

-0.086

0.933

150m

87.38

5.21

94.67

-1.309

0.239

160m

89.67

3.44

93.00

-0.896

0.411

170m

90.50

6.36

95.33

-0.620

0.647

180m

94.00

0.00

90.33

At desuf

39

86.26

5.75

14

84.50

2.90

1.090

0.281

5m desuf
10m
desuf
15m
desuf

39

85.18

5.12

14

85.57

3.18

-0.267

0.790

39

83.26

5.04

14

82.71

3.00

0.378

0.707

39

82.46

4.09

14

82.36

4.65

0.079

0.937

Student "t"-test

No difference between two types of surgery was observed at any

time interval.

Table 16: Comparison of Oxygen Saturation in abdominal

Laparoscopic surgery and Thorasic laparoscpic surgery types
at different time intervals
Laparoscopic
No.
Mean
SD

Thoracostomy
No.
Mean
SD

"t"

"p"

Baseline

39

99.26

0.72

14

96.71

1.90

7.157

<0.001

AI

39

99.74

0.44

14

97.64

1.15

9.698

<0.001

Insuff

39

99.82

0.39

14

97.57

0.94

12.440

<0.001

5m

39

99.72

0.51

14

97.00

1.04

12.744

<0.001

10m

39

99.67

0.48

14

97.14

1.10

11.716

<0.001

15m

39

99.77

0.43

14

97.36

0.74

14.705

<0.001

20m

39

99.74

0.50

14

96.93

0.73

15.950

<0.001

25m

39

99.67

0.58

14

97.43

0.85

10.914

<0.001

30m

39

99.72

0.51

14

96.93

0.73

15.587

<0.001

40m

39

99.77

0.43

14

97.57

0.94

11.760

<0.001

50m

39

99.77

0.43

14

96.71

0.83

17.627

<0.001

60m

38

99.76

0.49

14

97.29

0.91

12.616

<0.001

70m

36

99.78

0.42

14

97.14

0.95

13.685

<0.001

80m

34

99.88

0.33

14

97.14

0.86

16.078

<0.001

90m

32

99.91

0.30

14

97.21

1.05

13.485

<0.001

100m

27

99.67

0.55

14

97.21

0.89

10.854

<0.001

110m

23

99.87

0.34

12

97.25

0.97

11.784

<0.001

120m

19

99.84

0.37

97.44

1.24

7.867

<0.001

130m

15

99.73

0.46

98.00

1.10

5.233

<0.001

140m

10

99.90

0.32

100.00

-0.305

0.767

150m

99.88

0.35

100.00

-0.333

0.749

160m

99.83

0.41

100.00

-0.378

0.721

170m

100.00

0.00

100.00

180m

100.00

0.00

100.00

At desuf

39

99.23

0.67

14

96.57

3.76

4.306

0.000

5m desuf

39

99.38

0.59

14

97.57

0.65

9.621

0.000

10m desuf

39

99.49

0.64

14

97.64

1.01

7.856

0.000

15m desuf

39

99.62

0.49

14

98.07

1.21

6.669

0.000

Student "t"-test

In laparoscopic surgery group the mean value was higher as

compared to thoracoscopic surgery group upto 130 minutes and the
difference was significant statistically too. Thereafter, till desufflation
the value in laparoscopic group was lower as compared to
thoracoscopic group but the difference was not significant statistically.

Table 17: Comparison of End tidal CO2 concentration

abdominal Laparoscopic surgery and Thorasic laparoscpic
surgery types at different time intervals
abdominal
Laparoscopy

"t"

"p"

Thorasic laparoscpy

No.

Mean

SD

No.

Mean

SD

Baseline

39

29.85

3.80

14

30.93

2.20

-1.003

0.321

AI

39

33.92

4.28

14

35.14

2.07

-1.021

0.312

Insuff

39

40.54

4.20

14

42.93

4.68

-1.773

0.082

5m

39

42.77

4.06

14

46.79

2.55

-3.457

0.001

10m

39

42.95

4.36

14

46.57

3.25

-2.829

0.007

15m

39

42.28

3.59

14

46.79

2.94

-4.206

<0.001

20m

39

42.62

3.13

14

46.50

2.93

-4.044

<0.001

25m

39

42.79

2.71

14

46.00

2.25

-3.959

<0.001

30m

39

42.15

3.40

14

47.14

4.19

-4.429

<0.001

40m

39

42.26

4.09

14

45.79

2.08

-3.076

0.003

50m

39

42.46

2.89

14

46.43

2.93

-4.390

<0.001

60m

38

42.74

3.24

14

45.86

2.32

-3.294

0.002

70m

36

42.89

3.39

14

45.14

3.23

-2.139

0.038

80m

34

42.62

2.88

14

46.64

1.39

-4.970

<0.001

90m

32

42.75

3.10

14

46.43

1.34

-4.247

<0.001

100m

27

42.22

2.97

14

45.93

2.27

-4.088

<0.001

110m

23

42.87

2.51

12

45.83

1.59

-3.708

0.001

120m

19

41.95

2.70

46.00

1.66

-4.129

<0.001

130m

15

42.07

3.17

46.00

0.89

-2.948

0.008

140m

10

41.30

5.25

45.00

-0.672

0.519

150m

40.63

5.80

45.00

-0.711

0.500

160m

40.67

4.72

45.00

-0.850

0.434

170m

42.50

6.36

46.00

-0.449

0.731

180m

43.50

4.95

45.00

-0.247

0.846

At desuf

39

34.13

3.51

14

36.29

4.34

-1.852

0.070

5m desuf

39

33.51

2.60

14

35.93

3.45

-2.726

0.009

10m desuf

39

32.49

2.84

14

35.43

3.65

-3.080

0.003

15m desuf

39

31.46

2.38

14

33.71

1.86

-3.199

0.002

Student "t"-test

At all time intervals the mean value was higher in thoracoscopic

group as compared to laparoscopic group but the difference was
significant only between 5min to 130 min intervals and from 5 min
after desufflation till the end.

POSITION
Table 18: Comparison of Heart Rate in Different positions
SN

Parameter

Lateral (n=15)

Reverse
Trendelenberg
(n=9)

Mean

SD

Mean

SD

Supine (n=5)

Mean

SD

Trendlenberg
(n=24)
n

Mean

SD

ANOVA

Baseline

15 128.1 20.8 9

133.7 13.2 5

132.0 14.7 24 130.3 14.1

0.236

0.871

AI

15 148.5 15.9 9

151.6 14.2 5

152.0 16.2 24 148.9 14.8

0.134

0.939

Insuff

15 154.5 19.0 9

154.4 10.7 5

161.0 13.5 24 153.2 13.0

0.388

0.762

5m

15 146.7 18.8 9

154.2 13.6 5

156.4 16.9 24 150.0 13.6

0.712

0.550

10m

15 146.8 19.9 9

150.2 12.3 5

155.2 14.7 24 150.5 11.8

0.443

0.723

15m

15 147.3 20.8 9

153.3 12.3 5

153.0 15.8 24 151.5 12.2

0.392

0.759

20m

15 146.6 18.6 9

153.1 12.5 5

152.0 15.7 24 150.6 11.6

0.463

0.710

25m

15 146.6 18.0 9

153.0 13.6 5

150.8 12.2 24 150.7 11.4

0.460

0.712

30m

15 144.2 19.6 9

154.3 14.4 5

149.4 10.1 24 146.9 14.4

0.813

0.493

10 40m

15 147.2 14.6 9

155.1 16.0 5

147.2 10.6 24 148.8 14.6

0.626

0.601

11 50m

15 147.7 17.3 9

154.1 11.2

150.8 13.7 24 149.6 13.4

0.987

0.406

12 60m

15 145.3 20.7 9

152.2 12.0 5

157.0 11.3 24 150.8 11.0

0.380

0.768

13 70m

15 147.7 17.3 9

154.1 11.2

150.8 13.7 24 149.6 13.4

0.880

0.459

14 80m

15 144.8 18.0 9

154.4 11.7

150.5 13.8 22 150.0 13.0

0.954

0.423

15 90m

15 146.5 16.7 9

152.4 12.1 3

141.3

1.5 21 152.4 13.7

0.314

0.815

16 100m

15 148.0 17.2 8

152.5

149.3

5.8 20 152.6 15.3

0.360

0.782

17 110m

14 148.9 17.4 7

155.4 13.0 3

148.7 16.7 17 149.8 11.5

0.849

0.478

18 120m

11

149.1 16.9 5

156.0 11.6

138.0

4.2 17 149.2 12.3

1.172

0.341

19 130m

144.4 20.2 5

157.0 10.8 2

139.0

0.0 13 148.1 10.3

0.423

0.739

20 140m

143.8 20.3 4

153.5 11.9

141.0

11

144.9 13.3

0.544

0.600

21 150m

152.5 17.7 1

139.0

139.8 15.5

0.181

0.838

22 160m

143.0

140.0

146.1 10.2

1.067

0.425

9.3

At desuf

15 142.0 18.6 9

144.0 10.9 5

141.4 19.0 24 138.8 12.4 0.327

0.806

5m desuf
10m
desuf
15m
desuf

15 135.8 18.0 9

139.7 11.7

138.0 18.8 24 136.2 12.9 0.157

0.925

15 132.9 19.2 9

137.6 13.6 5

133.4 14.9 24 134.7 13.6 0.177

0.911

15 132.9 19.3 9

133.9 11.7

131.2 11.5 24 132.5 12.2 0.041

0.989

No significant difference was observed at any time interval.

Table 19: Comparison of SBP in Different positions

SN

Parameter

Lateral (n=15)

Reverse
Trendelenberg
(n=9)

Supine (n=5)

Trendlenberg
(n=24)

ANOVA

Mean

SD

Mean

SD

Mean

SD

Mean

SD

11.3

Baseline

15

99.6

12.8

94.0

97.2

6.4 24

93.8

8.3

1.124

0.348

AI

15 134.9

7.5

126.0 12.4 5

132.4

5.1 24 129.7

6.8

2.614

0.062

Insuff

15 144.5 12.9

139.2 10.7 5

142.4

5.7 24 141.3

6.5

0.671

0.574

5m

15 138.1 12.1

132.8

8.8

137.4

6.3 24 134.5

4.9

1.042

0.382

10m

15 133.3

8.8

133.0

8.7

131.4

4.6 24 131.6

4.7

0.238

0.870

15m

15 132.5

9.2

131.4

5.5

130.0

7.2 24 130.7

5.2

0.270

0.847

20m

15 129.7

8.9

131.7

6.7

130.4

4.9 24 130.2

4.5

0.175

0.913

25m

15 128.3

8.7

130.7

8.0

129.8

4.0 24 129.2

3.9

0.263

0.852

30m

15 127.8

9.7

132.0

7.4

127.8

4.2 24 129.0

4.8

0.763

0.521

10 40m

15 129.5

9.7

132.9

7.5

127.4

4.0 24 127.2

6.5

1.344

0.271

11 50m

15 129.2

5.7

131.1

4.4

129.0

3.2 24 127.8

4.4

0.845

0.476

12 60m

15 127.9

8.8

130.4

6.4

129.2

3.9 24 126.8

4.3

1.126

0.348

13 70m

15 129.2

5.7

131.1

4.4

129.0

3.2 24 127.8

4.4

0.426

0.735

14 80m

15 128.1

9.6

129.4

6.8

125.3

3.9 22 127.1

5.1

0.608

0.614

15 90m

15 127.5

9.8

130.3

8.2

128.0

2.6 21 126.6

3.8

0.663

0.580

16 100m

15 129.3 10.2

130.1

7.6

127.7

2.1 20 126.5

4.3

0.025

0.994

17 110m

14 128.4

6.9

128.0

7.6

127.7

3.2 17 128.0

2.9

0.424

0.737

18 120m

11

128.1

5.1

128.4

6.2

129.0

2.8 17 126.5

4.4

0.591

0.627

19 130m

128.9

3.9

129.6

6.7

126.5

2.1 13 126.9

4.4

0.757

0.533

20 140m

125.6

6.4

129.8

5.3

131.0

11

126.4

4.5

0.992

0.412

21 150m

131.0

1.4

129.0

126.5

4.4

0.126

0.884

22 160m

129.0

131.0

129.1

3.5

1.506

0.325

At desuf

15

115.0

7.0

113.9

5.9

118.6

7.3 24

115.7

6.3

0.591

0.624

5m desuf
10m
desuf
15m
desuf

15

111.6

8.4

108.4

6.6

115.8

5.9 24

111.3

4.8

1.431

0.245

15 107.8

7.7

106.3

7.5

109.2

3.3 24 109.6

6.2

0.594

0.622

15 108.0

7.7

105.6

6.3

107.8

8.8 24 107.2

6.1

0.252

0.860

No significant difference was observed at any time interval.

Table 20: Comparison of DBP in Different positions

SN

Parameter

Lateral (n=15)

Reverse
Trendelenberg
(n=9)

Supine (n=5)

Trendlenberg
(n=24)

ANOVA

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Baseline

15

65.1

6.7

62.3

6.5

64.4

3.3 24

62.9

5.7

0.581

0.631

AI

15

77.0

6.6

79.1

6.1

78.4

1.5 24

77.8

5.9

0.255

0.857

Insuff

15

79.2

6.0

83.6

4.2

81.0

3.3 24

81.7

6.2

1.192

0.322

5m

15

78.7

6.6

80.9

5.7

79.6

3.6 24

79.4

4.0

0.337

0.799

10m

15

79.1

6.1

79.8

5.0

79.8

3.3 24

78.3

3.1

0.343

0.794

15m

15

76.5

4.9

79.3

5.8

78.8

4.0 24

78.5

3.4

0.993

0.404

20m

15

77.5

5.1

78.3

3.3

78.6

3.8 24

77.4

3.1

0.246

0.864

25m

15

76.9

5.2

80.0

4.9

77.0

2.8 24

78.0

2.8

1.242

0.305

30m

15

76.1

5.3

79.0

4.2

78.4

6.2 24

77.8

2.8

1.036

0.385

10 40m

15

77.8

4.4

79.3

4.6

78.2

3.3 24

78.2

3.7

0.279

0.840

11 50m

15

77.9

4.6

79.4

1.7

78.5

2.9 24

77.0

3.9

1.959

0.132

12 60m

15

77.0

4.6

78.8

2.9

79.4

5.3 24

76.2

2.4

1.020

0.392

13 70m

15

77.9

4.6

79.4

1.7

78.5

2.9 24

77.0

3.9

1.833

0.154

14 80m

15

80.1

7.6

78.2

4.2

80.3

2.2 22

76.5

2.7

0.223

0.880

15 90m

15

78.3

8.8

79.2

3.4

79.0

7.0 21

77.5

3.3

0.304

0.823

16 100m

15

80.4

17.9 8

76.9

3.4

79.3

3.1 20

77.4

2.8

0.583

0.630

17 110m

14

77.5

4.5

77.4

2.3

81.7

7.6 17

77.6

6.1

1.066

0.378

18 120m

11

75.8

4.8

78.4

1.5

79.5

2.1 17

77.1

2.8

0.038

0.990

19 130m

77.0

3.7

76.4

3.6

76.5

3.5 13

76.7

2.8

0.361

0.782

20 140m

74.6

4.3

76.3

2.5

76.0

11

76.5

3.1

0.478

0.636

21 150m

77.5

0.7

78.0

76.3

2.3

0.586

0.586

22 160m

82.0

79.0

77.1

4.3

3.410

0.137

At desuf

15

72.7

2.8

72.1

3.4

73.6

3.6 24

73.5

5.0

0.307

0.820

5m desuf
10m
desuf
15m
desuf

15

71.7

4.0

70.1

3.2

75.2

2.6 24

72.7

4.4

1.963

0.132

15

71.4

3.6

69.1

4.4

71.4

3.2 24

70.0

3.2

1.022

0.391

15

72.5

5.7

68.2

2.9

70.8

2.9 24

69.5

3.1

2.773

0.051

No significant difference was observed at any time interval.

Table 21: Comparison of MAP in Different positions

SN

Parameter

Lateral (n=15)

Reverse
Trendelenberg
(n=9)

Supine (n=5)

Trendlenberg
(n=24)

ANOVA

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Baseline

15

77.1

8.1

74.3

8.3

74.8

3.5 24

74.1

6.9

0.553

0.649

AI

15

96.0

5.6

94.7

7.3

96.4

2.5 24

94.9

5.4

0.212

0.888

Insuff

15 100.0

6.9

100.0

8.7

96.5

6.0 24 101.5

5.4

0.861

0.468

5m

15

98.5

6.6

98.2

5.6

94.4

5.5 24

97.0

4.9

0.787

0.507

10m

15

97.2

5.0

97.5

6.0

97.0

3.1 24

95.5

4.1

0.622

0.604

15m

15

95.2

5.5

96.7

5.1

93.4

7.1 24

95.9

3.5

0.591

0.624

20m

15

94.9

5.4

96.1

4.2

94.1

6.3 24

95.0

3.0

0.274

0.844

25m

15

94.0

5.6

96.9

5.9

94.6

3.0 24

94.8

3.0

0.818

0.490

30m

15

93.4

6.1

96.7

4.5

90.1

8.7 24

94.9

3.1

2.155

0.105

10 40m

15

95.0

4.9

97.2

5.1

94.6

2.3 24

94.5

3.8

0.871

0.463

11 50m

15

95.0

4.1

96.7

2.3

93.4

4.4 24

93.9

3.4

2.230

0.096

12 60m

15

94.0

4.8

96.0

3.8

96.0

4.3 24

92.8

2.5

1.541

0.216

13 70m

15

95.0

4.1

96.7

2.3

93.4

4.4 24

93.9

3.4

0.962

0.419

14 80m

15

96.1

7.6

95.3

4.6

95.3

2.0 22

93.4

2.9

0.545

0.654

15 90m

15

94.7

8.5

96.3

4.8

95.3

4.6 21

93.4

3.7

0.302

0.824

16 100m

15

92.0

9.6

94.6

4.5

93.6

6.6 20

93.3

3.0

0.157

0.924

17 110m

14

92.8

5.1

94.3

4.0

94.1

9.2 17

93.9

5.4

0.712

0.552

18 120m

11

93.2

4.1

95.1

2.9

90.5

9.2 17

93.0

3.4

0.292

0.831

19 130m

94.3

3.4

94.1

4.1

93.2

3.1 13

92.9

3.9

0.457

0.716

20 140m

91.6

4.5

94.1

2.2

94.3

11

91.6

4.5

0.898

0.445

21 150m

95.3

0.0

95.0

91.7

4.1

0.016

0.902

22 160m

89.0

88.2

5.9

5.325

0.075

At desuf

15

84.9

4.4

84.8

2.5

86.4

4.6 24

86.6

6.4

0.489

0.691

5m desuf
10m
desuf
15m
desuf

15

85.6

5.7

82.9

2.9

87.4

2.9 24

85.5

4.6

1.195

0.321

15

83.8

4.2

81.1

4.6

86.6

9.2 24

82.7

3.2

1.803

0.159

15

84.0

5.8

80.9

3.9

82.4

3.6 24

82.0

3.1

1.184

0.326

No significant difference was observed at any time interval.

Table 22: Comparison of Oxygen Saturation in

Different positions
SN

Parameter

Lateral (n=15)

Reverse

Supine (n=5)

Trendlenberg

Trendelenberg

ANOVA

(n=24)

(n=9)
n

Mean

SD

Mean

SD

Mean

SD

Mean

SD

Baseline

15

97.0

2.1

99.2

0.7

99.4

0.5

24

99.2

0.8

10.764

<0.001

AI

15

97.8

1.3

99.9

0.3

100.0

0.0

24

99.6

0.5

23.273

<0.001

Insuff

15

97.9

1.2

99.9

0.3

99.8

0.4

24

99.7

0.6

20.915

<0.001

5m

15

97.1

1.0

99.8

0.4

99.4

0.5

24

99.8

0.4

61.362

<0.001

10m

15

97.2

1.0

99.7

0.5

99.6

0.5

24

99.8

0.4

50.183

<0.001

15m

15

97.6

1.1

99.8

0.4

100.0

0.0

24

99.7

0.5

33.073

<0.001

20m

15

97.1

0.9

99.9

0.3

100.0

0.0

24

99.7

0.6

67.228

<0.001

25m

15

97.6

1.1

99.7

0.5

100.0

0.0

24

99.6

0.7

27.545

<0.001

30m
10 40m
11 50m

15

97.2

1.2

99.9

0.3

99.4

0.5

24

99.7

0.6

36.782

<0.001

15

97.7

1.1

99.7

0.5

99.8

0.4

24

99.8

0.4

30.625

<0.001

15

97.5

1.1

99.8

0.4

99.0

0.8

24

99.9

0.3

54.822

<0.001

12 60m
13 70m

15

96.9

1.2

99.7

0.5

99.8

0.4

24

99.8

0.4

39.211

<0.001

15

97.5

1.1

99.8

0.4

99.0

0.8

24

99.9

0.3

50.391

<0.001

15

97.3

1.0

99.8

0.4

99.8

0.5

22

99.8

0.4

47.453

<0.001

90m
16 100m
17 110m

15

97.3

1.1

99.8

0.4

100.0

0.0

21

99.9

0.3

36.936

<0.001

15

97.4

1.2

99.9

0.4

99.7

0.6

20

100.0

0.2

84.095

<0.001

14

97.1

0.7

100.0

0.0

98.7

0.6

17

99.8

0.4

141.273 <0.001

18 120m
19 130m

11

97.0

0.4

99.8

0.4

100.0

0.0

17

99.9

0.3

46.139

<0.001

97.1

0.8

99.8

0.4

100.0

0.0

13

99.8

0.4

9.600

0.001

20 140m
21 150m

97.8

1.1

99.8

0.5

100.0

11

99.6

0.5

41475

<0.001

100.0

0.0

100

99.9

0.4

0.156

0.858

160m

100.0

100.0

99.9

0.4

0.143

0.871

At desuf

15

96.7

3.6

99.1

0.6

99.0

0.7

24

99.4

0.7

5.996

0.001

5m desuf

15

97.7

0.7

99.3

0.9

99.2

0.4

24

99.5

0.5

26.369

0.000

10m desuf

15

97.8

1.1

99.2

1.0

99.4

0.5

24

99.6

0.5

15.354

0.000

15m desuf

15

98.2

1.3

99.6

0.5

99.8

0.4

24

99.6

0.5

11.215

0.000

1
2
3
4
5
6
7
8
9

14

80m

15

22

The mean oxygen saturation among patients with lateral position

as compared to other positions was significantly lower at all time
intervals except 150 and 160 minutes intervals.

Table 23: Comparison of End tidal CO2 in Different positions

SN

Parameter

Lateral (n=15)

Reverse
Trendelenberg
(n=9)

Mean

SD

Mean

SD

Supine (n=5)

Mean

SD

Trendlenberg
(n=24)
n

Mean

SD

ANOVA

Baseline

15

31.0

3.7

31.4

2.7

28.2

3.6 24

29.5

3.4

1.580

0.206

AI

15

35.5

2.6

33.1

3.6

29.6

5.2 24

34.9

3.6

4.024

0.012

Insuff

15

42.6

4.8

39.1

4.6

41.8

3.5 24

40.9

4.2

1.256

0.300

5m

15

46.3

3.3

41.0

6.1

43.0

2.9 24

43.5

3.1

3.838

0.015

10m

15

46.3

3.4

39.8

6.2

42.8

3.2 24

44.2

3.2

5.333

0.003

15m

15

46.3

3.4

40.6

5.2

42.2

4.1 24

43.0

2.6

5.775

0.002

20m

15

46.1

3.3

43.4

2.8

41.4

2.5 24

42.7

3.4

4.426

0.008

25m

15

45.7

2.7

42.8

2.9

40.6

2.4 24

43.3

2.5

5.720

0.002

30m

15

46.6

4.6

42.3

3.8

40.8

3.8 24

42.5

3.2

5.013

0.004

10 40m

15

45.6

3.1

41.9

4.0

41.4

4.6 24

42.5

3.9

3.034

0.038

11 50m

15

45.2

2.4

42.4

2.3

42.0

4.1 24

43.3

3.7

5.524

0.002

12 60m

15

46.1

3.2

42.9

3.2

41.6

3.4 24

42.5

2.7

2.054

0.119

13 70m

15

45.2

2.4

42.4

2.3

42.0

4.1 24

43.3

3.7

1.680

0.184

14 80m

15

45.1

3.7

43.2

2.9

43.0

4.7 22

42.6

3.1

5.189

0.004

15 90m

15

46.1

2.4

43.1

2.7

41.3

6.0 21

42.8

2.5

4.739

0.006

16 100m

15

46.1

2.1

43.0

3.6

42.7

4.0 20

42.7

2.8

4.091

0.013

17 110m

14

45.6

2.6

43.1

3.4

40.7

2.3 17

42.4

3.0

5.405

0.004

18 120m

11

45.9

1.6

41.8

2.9

45.0

0.0 17

43.1

2.4

5.229

0.006

19 130m

45.9

1.7

42.4

2.9

39.0

0.0 13

42.6

2.9

1.883

0.171

20 140m

46.0

1.0

42.0

3.2

43.0 .

11

42.4

3.5

0.071

0.932

21 150m

0 .

42.5

0.7

43.0 .

41.3

6.0

0.011

0.989

22 160m

0 .

41.0 .

42.0 .

41.0

6.5

0.175

0.846

At desuf

15

35.7

3.2

36.1

2.2

30.8

4.3 24

34.4

4.1

2.774

0.051

5m desuf
10m
desuf
15m
desuf

15

35.0

2.0

34.6

2.1

32.6

3.7 24

33.8

3.6

1.005

0.398

15

34.4

2.4

34.9

2.5

30.4

3.8 24

32.5

3.5

3.347

0.026

15

33.5

1.9

32.9

1.5

29.4

3.4 24

31.4

2.2

5.723

0.002

Mean End tidal CO2 was maximum in Lateral group and minimum
in reverse trendelenberg and supine groups. The differences among
groups were significant statistically at all time intervals upto 130
minutes except baseline, at insufflation, 60 min and 70 min and at
desufflation and 5 min after desufflation.

AGEWISE Upto 1 Year

Table 24: Change in Heart Rate at different time intervals
Corresponding values
at baseline
No.

Mean

SD

Baseline

25

143.5

9.9

AI

25

143.5

Insuff

25

5m

At different time
intervals

"t"

"p"

No.

Mean

SD

9.9

25

161.1

10.6

-9.502

<0.001

143.5

9.9

25

166.2

9.8

-11.846

<0.001

25

143.5

9.9

25

162.5

10.5

-10.856

<0.001

10m

25

143.5

9.9

25

160.8

10.9

-10.908

<0.001

15m

25

143.5

9.9

25

162.1

11.6

-11.495

<0.001

20m

25

143.5

9.9

25

161.4

11.2

-8.659

<0.001

25m

25

143.5

9.9

25

161.2

10.2

-9.565

<0.001

30m

25

143.5

9.9

25

160.2

9.5

-9.785

<0.001

40m

25

143.5

9.9

25

161.8

9.3

-10.070

<0.001

50m

25

143.5

9.9

25

161.0

10.5

-9.661

<0.001

60m

25

143.5

9.9

25

161.4

10.7

-8.453

<0.001

70m

25

143.5

9.9

25

160.5

10.9

-8.550

<0.001

80m

24

143.3

10.1

24

160.8

11.7

-7.900

<0.001

90m

24

143.3

10.1

24

161.7

10.6

-10.421

<0.001

100m

20

144.7

10.3

20

162.4

9.8

-10.428

<0.001

110m

16

143.2

9.2

16

161.1

10.6

-8.927

<0.001

120m

13

144.3

7.1

13

159.9

8.8

-11.759

<0.001

130m

142.7

6.0

158.6

7.9

-7.598

<0.001

140m

148.0

2.0

158.0

7.0

-3.464

0.074

150m

147.0

1.4

154.5

7.8

-1.667

0.344

160m

148.0

165.0

At desuf

25

143.5

9.9

25

151.7

13.1

-4.272

<0.001

5m desuf
10m
desuf
15m
desuf

25

143.5

9.9

25

148.3

11.7

-2.548

0.018

25

143.5

9.9

25

146.8

10.8

-1.954

0.062

25

143.5

9.9

25

144.3

10.4

-0.499

0.622

(Paired t-test)

At all time intervals the mean heart rate was significantly higher
as compared to baseline (p<0.05) except at 10 and 15 min after
desufflation.

Table 25: Change in SBP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

25

87.5

5.4

25

127.7

9.0

AI

25

87.5

5.4

25

127.7

9.0

-25.559

<0.001

Insuff

25

87.5

5.4

25

140.2

11.0

-23.585

<0.001

5m

25

87.5

5.4

25

134.2

9.6

-23.630

<0.001

10m

25

87.5

5.4

25

130.3

7.1

-26.514

<0.001

15m

25

87.5

5.4

25

130.0

7.6

-22.492

<0.001

20m

25

87.5

5.4

25

129.2

7.1

-21.963

<0.001

25m

25

87.5

5.4

25

126.6

6.3

-21.786

<0.001

30m

25

87.5

5.4

25

127.4

7.5

-18.952

<0.001

40m

25

87.5

5.4

25

128.0

7.1

-19.874

<0.001

50m

25

87.5

5.4

25

126.8

6.7

-22.473

<0.001

60m

25

87.5

5.4

25

127.2

5.2

-25.773

<0.001

70m

25

87.5

5.4

25

125.0

6.4

-21.016

<0.001

80m

24

87.3

5.5

24

125.3

7.5

-17.575

<0.001

90m

24

87.3

5.5

24

126.0

7.3

-19.314

<0.001

100m

20

87.4

5.9

20

126.2

6.2

-21.751

<0.001

110m

16

87.0

5.5

16

125.4

4.9

-20.498

<0.001

120m

13

87.4

5.8

13

126.5

4.5

-25.163

<0.001

130m

85.1

4.5

124.9

5.2

-17.371

<0.001

140m

84.0

4.0

129.0

1.7

-13.999

0.005

150m

86.0

2.8

130.5

2.1

-12.714

0.050

160m

88.0

130.0

At desuf

25

87.5

5.4

25

113.4

6.6

-19.145

<0.001

5m desuf

25

87.5

5.4

25

109.1

7.5

-16.632

<0.001

10m desuf

25

87.5

5.4

25

105.0

6.6

-14.223

<0.001

15m desuf

25

87.5

5.4

25

104.6

7.2

-12.876

<0.001

(Paired t-test)

At all time intervals the mean SBP was significantly higher as

compared to baseline (p<0.05).

Table 26: Change in DBP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

25

59.7

3.6

AI

25

59.7

3.6

25

76.5

6.7

-11.426

<0.001

Insuff

25

59.7

3.6

25

80.8

6.6

-13.337

<0.001

5m

25

59.7

3.6

25

78.4

4.9

-16.517

<0.001

10m

25

59.7

3.6

25

77.7

4.7

-17.620

<0.001

15m

25

59.7

3.6

25

77.4

4.7

-14.016

<0.001

20m

25

59.7

3.6

25

77.3

3.7

-20.552

<0.001

25m

25

59.7

3.6

25

76.4

4.1

-15.449

<0.001

30m

25

59.7

3.6

25

77.0

5.0

-13.515

<0.001

40m

25

59.7

3.6

25

78.1

4.3

-17.544

<0.001

50m

25

59.7

3.6

25

76.2

4.1

-14.470

<0.001

60m

25

59.7

3.6

25

76.9

4.0

-17.436

<0.001

70m

25

59.7

3.6

25

76.4

3.4

-16.151

<0.001

80m

24

59.5

3.6

24

76.8

5.1

-12.508

<0.001

90m

24

59.5

3.6

24

75.1

5.3

-10.771

<0.001

100m

20

59.3

3.9

20

75.9

4.5

-13.160

<0.001

110m

16

59.1

3.9

16

76.3

4.2

-12.199

<0.001

120m

13

59.0

3.8

13

76.2

3.4

-13.042

<0.001

130m

57.3

2.4

75.6

4.1

-11.351

<0.001

140m

57.0

1.0

77.3

2.1

-16.918

0.003

150m

57.5

0.7

80.0

8.5

-4.091

0.153

160m

58.0

78.0

<0.001

<0.001

At desuf

25

59.7

3.6

25

72.4

5.1

-11.054

<0.001

5m desuf

25

59.7

3.6

25

70.6

4.3

-12.259

<0.001

10m desuf

25

59.7

3.6

25

68.5

3.1

-10.307

<0.001

15m desuf

25

59.7

3.6

25

68.6

4.4

-10.787

<0.001

(Paired t-test)

At all time intervals the mean DBP was significantly higher as

compared to baseline (p<0.05).

Table 27: Change in MAP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

25

71.1

6.6

AI

25

71.1

6.6

25

93.2

6.0

-12.981

<0.001

Insuff

25

71.1

6.6

25

99.3

7.5

-12.663

<0.001

5m

25

71.1

6.6

25

96.2

5.8

-15.757

<0.001

10m

25

71.1

6.6

25

94.7

4.8

-15.066

<0.001

15m

25

71.1

6.6

25

94.9

4.9

-14.103

<0.001

20m

25

71.1

6.6

25

94.6

4.1

-17.281

<0.001

25m

25

71.1

6.6

25

92.9

4.3

-13.561

<0.001

30m

25

71.1

6.6

25

93.8

5.1

-13.617

<0.001

40m

25

71.1

6.6

25

94.7

3.9

-14.925

<0.001

50m

25

71.1

6.6

25

92.8

4.1

-13.737

<0.001

60m

25

71.1

6.6

25

93.7

3.7

-16.615

<0.001

70m

25

71.1

6.6

25

92.6

3.7

-16.219

<0.001

80m

24

71.0

6.7

24

92.6

5.8

-10.525

<0.001

90m

24

71.0

6.7

24

91.1

5.4

-10.168

<0.001

100m

20

69.6

5.4

20

91.5

4.4

-14.061

<0.001

110m

16

69.1

5.2

16

92.1

4.1

-13.999

<0.001

120m

13

69.3

5.4

13

92.4

4.2

-13.625

<0.001

130m

66.7

3.0

90.2

5.2

-12.191

<0.001

140m

66.0

2.0

91.1

7.0

-5.917

0.027

150m

67.0

1.4

80.5

3.5

-3.857

0.161

160m

68.0

90.0

At desuf

25

71.1

6.6

25

84.7

6.4

-7.723

<0.001

5m desuf

25

71.1

6.6

25

84.2

5.7

-8.827

<0.001

10m desuf

25

71.1

6.6

25

81.8

5.4

-6.816

<0.001

15m desuf

25

71.1

6.6

25

80.9

4.6

-7.307

<0.001

(Paired t-test)

At all time intervals the mean MAP was significantly higher as

compared to baseline (p<0.05).

Table 28: Change in Oxygen Saturation at different time

intervals
Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

25

98.8

1.5

AI

25

98.8

1.5

25

99.3

1.2

-2.177

0.040

Insuff

25

98.8

1.5

25

99.4

1.1

-2.683

0.013

5m

25

98.8

1.5

25

99.1

1.3

-1.518

0.142

10m

25

98.8

1.5

25

99.2

1.2

-2.193

0.038

15m

25

98.8

1.5

25

99.4

1.2

-2.777

0.010

20m

25

98.8

1.5

25

99.2

1.3

-2.138

0.043

25m

25

98.8

1.5

25

99.4

0.8

-2.698

0.013

30m

25

98.8

1.5

25

99.2

1.3

-1.792

0.086

40m

25

98.8

1.5

25

99.4

0.9

-2.874

0.008

50m

25

98.8

1.5

25

99.1

1.4

-1.445

0.161

60m

25

98.8

1.5

25

99.2

1.1

-1.953

0.063

70m

25

98.8

1.5

25

99.3

1.1

-2.397

0.025

80m

24

98.7

1.5

24

99.3

1.2

-2.696

0.013

90m

24

98.7

1.5

24

99.3

1.1

-3.021

0.006

100m

20

98.7

1.7

20

99.0

1.2

-1.234

0.232

110m

16

98.8

1.3

16

99.3

1.2

-1.581

0.135

120m

13

98.8

1.5

13

99.1

1.3

-1.171

0.264

130m

98.7

1.6

99.2

1.3

-1.250

0.247

140m

99.7

0.6

100.0

0.0

-1.000

0.423

150m

100.0

0.0

100.0

0.0

<0.001

<0.001

160m

100.0

100.0

-6.262

0.002

At desuf

25

98.8

1.5

25

98.7

1.1

0.153

0.880

5m desuf

25

98.8

1.5

25

99.0

1.0

-0.947

0.353

10m desuf

25

98.8

1.5

25

99.0

0.9

-1.098

0.283

15m desuf

25

98.8

1.5

25

99.4

0.8

-2.216

0.036

(Paired t-test)

At all time intervals, mean oxygen saturation was higher as

compared to corresponding baseline values. At 140 min interval the
mean oxygen saturation was lower as compared to corresponding
baseline value. The change from baseline was significant at intubation,
at insufflation and at 10, 15, 20, 25, 40, 70, 80, 90, 150 and 160 min
intervals.

Table 29: Change in End tidal CO2 at different time

intervals
Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

25

29.4

3.7

AI

25

29.4

3.7

25

33.0

4.3

-4.727

<0.001

Insuff

25

29.4

3.7

25

38.8

4.3

-9.778

<0.001

5m

25

29.4

3.7

25

42.4

4.8

-12.201

<0.001

10m

25

29.4

3.7

25

43.0

5.8

-9.832

<0.001

15m

25

29.4

3.7

25

42.3

4.8

-11.081

<0.001

20m

25

29.4

3.7

25

43.0

4.4

-14.928

<0.001

25m

25

29.4

3.7

25

43.4

3.8

-15.492

<0.001

30m

25

29.4

3.7

25

42.5

5.0

-11.577

<0.001

40m

25

29.4

3.7

25

41.7

4.7

-12.290

<0.001

50m

25

29.4

3.7

25

42.7

3.4

-18.198

<0.001

60m

25

29.4

3.7

25

42.3

3.5

-14.071

<0.001

70m

25

29.4

3.7

25

43.1

3.8

-12.932

<0.001

80m

24

29.6

3.6

24

42.8

3.3

-15.327

<0.001

90m

24

29.6

3.6

24

43.0

3.2

-15.169

<0.001

100m

20

29.9

3.6

20

42.9

3.4

-13.950

<0.001

110m

16

30.4

3.4

16

43.1

2.4

-12.598

<0.001

120m

13

30.5

3.6

13

42.9

2.8

-9.647

<0.001

130m

31.4

3.6

42.2

3.9

-5.721

<0.001

140m

34.0

1.7

37.0

6.2

-0.688

0.562

150m

35.0

0.0

33.0

7.1

0.400

0.758

160m

35.0

32.0

At desuf

25

29.4

3.7

25

33.4

3.9

-3.802

0.001

5m desuf

25

29.4

3.7

25

33.4

3.2

-3.909

0.001

10m desuf

25

29.4

3.7

25

32.3

3.0

-3.559

0.002

15m desuf

25

29.4

3.7

25

31.7

3.0

-3.984

0.001

(Paired t-test)

Except at 150 min interval at all time intervals, mean oxygen

saturation was higher as compared to corresponding baseline values.
At 150 min interval the mean oxygen saturation was lower as
compared to corresponding baseline value. The change from baseline
was significant at all time intervals except after 140 min interval.

AGEWISE Above 1 Year

Table 30: Change in Heart Rate at different time intervals
Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

28

118.8

9.9

AI

28

118.8

9.9

28

139.2

9.2

-14.445

<0.001

Insuff

28

118.8

9.9

28

144.1

8.7

-14.460

<0.001

5m

28

118.8

9.9

28

139.6

10.2

-10.203

<0.001

10m

28

118.8

9.9

28

140.0

9.7

-9.995

<0.001

15m

28

118.8

9.9

28

140.6

9.8

-11.621

<0.001

20m

28

118.8

9.9

28

139.9

7.1

-11.891

<0.001

25m

28

118.8

9.9

28

139.9

7.1

-11.070

<0.001

30m

28

118.8

9.9

28

136.5

11.0

-6.790

<0.001

40m

28

118.8

9.9

28

138.1

7.0

-8.170

<0.001

50m

28

118.8

9.9

28

140.3

10.1

-10.627

<0.001

60m

27

118.6

10.1

27

139.4

6.5

-8.658

<0.001

70m

25

118.0

10.2

25

138.0

6.8

-9.102

<0.001

80m

24

116.9

8.8

24

139.0

5.1

-11.443

<0.001

90m

22

116.8

8.8

22

139.0

7.0

-10.266

<0.001

100m

21

117.6

8.2

21

139.0

4.7

-12.489

<0.001

110m

19

118.4

8.2

19

139.7

5.9

-8.931

<0.001

120m

15

117.5

8.4

15

137.6

7.8

-7.426

<0.001

130m

12

116.6

8.4

12

136.8

10.4

-7.084

<0.001

140m

117.4

9.6

136.0

12.5

-4.335

0.003

150m

118.6

9.7

142.4

8.0

-5.775

0.001

160m

121.7

5.6

140.2

6.2

-5.359

0.003

170m

118.3

5.7

145.0

8.2

-6.576

0.022

180m

118.3

5.7

143.7

5.0

-9.285

0.011

At desuf

28

118.8

9.9

28

131.1

6.8

-6.166

<0.001

5m desuf

28

118.8

9.9

28

126.6

7.4

-4.050

<0.001

10m desuf

28

118.8

9.9

28

123.6

8.6

-2.468

0.020

15m desuf

28

118.8

9.9

28

122.3

7.1

-1.966

0.060

(Paired t-test)

At all time intervals the mean heart rate was significantly higher
as compared to baseline (p<0.05).

Table 31: Change in SBP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

28

103.2

7.3

AI

28

103.2

7.3

28

133.6

6.8

-17.029

<0.001

Insuff

28

103.2

7.3

28

143.5

7.4

-20.028

<0.001

5m

28

103.2

7.3

28

136.6

6.9

-19.095

<0.001

10m

28

103.2

7.3

28

134.1

5.9

-17.889

<0.001

15m

28

103.2

7.3

28

132.4

5.5

-19.297

<0.001

20m

28

103.2

7.3

28

131.3

5.3

-16.959

<0.001

25m

28

103.2

7.3

28

131.6

5.3

-19.404

<0.001

30m

28

103.2

7.3

28

130.6

6.0

-20.981

<0.001

40m

28

103.2

7.3

28

129.6

8.1

-21.256

<0.001

50m

28

103.2

7.3

28

128.9

5.7

-16.547

<0.001

60m

27

103.4

7.4

27

130.3

4.0

-19.041

<0.001

70m

25

103.6

7.7

25

130.4

6.3

-21.100

<0.001

80m

24

104.0

7.6

24

130.0

5.6

-18.124

<0.001

90m

22

103.9

7.9

22

130.5

6.4

-18.250

<0.001

100m

21

102.5

4.2

21

130.0

3.4

-22.559

<0.001

110m

19

102.2

4.3

19

129.1

4.0

-29.018

<0.001

120m

15

102.2

4.8

15

129.1

4.4

-21.015

<0.001

130m

12

102.3

5.3

12

128.7

4.5

-14.199

<0.001

140m

101.1

6.0

127.0

4.8

-11.472

<0.001

150m

100.0

5.5

129.0

3.4

-13.289

<0.001

160m

99.0

5.3

129.7

1.8

-17.025

<0.001

170m

96.3

5.7

129.0

2.6

-6.947

0.020

180m

96.3

5.7

128.3

3.2

-12.095

0.007

At desuf

28

103.2

7.3

28

117.3

5.9

-10.766

<0.001

5m desuf

28

103.2

7.3

28

113.3

4.8

-7.351

<0.001

10m desuf

28

103.2

7.3

28

111.6

4.9

-7.010

<0.001

15m desuf

28

103.2

7.3

28

109.5

5.4

-7.331

<0.001

(Paired t-test)

At all time intervals the mean SBP was significantly higher as

compared to baseline (p<0.05).

Table 32: Change in DBP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

28

67.0

5.4

28

AI

28

67.0

5.4

28

79.0

4.6

-9.858

<0.001

Insuff

28

67.0

5.4

28

81.6

4.9

-10.928

<0.001

5m

28

67.0

5.4

28

80.5

5.0

-10.428

<0.001

10m

28

67.0

5.4

28

80.0

3.9

-10.633

<0.001

15m

28

67.0

5.4

28

78.8

4.1

-10.345

<0.001

20m

28

67.0

5.4

28

78.0

3.8

-9.289

<0.001

25m

28

67.0

5.4

28

79.3

3.5

-10.938

<0.001

30m

28

67.0

5.4

28

78.1

3.3

-11.344

<0.001

40m

28

67.0

5.4

28

78.5

3.6

-10.743

<0.001

50m

28

67.0

5.4

28

78.0

2.9

-10.476

<0.001

60m

27

67.0

5.5

27

78.6

3.4

-11.809

<0.001

70m

25

67.0

5.7

25

80.0

5.8

-11.163

<0.001

80m

24

67.5

5.1

24

79.5

5.9

-9.642

<0.001

90m

22

67.3

5.2

22

82.0

13.3

-5.111

<0.001

100m

21

66.7

4.5

21

79.8

5.1

-8.175

<0.001

110m

19

66.5

4.7

19

77.6

2.7

-12.457

<0.001

120m

15

66.5

4.7

15

77.1

2.9

-7.394

<0.001

130m

12

66.3

5.3

12

76.3

2.5

-6.655

<0.001

140m

65.0

5.7

76.4

2.1

-5.407

0.001

150m

64.1

5.5

77.3

2.9

-5.029

0.002

160m

62.7

4.3

77.8

3.2

-8.716

<0.001

170m

60.3

5.0

77.0

4.0

-5.735

0.029

180m

60.3

5.0

76.3

3.8

-16.000

0.004

At desuf

28

67.0

5.4

28

73.7

2.7

-6.232

<0.001

5m desuf

28

67.0

5.4

28

73.7

3.3

-5.926

<0.001

10m desuf

28

67.0

5.4

28

72.0

3.1

-6.009

<0.001

15m desuf

28

67.0

5.4

28

71.8

3.4

-5.624

<0.001

(Paired t-test)

At all time intervals the mean DBP was significantly higher as

compared to baseline (p<0.05).

Table 33: Change in MAP at different time intervals

Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

28

78.7

5.7

AI

28

78.7

5.7

28

97.2

4.3

-15.390

<0.001

Insuff

28

78.7

5.7

28

101.4

5.4

-15.892

<0.001

5m

28

78.7

5.7

28

98.4

5.3

-14.881

<0.001

10m

28

78.7

5.7

28

98.0

3.8

-15.606

<0.001

15m

28

78.7

5.7

28

96.2

4.6

-14.662

<0.001

20m

28

78.7

5.7

28

95.5

4.4

-12.655

<0.001

25m

28

78.7

5.7

28

96.7

3.7

-16.013

<0.001

30m

28

78.7

5.7

28

94.8

5.2

-14.374

<0.001

40m

28

78.7

5.7

28

95.5

4.6

-18.694

<0.001

50m

28

78.7

5.7

28

95.0

3.3

-14.579

<0.001

60m

27

78.7

5.8

27

95.6

3.4

-16.303

<0.001

70m

25

78.7

6.1

25

96.8

5.3

-18.481

<0.001

80m

24

79.2

5.7

24

96.4

5.2

-16.384

<0.001

90m

22

79.0

5.9

22

95.3

6.4

-14.318

<0.001

100m

21

78.1

4.2

21

95.6

5.2

-11.798

<0.001

110m

19

77.9

4.3

19

94.2

3.5

-17.261

<0.001

120m

15

77.7

4.5

15

94.5

2.8

-13.276

<0.001

130m

12

78.0

5.0

12

93.7

2.0

-10.707

<0.001

140m

76.8

5.5

93.3

2.3

-8.556

<0.001

150m

75.9

5.7

90.9

2.6

-5.495

0.003

160m

74.5

4.1

90.2

3.7

-6.262

0.002

170m

72.3

5.2

92.1

5.3

-4.205

0.052

180m

72.3

5.2

92.8

2.1

-10.606

0.009

At desuf

28

78.7

5.7

28

86.8

3.7

-6.533

<0.001

5m desuf

28

78.7

5.7

28

86.2

3.4

-7.704

<0.001

10m desuf

28

78.7

5.7

28

84.3

3.4

-5.909

<0.001

15m desuf

28

78.7

5.7

28

83.8

3.3

-6.101

<0.001

(Paired t-test)

At all time intervals the mean MAP was significantly higher as

compared to baseline (p<0.05) except at 170 min.

Table 34: Change in Oxygen Saturation at different

time intervals
Corresponding values
at baseline

At different time
intervals
Mean

"p"

No.

Mean

SD

Baseline

28

98.4

1.7

AI

28

98.4

1.7

28

99.1

1.2

-3.195

0.004

Insuff

28

98.4

1.7

28

99.1

1.2

-3.022

0.005

5m

28

98.4

1.7

28

98.9

1.5

-2.372

0.025

10m

28

98.4

1.7

28

98.8

1.4

-1.737

0.094

15m

28

98.4

1.7

28

98.9

1.2

-2.469

0.020

20m

28

98.4

1.7

28

98.8

1.4

-1.473

0.152

25m

28

98.4

1.7

28

98.8

1.4

-1.383

0.178

30m

28

98.4

1.7

28

98.8

1.4

-1.627

0.115

40m

28

98.4

1.7

28

99.0

1.3

-2.400

0.024

50m

28

98.4

1.7

28

98.9

1.5

-2.121

0.043

60m

27

98.4

1.7

27

99.0

1.4

-2.367

0.026

70m

25

98.3

1.7

25

98.8

1.5

-1.953

0.063

80m

24

98.3

1.7

24

98.9

1.5

-2.532

0.019

90m

22

98.1

1.8

22

98.8

1.6

-2.732

0.012

100m

21

98.0

1.7

21

98.7

1.5

-2.280

0.034

110m

19

98.2

1.7

19

98.7

1.5

-1.874

0.077

120m

15

98.2

1.7

15

99.1

1.5

-2.982

0.010

130m

12

98.5

1.7

12

99.3

0.9

-2.138

0.056

140m

99.3

0.7

99.9

0.35

-2.376

0.049

150m

99.1

0.7

99.9

0.4

-3.873

0.008

160m

99.2

0.8

99.8

0.4

-2.000

0.102

170m

99.3

0.6

100.0

0.0

-2.000

0.184

180m

99.3

0.6

100.0

0.0

-2.000

0.184

At desuf

28

98.4

1.7

28

98.4

3.0

0.162

0.873

5m desuf

28

98.4

1.7

28

98.8

1.0

-1.616

0.118

10m desuf

28

98.4

1.7

28

99.0

1.3

-3.074

0.005

15m desuf

28

98.4

1.7

28

99.1

1.2

-3.104

0.004

(Paired t-test)

No.

"t"
SD

At all time intervals, mean oxygen saturation was higher as

compared to corresponding baseline values. The change from baseline
was significant at all time intervals except at 140, 160, 170, 180 min
intervals, at desufflation and at 5 min after desufflation..

Table 35: Change in End tidal CO2 at different time

intervals
Corresponding values
at baseline
No.
Mean
SD

At different time
intervals
No.
Mean
SD

"t"

"p"

Baseline

28

30.8

3.2

AI

28

30.8

3.2

28

35.4

3.0

-5.685

<0.001

Insuff

28

30.8

3.2

28

43.3

3.3

-13.019

<0.001

5m

28

30.8

3.2

28

45.1

2.9

-16.705

<0.001

10m

28

30.8

3.2

28

44.7

2.3

-17.447

<0.001

15m

28

30.8

3.2

28

44.5

2.6

-15.681

<0.001

20m

28

30.8

3.2

28

44.2

2.5

-18.969

<0.001

25m

28

30.8

3.2

28

43.9

1.9

-19.160

<0.001

30m

28

30.8

3.2

28

44.4

3.2

-15.123

<0.001

40m

28

30.8

3.2

28

44.5

2.7

-19.312

<0.001

50m

28

30.8

3.2

28

44.2

3.2

-16.055

<0.001

60m

27

30.9

3.2

27

44.7

2.7

-16.096

<0.001

70m

25

31.0

3.1

25

44.0

3.1

-15.974

<0.001

80m

24

31.1

3.1

24

44.8

2.7

-15.832

<0.001

90m

22

31.0

3.2

22

44.8

2.9

-14.345

<0.001

100m

21

30.6

2.6

21

44.0

3.1

-15.860

<0.001

110m

19

30.4

2.7

19

44.5

2.7

-14.773

<0.001

120m

15

30.6

2.8

15

43.5

3.4

-11.222

<0.001

130m

12

30.7

2.9

12

43.9

2.6

-10.979

<0.001

140m

30.0

3.3

43.4

3.7

-8.122

<0.001

150m

30.3

3.5

43.4

2.4

-7.390

<0.001

160m

31.3

2.3

42.8

2.3

-12.993

<0.001

At desuf

28

30.8

3.2

28

35.9

3.4

-6.339

<0.001

5m desuf

28

30.8

3.2

28

34.8

2.7

-5.499

<0.001

10m desuf

28

30.8

3.2

28

34.1

3.4

-4.134

<0.001

15m desuf

28

30.8

3.2

28

32.4

1.9

-2.320

0.028

(Paired t-test)

At all time intervals the mean value was significantly higher as

compared to baseline.

Discussion

Physiological changes during laparoscopic surgery in paediatric

patients are related to the changes associated with the increased intra
abdominal pressure(IAP) due to the insufflation of the abdomen by
CO2, the patients postural modifications (head-up or head-down) and
the

CO2

absorption.

Smaller

distance

between

capillaries

and

peritoneum and greater absorptive area of peritoneum in relation to

body weight leads to significant vascular absorption in children.

Hypercarbia has direct effects on the myocardium and secondary

effects

mediated

cardiovascular

via

the

physiology

in

autonomic
children

nervous

and

system.

especially

The

infants

is

significantly different from that of adults. The blood pressure and

systemic vascular resistance are lower in children and the heart rate,
oxygen consumption and cardiac output are relatively higher.
The IAP (intra-abdominal pressure), the major factor responsible
for

the

cardiovascular

effects,

involves

changes

in

myocardial

contractility and systemic vascular resistance (SVR). A decreased

venous return and increased SVR will decrease cardiac output (CO). In
adults with minor increases in IAP of less than 15mmHg, there is an
increase in venous return and CO due to displacement of blood from
the splanchnic bed. When IAP goes above 20mm of Hg, SVR increases
and preload decreases, leading to decreased CO. In paediatric patients
similar changes are seen even with lower IAP. Up to 10 mm Hg, the
filling pressures are maintained and CO may increase in older children.
After 12 mm Hg, there is an increase in SVR and afterload, leading to a
fall in preload and cardiac output.
Intraoperative ventilatory and hemodynamic changes induced by
pneumoperitoneum
Cardiovascular

may

changes

complicate
during

anaesthetic

laparoscopic

management.

surgery

have

been

investigated in adult patients, however, information concerning the

hemodynamic effects of pneumoperitoneum in infants is lacking.
Therefore, we conducted a prospective clinical study to find out the
hemodynamic changes during minimal invasive surgery in paediatric
patients through noninvasive monitoring.
We conducted this study in 53 paediatric patients admitted to
paediatric surgery department of CSM Medical University, Lucknow,

undergoing a spectrum of 24 different surgical procedures being performed

laparoscopically and thoracoscopically. Intra abdominal pressure was kept
between 6-10 mm of Hg during abdominal laparoscopy, and 4 mm of
Hg during thoracic laparoscopy.
The demographic data (table 1) of all the patients was mean age (yrs.)
3.263.4, male and female ratio 45:8 and mean weight (in kg) of
10.876.57.
At baseline all the children were afebrile and in sinus rhythm as
shown by ECG. The systolic blood pressure (SBP) of children ranged
from 79 to 134 mm of Hg with a mean value of 95.810.2 mm of Hg
Mean diastolic blood pressure (DBP) of the children was 63.55.9 mm
of Hg with a range from 53 to 80 mm of Hg.

Mean mean arterial

pressure (MAP) ranged from 61.7 to 98.0 mm of Hg with a mean of

75.17.2 mm of Hg. The oxygen saturation range varied from 94 to
100%. Mean end tidal CO2 (EtCO2) was 30.13.5% with a range from
24 to 40% (table 4).

Heart Rate
In our study at baseline the heart rate of patients varied from
100 to 171 beats per minute (bpm) with a mean value of 130.415.9
bpm. After insufflation all the patients had significant increase of heart
rate with mean value of 154.5 14.4 bpm. After 5min,10min and
30min of insufflations heart rate increased with the mean value of
150.4 15.4 , 149 14.6 ,and 147.6 15.7 bpm respectively, and
showed significant increase as compared with base line (p<0.05). At
desufflation, after 5min and 10min of desufflation there was significant
increase of heart rate with mean value of 140.8 140.6 , 136.814.5
and 134.615.1 bpm respectively and a significant increase compared

with base line(p<0.05). After 15min there was slight increase of heart
rate with the mean value of 132.7 14.1 bpm but that was not
significant statistically. At all time intervals except 15 m after
desufflation the mean heart rate was significantly higher as compared
to baseline (p<0.05) (table 6).
On comparing heart rate between age group of 0-1yr to 112yrs,mean heart rate at baseline of age group 0-1yr(table 24) was
143.5 9.9 and after insufflation, it increased to 166.29.8 (15.81%
increase) while after

5min, 10min, and 30min it increased to

162.510.5 (13.24%), 160.810.9 (12.05%) and 160.29.5 (11.63%)

respectively.

After

desufflation,

5min,

10min

and

15min

after

desufflation it increased to 151.713.1 (5.71%), 148.311.7 (3.34%),

146.810.8 (2.29%) and 144.310.4 (0.55%) respectively. While in
age group 1-12yrs. (table 29) mean heart rate at baseline was
118.89.9 and after insufflations, it increased to 144.18.7 (21.29%)
and after 5min, 10min and 30min it increased to 139.610.2 (17.52%),
140.09.7 (17.84%), and 136.511.0 (14.89%)

respectively. After

desufflation, 5min, 10min and 15min after desufflation it increased to

131.16.8 (10.35%), 126.67.4 (6.56%), 123.68.6 (4.04%)

and

122.37.1 (2.94%)respectively.
The age group(<1year) showed less increase in heart rate as compared to age
group(1 12years ) in our study.
When we compared heart rate between abdominal Laparoscopic
surgery

and

thoracic

laparoscopic

statistically significant (table 12).

surgery,

changes

were

not

When we compared heart rate according to position of

surgery (Lateral, Reverse Trendelenberg, Supine, Trendelenberg),
changes were not statistically significant (table18).
Rowney and Aldridge (2000) reviewed case records of 50
patients with median age 6 years (5 months to 20 years). During the
procedure, they found the heart rate increased by more than 20% over
baseline.
De Waal et al (2003) examined haemodynamic changes during lowpressure carbon dioxide pneumoperitoneum in thirteen children, aged 6-36
months, ASA physical status I-III, scheduled for laparoscopic fundoplication for gastrooesophageal reflux. They found that HR increased from 108 10 to 12622 bpm (P <
0.01).
A study conducted by Ahmed et al (2009) included 36 children below 5 years of
age (mean age 2.661.23yrs) undergoing laparoscopic surgery. Intra abdominal pressure
was fixed at 12 mm of Hg. They found rise of pulse rate (+16.96%).
In all the above studies there was significant increase of heart rate after
insufflations compared with baseline as noticed in our study.
On comparing mean difference of heart rate at different time intervals of
insufflation

and desufflation from baseline in our study, there is clinically and

statistically significant

increase in heart rate (p<0.05) from baseline. This is in

accordance with study done by Rowney and Aldridge (2000), De Waal et al (2003)
and Ahmed et al (2009). This can be explained by systemic absorption of CO2 during
laparoscopy leading to release of catecholamines, which causes increase in heart rate.
However, Bozkurt et al (2000) found no statistically significant
alterations in heart rate while assessing the cardiorespiratory effects of
laparoscopic procedures in 27 infants aged between 36 and 365 days.
Baroncini et al (2002) reviewed 585 patients from April 1995
to March 2002 for videolaparoscopy with average age of 6.04.8 years

(range 11 days-21years) and with average body weight of 23.916.3

kg (range 3-83 kg). They found that HR was constantly within normal
ranges without undergoing statistically significant modifications during
the different moments of the surgical procedures.
Lorenzoa et al (2006) conducted a prospective study and enrolled a total of 18
children. Mean SD for age and weight were 79.4 53.2 months and 26.7 15.5 kg,
respectively. Mean retroperitoneal CO2 insufflation pressure was kept at 12 mm Hg.
They found that heart rate did not change significantly.
Our findings are in contrast to the study done by Bozkurt et al
(2000), Baroncini et al (2002), and Lorenzoa et al (2006), who found no
change in heart rate.

Systolic Blood Pressure

In our study at baseline the systolic blood pressure (SBP) of
patients varied from 79.0 to 134.0mm of Hg with a mean value of
95.810.2 mm of Hg. After insufflation all the patients had significant
increase of SBP with mean value of 142.0 9.3 mm of Hg. The mean
value of SBP after 5min, 10min and 30min of insufflations

was

135.58.3, 132.36.7, and 129.16.9 mm of Hg respectively, and

showed significant increase (p<0.05) as compared with base line. At
desufflation, after 5min ,10min and 15min there were significant
increase of SBP with mean value of 115.56.5, 111.36.5, 108.56.6
and 107.26.7 mm of Hg respectively, which was a significant increase
as compared with base line(p<0.05). At all time intervals

the mean

SBP was significantly higher as compared to baseline (p<0.05) (table

7).
On comparing SBP between age group of 0-1yr to 1-12yrs
mean SBP at baseline of age group 0-1yr(table 25) was 87.55.4 mm

of Hg and after insufflations, it increased to 140.211.0 mm of Hg

(60.22% ) while after 5min,10min,and 30min it increased to 134.29.6
(53.37%), 130.37.1 (48.91%), and 127.47.5 (45.60%)mm of Hg
respectively. After desufflation, 5min, 10min, and 15min SBP increased
to 113.46.6 (29.63%), 109.17.5 (24.68%), 105.06.6 (20%) and
104.67.2 (19.54%) mm of Hg respectively. In age group 1-12years
(table 31) mean SBP at baseline was 103.27.3, while after
insufflations, it increased to 143.5 6.9 mm of Hg (39.12%) and after
5min, 10min, and 30min, it increased to 139.610.2 (17.52%),
140.09.7 (17.84%), and 136.511.0 (14.89%) mm of Hg respectively.
After desufflation, 5min, 10min, and 15min it increased to 117.35.9
(13.66%), 113.34.8 (9.78%), 111.64.9 (8.13%)

and 109.55.4

(6.10%) mm of Hg respectively.
The age group(<1 year) showed more increase in systolic blood pressure as
compared to age group(1 12years ) in our study.
When we compared SBP between abdominal Laparoscopic
surgery

and

thoracic

laparoscopic

surgery,

changes

were

not

statistically significant (table 13).

When we compared SBP according to position of surgery (Lateral,
Reverse Trendelenberg, Supine, Trendelenberg), changes were not
statistically significant (table19).
Tobias and colleagues (1995) found minimal cardiovascular
changes in paediatric patients during laparoscopy in their study. An
increase in blood pressure was seen which probably resulted from an
increase in systemic vascular resistance related to the increased IAP
and the increased PaCO2. In a retrospective paediatric study, it was
found that arterial pressure increased only when IAP was higher than
6mmHg.

Rowney and Aldridge (2000) found in their study that blood

pressure increased by more than 20% over baseline.
Baroncini et al (2002) found statistically significant increase in
SBP (p<0.001) during the whole pneumoperitoneum time.
Ahmed et al (2009) found in their study that

systolic blood pressure

increased by more than (+12.19%) over baseline.

In all the above studies there was an increase of systolic blood
pressure significantly after insufflations when compared to baseline as
noticed in our study.
On comparing mean difference of SBP at different time intervals of insufflation
and desufflation from baseline in our study, there was clinically and statistically
significant increase in SBP (p<0.05) from baseline. This was in accordance with study
done by Rowney and Aldridge (2000), Baroncini et al (2002), Ahmed et al
(2009) and Tobias and colleagues (1995).
However Bozkurt et al (2000) in their study found that there
were no statistically significant alterations in systolic blood pressure.

Diastolic Blood Pressure

In our study at baseline the diastolic blood pressure (DBP) of
patients varied from 53.0 to 80 mm of Hg with a mean value of
63.55.9 mm of Hg. After insufflation all the patients had significant
increase of DBP with mean value of 81.25.7 mm of Hg. After
5min,10min and 30min of insufflation, the DBP with the mean value of
79.55.0,

78.94.4,

77.94.0

respectively,

showed

significant

increase as compared with base line (p<0.05). At desufflation ,after

5min 10min and 15min,
mean

value

respectively,

of

there was significant increase of DBP with

73.14.1,

with significant

72.24.1,

70.43.6

and

70.24.2

increase as compared with base

line(p<0.05).

At all time intervals the mean DBP was significantly

higher as compared to baseline (p<0.05) (table 8).

On comparing DBP between age group of 0-1yr to 1-12yrs,
mean

DBP

at

baseline

of

age

group

0-1yr(table

26)

was

59.73.6mmhg and after insufflation, it increased to 80.86.6

(35.34%) while after 5min,10min,and 30min it increased to 78.44.9
(31.32%), 77.74.7(31.15%) and

77.05.0(28.97%)

mm of Hg

respectively. After desufflation, 5min , 10min, and 15min it increased

to 72.45.1 (21.27%), 70.64.3 (18.25%), 68.53.1 (14.74%)

and

68.64.4 (14.90%) mm of Hg respectively. While in age group 1-12yrs

(table 32) mean DBP at baseline was 67.05.4 mm of Hg and after
insufflations, it increased to 81.65.0 mm of Hg (21.79%) and after
5min, 10min ,and 30min it increased to 80.55.0 (20.14%), 80.03.9
(19.40%) and 78.13.3 (16.56%) mm of Hg respectively. After
desufflation, 5min , 10min, and 15min it increased to 73.72.7
(10.0%), 73.73.3 (10.0%), 72.03.1 (7.46%), and 71.83.4 (7.10%)
mm of Hg respectively .
The age group(<1 year) showed more increase in diastolic blood pressure as
compared to age group(1 12years ) in our study.
When we compared DBP between abdominal Laparoscopic
surgery

and

thoracic

laparoscopic

surgery,

changes

were

not

statistically significant (table 14).

When we compared DBP according to position of surgery
(Lateral, Reverse Trendelenberg, Supine, Trendelenberg), changes were
not statistically significant (table20).

Baroncini et al (2002) found in their study that DBP tended

towards a statistically significant rise (p<0.001) during the whole
pneumoperitoneum time.
Ahmed et al(2009) ) noticed in their study a rise of diastolic blood
pressure (+14.58%).
In both of the above studies there was increase of diastolic blood pressure
significantly after insufflations as compared with baseline as noticed in our study.
On comparing mean difference of DBP at different time intervals of insufflation and
desufflation from baseline in our study, there was a clinically and statistically significant
increase in DBP (p<0.05) from baseline. This is in accordance with studies done by
Baroncini et al (2002), Ahmed et al (2009).

Mean Arterial Pressure

In our study at baseline the mean arterial pressure (MAP) of
patients varied from 61.7 to 98.0 mm of Hg with a mean value of
75.17.2 mm of Hg . After insufflation all the patients had significant
increase of MAP with mean value of 100.46.5 mm of Hg. After 5min,
10min and 30min of insufflations the mean value of MAP was 97.45.6
,96.54.6 and 94.35.1 mm of Hg respectively, and showed significant
increase

as compared with base line(p<0.05). At desufflation ,after

5min 10min and 15min of desufflation there was significant increase of

MAP with mean value of 85.85.2, 85.34.7, 83.14.6 and 82.44.2
mm of Hg respectively, which showed significant increase compared
with base line (p<0.05).

At all time intervals the mean MAP was

significantly higher as compared to baseline (p<0.05). (table 9)

On comparing MAP between age group of 0-1yr to 1-12yrs
baseline value of age group 0-1yr(table 27) was 71.16.6 mmhg and
after insufflation, it increased to 99.37.5 (39.66%) while after 5min,

10min,and 30min it increased to 96.25.8 (35.30%), 94.74.8

(33.19%), and 93.85.1 (31.92%) respectively. After

desufflation,

5min , 10min, and 15min it increased to 84.76.4 (19.12%), 84.25.7

(18.45%),

81.85.4

respectively.

(15.7%)

In the

and

80.94(13.78%)

mm

of

Hg.

age group 1-12yrs. (table 33) mean MAP at

baseline was 78.75.7 mm of Hg and after insufflations, it increased to

101.45.4 mm of Hg (28.84%) and after 5min, 10min, and 30min it
increased to 98.45.3 (25.03%), 98.03.8 (24.52%), and 94.85.2
(20.45%)mm of Hg respectively. After desufflation, 5min, 10min, and
15min it increased to 86.83.7 (10.29%), 86.23.4 (9.52%), 84.33.4
(7.11%) and 83.83.3 (6.48%) mm of Hg respectively.
The age group(<1 year) showed more increase in MAP as compared to age
group(1 12years ) in our study.
When we compared MAP between abdominal Laparoscopic
surgery

and

thoracic

laparoscopic

surgery,

changes

were

not

statistically significant (table 15).

When we compared MAP according to position of surgery
(Lateral, Reverse Trendelenberg, Supine, Trendelenberg), changes
were not statistically significant (table21).
Tobias and colleagues (1995)

in their study reported

only minimal cardiovascular changes with brief laparoscopy in children.

They actually found an increase in arterial BP probably due to an
increase in SVR.
De Waal et al (2003) found in their study that MAP increased from 52 +/- 10
to 63 +/- 9 (P < 0.05) from baseline.
In both of the above studies there was an increase of MAP significantly after
insufflations when compared with baseline as noticed in our study.

On comparing mean difference of MAP at different time intervals of insufflation and

desufflation from baseline in our study, there was a clinically and statistically significant
increase in MAP (p<0.05) from baseline. This was in accordance with study done by
De Waal et al (2003).

End tidal CO2

In our study at baseline the endtidal CO2 (EtCO2) of patients varied
from 24 to 40 mm of Hg with a mean value of 30.13.5 mm of Hg.
After insufflation all the patients had significant increase of EtCO2 with
mean value of 41.24.4 mm of Hg. After 5min, 10min and 30min of
insufflations EtCO2 with the mean value of 43.84.4, 43.94.4, and
43.54.2 mm of Hg respectively(table 10), and showed significant
increase as compared with base line (p<0.05). At desufflation ,after
5min 10min and 15min of desufflation there was significant increase of
EtCO2 with mean value of 34.73.8, 34.23.0, 33.33.3 and 32.12.5
mm of Hg respectively, and showed significant
with base line (p<0.05).

increase

compared

At all time intervals the mean EtCO2 was

significantly higher as compared to baseline (p<0.05).

On comparing EtCO2 between age group of 0-1yr to 1-12yrs,
mean EtCO2 at baseline of age group 0-1yr(table 28) was 29.43.7
mm of Hg and after insufflations, it increased to 38.8 4.3 mm of Hg
(31.97%) while after 5min ,10min, and 30min it increased to 42.44.8
(44.21%), 43.05.8 (46.25%), and 42.55.0 (44.21%) mm of Hg
respectively. After

desufflation, 5min, 10min, and 15min it increased

to 33.43.9 (13.60%), 33.43.2 (13.60%) ,32.33.0 (9.86%), and

31.73.0 (7.93%) mm of Hg respectively. While in age group 1-12yrs
(table 35). mean EtCO2 at baseline was 30.83.2 mm of Hg and after
insufflations, it increased to 43.3 3.3 (40.58%) mm of Hg and after

5min, 10min, and 30min it increased to 45.12.9 (46.42%). 44.72.3

(45.12%), and 44.43.2 (44.15%) mm of Hg respectively. After
desufflation, 5min, 10min, and 15min it increased to 35.93.4
(16.55%), 34.82.7 (12.98%), 34.13.4 (10.71%), and 32.41.9
(5.19%) mm of Hg respectively.
When we compared EtCO2 between abdominal Laparoscopic
surgery and thoracic laparoscopic surgery, at all time intervals the
mean value was higher in thoracic laparoscopic group as compared to
abdominal Laparoscopic group and the difference was significant
statistically (table 17).
When we compared EtCO2 according to position of surgery
(Lateral, Reverse Trendelenberg, Supine, Trendelenberg), Mean EtCO2
was maximum in Lateral group and minimum in reverse trendelenberg
and supine groups. The differences among groups were significant
statistically (table 3) .
In retrospective study conducted by Sfez et al (1994)
intraoperative

high EtCO2 in 37% of cases was found

during

laparoscopic surgery.
Hsing et al (1995) examined the physiological effect of CO2 pneumoperitoneum
in paediatric laparoscopy in 126 children aged from 11 month to 13 yr undergoing
laparoscopic inguinal exploration

and found significant increase in EtCO2 during

laparoscopy (18-20%) in all cases.

Rowney and Aldridge (2000) observed Median increase in
EtCO2 of 7.6 (2.3-18)

mm of Hg .

In a prospective study Tobias et al (2002) evaluated the

respiratory effects of a short (<10min) laparoscopic exploration in 53

infants and children. The ETCO2 increased from 32 3.1 to a maximum

of 35 4.8 mmHg (P<0.01).
Manner et al (2002) found End tidal CO2 increase from a baseline value of 3342
mmHg in 10 consecutive patients (age 115 years) scheduled for laparoscopic procedure
in their open prospective single-group study.
De Waal et al (2003) in their study observed that EtCO2 increased from 29 +/4 to 37 +/- 5 mmHg (P < 0.001).
Bannister and colleague (2003) enrolled nineteen ASA I-II patients
less than 1 year of age undergoing laparoscopic procedures in their direct observational
study. They found average Et CO2 concentration increased 13%.
Ahmed M et al (2009) found rise of end tidal CO2 (+21.21%) in their study.
In all the above studies there is increase of EtCO2 significantly after insufflations
when compared with baseline as in our study.
On comparing mean difference of EtCO2 at different time intervals of insufflation
and desufflation from baseline in our study,

there was clinically and statistically

significant increase in EtCO2 (p<0.05) from baseline. This is in accordance with

studies done by Rowney and Aldridge (2000) , Tobias et al (2002), Manner et
al(2002), Bannister and colleagues1(2003) , De Waal et al (2003), Carolyn et
al(2003) and Ahmed et al(2009) .

SpO2
The oxygen saturation range varied from 94 to 100%. In
laparoscopic surgery group the mean value was higher as compared to
thoracoscopic surgery group upto 130 minutes and the difference was
significant statistically too. Thereafter, till desufflation the value in
laparoscopic group was lower as compared to thoracoscopic group but
the difference was not significant statistically (table 16).

A clinically and statistically significant increase in heart rate, systolic blood

pressure, diastolic blood pressure, mean arterial pressure, and end tidal carbon dioxide
(EtCO2) from preoperative (baseline) value was observed in the paediatric patients in
our study during the period of laparoscopy.
These haemodynamic and cardiorespiratory changes serve as a
reminder of the care and planning needed in performing these
procedures, especially in sick and smaller children in ensuring a safe
and event-free course for the small pediatric patient.

Conclusion

The present prospective study entitled The haemodynamic

changes in minimal invasive surgery in paediatric patients. was
conducted in 53 paediatric patients of ASA Iand II of mean age (yrs.)
3.263.4, male and female ratio 45:8 and mean weight (in kg) of
10.876.57 , admitted to paediatric surgery department of CSM
Medical University, Lucknow, undergoing a spectrum of 24 different
surgical procedures being performed laparoscopically and thoracoscopically. Intra
abdominal pressure was kept between 6-10 mm of Hg during
abdominal laparoscopy, and 4 mm of Hg during thoracic laparoscopy.
After

getting

adequate

data

and

statistical

analysis,

following

conclusions were drawn:

1-There was a significant increase in heart rate compared with

base line (p<0.05),and the age group<1year showed less increase in heart rate as
compared to age group112years. On comparison of heart rate between
abdominal Laparoscopic surgery and thoracic laparoscopic surgery and

according to position of surgery, changes were not statistically

significant.
2- There was a significant increase in systolic blood pressure
compared with base line (p<0.05),and The age group<1year showed less
increase in heart rate as compared to age group112years. Systolic blood pressure
changes between abdominal Laparoscopic surgery and thoracic
laparoscopic surgery and according to position of surgery, were not
statistically significant.
3- There was a significant increase in diastolic blood pressure
compared with base line (p<0.05),and The age group<1year showed less
increase in heart rate as compared to age group112years. On comparison of
diastolic blood pressure between abdominal Laparoscopic surgery and
thoracic laparoscopic surgery and according to position of surgery,
changes were not statistically significant.
4- There was a significant increase in mean arterial pressure
compared with base line (p<0.05),and The age grou(<1year showed less
increase in heart rate as compared to age group112years. Mean arterial pressure
changes between abdominal Laparoscopic surgery and thoracic
laparoscopic surgery and according to position of surgery, were not
statistically significant.
5- There was a significant increase in end tidal CO2 compared
with base line (p<0.05) and the age group<1year showed less increase in heart
rate as compared to age group112years. End tidal CO2 between abdominal
Laparoscopic surgery and thoracic laparoscopic surgery. At all time
intervals the mean value was higher in thoracic laparoscopic group as
compared to abdominal Laparoscopic group and the difference was

significant statistically. According to position of surgery mean EtCO2

was maximum in Lateral group and minimum in reverse trendelenberg
and supine groups. The differences among groups were significant.
6- The oxygen saturation range varied from 94 to 100%. Mean
end tidal CO2 (EtCO2) was 30.13.5% with a range from 24 to 40% .
From the above study we conclude that there were clinically and statistically
significant increase in heart rate, systolic blood pressure, diastolic blood pressure, mean
arterial pressure, and end tidal carbon dioxide (EtCO2) from preoperative (baseline)
value in the paediatric patients during the period of laparoscopy.
Physiological changes during laparoscopic surgery in paediatric patients are
related to the changes associated with the increased intra abdominal pressure(IAP) due to
the insufflation of the abdomen by CO2, the patients postural modifications (head-up or
head-down) and the CO2 absorption. Smaller distance between capillaries and
peritoneum and greater absorptive area of peritoneum in relation to body weight leads to
significant vascular absorption in children. Hypercarbia has direct effects on the
myocardium and secondary effects mediated via the autonomic nervous system.
These hemodynamic and cardiorespiratory changes serve as a
reminder of the care and planning needed in performing these
procedures, especially in sick and smaller children in ensuring a safe
and event-free course for the small pediatric patient.

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