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Wise PA, Preukschas AA, Özmen E, Bellemann N, Norajitra T, Sommer CM, Stock C, Mehrabi A, Müller-Stich BP, Kenngott HG, Nickel F. Intraoperative liver deformation and organ motion caused by ventilation, laparotomy, and pneumoperitoneum in a porcine model for image-guided liver surgery. Surg Endosc 2024; 38:1379-1389. [PMID: 38148403 PMCID: PMC10881715 DOI: 10.1007/s00464-023-10612-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 11/26/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Image-guidance promises to make complex situations in liver interventions safer. Clinical success is limited by intraoperative organ motion due to ventilation and surgical manipulation. The aim was to assess influence of different ventilatory and operative states on liver motion in an experimental model. METHODS Liver motion due to ventilation (expiration, middle, and full inspiration) and operative state (native, laparotomy, and pneumoperitoneum) was assessed in a live porcine model (n = 10). Computed tomography (CT)-scans were taken for each pig for each possible combination of factors. Liver motion was measured by the vectors between predefined landmarks along the hepatic vein tree between CT scans after image segmentation. RESULTS Liver position changed significantly with ventilation. Peripheral regions of the liver showed significantly higher motion (maximal Euclidean motion 17.9 ± 2.7 mm) than central regions (maximal Euclidean motion 12.6 ± 2.1 mm, p < 0.001) across all operative states. The total average motion measured 11.6 ± 0.7 mm (p < 0.001). Between the operative states, the position of the liver changed the most from native state to pneumoperitoneum (14.6 ± 0.9 mm, p < 0.001). From native state to laparotomy comparatively, the displacement averaged 9.8 ± 1.2 mm (p < 0.001). With pneumoperitoneum, the breath-dependent liver motion was significantly reduced when compared to other modalities. Liver motion due to ventilation was 7.7 ± 0.6 mm during pneumoperitoneum, 13.9 ± 1.1 mm with laparotomy, and 13.5 ± 1.4 mm in the native state (p < 0.001 in all cases). CONCLUSIONS Ventilation and application of pneumoperitoneum caused significant changes in liver position. Liver motion was reduced but clearly measurable during pneumoperitoneum. Intraoperative guidance/navigation systems should therefore account for ventilation and intraoperative changes of liver position and peripheral deformation.
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Affiliation(s)
- Philipp A Wise
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Anas A Preukschas
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Emre Özmen
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Nadine Bellemann
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Tobias Norajitra
- Division of Medical and Biological Informatics, German Cancer Research Center, Im Neuenheimer Feld 280, 69120, Heidelberg, Germany
| | - Christof M Sommer
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Christian Stock
- Institute for Medical Biometry and Informatics, Heidelberg University, Im Neuenheimer Feld 305, 69120, Heidelberg, Germany
| | - Arianeb Mehrabi
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Beat P Müller-Stich
- Division of Abdominal Surgery, Clarunis-Academic Centre of Gastrointestinal Diseases, St. Clara and University Hospital of Basel, Petersgraben 4, 4051, Basel, Switzerland
| | - Hannes G Kenngott
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 420, 69120, Heidelberg, Germany.
- Department of General, Visceral and Thoracic Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Wang C, Reynolds JC, Calle P, Ladymon AD, Yan F, Yan Y, Ton S, Fung KM, Patel SG, Yu Z, Pan C, Tang Q. Computer-aided Veress needle guidance using endoscopic optical coherence tomography and convolutional neural networks. JOURNAL OF BIOPHOTONICS 2022; 15:e202100347. [PMID: 35103420 PMCID: PMC9097560 DOI: 10.1002/jbio.202100347] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 01/17/2022] [Accepted: 01/20/2022] [Indexed: 05/03/2023]
Abstract
During laparoscopic surgery, the Veress needle is commonly used in pneumoperitoneum establishment. Precise placement of the Veress needle is still a challenge for the surgeon. In this study, a computer-aided endoscopic optical coherence tomography (OCT) system was developed to effectively and safely guide Veress needle insertion. This endoscopic system was tested by imaging subcutaneous fat, muscle, abdominal space, and the small intestine from swine samples to simulate the surgical process, including the situation with small intestine injury. Each tissue layer was visualized in OCT images with unique features and subsequently used to develop a system for automatic localization of the Veress needle tip by identifying tissue layers (or spaces) and estimating the needle-to-tissue distance. We used convolutional neural networks (CNNs) in automatic tissue classification and distance estimation. The average testing accuracy in tissue classification was 98.53 ± 0.39%, and the average testing relative error in distance estimation reached 4.42 ± 0.56% (36.09 ± 4.92 μm).
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Affiliation(s)
- Chen Wang
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019
| | | | - Paul Calle
- School of Computer Science, University of Oklahoma, Norman, OK 73019
| | - Avery D. Ladymon
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019
| | - Feng Yan
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019
| | - Yuyang Yan
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019
| | - Sam Ton
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019
| | - Kar-ming Fung
- Department of Pathology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Sanjay G. Patel
- Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Zhongxin Yu
- Children’s Hospital, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73104
| | - Chongle Pan
- School of Computer Science, University of Oklahoma, Norman, OK 73019
- ,
| | - Qinggong Tang
- Stephenson School of Biomedical Engineering, University of Oklahoma, Norman, OK 73019
- ,
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Banerjee A, Saini S, Lal J. Evaluation of hemodynamic changes during laparoscopic cholecystectomy by transthoracic echocardiography. J Anaesthesiol Clin Pharmacol 2021; 37:436-442. [PMID: 34759558 PMCID: PMC8562441 DOI: 10.4103/joacp.joacp_173_19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 01/29/2020] [Accepted: 03/06/2020] [Indexed: 11/11/2022] Open
Abstract
Background and Aims: The purpose of this study was to prospectively examine the effects of pneumoperitoneum and the reverse Trendelenburg position on cardiac hemodynamics during laparoscopic cholecystectomy using transthoracic echocardiography (TTE). Material and Methods: In this prospective observational study, after institutional review board clearance, forty patients of either sex of ASA I-II status undergoing laparoscopic cholecystectomy were enrolled in the study. Changes in cardiac output, stroke volume, and ejection fraction were recorded using TTE at different time intervals: Preoperatively, before creation of pneumoperitoneum, 5 min after creation of pneumoperitoneum, and 5 min after setting the operative reverse Trendelenburg position with legs at the level of the hips. All statistical analyses were performed using the statistical program SPSS version 16 and P value less than 0.05 was considered as statistically significant. Data were examined using mixed analysis of variance (ANOVA) followed by post hoc Bonferroni correction. Results: There was significant fall in cardiac output (CO) (45%, P < 0.001), stroke volume (SV) (42%, P < 0.001), and ejection fraction (EF) (31.8% change, P < 0.001) after creation of pneumoperitoneum with significant rise in MAP (11%, P < 0.001). But with reverse Trendelenburg position, there was a significant improvement of CO (30%), SV (28%), and EF (21% change) in comparison to values after pneumoperitoneum, but still remained below baseline. There was no change in heart rate at different time intervals. There was no significant difference in hemodynamics between ASA I and II patients. Conclusion: Patients undergoing laparoscopic cholecystectomy undergo significant hemodynamic changes after pneumoperitoneum and reverse Trendelenburg position.
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Affiliation(s)
- Arnab Banerjee
- Department of Anaesthesiology and Critical Care, Pt. BD Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Savita Saini
- Department of Anaesthesiology and Critical Care, Pt. BD Sharma University of Health Sciences, Rohtak, Haryana, India
| | - Jatin Lal
- Department of Anaesthesiology and Critical Care, Pt. BD Sharma University of Health Sciences, Rohtak, Haryana, India
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Poerwosusanta H, Gunadi, Noor Z, Oktaviyanti IK, Mintaroem K, Pardjianto B, Widodo MA, Widjajanto E. The effect of laparoscopy on mast cell degranulation and mesothelium thickness in rats. BMC Surg 2020; 20:111. [PMID: 32448270 PMCID: PMC7247274 DOI: 10.1186/s12893-020-00775-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
Background Laparoscopy induces adhesion due to ischemia-reperfusion injury. However, the detail pathomechanism is poorly understood. This study aimed to investigate the impact of laparoscopy on mast cell and mesothelium morphological changes in the rat. Methods Forty-nine males of Sprague-Dawley Rattus norvegicus were divided into four groups: a) control and b) intervention groups P1, P2, and P3 that underwent 60 min laparoscopic using carbon dioxide (CO2) insufflation at 8, 10, and 12 mmHg groups, respectively. Serum hydrogen peroxide (H2O2), catalase (CAT), superoxide dismutase (SOD), malondialdehyde (MDA), and oxidative stress index (OSI) levels were determined 24 h after laparoscopy. Histopathological analyses of mast cell infiltration and degranulation and mesothelium thickness in the liver, greater omentum, mesenterium, small intestine, and peritoneum were performed 7 days after the procedure. Results H2O2, MDA, and OSI levels were significantly increased in the intervention groups compared with the control (p<0.05), while the SOD and CAT levels were decreased in the intervention groups compared with the control (p<0.05). Mast cell infiltration and degranulation were higher in the intervention groups than in control (p<0.05), while the mesothelium thickness was significantly lower in the laparoscopic groups than in control (p<0.05). Interestingly, the decrease in mesothelium thickness was strongly associated with the increase in mast cell infiltration and degranulation (p<0.01). Conclusions Our study shows that laparoscopy in rats increases mast cell infiltration and degranulation, which also results in and correlates with a decrease in mesothelial thickness.
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Affiliation(s)
- Hery Poerwosusanta
- Doctoral Study Program, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia. .,Department of Surgery, Ulin General Hospital, Faculty of Medicine, Universitas Lambung Mangkurat, Banjarmasin, Indonesia.
| | - Gunadi
- Pediatric Surgery Division, Department of Surgery, Faculty of Medicine, Public Health and Nursing, Universitas Gajah Mada /Dr. Sardjito Hospital, Yogyakarta, Indonesia
| | - Zairin Noor
- Department of Surgery, Ulin General Hospital, Faculty of Medicine, Universitas Lambung Mangkurat, Banjarmasin, Indonesia
| | - Ika Kustiyah Oktaviyanti
- Department of Anatomical Pathology, Faculty of Medicine, Universitas Lambung Mangkurat, Banjarmasin, Indonesia
| | - Karyono Mintaroem
- Department of Biomedical Science, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Bambang Pardjianto
- Department of Biomedical Science, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Moch Aris Widodo
- Department of Biomedical Science, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
| | - Edi Widjajanto
- Department of Biomedical Science, Faculty of Medicine, Universitas Brawijaya, Malang, Indonesia
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Scott J, Singh A, Valverde A. Pneumoperitoneum in Veterinary Laparoscopy: A Review. Vet Sci 2020; 7:E64. [PMID: 32408554 PMCID: PMC7356543 DOI: 10.3390/vetsci7020064] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Revised: 04/27/2020] [Accepted: 05/09/2020] [Indexed: 01/25/2023] Open
Abstract
Objective: To review the effects of carbon dioxide pneumoperitoneum during laparoscopy, evaluate alternative techniques to establishing a working space and compare this to current recommendations in veterinary surgery. Study Design: Literature review. Sample Population: 92 peer-reviewed articles. Methods: An electronic database search identified human and veterinary literature on the effects of pneumoperitoneum (carbon dioxide insufflation for laparoscopy) and alternatives with a focus on adaptation to the veterinary field. Results: Laparoscopy is the preferred surgical approach for many human and several veterinary procedures due to the lower morbidity associated with minimally invasive surgery, compared to laparotomy. The establishment of a pneumoperitoneum with a gas most commonly facilitates a working space. Carbon dioxide is the preferred gas for insufflation as it is inert, inexpensive, noncombustible, colorless, excreted by the lungs and highly soluble in water. Detrimental side effects such as acidosis, hypercapnia, reduction in cardiac output, decreased pulmonary compliance, hypothermia and post-operative pain have been associated with a pneumoperitoneum established with CO2 insufflation. As such alternatives have been suggested such as helium, nitrous oxide, warmed and humidified carbon dioxide and gasless laparoscopy. None of these alternatives have found a consistent benefit over standard carbon dioxide insufflation. Conclusions: The physiologic alterations seen with CO2 insufflation at the current recommended intra-abdominal pressures are mild and of transient duration. Clinical Significance: The current recommendations in veterinary laparoscopy for a pneumoperitoneum using carbon dioxide appear to be safe and effective.
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Affiliation(s)
- Jacqueline Scott
- College of Veterinary Medicine, University of Illinois, Urbana-Champaign, IL 61802, USA
| | - Ameet Singh
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada; (A.S.); (A.V.)
| | - Alexander Valverde
- Department of Clinical Studies, Ontario Veterinary College, University of Guelph, Guelph, ON N1G 2W1, Canada; (A.S.); (A.V.)
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Laparoscopic surgery for T4 colon cancer: a risk factor for peritoneal recurrences? Surgery 2020; 168:119-124. [PMID: 32305228 DOI: 10.1016/j.surg.2020.02.026] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 02/17/2020] [Accepted: 02/29/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Although some preclinical studies have inferred that laparoscopic surgery for advanced cancer may increase the risk of peritoneal metastasis, this potential hazard has not been fully evaluated in the clinical setting. This study aimed to clarify whether laparoscopic surgery is associated with an increased risk of postoperative peritoneal recurrence after resection of T4 colon cancer. METHODS This study included 272 patients who underwent curative resection for pathological T4a colon cancer without distant metastases at the University of Tokyo Hospital between 1997 and 2017. Multivariable Fine-Gray analysis was performed to evaluate whether the use of laparoscopy was an independent risk factor for postoperative peritoneal recurrence. Thereafter, oncological outcomes (overall and relapse-free survival, and organ-specific recurrence) were compared between laparoscopic colectomy and open colectomy using propensity score matching. RESULTS Multivariable analysis found that laparoscopic surgery was a significant risk factor for postoperative peritoneal recurrence (hazard ratio: 1.89; 95% confidence interval: 1.01-3.65; P = .046). Comparison after propensity score matching revealed that the incidence of peritoneal recurrence was significantly higher after laparoscopic colectomy than after open colectomy (5-year cumulative incidence: 28.1% vs 12.1%; P = .003). CONCLUSION This study suggested that laparoscopic surgery may be related to an increased risk of peritoneal recurrence in patients with pathological T4a colon cancer. Clinicians should be fully aware of this potential risk and seek an optimal treatment plan for the prevention and early detection of peritoneal metastasis.
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An Y, Zhao L, Wang T, Huang J, Xiao W, Wang P, Li L, Li Z, Chen X. Preemptive oxycodone is superior to equal dose of sufentanil to reduce visceral pain and inflammatory markers after surgery: a randomized controlled trail. BMC Anesthesiol 2019; 19:96. [PMID: 31185942 PMCID: PMC6560747 DOI: 10.1186/s12871-019-0775-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/31/2019] [Indexed: 01/27/2023] Open
Abstract
Background Postoperative visceral pain is common after surgery and previous studies have demonstrated that oxycodone is an effective treatment. In this study, we compared the effects of preemptive oxycodone to equal dose of sufentanil on postoperative pain and serum level of inflammatory factors (TNF-α, IL-6, IL-10) after laparoscopic cholecystectomy. Methods Forty patients undergoing laparoscopic cholecystectomy were randomized into preemptive oxycodone group or preemptive sufentanil group. Patients were given either oxycodone 0.1 mg/kg (oxycodone group, n = 20) or sufentanil 0.1 μg/kg (sufentanil group, n = 20) for preemptive analgesia. We evaluated pain/sedation scores at 0 h, 0.5 h, 2 h, 4 h, 6 h, 8 h and 24 h after surgery and measured serum concentrations of TNF-α, IL-6 and IL-10 before surgery and at 0 h, 6 h and 24 h after surgery. Results Twenty patients were recruited in each group. Numerical rating scale (NRS) of visceral pain in the oxycodone group at 2 h when resting (0.5(0,2.75) vs 3(2,4), P = 0.008) and moving (0.5(0,3) vs 3(2.25,4), P = 0.015) and 4 h when moving (2(0,3) vs 3(0,4.75), P = 0.043) after surgery were significantly lower than the sufentanil group. Serum concentrations of TNF-α at 6 h (38.68 ± 10.49 vs 73.02 ± 16.27, P<0.001) and 24 h (43.12 ± 8.40 vs 74.00 ± 21.30, P<0.001) in the oxycodone group were lower than the sufentanil group. Conclusions Preemptive oxycodone 0.1 mg/kg administration could effectively suppress visceral pain at 2 h and 4 h after surgery and had lower inflammatory marker, serum TNF-α, level when compared to equal dose of sufentanil. Trial registration Clinical trials registration number: ChiCTR-IOR-17013738http://www.chictr.org.cn/showproj.aspx?proj=17346. Date of registration: 6th December 2017.
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Affiliation(s)
- Yi An
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Lei Zhao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, China.
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Jiapeng Huang
- Department of Anesthesiology, Jewish Hospital and Department of Anesthesiology & Perioperative Medicine, University of Louisville, Louisville, KY, USA
| | - Wei Xiao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Ping Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Lixia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Zhongjia Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
| | - Xiaoxu Chen
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, 45 Changchun Street, Xicheng District, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, China
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Zheng L, Zhou D, Lu L, Liu Z, Fang L. Effects of CO 2 pneumoperitoneum on proliferation, apoptosis, and migration of gastrointestinal stromal tumor cells. Surg Endosc 2019; 33:3384-3395. [PMID: 30604263 DOI: 10.1007/s00464-018-06633-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 12/19/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND The purpose of the study was to investigate the proliferation and migration capability of human gastrointestinal stromal tumor line GIST-T1 after exposure to different pressures and times of CO2 pneumoperitoneum. METHODS We established simulated CO2 pneumoperitoneum environment in vitro and divided the human GIST cell GIST-T1 into open control group, 8 mmHg CO2 pneumoperitoneum treatment group and 15 mmHg CO2 pneumoperitoneum treatment group. Each group was divided into two subgroups respectively cultured for 1 h and 3 h. pH value of cell culture, cell growth curve, and cell cycle distribution of each group was measured. By application of scratch healing tests and Transwell chamber experiments, mobility ratio and number of cells through 8 µm membranes were measured to assess the migration ability of cells in each group after intervention. RESULTS Cell culture pH value of each subgroup in CO2 group decreased significantly after exposed in CO2 pneumoperitoneum (P < 0.01). The proliferation of GIST-T1 cells in 15 mmHg CO2 group was significantly inhibited early (1-2 days) (P < 0.05) and the proliferation of GIST-T1 cells in 8 mmHg CO2 1 h subgroup and 15 mmHg CO2 1 h subgroup was increased significantly late (4-6 days) (P < 0.05) after the interventions of CO2 pneumoperitoneum. The percentage of cells in G0-G1 phase increased, the percentage of S phase cells decreased (P < 0.01) in 1-h subgroup and 3-h subgroup of 15 mmHg CO2 group 24 h after exposure to CO2. The percentage of cells in S phase increased in 1-h subgroup of 8 mmHg CO2 group and decreased in 3-h subgroup of 15 mmHg CO2 group 72 h after exposure to CO2. In the Transwell chamber experiment, the cell number through 8-µm membrane increased significantly (P < 0.01) in 3-h subgroup of CO2 group compared to that in 3-h subgroup of control group. CONCLUSIONS The routine pressure and duration of CO2 pneumoperitoneum used in clinic did not promote the proliferation of gastrointestinal stromal tumors, but had a potential risk of increasing postoperative recurrence and distant metastasis.
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Affiliation(s)
- Lijun Zheng
- Department of General Surgery, Shanghai Tenth people's Hospital, Tongji University, No. 301 Middle Yanchang Road, Shanghai, 200072, People's Republic of China
| | - Donglei Zhou
- Department of General Surgery, Shanghai Tenth people's Hospital, Tongji University, No. 301 Middle Yanchang Road, Shanghai, 200072, People's Republic of China
| | - Liesheng Lu
- Department of General Surgery, Shanghai Tenth people's Hospital, Tongji University, No. 301 Middle Yanchang Road, Shanghai, 200072, People's Republic of China
| | - Zhongchen Liu
- Department of General Surgery, Shanghai Tenth people's Hospital, Tongji University, No. 301 Middle Yanchang Road, Shanghai, 200072, People's Republic of China
| | - Lin Fang
- Department of General Surgery, Shanghai Tenth people's Hospital, Tongji University, No. 301 Middle Yanchang Road, Shanghai, 200072, People's Republic of China.
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Effects of low intraperitoneal pressure and a warmed, humidified carbon dioxide gas in laparoscopic surgery: a randomized clinical trial. Sci Rep 2017; 7:11287. [PMID: 28900123 PMCID: PMC5595842 DOI: 10.1038/s41598-017-10769-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2017] [Accepted: 08/14/2017] [Indexed: 12/29/2022] Open
Abstract
Laparoscopic surgery technology continues to advance. However, much less attention has been focused on how alteration of the laparoscopic surgical environment might improve clinical outcomes. We conducted a randomized, 2 × 2 factorial trial to evaluate whether low intraperitoneal pressure (IPP) (8 mmHg) and/or warmed, humidified CO2 (WH) gas are better for minimizing the adverse impact of a CO2 pneumoperitoneum on the peritoneal environment during laparoscopic surgery and for improving clinical outcomes compared to the standard IPP (12 mmHg) and/or cool and dry CO2 (CD) gas. Herein we show that low IPP and WH gas may decrease inflammation in the laparoscopic surgical environment, resulting in better clinical outcomes. Low IPP and/or WH gas significantly lowered expression of inflammation-related genes in peritoneal tissues compared to the standard IPP and/or CD gas. The odds ratios of a visual analogue scale (VAS) pain score >30 in the ward was 0.18 (95% CI: 0.06, 0.52) at 12 hours and 0.06 (95% CI: 0.01, 0.26) at 24 hours in the low IPP group versus the standard IPP group, and 0.16 (95% CI: 0.05, 0.49) at 0 hours and 0.29 (95% CI: 0.10, 0.79) at 12 hours in the WH gas group versus the CD gas group.
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10
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Lotti M, Giulii Capponi M, Campanati L, Poiasina E, Ansaloni L, Poletti E, Frigerio L. The Onset of Intra-Abdominal Adhesions During Closed-Abdomen Hyperthermic Intraperitoneal Chemotherapy. J Laparoendosc Adv Surg Tech A 2016; 26:997-1002. [PMID: 27705085 DOI: 10.1089/lap.2016.0396] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
INTRODUCTION Hyperthermic intraperitoneal chemotherapy (HIPEC) is delivered after cytoreductive surgery (CRS) in selected patients with peritoneal carcinomatosis. The closed-abdomen technique, preferred by many centers, prevents heat loss and drug spillage, but does not warrant homogeneous distribution of the perfusion fluid (PF). The hypothesized formation of intra-abdominal adhesions during the closed-abdomen perfusion period has never been described. MATERIALS AND METHODS From March 2014 to April 2016, 10 consecutive patients with peritoneal carcinomatosis, selected for CRS, underwent the Laparoscopy-Enhanced HIPEC technique to explore the abdominal cavity during the perfusion. The aim of the study was to investigate the incidence and the extent of intra-abdominal adhesions that are formed after CRS during the perfusion period of closed-abdomen HIPEC. RESULTS During the perfusion, adhesions developed in 70% of the patients. Adhesions developed mainly in the period between the closure of the abdomen and the subsequent filling of the abdomen with the PF. After their first division, during the following perfusion period, adhesions between the bowel and the abdominal wall reformed in 3 patients (30%). CONCLUSIONS Intra-abdominal adhesions are frequently formed during closed-abdomen HIPEC and can hamper the adequate circulation of the PF. The Laparoscopy-Enhanced technique enables the early detection and the division of any intra-abdominal adhesions.
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Affiliation(s)
- Marco Lotti
- 1 Advanced Surgical Oncology Unit, Department of General Surgery 1, Papa Giovanni XXIII Hospital , Bergamo, Italy
| | | | - Luca Campanati
- 2 Department of General Surgery 1, Papa Giovanni XXIII Hospital , Bergamo, Italy
| | - Elia Poiasina
- 2 Department of General Surgery 1, Papa Giovanni XXIII Hospital , Bergamo, Italy
| | - Luca Ansaloni
- 2 Department of General Surgery 1, Papa Giovanni XXIII Hospital , Bergamo, Italy
| | - Eugenio Poletti
- 2 Department of General Surgery 1, Papa Giovanni XXIII Hospital , Bergamo, Italy
| | - Luigi Frigerio
- 3 Department of Gynecology and Obstetrics, Papa Giovanni XXIII Hospital , Bergamo, Italy
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Cezar C, Korell M, Tchartchian G, Ziegler N, Senshu K, Herrmann A, Larbig A, De Wilde RL. How to avoid risks for patients in minimal-access trials: Avoiding complications in clinical first-in-human studies by example of the ADBEE study. Best Pract Res Clin Obstet Gynaecol 2016; 35:84-96. [DOI: 10.1016/j.bpobgyn.2015.11.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 11/06/2015] [Indexed: 12/29/2022]
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12
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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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Kong TW, Chang SJ, Piao X, Paek J, Lee Y, Lee EJ, Chun M, Ryu HS. Patterns of recurrence and survival after abdominal versus laparoscopic/robotic radical hysterectomy in patients with early cervical cancer. J Obstet Gynaecol Res 2015; 42:77-86. [DOI: 10.1111/jog.12840] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Revised: 07/07/2015] [Accepted: 07/22/2015] [Indexed: 11/28/2022]
Affiliation(s)
- Tae-Wook Kong
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Obstetrics and Gynecology; Ajou University School of Medicine; Suwon Korea
| | - Suk-Joon Chang
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Obstetrics and Gynecology; Ajou University School of Medicine; Suwon Korea
| | - Xianling Piao
- Ajou University Graduate School of Medicine; Suwon Korea
| | - Jiheum Paek
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Obstetrics and Gynecology; Ajou University School of Medicine; Suwon Korea
| | - Yonghee Lee
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Pathology; Ajou University School of Medicine; Suwon Korea
| | - Eun Ju Lee
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Radiology; Ajou University School of Medicine; Suwon Korea
| | - Mison Chun
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Radiation Oncology; Ajou University School of Medicine; Suwon Korea
| | - Hee-Sug Ryu
- Gynecologic Cancer Center; Ajou University School of Medicine; Suwon Korea
- Department of Obstetrics and Gynecology; Ajou University School of Medicine; Suwon Korea
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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: 42] [Impact Index Per Article: 4.7] [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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15
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Özdemir-van Brunschot DMD, van Laarhoven KCJHM, Scheffer GJ, Pouwels S, Wever KE, Warlé MC. What is the evidence for the use of low-pressure pneumoperitoneum? A systematic review. Surg Endosc 2015; 30:2049-65. [PMID: 26275545 PMCID: PMC4848341 DOI: 10.1007/s00464-015-4454-9] [Citation(s) in RCA: 96] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 07/16/2015] [Indexed: 12/20/2022]
Abstract
Background Laparoscopic surgery has several advantages when compared to open surgery, including faster postoperative recovery and lower pain scores. However, for laparoscopy, a pneumoperitoneum is required to create workspace between the abdominal wall and intraabdominal organs. Increased intraabdominal pressure may also have negative implications on cardiovascular, pulmonary, and intraabdominal organ functionings. To overcome these negative consequences, several trials have been performed comparing low- versus standard-pressure pneumoperitoneum. Methods A systematic review of all randomized controlled clinical trials and observational studies comparing low- versus standard-pressure pneumoperitoneum. Results and conclusions Quality assessment showed that the overall quality of evidence was moderate to low. Postoperative pain scores were reduced by the use of low-pressure pneumoperitoneum. With appropriate perioperative measures, the use of low-pressure pneumoperitoneum does not seem to have clinical advantages as compared to standard pressure on cardiac and pulmonary function. Although there are indications that low-pressure pneumoperitoneum is associated with less liver and kidney injury when compared to standard-pressure pneumoperitoneum, this does not seem to have clinical implications for healthy individuals. The influence of low-pressure pneumoperitoneum on adhesion formation, anastomosis healing, tumor metastasis, intraocular and intracerebral pressure, and thromboembolic complications remains uncertain, as no human clinical trials have been performed. The influence of pressure on surgical conditions and safety has not been established to date. In conclusion, the most important benefit of low-pressure pneumoperitoneum is lower postoperative pain scores, supported by a moderate quality of evidence. However, the quality of surgical conditions and safety of the use of low-pressure pneumoperitoneum need to be established, as are the values and preferences of physicians and patients regarding the potential benefits and risks. Therefore, the recommendation to use low-pressure pneumoperitoneum during laparoscopy is weak, and more studies are required.
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Affiliation(s)
- Denise M D Özdemir-van Brunschot
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - Kees C J H M van Laarhoven
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Gert-Jan Scheffer
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Sjaak Pouwels
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Kim E Wever
- Systematic Review Centre for Laboratory Animal Experimentation (SYRCLE), Radboud University Medical Center, Nijmegen, The Netherlands
| | - Michiel C Warlé
- Division of Vascular and Transplant Surgery, Department of Surgery, Radboud University Medical Center, Geert Grooteplein-Zuid 10, PO Box 9101, 6500 HB, Nijmegen, The Netherlands
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Angioli R, Terranova C, Plotti F, Cafà EV, Gennari P, Ricciardi R, Aloisi A, Miranda A, Montera R, De Cicco Nardone C. Influence of pneumoperitoneum pressure on surgical field during robotic and laparoscopic surgery: a comparative study. Arch Gynecol Obstet 2014; 291:865-8. [PMID: 25260990 DOI: 10.1007/s00404-014-3494-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Accepted: 09/22/2014] [Indexed: 02/06/2023]
Abstract
PURPOSE Studies on the influence of CO₂ pneumoperitoneum on the abdominal cavity during robotic procedures are lacking. This is the first study to evaluate surgical field modifications related to CO₂ pressure, during laparoscopic and robotic surgery. METHODS Consecutive patients scheduled for laparoscopic or robotic hysterectomy were enrolled in the study. To evaluate the level of operative field visualization, a dedicated form has been designed based on the evaluation of four different areas: Douglas space, vesico-uterine fold and, bilaterally, the broad ligament. During the initial inspection, an assistant randomly set the CO₂ pressure at 15, 10 and 5 mmHg, and the surgeon, not aware of the CO₂ values, was asked to give an evaluation of the four areas for each set pressure. RESULTS In laparoscopic group, CO₂ pressure significantly influenced the surgical field visualization in all four areas analyzed. The surgeon had a good visualization only at 15 mmHg CO₂ pressure; visualization decreased with a statistically significant difference from 15 to 5, 15-10 and 10-5 mmHg. In robotic group, influence of CO₂ pressure on surgical areas visualization was not straightforward; operative field visualization remained stable at any pressure value with no significant difference. CONCLUSIONS Pneumoperitoneum pressure significantly affects the visualization of the abdomino-pelvic cavity in laparoscopic procedures. Otherwise, CO₂ pressure does not affect the visualization of surgical field during robotic surgery. These findings are particularly significant especially at low CO₂ pressure with potential implications on peritoneal environment and the subsequent post-operative patient recovery.
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Affiliation(s)
- Roberto Angioli
- Department of Obstetrics and Gynecology, "Campus Bio-Medico" University of Rome, Via Álvaro Del Portillo, 200-00128, Rome, Italy
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Lu Z, Zhang W, Jiang S, Zou J, Li Y. Effect of oxygen tensions on the proliferation and angiogenesis of endometriosis heterograft in severe combined immunodeficiency mice. Fertil Steril 2013; 101:568-76. [PMID: 24290003 DOI: 10.1016/j.fertnstert.2013.10.039] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2013] [Revised: 10/06/2013] [Accepted: 10/25/2013] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To investigate the effects of oxygen on the proliferation and angiogenesis of endometriosis in vivo. DESIGN Animal studies. SETTING Animal research facility. ANIMAL(S) Thirty-six female severe combined immunodeficiency (SCID) mice, implanted with eutopic endometrium from seven endometriosis patients. INTERVENTION(S) Human eutopic endometrial tissues were randomized to normoxia, hyperoxia, or hypoxia pretreatment and were subcutaneously implanted into estrogen-treated ovariectomized SCID mice. MAIN OUTCOME MEASURE(S) The growth and quality of the implants were measured, and the expression of proliferation- and angiogenesis-associated markers (i.e., Ki67, CD31, vascular endothelial growth factor, and hypoxia-inducible factor-1α) were assessed using immunohistochemistry and Western blot analyses. RESULT(S) The growth curves of the implants were distinct with different oxygen pretreatments. The growth of the implants of the hypoxia group was significantly increased compared with the normoxia group, but the growth of the implants of the hyperoxia group was significantly decreased compared with the normoxia group. Microscopic examination indicated that lesions with hyperplastic cylindrical glandular epithelium were surrounded by the endometrial stroma in the hypoxia group, but the glandular epithelium was partially depauperate in the hyperoxia group. The expression of Ki67, CD31, vascular endothelial growth factor, and hypoxia-inducible factor-1α in the hypoxia-pretreated implants was significantly higher compared with the hyperoxia or normoxia groups. CONCLUSION(S) Oxygen can alter the growth patterns of endometriosis implants in a SCID mouse model. Hypoxia pretreatment promoted the proliferation and angiogenesis of endometriosis, whereas hyperoxia pretreatment exhibited the opposite effect.
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Affiliation(s)
- Zechun Lu
- Department of Obstetrics and Gynecology, Chinese People's Liberation Army (PLA) 306 Hospital, Beijing, People's Republic of China; Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Weiyi Zhang
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Shufang Jiang
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, People's Republic of China
| | - Jie Zou
- Department of Obstetrics and Gynecology, China-Japan Friendship Hospital, Beijing, People's Republic of China
| | - Yali Li
- Department of Obstetrics and Gynecology, Chinese PLA General Hospital, Beijing, People's Republic of China.
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Seo YK, Lee HJ, Ha TK, Lee KG. Effect of Normal Saline Irrigation on Attenuation of Shoulder Tip Pain and on β-Endorphin Levels After Laparoscopic Cholecystectomy. J Laparoendosc Adv Surg Tech A 2012; 22:311-4. [DOI: 10.1089/lap.2011.0365] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Youn Kyoung Seo
- Department of Anatomy and Cell Biology, College of Medicine, Hanyang University, Seoul, Korea
| | - Hee Jong Lee
- Department of Anesthesiology and Pain Medicine, College of Medicine, Hanyang University, Seoul, Korea
| | - Tae Kyung Ha
- Department of Surgery, College of Medicine, Hanyang University, Seoul, Korea
| | - Kyeong Geun Lee
- Department of Surgery, College of Medicine, Hanyang University, Seoul, Korea
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Srivastava A, Niranjan A. Secrets of safe laparoscopic surgery: Anaesthetic and surgical considerations. J Minim Access Surg 2011; 6:91-4. [PMID: 21120064 PMCID: PMC2992667 DOI: 10.4103/0972-9941.72593] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2010] [Accepted: 01/06/2010] [Indexed: 02/07/2023] Open
Abstract
In recent years, laparoscopic surgery has gained popularity in clinical practice. The key element in laparoscopic surgery is creation of pneumoperitoneum and carbon dioxide is commonly used for insufflation. This pneumoperitoneum perils the normal cardiopulmonary system to a considerable extent. Every laparoscopic surgeon should understand the consequences of pneumoperitoneum; so that its untoward effects can be averted. Pneumoperitoneum increases pressure on diaphragm, leading to its cephalic displacement and thereby decreasing venous return, which can be aggravated by the position of patient during surgery. There is no absolute contraindication of laparoscopic surgery, though we can anticipate some problems in conditions like obesity, pregnancy and previous abdominal surgery. This review discusses some aspects of the pathophysiology of carbon dioxide induced pneumoperitoneum, its consequences as well as strategies to counteract them. Also, we propose certain guidelines for safe laparoscopic surgery.
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Affiliation(s)
- Arati Srivastava
- Department of Anaesthesiology, Subharti Medical College, Meerut, India
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Impact of pressure and gas type on adhesion formation and biomaterial integration in laparoscopy. Surg Endosc 2011; 25:3605-12. [PMID: 21643882 DOI: 10.1007/s00464-011-1766-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2010] [Accepted: 04/18/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND Laparoscopic mesh repair of inguinal and incisional hernias has been widely adopted. Nevertheless, knowledge about the impact of pneumoperitoneum on mesh integration is rare. The present study investigates pressure and gas-dependent effects of pneumoperitoneum on adhesion formation and biomaterial integration in a standardized animal model. METHODS Laparoscopic intraperitoneal onlay mesh implantation (IPOM) was performed in 32 female chinchilla rabbits using CO(2) or helium for pneumoperitoneum. Intra-abdominal pressures were 3 or 6 mmHg. Animals were killed after 21 days, and the abdominal wall was explanted for subsequent histopathological examinations. Adhesions were assessed qualitatively with a scoring system, and the adhesion surface was analyzed semiquantitatively by planimetry. Infiltration of macrophages (CD68), expression of matrix metalloproteinase 13 (MMP-13), and cell proliferation (Ki67) were analyzed at the mesh to host interface by immunohistochemistry. The collagen type I/III ratio was analyzed by cross-polarization microscopy to determine the quality of mesh integration. RESULTS After 21 days, perifilamental infiltration with macrophages (CD68) and percentage of proliferating cells (Ki67) were highest after 6 mmHg of CO(2) pneumoperitoneum. The extent of adhesions, as well as the expression of MMP-13 and the collagen type I/III ratio, were similar between groups. CONCLUSIONS Our experiments showed no pressure or gas-dependent alterations of adhesion formation and only minor effects on biomaterial integration. Altogether, there is no evidence for a clinically negative effect of CO(2) pneumoperitoneum.
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Belli G, Cioffi L, D'Agostino A, Limongelli P, Belli A, Russo G, Fantini C. Revision surgery for incidentally detected early gallbladder cancer in laparoscopic era. J Laparoendosc Adv Surg Tech A 2011; 21:531-4. [PMID: 21612445 DOI: 10.1089/lap.2011.0078] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Incidentally detected early gallbladder cancer (IDEGB) is an early carcinoma first diagnosed on microscopic examination after a cholecystectomy for symptomatic benign gallbladder disease. After diagnosis of IDEGB it is often necessary a completion of treatment by a second tailored revision procedure. Despite early reports contraindicating laparoscopic approach because of high risk of neoplastic seeding, recent data seem to demonstrate that this approach per se does not influence clinical outcomes. We refer our experience in revision surgery by a totally laparoscopic approach that includes hepatic resection, lymphadenectomy, and port-sites excision. METHODS From January 2006 to March 2008, four patients with IDEGB were carried out to revision procedure by a totally laparoscopic approach. The mean operative time of procedure has been 162 minutes, whereas blood loss has been <100 mL (mean 85.1±23.3 mL). The postoperative course has been uneventful in all patients and perioperative mortality (within 40 days from intervention) 0. Hospital stay has been, respectively, 4, 5, 5, and 6 days (mean 5 days). During follow-up, at the last fluorine-18-labeled fluordesoxyglucose-positron emission tomography (FDG-PET) scan examination, respectively, 4, 3, and--for 2 patients--2 years after revision laparoscopic procedure, pathologic FDG accumulation was not reported. CONCLUSIONS Totally laparoscopic revision surgery for IDEGC seems to be a legitimate procedure, and, in our experience, reports satisfactory clinical outcomes in terms of perioperative and middle term oncological results. Larger and prospective studies are needed to support definitively oncological safety of this approach.
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Affiliation(s)
- Giulio Belli
- Department of General and Hepato-Pancreato-Biliary Surgery, S.M. Loreto Nuovo Hospital, Naples, Italy.
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Sammour T, Mittal A, Delahunt B, Phillips ARJ, Hill AG. Warming and humidification have no effect on oxidative stress during pneumoperitoneum in rats. MINIM INVASIV THER 2011; 20:329-37. [PMID: 21395459 DOI: 10.3109/13645706.2011.556647] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Pneumoperitoneum is reported to induce oxidative stress due to the desiccative effect of cold, dry gas insufflation. The aim of this study is to compare the effect of warmed, humidified insufflation to standard gas, by measuring oxidative stress markers in a physiologically relevant animal model. Twenty male Wistar rats (330?650 g) were alternately assigned to the Warm Humidified group (WH, n = 10) and Control group (n = 10). All rats underwent pneumoperitoneum at 5 mmHg and a controlled flow rate for 110 min. The WH group received warmed (37?C) and humidified (98% Relative Humidity (RH)) gas and the control group received standard gas at room temperature (19?C) and 0% RH. At the end of pneumoperitoneum, samples of liver, kidney, pancreas, jejunum, and lung were excised. Levels of plasma and tissue malondialdehyde (MDA) and protein carbonyls (PC) were measured. Organ light microscopy was performed. There were no differences between groups for MDA or PC concentrations in plasma, liver, kidney, jejunum, or lung tissue. There were no differences in histological score between groups. Warming and humidification of pneumoperitoneum insufflation gas have no effect on measures of oxidative stress compared to non-warmed, non-humidified controls.
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Affiliation(s)
- Tarik Sammour
- Department of Surgery, South Auckland Clinical School.
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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: 1.6] [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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Krause P, Bobisch NS, Thelen P, Koehler K, Koenig S, Becker H, Leister I. The plasminogen activator inhibitor system in colon cancer cell lines is influenced by the CO2 pneumoperitoneum. Int J Colorectal Dis 2011; 26:37-43. [PMID: 20931209 PMCID: PMC3015214 DOI: 10.1007/s00384-010-1062-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2010] [Indexed: 02/04/2023]
Abstract
PURPOSE Laparoscopic surgery in the treatment of colon carcinoma causes pH value alterations as well as changes in fibrinolytic activity. This results in enhanced proliferation of colon carcinoma cells in vitro and also in enhanced growth of liver metastasis when compared to isobaric (gasless) laparoscopy in vivo. So far, the direct influence of CO(2) pneumoperitoneum on the invasiveness and metastatic capabilities of colon cancer cells remains unclear. We therefore evaluated transcripts of the uPA system. METHODS The influence of CO(2) pneumoperitoneum on the gene expression of plasminogen activator inhibitor-1 (PAI-1), urokinase-type plasminogen activator (uPA), and tissue-type plasminogen activator (tPA) was investigated in colon carcinoma cell lines (HT116, SW48, and WiDr) and mesothelial cells employing a pneumoperitoneum chamber in vitro. Quantitative gene expression data were collected using real-time RT-PCR and statistical analysis was performed by means of analysis of variance and Bonferroni correction. RESULTS The expression of uPA and PAI-1 was increased in colon carcinoma cell lines when cultivated at pH 6.1, a value corresponding to intraabdominal pH values during CO(2) insufflation. Elevated PAI-1 mRNA levels were also observed when CO(2) was simultaneously applied with a pressure of 10 mmHg. In contrast, there were no significant changes in mesothelial cells in the investigated parameter. CONCLUSION The conditions of CO(2) pneumoperitoneum cause changes in the expression of genes controlling the fibrinolytic activity. The increase of PAI-1 and uPA can contribute to the enhancement of metastasis and invasive potential of tumour cells. Therefore, changes in the conditions of laparoscopy may well optimise laparoscopic therapy in colon cancer.
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Affiliation(s)
- Petra Krause
- Department of General and Visceral Surgery, University Medical Centre Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Nina S. Bobisch
- Department of General and Visceral Surgery, University Medical Centre Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Paul Thelen
- Department of Urology, University Medical Centre Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Karola Koehler
- Department of Genetic Epidemiology, University Medical Centre Goettingen, Humboldtallee 32, 37073 Goettingen, Germany
| | - Sarah Koenig
- Department of General and Visceral Surgery, University Medical Centre Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Heinz Becker
- Department of General and Visceral Surgery, University Medical Centre Goettingen, Robert-Koch-Str. 40, 37075 Goettingen, Germany
| | - Ingo Leister
- Centre of Minimal Invasive, Endocrine, and Visceral Surgery, Hospital Waldfriede, Argentinische Allee 40, 14163 Berlin, Germany
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Braumann C, Guenther N, Doerner F, Schwenk W, Junghans T. Effects of Animal Positioning on Catecholamine and Vasopressin Levels in Pigs Undergoing Laparoscopy. Eur Surg Res 2011; 47:75-80. [DOI: 10.1159/000328777] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Accepted: 04/20/2011] [Indexed: 11/19/2022]
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Pérez-Medina T, Álvarez J, Degollada M, de Santiago J, Lara A, Pascual A, Pérez Milán F, Crowe AM. Documento de consenso del Grupo de Trabajo sobre las Adherencias de la sección de endoscopia de la SEGO. ACTA ACUST UNITED AC 2010. [DOI: 10.1016/j.pog.2010.07.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
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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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Peritoneal damage: the inflammatory response and clinical implications of the neuro-immuno-humoral axis. World J Surg 2010; 34:704-20. [PMID: 20049432 DOI: 10.1007/s00268-009-0382-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND The peritoneum is a bilayer serous membrane that lines the abdominal cavity. We present a review of peritoneal structure and physiology, with a focus on the peritoneal inflammatory response to surgical injury and its clinical implications. METHODS We conducted a nonsystematic clinical review. A search of the Ovid MEDLINE database from 1950 through January 2009 was performed using the following search terms: peritoneum, adhesions, cytokine, inflammation, and surgery. RESULTS The peritoneum is a metabolically active organ, responding to insult through a complex array of immunologic and inflammatory cascades. This response increases with the duration and extent of injury and is central to the concept of surgical stress, manifesting via a combination of systemic effects, and local neural pathways via the neuro-immuno-humoral axis. There may be a decreased systemic inflammatory response after minimally invasive surgery; however, it is unclear whether this is due to a reduced local peritoneal reaction. CONCLUSIONS Interventions that dampen the peritoneal response and/or block the neuro-immuno-humoral pathway should be further investigated as possible avenues of enhancing recovery after surgery, and reducing postoperative complications.
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Warming and Humidification of Insufflation Carbon Dioxide in Laparoscopic Colonic Surgery. Ann Surg 2010; 251:1024-33. [DOI: 10.1097/sla.0b013e3181d77a25] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Prushik SG, Stucchi AF, Matteotti R, Aarons CB, Reed KL, Gower AC, Becker JM. Open adhesiolysis is more effective in reducing adhesion reformation than laparoscopic adhesiolysis in an experimental model. Br J Surg 2010; 97:420-7. [PMID: 20101595 DOI: 10.1002/bjs.6899] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND This study compared adhesion reformation after open and laparoscopic adhesiolysis in a rat model. METHODS Adhesions were induced by surgically creating ischaemic buttons on the peritoneal side wall. After 7 days the animals underwent laparoscopy with carbon dioxide insufflation or laparotomy to score and lyse adhesions. Peritoneal tissue and fluid were collected after 24 h in a subset of animals, and adhesion reformation was scored 7 days after lysis in the remainder. Tissue plasminogen activator (tPA), plasminogen activator inhibitor (PAI) 1, transforming growth factor (TGF) beta1 and tumour necrosis factor (TNF) alpha mRNA, and total fibrinolytic activity were assessed. The abdomen of non-operated animals was insufflated for 7, 15 or 30 min with carbon dioxide, after which tPA and PAI-1 mRNA and total fibrinolytic activity were measured. RESULTS Animals that underwent open adhesiolysis had 60 per cent fewer reformed adhesions than the laparoscopic adhesiolysis group (P < 0.001). There were no differences in tPA activity or tPA, PAI-1 and TNF-alpha mRNA between groups, but TGF-beta1 mRNA levels were significantly increased in the open group. Carbon dioxide insufflation did not affect peritoneal tPA activity. CONCLUSION Open adhesiolysis may be more beneficial in minimizing adhesion reformation in the management of adhesion-related complications.
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Affiliation(s)
- S G Prushik
- Department of Surgery, Boston University School of Medicine, 88 East Newton Street, Boston, Massachusetts 02118, USA
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Sobiczewski P, Bidzinski M, Derlatka P, Panek G, Danska-Bidzinska A, Gmyrek L, Michalski W. Early cervical cancer managed by laparoscopy and conventional surgery: comparison of treatment results. Int J Gynecol Cancer 2010; 19:1390-5. [PMID: 20009895 DOI: 10.1111/igc.0b013e3181ba5e88] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION The goal of this retrospective analysis was to compare the results of treatment in patients with early cervical cancer managed by laparoscopy with those for patients observed after laparotomy. METHODS The retrospective analysis was carried out with 22 patients operated on with total laparoscopic hysterectomy and 58 patients treated by abdominal hysterectomy. Patients with clinical tumor stage IA, IB1, or IIA were eligible for surgery. The main efficacy end point was disease-free survival evaluated by the Kaplan-Meier method. The survival curves were compared using log-rank tests. In addition, length of hospitalization, duration of surgery, and complication rate were compared. P < 0.05 was set as statistically significant. RESULTS Predicted 3-year disease-free survival rates in the "open surgery" and "laparoscopy" groups were 0.86 (standard deviation [SD], 0.049) and 0.82 (SD, 0.098), respectively (P = 0.53). Recurrence rate was 13.6% after laparoscopy and 12% in open surgery. In 2 patients, intraperitoneal spread occurred after laparoscopy. The operation time was longer and hospitalization shorter after laparoscopy. CONCLUSIONS The 3-year disease-free survival was similar in both groups. Total laparoscopic radical hysterectomy may be an option in early cervical cancer; however, the intraperitoneal spread in 2 patients compels a search for possible risk factors in patients managed by laparoscopy.
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Affiliation(s)
- Piotr Sobiczewski
- Gynecologic Oncology Department, Maria Sklodowska-Curie Memorial Cancer Center, Warsaw, Poland.
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Gutt CN, Daume JM, Linker R, Paolucci V. VarioLift retraction system for laparoscopy without pneumoperitoneum. MINIM INVASIV THER 2009. [DOI: 10.3109/13645709809152857] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Kaufman Y, Hirsch I, Ostrovsky L, Klein O, Shnaider I, Khoury E, Pizov R, Lissak A. Pain relief by continuous intraperitoneal nebulization of ropivacaine during gynecologic laparoscopic surgery--a randomized study and review of the literature. J Minim Invasive Gynecol 2009; 15:554-8. [PMID: 18722968 DOI: 10.1016/j.jmig.2008.05.012] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2008] [Revised: 05/02/2008] [Accepted: 05/10/2008] [Indexed: 11/30/2022]
Abstract
STUDY OBJECTIVE To evaluate the efficacy of intraperitoneal nebulization of ropivacaine on pain relief during and after gynecologic laparoscopic procedures including a review of the literature. DESIGN Double-blinded, randomized, controlled, clinical trial (Canadian Task Force classification I). SETTING University hospital ambulatory gynecoendoscopic department. PATIENTS Forty patients (20 patients in each arm) undergoing elective gynecologic same-day outpatient laparoscopic surgery including unilateral/bilateral salpingo-oophorectomy or unilateral/bilateral ovarian cystectomy. INTERVENTIONS The study group received 10 mL of 1% ropivacaine and the control group received 10 mL of sterile water by intraperitoneal nebulization. During surgery, vital signs were recorded and summarized. Postoperatively patients were followed up for 24 hours including visual analog scale scores and analgesic use. MEASUREMENTS AND MAIN RESULTS No significant differences existed between the groups during surgery and at the recovery department in terms of arterial blood pressure (p=.42) or heart rate (p=.60). Regarding postoperative analgesia, no difference existed between the groups in terms of morphine consumption (p=.52) or other analgesics (p=.53). No significant difference existed between the groups in postoperative visual analog scale scores including visceral, abdominal wall, and shoulder pain during rest and during cough at the different time frames (30, 60, and 120 minutes and 6 and 24 hours after surgery). CONCLUSION Our study is the first to examine the effects of intraperitoneal nebulization of ropivacaine throughout laparoscopic gynecologic procedures on patients undergoing general anesthesia. Nebulization of 100 mg of ropivacaine under our specific regimen of anesthesia does not improve patients' outcome in terms of intraoperative and postoperative pain along with consumption of analgesics. Further research with other regimens is required.
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Affiliation(s)
- Yuval Kaufman
- Department of Obstetrics and Gynecology, The Lady Davis Carmel Medical Center affiliated to the Technion Institute of Technology Medical School, Haifa, Israel.
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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: 62] [Impact Index Per Article: 3.9] [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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Abstract
The extent of the problem of adhesions is considerable and poses a significant burden on healthcare systems, the workload of surgeons and the lives of patients. This paper reviews the work undertaken and the associated evidence for the impact of adhesions. It considers the various options and strategies to reduce adhesions alongside the fundamental necessity for good surgical technique.
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Affiliation(s)
- R Bhardwaj
- Department of Surgery, Darent Valley Hospital, Kent, UK
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Postoperative abdominal adhesions and their prevention in gynaecological surgery. Expert consensus position. Part 2—steps to reduce adhesions. ACTA ACUST UNITED AC 2007. [DOI: 10.1007/s10397-007-0333-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Palmes D, Röttgermann S, Classen C, Haier J, Horstmann R. Randomized clinical trial of the influence of intraperitoneal local anaesthesia on pain after laparoscopic surgery. Br J Surg 2007; 94:824-32. [PMID: 17571296 DOI: 10.1002/bjs.5810] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Abstract
Background
There is controversy about the effectiveness of intraperitoneal local anaesthesia (LA) in laparoscopic surgery. The aim of the present randomized clinical trial was to compare the analgesic effect of pre-emptive (preoperative) versus postoperative intraperitoneal LA in two different types of laparoscopic surgery.
Methods
Between July 2004 and January 2005, 133 consecutive patients scheduled to undergo laparoscopic fundoplication or hernia repair were randomly assigned to one of three treatments: placebo solution (50 ml 0·9 per cent saline) or LA (50 ml 0·5 per cent lidocaine) administered immediately after creation of the pneumoperitoneum, or LA (50 ml 0·5 per cent lidocaine) at the end of the operation. Analgesic requirements were analysed, and pain was assessed using a visual analogue scale (VAS) from 0 to 100 at 6, 12, 24 and 48 h after surgery.
Results
The duration of pneumoperitoneum (median 66 versus 46 min respectively; P < 0·001) and overall pain intensity (median VAS score 46·7 versus 6·5; P < 0·001) were higher for laparoscopic fundoplication than for hernia repair. Preoperative application of LA reduced abdominal pain (median 28·6 versus 74·9; P < 0·005), shoulder pain (median 24·3 versus 43·8; P = 0·004) and analgesic consumption (mean(s.d.) 11·1(5·0) versus 18·5(5·4) mg piritramide per 48 h; P = 0·002) after fundoplication, but had no analgesic effects after hernia repair.
Conclusion
Pre-emptive application of LA reduced postoperative pain and analgesic requirements after laparoscopic fundoplication.
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Affiliation(s)
- D Palmes
- Department of General Surgery, Münster University Hospital, Münster, Germany
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Kuebler JF, Vieten G, Shimotakahara A, Metzelder ML, Jesch NK, Ure BM. Acidification during carbon dioxide pneumoperitoneum is restricted to the gas-exposed peritoneal surface: effects of pressure, gas flow, and additional intraperitoneal fluids. J Laparoendosc Adv Surg Tech A 2007; 16:654-8. [PMID: 17243891 DOI: 10.1089/lap.2006.16.654] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND There are varying data regarding the degree and extent of abdominal acidification during laparoscopy. The aim of this study was to determine the extent of peritoneal acidification during carbon dioxide insufflation and the effects of different pressures, insufflation rates, and free intraperitoneal fluids. MATERIALS AND METHODS Sixteen male Sprague-Dawley rats weighing 250-300 g were anesthetized and a two-point pH probe was inserted in the abdominal cavity. After closure of the abdominal wall, each group of 4 rats was subjected to one of four insufflation regimens: low pressure (2 mm Hg, no leakage); high pressure (10 mm Hg, no leakage); leakage (2 mm Hg, leakage 0.5 mL/min); and fluid (2 mm Hg, 10 mL intraperitoneal 0.9% NaCl). During insufflation peritoneal pH was continuously measured. RESULTS Carbon dioxide insufflation significantly decreased the peritoneal pH to <7.0 only in areas exposed to the insufflation gas. Neither changes in pressure nor insufflation rate had major effects on the peritoneal pH. The addition of 10 mL normal saline into the abdominal cavity significantly enhanced the pH change during insufflation. conclusion: Acidification associated with carbon dioxide pneumoperitoneum is limited to the area of inspection and manipulation. The increased acidification following injection of normal saline could offer a useful mechanism to alter the inflammatory response.
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Affiliation(s)
- Joachim F Kuebler
- Department of Pediatric Surgery, Hannover Medical University, Hannover, Germany
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Mynbaev OA, Koninckx PR, Dolle' L, Bracke M. A possible mechanism of peritoneal pH changes during carbon dioxide pneumoperitoneum. Surg Endosc 2006; 21:489-91. [PMID: 17103284 DOI: 10.1007/s00464-006-9009-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2005] [Accepted: 04/02/2006] [Indexed: 10/23/2022]
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Burns JM, Matthews BD, Pollinger HS, Mostafa G, Joels CS, Austin CE, Kercher KW, Norton HJ, Heniford BT. Effect of carbon dioxide pneumoperitoneum and wound closure technique on port site tumor implantation in a rat model. Surg Endosc 2005; 19:441-7. [PMID: 15645327 DOI: 10.1007/s00464-004-8937-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2004] [Accepted: 08/25/2004] [Indexed: 11/26/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the effects of carbon dioxide (CO2) pneumoperitoneum and wound closure technique on port site tumor implantation. METHODS A standard quantity of rat mammary adenocarcinoma (SMT2A)was allowed to grow in a flank incision in Wistar-Furth rats (n = 90) for 14 days. Thereafter, 1-cm incisions were made in each animal in three quadrants. There were six control animals. The experimental animals were divided into a 60-min CO2 pneumoperitoneum group (n = 42) and a no pneumoperitoneum (n = 42) group. The flank tumor was lacerated transabdominally in the experimental groups. The three wound sites were randomized to closure of (a) skin; (b) skin and fascia; and (c) skin, fascia, and peritoneum. The abdominal wounds were harvested en bloc on postoperative day 7. RESULTS Histologic comparison of the port sites in the pneumoperitoneum and no-pneumoperitoneum groups did not demonstrate a statistically significant difference in tumor implantation for any of the closure methods. Evaluation of the closure techniques showed no statistical difference between the pneumoperitoneum group and the no-pneumoperitoneum group in the incidence of port site tumor implantation. Within the no-pneumoperitoneum group, there was a significant increase (p = 0.03) in tumor implantation with skin closure alone vs all three layers. Additionally, when we compared all groups by closure technique, the rate of tumor implantation was found to be significantly higher (p = 0.01) for skin closure alone vs closure of all three layers. CONCLUSIONS This study suggests that closure technique may influence the rate of port site tumor implantation. The use of a CO2 pneumoperitoneum did not alter the incidence of port site tumor implantation at 7 days postoperatively.
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Affiliation(s)
- J M Burns
- Department of General Surgery, James G. Cannon Research Center, Carolinas Medical Center, Charlotte, NC, USA
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Wittich P, Mearadji A, Marquet RL, Bonjer HJ. Increased tumor growth after high pressure pneumoperitoneum with helium and air. J Laparoendosc Adv Surg Tech A 2004; 14:205-8. [PMID: 15345156 DOI: 10.1089/lap.2004.14.205] [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] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Tumor growth appears proportional to the pressure of carbon dioxide insufflation during laparoscopic surgery. Air and helium are alternative insufflation gases. The objective of this study is to assess tumor growth after air and helium insufflation at different pressures. METHOD Ninety-six WAG rats were allocated to either air or helium. In both arms, rats were randomly exposed to a one hour gasless procedure, or to 4 mm Hg, 10 mm Hg, or 16 mm Hg insufflation. At the start of the procedure, 500,000 CC531 tumor cells were injected intraperitoneally. After three weeks, intraperitoneal tumor growth was assessed. RESULTS Higher insufflation pressures were associated with greater tumor growth. No difference of tumor growth between air and helium insufflation was found. CONCLUSION In this experimental model, insufflation pressure appeared to have a greater impact on tumor growth than the type of gas. Further studies are necessary but it seems prudent to recommend employment of lower insufflation pressures in laparoscopic oncologic surgery.
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Leister I, Schüler P, Vollmar B, Füzesi L, Kahler E, Becker H, Markus PM. Microcirculation and excretory function of the liver under conditions of carbon dioxide pneumoperitoneum. Surg Endosc 2004; 18:1358-63. [PMID: 15803236 DOI: 10.1007/s00464-003-9252-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2003] [Accepted: 02/13/2004] [Indexed: 01/18/2023]
Abstract
BACKGROUND To date, the effects of increased abdominal pressure, as given during carbon dioxide (CO(2)) pneumoperitoneum, on hepatic microcirculation and biliary excretion are unknown. METHODS Using a custom-made peritoneal cavity chamber, we performed intravital microscopy of the left liver lobe under conditions of CO(2) pneumoperitoneum in a rat model. In addition, biliary excretion was assessed. RESULTS The establishment of a CO(2) pneumoperitoneum of 4 or 8 mmHg resulted in sinusoidal perfusion failure that was more pronounced in the periportal regions than in the midzonal and pericentral regions of the liver acinus. Biliary excretion was considerably reduced at an intraabdominal pressure of 8 mmHg. Leukocyte-endothelial cell interactions increased significantly in both hepatic sinusoids and postsinusoidal venules. CONCLUSION Alterations in hepatic microcirculation and liver function must be taken into consideration in any kind of laparoscopic surgery and may be of particular clinical relevance in patients with liver pathology.
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Affiliation(s)
- I Leister
- Department of General Surgery, Georg August University, Robert Kochstrasse 40, D-37075, Göttingen, Germany.
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Perry Y, Reissman P, Blumental M, Lyass S, Pizov R. Pressure-related hemodynamic effects of CO2 pneumoperitoneum in a model of acute cardiac failure. J Laparoendosc Adv Surg Tech A 2004; 13:341-7. [PMID: 14733695 DOI: 10.1089/109264203322656388] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The adverse effects related to CO2 pneumoperitoneum (PP) have been well documented. Although these effects in the state of cardiac failure have not been investigated, it appears to be common current clinical practice to use low-pressure PP in this clinical setting, assuming it to be safer. OBJECTIVE The aim of our study was to compare the hemodynamic changes with the application of conventional 15 mm Hg PP versus low-pressure 10 mm Hg PP in control and acute cardiac failure (ACF) animal models. METHODS We studied changes in cardiac output (CO), stroke volume (SV), and systemic vascular resistance (SVR), applying 10 mm Hg and 15 mm Hg CO2 PP in control and, following the pharmacological induction of acute cardiac failure, in 10 domestic pigs. RESULTS In control, the application of 10 mm Hg PP did not cause any significant hemodynamic changes compared to baseline parameters. The use of 15 mm Hg PP in the model with normal cardiac function, however, produced a significant change in the tested hemodynamic values: CO decreased from 3.8L/min to 2.8L/min (P =.0018); SV declined from 38 mL to 30 mL (P =.046); SVR increased from 1677 dyne.s.cm-5 to 2414 dyne.s.cm-5 (P =.049) compared to baseline. In the model of ACF induced by the intravenous infusion of sodium pentobarbital, the application of either 10 mm Hg or 15 mm Hg PP was found to have a similar hemodynamic trend: CO, 1.65 L/min vs. 1.41 L/min; SV, 23.2 L vs. 20.9 L; SVR, 2487 dyne.s.cm-5 vs. 2597 dyne.s.cm-5 (P = NS for all). CONCLUSIONS The application of low-pressure 10 mm Hg PP, compared to conventional 15 mm Hg PP, in the animal model of ACF does not appear to have any hemodynamic advantages.
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Affiliation(s)
- Yaron Perry
- Division of Thoracic and Foregut Surgery and the Minimally Invasive Surgery Center, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA.
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Cheng PGB, Lim MJ, Onsiong MK, Chiu KYW, Chan MK, Li KWM, Tang CN. Celecoxib premedication in post-operative analgesia for laparoscopic cholecystectomy. ACTA ACUST UNITED AC 2004. [DOI: 10.1016/j.acpain.2004.01.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Neuhaus SJ, Watson DI. Pneumoperitoneum and peritoneal surface changes: a review. Surg Endosc 2004; 18:1316-22. [PMID: 15136922 DOI: 10.1007/s00464-003-8238-2] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2003] [Accepted: 01/07/2004] [Indexed: 10/26/2022]
Abstract
BACKGROUND Recent evidence suggests that the use of carbon dioxide to create a pneumoperitoneum during laparoscopy can lead to adverse structural, metabolic, and immune derangements within the peritoneal cavity, and that these can be dependent on the specific insufflation gas used. These changes include structural alterations in the mesothelial lining, pH disturbances, and alterations in peritoneal macrophage responsiveness. This contrasts with an apparent systemic benefit associated with laparoscopic, as compared with open, surgery. METHODS Recently published clinical and experimental studies related to the effect of pneumoperitoneum on the peritoneal surface are reviewed, and their relevance is discussed. RESULTS Structural changes in the peritoneal mesothelial surface layer such as widening of the intercellular junctions can be demonstrated with electron microscopy. Acidification of the peritoneum in response to carbon dioxide insufflation occurs not only at the peritoneal surface, but also in the underlying connective tissue, resulting in disturbances in the electrical surface charge and the release of various immune mediators such as endotoxin. Pneumoperitoneum also affects the local peritoneal immune environment resulting in alterations in cytokine production and phagocytic function, as well as diminished antitumor cell cytotoxicity. CONCLUSIONS Ultrastructural, metabolic, and immune alterations are observed at the peritoneal surface in response to a pneumoperitoneum. Experimental evidence suggests that these changes are carbon dioxide-specific effects. The consequences of these alterations to the local peritoneal environment are not well understood, but they may facilitate tumor implantation within the peritoneal cavity and adversely affect the ability to clear intraperitoneal infections. Further investigation into this area is warranted.
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Affiliation(s)
- S J Neuhaus
- Flinders University Department of Surgery, Flinders Medical Centre, 5042, Bedford Park, South Australia, Australia
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Myre K, Rostrup M, Eriksen M, Buanes T, Raeder J, Stokland O. Increased spillover of norepinephrine to the portal vein during CO-pneumoperitoneum in pigs. Acta Anaesthesiol Scand 2004; 48:443-50. [PMID: 15025606 DOI: 10.1111/j.0001-5172.2004.00366.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Elevated intra abdominal pressure (IAP) during CO2-insufflation has been associated with increased catecholamine concentrations in plasma. We have previously indicated that this may be due to a regional increased spillover from the abdominal region. In this experimental study we investigated catecholamine spillover from the drainage area of the portal vein during CO2-pneumoperitoneum. METHODS Eight pigs under general anesthesia were investigated before and after CO2-pneumoperitoneum with an IAP of 15 mmHg. Regional spillover of catecholamines was determined by measuring plasma catecholamine concentrations and flow simultaneously. Plasma concentrations of catecholamines were measured from the portal and femoral veins, the pulmonary and carotid arteries. Flow data were collected with laser-Doppler transit time flow probes around the portal and femoral veins. Cardiac output was measured by the thermo-dilution technique. Estimated spillover was calculated by the veno-arterial difference multiplied by flow. RESULTS We found a significant increase in estimated spillover of norepinephrine from the drainage area of the portal vein from 10 (-1.2, 78) ng x min(-1) to 27 (1.8, 475) ng x min(-1)[median (range)] (P = 0.05), but no change in estimated spillover of norepinephrine from the drainage area of the femoral vein. Plasma concentrations of norepinephrine increased in central venous and arterial blood. There was no significant change in epinephrine concentrations in arterial blood. CONCLUSION Estimated norepinephrine spillover from the drainage area of the portal vein increased during CO2-pneumoperitoneum in pigs. This may indicate that the increased norepinephrine concentrations found in arterial plasma reflects a local activation of sympathetic nerves in the region of the portal drainage area.
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Affiliation(s)
- K Myre
- Department of Anesthesiology, Ullevaal University Hospital, Oslo, Norway.
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Molinas CR, Tjwa M, Vanacker B, Binda MM, Elkelani O, Koninckx PR. Role of CO2 pneumoperitoneum-induced acidosis in CO2 pneumoperitoneum-enhanced adhesion formation in mice. Fertil Steril 2004; 81:708-11. [PMID: 15037429 DOI: 10.1016/j.fertnstert.2003.10.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2003] [Revised: 10/28/2003] [Accepted: 10/28/2003] [Indexed: 10/26/2022]
Abstract
The effect of assisted ventilation and CO(2) pneumoperitoneum during laparoscopic surgery upon blood gases and adhesion formation were evaluated in mice. We confirmed that the CO(2) pneumoperitoneum induces acidosis and enhances adhesion formation, and an association between both effects was demonstrated, together with its modulation by the assisted ventilation.
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Telles de Sousa ID, Candido dos Reis FJ, Brito Garcia S, Alberto Nogueira A. Adhesion formation after uterine horn resection in rabbit model: comparative study of laparoscopic procedure vs. laparotomy. ACTA ACUST UNITED AC 2003. [DOI: 10.1111/j.1365-2508.2002.00551.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Bergström M, Falk P, Holmdahl L. CO2 promotes plasminogen activator inhibitor type 1 expression in human mesothelial cells. Surg Endosc 2003; 17:1818-22. [PMID: 12802648 DOI: 10.1007/s00464-002-9113-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2002] [Accepted: 10/24/2002] [Indexed: 11/28/2022]
Abstract
BACKGROUND Previous observations have indicated that CO2 insufflation increases peritoneal plasminogen activator inhibitor type 1 (PAI-1) expression. METHODS Primarily cultured human peritoneal mesothelial cells were exposed to either flowing or pressurized CO2 for 90 min. Unexposed cultures served as controls. Samples of cell culture media were taken at 0, 5, and 24 h after exposure to measure media pH, PAI-1, and tissue-type plasminogen activator (t-PA) protein release. Simultaneous samples were taken to measure PAI-1 and t-PA mRNA expression. RESULTS Mesothelial cells exposed to flowing CO2 released more PAI-1 than those exposed to pressurized CO2 ( p < 0.001) and controls ( p < 0.001). Cells exposed to flowing CO2 had an increased PAI-1 mRNA expression at 5 h. CONCLUSIONS CO2 increased mesothelial cell PAI-1 expression involving a transcriptional mechanism. These findings might provide a mechanism for adhesion formation and cancer progression following laparoscopic surgery.
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Affiliation(s)
- M Bergström
- Department of Surgery, Sahlgrenska University Hospital/Ostra, Göteborg University, SE-41685 Göteborg, Sweden.
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