Practice Of Gynecological Laparoscopic Surgery And The Clinical And Basic Study Of Effect Of Carbon Dioxide Pneumoperitoneum On The Body

BackgroundMinimally invasive surgery has been regarded as an integrated system of surgical treatment since middle 1980s. Especially the clinical and basic study related to gynecological laparoscopic surgery has been a hot spot of minimally gynecological invasive surgery in the past ten years. Laparoscopic surgery has not been mysterious for most surgeons. To better grasp the technique of laparoscopic surgery, folllow the trends of surgical treatments, and deeply understand MIS, I have been guided by the concept during the course of my study as a postgraduate student in the past nealy five years. The process contains the study of the technique of laparoscopic surgery from my advisor and the understanding of her concept of MIS. Also it is a process of deepening and sublimating the concept. For the technique, I experienced a surgical procedure from simple to complex, from unskilled to familiar till skilled. I gradually comprehend in my study that MIS is relative and has two sides, the same as other treating methods. The progress of technique in fact comprise challenge to MIS, whose typical representation is pneumoperitoneum. If the laparoscopic surgery is improperly used, the minimal invasiveness may be transformed into huge trauma. There appears many problems, for example, the special physico-chemical property may lead to its accumulation, even acidosis of patients. Moreover, CO2 pneumoperitoneum has the potential of facilitating the implantation and diversion of tumor cells, and so on. We had to transfer our view angle to the question"how CO2 pneumoperitoneum affects patients?". In this research, based on my own clinical practice, I investigated my learning curve of gynecological laparoscopic surgery, meanwhile, I investigated how CO2 pneumoperitoneum affects the body and makes the transformation from minimal invasiveness to huge trauma by means of clinical test and animal experiments, in order to find a more perfect treating strategy and optimize the the system of gynecological laparoscopic surgery.Objective1. To deeply understand the academic theory of my advisor about MIS and to grasp the technique of gynecological laparoscopic surgery. 2. To investigate the effect of different mode CO2 pneumoperitoneum on the body. (1)To detect the effect of two different types of insufflator on the iintraabdominal pressure during gynecological laparoscopic surgery. (2)To investigate the effect of two different types of CO2 pneumoperitoneum on the peritoneal ultrastructure in rats, and to illustrate the possible anatomic base of port-site metastasis of tumor cells after gynecological laparoscopic surgery. (3)To investigate the effect of CO2 pneumoperitoneum on the adhension, invasiveness and angiogenesis of peritoneum tissues, and to illustrate the molecular biological base of port-site metastasis after gynecological laparoscopic surgery.Methods1. Communicating and working with my advisor during clinical practice, I fulfilled daily work of surgery and peri-operation management. For one of the series of laparoscopic surgeries, I chose 21 cases of laparoscopic cysterectomy to investigate the learning curve of minimally invasive gynecological surgery. 2. Using two different types of insufflators, we detected the real intraabdominal pressure of a hard container simulating abdonimal cavity, rat models and patients during laparoscopic surgeries. 3. We filled carbon dioxide into the cavity of rats by two different insufflators, and observed the ultrastructure of the peritoneum and the muscular tissues outside of it at 60min, 90min, 120min and 180min of pneumoperitoneum, as well as 24h, 48h and 72h after the pneumoperitoneum ceased, respectively. 4. After exposed under two different CO2 pneumoperitoneum for 1h or 3h, the peritoneum tissues of 48 rats were obtained to detect the expression of CD44v6, ICAM-1, MMP-2, TIMP-1, VEGF, ENS and TNF-αby real-time PCR and we made a comparative study with the control group, whose rats were only anesthetized.Results1. The MIS theory of my advisor: MIS is a principle for both the doctors and the patients. We should remember any kind of MIS may be transformed into huge trauma, even death. The real concept and core of MIS is to cure the disease and minimize the damage of patients at the same time during the course of medical intervention. It is:①To decrease the total damage, which contains the harmful stimulation of machinery, phsiology, mental state and psychology.②To relieve the violent stress response.③To regulate the process of reaction of damages.④To improve the wound healing。This concept should be thoughout the whole diagnositc and surgical procedures, including the preparation, the operation process and the recovery period of the surgeries.2. The mean operative time of 21cases of laparoscopic ovarian cysterectomy was 2325.71±1111.69sec(600~4620sec), the mean blood loss was 27.62±21.07ml(10~80ml) and the mean operation score was 6. The comparison of operative time between two neighboring groups showed that there was significance between group 5 and group 6 (P=0.034). The comparison of blood loss and operation score between two neighboring groups both showed no significance. Also, we found significant difference between group4 and group 7, as well as group5 and group 7 in their operative time comparison (P=0.045 and 0.028, respectively). No complications but a slight subcutaneous emphysema happened on the 21 cases.3. When the electronic pulse-wave mode insufflator is working, IAP of patients may reach 40mmHg, more than twice of the setting point, 15mmHg. When the constant-pressure insufflator is used, IAP of patients fluctuates in a±10% interval of the setting 15mmHg.4. In both groups, there appeared the swelling mesothelial cells and the intercellular cleft after 30min of pneumoperitoneum and the basal membrane was laid bare after 60min. It was still obvious after the pneumoperitoneum ceased for 24 to 48h and the recovery of the mesothelial cell morphology was observed after 72h. Vacuolar degeneration could be found within the myocytes outside the peritoneum in both groups after 60 minutes of pneumoperitoneum. It appeared more and more significant with the prolonged pneumoperitoneum time. The phenomena of widened gaps among the myocytes and the vacuolar degeneration were more obvious in pulse-mode insufflator group than in the other one.5. Two types of pneumoperitoneum both led to the significant descending expression of CD44v6(P<0.05), and the pulse-mode pneumoperitoneum made a more obvious change of its expression. The significant down-regulation of ICAM-1 were found after 3h of pneumoperitoneum in both groups(P<0.05). 3h of pulse-mode pneumoperitoneum significantly down-regulated the expression of MMP-2 (P<0.05), while for constant-pressure mode one, there was no significance. 3h of constant-pressure mode pneumoperitoneum significantly up-regulated the expression of TIMP-1(P<0.05), while for pulse-mode one, there was no significance. The ratio of MMP-2/TIMP-1 was descending on the whole, but there was no statistical significance. 3h of constant-pressure mode pneumoperitoneum significantly down-regulated the expression of VEGF(P<0.05), but the other intervention didn't work. It was surprised that the expression of ENS was up-regulated in all the groups(P<0.05), and 3h of pulse-mode pneumoperitoneum affected it more than constant-pressure mode one did (P=0.007). The ratio of VEGF/ENS was significantly up-regulated(P<0.05). 3h of pulse-mode pneumoperitoneum significantly up-regulated the expression of TNF-α, but no significance was found in the other groups, and the effect of pulse-mode pneumoperitoneum on the expression of TNF-αwas severe than the other one (P=0.003).Conclusion1. The MIS theory of my advisor is important to performe gynecological laparoscopic surgery, to efficiently avoid complications and to carry out research work. It should be the guidance for learners to performing gynecological laparoscopic surgery unbiasedly in the early stage.2. As was shown in the learning curve of laparoscopic cysterectomy, an inexperienced surgeon can reach a certain level of skills after adequate laparoscopic surgery practice, and the early learning curve of laparoscopic ovarian cystectomy was approximately fifteen cases.3. The electronic pulse-wave mode insufflators made great variation of IAP during laparoscopic procedures, while the constant-pressure mode insufflators made the pressure comparatively constant. Due to its transient variation of pressure, the electronic pulse-wave mode insufflator is presumed to affect more on patients than the constant-pressure mode one, and maybe the latter is more suitable for gynecological laparoscopic surgeries.4. Two types of CO2 pneumoperitoneum both led to the change of the ultrastructure of peritoneal mesothelial cell in rats, which indicats that the injury of peritoneum is independent of the mode of CO2 pneumoperitoneum. The electronic pulse-wave mode insufflator produced more severe injuries on the muscular tissues outside the peritoneum than the constant-pressure mode one, and the latter is probably helpful to decrease such injuries.5. Exposed under CO2 pneumoperitoneum, the adhesive ability of peritoneum in rats was descended, the invasiveness tended to be weakened but not significant, and the angiogenesis was sinificantly strengthened. Two types of CO2 pneumoperitoneum had different effects on the function of rats peritoneum. In general, the electronic pulse-wave mode insufflator affected more on the function of peritoneum than the constant-pressure mode one did. It is undoubted that the variation of intra-abdominal pressure during laparoscopic surgery has effect on the function of peritoneum.