| Part 1Background:Surgery is an invasive treatment. In the treatment of disease it will inevitably take different trauma to the body. Surgical trauma as a stimulant factor can result in stress responses of body, thereby affecting the body's immune function. Numerous studies showed that immune functions and stress responses affected in direct proportion with the degree of trauma. Therefore, how to minimize the trauma to achieve a satisfactory therapeutic effect has been the surgeons'goal to pursue.Laparoendoscopic single-site surgery (LESS) is one of minimally invasive laparoscopic surgical techniques which is carried out just now in the world. The fundamental concept of LESS is to perform laparoscopic surgery through one single incision via one platform with multiple working channels or via multiple separate ports, and the incision is usually less than 2.5cm. The incision where specimen is taken out near umbilicus appears cosmetic. LESS based on laparoscopic technique develops fast and has been applied in general surgery, gynecology, urinary surgery and paediatrics.However, for LESS, especially complex LESS surgery, basic research is far behind clinical research and how LESS impacts on the internal environment of the body is still not clear compared to conventional laparoscopic surgery. Our study takes laparoendoscopic single-site left lateral hepatectomy (LESH) as a sample to explore the impacts of LESS on the immune functions and stress responses of body though a perspective comparison. The operative experience is also summarized for other complex LESS carried out.Aim:This study is to evaluate the technical feasibility of LESH and compared immune functions and stress responses with laparoscopic hepatectomy (LH) through a perspective controlled trial. The operative experience is also summarized for other complex LESS carried out.Methods:30 small female family pigs as animal models were divided into LESH group and the LH group randomly, each group 15 pigs. Under general anesthesia LESH or LH was performed. The data about operations including operating time, blood loss, mortality, complication rates, was recorded and compared. The stress and immune indicators, including adrenaline, serum cortisol, interleukin-1, interleukin-6, white blood cell count, immunoglobulin G, immunoglobulin A and immunoglobulin M, complement 3 and complement 4, were also recorded before operation, at operative endpoint, first day and second day after operation.Results:in LESH group,1 case was converted to the LH due to blooding uncontrolled. The other 29 cases underwent respective operations successfully. Postoperative recovery was even and no complications such as bleeding, thrombosis, bile leakage, bile duct injury, wound infection were found. The masses of excisional specimens were no difference between two groups. The mean operative time of LESH group was 94.7±31.3 min which was no statistical difference from LH group (p=0.0929). The blood loss of two groups was 72.5±26.4 ml vs.66.3±21.2 ml and there was no statistical difference.In both groups adrenaline, cortisol, interleukin-1. interleukin 6 and white blood cell count showed a rising trend after operations and the concentrations of the indicators in two groups had no significant difference at the same time point. After operations the immune indicators in both groups showed a descended trend. The concentration of immunoglobulin G in LESH group was higher than in LH group on the first day after operation. The other indicators at the same time point were no statistical difference.Conclusions:(1) Both of LESH and LH will affect stress responses of body which appears stress state. The levels of adrenaline, serum cortisol, interleukin-1, interleukin-6 and white blood cell count were significantly higher after operations than these before. Though the raising trend of LESH group was relatively small to LH group, the concentrations of these indicators had no significant difference at the same time point by comparison between the two groups. Compared to LH, LESH had no different impact on stress responses of body.(2) Both of LESH and LH will affect immune functions of the body. The levels of immunoglobulin G, immunoglobulin A, immunoglobulin M, complement 3 and complement 4 all showed a descended trend. Except that the level of immunoglobulin G in LESH group on the first day after operation was higher than that in LH group, the indicators at other time points had no significant difference. Compared to LH, LESH had no different impact on immune functions of body.(3) Through animal experiment, it was indicated that LESH is a safe, feasible, minimally invasive, cosmetic and effective technique which had a short learning curve.(4) Unlike conventional laparoscopic surgery, LESH has its own characteristics. Operator should change his original operative habits and try to apply cross-handed instruments in the operation. The operator also has to fit for the linear vision which is unique vision of LESS. Due to these difficulties, it should be carried out by experienced laparoscopic physicians. Part 2Background:Laparoscopic surgery has been made a lot of progress in the past 20 years. Clinical practice shows that laparoscopic surgery, as a new trend, is a successful model of combining modern technology and conventional surgery, which obeys surgical principles and accomplishes conventional operations with minimal invasion. With the development of minimally invasive surgical techniques, minimally invasive concepts are popular to both surgeons and patients. More and more operations can be accomplished by laparoscopic surgery. Nowadays, surgeons pursuit to reduce surgical trauma by reducing the number of ports. Laparoendoscopic single-site surgery (LESS) was invented in this context. Just like laparoscopic cholecystectomy (LC), LESS was also used in cholecystectomy firstly. But there were a few large prospective randomized controlled studies all over the world because it had shorter history and technologies were also relatively immature.Minimally Invasive Surgical Center of Tianjin Nankai Hospital applied LESS in clinical practice of general surgery from August 2008 beginning. Relying on the center, we compared LESS cholecystectomy with LC through a prospective comparative study to explore the advantages and disadvantages of LESS. The operative experience was summarized to help LESS develop fast.Aim:To explore the safety, feasibility, minimally invasive trauma of LESS cholecystectomy comparing with LC through a prospective randomized controlled study. The operative experience was summarized to help LESS carried out extensively.Methods:Between August 2008 and August 2010, a randomized controlled study was undertaken in our center to compare LESS cholecystectomy to LC in patients with uncomplicated cholelithiasis or PLG. Selective 60 patients diagnosed as cholelithiasis or polyp lesion of gallbladder (PLG) were divided into two groups randomly undergoing LESS cholecystectomy or LC separately. The clinical data about operations and recovery of the two groups, including operative time, intraoperative and postoperative complications, postoperative hospital stay, was recorded and compared. Numeric rating scale (NRS) was used to record postoperative pain score. The satisfaction scores with the operation treaments were obtained through telephone follow-up. The stress indicators before operation, first day after operation and third day after operation, including serum cortisol, interleukin-6 and white blood cell count, were also recorded and compared.Results:In LESS group 28 of 30 patients underwent LESS cholecystectomy successfully and the other 2 (6.7%) were converted to standard laparoscopic surgery. LC was successfully performed in all patients in control group. Mean operative time of LESS cholecystectomy group (46.3±24.7 min) was longer than LC group (28.6±11.4 min) (P< 0.05). Mean postoperative hospital stay was 3.7±1.3 versus 3.8+0.8 days (P>0.05). Mean pain index was 2.8±0.6 versus 3.7±1.1(P< 0.05). Through questionnaire mean satisfaction scores with the operations were 8.9±0.7 versus 8.1±1.5 (P<0.05).Serum cortisol, interleukin-6 and white blood cell count in the two groups showed a rising trend in which white blood cell count increased constantly, the levels of serum cortisol and interleukin-6 raised on the first day after operations and descended slightly on the third day after operations. But the levels of the three indicators had no significant difference at the same time point comparing between the two groups.Conclusion:LESS cholecystectomy is safe, feasible, minimally invasive, and cosmetic. It is a reasonable alternative to selective patients with uncomplicated cholelithiasis and PLG. However, LESS cholecystectomy is more difficult than conventional LC with longer operative time. So it should be careful to control the operative indications and LESS should be carried out by experienced laparoscopic physicians. It is believed that with the development of operative instruments LESS will have a prospective future. |
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