Standard vs lower pressure pneumoperitoneum in laparoscopic gynecologic surgery: a randomized controlled trial

BACKGROUND: Postoperative pain following laparoscopic surgery can delay recovery and increase opioid use. Lower insufflation pressures have been consistently shown to reduce pain in general surgery procedures, but their impact in gynecologic surgery is not well established. OBJECTIVE: To investigate the effect of varying insufflation pressures on postoperative pain and operative field visualization among patients undergoing laparoscopic gynecologic surgery. STUDY DESIGN: We conducted a randomized controlled trial of patients undergoing conventional laparoscopy within a minimally invasive gynecologic surgery practice at an academic hospital in the United States. Exclusion criteria included pregnancy, urgent surgery, concomitant nongynecologic surgery, allergy/intolerance to standard perioperative pain medications, and planned postoperative admission. Patients were randomized to pressures of 10 mmHg, 12 mmHg, or 15 mmHg. The assigned pressure was set following laparoscopic entry and could be changed at the surgeon's discretion. The primary outcome was the maximum postanesthesia care unit pain score (11-point numerical rating scale). Secondary outcomes included surgeon satisfaction with operative field visualization, alterations in insufflation pressure, operative time, estimated blood loss, first and last documented postanesthesia care unit pain scores, postanesthesia care unit length of stay, and postoperative opioid requirements. RESULTS: From May 2024 to February 2025, 147 patients were randomized and included in the analysis (49 per group). Procedures performed among the cohort included adnexal surgery (cystectomy, salpingectomy, or oophorectomy) (64.6%), excision of endometriosis (61.2%), myomectomy (34.0%), ureterolysis (29.9%), lysis of adhesions (25.9%), hysterectomy (25.1%), and appendectomy (9.5%). There was no difference in maximum postanesthesia care unit pain scores among groups (median 6.0 [IQR 3.0-7.0] at 10 mmHg, 6.0 [3.0-7.0] at 12 mmHg, and 6.0 [4.0-7.0] at 15 mmHg; P=.59). Surgeons reported adequate visualization in 83.3% of cases at 10 mmHg, 97.9% at 12 mmHg, and 100% at 15 mmHg (P<.001). Insufflation pressure was increased in 6 cases due to suboptimal visualization, all in the 10 mmHg group, and decreased in 3 cases due to concern for abdominal wall overdistension. No differences were observed in opioid use or other secondary outcomes. CONCLUSIONS: Lower insufflation pressures did not reduce postoperative pain or opioid requirements in this randomized cohort of patients undergoing laparoscopic gynecologic surgery. Operative field visualization was rarely compromised at 10 mmHg and was unaffected at 12 mmHg. Intraoperative pressure changes were uncommon and occurred in both directions, supporting individualization of insufflation pressure based on patient factors. The findings of this study may be most applicable to similar patient populations undergoing complex benign gynecologic procedures, particularly excision of endometriosis.