Ure B M, Niewold T A, Bax N M A, Ham M, van der Zee D C, Essen G J
Department of Pediatric Surgery, University Medical Center Utrecht, Utrecht, The Netherlands.
Surg Endosc. 2002 May;16(5):836-42. doi: 10.1007/s00464-001-9093-7. Epub 2002 Feb 8.
Advantages of laparoscopic surgery have, among other factors, been attributed to a shorter length of abdominal incision and the use of CO2 versus air. An analysis of these factors taking pressure-induced alterations into account is lacking. The objective of the study was to determine the impact of laparoscopy and laparotomy with exposure to CO2 and room air under a similar pressure on local, systemic, and distant organ immune responses.
Twenty piglets were randomized into four groups: CO2 laparoscopy, air laparoscopy, CO2 laparotomy, and air laparotomy. Laparotomy was performed in a sterile balloon pressurized similar to laparoscopy. Peritoneal interleukin-1, interleukin-6, tumor necrosis factor-a, and counts of polymorphnuclear cells (PMNs), and macrophages (MFs) were determined in abdominal lavage fluids at 0, 2, and 48 h. Macrophages were assessed for reactive oxygen species (ROS) production. Systemic responses were gauged by white blood cell count (WBC) and cytokines. Alveolar lavage was performed at 48 h to determine cytokine levels, cell counts, and MF ROS production. Blood, lavage fluids, and mesenteric lymph nodes were tested for bacterial translocation.
Regarding the peritoneal response, laparotomy versus laparoscopy when performed with CO2 significantly increased PMN and decreased the percentage of macrophages (%MF) up to 48 h. There was a significant increase in interleukin-6, and there was a fourfold increase in MF ROS production. Similar differences between the procedures were found with exposure to air. The use of air versus CO2 in laparoscopy, but not in laparotomy, resulted in an increase of peritoneal PMN and a decrease of the %MF up to 48 h. Air increased the local interleukin-6 release in both procedures and increased MF ROS production fourfold. Regarding the systemic response, laparotomy produced a significant increase in WBC, which was significantly more pronounced with exposure to air. No alteration of other systemic cytokines was seen. Regarding the pulmonary response, the number of MFs and MF ROS production were significantly increased after air versus CO2 laparoscopy. There were no such differences between the laparotomy groups. Regarding bacterial translocation, no bacteria were cultured from peritoneal fluids, lymph nodes, or blood.
Inflammatory responses were reduced by a laparoscopic approach and by exposure to CO2 versus air. Peritoneal responses were affected to a larger degree than systemic parameters. Laparotomy overruled the effects of CO2 on chemotaxis and distant organ injury but not on peritoneal cytokine release.
腹腔镜手术的优势，除其他因素外，还归因于腹部切口长度较短以及使用二氧化碳而非空气。目前缺乏对这些因素并考虑压力诱导变化的分析。本研究的目的是确定在相似压力下，腹腔镜手术和开腹手术暴露于二氧化碳和室内空气时对局部、全身及远处器官免疫反应的影响。
将20只仔猪随机分为四组：二氧化碳腹腔镜组、空气腹腔镜组、二氧化碳开腹组和空气开腹组。开腹手术在类似于腹腔镜手术的无菌气囊加压下进行。在0、2和48小时测定腹腔灌洗液中的白细胞介素-1、白细胞介素-6、肿瘤坏死因子-α以及多形核细胞（PMN）和巨噬细胞（MF）计数。评估巨噬细胞的活性氧（ROS）生成情况。通过白细胞计数（WBC）和细胞因子评估全身反应。在48小时进行肺泡灌洗以确定细胞因子水平、细胞计数和MF的ROS生成情况。检测血液、灌洗液和肠系膜淋巴结中的细菌移位情况。
关于腹腔反应，与二氧化碳腹腔镜手术相比，开腹手术在48小时内显著增加了PMN数量并降低了巨噬细胞百分比（%MF）。白细胞介素-6显著增加，MF的ROS生成增加了四倍。在暴露于空气的情况下，两种手术方式之间也发现了类似差异。在腹腔镜手术中使用空气而非二氧化碳，但开腹手术中未出现这种情况，在48小时内导致腹腔PMN增加和%MF降低。空气在两种手术方式中均增加了局部白细胞介素-6释放，并使MF的ROS生成增加了四倍。关于全身反应，开腹手术使WBC显著增加，暴露于空气时更为明显。未观察到其他全身细胞因子的改变。关于肺部反应，空气腹腔镜手术与二氧化碳腹腔镜手术相比，MF数量和MF的ROS生成显著增加。开腹手术组之间没有此类差异。关于细菌移位，在腹腔液、淋巴结或血液中未培养出细菌。
腹腔镜手术方式以及暴露于二氧化碳而非空气可减轻炎症反应。腹腔反应比全身参数受到的影响更大。开腹手术抵消了二氧化碳对趋化作用和远处器官损伤的影响，但对腹腔细胞因子释放没有影响。
