Michele Diana1,2,3,4, Eric Noll5, Andras Legnèr6, Seong-Ho Kong6,7, Yu-Yin Liu8, Luigi Schiraldi8, Francesco Marchegiani6, Jordan Bano8, Bernard Geny9, Anne-Laure Charles9, Bernard Dallemagne8, Véronique Lindner10, Didier Mutter11, Pierre Diemunsch5, Jacques Marescaux8,6. 1. IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France. michele.diana@ircad.fr. 2. Institute for Image-Guided Surgery, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France. michele.diana@ircad.fr. 3. Physiology Institute, EA3072 Mitochondria and Oxidative Stress, University of Strasbourg, Strasbourg, France. michele.diana@ircad.fr. 4. Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France. michele.diana@ircad.fr. 5. Anesthesiology Department, University Hospital of Strasbourg, Strasbourg, France. 6. Institute for Image-Guided Surgery, IHU-Strasbourg, 1, place de l'Hôpital, 67091, Strasbourg, France. 7. Department of Surgery, Seoul National University Hospital, Seoul, South Korea. 8. IRCAD, Research Institute Against Cancer of the Digestive System, Strasbourg, France. 9. Physiology Institute, EA3072 Mitochondria and Oxidative Stress, University of Strasbourg, Strasbourg, France. 10. Pathology Department, University Hospital of Strasbourg, Strasbourg, France. 11. Department of General, Digestive and Endocrine Surgery, University Hospital of Strasbourg, Strasbourg, France.
Abstract
BACKGROUND: Standard insufflators compensate for intra-abdominal pressure variations with pressure spikes. Our aim was to evaluate the impact of a stable, low-pressure pneumoperitoneum induced by a valve-less insufflator, on working space, hemodynamics, inflammation, and peritoneal physiology, in a model of laparoscopic sigmoid resection. MATERIALS AND METHODS: Twelve pigs (47 ± 3.3 kg) were equipped for invasive hemodynamic monitoring and randomly assigned to Standard (n = 6) vs. valve-less (n = 6) insufflation. Animals were positioned in a 30° Trendelenburg on a CT scan bed. A low-pressure pneumoperitoneum (8 mmHg) was started and duration was set for 180 min. Abdominal CT scans were performed, under neuromuscular blockade, before, immediately after, and 1 and 3 h after insufflation. Pneumoperitoneum volumes were calculated on 3D reconstructed CT scans. After creation of a mesenteric window, capillary blood was obtained by puncturing the sigmoid serosa and local lactatemia (mmol/L) was measured using a handheld analyzer. Surgical resection was performed according to the level of lactates, in order to standardize bowel stump perfusion. IL-1 and IL-6 (ng/mL) were measured repeatedly. The peritoneum was sampled close to the surgical site and distantly for the oxygraphic assessment of mitochondrial respiration. A pathologist applied a semi-quantitative score to evaluate the anastomosis. RESULTS:Mean arterial pressure, pulse, body temperature, oximetry, systemic lactatemia, and local lactates were similar. IL-6 was lower in the valve-less group, reaching a statistically significant difference after 3 h of insufflation (64.85 ± 32.5 vs. 133.95 ± 59.73; p = 0.038) and 48 h (77.53 ± 68.4 vs. 190.74 ± 140.79; p = 0.029). Peritoneal mitochondrial respiration was significantly increased after the survival period, with no difference among the groups. The anastomoses in the valve-less group demonstrated a lower acute (p = 0.04) inflammatory infiltration. The mean anterior posterior thickness was slightly, yet significantly higher in the valve-less group, on all post-insufflation CT scans. CONCLUSIONS: Valve-less insufflation achieved a slightly higher working space and a lower systemic and localized inflammatory response in this experimental setting.
RCT Entities:
BACKGROUND: Standard insufflators compensate for intra-abdominal pressure variations with pressure spikes. Our aim was to evaluate the impact of a stable, low-pressure pneumoperitoneum induced by a valve-less insufflator, on working space, hemodynamics, inflammation, and peritoneal physiology, in a model of laparoscopic sigmoid resection. MATERIALS AND METHODS: Twelve pigs (47 ± 3.3 kg) were equipped for invasive hemodynamic monitoring and randomly assigned to Standard (n = 6) vs. valve-less (n = 6) insufflation. Animals were positioned in a 30° Trendelenburg on a CT scan bed. A low-pressure pneumoperitoneum (8 mmHg) was started and duration was set for 180 min. Abdominal CT scans were performed, under neuromuscular blockade, before, immediately after, and 1 and 3 h after insufflation. Pneumoperitoneum volumes were calculated on 3D reconstructed CT scans. After creation of a mesenteric window, capillary blood was obtained by puncturing the sigmoid serosa and local lactatemia (mmol/L) was measured using a handheld analyzer. Surgical resection was performed according to the level of lactates, in order to standardize bowel stump perfusion. IL-1 and IL-6 (ng/mL) were measured repeatedly. The peritoneum was sampled close to the surgical site and distantly for the oxygraphic assessment of mitochondrial respiration. A pathologist applied a semi-quantitative score to evaluate the anastomosis. RESULTS: Mean arterial pressure, pulse, body temperature, oximetry, systemic lactatemia, and local lactates were similar. IL-6 was lower in the valve-less group, reaching a statistically significant difference after 3 h of insufflation (64.85 ± 32.5 vs. 133.95 ± 59.73; p = 0.038) and 48 h (77.53 ± 68.4 vs. 190.74 ± 140.79; p = 0.029). Peritoneal mitochondrial respiration was significantly increased after the survival period, with no difference among the groups. The anastomoses in the valve-less group demonstrated a lower acute (p = 0.04) inflammatory infiltration. The mean anterior posterior thickness was slightly, yet significantly higher in the valve-less group, on all post-insufflation CT scans. CONCLUSIONS:Valve-less insufflation achieved a slightly higher working space and a lower systemic and localized inflammatory response in this experimental setting.
Authors: Michele Diana; Eric Noll; Pierre Diemunsch; Bernard Dallemagne; Malika A Benahmed; Vincent Agnus; Luc Soler; Brian Barry; Izzie Jacques Namer; Nicolas Demartines; Anne-Laure Charles; Bernard Geny; Jacques Marescaux Journal: Ann Surg Date: 2014-04 Impact factor: 12.969