Comparison of Volume-Controlled and Pressure-Controlled Ventilation during Laparoscopic Cholecystectomy Surgeries in the Trendelenburg Position: A Systematic Review
Keywords:
Laparoscopic cholecystectomy, Trendelenburg position, Pressure-controlled ventilation, Volume-controlled ventilation, Pneumoperitoneum, Respiratory mechanics, Randomized controlled trialAbstract
Laparoscopic cholecystectomy with pneumoperitoneum and head-up or modified Trendelenburg positioning leads to reduced lung compliance, higher airway pressures and ventilation–perfusion mismatch. Selecting an optimal ventilatory mode is important to limit barotrauma and postoperative pulmonary complications. Volume-controlled ventilation (VCV) ensures a fixed tidal volume but may generate higher peak airway pressure (Ppeak), whereas pressure-controlled ventilation (PCV) delivers a decelerating inspiratory flow with lower Ppeak and higher mean airway pressure (Pmean), potentially improving compliance and oxygenation. Several randomized controlled trials (RCTs) and meta-analyses have compared these modes during laparoscopic surgery, including laparoscopic cholecystectomy, but findings have been heterogeneous.1–5 Aim: To summarize evidence from randomized and prospective studies comparing VCV and PCV in adult patients undergoing laparoscopic cholecystectomy in Trendelenburg or reverse Trendelenburg position, focusing on intraoperative respiratory mechanics, gas exchange, and early postoperative outcomes. A narrative review of RCTs and prospective studies was performed using PubMed, Scopus, and Google Scholar up to October 2025. Studies including adult patients undergoing laparoscopic cholecystectomy or closely related laparoscopic abdominal procedures with pneumoperitoneum and Trendelenburg/reverse Trendelenburg positioning were considered. Trials comparing VCV with PCV or pressure-controlled volumeguaranteed (PCV-VG) modes and reporting respiratory mechanics, blood gases or clinical outcomes were included.1-5,8-12 Two reviewers independently screened studies and extracted data. Results: Across multiple RCTs of laparoscopic cholecystectomy, PCV compared with VCV consistently produced lower Ppeak and higher dynamic compliance (Cdyn) while maintaining similar minute ventilation.1,6,8-11 In obese patients undergoing laparoscopic cholecystectomy, PCV improved intraoperative PaO₂ and reduced alveolar–arterial oxygen gradient compared with VCV.1,6 RCTs in other laparoscopic procedures conducted in steep Trendelenburg (gynaecologic or colorectal surgery) and meta-analyses also demonstrate that PCV or PCV-VG provides significantly lower Ppeak and higher Cdyn without clear superiority in oxygenation or clinical outcomes such as postoperative pulmonary complications.2-5,9,12,13 Recent trials in laparoscopic cholecystectomy show no major differences in haemodynamics, end-tidal CO₂ or length of stay between PCV and VCV, although mechanical power and endotracheal cuff pressure may be lower with PCV.7,10,11,14 Evidence from randomized studies suggests that during laparoscopic cholecystectomy with pneumoperitoneum and Trendelenburg/reverse Trendelenburg positioning, PCV (and PCV-VG) provides more favourable respiratory mechanics—lower Ppeak and higher Cdyn—than VCV, with broadly comparable oxygenation and haemodynamics. These physiological benefits may be particularly relevant in obese or high-risk patients, although consistent reductions in hard clinical outcomes have not yet been demonstrated. Well-designed RCTs focused specifically on laparoscopic cholecystectomy in varying BMI categories and positional strategies are still needed.
References
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