European Journal of Cardiovascular Medicine

With the progress in minimally invasive surgical techniques, laparoscopic surgery has become essential in both treatment and diagnostic procedures, offering benefits such as reduced pain, improved cosmetic results, shorter hospital stays, quicker recovery, and a faster return to normal activities. As technology has evolved, laparoscopy has become an integral part of the surgical domain. The field of minimal access surgery has seen significant growth following the successful implementation of laparoscopic cholecystectomy¹.

Establishing pneumoperitoneum to create a working space is a crucial phase in laparoscopic operations². The use of carbon dioxide pneumoperitoneum provides several advantages during laparoscopic procedures, as it can be easily absorbed by the peritoneum and is non-flammable, allowing for the safe use of electrocoagulation during surgeries³.

CO2 pneumoperitoneum impacts multiple bodily systems, including cardiac, respiratory, renal, and coagulation systems. The elevated pressure within the pneumoperitoneum raises abdominal pressure and exerts pressure on the inferior vena cava (IVC), leading to venous stasis in the lower extremities, a condition that worsens when in the reverse Trendelenburg position.

Numerous studies present conflicting findings, including the assertion that "DVT prophylaxis during laparoscopic cholecystectomy is not needed^4,5, along with research that supports the necessity of both mechanical and pharmacological methods for deep vein thrombosis (DVT) prevention⁶. Several studies have reported a rise in Prothrombin time, D-dimers, and plasma fibrinogen levels during laparoscopic cholecystectomy^7,8. Conversely, other research, including, documented a reduction in postoperative Prothrombin time and D-dimers⁹.

Due to the limited research on the impact of laparoscopic surgery on the coagulation system and the conflicting outcomes found in previous studies, we developed this research to assess how carbon dioxide pneumoperitoneum affects the coagulation system in patients undergoing laparoscopic procedures at our tertiary care facility.

AIM: To study the effects of carbon dioxide pneumoperitoneum on coagulation system in patients undergoing laparoscopic surgeries.

OBJECTIVES:  

• To study the effects of carbon dioxide pneumoperitoneum on coagulation system by estimating coagulation parameters like Prothrombin time (PT), activated partial thromboplastin time (aPTT) and D-dimers.
• To study the risk of postoperative thrombosis.
• To study the need for DVT prophylaxis in patients undergoing laparoscopic surgeries.

Study Design:  Prospective Observational Study.    

Study area:  The study was conducted in Department of General Surgery of a tertiary care hospital.

Study Period: 1 year.     

Study population: All the Patients satisfying the inclusion criteria and were posted for Laparoscopic surgeries were studied.

Sample size: The study consisted of a total of 50 cases.

Sampling method: Convenient sampling method.

Inclusion Criteria: Our study included all the patients satisfying inclusion criteria such as, patients planned for Laparoscopic surgeries like laparoscopic cholecystectomy, patients of both sexes, Age between 18years to 60 years, Surgery time between 90 minutes to 180 minutes, Patients who gave consent for study were included.

Exclusion criteria:

• Age <18 years (consent issues)
• Age >60 years (abnormal coagulation profile)
• Surery >3 hours
• Laparoscopic → laparotomy conversion
• Acute cholecystitis
• Hypertension, malignancy, anticoagulant / OCP use
• Bleeding/clotting disorders
• Deep vein thrombosis (DVT)
• Pregnancy
• Pelvic laparoscopic surgery

Ethical consideration: Institutional Ethical committee permission was taken before the commencement of the study.

Study tools and Data collection procedure:

50 patients were included in the study. A written and informed consent were taken from all the included patients. Thorough history was taken followed by clinical examination. Basic investigations were done.5cc blood was drawn from peripheral vein prior to surgery. Blood samples were processed for PT, APTT, and D Dimer. All the surgeries were done under General anaesthesia with 30-to-40-degree reverse Trendelenburg position. Pneumoperitoneum pressures between 10 to 14 mmHg were maintained for all the surgeries. Duration of the surgeries between 90 minutes to 180 minutes were included in the study. Surgeries exceeding 180 minutes were excluded from the study. Surgeries converted to Laparotomy were excluded from the study. Once abdomen is accessed Pneumoperitoneum is created with Carbondioxide and pressure maintained between 12mmhg to 14mmhg with flow rate around 3.5 to 4 liters per minute. A 30-degree telescope with attached light source and camera is introduced through the port and abdominal cavity is examined to exclude any other suspicious or associated pathologies and to assess the possibility of planned laparoscopic procedure. Rest of the ports will be placed under vision. A 10mm epigastric port, two 5mm ports in mid clavicular line and anterior axillary line in case of laparoscopic cholecystectomy. 5cc blood was drawn from peripheral vein 6 hours after surgery. Blood samples were processed for PT, APTT, and D Dimer. Preoperative and Postoperative values of PT, aPTT and D Dimers were entered into preformed proforma sheet and were statistically analyzed. Patients were also be monitored for signs of DVT such as Swelling of lower limbs, calf muscle tenderness. In case any signs of DVT are present, Duplex scan was done to rule out DVT.

STATISTICAL ANALYSIS:

To know the effects of carbondioxide pneumoperitoneum in laparoscopic surgeries on coagulation and fibrinolysis and the incidence of DVT, the quantitative variables were analyzed by student paired t test and qualitative variables were analyzed by chi-square test. A p value of 0.05 was taken as significant. Data was presented as mean and standard deviation. Microsoft excel was used to enter the data and statistical analysis was done online on a personal computer.

TABLE 1: SEX DISTRIBUTION OF THE STUDY POPULATION

Among the fifty patients included in the study 18 were male and 32 were female.

Among the thirty-two female patients included in the study majority of the patients belong to 45 years to 60 years age group (14 out of 50). Nine patients belong to 35 years to 44 years age group. Seven patients belong to 25 years to 34 years age group. Two patients belong to 18 years to 24 years age group. Among the eighteen male patients majority of them belong to 45 years to 60 years age group (10 out of 18). Five patients belong to 35 years to 44 years. Two patients belong to 25 years to 34 years. One patient belongs to 18 years to 24 years.

TABLE 2: SHOWING DURATION OF SURGERY

Out of 50 patients the duration of surgery lasted for 1.5 to 2 hours in 33 patients and lasted for more than 2hours to 3hours in 17 patients.

Postoperative complications like port site infection were observed in 5 patients. No patient presented with symptoms of deep vein thrombosis or other surgical complications.

TABLE 3: MEAN PROTHROMBIN TIME MEASURED BEFORE AND AFTER SURGERY

The mean preoperative Prothrombin time was 11.912+1.143 seconds. The mean post-operative Prothrombin time was 11.78 + 1.1 seconds. The difference in mean was 0.132. The 'p' value was 0.5 at 95% confidence interval which is not significant.

TABLE 4: SHOWING MEAN ACTIVATED PARTIAL THROMBOPLASTIN TIME (IN SECONDS) BEFORE AND AFTER SURGERY

The mean preoperative aPTT was 27.532+1.999 seconds and mean postoperative aPTT was 27.304 + 1.948 seconds. Difference of two means was 0.228 with a 'p 'value of 0.5 at 95% confidence interval which is not statistically significant.

TABLE 5: SHOWING MEAN D-DIMERS BEFORE AND AFTER SURGERY

The mean preoperative D-dimer was 0.255+ 0.041 micrograms/ml and the mean Post-operative D-dimer was 0.696+ 0.145 micrograms/ml with 'p' value <0.0001 at 95%confidence interval which was highly significant statistically.

The present study evaluated perioperative alterations in coagulation parameters—Prothrombin Time (PT), activated Partial Thromboplastin Time (aPTT), and D-dimer levels—in patients undergoing laparoscopic cholecystectomy. Although laparoscopic surgery is generally considered minimally invasive, it is associated with unique physiological changes due to pneumoperitoneum, altered patient positioning, and surgical manipulation, all of which may influence the coagulation and fibrinolytic systems. The present results demonstrated no statistically significant postoperative changes in PT and aPTT; however, a highly significant elevation in postoperative D-dimer levels was observed, suggesting a transient hypercoagulable state and a potential predisposition to thrombotic complications.

Prothrombin Time (PT):

In this study, the mean preoperative PT was 11.91 ± 1.14 seconds, and the mean postoperative PT was 11.78 ± 1.10 seconds. Although there was a minor postoperative reduction, the difference was not statistically significant (p=0.5). These findings are consistent with earlier reports by Garg et al.⁹ and Papaziogas et al.¹⁰, both of whom observed negligible postoperative changes in PT following laparoscopic cholecystectomy. Similarly, Milic et al. ⁷ reported only a slight postoperative elevation in PT that did not correlate with the incidence of deep vein thrombosis (DVT).

Conversely, Buhe et al.¹¹ and Marakis et al.¹² observed significant decreases in postoperative PT, attributing this to pneumoperitoneum-related hemodynamic changes. Diamantis et al.¹³ also reported statistically significant increases in PT both immediately after and 24 hours post-surgery. These differences may be explained by variability in study design, timing of postoperative sampling, patient demographics, and surgical protocols. In particular, the present study measured PT at six hours postoperatively, while others reported values at 8–24 hours, which may account for discrepancies. Overall, the present findings suggest that PT alone may not reliably reflect perioperative coagulopathy in laparoscopic surgery and should be interpreted alongside other parameters.

Activated Partial Thromboplastin Time (aPTT):

The mean preoperative aPTT was 27.53 ± 1.99 seconds compared with 27.30 ± 1.94 seconds postoperatively. Although a minor decline was noted, the difference was not statistically significant (p=0.5). These results concur with those of Buhe et al.¹¹, Diamantis et al.¹³, and Dimitris et al.¹⁴, who also reported no meaningful postoperative change in aPTT. Moreover, Marakis et al.¹² and Milic et al.⁷ demonstrated similar findings, emphasizing that aPTT values remain relatively stable after laparoscopic cholecystectomy and do not correlate with thrombotic risk.

In contrast, Garg et al.⁹ reported a significant postoperative reduction in aPTT, while Turgat et al.¹ noted a rise in aPTT levels, especially in patients undergoing high-pressure (14 mmHg) pneumoperitoneum. These inconsistencies highlight the multifactorial nature of coagulation changes during laparoscopic surgery, influenced by pneumoperitoneum pressure, patient physiology, and operative duration.

From a clinical standpoint, the lack of significant change in aPTT supports the safety of laparoscopic cholecystectomy in terms of intrinsic coagulation pathway activity. However, isolated stability in aPTT should not be interpreted as absence of thrombotic risk, given that fibrinolytic activation may occur independently.

D-dimer Levels:

Unlike PT and aPTT, D-dimer levels in this study showed a highly significant postoperative increase, rising from 0.25 ± 0.04 µg/ml preoperatively to 0.69 ± 0.14 µg/ml postoperatively (p < 0.0001). This finding is consistent with several studies, including those of Turgat et al.¹, Buhe et al.¹¹, Dimitris et al.¹⁴, and Vecchio et al.⁸, which all demonstrated a significant postoperative elevation in D-dimer levels after laparoscopic cholecystectomy. Elevated D-dimer is a marker of fibrin degradation, reflecting increased fibrinolytic activity and indicating a hypercoagulable state.

The clinical implications of elevated D-dimers remain debated. Some authors, such as Vecchio et al.⁸ and Papaziogas et al.¹⁰, have recommended routine postoperative thromboprophylaxis due to the risk of venous thromboembolism (VTE). Others, including Blake et al.⁵ and Pakanah et al.¹⁵, have argued that laparoscopic cholecystectomy is a low-risk procedure, and routine prophylaxis is unnecessary in patients without additional risk factors. The current findings suggest that although D-dimer elevation is consistent and statistically significant, its direct translation into thrombotic events is less clear. Indeed, none of the patients in this cohort developed clinical or radiological evidence of DVT, despite marked biochemical changes.

Pathophysiological Considerations:

The changes observed in coagulation parameters can be explained using Virchow’s triad—venous stasis, endothelial injury, and hypercoagulability. Pneumoperitoneum-induced intra-abdominal pressure reduces venous return and predisposes to venous stasis, particularly in the lower extremities. Reverse Trendelenburg positioning during laparoscopic cholecystectomy may further exacerbate this effect. In addition, surgical trauma triggers endothelial activation and systemic inflammatory responses, which enhance procoagulant activity. The rise in D-dimers likely reflects the fibrinolytic response to increased fibrin turnover in this hypercoagulable state.

These findings highlight the multifactorial etiology of perioperative coagulopathy, suggesting that no single factor, such as CO₂ pneumoperitoneum, can fully explain the observed changes. Instead, patient-specific risk factors, operative duration, and pressure settings collectively influence the coagulation profile.

Study Limitations:

Several limitations must be acknowledged. First, the sample size was relatively small (n=50), which may limit the generalizability of results. Second, only PT, aPTT, and D-dimer were assessed; other parameters such as fibrinogen, factor VII, and antithrombin III were not studied. Third, postoperative measurements were limited to a single time point (6 hours), whereas serial sampling might have provided a more comprehensive understanding of dynamic changes. Fourth, duplex ultrasonography was not performed to detect subclinical DVT. Finally, the study excluded open surgeries, pelvic laparoscopic procedures, and varying pneumoperitoneum pressures, which could influence outcomes.

This study demonstrates that laparoscopic cholecystectomy does not significantly alter PT and aPTT values but is associated with a statistically significant postoperative rise in D-dimer levels, reflecting a transient hypercoagulable state. Despite these biochemical changes, no patient in the study developed clinical evidence of thrombotic complications. These findings suggest that while routine prophylaxis for all patients may not be warranted, careful risk stratification is essential. Patients with predisposing factors for thrombosis may benefit from targeted thromboprophylaxis.

Future research should focus on larger, multicentric trials with extended follow-up and serial postoperative sampling of coagulation parameters. The influence of pneumoperitoneum pressure, operative duration, and patient positioning warrants further evaluation. Until more definitive evidence is available, the present study supports a balanced approach—recognizing the hypercoagulable changes induced by laparoscopic surgery while tailoring thromboprophylaxis to individual patient risk profiles.

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