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Wilson RB. Changes in the coelomic microclimate during carbon dioxide laparoscopy: morphological and functional implications. Pleura Peritoneum 2017. [DOI: 10.1515/pp-2017-0001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
AbstractIn this article the adverse effects of laparoscopic CO2 pneumoperitoneum and coelomic climate change, and their potential prevention by warmed, humidified carbon dioxide insufflation are reviewed. The use of pressurized cold, dry carbon dioxide (C02) pneumoperitoneum causes a number of local effects on the peritoneal mesothelium, as well as systemic effects. These can be observed at a macroscopic, microscopic, cellular and metabolic level. Local effects include evaporative cooling, oxidative stress, desiccation of mesothelium, disruption of mesothelial cell junctions and glycocalyx, diminished scavenging of reactive oxygen species, decreased peritoneal blood flow, peritoneal acidosis, peritoneal hypoxia or necrosis, exposure of the basal lamina and extracellular matrix, lymphocyte infiltration, and generation of peritoneal cytokines such as IL-1, IL-6, IL-8 and TNFα. Such damage is increased by high CO2 insufflation pressures and gas velocities and prolonged laparoscopic procedures. The resulting disruption of the glycocalyx, mesothelial cell barrier and exposure of the extracellular matrix creates a cascade of immunological and pro-inflammatory events and favours tumour cell implantation. Systemic effects include cardiopulmonary and respiratory changes, hypothermia and acidosis. Such coelomic climate change can be prevented by the use of lower insufflation pressures and preconditioned warm humidified CO2. By achieving a more physiological temperature, pressure and humidity, the coelomic microenvironment can be better preserved during pneumoperitoneum. This has the potential clinical benefits of maintaining isothermia and perfusion, reducing postoperative pain, preventing adhesions and inhibiting cancer cell implantation in laparoscopic surgery.
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Affiliation(s)
- Robert B. Wilson
- 1Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Elizabeth St, Liverpool, Sydney, NSW, 2170, Australia
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Wilson RB. Changes in the coelomic microclimate during carbon dioxide laparoscopy: morphological and functional implications. Pleura Peritoneum 2017; 2:17-31. [PMID: 30911629 PMCID: PMC6328073 DOI: 10.1515/pp-pp-2017-0001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 02/17/2017] [Indexed: 02/06/2023] Open
Abstract
In this article the adverse effects of laparoscopic CO2 pneumoperitoneum and coelomic climate change, and their potential prevention by warmed, humidified carbon dioxide insufflation are reviewed. The use of pressurized cold, dry carbon dioxide (C02) pneumoperitoneum causes a number of local effects on the peritoneal mesothelium, as well as systemic effects. These can be observed at a macroscopic, microscopic, cellular and metabolic level. Local effects include evaporative cooling, oxidative stress, desiccation of mesothelium, disruption of mesothelial cell junctions and glycocalyx, diminished scavenging of reactive oxygen species, decreased peritoneal blood flow, peritoneal acidosis, peritoneal hypoxia or necrosis, exposure of the basal lamina and extracellular matrix, lymphocyte infiltration, and generation of peritoneal cytokines such as IL-1, IL-6, IL-8 and TNFα. Such damage is increased by high CO2 insufflation pressures and gas velocities and prolonged laparoscopic procedures. The resulting disruption of the glycocalyx, mesothelial cell barrier and exposure of the extracellular matrix creates a cascade of immunological and pro-inflammatory events and favours tumour cell implantation. Systemic effects include cardiopulmonary and respiratory changes, hypothermia and acidosis. Such coelomic climate change can be prevented by the use of lower insufflation pressures and preconditioned warm humidified CO2. By achieving a more physiological temperature, pressure and humidity, the coelomic microenvironment can be better preserved during pneumoperitoneum. This has the potential clinical benefits of maintaining isothermia and perfusion, reducing postoperative pain, preventing adhesions and inhibiting cancer cell implantation in laparoscopic surgery.
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Affiliation(s)
- Robert B. Wilson
- Department of Upper Gastrointestinal Surgery, Liverpool Hospital, Elizabeth St, Liverpool, Sydney, NSW, 2170, Australia
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Koninckx PR, Gomel V, Ussia A, Adamyan L. Role of the peritoneal cavity in the prevention of postoperative adhesions, pain, and fatigue. Fertil Steril 2016; 106:998-1010. [PMID: 27523299 DOI: 10.1016/j.fertnstert.2016.08.012] [Citation(s) in RCA: 67] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 07/30/2016] [Accepted: 08/02/2016] [Indexed: 02/08/2023]
Abstract
A surgical trauma results within minutes in exudation, platelets, and fibrin deposition. Within hours, the denuded area is covered by tissue repair cells/macrophages, starting a cascade of events. Epithelial repair starts on day 1 and is terminated by day 3. If repair is delayed by decreased fibrinolysis, local inflammation, or factors in peritoneal fluid, fibroblast growth starting on day 3 and angiogenesis starting on day 5 results in adhesion formation. For adhesion formation, quantitatively more important are factors released into the peritoneal fluid after retraction of the fragile mesothelial cells and acute inflammation of the entire peritoneal cavity. This is caused by mechanical trauma, hypoxia (e.g., CO2 pneumoperitoneum), reactive oxygen species (ROS; e.g., open surgery), desiccation, or presence of blood, and this is more severe at higher temperatures. The inflammation at trauma sites is delayed by necrotic tissue, resorbable sutures, vascularization damage, and oxidative stress. Prevention of adhesion formation therefore consists of the prevention of acute inflammation in the peritoneal cavity by means of gentle tissue handling, the addition of more than 5% N2O to the CO2 pneumoperitoneum, cooling the abdomen to 30°C, prevention of desiccation, a short duration of surgery, and, at the end of surgery, meticulous hemostasis, thorough lavage, application of a barrier to injury sites, and administration of dexamethasone. With this combined therapy, nearly adhesion-free surgery can be performed today. Conditioning alone results in some 85% adhesion prevention, barriers alone in 40%-50%.
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Affiliation(s)
- Philippe R Koninckx
- Department of Obstetrics and Gynecology, Catholic University Leuven, University Hospital, Gasthuisberg, Leuven, Belgium; Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy.
| | - Victor Gomel
- Department of Obstetrics and Gynecology, University of British Columbia, Women's Hospital, Vancouver, British Columbia, Canada
| | - Anastasia Ussia
- Gruppo Italo Belga, Villa del Rosario and Gemelli Hospitals Università Cattolica, Rome, Italy
| | - Leila Adamyan
- Department of Operative Gynecology, Federal State Budget Institution V. I. Kulakov Research Center for Obstetrics, Gynecology, and Perinatology, Ministry of Health of the Russian Federation, Moscow, Russia; Department of Reproductive Medicine and Surgery, Moscow State University of Medicine and Dentistry, Moscow, Russia, Russian Federation
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Possible cause-effect mechanisms of GI microcirculation changes during transgastric natural orifice transluminal endoscopic surgery. Gastrointest Endosc 2016; 84:204-5. [PMID: 27315738 DOI: 10.1016/j.gie.2016.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 02/05/2016] [Indexed: 12/11/2022]
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Taura P, Adelsdorfer C, Ibarzábal A, Vendrell M. Response. Gastrointest Endosc 2016; 84:205-6. [PMID: 27315739 DOI: 10.1016/j.gie.2016.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 02/26/2016] [Indexed: 02/08/2023]
Affiliation(s)
- Pilar Taura
- Department of Anesthesiology, Institute of Digestive and Metabolic Diseases, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Cedric Adelsdorfer
- Department of Gastrointestinal Surgery, Hospital Clinic, Institute of Digestive and Metabolic Diseases, University of Barcelona, Barcelona, Spain
| | - Ainitze Ibarzábal
- Department of Gastrointestinal Surgery, Hospital Clinic, Institute of Digestive and Metabolic Diseases, University of Barcelona, Barcelona, Spain
| | - Marina Vendrell
- Department of Anesthesiology, Hospital Clinic, Institute of Digestive and Metabolic Diseases, University of Barcelona, Barcelona, Spain
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Gerntke IC, Eliseeva MY, Kosmas IP, Ivanov AA, Benhidjeb T, Mynbaev OA. Low and standard pressure pneumoperitoneum effects during laparoscopic procedures: Problems of study design, analysis and presentation of results. Int J Surg 2016; 30:45-7. [PMID: 27109911 DOI: 10.1016/j.ijsu.2016.03.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 03/22/2016] [Accepted: 03/24/2016] [Indexed: 10/21/2022]
Affiliation(s)
- Isabel C Gerntke
- The International Translational Medicine & Biomodeling Research Team, Laboratory of Human Physiology, Moscow Institute of Physics & Technology (State University), Dolgoprudny, Moscow region, Russia; Burjeel Hospital, Abu Dhabi, UAE
| | - Marina Yu Eliseeva
- The International Translational Medicine & Biomodeling Research Team, Laboratory of Human Physiology, Moscow Institute of Physics & Technology (State University), Dolgoprudny, Moscow region, Russia; The Institute of Plastic Surgery, Cosmetology and Stem Cell Technologies, Moscow, Russia; Russian-German Center for Reproduction and Clinical Embryology, Moscow, Russia
| | - Ioannis P Kosmas
- The International Translational Medicine & Biomodeling Research Team, Laboratory of Human Physiology, Moscow Institute of Physics & Technology (State University), Dolgoprudny, Moscow region, Russia; Ioannina University, Ioannina, Greece
| | - Alexey A Ivanov
- The Training Center of Innovative Medical Technologies, The Russian National Research Medical University Named After N.I. Pirogov, Moscow, Russia
| | - Tahar Benhidjeb
- The International Translational Medicine & Biomodeling Research Team, Laboratory of Human Physiology, Moscow Institute of Physics & Technology (State University), Dolgoprudny, Moscow region, Russia; Burjeel Hospital, Abu Dhabi, UAE; The New European Surgical Academy, Berlin, Germany
| | - Ospan A Mynbaev
- The International Translational Medicine & Biomodeling Research Team, Laboratory of Human Physiology, Moscow Institute of Physics & Technology (State University), Dolgoprudny, Moscow region, Russia; The New European Surgical Academy, Berlin, Germany.
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Mynbaev OA, Simakov SS, Malvasi A, Tinelli A. Is CO2 Pneumoperitoneum Desufflation Triggering Factor of Postsurgical Oxidative Stress? J Minim Invasive Gynecol 2016; 23:1013-5. [PMID: 26997418 DOI: 10.1016/j.jmig.2016.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 02/13/2016] [Indexed: 12/19/2022]
Affiliation(s)
- Ospan A Mynbaev
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow, Russia; Institute of Numerical Mathematics, The Russian Academy of Sciences, Moscow, Russia
| | - Sergei S Simakov
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow, Russia; Institute of Numerical Mathematics, The Russian Academy of Sciences, Moscow, Russia
| | - Antonio Malvasi
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow, Russia; Department of Obstetrics & Gynecology, Santa Maria Hospital, Bari, Italy
| | - Andrea Tinelli
- Laboratory of Human Physiology, Moscow Institute of Physics and Technology (State University), Dolgoprudny, Moscow, Russia; Department of Obstetrics and Gynecology, Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Vito Fazzi Hospital, Lecce, Italy
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Liao CC, Kau YC, Ting PC, Tsai SC, Wang CJ. Reply to "Is CO2 Pneumoperitoneum Desufflation Triggering Factor of Postsurgical Oxidative Stress?". J Minim Invasive Gynecol 2016; 23:1015-6. [PMID: 26997420 DOI: 10.1016/j.jmig.2016.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 03/10/2016] [Indexed: 12/08/2022]
Affiliation(s)
- Chia-Chih Liao
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan
| | - Yi-Chuan Kau
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan
| | - Pei-Chi Ting
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan
| | - Shih-Chang Tsai
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan
| | - Chin-Jung Wang
- Department of Anesthesiology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan; Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital at Linkou and Chang Gung University College of Medicine, Kwei-Shan, Taoyuan, Taiwan
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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: 39] [Impact Index Per Article: 4.3] [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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Mynbaev OA, Tinelli A, Malvasi A, Kadayifci O, Benhidjeb T, Stark M. Is there only CO2 insufflation pressure impact on surgical field visualization during robotic surgery? Arch Gynecol Obstet 2015; 292:1177-8. [PMID: 26335187 DOI: 10.1007/s00404-015-3876-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 08/26/2015] [Indexed: 10/23/2022]
Affiliation(s)
- Ospan A Mynbaev
- Moscow Institute of Physics and Technology (State University), 9 Instituskii Lane, Dolgoprudny, Moscow, 141700, Russia. .,Peoples' Friendship University of Russia, 21/3 Miklukho-Maklay Str, Moscow, 117198, Russia.
| | - Andrea Tinelli
- Division of Experimental Endoscopic Surgery, Imaging, Technology and Minimally Invasive Therapy, Department of Obstetrics and Gynecology, Vito Fazzi Hospital, Lecce, Italy
| | - Antonio Malvasi
- Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy
| | | | - Tahar Benhidjeb
- Department of General, Visceral, Bariatric and Endocrine Surgery, Center for Minimally Invasive and Scarless Surgery, Burjeel Hospital, Abu Dhabi, United Arab Emirates
| | - Michael Stark
- The New European Surgical Academy, Unter den Linden 21, 10117, Berlin, Germany.
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Comment on "Evidence for Negative Effects of Elevated Intra-Abdominal Pressure on Pulmonary Mechanics and Oxidative Stress". ScientificWorldJournal 2015; 2015:746937. [PMID: 26171420 PMCID: PMC4480807 DOI: 10.1155/2015/746937] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2015] [Accepted: 05/25/2015] [Indexed: 11/24/2022] Open
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Mynbaev OA, Eliseeva MY, Tinelli A, Malvasi A, Massaro F, Simakov SS, Stark M. Re. 'Abdominal hypertension and decompression: the effect on peritoneal metabolism in an experimental porcine study'. Eur J Vasc Endovasc Surg 2014; 48:229-30. [PMID: 24931381 DOI: 10.1016/j.ejvs.2014.03.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/28/2014] [Indexed: 12/01/2022]
Affiliation(s)
- O A Mynbaev
- International Translational Medicine and Biomodeling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), 9 Institutsky per, Dolgoprudny, Moscow 141700, Russia; Department of Obstetrics, Gynecology and Reproductive Medicine, Peoples' Friendship University of Russia, Moscow, Russia; Laboratory of Pilot Projects, Moscow State University of Medicine and Dentistry, Moscow, Russia; The New European Surgical Academy, Berlin, Germany.
| | - M Yu Eliseeva
- Department of Obstetrics, Gynecology and Reproductive Medicine, Peoples' Friendship University of Russia, Moscow, Russia
| | - A Tinelli
- Department of Obstetrics and Gynaecology, Division of Experimental Endoscopic Surgery, Imaging, Minimally Invasive Therapy and Technology, Vito Fazzi Hospital, Lecce, Italy
| | - A Malvasi
- Department of Obstetrics and Gynecology, Santa Maria Hospital, Bari, Italy
| | - F Massaro
- Anesthesia and Intensive Care Unit, Department of Emergency and Organ Transplantation, University of Bari Aldo Moro, Bari, Italy
| | - S S Simakov
- International Translational Medicine and Biomodeling Research Group, Department of Applied Mathematics, Moscow Institute of Physics and Technology (State University), 9 Institutsky per, Dolgoprudny, Moscow 141700, Russia
| | - M Stark
- The New European Surgical Academy, Berlin, Germany
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Skoog P. Response to letter to the editor Re "Abdominal hypertension and decompression: the effect on peritoneal metabolism in an experimental porcine study". Eur J Vasc Endovasc Surg 2014; 48:231. [PMID: 24931382 DOI: 10.1016/j.ejvs.2014.04.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Accepted: 04/15/2014] [Indexed: 11/19/2022]
Affiliation(s)
- P Skoog
- Vascular Department, Clinic for Cardio-Thoracic and Vascular Surgery, Örebro University Hospital, S-70185 Örebro, Sweden.
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Mynbaev OA, Biro P, Eliseeva MY, Tinelli A, Malvasi A, Kosmas IP, Medvediev MV, Babenko TI, Mazitova MI, Simakov SS, Stark M. A surgical polypragmasy: Koninckx PR, Corona R, Timmerman D, Verguts J, Adamyan L. Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery. J Ovarian Res. 2013 Dec 11;6(1):90. J Ovarian Res 2014; 7:29. [PMID: 24606970 PMCID: PMC3984740 DOI: 10.1186/1757-2215-7-29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2014] [Accepted: 03/04/2014] [Indexed: 12/11/2022] Open
Affiliation(s)
- Ospan A Mynbaev
- The International Translational Medicine & Biomodeling Research Group, Department of Applied Mathematics, Moscow Institute of Physics & Technology (State University), 9 institutsky per, Dolgoprudny, Moscow Region 141700, Russia.
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Koninckx PR, Corona R, Timmerman D, Verguts J, Adamyan L. Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery. J Ovarian Res 2013; 6:90. [PMID: 24326155 PMCID: PMC4029570 DOI: 10.1186/1757-2215-6-90] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 12/06/2013] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND To translate the concept of full-conditioning (FC) from animal experiments to the human, and to evaluate the efficacy for adhesion prevention. FC consisted of decreasing acute inflammation by 86% CO2+ 10% N2O + 4% O2 for the pneumoperitoneum, cooling of the peritoneal cavity, humidification, heparinized rinsing solution and 5 mg of dexamethasone as demonstrated in animal models. METHODS A randomized controlled trial (RCT: NCT01344486) comparing standard laparoscopy with full conditioning together with a barrier in a 2/3 ratio in 44 women undergoing deep endometriosis surgery at KULeuven. The primary aim was reduction of adhesions. Secondary aims were CO2 resorption, postoperative pain and recovery. Randomization was performed after signing informed consent. Adhesion scoring during second look laparoscopy and pain scoring were done blindly. RESULTS In the FC group (n = 16) adhesions were completely prevented in 12/16 women whereas in the control group (n = 11) all women had severe adhesions (P < 0.0005). Also the area, density and severity of adhesions were less. (P <0.001). In the control group, severity, density and area of adhesions were strongly interrelated (P = 0.0001 for all areas) suggesting a common enhancing factor. In the FC group CO2 resorption (P < 0.001), postoperative pain (P < 0.001), and CRP concentrations (P < 0.01) were lower while clinical recovery was faster (P < 0.0001) and time to first flatus (P < 0.002) shorter. IN CONCLUSION This translational research confirms in the human the efficacy of FC in reducing CO2 resorption and adhesions with in addition less postoperative pain, lower postoperative CRP concentrations and an accelerated recovery.
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Affiliation(s)
- Philippe R Koninckx
- Department of Obstetrics and Gynecology, UZ Gasthuisberg, KULeuven, Leuven B-3000, Belgium.
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Tinelli A, Mettler L, Malvasi A, Hurst B, Catherino W, Mynbaev OA, Guido M, Alkatout I, Schollmeyer T. Impact of surgical approach on blood loss during intracapsular myomectomy. MINIM INVASIV THER 2013; 23:87-95. [DOI: 10.3109/13645706.2013.839951] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Pismensky SV, Kalzhanov ZR, Eliseeva MY, Kosmas IP, Mynbaev OA. Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation. BMC Surg 2011; 11:30. [PMID: 22082071 PMCID: PMC3266192 DOI: 10.1186/1471-2482-11-30] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2011] [Accepted: 11/14/2011] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Many factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions. METHODS A prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO2 insufflation at the 10 cm of water. TIR was evaluated at the 24th, 72nd, 120th and 168th hour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests. RESULTS More pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24th and 72nd; p < 0.01--120th and p < 0.001--168th hrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group. CONCLUSIONS MIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO2 insufflation however, led to moderate inflammation and less adhesion formation.
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Affiliation(s)
- Sergei V Pismensky
- Laboratory of Pathophysiology, Faculty of Basic Medicine, M.V. Lomonosov Moscow State University, Lomonosovsky Prospekt 31-5, Moscow, 117192, Russia
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Mynbaev OA, Corona R. Possible mechanisms of peritoneal tissue-oxygen tension changes during CO2-pneumoperitoneum: the role of design, methodology and animal models. Hum Reprod 2009; 24:1242-6. [PMID: 19258347 DOI: 10.1093/humrep/dep025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Affiliation(s)
- Ospan A Mynbaev
- Moscow State University of Medicine and Dentistry, Delegatskaya str. 20/1 127473, Moscow, Russian Federation.
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Mynbaev OA, Adamyan LV, Mailova K, Vanacker B, Koninckx PR. Effects of adding small amounts of oxygen to a carbon dioxide-pneumoperitoneum of increasing pressure in rabbit ventilation models. Fertil Steril 2008; 92:778-84. [PMID: 18823885 DOI: 10.1016/j.fertnstert.2008.07.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2008] [Revised: 05/28/2008] [Accepted: 07/09/2008] [Indexed: 11/18/2022]
Abstract
OBJECTIVE To evaluate the metabolic consequences of the addition of oxygen to the CO(2)-pneumoperitoneum. DESIGN Prospective randomized study in rabbits. After 30 minutes of ventilation pneumoperitoneum was maintained for 90 minutes with pure CO(2) or CO(2) with 2% or 6% of oxygen. The intraperitoneal pressure was increased from 10 to 15 and 20 mm Hg every 30 minutes. Ventilation rate was either fixed or a progressive hyperventilation. End points were changes in arterial blood gases (Pco(2), Po(2)), pH, acid-base balance (actual base excess [ABE], standard bicarbonate [SBC], standard base excess [SBE], hydrogen carbonate [HCO(3)(-)], concentration of total carbon dioxide [Tco(2)]); oxygen and oximetry (oxyhemoglobin [O(2)Hb], oxygen saturation [So(2)], reduced hemoglobin [RHb], total oxygen concentration [To(2)], and oxygen tension at half saturation assessing hemoglobin oxygen affinity [p50]); and lactate concentrations assayed every 15 minutes. SETTING University research center. ANIMALS Twenty-four adult female New Zealand white rabbits. INTERVENTION(S) Anesthesia, mechanical ventilation, and pneumoperitoneum. RESULT(S) The effects of CO(2)-pneumoperitoneum on all end points increased with the elevated intraperitoneal pressure and were more pronounced when ventilation was fixed. Changes were less when 2% or 6% of oxygen had been added to the CO(2)-pneumoperitoneum. With use of logistic regression, the addition of oxygen, intraperitoneal pressure, and ventilation were found to be independent variables affecting Pco(2), pH, ABE, SBE, HCO(3)(-), O(2)Hb, So(2), p50, and end-tidal CO(2). CONCLUSION(S) The metabolic consequences of the combined effect of increased intraperitoneal pressure and CO(2)-pneumoperitoneum were less when 2% to 6% of oxygen was added or when animals were hyperventilated. We suggest that metabolic and mesothelial hypoxemia caused by CO(2) absorption can be reduced by adding small amounts of oxygen and by hyperventilation.
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Affiliation(s)
- Ospan A Mynbaev
- Department of Operative Gynaecology, Scientific Centre for Obstetrics, Gynaecology, Perinatalogy, Moscow State University of Medicine and Dentistry, Moscow, Russia.
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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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Mynbaev OA. Re: The Addition of O2 to the CO2 Does not Prevent the Systemic Effects of the CO2 Pneumoperitoneum in a Rabbit Model. Surg Lap Endosc Percut Tech. 2005;15(5):271???274. Surg Laparosc Endosc Percutan Tech 2006; 16:123-5; author reply 125-6. [PMID: 16773021 DOI: 10.1097/00129689-200604000-00020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fuentes JM, Hanly EJ, Bachman SL, Aurora AR, Marohn MR, Talamini MA. Videoendoscopic endotracheal intubation in the rat: A comprehensive rodent model of laparoscopic surgery1,2. J Surg Res 2004; 122:240-8. [PMID: 15555624 DOI: 10.1016/j.jss.2004.05.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2004] [Indexed: 12/20/2022]
Abstract
BACKGROUND Peritoneal absorption of CO(2) during abdominal insufflation in laparoscopy may disrupt the acid-base equilibrium and alter the physiological response to stress. Current nonventilated rodent models of laparoscopy do not manage the CO(2) load of pneumoperitoneum, but ventilated surgical rodent models are invasive (tracheotomy) and may independently induce the inflammatory response. MATERIALS AND METHODS A comprehensive rodent model of laparoscopy was developed. Rats were randomized to receive anesthesia alone, anesthesia plus CO(2) pneumoperitoneum, or anesthesia plus CO(2) pneumoperitoneum with videoendoscopic intubation and mechanical ventilation. Arterial blood-gas analysis was performed at baseline and after 30 min of intervention. RESULTS Baseline pH, pCO(2), and HCO(3)(-) arterial blood gas parameters were normal for all rats. After 30 min, pCO(2) and pH changed slightly but remained normal among rats receiving anesthesia alone (pCO(2) = 46.5 +/- 1.9; pH = 7.365 +/- 0.009) whereas animals receiving anesthesia plus CO(2) pneumoperitoneum that were dependent on spontaneous respiration for ventilation developed significant hypercarbic acidosis (pCO(2) = 53.2 +/- 1.9, P < 0.05; pH = 7.299 +/- 0.011, P < 0.001). This acidosis was completely corrected with increased minute ventilation in intubated rats receiving mechanical ventilation (pCO(2) = 36.8 +/- 1.5, P < 0.001; pH = 7.398 +/- 0.011, P < 0.001). CONCLUSIONS CO(2) pneumoperitoneum induces significant hypercarbic acidosis in nonventilated rats. Noninvasive endotracheal intubation is feasible in the rat with videoendoscopic assistance. Our noninvasive rodent model of laparoscopic surgery controls for anesthesia- and capnoperitoneum-related acid-base changes and provides an environment in which the biological response to pneumoperitoneum can be studied precisely.
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Affiliation(s)
- Joseph M Fuentes
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Saed GM, Diamond MP. Molecular Characterization of Postoperative Adhesions: The Adhesion Phenotype. ACTA ACUST UNITED AC 2004; 11:307-14. [PMID: 15559339 DOI: 10.1016/s1074-3804(05)60041-2] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Postoperative adhesion development remains a very frequent occurrence, which is often unrecognized by surgeons because of limited ability to conduct early second-look laparoscopies. The consequences include infertility, pelvic pain, bowel obstruction, and difficult reoperative procedures. To date, approaches to limit adhesions primarily have involved barriers to separate tissue during reepithelization. Future progress in regulating adhesion development and tissue fibrosis likely will require an improved understanding of the molecular processes involved in normal peritoneal repair and its aberrations leading to adhesion development. We hypothesize that tissue hypoxia (in part resulting from tissue incision, fulguration, suture ligation, etc.) is the major inciting event, which leads to a coordinated series of molecular events that promote an inflammatory response leading to enhanced tissue fibrosis. These events are reduced plasminogen activator activity, extracellular matrix deposition, increased cytokine production, increased angiogenesis, and reduced apoptosis (programmed cell death). Improved understanding of these events and their regulation will provide the opportunity to regulate better postoperative adhesion development and tissue fibrosis, thereby reducing the morbidity and mortality they cause.
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Affiliation(s)
- Ghassan M Saed
- Division of Reproductive Endocrinology and Infertility, Department of Obstetrics and Gynecology, Wayne State University, Detroit, Michigan, USA
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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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Bibliography Current World Literature. Curr Opin Obstet Gynecol 2003. [DOI: 10.1097/01.gco.0000084240.09900.81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Mynbaev OA, Molinas CR, Adamyan LV, Vanacker B, Koninckx PR. Reduction of CO(2)-pneumoperitoneum-induced metabolic hypoxaemia by the addition of small amounts of O(2) to the CO(2) in a rabbit ventilated model. A preliminary study. Hum Reprod 2002; 17:1623-9. [PMID: 12042288 DOI: 10.1093/humrep/17.6.1623] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND CO(2)-pneumoperitoneum used in endoscopic surgery induces system effects by CO(2) absorption. This study investigated the effect of the addition of O(2) to CO(2)-pneumoperitoneum, upon CO(2) absorption. METHODS The effect of a pneumoperitoneum using 100% CO(2) or 94% CO(2) + 6% O(2) upon arterial blood gases, acid base and O(2) homeostasis was evaluated. In series A suboptimal ventilation and a pneumoperitoneum pressure (PP) of 10 mmHg was used. In series B adequate ventilation and PP of 6 mmHg was used. RESULTS CO(2)-pneumoperitoneum profoundly affected blood gases and acid base homeostasis i.e. increasing pCO(2), HCO(3)(P < 0.001) and lactate concentrations (P < 0.05) and decreasing pH, actual base excess and standard bicarbonate (P < 0.001), resulting in metabolic hypoxaemia with desaturation, lower pO(2) (P < 0.001) and O(2)Hb (P < 0.05). These effects were more pronounced with higher PP and suboptimal ventilation. CONCLUSION CO(2)-pneumoperitoneum profoundly affected blood gases and acid base homeostasis resulting in metabolic hypoxaemia. The addition of 6% of O(2) to the CO(2)-pneumoperitoneum prevented these effects to a large extent. If these preliminary data are confirmed in the human, the addition of a few percent of O(2) to CO(2) could become important for endoscopic surgery of long duration, especially in obese patients with limited cardiorespiratory adaptation and steep Trendelenburg.
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Affiliation(s)
- Ospan A Mynbaev
- Centre for Surgical Technologies, Faculty of Medicine, Katholieke Universiteit Leuven, Belgium.
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