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Ippolito A, Mulier J, Hahn M, Wenzel M, Mandel P, Flinspach AN, Wenger KJ. Moderate Intra-Abdominal Pressure Levels in Robot-Assisted Radical Prostatectomy Seem to Have No Negative Impact on Clinical Outcomes. J Clin Med 2024; 13:1202. [PMID: 38592056 PMCID: PMC10932126 DOI: 10.3390/jcm13051202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2023] [Revised: 01/27/2024] [Accepted: 02/06/2024] [Indexed: 04/10/2024] Open
Abstract
Introduction: Radical prostatectomy is increasingly performed laparoscopically with robot assistance (RALRP). RALRP, as with all laparoscopic procedures, requires a pneumoperitoneum, which might result in peritoneal inflammatory response reactions and postoperative pain. The aim of this retrospective single-centre study was to analyse the effects of a pneumoperitoneum during RARLP on clinical outcomes. Methods: All patients who underwent robot-guided prostatectomy in our clinic were included, with the exception of patients who were converted to open prostatectomy. C-reactive protein was used as a marker for the primary outcome, namely the postoperative inflammatory response. Intra-abdominal pressure (IAP) was evaluated as a potential factor influencing inflammation. In addition, the waist-hip ratio was used to estimate the amount of visceral adipose tissue, and the administration of dexamethasone was considered as a factor influencing inflammation. The Visual Analogue Scale (VAS) was used to determine postoperative pain. Patients were consecutively recruited between 1 September 2020 and 31 March 2022. Results: A total of 135 consecutive patients were included. The median waist-hip ratio was 0.55. The median duration of the pneumoperitoneum was 143 min. The median values of the average and maximum IAP values were 10 mmHg and 15 mmHg, respectively. The mean CRP of the first postoperative day was 6.2 mg/dL. The median VAS pain level decreased from 2 to 1 from the first to the third postoperative day. On the first postoperative day, 16 patients complained of shoulder pain. In addition, 134 patients were given some form of opioid pain treatment following surgery. Conclusion: We could not identify any relevant associations between the duration and IAP of the pneumoperitoneum and the indirect markers of inflammation or indicators of pain, or between the latter and the amount of visceral adipose tissue. In addition, we found no significant effect of the administration of dexamethasone on postoperative inflammation. The results point to a noninferior tolerability of moderate pressure during the procedure compared to the commonly utilised higher pressure, yet this must be confirmed in randomised controlled trials.
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Affiliation(s)
- Angelo Ippolito
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Jan Mulier
- Department of Anaesthesiology, Intensive Care and Reanimation, AZ Sint Jan Brugge, 8000 Bruges, Belgium
- Department of Anesthesiology, KULeuven, 3000 Leuven, Belgium
- Department of Anesthesiology, UGhent, 9000 Ghent, Belgium
| | - Marta Hahn
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Mike Wenzel
- Department of Urology, University Hospital Frankfurt, Goethe-University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Philipp Mandel
- Department of Urology, University Hospital Frankfurt, Goethe-University Frankfurt, 60590 Frankfurt am Main, Germany
| | - Armin N. Flinspach
- Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Goethe-University Frankfurt, Theodor-Stern Kai 7, 60590 Frankfurt am Main, Germany
| | - Katharina J. Wenger
- Institute of Neuroradiology, University Hospital Frankfurt, Goethe-University Frankfurt, 60528 Frankfurt am Main, Germany
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Binda MM, Riiskjaer M, Koninckx PR. Pneumoperitoneum induced mesothelial cell changes in a laparoscopic mouse model. Eur J Obstet Gynecol Reprod Biol 2021; 265:107-112. [PMID: 34482234 DOI: 10.1016/j.ejogrb.2021.08.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/03/2021] [Accepted: 08/19/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND CO2 pneumoperitoneum (PP) during laparoscopic surgery, can cause hypoxia and desiccation in the peritoneal mesothelial cell, resulting in a time-dependent retraction and bulging of these cells, an acute inflammatory reaction and enhanced adhesion formation. Since hypoxia is prevented by adding 4% of oxygen (O2) to the CO2 PP, the aim of this study was to evaluate the effect of adding 4% O2 to the CO2 PP on mesothelial cell morphology. METHODS In a standardized laparoscopic mouse model (n=8 mice per group), a control group with a 30- or 60-min PP with humidified CO2 + 4% of O2 (groups I and II) was compared to a hypoxic group with 30- or 60-min humidified pure CO2 (groups III and IV) and a desiccation group with 60-min of dry CO2 PP (group V). The effect upon the peritoneum morphology was evaluated by scanning electron microscopy (SEM) of abdominal wall peritoneal biopsies. Biopsies, taken immediately (n=4) and 24 hrs (n=4) after surgery, were compared to a group without PP (group VI, n=4). SEM pictures were blindly scored for cell retraction, deletion of microvilli, fibrin deposition, holes in the epithelial layer and visibility of cell borders using a semi-quantitative scoring system. RESULTS PP Hypoxia (CO2 PP) has a deleterious effect upon mesothelial morphology, immediately (holes: p= 0.04) and 24 hrs later (cell retraction: p=0.005; total score: p=0.03) . Desiccation has also a deleterious effect immediately (microvilli p=0.0090; fibrin deposition p=0.05) and 24 hrs after surgery (cell retraction: p=0.0036; holes: p=0.0004; microvilli: p< 0.0001, fibrin deposition: p=0.0225; borders: p=0.0007). This deleterious effect increases with duration of CO2 PP, affecting cell retraction (p=0.016), holes (p=0.0441), and the total score (p=0.0488). The addition of 4% of O2 to the CO2 PP failed to reach statistical significance. CONCLUSIONS These data confirm that CO2 PP and dry gas have a deleterious effect on mesothelial cell morphology. Humidification of the insufflation gas reduces this deleterious effect. The hypothesis of a protective effect of adding O2 failed to reach significance.
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Affiliation(s)
- Maria Mercedes Binda
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven (KULeuven), Leuven, Belgium.
| | - Mads Riiskjaer
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven (KULeuven), Leuven, Belgium.
| | - Philippe Robert Koninckx
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven (KULeuven), Leuven, Belgium.
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The "Dark Side" of Pneumoperitoneum and Laparoscopy. Minim Invasive Surg 2021; 2021:5564745. [PMID: 34094598 PMCID: PMC8163537 DOI: 10.1155/2021/5564745] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 04/29/2021] [Accepted: 05/08/2021] [Indexed: 12/14/2022] Open
Abstract
Laparoscopic surgery has been one of the most common procedures for abdominal surgery at pediatric age during the last few decades as it has several advantages compared to laparotomy, such as shorter hospital stays, less pain, and better cosmetic results. However, it is associated with both local and systemic modifications. Recent evidence demonstrated that carbon dioxide pneumoperitoneum might be modulated in terms of pressure, duration, temperature, and humidity to mitigate and modulate these changes. The aim of this study is to review the current knowledge about animal and human models investigating pneumoperitoneum-related biological and histological impairment. In particular, pneumoperitoneum is associated with local and systemic inflammation, acidosis, oxidative stress, mesothelium lining abnormalities, and adhesion development. Animal studies reported that an increase in pressure and time and a decrease in humidity and temperature might enhance the rate of comorbidities. However, to date, few studies were conducted on humans; therefore, this research field should be further investigated to confirm in experimental models and humans how to improve laparoscopic procedures in the spirit of minimally invasive surgeries.
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Papparella A, Noviello C, Ranucci S, Paciello O, Papparella S, De Biase D, Cirillo G, Umano GR. Pneumoperitoneum Modifies Serum and Tissue CCL2-CCL5 Expression in Mice. JSLS 2020; 24:JSLS.2020.00017. [PMID: 32508487 PMCID: PMC7242020 DOI: 10.4293/jsls.2020.00017] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background and Objectives: Laparoscopy is the preferred method when operating in the abdomen. In this study, we evaluated systemic and morphological peritoneal cytokine modifications (RANTES/CCL5 and MCP-1/CCL2) due to CO2 pneumoperitoneum in rats. Methods: Twenty-five prepubertal Sprague-Dawley rats were randomized into three groups. Pneumoperitoneum lasting 30 minutes, was induced with a flow of 0.5 L/min, in two groups (S1 and S2, n = 20), at a P/CO2 of 6 and 10 mm Hg, respectively. In the control group (C, n = 5), only anesthesia was carried out. All animals were sacrificed after 24 hours. The serum of the rats was collected for ELISA, and the levels of the cytokines RANTES and MCP-1 were investigated. An immunohistochemical analysis of RANTES and MCP-1 was performed on samples of the peritoneum, and the morphological evaluation was conducted with a blinded evaluation by two independent, experienced pathologists by using a grading system (0, 1+, 2+, 3+: no, faint, moderate, and strong reactivity, respectively). Results: RANTES mean levels were significantly different in the S1, S2, and C groups (70.3 ± 2.26, 58.23 ± 4.32, 29.66 ± 4.03, respectively, P = .0001). The levels of MCP-1 were 32.1 ± 1.63 in the S1 group, 27.0 ± 9.26 in the S2 group, and 16.4 ± 9.55 in the C group (P = .159). Normal control peritoneum showed little reactivity, whereas a moderate to strong cytoplasmic reaction to anti-CCL5/CCL2 antibodies was observed in mesothelial and inflammatory cells in the S1 and S2 groups. Conclusion: CO2 pneumoperitoneum evokes an inflammatory response by modifying plasma RANTES levels and peritoneal CCL5/CCL2 expression.
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Affiliation(s)
- Alfonso Papparella
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | | | - Sara Ranucci
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Orlando Paciello
- Faculty of Veterinary Medicine, Department of Pathology and Animal Health, University of Naples Federico II, Naples, Italy
| | - Serenella Papparella
- Faculty of Veterinary Medicine, Department of Pathology and Animal Health, University of Naples Federico II, Naples, Italy
| | - Davide De Biase
- Faculty of Veterinary Medicine, Department of Pathology and Animal Health, University of Naples Federico II, Naples, Italy
| | - Grazia Cirillo
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
| | - Giuseppina Rosaria Umano
- Department of Woman, Child, and General and Specialized Surgery, University of Campania "Luigi Vanvitelli," Naples, Italy
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Ioannidis A, Arvanitidis K, Filidou E, Valatas V, Stavrou G, Michalopoulos A, Kolios G, Kotzampassi K. The Length of Surgical Skin Incision in Postoperative Inflammatory Reaction. JSLS 2018; 22:e2018.00045. [PMID: 30518991 PMCID: PMC6251478 DOI: 10.4293/jsls.2018.00045] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Surgery provokes inflammatory and immune responses, so efforts have been made to reduce host response by using less invasive techniques. The purpose of this experimental study was to investigate the surgical stress induced by skin incision and the role of liver response in this process. METHODS Seventy male anesthetized Wistar rats were subjected to a midline incision confined strictly to the skin (dermis) of either 1 cm long (n = 20), 10 cm long (n = 20), or no incision (n = 20) or served as controls (n = 10). Skin trauma was left open for a 20-minutes period, and then was meticulously sutured. At 3 and 24 hours later, laparotomy was performed on half the rats of each group, for blood and liver sampling. In serum and liver homogenates, cytokine-induced neutrophil chemoattractant (CINC)1/interleukin (IL)-8 and tumor necrosis factor (TNF)-α levels were measured with enzyme-linked immunosorbent assays and nitric oxide (NO) using a Griess reaction. RESULTS Skin trauma was found to significantly (P < .01) increase all inflammatory mediators tested (CINC1/IL-8, TNF-α, NO) in serum of operated rats versus controls, the increase being proportionally dependent on the length of skin incision. In liver homogenates, CINC1/IL-8 was significantly (P < .01) increased in operated animals versus controls, similarly to serum levels. In contrast, liver TNF-α levels were inversely related to serum levels, and a significant (P < .01) decrease in TNF-α was observed in liver homogenates of operated animals compared with the controls, indicating that the increased TNF-α in blood reflects liver TNF-α secretion. CONCLUSION Our findings suggest that inflammatory and immune reactions induced by skin-only surgical trauma are closely correlated to the length of skin incision.
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Affiliation(s)
- Aristidis Ioannidis
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Eirini Filidou
- Laboratory of Pharmacology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Vassilis Valatas
- Gastroenterology Laboratory, Medical Department, University of Crete, Heraklion, Greece
| | - George Stavrou
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - George Kolios
- Laboratory of Pharmacology, Democritus University of Thrace, Alexandroupolis, Greece
| | - Katerina Kotzampassi
- Department of Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Koninckx PR, Gomel V, Ussia A, Adamyan L. Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue. Fertil Steril 2016; 106:998-1010. [PMID: 27523299 DOI: 10.1016/j.fertnstert.2016.08.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 02/08/2023]
Abstract
A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO2 pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N2O to the CO2 pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.
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Affiliation(s)
- Philippe R Koninckx
- Department of Obstetrics and Gynecology, Catholic University Leuven, University Hospital, Gasthuisberg, Leuven, Belgium; Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy.
| | - Victor Gomel
- Department of Obstetrics and Gynecology, University of British Columbia, Women's Hospital, Vancouver, British Columbia, Canada
| | - Anastasia Ussia
- Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Center for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia, Russian Federation
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7
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Peterse DP, Fassbender A, O DF, Vanhie A, Saunders P, Vriens J, Binda MM, D’Hooghe TM. Laparoscopic Surgery. Reprod Sci 2016; 23:1332-9. [DOI: 10.1177/1933719116638178] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- Daniëlle P. Peterse
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
| | - Amelie Fassbender
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
| | - Dorien F. O
- Department of Obstetrics and Gynaecology, Leuven University Fertility Centre, University Hospital Leuven, Leuven, Belgium
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
| | - Arne Vanhie
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
| | - Philippa Saunders
- MRC Centre for Inflammation Research, The University of Edinburgh, Edinburgh, Scotland, United Kingdom
| | - Joris Vriens
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
| | - M. Mercedes Binda
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
- *These authors contributed equally to the article
| | - Thomas M. D’Hooghe
- Department of Development and Regeneration, Laboratory of Experimental Gynaecology, KU Leuven, Leuven, Belgium
- Division of Reproductive Biology, Institute of Primate Research, Nairobi, Kenya
- *These authors contributed equally to the article
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Bette M, Springmann V, Rossmann A, Weihe E, Schütz B. Evidence for the absence of visceral pain in C57BL6/N mice subjected to therapeutically relevant O 3/O 2-pneumoperitoneum. Lab Anim 2016; 51:17-23. [PMID: 26946118 DOI: 10.1177/0023677216636832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Each different gas that is used to induce a pneumoperitoneum (PP) exhibits individual effects within the peritoneal cavity. This might include adverse effects such as pain and/or inflammatory reactions. The acute effects of ozonized oxygen (O3/O2), a highly oxidative gas mixture, after being insufflated into the peritoneal cavity are analysed in this study. Using the abdominal constriction response ('writhing') assay of chemical nociception in C57BL6/N mice, O3/O2-PP was found not to be associated with visible pain responses and did not alter the c-fos expression in the spinal cord. In addition, mRNA expression levels of the pro-inflammatory cytokines, interleukin (IL)-1β and IL-6, were found unaltered in the spleen 2 h after insufflation. In conclusion, O3/O2-PP is free of adverse pain and does not trigger inflammatory immune responses.
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Affiliation(s)
- Michael Bette
- Department of Molecular Neuroscience, Institute of Anatomy and Cell Biology, Philipps University, Marburg, Germany
| | - Volker Springmann
- Department of Molecular Neuroscience, Institute of Anatomy and Cell Biology, Philipps University, Marburg, Germany
| | - Annette Rossmann
- Department of Molecular Neuroscience, Institute of Anatomy and Cell Biology, Philipps University, Marburg, Germany
| | - Eberhard Weihe
- Department of Molecular Neuroscience, Institute of Anatomy and Cell Biology, Philipps University, Marburg, Germany
| | - Burkhard Schütz
- Department of Molecular Neuroscience, Institute of Anatomy and Cell Biology, Philipps University, Marburg, Germany
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Binda MM. Humidification during laparoscopic surgery: overview of the clinical benefits of using humidified gas during laparoscopic surgery. Arch Gynecol Obstet 2015; 292:955-71. [PMID: 25911545 PMCID: PMC4744605 DOI: 10.1007/s00404-015-3717-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 04/02/2015] [Indexed: 12/21/2022]
Abstract
PURPOSE The peritoneum is the serous membrane that covers the abdominal cavity and most of the intra-abdominal organs. It is a very delicate layer highly susceptible to damage and it is not designed to cope with variable conditions such as the dry and cold carbon dioxide (CO2) during laparoscopic surgery. The aim of this review was to evaluate the effects caused by insufflating dry and cold gas into the abdominal cavity after laparoscopic surgery. METHODS A literature search using the Pubmed was carried out. Articles identified focused on the key issues of laparoscopy, peritoneum, morphology, pneumoperitoneum, humidity, body temperature, pain, recovery time, post-operative adhesions and lens fogging. RESULTS Insufflating dry and cold CO2 into the abdomen causes peritoneal damage, post-operative pain, hypothermia and post-operative adhesions. Using humidified and warm gas prevents pain after surgery. With regard to hypothermia due to desiccation, it can be fully prevented using humidified and warm gas. Results relating to the patient recovery are still controversial. CONCLUSIONS The use of humidified and warm insufflation gas offers a significant clinical benefit to the patient, creating a more physiologic peritoneal environment and reducing the post-operative pain and hypothermia. In animal models, although humidified and warm gas reduces post-operative adhesions, humidified gas at 32 °C reduced them even more. It is clear that humidified gas should be used during laparoscopic surgery; however, a question remains unanswered: to achieve even greater clinical benefit to the patient, at what temperature should the humidified gas be when insufflated into the abdomen? More clinical trials should be performed to resolve this query.
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Affiliation(s)
- Maria Mercedes Binda
- Institut de Recherche Expérimentale et Clinique (IREC), Pôle de Gynécologie, Avenue Mounier 52, bte B1.52.02, 1200, Brussels, Belgium.
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Bolnick A, Bolnick J, Diamond MP. Postoperative Adhesions as a Consequence of Pelvic Surgery. J Minim Invasive Gynecol 2015; 22:549-63. [DOI: 10.1016/j.jmig.2014.12.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Revised: 12/05/2014] [Accepted: 12/08/2014] [Indexed: 01/12/2023]
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Extracorporal rat cecum mesothelium desiccation-induced by CO2 insufflation: is there a clinical sense of this adhesion formation model? Colloids Surf B Biointerfaces 2015; 128:620-621. [PMID: 25758291 DOI: 10.1016/j.colsurfb.2015.02.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2014] [Revised: 01/21/2015] [Accepted: 02/12/2015] [Indexed: 11/24/2022]
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12
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Carpinteri S, Sampurno S, Bernardi MP, Germann M, Malaterre J, Heriot A, Chambers BA, Mutsaers SE, Lynch AC, Ramsay RG. Peritoneal Tumorigenesis and Inflammation are Ameliorated by Humidified-Warm Carbon Dioxide Insufflation in the Mouse. Ann Surg Oncol 2015; 22 Suppl 3:S1540-7. [PMID: 25794828 PMCID: PMC4687477 DOI: 10.1245/s10434-015-4508-1] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2014] [Indexed: 11/18/2022]
Abstract
Background Conventional laparoscopic surgery uses CO2 that is dry and cold, which can damage peritoneal surfaces. It is speculated that disseminated cancer cells may adhere to such damaged peritoneum and metastasize. We hypothesized that insufflation using humidified-warm CO2, which has been shown to reduce mesothelial damage, will also ameliorate peritoneal inflammation and tumor cell implantation compared to conventional dry-cold CO2. Methods Laparoscopic insufflation was modeled in mice along with anesthesia and ventilation. Entry and exit ports were introduced to maintain insufflation using dry-cold or humidified-warm CO2 with a constant flow and pressure for 1 h; then 1000 or 1 million fluorescent-tagged murine colorectal cancer cells (CT26) were delivered into the peritoneal cavity. The peritoneum was collected at intervals up to 10 days after the procedure to measure inflammation, mesothelial damage, and tumor burden using fluorescent detection, immunohistochemistry, and scanning electron microscopy. Results Rapid temperature control was achieved only in the humidified-warm group. Port-site tumors were present in all mice. At 10 days, significantly fewer tumors on the peritoneum were counted in mice insufflated with humidified-warm compared to dry-cold CO2 (p < 0.03). The inflammatory marker COX-2 was significantly increased in the dry-cold compared to the humidified-warm cohort (p < 0.01), while VEGFA expression was suppressed only in the humidified-warm cohort. Significantly less mesothelial damage and tumor cell implantation was evident from 2 h after the procedure in the humidified-warm cohort. Conclusions Mesothelial cell damage and inflammation are reduced by using humidified-warm CO2 for laparoscopic oncologic surgery and may translate to reduce patients’ risk of developing peritoneal metastasis. Electronic supplementary material The online version of this article (doi:10.1245/s10434-015-4508-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sandra Carpinteri
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Shienny Sampurno
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Maria-Pia Bernardi
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia.,Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Markus Germann
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Jordane Malaterre
- Cancer Research Division, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Alexander Heriot
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Brenton A Chambers
- Faculty of Veterinary Science, University of Melbourne, Parkville, VIC, Australia
| | - Steven E Mutsaers
- Lung Institute of Western Australia and Centre for Cell Therapy and Regenerative Medicine, Nedlands, WA, Australia
| | - Andrew C Lynch
- Department of Surgical Oncology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
| | - Robert G Ramsay
- Peter MacCallum Cancer Centre, Sir Peter MacCallum Department of Oncology, The University of Melbourne, Melbourne, VIC, Australia.
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The effect of peritoneal air exposure on intestinal mucosal barrier. Gastroenterol Res Pract 2014; 2014:674875. [PMID: 25210511 PMCID: PMC4158158 DOI: 10.1155/2014/674875] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Revised: 07/17/2014] [Accepted: 08/04/2014] [Indexed: 11/25/2022] Open
Abstract
Background. Damage of the intestinal mucosa barrier may result in intestinal bacterial and endotoxin translocation, leading to local and systemic inflammation. The present study was designed to investigate whether peritoneal air exposure induces damage of intestinal mucosal barrier. Methods. Sprague-Dawley rats (weighing 210 to 230 g) were randomized into five groups (6/group): a control group, a sham group, and three exposure groups with peritoneal air exposure for 1, 2, and 3 h, respectively. At 24 h after surgery, blood and terminal ileum were sampled. The serum D-lactate levels were determined using an ELISA kit. The intestinal permeability was determined by measuring the intestinal clearance of FITC-dextran (FD4). The histopathological changes in terminal ileum were also assessed. Results. Compared with the controls, peritoneal air exposure caused an increase in both serum D-lactate level and intestinal FD4 clearance, which were proportional to the length of peritoneal air exposure and correlated to Chiu's scores, indices for intestinal mucosal injury. Edema and inflammatory cells were also observed in mucosa and submucosa of ileum in three exposure groups. Conclusions. Peritoneal air exposure could induce damage to the intestinal mucosal barrier, which is proportional to the time length of peritoneal air exposure.
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Matsuzaki S, Canis M, Botchorishvili R. "Gain more working space at a low intraperitoneal pressure" may be a difficult, but worthy anesthesiologic challenge. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2014; 61:2-5. [PMID: 24342168 DOI: 10.1016/j.redar.2013.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/17/2013] [Accepted: 10/21/2013] [Indexed: 06/03/2023]
Affiliation(s)
- S Matsuzaki
- CHU Clermont-Ferrand, CHU Estaing, Chirurgie Gynécologique, Clermont-Ferrand, France; Clermont Université, Université d'Auvergne, ISIT UMR6284, Clermont-Ferrand, France; CNRS, ISIT UMR6284, Clermont-Ferrand, France.
| | - M Canis
- CHU Clermont-Ferrand, CHU Estaing, Chirurgie Gynécologique, Clermont-Ferrand, France; Clermont Université, Université d'Auvergne, ISIT UMR6284, Clermont-Ferrand, France; CNRS, ISIT UMR6284, Clermont-Ferrand, France
| | - R Botchorishvili
- CHU Clermont-Ferrand, CHU Estaing, Chirurgie Gynécologique, Clermont-Ferrand, France; Clermont Université, Université d'Auvergne, ISIT UMR6284, Clermont-Ferrand, France; CNRS, ISIT UMR6284, Clermont-Ferrand, France
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de Vries A, Mårvik R, Kuhry E. Reply to the letter entitled 'An inexact study design produces misleading conclusions'. Int J Surg 2014; 12:251-2. [PMID: 24378912 DOI: 10.1016/j.ijsu.2013.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2013] [Revised: 12/13/2013] [Accepted: 12/19/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Arild de Vries
- Norwegian University of Science and Technology (NTNU), Department of Cancer Research and Molecular Medicine, Trondheim, Norway.
| | - Ronald Mårvik
- Norwegian University of Science and Technology (NTNU), Department of Cancer Research and Molecular Medicine, Trondheim, Norway; Trondheim University Hospital, National Center for Advanced Laparoscopic Surgery (NSALK), Department of Surgery, St. Olavs Hospital, Olav Kyrres Gate 17, 7491 Trondheim, Norway
| | - Esther Kuhry
- Norwegian University of Science and Technology (NTNU), Department of Cancer Research and Molecular Medicine, Trondheim, Norway; Trondheim University Hospital, National Center for Advanced Laparoscopic Surgery (NSALK), Department of Surgery, St. Olavs Hospital, Olav Kyrres Gate 17, 7491 Trondheim, Norway
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de Vries A, Mårvik R, Kuhry E. To perform operative procedures in an optimized local atmosphere: can it reduce post-operative adhesion formation? Int J Surg 2013; 11:1118-22. [PMID: 24080114 DOI: 10.1016/j.ijsu.2013.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2012] [Revised: 09/10/2013] [Accepted: 09/12/2013] [Indexed: 01/12/2023]
Abstract
BACKGROUND Adhesion formation is a major problem following abdominal surgery as it creates a considerable economic burden in addition to an increased risk for complications. In the present study, an effort was made to reduce post-operative adhesion formation by creating an artificial atmosphere within and around the abdominal cavity during an open surgical procedure. METHODS 82 Wistar male rats (Clr:WI) (200 gr, 7 weeks) were randomized into two groups. The abdominal cavity of the control group was exposed to the normal atmosphere of the operating-theatre during surgery (21% O₂, 21 °C, 40-47% relative humidity (RH)), while the abdominal cavity of the study group was exposed to an artificial atmosphere during surgery (3-6% O₂, >75% CO₂, 95-100% RH, 37 °C). Adhesion induction consisted of a laparotomy along linea-alba, four lesions in the anterior abdominal-wall, blood from the tail vein dripped inside the abdominal cavity and exposure to the atmosphere around the wound by use of self-retaining retractors. In addition, a liquid-sample for quantitative bacteriologic cultivation and bacterial load (CFU/ml) calculation was taken just before closure. After 3 weeks the abdominal cavity was scored for the extent, tenacity and severity of adhesions before the rats were euthanized. The two-sample-Wilcoxon-rank-sum test was used in the analysis. RESULTS Highly significant differences in postoperative total adhesion score, extent-, severity- and tenacity-score were found (P < 0.01). No differences were found between the two groups regarding mean bacterial load (P > 0.05). CONCLUSIONS The rats exposed to the warmed and humidified artificial atmosphere consisting of more than 75% carbon dioxide and 3-4% oxygen during surgery had more severe and more post-operative adhesions compared to the rats that were exposed to the ambient air during surgery.
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Affiliation(s)
- Arild de Vries
- Norwegian University of Science and Technology (NTNU), Department of Cancer Research and Molecular Medicine, Trondheim, Norway.
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The effects of insufflation conditions on rat mesothelium. Int J Inflam 2013; 2013:816283. [PMID: 23864985 PMCID: PMC3707227 DOI: 10.1155/2013/816283] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 06/11/2013] [Accepted: 06/11/2013] [Indexed: 11/18/2022] Open
Abstract
Aim. The aim of this investigation was to examine the alterations in the peritoneum after cold dry CO2, heated dry CO2, and humidified heated CO2 at pressures equivalent to intraperitoneal pressures used in human laparoscopy. Methods. Eighteen rats were divided into 4 treatment groups—group 1: untreated control; group 2: insufflation with cold dry CO2; group 3: insufflation with heated, dry CO2; group 4: insufflation with heated and humidified CO2. The abdomen was insufflated to 5 mm/Hg (flow rate 50 mL/min) for 2 h. Twelve hours later, tissue samples were collected for analysis by light microscopy (LM) and scanning electron microscopy (SEM). Results. Group 1: no abnormalities were detected. Group 2: specimens revealed an inflammatory response with loss of mesothelium and mesothelial cell nuclei showing lytic change. Cells were rounded with some areas of cell flattening and separation. Group 3: some animals showed little or no alteration, while others had a mild inflammatory response. Mesothelial cells were rounded and showed crenation on the exposed surface. Group 4: specimens showed little change from the control group. Conclusions. The LM results indicate that insufflations with heated, humidified CO2 are the least likely to induce mesothelial damage.
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Tarhan OR, Barut I, Ozogul C, Bozkurt S, Baykara B, Bulbul M. Structural deteriorations of the human peritoneum during laparoscopic cholecystectomy. A transmission electron microscopic study. Surg Endosc 2013; 27:2744-50. [PMID: 23392979 DOI: 10.1007/s00464-013-2801-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 12/31/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND In previous studies, changes in the surface of the peritoneum during laparoscopic surgery are well defined. Nevertheless, almost all of these studies were performed on rodents via scanning electron microscopy. In the present study, structural alterations of the mesothelial cells of peritoneum were examined during laparoscopic cholecystectomy using transmission electron microscopy. METHODS Twenty patients with symptomatic cholelithiasis were included in the study. Peritoneal biopsy was performed immediately after CO2 pneumoperitoneum creation and at the end of surgery just before gallbladder removal. Biopsies were taken from the right upper quadrant, i.e., apart from operative manipulation. Peritoneal sample cross-sections were compared using transmission electron microscopy. RESULTS The carbon dioxide pneumoperitoneum during laparoscopic cholecystectomy caused deteriorations of the peritoneal mesothelium. Apoptosis were developed in mesothelial cells. Bulging of mesothelial cells, irregular cell junctions, focal intercellular clefts, apical cell membrane degeneration, deep nuclear invaginations, and lipid droplets in the cytoplasm of the mesothelial cells were other remarkable findings. Mesothelial edema also was determined. DISCUSSION As seen in previous studies, basement membrane nudity appeared after carbon dioxide pneumoperitoneum could be attributable to mesothelial cell apoptosis, deterioration of the cell structure, and cell organelles.
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Affiliation(s)
- Omer Ridvan Tarhan
- Department of General Surgery, Faculty of Medicine, Suleyman Demirel University, Mehmet Tonge Mah. Unikent Sitesi 23/A, 32000 Isparta, Turkey.
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Matsuzaki S, Botchorishvili R, Jardon K, Maleysson E, Canis M, Mage G. Impact of intraperitoneal pressure and duration of surgery on levels of tissue plasminogen activator and plasminogen activator inhibitor-1 mRNA in peritoneal tissues during laparoscopic surgery. Hum Reprod 2011; 26:1073-81. [PMID: 21393301 DOI: 10.1093/humrep/der055] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Our objective was to evaluate the impact of intraperitoneal pressure (IPP) and duration of a CO(2) pneumoperitoneum on the peritoneal fibrinolytic system during laparoscopic surgery. METHODS Human study: Patients undergoing laparoscopic surgery were divided into two groups: low (8 mmHg, n= 32) or standard (12 mmHg, n= 36) IPP. Normal peritoneum was collected from the parietal wall at the beginning of surgery and every 60 min thereafter. Mouse study: Mice were divided into three groups: low (2 mmHg) or high (8 mmHg) IPP or laparotomy. Peritoneal tissue was collected at 0, 4, 8, 24, 48 and 72 h, and 5 and 7 days after surgery. Real-time RT-PCR was performed in humans and mice to measure the levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor-1 (PAI-1) mRNA in peritoneal tissues. RESULTS Human study: The tPA/PAI-1 mRNA ratio was significantly decreased in the 12 mmHg group at 1 h [P < 0.0001 versus matched initial peritoneal biopsies (MI)]. The tPA/PAI-1 mRNA ratio decreased in both groups at 2 h (P < .0.01 versus MI). Mouse study: The tPA/PAI-1 ratio was decreased at 0 h, and the difference was significant at 4 h in both the laparotomy (P < 0.001 versus controls, 0 h, 5 and 7 days) and high-IPP (P < 0.0001 versus 0, 48 and 72 h, 5 and 7 days) groups. No changes in tPA/PAI-1 ratio were observed in the low-IPP group. CONCLUSIONS A low IPP and shorter duration of surgery appear to minimally impact the fibrinolytic system during a CO₂ pneumoperitoneum.
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Affiliation(s)
- Sachiko Matsuzaki
- Chirurgie Gynécologique, CHU Clermont-Ferrand, Clermont-Ferrand, France.
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Chui CH, Lee ACW. Peritoneal metastases after laparoscopic nephron-sparing surgery for localized Wilms tumor. J Pediatr Surg 2011; 46:e19-e21. [PMID: 21376182 DOI: 10.1016/j.jpedsurg.2010.11.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 11/03/2010] [Accepted: 11/04/2010] [Indexed: 02/05/2023]
Abstract
A 2-year-old girl was referred for the management of the progression of her localized Wilms tumor. She had undergone laparoscopic nephron-sparing surgery for her right Wilms tumor 3 months earlier. Postoperative chemotherapy was commenced 6 weeks later. Subsequent computer tomographic evaluation 12 weeks postsurgery showed local recurrence and peritoneal tumors. These findings were confirmed at laparotomy. We report the first case of peritoneal tumor dissemination after laparoscopic nephron-sparing surgery for localized Wilms tumor.
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Affiliation(s)
- Chan-Hon Chui
- Surgery Centre for Children Pte Ltd, Mount Elizabeth Medical Centre, Singapore.
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A prospective case-control study of the local and systemic cytokine response after laparoscopic versus open colonic surgery. J Surg Res 2010; 173:278-85. [PMID: 21195431 DOI: 10.1016/j.jss.2010.10.009] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Revised: 09/11/2010] [Accepted: 10/13/2010] [Indexed: 12/23/2022]
Abstract
BACKGROUND There is a sequential, high concentration cytokine response after major abdominal surgery. The magnitude of this response has been directly linked to postoperative metabolic derangement, ileus, adhesions, and oncological outcomes. We aimed to compare the local and systemic cytokine response in laparoscopic and open colonic surgery and relate this to postoperative recovery parameters. METHODS Using a prospectively collected patient database, we compared a Study Group (n = 50) of patients undergoing elective laparoscopic colonic resection with a Control Group (n = 25) of patients undergoing equivalent open colonic surgery within an ERAS program. Patients were matched for age, gender, BMI, ASA, Cr Possum, side of resection, diagnosis, and histologic stage. Plasma and peritoneal fluid concentrations of IL-6, IL-8, IL-10, and TNFα were measured at 20-24 h after surgery. The Surgical Recovery Score was determined pre-operatively and at 3, 7, 30, and 60 d postoperatively. All data were prospectively collected, and a priori definitions were used for discharge parameters, complications, and complication severity. RESULTS Peritoneal fluid IL-6 concentration was lower after laparoscopic surgery. There were no significant differences in the other cytokines measured, or in any postoperative recovery outcomes. Significant correlations were found between cytokine levels and discharge criteria achievement, day stay, postoperative complications, and the Surgical Recovery Score. CONCLUSION With the exception of a lower peritoneal IL-6 level, the systemic and peritoneal cytokine response at 20-24 h is similar after laparoscopic versus open colonic resection within an ERAS program, with corresponding equivalent rates of postoperative recovery.
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Application of stereology to study the effects of pneumoperitoneum on peritoneum. Surg Endosc 2010; 25:619-27. [PMID: 20625769 DOI: 10.1007/s00464-010-1235-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2009] [Accepted: 06/14/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Scanning electron microscopy is unable to provide sufficient data to obtain definitive results for research into the morphologic effect of pneumoperitoneum on peritoneum. To overcome this difficulty, we adopted stereology to examine the effect of the type of gas insufflated, pressure, duration, and gas flow on morphologic alterations of peritoneum. METHODS Fifty SD rats were divided into ten groups. One group served as control. Pneumoperitoneum was established at 5 mmHg and 1.0 l/min gas flow for 1, 2 or 3 h with CO2 (in groups C1h, C2h, and C3h, respectively) or with He (in groups H1h, H2h, and H3h, respectively). CO2 pneumoperitoneum was further established at 8 mmHg and 1.0 l/min gas flow for 1 h (group C8p), at 5 mmHg and 2.0 l/min gas flow for 1 h (group C2f), and at 5 mmHg and 3.0 l/min gas flow for 1 h (group C3f). After the procedures, five specimens were sampled from anterior peritoneum and measured by stereological and electron-microscopic techniques. RESULTS Groups H1h and C1h, H2h and C2h, and H3h and C3h, respectively, were the same in terms of area fraction of basal lamina exposed and diameter of mesothelial cells (P>0.05). The magnitudes of peritoneal trauma in groups C2h, C3h, C8p, C2f, and C3f were significantly higher than that in group C1h (P<0.01), and the same result was observed in groups H2h and H3h against group H1h (P<0.01), and in group C3f against group C2f (P<0.01). Furthermore, the area fractions of basal lamina exposed in groups C3h and H3h were remarkably higher than those in groups C2h and H2h, respectively (P<0.01). The mechanism of basal lamina exposure comprises mesothelial cell desquamation and plasmatorrhexis. CONCLUSIONS Peritoneal morphologic trauma during pneumoperitoneum can be attributed to the pressure, duration, and gas flow instead of the type of gas insufflated.
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Brokelman WJA, Lensvelt M, Borel Rinkes IHM, Klinkenbijl JHG, Reijnen MMPJ. Peritoneal changes due to laparoscopic surgery. Surg Endosc 2010; 25:1-9. [PMID: 20552372 PMCID: PMC3003799 DOI: 10.1007/s00464-010-1139-2] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2009] [Accepted: 04/30/2010] [Indexed: 12/01/2022]
Abstract
Background Laparoscopic surgery has been incorporated into common surgical practice. The peritoneum is an organ with various biologic functions that may be affected in different ways by laparoscopic and open techniques. Clinically, these alterations may be important in issues such as peritoneal metastasis and adhesion formation. Methods A literature search using the Pubmed and Cochrane databases identified articles focusing on the key issues of laparoscopy, peritoneum, inflammation, morphology, immunology, and fibrinolysis. Results Laparoscopic surgery induces alterations in the peritoneal integrity and causes local acidosis, probably due to peritoneal hypoxia. The local immune system and inflammation are modulated by a pneumoperitoneum. Additionally, the peritoneal plasmin system is inhibited, leading to peritoneal hypofibrinolysis. Conclusion Similar to open surgery, laparoscopic surgery affects both the integrity and biology of the peritoneum. These observations may have implications for various clinical conditions.
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Affiliation(s)
- W J A Brokelman
- Department of Surgery, Jeroen Bosch Hospital, P.O. Box 1101, 5200 BD, 's-Hertogenbosch, The Netherlands.
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Sammour T, Kahokehr A, Chan S, Booth RJ, Hill AG. The humoral response after laparoscopic versus open colorectal surgery: a meta-analysis. J Surg Res 2010; 164:28-37. [PMID: 20828745 DOI: 10.1016/j.jss.2010.05.046] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 04/15/2010] [Accepted: 05/20/2010] [Indexed: 12/20/2022]
Abstract
BACKGROUND The local and systemic humoral response after colorectal surgery is thought to affect postoperative recovery. It is commonly claimed that laparoscopic surgery elicits a diminished inflammatory response than equivalent open surgery. Despite these claims, the evidence is conflicting. Therefore, we aimed to systematically review the results from randomized controlled clinical trials comparing the humoral response associated with laparoscopic versus open colorectal surgery. MATERIALS AND METHODS A high-sensitivity search was conducted independently by two of the authors with no language restriction. Studies were identified from the Cochrane Central Register of Controlled Trials (CENTRAL/CCTR), Cochrane Library, Medline (January 1966 to January 2009), PubMed (1950 to January 2009), and Embase (1947 to January 2009). Relevant meeting abstracts and reference lists were manually searched. Data analysis was performed using Review Manager ver. 5.0. RESULTS Thirteen randomized controlled trials were included. Meta-analysis demonstrated a significantly higher serum IL-6 on d 1 after open colorectal resection for neoplasia (n = 97) compared with laparoscopic resection (n = 76, P = 0.0008) without significant heterogeneity. Data for plasma IL-6 were heterogeneous, with no apparent difference between groups. No other significant differences were identified, and there were not enough data on local peritoneal humoral factors to allow meta-analysis. CONCLUSION Open colorectal resection for neoplasia is associated with higher postoperative serum levels of IL-6 on d 1 than equivalent laparoscopic surgery. The aetiology and clinical significance of this finding is uncertain, and further studies are required to elucidate any differences in the local humoral response which may be more clinically relevant in surgery for this indication.
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Affiliation(s)
- Tarik Sammour
- Department of Surgery, South Auckland Clinical School, University of Auckland, Auckland, New Zealand.
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Carbon dioxide pneumoperitoneum, intraperitoneal pressure, and peritoneal tissue hypoxia: a mouse study with controlled respiratory support. Surg Endosc 2010; 24:2871-80. [DOI: 10.1007/s00464-010-1069-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2009] [Accepted: 04/02/2010] [Indexed: 11/25/2022]
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Sammour T, Mittal A, Loveday BPT, Kahokehr A, Phillips ARJ, Windsor JA, Hill AG. Systematic review of oxidative stress associated with pneumoperitoneum. Br J Surg 2009; 96:836-50. [DOI: 10.1002/bjs.6651] [Citation(s) in RCA: 103] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Abstract
Background
There have been several reports of ischaemic complications after routine laparoscopy. The aim of this review was to investigate the relationship between this oxidative stress and pneumoperitoneum.
Methods
Medline, Medline in-process, The Cochrane Library, PubMed and EMBASE were searched for papers on oxidative stress and pneumoperitoneum, from 1947 to March 2008 with no language restriction or restriction on trial design. Papers that did not investigate pneumoperitoneum as a causative factor, or did not report outcome measures related to oxidative stress, were excluded.
Results
A total of 73 relevant papers were identified: 36 animal studies, 21 human clinical trials, nine case reports, five review articles and two comments. Pneumoperitoneum causes a reduction in splanchnic blood flow, resulting in biochemical evidence of oxidative stress in a pressure- and time-dependent manner. There is evidence that the use of carbon dioxide for insufflation is contributory. Several measures proposed to minimize the oxidative stress have shown promise in animal studies, but few have been evaluated in the clinical setting.
Conclusion
There is an increasing body of evidence, mainly from animal studies, that pneumoperitoneum decreases splanchnic perfusion with resulting oxidative stress. It is now appropriate to investigate the clinical significance of pneumoperitoneum-associated oxidative stress.
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Affiliation(s)
- T Sammour
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Mittal
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - B P T Loveday
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A Kahokehr
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A R J Phillips
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - J A Windsor
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - A G Hill
- Department of Surgery, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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Mynbaev OA, Adamyan LV, Mailova K, Vanacker B, Koninckx PR. Effects of adding small amounts of oxygen to a carbon dioxide-pneumoperitoneum of increasing pressure in rabbit ventilation models. Fertil Steril 2008; 92:778-84. [PMID: 18823885 DOI: 10.1016/j.fertnstert.2008.07.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 05/28/2008] [Accepted: 07/09/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the metabolic consequences of the addition of oxygen to the CO(2)-pneumoperitoneum. DESIGN Prospective randomized study in rabbits. After 30 minutes of ventilation pneumoperitoneum was maintained for 90 minutes with pure CO(2) or CO(2) with 2% or 6% of oxygen. The intraperitoneal pressure was increased from 10 to 15 and 20 mm Hg every 30 minutes. Ventilation rate was either fixed or a progressive hyperventilation. End points were changes in arterial blood gases (Pco(2), Po(2)), pH, acid-base balance (actual base excess [ABE], standard bicarbonate [SBC], standard base excess [SBE], hydrogen carbonate [HCO(3)(-)], concentration of total carbon dioxide [Tco(2)]); oxygen and oximetry (oxyhemoglobin [O(2)Hb], oxygen saturation [So(2)], reduced hemoglobin [RHb], total oxygen concentration [To(2)], and oxygen tension at half saturation assessing hemoglobin oxygen affinity [p50]); and lactate concentrations assayed every 15 minutes. SETTING University research center. ANIMALS Twenty-four adult female New Zealand white rabbits. INTERVENTION(S) Anesthesia, mechanical ventilation, and pneumoperitoneum. RESULT(S) The effects of CO(2)-pneumoperitoneum on all end points increased with the elevated intraperitoneal pressure and were more pronounced when ventilation was fixed. Changes were less when 2% or 6% of oxygen had been added to the CO(2)-pneumoperitoneum. With use of logistic regression, the addition of oxygen, intraperitoneal pressure, and ventilation were found to be independent variables affecting Pco(2), pH, ABE, SBE, HCO(3)(-), O(2)Hb, So(2), p50, and end-tidal CO(2). CONCLUSION(S) The metabolic consequences of the combined effect of increased intraperitoneal pressure and CO(2)-pneumoperitoneum were less when 2% to 6% of oxygen was added or when animals were hyperventilated. We suggest that metabolic and mesothelial hypoxemia caused by CO(2) absorption can be reduced by adding small amounts of oxygen and by hyperventilation.
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Affiliation(s)
- Ospan A Mynbaev
- Department of Operative Gynaecology, Scientific Centre for Obstetrics, Gynaecology, Perinatalogy, Moscow State University of Medicine and Dentistry, Moscow, Russia.
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Heated and humidified CO2 prevents hypothermia, peritoneal injury, and intra-abdominal adhesions during prolonged laparoscopic insufflations. J Surg Res 2008; 151:40-7. [PMID: 18639246 DOI: 10.1016/j.jss.2008.03.039] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2007] [Revised: 03/04/2008] [Accepted: 03/27/2008] [Indexed: 12/15/2022]
Abstract
BACKGROUND Insufflation with standard cold-dry CO(2) during laparoscopic surgery has been shown to predispose patients to hypothermia and peritoneal injury. This study aimed to compare the effect of prolonged cold-dry CO(2) insufflation with heated-humidified CO(2) insufflation (3-5 h) on hypothermia, peritoneal damage, and intra-abdominal adhesion formation in a rat model. MATERIALS AND METHODS A total of 160 Wistar rats were randomized to undergo no insufflation or insufflation with cold-dry CO(2) (21 degrees C, <1% relative humidity) or heated-humidified CO(2) (37 degrees C, 95% relative humidity) for 3, 4, or 5 h. Core body temperature was measured via rectum before and during insufflations. Peritoneal samples were taken at 6, 24, 48, and 96 h after treatments and analyzed with light microscopy and scanning electron microscopy. Intra-abdominal adhesions were evaluated 2 weeks later. RESULTS Core body temperature significantly decreased in the cold-dry group, whereas it was maintained and increased in the heated-humidified group. Scanning electron microscopy and light microscopy studies showed intense peritoneal injury in the cold-dry CO(2) group but significantly less damages in the heated-humidified group. Increased intra-abdominal adhesion formation was observed in the cold-dry CO(2) group, while no adhesions were found in the rats insufflated with heated-humidified CO(2). CONCLUSIONS Heated-humidified CO(2) insufflation results in significantly less hypothermia, less peritoneal damage, and decreased adhesion formation as compared with cold-dry CO(2) insufflation. Heated-humidified CO(2) may be more suitable for insufflation application in prolonged laparoscopic surgery.
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Anti-beta1 integrin antibody reduces surgery-induced adhesion of colon carcinoma cells to traumatized peritoneal surfaces. Ann Surg 2008; 247:85-94. [PMID: 18156927 DOI: 10.1097/sla.0b013e3181588583] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE To study the mechanisms behind surgery-induced augmentation of tumor outgrowth. SUMMARY BACKGROUND DATA Surgery provides the best chance of cure for most primary intra-abdominal carcinomas. Effective treatment is however relatively frequent complicated by peritoneal recurrences, which often originate from free-floating intraperitoneal tumor cells that implant on peritoneal surfaces. We previously reported that surgical trauma promotes development of peritoneal metastases. METHODS Evaluation of adhesion of CC531s rat colon carcinoma cell line intraperitoneally after laparotomy using in vivo, ex vivo, and in vitro models. Also, human ex vivo models were used to study peritoneal tumor cell adhesion. RESULTS Peritoneal imprints of operated rats showed that direct damaging of the peritoneum resulted in enhanced adhesion of rat CC531 colon carcinoma cells to submesothelial extracellular matrix (ECM) proteins in vivo, which was confirmed by electron microscopy. Additionally, the inflammatory reaction of the peritoneal cavity led to retraction of mesothelial cells, hereby also exposing ECM at peritoneal surfaces that had not been traumatized directly. Furthermore, we demonstrated that beta1 integrin subunits represented the primary mediators involved in adherence to either isolated ECM components or excised traumatized rat and human peritoneum. Importantly, incubation of CC531s cells with anti-beta1 integrin antibodies resulted in a significant decrease of tumor cell adhesion in vivo. CONCLUSIONS Surgical trauma results in exposure of ECM at directly and nondirectly damaged peritoneal surfaces, leading to increased beta1 integrin-dependent tumor cell adhesion. Perioperative therapies, which aim to block beta1 integrin subunits, might therefore serve as new clinical tools for the prevention of peritoneal recurrences.
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Abstract
Aside from the normal 'ad integrum' peritoneal regeneration, the postoperative intraperitoneal adhesion formation process may be considered as the pathological part of peritoneal healing following any injury, particularly a surgical one. Despite a large body of clinical and experimental studies, its pathophysiology remains controversial. Moreover, a better understanding of the pathophysiological events and of the medical and surgical factors involved in the adhesion formation process is pivotal in any attempt to control this very frequent phenomenon and its serious consequences.
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Affiliation(s)
- J-J Duron
- Chirurgie Générale et Digestive, Hôpital de la Pitié Salpêtrière, 83 Boulevard de l'Hôpital, Paris, France.
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Tarhan OR, Barut I, Akdeniz Y, Sutcu R, Cerci C, Bulbul M. Fibrinolytic responses of human peritoneal fluid in laparoscopic cholecystectomy: a prospective clinical study. Surg Endosc 2007; 22:1008-13. [PMID: 17763904 DOI: 10.1007/s00464-007-9566-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2006] [Revised: 09/07/2006] [Accepted: 09/15/2006] [Indexed: 01/28/2023]
Abstract
BACKGROUND The reduction in peritoneal fibrinolysis is believed to be the pathogenetic mechanism of adhesion formation. The general conclusion based on previous clinical and experimental studies is that laparoscopic procedures produce less adhesion formation. The association between this beneficial effect of laparoscopic cholecystectomy and peritoneal fibrinolytic changes is not clear. Therefore, the authors aimed to compare the effects of open and laparoscopic cholecystectomy on peritoneal fibrinolysis. For this purpose, fibrinolytic parameters in peritoneal fluid were investigated 24 h after laparoscopic and open cholecystectomies. METHODS In a prospective clinical study, peritoneal fluid was sampled via a drain 24 h after laparoscopic (n = 10) and open (n = 9) cholecystectomies. Activities and concentrations of tissue plasminogen activator (tPA), plasminogen activator inhibitor type 1 (PAI-1), and tPA/PAI-1 complex were determined by enzyme-linked immunosorbent assay (ELISA) kits. RESULTS In peritoneal fluids, tPA and tPA/PAI-1 complex concentrations were higher in the open cholecystectomy group (p = 0.009 and p < 0.001, respectively), but tPA activity and PAI-1 concentrations did not differ between the groups (p = 0.514 and p = 0.716, respectively). CONCLUSIONS Fibrinolytic changes in peritoneal fluid have several similarities in open and laparoscopic cholecystectomies with regard to tPA activity and PAI-1 levels. However, higher tPA levels after the open procedure probably are secondary to more intense tissue handling leading to mesothelial release of tPA.
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Affiliation(s)
- O R Tarhan
- Department of General Surgery, Faculty of Medicine, Suleyman Demirel University, Isparta, Turkey.
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Tanaka F, Sonoda H, Okamoto M, Mimori K, Utsunomiya T, Inoue H, Hanai T, Mori M. TIMP-3 and Phosphatidylinositol 3-kinase Genes Were Found to Be Related to the Progression of Colon Cancer in a Comparison of Pneumoperitoneum and Laparotomy in a Murine Model. Surg Today 2007; 37:220-5. [PMID: 17342361 DOI: 10.1007/s00595-006-3370-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2006] [Accepted: 07/25/2006] [Indexed: 11/24/2022]
Abstract
PURPOSE Laparoscopic surgery has been performed on a wide variety of patients because the clinical benefits of a perioperative recovery result in a better short-time outcome than an open colectomy. However, no basic and molecular-biological examinations have yet to elucidate the mechanisms of such an improved outcome. METHOD To examine the gene expression profiles of mice inoculated with colon cancer cells, the tumors, the livers and the lungs of mice were analyzed using a microarray. RESULTS In the laparotomy and control group, we observed a significant enhancement of tumor growth in comparison to the laparoscopic group. When analyzing the genes that became more remarkably upregulated or downregulated in the laparoscopic group in comparison to those in the laparotomy or control group, we focused our attention on the TIMP-3 gene and PI3-kinase gene expression. The downregulation of TIMP-3 and the upregulation of PI3-kinase were observed. To confirm the downstream signal of the PI3-kinase gene, we examined the expression of Skp-2 gene and p27 protein. We observed the expression level of the Skp-2 to be upregulated, while the expression level of p27 protein decreased. CONCLUSIONS The surgical procedures of a laparotomy induced a downregulation of TIMP-3 and an upregulation of PI3-kinase, which together resulted in an enhancement of cancer cell growth thus leading to an increased invasion activity and cell cycle in comparison to treatment using a laparoscopic approach.
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Affiliation(s)
- Fumiaki Tanaka
- Division of Molecular and Surgical Oncology, Department of Molecular and Cellular Biology, Medical Institute of Bioregulation, Kyushu University, 4546 Tsurumihara, Beppu 874-0838, Japan
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Brokelman WJA, Holmdahl L, Bergström M, Falk P, Klinkenbijl JHG, Reijnen MMPJ. Peritoneal fibrinolytic response to various aspects of laparoscopic surgery: a randomized trial. J Surg Res 2006; 136:309-13. [PMID: 17054995 DOI: 10.1016/j.jss.2006.07.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2006] [Revised: 07/24/2006] [Accepted: 07/25/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Peritoneal fibrinolysis is important in peritoneal wound healing processes and adhesion formation. The peritoneal fibrinolytic response to laparoscopy is merely unknown. In the present study we investigate the effect of short-term laparoscopy on the peritoneal fibrinolytic response and the influence of intra-abdominal pressure, light intensity and choice of dissection device on this response. METHODS There were 50 patients scheduled for laparoscopic cholecystectomy randomized in five groups operated with various pressures, light intensities, and dissection devices. Peritoneal biopsies were taken at the beginning and the end of the procedure. Tissue concentrations of tissue-type plasminogen activator (tPA), urokinase-type plasminogen activator (uPA), plasminogen activator inhibitor type 1 (PAI-1), and the tPA-activity were measured using ELISA techniques. RESULTS There were no differences in tPA antigen, tPA-activity, uPA antigen, or PAI-1 antigen concentrations in biopsies taken at the beginning compared to samples taken at the end of the operation. Different intra-abdominal pressures, light intensities and the choice dissection device did not affect any of the measured parameters. CONCLUSION Short-term laparoscopy does not affect the peritoneal fibrinolytic activity. The used intra-abdominal pressure, light intensity and choice of dissection device do not affect peritoneal activity during short-term laparoscopy.
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Affiliation(s)
- Walter J A Brokelman
- Department of Surgery, Alysis Zorggroep, Locatie Rijnstate, Arnhem, The Netherlands.
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Binda MM, Molinas CR, Hansen P, Koninckx PR. Effect of desiccation and temperature during laparoscopy on adhesion formation in mice. Fertil Steril 2006; 86:166-75. [PMID: 16730008 DOI: 10.1016/j.fertnstert.2005.11.079] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2005] [Revised: 11/29/2005] [Accepted: 11/29/2005] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To investigate the effects of desiccation (without cooling) and of oversaturation of the pneumoperitoneum on adhesion formation. DESIGN Prospective randomized trial. SETTING Academic research center. ANIMAL(S) BALB/c and NMRI female mice. INTERVENTION(S) The effect of desiccation using nonhumidified CO(2) on adhesion formation was evaluated in a laparoscopic mouse model. Body temperature (BT) was maintained at 37 degrees C using a homeothermic blanket. In addition to controls without desiccation, the effect of both hypothermia and desiccation on adhesion formation was evaluated. Subsequently the effect of oversaturating the pneumoperitoneum using a high energy gas to avoid any desiccation was studied. MAIN OUTCOME MEASURE(S) During surgery BT, pneumoperitoneum temperature, and relative humidity were monitored. Adhesions were scored after 7 days. RESULT(S) Adhesions increased with increasing levels of desiccation when BT was kept at 37 degrees C. This was prevented with humidified gas. If BT decreased, adhesions were fewer. Oversaturating the pneumoperitoneum increased adhesions due to high energy gas causing an increase in both BT and pneumoperitoneum temperature. CONCLUSION(S) Adhesions increase with desiccation and decrease when BT is reduced. Adhesions are minimized when humidified gas is used. Since desiccation is associated with cooling, its effect is generally underestimated because of the counterbalance with cooling. The concept of combining controlled intraperitoneal cooling with a rigorous prevention of desiccation might be important for clinical adhesion prevention.
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Affiliation(s)
- Maria Mercedes Binda
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium.
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Pitombo MB, Lupi OH, Gomes RN, Amâncio R, Refinetti RA, Bozza PT, Castro-Faria-Neto HC. Inflammatory response and bacterial dissemination afterlaparotomy and abdominal CO2 insufflation in a murine model of peritonitis. Surg Endosc 2006; 20:1440-7. [PMID: 16703442 DOI: 10.1007/s00464-005-0117-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2005] [Accepted: 05/15/2005] [Indexed: 11/30/2022]
Abstract
BACKGROUND The immunologic repercussions due to cavity insufflation are the focus of great discussion. The aim of this study was to compare the inflammatory response and bacterial dissemination after laparotomy and abdominal CO2 insufflation in a murine model of peritonitis. METHODS Swiss mice were inoculated intraperitoneally with 0.5 ml of a solution containing 1 x 10(8) colony-forming units (CFU)/ml of Escherichia coli and were divided into three groups as follow: control (anesthesia for 30 min), laparotomy (2.5-cm midline incision for 30 min), and CO2 pneumoperitoneum (CO2 cavity insufflation for 30 min). The number of leukocytes, CFU/ml counting, and the levels of interleukin (IL)-6, tumor necrosis factor-alpha (TNF-alpha), and IL-10 were evaluated in blood, peritoneal, and pleural fluid samples obtained at 90 min and 18 h after the procedures. RESULTS The laparotomy group showed a greater bacterial dissemination to the blood, peritoneum, and pleural cavity and also greater neutrophil migration to the peritoneal cavity compared to the CO2 insufflated and control groups. The 24-h mortality was also significantly higher in the laparotomy group. The IL-6 levels showed a precocious rise in all groups submitted to bacterial inoculation at the 90-min time point. At the 18-h time point, IL-6 levels in the peritoneum were significantly higher in the laparotomy group than in the control or CO2 insufflated groups. At the same time, TNF-alpha levels were higher in the laparotomy and CO2 insufflated groups than in controls; IL-10 levels showed no differences among the groups. CONCLUSIONS Our results suggest that cavity insufflation with CO2 is a more effective method of access, inducing less bacterial dissemination and also a less intense inflammatory response. Cavity insufflation with CO2 may present a good option for the surgical treatment of patients with bacterial peritonitis.
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Affiliation(s)
- M B Pitombo
- Departamento de Cirurgia Geral, Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro, UERJ, AV 28 de setbmbno 77, 40 Andar, Rio de Janeino, RJ, Brazil, 20550-030
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Canis M, Farina M, Jardon K, Rabischong B, Rivoire C, Nohuz E, Botchorishvili R, Pouly JL, Mage G. Cœlioscopie et cancer en gynécologie : le point en 2005. ACTA ACUST UNITED AC 2006; 35:117-35. [PMID: 16575358 DOI: 10.1016/s0368-2315(06)76386-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
All the surgical procedures, which may be required to treat a gynecologic cancer, can be performed endoscopically. However prospective randomized studies required to confirm the oncologic efficacy of the technique are still lacking in gynecology, whereas such studies are available in digestive surgery. Animal studies suggested that the risk of tumor dissemination in non traumatized peritoneum is higher after a pneumoperitoneum than after a laparotomy. Experimental studies also emphasized two points: the surgeon and the surgical technique are essential, all the parameters of the pneumoperitoneum may influence the postoperative dissemination. Changing these parameters we may, in the future, be able to create a peritoneal environment adapted to oncologic patients in order to prevent or to decrease the risks of peritoneal dissemination and/or of postoperative tumor growth. Until the results of prospective randomized studies become available, the preoperative selection of the patients and the surgical technique should be very strict. In patients with endometrial cancer, the laparoscopic approach should be reserved to clinical stage I disease, if the vaginal extraction is anticipated to be easy accounting for the volume of the uterus and the local conditions. In cervical cancer, the laparoscopic approach should be reserved to patients with favorable prognostic factors: stage IB of less than 2 cm in diameter. Laparoscopy is the gold standard for the surgical diagnosis of adnexal masses. But the puncture should be avoided whenever possible. The surgical treatment of invasive ovarian cancer should be performed by laparotomy whatever the stage. In contrast restaging of an early ovarian cancer initially managed as a benign mass, is a good indication of the laparoscopic approach. The laparoscopic management of low malignant potential tumors should include a complete staging of the peritoneum. Knowledge of the principles of endoscopy and of oncologic surgery is required. Teaching and diffusion of endoscopic oncological techniques are among the major challenges of gynecologic surgery within the next few years.
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Affiliation(s)
- M Canis
- Département de Gynécologie Obstétrique et Médecine de la Reproduction, CHU de Clermont-Ferrand, Polyclinique de l'Hôtel-Dieu, boulevard Léon-Malfreyt, 63058 Clermont-Ferrand
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Ishibashi S, Takeuchi H, Fujii K, Shiraishi N, Adachi Y, Kitano S. Length of laparotomy incision and surgical stress assessed by serum IL-6 level. Injury 2006; 37:247-51. [PMID: 16434039 DOI: 10.1016/j.injury.2005.08.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2005] [Revised: 08/07/2005] [Accepted: 08/15/2005] [Indexed: 02/02/2023]
Abstract
BACKGROUND Because surgical stress is thought to have an effect on morbidity, mortality, and remnant tumour progression after surgery, diminishing surgical stress is important. The purpose of this study was to assess in a murine model whether the length and type of laparotomy incision influence surgical stress. METHODS Serum IL-6 concentrations were measured sequentionally in 220 male BALB/c mice who were assigned to different basic laparotomies, (1-cm versus 2-cm versus 3-cm laparotomy with or without caecal resection), other types of laparotomy (3-cm, 1-cm x 3, 3-cm transverse, 3-cm laparotomy with rapid closure), or 3-cm skin incision with or without laparotomy. The serum level of IL-6 was measured by ELISA. RESULTS Serum IL-6 levels at 3 and 6h after surgery were significantly higher in the 3-cm laparotomy group (1,680+/-802pg/ml and 1,066+/-507pg/ml, respectively), than in the 1-cm laparotomy group (797+/-427pg/ml and 515+/-212pg/ml, respectively). When caecal resection was added, the serum IL-6 level at 6h was significantly higher in the 3-cm laparotomy group (2,844+/-134pg/ml) than in the 1-cm laparotomy group (2,200+/-379pg/ml). Although the type of laparotomy incision was not associated with the serum level of IL-6, the serum IL-6 level after midline skin incision without laparotomy (245+/-142pg/ml) was significantly lower than that after 3-cm laparotomy (1,680+/-802pg/ml). CONCLUSIONS The length of laparotomy incision was correlated with the serum level of IL-6 in a murine model. The surgical stress related to abdominal procedures might be decreased when laparotomy wounds are kept as small as possible.
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Affiliation(s)
- Shozo Ishibashi
- Department of Surgery I, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Oita 879-5593, Japan.
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Rodríguez M, Targarona EM, Camacho M, Balagué C, Vila L, Trias M. [Immediate peritoneal response to contamination during laparoscopic surgery in an experimental mouse model]. Cir Esp 2006; 79:28-35. [PMID: 16426530 DOI: 10.1016/s0009-739x(06)70810-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Several studies have shown that laparoscopic surgery (LS) minimizes surgical trauma and preserves immune response. Another advantage is the lower incidence of infectious complications. However, several in vitro studies have shown that an atmosphere with CO2 affects macrophage physiology, which would affect the response to peritoneal contamination. This observation is controversial, given the experimental evidence of a better conserved response to peritoneal contamination. The aim of the present study was to investigate the immediate response of the peritoneum to contamination in an atmosphere with CO2. MATERIAL AND METHOD A total of 192 CD-1 rats were distributed into three groups: group I, LP, n= 64, (laparotomy); group II, LC-CO2, n= 64, (laparoscopy-CO2), group III, LC-T, n= 64, (laparoscopy-traction). The rats were randomized to receive 1 ml of a suspension of Escherichia coli (1x10(4) CFU/ml) (contamination [C]) or saline serum (no contamination [NC]). Peritoneal fluid was obtained at 1.5, 3, 6, and 12 h after surgery. Monocyte chemotactic protein-1 (MCP-1), interleukin (IL)-6 and prostaglandin.E2 (PGE2) were determined. RESULTS MCP-1 levels were significantly higher and increased earlier in group II (LC-CO2-NC) than in group I (LP-NC) (p< .007). Simultaneously, the increase in the traction group was significantly higher (p< .002) than after laparotomy, without differences with respect to group II (LC-CO2-NC). When contamination was added, there was a significant increase in the three groups (p< .5). The modifications in MCP-1 in the LP-C group were statistically significantly greater and appeared earlier than those in the traction groups, LC-T-C (p< .002) and LC-CO2-C (p< .02). Interleukin 6: the three models showed a significant increase, which appeared later in the LP-NC group. Simultaneously, the increase in IL-6 appeared earlier and was significantly greater in the LC-T-NC group than in the LP group (p< .003), with no differences between the LC-CO2-NC and LC-T-NC groups. There was a significant difference between contaminated and uncontaminated groups in the LC-CO2 model. The traction model (LC-T-C group) showed a greater increase than the LP-C and LC-CO2-C groups (p< .001). PGE2: a significant increase was observed in the three models without contamination. However, when contamination was added, no differences were observed. CONCLUSION Pneumoperitoneum with CO2 provokes a peritoneal response that is qualitatively different from open surgery and modifies the response to contamination with a greater increase in MCP-1 and IL-6.
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Affiliation(s)
- Manuel Rodríguez
- Servicio de Cirugía, Hospital de Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain
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Rosário MTA, Ribeiro U, Corbett CEP, Ozaki AC, Bresciani CC, Zilberstein B, Gama-Rodrigues JJ. Does CO2 pneumoperitoneum alter the ultra-structuture of the mesothelium? J Surg Res 2005; 133:84-8. [PMID: 16360175 DOI: 10.1016/j.jss.2005.09.032] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2005] [Revised: 08/19/2005] [Accepted: 09/26/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Pneumoperitoneum may be responsible for ultra-structural alterations in the mesothelium during laparoscopy. To characterize the effect of pneumoperitoneum on the mesothelial cells with CO(2) and compressed air; and to compare to laparotomy and control group (anesthesia only). MATERIALS AND METHODS Forty C-57 mice were divided in four groups of 10 animals each: CO(2), air, laparotomy, and control group. The animals were submitted to pneumoperitoneum at 8 mmHg during 30 min (CO(2) or compressed air). Five animals of each group were sacrificed 2 and 24 h after the procedure. Fragments of parietal peritoneum were collected and processed for scanning electron microscopy. RESULTS Control group revealed uninterrupted mesothelial cells, without any evidence of cellular limits; close contact between the cells; absence of intercellular clefts and presence of microvilli. In the laparotomy group, similar results to the control group, with decreased microvilli were noted. Air pneumoperitoneum was associated with alterations in the morphology of the mesothelial cells, clear cellular limits, and cells with spherical and fusiforme formats. CO(2) pneumoperitoneum showed mesothelial cells with clear cellular limits, predominantly spherical cellular format, and intercellular clefts that allowed the visualization of the exposed basal membrane. These alterations were more intense after 24 h. There was a statistical significance between CO(2) group (2 and 24 h) compared to the control group and laparotomy for cellular limits, intercellular clefts and microvilli, P < 0.0001. CONCLUSIONS Pneumoperitoneum causes damage in the mesothelial ultra-structure, which differs from the laparotomy group. CO(2) pneumoperitoneum is more harmful to the mesothelium than the air.
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Affiliation(s)
- Marcos T A Rosário
- Department of Gastroenterology, University of São Paulo, São Paulo, Brazil
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Targarona EM, Rodríguez M, Camacho M, Balagué C, Gich I, Vila L, Trias M. Immediate peritoneal response to bacterial contamination during laparoscopic surgery. Surg Endosc 2005; 20:316-21. [PMID: 16247573 DOI: 10.1007/s00464-005-0367-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2005] [Accepted: 08/31/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND Several studies have shown that laparoscopic surgery (LS) minimizes surgical trauma and the immune function is better preserved. Another major advantage of LS is the lower incidence of septic complications. However, several in vitro studies have shown that CO(2) severely impairs macrophage physiology. In theory, this would reduce the ability to respond to peritoneal contamination. However, there is some controversy in view of the evidence of a better preserved peritoneal response to sepsis. This study analyzed the early response of the peritoneum to contamination in a CO(2) ambience. METHODS A total of 192 CD-1 mice were distributed in three groups: group 1, laparotomy (LAP, n = 64); group 2, CO(2) laparoscopy (CO(2)-LC, n = 64); and group 3, wall lift laparoscopy (WL-LC, n = 64). Mice in each group were randomized to receive 1 ml of Escherichia coli suspension (1 x 10(4) colony-forming units/ml) or saline. Peritoneal fluid was obtained at 1.5, 3, 6, and 12 h after surgery. Monocyte chemoattractant protein-1 (MCP-1), interleukin-6 (IL-6), and prostaglandin E(2) (PGE(2)) were measured. RESULTS MCP-1 levels were significantly greater and higher earlier in group 2 (CO(2)-LC) than in group 1 (LAP) (p < 0.007). Simultaneously, the increment in the traction group (WL-LC, group 3) was significantly higher (p < 0.002) than after laparotomy, with no differences in group 2 (CO(2)-LC). When a contamination was added to the laparotomy subgroup, there was a significant increase compared to the group without contamination (p < 0.5). MCP-1 modifications after contamination in the LAP group were statistically significant and appeared later than in the WL-LC (p < 0.002) and CO(2)-LC groups (p < 0.02). For IL-6, the three models presented a significant increase in the noncontaminated groups. This occurred significantly later in the LAP group. Simultaneously, the increase in IL-6 occurred earlier and was significantly higher in the WL-LC group compared to the LAP group (p < 0.003), without differences between CO(2)-LC and wall lift groups. Significant differences between contaminated and noncontaminated subgroups were only observed in the LC-CO(2) groups. When contaminated, the traction model sustained a higher and earlier rise in IL-6 levels compared to the LAP and LC-CO(2) groups (p < 0.001). For PGE(2), The three models showed a significant increase in PGE(2) levels in the noncontaminated groups. However, there were no significant differences between them. In the contaminated groups, there was no statistical difference between the groups. CONCLUSION Despite a transient impairment of the immediate peritoneal response to a septic challenge, the degree of injury with LS is lower than that with open surgery, and abdominal infection can therefore be better controlled.
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Affiliation(s)
- E M Targarona
- Service of Surgery, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Oosterling SJ, van der Bij GJ, van Egmond M, van der Sijp JRM. Surgical trauma and peritoneal recurrence of colorectal carcinoma. Eur J Surg Oncol 2005; 31:29-37. [PMID: 15642423 DOI: 10.1016/j.ejso.2004.10.005] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2004] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Local peritoneal recurrence is a relatively common complication after intentionally curative surgery for colorectal cancer and has unfavourable prognosis. METHODS This manuscript reviews the relevant experimental and clinical literature on surgical trauma and development of local recurrences, which was obtained by extensive search in the PubMed database. RESULTS AND CONCLUSION Although surgery is required as the only option for treatment, operative trauma and subsequent wound healing promote development of local recurrences. Minimizing peritoneal trauma reduces local tumour outgrowth in animal models, but clinical trials have not been conclusive so far. Recognition of the increased susceptibility to tumour establishment in the early post-operative phase challenges the aim for further research, targeting at strategies that obstruct local tumour implantation or outgrowth and/or improve (local) anti-tumour response.
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Affiliation(s)
- S J Oosterling
- Department of Surgical Oncology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands
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Izumi K, Ishikawa K, Shiroshita H, Matsui Y, Shiraishi N, Kitano S. Morphological changes in hepatic vascular endothelium after carbon dioxide pneumoperitoneum in a murine model. Surg Endosc 2005; 19:554-8. [PMID: 15696359 DOI: 10.1007/s00464-004-9081-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2004] [Accepted: 10/01/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND Liver metastasis is an important prognostic factor in advanced colorectal cancer. Several studies have demonstrated that carbon dioxide (CO2) pneumoperitonem enhances liver metastasis in an animal model. In the present study, we used scanning electron microscopy (SEM) to investigate morphological changes in hepatic vascular endothelium after CO2 pneumoperitoneum in a murine model. METHODS Thirty-three male BALB/c mice were randomized to undergo pneumoperitoneum (CO2, air, or helium), open laparotomy, and anesthesia alone. After each procedure, the animals' livers were excised at days 0, 1, and 3 and examined by SEM. RESULTS In the CO2 pneumoperitoneum group, we observed rough surface and derangement of the hepatic vascular endothelial cells and intercellular clefts on day 1. In the other groups, no major morphologic changes were observed at any time. CONCLUSIONS Hepatic vascular endothelium changes after CO2 pneumoperitoneum. Such characteristic changes may play an important role in establishing liver metastasis after CO2 pneumoperitoneum.
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Affiliation(s)
- K Izumi
- Department of Surgery I, Oita University Faculty of Medicine, 1-1 Idaigaoka, Hasama-machi, Oita 879-5593, Japan.
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Elkelani OA, Binda MM, Molinas CR, Koninckx PR. Effect of adding more than 3% oxygen to carbon dioxide pneumoperitoneum on adhesion formation in a laparoscopic mouse model. Fertil Steril 2005; 82:1616-22. [PMID: 15589868 DOI: 10.1016/j.fertnstert.2004.07.933] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2003] [Revised: 07/12/2004] [Accepted: 07/12/2004] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To investigate the effect of the addition of 3% or higher oxygen concentrations to the carbon dioxide (CO2) pneumoperitoneum. DESIGN Prospective, randomized trial. SETTING Academic research center. ANIMAL(S) Female Naval Medical Research Institute mice (n = 100). INTERVENTION(S) Sixty minutes of CO2 pneumoperitoneum with 0%, 3%, 6%, 9%, or 12% oxygen; induction of adhesions by the creation of standardized peritoneal lesions during laparoscopy. MAIN OUTCOME MEASURE(S) Adhesions were quantitatively and qualitatively scored after 7 days during laparotomy to determine [1] the effect of 60 minutes of CO2 pneumoperitoneum with 0%, 3%, 6%, 9%, or 12% oxygen on adhesion formation, and [2] the effect of duration of CO2 pneumoperitoneum and insufflation pressure on adhesion formation with the addition of 0%, 3%, and 12% oxygen. RESULT(S) Compared with a CO2 pneumoperitoneum with 3% oxygen, adhesion formation is greater when either no oxygen or more than 3% oxygen is added to the CO2 pneumoperitoneum. These effects persisted at higher insufflation pressures and longer duration of pneumoperitoneum, both known to increase adhesion formation with pure CO2. CONCLUSION(S) This study confirms that adhesion formation is decreased with the addition of 3% oxygen to the CO2 pneumoperitoneum. The addition of higher oxygen concentrations, however, is deleterious. Adhesions always increase with time and duration of the pneumoperitoneum.
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Affiliation(s)
- Osama Ali Elkelani
- Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
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Raa ST, Oosterling SJ, van der Kaaij NP, van den Tol MP, Beelen RHJ, Meijer S, van Eijck CHJ, van der Sijp JRM, van Egmond M, Jeekel J. Surgery promotes implantation of disseminated tumor cells, but does not increase growth of tumor cell clusters. J Surg Oncol 2005; 92:124-9. [PMID: 16231370 DOI: 10.1002/jso.20273] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
INTRODUCTION Local recurrence and peritoneal dissemination is common after intentionally curative resection of colorectal carcinoma. It is not yet clear which mechanisms stimulate post-operative intra-abdominal tumor development. Enhanced adhesion or growth of tumor cells and/or post-operative immuno suppression may influence tumor recurrence. AIMS OF THE STUDY In the present study, we evaluated effects of local and remote surgery on intra-abdominal tumor development. MATERIALS AND METHODS A standardized intra-abdominal trauma was inflicted by rubbing both uterus horns in laparotomy groups, while a dorsolateral thoracotomy was performed in thoracotomy groups (on day -1, 0, or +3). To induce tumor development rats were injected intra-peritoneally with the coloncarcinoma cell line CC531s on day 0 and evaluated after 21 days. RESULTS Rats undergoing laparotomy and injection on day 0 showed significantly higher tumorload than control rats (195 +/- 20 vs. 47 +/- 29, P < 0.001). When a laparotomy was performed, the day before tumor inoculation even higher tumorload was seen (245 +/- 37 vs. 195 +/- 20, P < 0.01). Strikingly, performing a thoracotomy on the day before or on the same day as tumor inoculation resulted in enhanced tumorload compared to controls as well (135 +/- 84 vs. 47 +/- 29; P < 0.001 and 88 +/- 38 vs. 47 +/- 29; P < 0.02, respectively). Either laparotomy or thoracotomy 3 days after tumor cell inoculation did not affect growth of pre-existing tumor cell clusters. CONCLUSIONS The (post) surgical intra-peritoneal microenvironment enhances successful implantation of spilled tumor cells, whereas growth of adhered tumor cell clusters is not affected. The inflammatory response as a result of remote surgery promotes successful tumor development as well.
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Affiliation(s)
- S Ten Raa
- Department of General Surgery, ErasmusMC, Rotterdam, The Netherlands
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Takeuchi H, Inomata M, Fujii K, Ishibashi S, Shiraishi N, Kitano S. Increased peritoneal dissemination after laparotomy versus pneumoperitoneum in a mouse cecal cancer model. Surg Endosc 2004; 18:1795-9. [PMID: 15809793 DOI: 10.1007/s00464-003-9322-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2003] [Accepted: 06/17/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND The effect of carbon dioxide (CO(2)) pneumoperitoneum on the liberation of cancer cells from the primary tumor is not clear. This study investigated the influence of laparotomy versus CO(2) pneumoperitoneum on the progression of colon cancer with serosal invasion in a mouse model. METHODS Pieces of human colon adenocarcinoma (HT29) tumor were implanted in the cecal wall of 45 BALB/c nude mice. Each mouse underwent one of three procedures: laparotomy, CO(2) pneumoperitoneum, or anesthesia (control). Three weeks later, the size and weight of cecal tumors, the number of nodules, and the tumor volume score of peritoneal dissemination were examined. Another 45 mice were treated in the same way. The cecal tumor was resected on days 1, 3, or 5 after treatment. Total RNA was isolated from the resected tumors. The expression of E-cadherin and beta-1 integrin messenger RNA (mRNA) was examined by semiquantitative real-time reverse transcriptase-polymerase chain reaction assay. RESULTS Significantly more nodules of peritoneal dissemination were found in the laparotomy group than in the control group (p < 0.05). The tumor volume score of peritoneal dissemination in the laparotomy group was significantly higher than in the other two groups (p < 0.05). The expression of E-cadherin mRNA at day 5 in the laparotomy group was significantly less than in the other two groups (p < 0.05). There were no differences in beta-1 integrin among three groups. CONCLUSIONS Peritoneal dissemination was more extensive after laparotomy than after CO(2) pneumoperitoneum in a mouse model of cecal cancer with serosal invasion. Decreased expression of E-cadherin mRNA in tumors after laparotomy, but not after CO(2) pneumoperitoneum, may be associated with the increase in peritoneal dissemination.
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Affiliation(s)
- H Takeuchi
- Department of Surgery I, Faculty of Medicine, Oita University, 1-1 Idaigaoka, Hasama-machi, Oita, 879-5593, Japan.
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Binda MM, Molinas CR, Mailova K, Koninckx PR. Effect of temperature upon adhesion formation in a laparoscopic mouse model. Hum Reprod 2004; 19:2626-32. [PMID: 15333592 DOI: 10.1093/humrep/deh495] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Pneumoperitoneum can be a cofactor in adhesion formation. Pneumoperitoneum with non-humidified gas causes desiccation in the peritoneal cavity which decreases temperature. The effect of desiccation upon adhesion formation is widely accepted. The specific effect of the associated cooling upon adhesion formation remains unexplored, and was addressed specifically in our laparoscopic mouse model. METHODS Adhesions were induced during laparoscopy and scored after 7 days during laparotomy. Pneumoperitoneum was performed using CO2 or CO2 with oxygen with or without humidification. Animals were placed at different environmental temperatures to modulate body and intraperitoneal temperature. RESULTS Anaesthesia, environment with a lower temperature and pneumoperitoneum all independently decrease body temperature. A decrease in body temperature decreases adhesion formation (P=0.004). Therefore, at 37 degrees C, pneumoperitoneum-enhanced adhesion formation is more important than at room temperature (P=0.04). As was observed at room temperature, adhesion formation at 37 degrees C increases with the duration (P=0.01) of pneumoperitoneum and decreases with the addition of 3% of oxygen (P=0.03). CONCLUSIONS Hypothermia reduces pneumoperitoneum-enhanced adhesion formation, which supports hypoxia as a driving mechanism, since hypothermia decreases the toxic effects of hypoxia and of the ischaemia-reperfusion process. These data could open up new possibilities for adhesion prevention in laparoscopic surgery.
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Affiliation(s)
- M M Binda
- Department of Obstetrics and Gynaecology, University Hospital Gasthuisberg, Katholieke Universiteit Leuven, Herestraat 49, B3000 Leuven, Belgium.
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Ordemann J, Jakob J, Braumann C, Kilian M, Bachmann S, Jacobi CA. Morphology of the rat peritoneum after carbon dioxide and helium pneumoperitoneum: a scanning electron microscopic study. Surg Endosc 2004; 18:1389-93. [PMID: 15803241 DOI: 10.1007/s00464-003-9217-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2003] [Accepted: 02/13/2004] [Indexed: 01/01/2023]
Abstract
BACKGROUND Laparoscopic surgery for patients with cancer has been debated because of the susceptibility that laparoscopic incisions have shown for metastatic tumor growth. Structural damage of the mesothelial layer attributable to the pneumoperitoneum may facilitate intraabdominal tumor cell adhesion and growth. The influence of carbon dioxide (CO(2)) and helium pneumoperitoneum on the morphology of the peritoneum was examined. METHODS A total of 50 rats received colon carcinoma (DHB/TRb) cells intraperitoneally and CO(2) (n = 25) or helium (n = 25) pneumoperitoneum at 15 mmHg for 15 min. After different periods (2, 12, 24, 48, and 96 h), the rats were killed, and the peritoneum was examined by scanning electron microscopy. Control animals (n = 5) were without pneumoperitoneum. RESULTS The control animals and most of the rats with pneumoperitoneum showed no peritoneal alterations. In four animals of each group, inflammatory alterations of the peritoneum such as bulging and retraction of mesothelial cells were observed at different time points. Tumor cells adherent to the peritoneum were found in a total of six animals. Peritoneal carcinomatosis, tumor nodules, or infiltration of the peritoneum by tumor cells was not observed. CONCLUSIONS The study demonstrated that the morphologic integrity of the rat peritoneum is not disturbed when CO(2) or helium is used for insufflation combined with the intraperitoneal injection of carcinoma cells. Pneumoperitoneum therefore probably is not the condition causing peritoneal changes that favor intraperitoneal tumor growth.
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Affiliation(s)
- J Ordemann
- Department of General, Visceral, Vascular, and Thoracic Surgery, Medical Faculty, Humboldt University Shumannstrasse 20/21, 10117 Berlin, Germany
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Gutt CN, Oniu T, Schemmer P, Mehrabi A, Büchler MW. Fewer adhesions induced by laparoscopic surgery? Surg Endosc 2004; 18:898-906. [PMID: 15108105 DOI: 10.1007/s00464-003-9233-3] [Citation(s) in RCA: 233] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2003] [Accepted: 11/21/2003] [Indexed: 12/12/2022]
Abstract
BACKGROUND Laparoscopic surgery has potential theoretical advantages over open surgery in reducing the rate of adhesion formation, but very few comparative studies are available to prove this. METHODS A literature search was performed within Medline and Cochrane databases using the key words: adhesion*, adhesiolysis, laparoscop*, laparotomy, open surgery. Further articles were identified from the reference lists of retrieved literature. Both clinical and experimental studies comparing laparoscopy and laparotomy with regard to adhesion formation were retained. In each article, the rates of adhesion formation were identified or deduced for the operative site, access wound site, and distant sites. RESULTS Fifteen studies from 1987 to 2001 were identified. Most studies assessed the operative site. Thus, three clinical studies and six experimental ones found fewer adhesions following laparoscopy than laparotomy, while other five experimental studies found similar adhesion rates for the two surgical methods. There were fewer adhesions to trocar wounds than to the laparotomy wounds in seven studies and equal rates of adhesion in one study. The problem of distant adhesions is poorly represented in literature; three studies favored laparoscopy as being followed by fewer adhesions. Because of the important differences between studies with regard to the design, end points, and statistical calculations, a metaanalysis could not be achieved. The conclusion is based on the prevalence of evidence. CONCLUSIONS All clinical studies and most of the experimental studies found a reduction of adhesion formation after laparoscopic surgery compared to open surgery.
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Affiliation(s)
- C N Gutt
- Department of General, Visceral- and Trauma Surgery, Ruprecht Karls-University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany,
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