No Renal Injury From Trendelenburg Position For Laparoscopic Colorectal Surgery

Author: Chase Doyle

Anesthesiology News

Despite compelling potential mechanisms, a new study suggests that the combination of laparoscopic approach and Trendelenburg position does not increase risk for patients undergoing colorectal surgery.

When compared with matched control cases, this retrospective analysis found that the combined approach did not alter postoperative estimated glomerular filtration rates (eGFRs) and decreased the risk for postoperative acute kidney injury (AKI). Patients undergoing laparoscopic colorectal surgery in the Trendelenburg position also had shorter hospital lengths of stay (LOS) after their procedures compared with the open approach, researchers noted.

“The Trendelenburg position is used for laparoscopic procedures, especially colorectal procedures, because it offers better visualization of the surgical field,” said Kurt Ruetzler, MD, an anesthesiologist in the Department of Outcomes Research at the Cleveland Clinic, in Ohio. “But the effects of intraoperative increase in intraabdominal pressure compared with laparotomy are unknown.”

A Surprising Result

As Dr. Ruetzler reported at the European Society of Anaesthesiology 2018 annual congress, of 7,357 eligible patients, 1,846 laparoscopic cases using the Trendelenburg position were matched to 1,846 control cases. The researchers found no difference in eGFR reduction between the groups.

Further analysis of kidney damage showed a lower prevalence of AKI in stage I (5.0% vs. 6.8%) and stage II (0.8% vs. 1.4%) in the combined laparoscopy/Trendelenburg approach, although prevalence was slightly higher in stage III (0.33% vs. 0.22%). According to Dr. Ruetzler, this general trend—lower prevalence of AKI in the combined group—across stages was statistically significant (P=0.0189).

“AKI stage I is a concern and does appear to be prognostic, but if you treat patients with volume, they might not suffer any major issues afterwards,” he explained. “With stage II, however, there is a high chance that the patient might have end-stage kidney disease. Stage III, which is really concerning, is already end-stage disease, but there was not a significant difference observed between groups.”

As Dr. Ruetzler reported, it is well established that laparoscopic procedures enhance recovery, decrease postoperative pain, and shorten the duration of hospitalization. However, increased intraabdominal pressure is also associated with decreased renal blood flow, renal hypoxia and AKI. When combined with the Trendelenburg position, during which supine patients’ heads are lower than their feet, the researchers had hypothesized that renal function may further deteriorate due to increased central venous pressure.

“We expected that the combination of laparoscopic approach and Trendelenburg position might be associated with reduced eGFR and an increased incidence of acute kidney injury, compared to an open approach without the Trendelenburg position,” Dr. Ruetzler said. “We were absolutely surprised by these results, which contradicted our hypothesis.”