Room air versus carbon dioxide pneumoperitoneum: effects on oxidative state, apoptosis and histology of splanchnic organs

Gases for establishing pneumoperitoneum during laparoscopic abdominal surgery

BACKGROUND

This is the second update of a Cochrane Review first published in 2013 and last updated in 2017. Laparoscopic surgery is now widely performed to treat various abdominal diseases. Currently, carbon dioxide is the most frequently used gas for insufflation of the abdominal cavity (pneumoperitoneum). Although carbon dioxide meets most of the requirements for pneumoperitoneum, the absorption of carbon dioxide may be associated with adverse events. Therefore, other gases have been introduced as alternatives to carbon dioxide for establishing pneumoperitoneum.

OBJECTIVES

To assess the safety, benefits, and harms of different gases (e.g. carbon dioxide, helium, argon, nitrogen, nitrous oxide, and room air) used for establishing pneumoperitoneum in participants undergoing laparoscopic abdominal or gynaecological pelvic surgery.

SEARCH METHODS

We searched CENTRAL, Ovid MEDLINE, Ovid Embase, four other databases, and three trials registers on 15 October 2021 together with reference checking, citation searching, and contact with study authors to identify additional studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different gases for establishing pneumoperitoneum in participants (irrespective of age, sex, or race) undergoing laparoscopic abdominal or gynaecological pelvic surgery under general anaesthesia.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

We included 10 RCTs, randomising 583 participants, comparing different gases for establishing pneumoperitoneum: nitrous oxide (four trials), helium (five trials), or room air (one trial) was compared to carbon dioxide. All the RCTs were single-centre studies. Four RCTs were conducted in the USA; two in Australia; one in China; one in Finland; one in Iran; and one in the Netherlands. The mean age of the participants ranged from 27.6 years to 49.0 years. Four trials randomised participants to nitrous oxide pneumoperitoneum (132 participants) or carbon dioxide pneumoperitoneum (128 participants). None of the trials was at low risk of bias. The evidence is very uncertain about the effects of nitrous oxide pneumoperitoneum compared to carbon dioxide pneumoperitoneum on cardiopulmonary complications (Peto odds ratio (OR) 2.62, 95% CI 0.78 to 8.85; 3 studies, 204 participants; very low-certainty evidence), or surgical morbidity (Peto OR 1.01, 95% CI 0.14 to 7.31; 3 studies, 207 participants; very low-certainty evidence). There were no serious adverse events related to either nitrous oxide or carbon dioxide pneumoperitoneum (4 studies, 260 participants; very low-certainty evidence). Four trials randomised participants to helium pneumoperitoneum (69 participants) or carbon dioxide pneumoperitoneum (75 participants) and one trial involving 33 participants did not state the number of participants in each group. None of the trials was at low risk of bias. The evidence is very uncertain about the effects of helium pneumoperitoneum compared to carbon dioxide pneumoperitoneum on cardiopulmonary complications (Peto OR 1.66, 95% CI 0.28 to 9.72; 3 studies, 128 participants; very low-certainty evidence), or surgical morbidity (5 studies, 177 participants; very low-certainty evidence). There were three serious adverse events (subcutaneous emphysema) related to helium pneumoperitoneum (3 studies, 128 participants; very low-certainty evidence). One trial randomised participants to room air pneumoperitoneum (70 participants) or carbon dioxide pneumoperitoneum (76 participants). The trial was at high risk of bias. There were no cardiopulmonary complications, serious adverse events, or deaths observed related to either room air or carbon dioxide pneumoperitoneum.    AUTHORS' CONCLUSIONS: The evidence is very uncertain about the effects of nitrous oxide, helium, and room air pneumoperitoneum compared to carbon dioxide pneumoperitoneum on any of the primary outcomes, including cardiopulmonary complications, surgical morbidity, and serious adverse events. The safety of nitrous oxide, helium, and room air pneumoperitoneum has yet to be established, especially in people with high anaesthetic risk.

Gut-Barrier Disruption After Laparoscopic Versus Open Major Liver Resection in the Rat

BACKGROUND

Major liver resection may compromise gut-barrier function, increasing the risk of postoperative infectious complications. The aim of the present experimental study was to compare the effect of the laparoscopic versus the open technique for major liver resection on integrity as well as inflammatory and immune responses of the gut barrier.

METHODS

Wistar rats were subjected to open 70% hepatectomy (group H), laparoscopic 70% hepatectomy (group LH), sham operation (group S) or no intervention (group C). At various timepoints (1 hour-1 week) after operation, ileal tissue was excised for oxidative state assessment (TBARS levels), histopathologic examination, histomorphometric analysis, immunohistochemical assessment of the mitotic and apoptotic activity, and tissue expression of inflammatory (interleukin-6, tumor necrosis factor-α, nuclear factor-κB and vascular cell adhesion molecule-1) and immune response biomarkers (CD4⁺ and CD8⁺ T-lymphocytes) of the intestinal mucosa.

RESULTS

No changes were noted in oxidative state. The histopathologic profile was less deteriorated in group LH compared to group H. Intestinal mucosa atrophy was less intense in group LH compared to group H and was related to an equally compromised crypt cell mitotic activity. Tissue overexpression of interleukin-6, tumor necrosis factor-α, nuclear factor-κΒ, vascular cell adhesion molecule-1, CD4⁺, and CD8⁺ T-lymphocytes was less pronounced in group LH compared to group H.

CONCLUSION

The employment of the laparoscopic technique for major liver resection in the rat attenuated disruption of the gut barrier compared to the open procedure. This was related to less pronounced inflammatory and immune responses of the intestinal mucosa.

Carbon Dioxide Pneumoperitoneum May Alter Ovarian Apoptosis: An Experimental Study

Objectives:

The aim of this study was to evaluate ovarian immunohistochemical CD95 expression in a rabbit carbon dioxide pneumoperitoneum model.

Materials and Methods:

The study group including seven rabbits was subjected to intra-abdominal pressure (IAP) (12 mmHg); the control group was not subjected to IAP (the sham group, n = 7). At the end of the experiment, ovariectomy was performed. Immunohistochemical stained histologic specimen of the ovary with CD95 was evaluated. Based on the degree of cytoplasmic or membranous staining for CD95 from 0 (none) to 3 (severe), a microscopic apoptosis scoring system was used.

Results:

Statistically significantly higher apoptosis scores in ovarian surface epithelial cells (2.57 ± 0.53, vs. 1.14 ± 0.38, P = 0.002, Mann–Whitney U-test, respectively), follicular epithelial cells (2.85 ± 0.38, vs. 1.85 ± 0.38, P = 0.002, Mann–Whitney U-test, respectively), and stromal cells (2.71 ± 0.49, vs. 1.29 ± 0.49, P = 0.002, Mann–Whitney U-test, respectively) were observed in pneumoperitoneum group, compared with no-pneumoperitoneum group.

Conclusion:

Even at safe IAP (12 mmHg) for an acceptable operation time period, there was a significant increase in apoptosis of ovarian cells.

Effects of deep neuromuscular block with low-pressure pneumoperitoneum on respiratory mechanics and biotrauma in a steep Trendelenburg position

We hypothesized that deep neuromuscular blockade (NMB) with low-pressure pneumoperitoneum (PP) would improve respiratory mechanics and reduce biotrauma compared to moderate NMB with high-pressure PP in a steep Trendelenburg position. Seventy-four women undergoing robotic gynecologic surgery were randomly assigned to two equal groups. Moderate NMB group was maintained with a train of four count of 1–2 and PP at 12 mmHg. Deep NMB group was maintained with a post-tetanic count of 1–2 and PP at 8 mmHg. Inflammatory cytokines were measured at baseline, at the end of PP, and 24 h after surgery. Interleukin-6 increased significantly from baseline at the end of PP and 24 h after the surgery in moderate NMB group but not in deep NMB group (P_group*time = 0.036). The peak inspiratory, driving, and mean airway pressures were significantly higher in moderate NMB group than in deep NMB group at 15 min and 60 min after PP (P_group*time = 0.002, 0.003, and 0.048, respectively). In conclusion, deep NMB with low-pressure PP significantly suppressed the increase in interleukin-6 developed after PP, by significantly improving the respiratory mechanics compared to moderate NMB with high-pressure PP during robotic surgery.

Effect of laparoscopic liver resection versus the open technique on hepatocyte regenerating activity in the rat

BACKGROUND

Laparoscopic liver resection offers a safe and feasible option primarily for the excision of hepatic neoplasms. Timely recovery of liver volume is a key factor for improving prognosis and post-operative mortality of patients undergone liver resection. The aim of the present study was to compare liver regeneration after laparoscopic over open partial hepatectomy.

METHODS

Wistar rats were subjected to laparoscopic 70% hepatectomy (group LAP-HEP), open 70% hepatectomy (group HEP), sham operation (group Sham) or no intervention (group Control). At various timepoints following operation (1 h-2 weeks), the liver was excised to assess relative liver weight, thiobarbituric acid reactive substances (TBARS) levels, mitotic activity, tissue expression of Nuclear Factor-κB (NFκB), Intercellular Adhesion Molecule-1 (ICAM-1) and Vascular Cell Adhesion Molecule-1 (VCAM-1) and the histopathologic profile.

RESULTS

No differences were seen in relative liver weight between hepatectomy groups. Mitotic index was increased in all operative study groups, being higher in group LAP-HEP than in group HEP. TBARS levels were higher in group LAP-HEP compared to group HEP. NFκB and VCAM-1 tissue expression scores were increased in all operative study groups with VCAM-1 being higher in group HEP, while ICAM-1 was overexpressed only in hepatectomy groups. Mild histopathologic lesions were noted in hepatectomy groups with the histopathologic score being higher in group HEP (24 h).

CONCLUSIONS

Laparoscopic liver resection enhanced hepatocyte mitotic activity which was accompanied by mild oxidative stress and a less pronounced local inflammatory response and tissue injury to that of the open technique.

Protective effects of postconditioning in transvaginally created pneumoperitoneum

There are reports of ischemic complications in clinical practice after laparoscopy using pneumoperitoneum. Conditioning has a beneficial effect for various ischemic diseases. This experimental study was designed to evaluate the effects of postconditioning in transvaginally created pneumoperitoneum. Sixty adult female rats, weighing 300±50 g were divided into four equal groups. Pneumoperitoneum was created by CO₂ insufflation under a pressure of 10 mmHg. Rats in the first group (sham) were subjected to only sham-operation or gas insufflation. The second group (TV/PP) was subjected to pneumoperitoneum for 60 min followed by 30 min of desufflation. The third group (post-5) was subjected to pneumoperitoneum for 60 min followed by 5 min of desufflation, 5 min of insufflation and again followed by 30 min of desufflation. The fourth group (post-2.5) was subjected to pneumoperitoneum for 60 min followed by 2.5 min of desufflation and 2.5 min of insufflation-repeated in two cycles- and then followed by 30 min of desufflation. The rats were sacrificed, and blood was collected after 30 min, 2 and 6 h from the last desufflation. Levels of oxidative stress markers, malondialdehyde (MDA), superoxide dismutase (SOD), reduced glutathione (GSH), sulfhydryl groups (SH) and inflammatory cytokine TNF-α, were analyzed. Levels of MDA in the post-5 group were significantly reduced compared to the TV/PP and post-2.5 groups. The level of GSH in TV/PP animals was markedly reduced compared to the Sham, Post-5 and Post-2.5 groups. In addition, levels of SH were increased in the Post-5 group in comparison to the Sham, TV/PP and Post-2.5 groups. No difference in the activity of SOD between the groups was found, and the concentration of TNF-α in TV/PP animals was significantly higher than that in the Sham and postconditioning groups. Overall, the results of the present study indicate that postconditioning can reduce pneumoperitoneum-induced oxidative injury.

Effects of a multifaceted individualized pneumoperitoneum strategy in elderly patients undergoing laparoscopic colorectal surgery: A retrospective study

BACKGROUND

Laparoscopic colorectal surgery may adversely affect respiration, circulation, and acid-base balance in elderly patients, owing to the relatively long duration of CO2 absorption. We conducted this retrospective study to determine the safety and efficacy of warmed, humidified CO2 pneumoperitoneum in elderly patients undergoing laparoscopic colorectal surgery.

METHODS

We enrolled 245 patients between January 2016 and August 2018.The experimental group (warming and humidification group [WH]) received warmed (37°C), humidified (98%) insufflation of CO2, and the control group (cold, dry CO2/control group [CD]) received standard CO2 (19°C, 0%). All other aspects of patient care were standardized. Intraoperative hemodynamic data, arterial blood pH, and lactic acid levels were recorded. We also recorded intra-abdominal pressure, incidence of shivering 1 hour after surgery, satisfaction scores of patients and surgeons 24 hours after surgery, times to first flatus/defecation, first bowel movement, and tolerance of semiliquid food, discharge time, and incidence of vomiting, diarrhea, and surgical site infections.

RESULTS

Compared with the WH group, heart rate and mean arterial pressure were significantly higher from T3 to T8 (P < .05), lactic acid levels were significantly higher from T4 to T9 (P < .05), and recovery time in the post-anesthesia care unit (PACU) was significantly longer in the CD group (P < .05). Patient and surgeon satisfaction scores were significantly higher in the WH group than the CD group (P < .05). In addition, the times to first flatus/defecation and bowel movement were significantly longer in the CD group (P < .05). No significant differences were noted between the groups in the time to tolerance of semiliquid food and time of discharge (P > .05). The incidence of vomiting, diarrhea, and shivering was significantly lower in the WH group (P < .05). The number of patients with a shivering grade of 0 was significantly higher in the WH group, whereas the number with a shivering grade of 3 was significantly higher in the CD group (P < .05).

CONCLUSION

Warmed, humidified insufflation of CO2 in elderly patients undergoing laparoscopic colorectal surgery could stabilize hemodynamics, and reduce lactic acid levels, recovery time in the PACU, and the incidence of acute gastrointestinal injury-related symptoms.