Corsale I, Fantini C, Gentili C, Sapere P, Garruto O, Conte R
Divisione di Chirurgia Generale, Nuovo Ospedale Santa Maria di Loreto, Napoli.
Minerva Chir. 2000 Apr;55(4):205-10.
30-67% of patients undergoing laparoscopic surgery reports shoulder pain. Besides, post-surgical course of patients undergoing converted laparoscopic procedures is similar to the course of patients who received a completely laparoscopic procedure. It is supposed that there is a temporary neurotoxic damage of the peritoneal sensitive nervous fibres defined by CO2.
A prospective review has been carried out by histologically analyzing 38 peritoneal biopsies from 10 selected patients, during different laparoscopic surgical procedures (6 cholecystectomies, 2 appendectomies, 1 selective bilateral ligature of the spermatic vessles) and at different times during each operation. Patients whom anamnesis, clinical or local conditions were suggestive for peritoneal flogosis were excluded from the study: therefore only 29 biopsies from 8 patients have been considered useful to the study.
Histological analysis has been carried out with different methods of coloration (hematoxylin eosin, argentic staining) and at different magnifications (30x, 60x, 100x), without electronical microscopy or immunohistochemical studies. No biopsy showed signs of damage of the nervous structures.
Certainly, the realization of a pneumoperitoneum at CO2 doesn't cause damages of the peritoneal sensitive fibres. It has been demonstrated that the abdominal introduction of CO2 causes a "relative peritoneal acidosis", directly depending from the percentage of CO2 employed: the peritoneal pH decreases to 6.9 after 15 min of pneumoperitoneum with CO2 at 100% and to 7.35% with CO2 at 5% of air. Probably this condition causes a temporary biochemical change that defines reduction of the nervous impulses and, therefore, the "peritoneization" of the patient subjected to laparoscopic procedure. The "biochemical hypoesthesia", based on a change of the peritoneal homeostasis, would translate itself in a beneficial effect for the patient, persisting also when converted to laparotomic operation due the impossibility to proceed under laparoscopy, held up by the residual pneumoperitoneum.
30%至67%接受腹腔镜手术的患者报告有肩部疼痛。此外，接受中转腹腔镜手术患者的术后病程与接受完全腹腔镜手术患者的病程相似。据推测，存在由二氧化碳导致的腹膜敏感神经纤维的暂时性神经毒性损伤。
通过对10例选定患者在不同腹腔镜手术过程（6例胆囊切除术、2例阑尾切除术、1例选择性双侧精索血管结扎术）及各手术不同时间点的38份腹膜活检组织进行组织学分析，开展了一项前瞻性研究。有既往史、临床或局部情况提示腹膜炎症的患者被排除在研究之外：因此仅8例患者的29份活检组织被认为对研究有用。
采用不同染色方法（苏木精伊红染色、银染色）及不同放大倍数（30倍、60倍、100倍）进行组织学分析，未进行电子显微镜或免疫组织化学研究。没有活检显示神经结构有损伤迹象。
当然，二氧化碳气腹的形成不会导致腹膜敏感纤维受损。已证实腹腔内注入二氧化碳会导致“相对性腹膜酸中毒”，这直接取决于所用二氧化碳的百分比：100%二氧化碳气腹15分钟后腹膜pH值降至6.9，5%二氧化碳与空气混合时降至7.35%。可能这种情况会导致暂时性生化改变，从而减少神经冲动，进而导致接受腹腔镜手术患者出现“腹膜化”。基于腹膜内环境稳定变化的“生化性感觉减退”对患者有有益影响，即使因腹腔镜手术无法进行而转为开腹手术时，由于残留气腹的存在，这种影响依然持续。
