Eur J Anaesthesiol 2021; 38:275–284

ORIGINAL ARTICLE

Ultrasound-guided versus conventional lung recruitment

manoeuvres in laparoscopic gynaecological surgery
A randomised controlled trial
Sun-Kyung Park, Hyojun Yang, Seokha Yoo, Won Ho Kim, Young-Jin Lim, Jae-Hyon Bahk
and Jin-Tae Kim
Downloaded from http://journals.lww.com/ejanaesthesiology by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC1y0abggQZXdtwnfKZBYtws= on 05/02/2021

BACKGROUND Pneumoperitoneum and steep Trendelen-
burg position promote the formation of pulmonary atelectasis
during laparoscopic gynaecological surgery.
OBJECTIVE To determine whether lung ultrasound-guided
alveolar recruitment manoeuvres could reduce peri-operative
atelectasis compared with conventional recruitment man-
oeuvres during laparoscopic gynaecological surgery.
DESIGN Randomised controlled trial.
SETTING Tertiary hospital, Republic of Korea, from August
2018 to January 2019.
PATIENTS Adult patients scheduled for laparoscopic gynae-
cological surgery under general anaesthesia.
INTERVENTION Forty patients were randomised to receive
either ultrasound-guided recruitment manoeuvres (manual
inflation until no visibly collapsed area was seen with lung
ultrasonography; intervention group) or conventional recruit-
ment manoeuvres (single manual inflation with 30 cmH2O
pressure; control group). Recruitment manoeuvres were
performed 5 min after induction and at the end of surgery
in both groups. All patients received volume-controlled ven-
tilation with a tidal volume of 8 ml kg1 and a positive end-
expiratory pressure of 5 cmH2O.
MAIN OUTCOME MEASURES The primary outcome was
the lung ultrasound score at the end of surgery; a higher
score indicates worse lung aeration.
RESULTS Lung ultrasound scores at the end of surgery were
significantly lower in the intervention group compared with
control group (median [IQR], 7.5 [6.5 to 8.5] versus 9.5 [8.5
to 13.5]; difference, 2 [95% CI, 4.5 to 1]; P ¼ 0.008).
The intergroup difference persisted in the postanaesthesia
care unit (7 [5 to 8.8] versus 10 [7.3 to 12.8]; difference, 3
[95% CI, 5.5 to 1.5]; P ¼ 0.005). The incidence of
atelectasis was lower in the intervention group compared
with control group at the end of surgery (35 versus 80%;
P ¼ 0.010) but was comparable in the postanaesthesia care
unit (40 versus 55%; P ¼ 0.527).
CONCLUSIONS The use of ultrasound-guided recruitment
manoeuvres improves peri-operative lung aeration; these
effects may persist in the postanaesthesia care unit. How-
ever, the long-term effects of ultrasound-guided recruitment
manoeuvres on clinical outcomes should be the subject of
future trials.
TRIAL REGISTRATION ClinicalTrials.gov (NCT03607240).
Published online 4 January 2021

Introduction
Pulmonary atelectasis develops in most patients under
general anaesthesia.1–3 Both pneumoperitoneum and a
steep Trendelenburg position can worsen the atelectasis
during laparoscopic surgery.4–8 The formation of atelec-
tasis causes gas exchange impairments, hypoxaemia and a
decrease in functional residual capacity, which can lead to
postoperative pulmonary complications (PPCs).3,4,7,9–17
As PPCs can adversely affect clinical outcomes after
surgery, prevention of these complications is a main
concern of anaesthetic providers.16–21

From the Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
(SKP, HY, SY, WHK, YJL, JHB, JTK)
Correspondence to Jin-Tae Kim, MD, PhD, Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of
Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Republic of Korea
E-mail: jintae73@gmail.com

0265-0215 Copyright ß 2021 European Society of Anaesthesiology and Intensive Care. Unauthorised reproduction of this article is prohibited.
DOI:10.1097/EJA.0000000000001435
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 276 Park et al.
Lung-protective ventilation consists of the application of
positive end-expiratory pressure (PEEP), low tidal vol-
ume and recruitment manoeuvres.18 Alveolar recruit-
ment manoeuvre, which refers to the periodic
hyperinflation of the lungs, has been used to reverse
lung collapse in anaesthetised patients.3,4,7,9,18 The use
of recruitment manoeuvres has been shown to reduce the
incidence and extent of atelectasis during general anaes-
thesia.4,9,17,22 However, the optimal recruitment strate-
gies, in terms of frequency, timing, inflation pressures
and methods remain unknown.9,16
Lung ultrasonography has emerged as a useful tool for peri-
operative care.4,9,11,23,24 Recent research showed that lung
ultrasonography can assess lung aeration and diagnose
atelectasis accurately in the peri-operative period.11,24
The scoring system for the measurements of the extent
of atelectasis has been validated by numerous previous
publications.11,17,24 By using lung ultrasonography, the
response to recruitment manoeuvres for each patient
can be easily assessed. Thus, it has great potential as a
bedside tool for guiding effective recruitment manoeuvres
to reduce the formation of pulmonary atelectasis in surgical
settings. However, whether the use of ultrasound-guided
recruitments can reduce peri-operative atelectasis in an
adult surgical population has not yet been tested.
Therefore, this study aimed to investigate whether ultra-
sound-guided alveolar recruitment manoeuvres could
improve lung ultrasound findings and reduce peri-opera-
tive pulmonary atelectasis in adult patients undergoing
gynaecological laparoscopic surgery, as compared with
the standard practice of alveolar recruitment manoeuvres.
Methods
Trial design
This prospective, randomised, controlled study was
approved by the Institutional Review Board of Seoul
National University Hospital (No. 1805-148-948; Chair-
person Professor BJ Park; date of approval, 27 June 2018)
and was registered with ClinicalTrials.gov
(NCT03607240; principal investigator: Jin-Tae Kim;
date of registration, 1 July 2018). We have prepared this
article in accordance with the Consolidated Standards of
Reporting Trials guidelines.25 The study was conducted
between August 2018 and January 2019 at Seoul National
University Hospital, Seoul, Korea. All included partici-
pants provided written informed consent, and the study
was conducted in accordance with the ethical principles
as set out in the Declaration of Helsinki.
Patients
Adult patients (American Society of Anesthesiologists
physical status of I or II) scheduled to undergo elective
gynaecological laparoscopic surgery with an expected
duration of at least 1 h under general anaesthesia were
considered for eligibility. Eligible operations included
laparoscopic hysterectomy, laparoscopic myomectomy,
Eur J Anaesthesiol 2021; 38:275–284
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laparoscopic ovarian cystectomy and laparoscopic sal-
pingo-oophorectomy. Patients with a previous history
of thoracic surgery, pneumothorax, bullae, pre-existing
lung or cardiac disease, abnormal pre-operative chest
radiographs, or morbid obesity (BMI 40 kg.m2) were
excluded from the study.
Randomisation and blinding
Patients were randomly assigned to receive either lung
ultrasound-guided recruitment manoeuvres (interven-
tion group) or conventional recruitment manoeuvres
(control group) using a computer-generated table of
random numbers. Group allocation was concealed by
sequentially numbered, sealed opaque envelopes, which
were opened only by the attending anaesthesiologist
immediately before the induction of general anaesthesia.
All patients and the outcome assessors were blinded to
the group allocations. The ultrasound assessor and inves-
tigators who scored the lung ultrasound score (LUS) were
blinded to the group allocations.
Anaesthesia protocol and ventilator settings
No premedication was provided. Standard monitoring
including electrocardiography, pulse oximetry, noninva-
sive blood pressure and bispectral index (Medtronic,
Ireland) was applied. All patients were pre-oxygenated
with 100% oxygen for 3 min before induction. Total
intravenous anaesthesia was induced using propofol
and remifentanil. Intravenous rocuronium (0.6 mg kg1)
was administered. After tracheal intubation with a cuffed
endotracheal tube with an internal diameter 7.0 mm, all
patients were ventilated with a Carestation 650 ventilator
machine (GE Healthcare, United States) using volume-
controlled ventilation with a tidal volume of 8 ml kg1 of
predicted body weight, a PEEP of 5 cmH2O, a fractional
inspired oxygen tension (FiO2) of 0.4 and an initial
respiratory rate of 12 min1. The respiratory rate was
adjusted to maintain the end-tidal carbon dioxide
(ETCO2) between 4.7 and 6.0 kPa (35 and 45 mmHg).
General anaesthesia was maintained with a target-con-
trolled infusion of propofol and remifentanil. The bis-
pectral index was maintained between 40 and 60
throughout the operation. A radial arterial catheter was
inserted, and invasive blood pressure was monitored in
every patient. Systolic arterial pressure was maintained
between 120 and 140 mmHg throughout the surgery.
Neuromuscular blockade was reversed using sugamma-
dex (2 mg kg1) following checking the train of four
greater than 0.7 before emergence. All patients were
extubated in the operating room and were transferred
to the postanaesthesia care unit (PACU). Every patient
underwent a chest X-ray while in the PACU.
In every patient, the intra-abdominal insufflation pres-
sure was set as 12 mmHg during the entire capnoperito-
neum period. Laparoscopic surgery was performed in the
steep Trendelenburg position (angle of surgical bed: 408).

Lung ultrasonography
In both groups, a lung ultrasound examination was done
at three predefined time points: 5 min after the induction
of anaesthesia (time point T1), at the end of surgery
(before administrating reversal agents for neuromuscular
blockade; time point T2) and before discharge from the
PACU (time point T3). All ultrasound examinations were
performed by a single anaesthesiologist (S-KP), who was
experienced with lung ultrasound scans, using a TE7
Ultrasound System (Mindray Medical International Co.,
China) with a C5-2 s convex probe of 2 to 5 MHz. Each
hemithorax was divided into six quadrants as described
previously.11,24 The intercostal space of each of the
sections was scanned and video clips of the most patho-
logical area of each region was stored for analysis.
After the acquisition of video clips, each region was
assigned a score of 0 to 3 according to a previously
described grading system.11 Ultrasound images were
analysed independently by the two investigators (SY
and J-TK), who were blinded to group allocations and
time points but not to lung quadrants. Discordant read-
ings were reconciled by consensus. The LUS was calcu-
lated to quantitatively assess the aeration loss of each of
the 12 quadrants as described previously.11
Each of the 12 quadrants was assigned a score of 0 to 3
based on the following scoring system: 0, 0 to 2 B lines; 1,
at least three B lines or one or more small subpleural
consolidations separated by a normal pleural line; 2,
multiple coalescent B lines or multiple small subpleural
consolidations separated by a thickened or irregular pleu-
ral line; 3, consolidation or subpleural consolidation of
more than 1 cm  2cm. The LUS (0 to 36) was calculated
by adding up the scores for the 12 quadrants with higher
scores indicating more severe aeration loss. The B line
scores and consolidation scores were recorded at each
time point.
Fig. 1 Schematic diagram of the study protocol
Operating room
Pre-oxygenation US-guided RM
Intervention group LUS
with O2 100% exam
Control group Pre-oxygenation LUS Conventional
with O2 100% exam RM
Anaesthesia T1: 5 min
induction after induction
LUS, lung ultrasound score; PACU, postanaesthesia care unit; RM, recruitment manoeuvre; US, ultrasound.
Eur J Anaesthesiol 2021; 38:275–284
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US-guided recruitments in laparoscopic surgery 277
Study interventions
In both groups, the recruitment manoeuvres were per-
formed after each lung ultrasound examination (Fig. 1).
In the intervention group, the recruitment manoeuvres
were performed under the direct real-time guidance of
ultrasound. Manual inflation was applied until no col-
lapsed areas were visible on the ultrasound. The maxi-
mum airway pressure was limited to 40 cmH2O, and the
tidal volume of each recruitment manoeuvre was limited
to 20 ml kg1. In the control group, the recruitment
manoeuvre was performed by manual inflation with a
pressure of 30 cmH2O for 10 s.
Rescue strategy for desaturation
In both groups, when SpO2 decreased to 95% or lower,
the following rescue ventilation strategies were per-
formed in a stepwise manner (i.e. if SpO2 did not increase
after a step, then the following step was applied; other-
wise, no further steps were applied). Steps were per-
formed according to the following order: step (1), three
rounds of recruitment manoeuvres with a pressure of
30 cmH2O for 10 s; step (2), three rounds of recruitment
manoeuvres with a pressure of 35 cmH2O for 10 s; and
step (3), increase in FIO2 to 1.0. If SpO2 did not increase
after all three rescue strategies, the ventilation strategies
could be modified according to the attending anaesthe-
siologist’s judgement.
Study endpoints
The primary outcome was the LUS at the end of surgery
(time point T2). Secondary outcomes included the LUS
before discharge from the PACU (time point T3), the
incidence of atelectasis (defined as a LUS score of 2 for
any of the 12 regions) at time points T2 and T3, the
incidence of intra-operative desaturation (defined as an
SpO2 95%), the incidence of postoperative fever
(defined as a body temperature 37.58C), postoperative
PACU
Pneumoperitoneum, US-guided RM
LUS LUS
Trendelenburg position exam exam
Pneumoperitoneum, LUS Conventional LUS
Trendelenburg position exam RM exam
T2: At the end Extubation T3: before
of surgery discharge from
PACU
 278 Park et al.
shoulder pain and PPCs during the 48-h postoperative
period. PPCs were predefined as the development of any
of the following four complications within the first 48-h
postoperative period; atelectasis as seen on a chest X-ray,
pneumonia, acute respiratory distress syndrome and pul-
monary aspiration, according to the recently published
consensus definitions for PPCs.17,26 Data on other respi-
ratory complications including pulmonary embolism,
pleural effusion, pulmonary oedema, pneumothorax
and bronchospasm were collected separately.26 Haemo-
dynamic parameters (pulse rate, blood pressure and oxy-
gen saturation), mechanical ventilation parameters (tidal
volume, peak inspiratory pressure, dynamic compliance
and modified airway driving pressure) and arterial blood
gas analysis results were recorded at each time point. Due
to a lack of plateau pressure data available in this study,
the modified driving pressure was calculated as peak
inspiratory pressure minus level of PEEP.27,28 The total
number and inflation pressure of applied recruitment
manoeuvres were recorded.
Sample size calculation
The primary hypothesis of this study was that the use of
ultrasound-guided recruitment manoeuvres would
reduce the LUS at the end of surgery compared with
the use of conventional recruitment manoeuvres. The
sample size was calculated based on a previous trial
conducted in patients undergoing laparoscopic surgery.11
We assumed that the mean LUS at the end of surgery in
the control group would be 10.54  SD 1.02.11 We
hypothesised that the use of ultrasound could decrease
the LUS to 9.54  1.02. To achieve a power of 0.8 and an
alpha error less than 0.05, 18 subjects were required in
each group. We estimated that at least 20 patients would
be needed in each group, allowing for a dropout rate of
10% of the subjects. A priori calculation of sample size
was based on a two-sample t test, whereas the primary
outcome was assessed using the Mann–Whitney U test
because of the observed distribution of the data.
Statistical analysis
Data were analysed with SPSS Statistics for Windows
(version 23.0, IBM Corp., Armonk, New York, USA) and
R software (version 3.6.3, R Foundation for Statistical
Computing, Vienna, Austria). All data were analysed on
an intention-to-treat basis. Continuous data were tested
for normality using Q-Q plots. Data showing a normal
distribution were presented as the mean  SD, and data
showing a nonnormal distribution were presented as the
median [IQR (range)]. Continuous variables were ana-
lysed using a Student’s t-test or Mann–Whitney U test for
intergroup differences, as appropriate. Intergroup differ-
ences in the LUS at the end of surgery, the primary
outcome, were assessed for significance using the Mann–
Whitney U test with a Bonferroni correction. For the
continuous variables including LUS, 10 000 bootstrap
samples were taken, and CIs for the difference in
Eur J Anaesthesiol 2021; 38:275–284
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medians were calculated using the bootstrap method
(sampling with replacement). The Wilcoxon-signed-rank
test was used for comparing the LUS within groups.
Categorical data are expressed as the number (propor-
tion) and were assessed using Pearson’s x2 test or Fisher’s
exact test, as appropriate. The relative risk of binary
variables is presented with the 95% CI. Two-tailed P
values less than 0.05 were considered statistically signifi-
cant. A Bonferroni correction was used for multiple
comparisons. The criterion for rejection of the null
hypothesis for the repeated measurement at each time
point was P less than 0.017.
Results
Of the 61 patients who were assessed for eligibility, 41
patients were included in the study and were randomly
allocated to either the control or intervention group
(Fig. 2). One subject in the control group did not com-
plete the study as she did not receive the ultrasound
examination at the end of surgery (time point T2) as the
ultrasound machine was unavailable. Therefore, data
from 40 patients (20 in each group) were included in
the final analysis. Baseline characteristics of the study
participants appear in Table 1.
Serial lung ultrasound scores
The median LUSs were comparable between the two
groups 5 min after the induction of general anaesthesia
(time point T1; Table 2; Supplemental Figure S1, http://
links.lww.com/EJA/A481). After the completion of sur-
gery, lung aeration deteriorated in both groups (time
point T2). The LUSs at the end of surgery, that is, the
primary outcome of the study, were lower in the inter-
vention group compared with the control group: differ-
ence between medians (95% CI) was 2 [4.5 to 1],
P ¼ 0.008 (Table 2; Supplemental Figure S1, http://
links.lww.com/EJA/A481). The intergroup difference
remained while patients were in the PACU (time point
T3): difference between medians 3 [5.5 to 1.5],
P ¼ 0.005. On ultrasound examination at time point
T2, the LUS of the posterior regions showed a significant
inter-group difference, whereas the LUSs of the anterior
and lateral regions showed no differences between
groups (Supplemental Table S1, http://links.lww.com/
EJA/A483 and Supplemental Figure S2, http://links.lww.-
com/EJA/A482). Representative ultrasound findings of
one patient from each group are shown in Fig. 3.
Secondary outcomes
The incidence of atelectasis assessed by lung ultrasonog-
raphy was lower in the intervention group (35%) com-
pared with the control group (80%; relative risk, 0.44; 95%
CI, 0.23 to 0.83; P ¼ 0.010) at the end of surgery but it was
comparable in the PACU (40 versus 55%; relative risk,
0.73; 95% CI, 0.37 to 1.42; P ¼ 0.527; Table 3). Substan-
tial inter-patient heterogeneity was seen in the number
and maximal inflation pressure of recruitment

Fig. 2 CONSORT flow diagram of patient recruitment
Enrolment
Allocated to intervention group (n = 20)
Received allocated intervention (n = 20)
Did not receive allocated intervention (n = 0)
Lost to follow-up (n = 0)
Discontinued intervention (n = 0)
Analysed (n = 20)
Excluded from analysis (n = 0)
manoeuvres applied until there was no visibly collapsed
area as seen with lung ultrasonography (Supplemental
Table S2, http://links.lww.com/EJA/A484). Data on hae-
modynamics and gas exchange are presented in Table 4.
No intergroup differences were observed in the PaO2 : -
FIO2 ratio or in the oxygenation index at any of the time
points. Dynamic compliance decreased during pneumo-
peritoneum and increased after deflation of the pneumo-
peritoneum (but not to the baseline level) in both groups.
Modified driving pressure increased during pneumoper-
itoneum and decreased after deflation of the pneumo-
peritoneum. However, no intergroup difference was
observed (Table 5).
Intra-operative desaturation occurred in two subjects in
the control group. No intergroup differences were
observed in atelectasis on chest X-rays in the PACU,
or in predefined PPCs, postoperative shoulder pain,
Eur J Anaesthesiol 2021; 38:275–284
Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
US-guided recruitments in laparoscopic surgery 279
Assessed for eligibility (n = 61)
Excluded (n = 20)
Not meeting inclusion criteria (n = 3)
Morbid obesity (BMI >40 kg m–2) (n = 1)
Research staff not available (n = 16)
Randomised (n = 41)
Allocation
Allocated to control group (n = 21)
Received allocated intervention (n = 21)
Did not receive allocated intervention (n = 0)
Follow-up
Lost to follow-up (n = 0)
Discontinued intervention (n = 1)
- No lung ultrasound examination at T2 due to
unavailability of ultrasound machine (n = 1)
Analysis
Analysed (n = 20)
Excluded from analysis (n = 0)
duration of PACU stay, or hospital stay (Table 6). One
patient in the intervention group developed a predefined
PPC; mild focal atelectasis was observed on the chest
X-ray in the PACU in this patient. However, she neither
required supplemental oxygen nor had any respiratory
symptoms. None of the patients developed other respi-
ratory complications including pulmonary embolism,
pleural effusion, pulmonary oedema, pneumothorax
and bronchospasm in the study period.
Discussion
Among adult patients undergoing laparoscopic gynaeco-
logical surgery, the use of ultrasound-guided recruitment
manoeuvres improved the LUS and reduced atelectasis
at the end of surgery compared with the use of conven-
tional recruitment manoeuvres. However, the ultra-
sound-guided recruitment manoeuvres did not improve
intra-operative respiratory mechanics or arterial
 280 Park et al.

Table 1 Baseline characteristics

Intervention group (nU20) Control group (n U 20)

Age (years) 46.2  9.6 49.4  14.8
Height (cm) 158.1  6.6 159.2  7.6
Actual weight (kg) 58.4  8.0 60.3  10.1
Predicted body weight (kg) 50.7  6.0 51.6  6.9
Body mass index (kg m2) 23.4  3.2 23.9  4.1
ASA physical status, I/II 18 (90)/2 (10) 13 (65)/7 (35)
Type of surgery
Total hysterectomy 8 (40) 8 (40)
Myomectomy 1 (5) 0 (0)
Ovarian cystectomy 6 (30) 5 (25)
Salpingo-oophorectomy 5 (25) 7 (35)
Pre-operative chest X-ray findings
No active lung lesion 19 (95) 19 (95)
Nodular opacities 1 (5) 1 (5)
Duration (min)
Pneumoperitoneum 35.5 [25 to 79.8] 37 [32.3 to 55.5]
Surgery 72.5 [50 to 133.8] 57.5 [42.5 to 88.8]
Anaesthesia 117.5 [90 to 175] 100 [86.3 to 133.8]
Crystalloid fluids (ml) 750 [575 to 900] 700 [400 to 850]
Urine output (ml) 150 [100 to 325] 200 [105 to 240]
Blood loss (ml) 150 [50 to 300] 100 [90 to 200]

Data are presented as mean  SD or median [IQR] or number (%). ASA, American Society of Anesthesiologists.

oxygenation and did not reduce PPCs in the laparoscopic
surgical setting.
To the best of our knowledge, the current study is the
first trial to test the effect of ultrasound-guided recruit-
ment manoeuvres on peri-operative atelectasis in an
adult surgical population. Previous trials in paediatric
patients showed that the ultrasound-guided recruit-
ment manoeuvres reduced intraoperative atelecta-
sis.9,29 The results of our study suggest that
ultrasound-guided recruitment manoeuvres can reduce
peri-operative atelectasis in adult laparoscopic surgical
patients. In addition, our data suggest that the inter-
group difference in lung aerations persisted after
recovery of spontaneous ventilation, as assessed by
lung ultrasonography in the PACU. However, the ultra-
sound-guided recruitment manoeuvres did not result in
an improved PaO2:FIO2 ratio or lower driving pressure
compared with the conventional recruitment man-
oeuvres in this study.
The optimal strategy for recruitment manoeuvres still
remains unclear.30,31 A recruitment manoeuvre is a tran-
sient increase in transpulmonary pressure and it has
become a component of lung protective ventilation strat-
egies.30 Recruitment manoeuvres during general anaes-
thesia have been shown to improve intra-operative
oxygenation, reduce the need for high FIO2, correct

Table 2 Lung ultrasound scores of the study participants

Intervention group Control group Difference in

(nU20) P valuea (nU20) P valueb mediansc P valuec
Lung ultrasound examination 5 min
after induction (T1)

Consolidation score 5 [2.3 to 6 (0 to 9)] 5.5 [2.3 to 8 (0 to 15)] 0.5 (3 to 2) 0.583
B-line score 2 [1 to 3.8 (0 to 6)] 0 [0 to 5 (0 to 9)] 2 (1 to 2.5) 0.289
Lung ultrasound score 5 [3 to 7 (0 to 9)] 5.5 [2.3 to 8 (0 to 15)] 0.5 (3 to 2.5) 0.718
Lung ultrasound examination at the T1 versus T2 T1 versus T2
end of surgery (T2)
Consolidation score 7.5 [6 to 8.8 (3 to 14)] 0.001 9 [7.3 to 13.3 (4 to 17)] <0.001 1.5 (4 to 0) 0.020
B-line score 5 [3 to 6 (0 to 8)] 0.006 7 [3.3 to 9 (0 to 13)] 0.001 2 (4.5 to 1.0) 0.086
Lung ultrasound score 7.5 [6.5 to 8.5 (3 to 14)] 0.001 9.5 [8.5 to 13.5 (4 to 18)] <0.001 2 (4.5 to 1) 0.008
Lung ultrasound examination at T2 versus T3 T2 versus T3
PACU (T3)
Consolidation score 6 [4 to 8 (1 to 14)] 0.079 10 [7.3 to 12 (5 to 17)] 0.692 4 (6 to 1.5) 0.003
B-line score 4 [2.3 to 5 (0 to 7)] 0.273 6 [3.3 to 9.8 (1 to 12)] 1.000 2 (4.5 to 1.0) 0.015
Lung ultrasound score 7 [5 to 8.8 (1 to 14)] 0.136 10 [7.3 to 12.8 (5 to 17)] 0.700 3 (5.5 to 1.5) 0.005

Lung ultrasound scores are summations of scores in the anterior, lateral and posterior regions. Data are presented as median [IQR (range)], difference in medians (95%
CI). Wilcoxon-signed-rank test was used for intragroup comparisons. Mann–Whitney U test with Bonferroni correction was used for intergroup comparisons. The criterion
for rejection of the null hypothesis for the repeated measurement at each time point was P < 0.017. CI, confidence interval; IQR, interquartile range; PACU,
postanaesthesia care unit. a Comparisons in the intervention group. b Comparisons in the control group. c Intervention group versus control group.

Eur J Anaesthesiol 2021; 38:275–284

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.
 US-guided recruitments in laparoscopic surgery 281

Fig. 3 Lung ultrasound images in the left inferoposterior quadrant of one representative patient per group at each time point

T1, 5 min after anaesthetic induction; T2, at the end of surgery; T3, before discharge from postanaesthesia care unit.

hypoxaemia and reduce PPCs.10,31 Hence, recruitment
manoeuvres have been recommended after anaesthetic
induction to prevent collapse of the alveoli.10 On the
other hand, recruitment manoeuvres can cause vascular
compression, hypotension, decreased cardiac output and
barotrauma.10,30–32 As the extent of alveoli collapse and
the responses to recruitment manoeuvres vary among
individuals, it has been suggested that individualised
assessment is required.30 As ultrasound-guided recruit-
ment manoeuvres can be applied while dynamically

Table 3 Incidence of atelectasis assessed by lung ultrasonography per group and per protocol step

Intervention group (nU20) P valuea Control group (nU20) P valueb P valuec

Atelectasis 5 min after induction (T1) 3 (15) 4 (20) 1.000
Atelectasis at the end of surgery (T2) 7 (35) 0.163 16 (80) <0.001 0.010
Atelectasis in PACU (T3) 8 (40) 0.716 11 (55) 0.021 0.527

Atelectasis was predefined as consolidation score at least 2 in any of the 12 regions. Data are presented as number (%). PACU, postanaesthesia care unit. a Comparisons
in the intervention group: T1 versus T2, T2 versus T3. b Comparisons in the control group: T1 versus T2, T2 versus T3. c Intervention group versus control group.

Table 4 Data on haemodynamics and gas exchange

Time points
T1 T2 T3
Intervention group Control group Intervention group Control group Intervention group Control group
Variables (nU20) (nU20) (nU20) (nU20) (nU20) (nU20)
Heart rate (bpm) 72  14 74  10 66  15M 67  14M
MBP (mmHg) 78  11 81  19 95  17M 85  18
SaO2 (%) 100 [100 to 100] 100 [100 to 100] 100 [99.5 to 100]M 100 [99 to 100]M 97 [96 to 98]M y 98 [95 to 99]M,y
PaCO2 (mmHg) 38 [35 to 40] 39 [37 to 40.5] 39 [36.5 to 41] 40.5 [38 to 42.5] 41 [34 to 45.5] 43 [30 to 46]
PaO2 (mmHg) 537.5 [463 to 577.5] 537 [466 to 565.5] 193.5 [151 to 212]M 184 [136.5 to 208]M 92.5 [85 to 105.5]M,y 90.5 [74.5 to 117]M,y
M M M
PaO2/FiO2 ratio 537.5 [460.5 to 580.8] 537 [465 to 568.8] 483.8 [363.8 to 535] 460 [335.6 to 522.5] 440.5 [402.4 to 510.7] 430.9 [353.6 to 566.7]
(mmHg)
Oxygenation 1 [0.9 to 1.4] 1.1 [0.9 to 1.3] 1.2 [1.1 to 1.6]M 1.3 [1 to 1.9]M
Index

Data are presented as mean  SD or median [IQR]. T1, 5 min after induction; T2, at the end of surgery; T3, before discharge from postanaesthesia unit. Paired t-test or
Wilcoxon-signed-rank test was used for intragroup comparisons. M P < 0.05 versus time point T1. y P < 0.05 versus time point T2.

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 282 Park et al.

Table 5 Intra-operative respiratory parameters

Time points
Before pneumoperitoneum During pneumoperitoneum After pneumoperitoneum
Intervention Control group Intervention Control group Intervention Control
Variables group (nU20) (nU20) group (nU20) (nU20) group (nU20) group (nU20)
Tidal volume (ml) 400  48 404  52 396  44 403  55 398  44 404  57
Tidal volume per predicted weight (ml kg1) 8 [7.6 to 8.3] 7.8 [7.4 to 8] 7.8 [7.7 to 8.1] 7.7 [7.5 to 7.9] 7.9 [7.5 to 8.1] 7.7 [7.6 to 7.9]
Peak inspiratory pressure (cmH2O) 13 [12 to 14] 14 [12 to 15] 23 [21 to 24]M 25 [21 to 27]M 15 [14 to 16]M,y 16 [14 to 18]M,y
Modified driving pressure (cmH2O)a 8 [7 to 9] 9 [7 to 10] 18 [16 to 19]M 20 [16 to 22]M 10 [9 to 11]M,y 11 [9 to 13]M,y
Dynamic compliance (ml cmH2O1) 49  11 46  11 23  6M 21  5M 40  9M,y 39  9M,y

Data are presented as mean  SD or median [IQR]. a Calculated as peak inspiratory pressure minus level of PEEP. Paired t-test or Wilcoxon-signed-rank test was used for
intragroup comparisons. M P less than 0.05 versus time point before pneumoperitoneum. y P less than 0.05 versus time point during pneumoperitoneum.

monitoring the responses to recruitment manoeuvres, we
hypothesised that they could be more effective in reduc-
ing peri-operative atelectasis compared with conven-
tional recruitment manoeuvres. In the intervention
group, we found substantial interindividual heterogene-
ity in the numbers and maximal inflation pressures of
recruitment manoeuvres until no visibly collapsed area
was seen with ultrasonography. Thus, the results of our
study suggest that the optimal recruitment manoeuvre
strategy might vary from patient to patient and that
ultrasound-guided recruitment manoeuvres could help
to find the optimal recruitment manoeuvres for
individual patients.
Additionally, our data showed both temporal and regional
distributions of aeration loss during general anaesthesia.
Whether atelectasis formed during general anaesthesia
persisted after extubation is controversial. Although a
recent trial showed that anaesthesia-induced atelectasis
rapidly resolved after extubation,17 our data suggest the
worsened lung aeration during general anaesthesia per-
sisted after the recovery of spontaneous ventilation.
Although our results suggest that some degree of aeration
loss persisted after extubation, the incidence of atelecta-
sis was not different between groups in the PACU. We
also found that atelectasis developed in the dependent
areas of the lungs more frequently, which is in line with
previous findings.3,8,9,17,24,33,34 Genereux et al.17 reported
that the inferoposterior quadrant had the worst LUS
during open gynaecological surgery in the supine posi-
tion. Further, Jang et al.33 recently showed a higher
incidence of atelectasis in the dependent anterior chest
after surgery in the prone position. In the present study,
the supero-posterior and infero-posterior quadrants
showed the worst LUSs after laparoscopic surgery in
the steep Trendelenburg position.
Optimal ventilation strategies during laparoscopic sur-
gery in the steep Trendelenburg position have provoked
concern in many investigators.7,8,34 Brandao et al.34 dem-
onstrated that the combination of pneumoperitoneum
and the Trendelenburg position significantly increased
the driving pressure and transpulmonary pressure. Shono
et al.8 showed that application of a PEEP of 15 cmH2O, as
compared with 5 cmH2O, increased ventilation in the
dorsal parts of the lung, resulting in lower driving pres-
sure and better oxygenation during robot-assisted lapa-
roscopic prostatectomy. Cinnella et al.7 demonstrated that
recruitment manoeuvres followed by the application of
PEEP increased transpulmonary pressure and led to
alveolar recruitment in patients undergoing laparoscopic
surgery in the Trendelenburg position. Our results also
showed that modified driving pressure increased and
dynamic compliance decreased during pneumoperito-
neum in the steep Trendelenburg position. Additionally,
our data suggest that ultrasound-guided recruitment
manoeuvres did not result in improved respiratory
mechanics or better oxygenation, despite the improved

Table 6 Incidence of adverse events within the first 48-h postoperative period

Intervention group (nU20) Control group (nU20) P value

Intra-operative desaturation events 0 (0) 2 (10) 0.487
Atelectasis on chest X-ray, at PACU 1 (5) 0 (0) 1.000
Postoperative fevera 13 (65) 11 (55) 0.519
Highest body temperature (8C) 37.5 [37.3 to 37.6 (36.9 to 38.1)] 37.5 [37.1 to 37.8 (36.7 to 38.2)] 0.640
Postoperative pulmonary complicationsb 1 (5) 0 (0) 1.000
Postoperative shoulder pain 4 (20) 7 (35) 0.480
NRS score of shoulder painc 2 [1 to 3.8 (1 to 4)] 3 [2 to 3 (1 to 5)] 0.648
Duration of PACU stay (min) 45.5 [42 to 49.8 (40 to 60)] 45.5 [41.3 to 52.5 (35 to 69)] 1.000
Length of hospital stay (days) 3 [3 to 3 (3 to 4)] 3 [3 to 3 (3 to 6)] 0.925

Data are presented as median [interquartile range (range)] or number (%). NRS, numeric rating scale. PACU, postanaesthesia care unit. a Defined as body temperature at
least 37.58C, during the 48-h postoperative period. b Postoperative pulmonary complications included atelectasis detected by chest radiograph, pneumonia, acute
respiratory distress syndrome and pulmonary aspiration. c Among the patients who experienced shoulder pain during the 48-h postoperative period (4 patients in the
intervention group and 7 patients in control group).

Eur J Anaesthesiol 2021; 38:275–284

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

aerations in the posterior part of the lungs, in these
surgical settings.
This study has some limitations. First and most impor-
tantly, although this study showed improved LUS in the
ultrasound-guided recruitment manoeuvre group, clini-
cally relevant outcomes including lung mechanics and
laboratory findings were comparable between the two
groups. Therefore, the clinical implications of the
improved LUS that we observed are uncertain and should
be assessed by future trials. Second, we included healthy
patients with normal lung function who were undergoing
relatively short procedures. Thus, the generalisability of
our results is limited to healthy patients and further
studies are required in high-risk patients or in high-risk
surgical settings. Third, we did not record the driving
pressures. Instead, we analysed modified driving pressure
as performed by previous studies.27,28 Fourth, the appli-
cation of lung ultrasound-guided recruitment man-
oeuvres may be limited in real practice as application
of the ultrasound probe to the posterior part of the body
can be difficult, particularly during surgery. Fifth, we
applied a PEEP of 5 cmH2O in every patient in this trial,
which might not be an optimal PEEP during laparoscopic
surgery.8 The results could be influenced by the different
ventilator settings. Lastly, we did not record the surgical
working conditions as rated by the surgeons. However, no
complaint was reported by surgeons during the entire
course of the study.
In conclusion, lung ultrasound-guided recruitment man-
oeuvres improve LUS at the end of surgery compared with
conventional recruitment manoeuvres in adult patients
undergoing laparoscopic surgery. The number and maxi-
mal inflation pressures of recruitment manoeuvres
required to restore lung aerations are highly variable
among individuals. However, ultrasound-guided recruit-
ment manoeuvres neither improved lung mechanics nor
reduced the PPCs in the low-risk surgical patients. Further
research is required to define the role of ultrasound-guided
recruitment manoeuvres in surgical settings.
Acknowledgements relating to this article
Assistance with the study: none.
Financial support and sponsorship: none.
Conflicts of interest: none.
Presentation: none.
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