Standard pneumoperitoneum pressure strategy (SPP group) | Individualised pneumoperitoneum pressure strategy (IPP group) |
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1. Trendelenburg (0–30°) placement | 1. Trendelenburg (0–30°) + ‘modified lithotomy position’, with flexed hips (between 45 and 90°) and legs raised in padded supports to increase anteroposterior intra-abdominal space |
2. Moderate neuromuscular blockade throughout surgery (TOF between 2 and 4) | 2. Deep neuromuscular blockade throughout surgery (TOF of 0 and a PTC between 1 and 5) |
3. No prestretching of abdominal wall muscles | 3. Prestretching of abdominal wall muscles by maintaining an IAP of 15 mmHg for 5 min during the first CO2 gas insufflation and insertion of trocars (flow rate at 3 L∙min− 1) |
4. IAP is set at 12 mmHg throughout surgery | 4. IAP down-titration (flow rate at 30 L∙min− 1) from 15 to 12 mmHg, and thereafter stepwise to 11, 10, 9 and finally 8 mmHg as long as ‘adequate’ workspace is preserved (by surgeon’s judgement) |
5. Surgeons can request an IAP increase if workspace becomes ‘inadequate. IAP is increased in steps of 1 mmHg during 1-min intervals to a maximum of 15 mmHg. Surgeons are warned when upper limit is reached | 5. Surgeons can request an IAP increase if workspace becomes ‘inadequate’; IAP is increased in steps of 1 mmHg during 1-min intervals to a maximum of 15 mmHg. Surgeons are warned when upper limit is reached |