Comment on: Impact of low-pressure pneumoperitoneum and deep neuromuscular blockade on surgeon satisfaction and patient outcomes in laparoscopic cholecystectomy patients: A prospective randomised controlled study

Dear Editor, We read with interest the article by Koç et al., ‘Impact of Low-Pressure Pneumoperitoneum and Deep Neuromuscular Blockade on Surgeon Satisfaction and Patient Outcomes in Laparoscopic Cholecystectomy Patients: A Prospective Randomised Controlled Study’.[1] The authors provide valuable insights, but several important considerations warrant further discussion. First, the benefits of low-pressure pneumoperitoneum for post-operative pain are well documented across the various laparoscopic procedures. While PROSPECT guidelines for laparoscopic cholecystectomy suggest that pressures below 12 mmHg may help reduce pain, they acknowledge conflicting evidence, with some randomised controlled trials showing inconclusive results or no significant differences.[2] Other strategies, such as peri-operative multimodal analgesia, intravenous dexamethasone and local anaesthetic infiltration at port sites, are well established and likely have a greater impact on optimising post-operative pain. This study did not account for these interventions nor control for their use, making it difficult to attribute the reported reduction solely to lower intra-abdominal pressures. Second, the imbalance in gender distribution, with more females in the normal-pressure group, may have influenced the findings, as females are reported to experience higher post-operative pain following laparoscopic cholecystectomy.[3] This limitation should be considered when interpreting the study’s pain-related outcomes, especially given the established sex-related differences in pain perception. Third, the study design limits the ability to draw the clear conclusions about the individual effects of intra-abdominal pressure and neuromuscular blockade. By comparing two groups – low pressure with deep neuromuscular blockade versus normal pressure without deep blockade – it remains unclear whether the observed differences are attributable to one factor or a combination. A factorial design with four groups (low/normal pressure, with/without deep blockade) would have provided a more robust analysis, allowing independent and combined effects to be assessed. The assessment of surgical conditions using a Surgeon Rating Scale also raises the concerns, as the surgeon was not blinded to intra-abdominal pressure. Larger, double-blinded trials have shown compromised visibility at lower pressures,[4] contradicting the findings reported here and suggesting the potential bias. Excluding the American Society of Anaesthesiologists (ASA), three patients raise questions about the generalisability of the findings. Patients with cardiopulmonary comorbidities, typically classified as ASA 3, may benefit most from lower pressures, as these can reduce the risks associated with pneumoperitoneum-related respiratory and haemodynamic compromise. Their exclusion limits the applicability of the results to a broader patient population. Finally, the clinical significance of reducing pain in laparoscopic cholecystectomy – a day-case procedure associated with mild-to-moderate baseline post-operative pain[3] – is debateable. Moreover, the study’s assessment of pain at 0 and 30 min post-extubation is too brief to capture meaningful post-operative pain trends. Future research should include extended follow-up periods over hours to days for a more accurate assessment of pain. In conclusion, while this study contributes to discussions on optimising pain management after laparoscopic surgery, future research should evaluate the independent effects of interventions, ensure balanced group matching and assess long-term outcomes. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.