Giraudo G, Brachet Contul R, Caccetta M, Morino M
Department of Surgery, University of Turnin, C.S. A.M. Dogliotti, A6, A10126 Torino, Italy.
Surg Endosc. 2001 Jul;15(7):741-6. doi: 10.1007/s004640090020. Epub 2001 Apr 3.
In a previous clinical study, we showed that the duration and level of pneumoperitoneum are responsible for changes in hepatic function during laparoscopic procedures. These findings encouraged us to evaluate hepatic function during laparoscopy with and without carbon dioxide (CO(2)) pneumoperitoneum in a clinical setting.
We performed 63 laparoscopic cholecystectomies and 30 non-hepatobiliary laparoscopic procedures in 93 consecutive patients with normal preoperative liver function tests. The anesthesiologic protocol was uniform, using drugs at low hepatic metabolism. We performed laparoscopic cholecystectomies in 43 patients with a pneumoperitoneum; in the remaining 20, we used a gasless technique. We randomized the 43 laparoscopic cholecystectomies into 23 performed with pneumoperitoneum at 14 mmHg and 20 performed at 10 mmHg. All non-hepatobiliary laparoscopic procedures were performed with a pneumoperitoneum of 14 mmHg. The postoperative serologic levels of AST, ALT, and bilirubin, and the prothrombin time were measured at 6, 24, 48, and 72 h. The alterations in the serologic hepatic tests were then related to the type of procedure, its duration, and the level of pneumoperitoneum.
The study group was comprised of 93 patients, 39 male and 54 female, with a mean age of 50.5 years (range, 15-74). There were no deaths. There was no morbidity in the pneumoperitoneum group, but there was one case of accidental omental injury during the placement of the abdominal, wall retractor in the gasless group. All patients had postoperative changes in serologic hepatic tests. Slow return to normality occurred 48 or 72 h after the operation. The increase in AST and ALT was statistically significant and correlated to the level and duration of pneumoperitoneum. The serologic change in the gasless group were significantly lower than in the laparoscopic cholecystectomy group with pneumoperitoneum at 14 mmHg. There was no statistically significant difference between the gasless group and the laparoscopic cholecystectomy group with pneumoperitoneum at 10 mmHg. There was a statistically the significant increase in the non-hepatobiliary laparoscopy group over the gasless group, despite the absence of hepatobiliary injuries in the first group. No symptoms were related to these serologic hepatic changes.
The gasless technique causes smaller alterations in serological hepatic parameters than pneumoperitoneum at 14 mmHg. By contrast, the gasless technique and low-pressure pneumoperitoneum have the same effect on hepatic function. Therefore, the use of a subcutaneous abdominal wall retractor combined with a low-pressure pneumoperitoneum is recommended for patients with severe hepatic failure. Transaminases
在之前的一项临床研究中，我们发现气腹的持续时间和压力是导致腹腔镜手术期间肝功能变化的原因。这些发现促使我们在临床环境中评估有或无二氧化碳（CO₂）气腹的腹腔镜手术期间的肝功能。
我们对93例术前肝功能测试正常的连续患者进行了63例腹腔镜胆囊切除术和30例非肝胆腹腔镜手术。麻醉方案统一，使用低肝代谢的药物。43例患者采用气腹进行腹腔镜胆囊切除术；其余20例采用免气腹技术。我们将43例腹腔镜胆囊切除术随机分为两组，23例采用14 mmHg的气腹压力，20例采用10 mmHg的气腹压力。所有非肝胆腹腔镜手术均采用14 mmHg的气腹压力。在术后6、24、48和72小时测量血清AST、ALT和胆红素水平以及凝血酶原时间。然后将血清肝脏检查的变化与手术类型、手术持续时间和气腹压力相关联。
研究组由93例患者组成，男性39例，女性54例，平均年龄50.5岁（范围15 - 74岁）。无死亡病例。气腹组无并发症，但免气腹组在放置腹壁牵开器时有1例意外网膜损伤。所有患者术后血清肝脏检查均有变化。术后48或72小时缓慢恢复正常。AST和ALT的升高具有统计学意义，且与气腹的压力和持续时间相关。免气腹组的血清学变化明显低于气腹压力为14 mmHg的腹腔镜胆囊切除术组。免气腹组与气腹压力为10 mmHg的腹腔镜胆囊切除术组之间无统计学显著差异。尽管非肝胆腹腔镜手术组无肝胆损伤，但该组血清学变化较免气腹组有统计学显著增加。这些血清肝脏变化均无相关症状。
免气腹技术引起的血清肝脏参数变化比14 mmHg的气腹小。相比之下，免气腹技术和低压气腹对肝功能的影响相同。因此，对于严重肝功能衰竭患者，建议使用皮下腹壁牵开器联合低压气腹。转氨酶
