Gasless Vs Pneumoperitoneum Basic Research

Many basic studies have compared gasless laparoscopic surgery and laparoscopic surgery using pneumoperitoneum in terms of invasiveness and effects on the patient.

Gasless surgery without carbon dioxide pneumoperitoneum is not associated with compression of the inferior vena cava and intestinal vessels, elevation of the diaphragm, and absorption of carbon dioxide gas into the blood. Therefore, the gasless laparoscopic surgery is superior with regard to the effects on hemodynamics and respiratory function (46-48).

The results with respect to several points other than cardiopulmonary effects are described here.

Tumor Seeding, Abdominal Wall and Port Metastases

In 1996, Bouvy et al. reported striking experimental results on tumor seeding and abdominal wall metastases in the Annals of Surgery (49). Using rats divided into three experimental groups (carbon dioxide pneumoperitoneum, gasless laparoscopy, and conventional laparotomy groups), they obtained the following results: (i) direct contact between a solid tumor and the port led to an increase of local tumor seeding, (ii) laparoscopy is associated with less intraperitoneal tumor seeding than laparotomy, and (iii) insufflation of carbon dioxide promotes peritoneal tumor seeding and is associated with more abdominal wall metastases than gasless laparoscopy. In response to their results, many other authors have reported data on the relationship between carbon dioxide pneumoperitoneum and tumor cell growth or port metastasis.

It has often been reported that the spread of tumor cells in the abdominal cavity and port metastasis is not due to carbon dioxide gas per se, but arises from widespread tumor cell dissemination and implantation caused by the aspiration or insufflation of gas into the abdominal cavity (50-56). However, port site metastases are considered to result from direct contact between the tumor and port when removing the lesion because these metastases have also been frequently reported after thoracoscopic surgery without carbon dioxide gas insufflation (57,58). In any case, it seems true that insufflating gas at a high pressure and desufflating it increases the risk of tumor cell dissemination to the peritoneum and intraabdominal organs.

Bouvy et al. also reported that carbon dioxide pneumoperitoneum stimulates tumor growth (49). Many subsequent studies have investigated the mechanism of tumor growth associated with pneumoperitoneum. Previously, it was considered that carbon dioxide pneumoperitoneum itself might play a role as a carbon dioxide incubator.

Tumor growth may be attributable not to carbon dioxide gas, but to reduced blood flow in the peritoneum, liver, and renal cortex secondary to high-pressure pneu-moperitoneum (59-64).

Immune Response

Several studies have compared immune response between pneumoperitoneum and gasless laparoscopic surgery. Animal experiments have shown the following results: (i) carbon dioxide pneumoperitoneum reduces the activity of T lymphocytes (65); (ii) it reduces the intraperitoneal pH, which decreases macrophage activity and lowers the production of interferon-a (66); and (iii) it reduces splenic and hepatic natural killer cell activity (67). However, clinical data remain controversial: one study showed that carbon dioxide pneumoperitoneum reduced immunocompetence compared with gasless laparoscopic surgery (68), while another found no difference in immunocompetence between the two techniques (69). Buunen et al. (70) reviewed the effect of carbon dioxide pneumoperitoneum on immunocompetence and stated that local (i.e., peritoneal) immune function was affected, but the production of tumor necrosis factor and the phagocytotic capacity of peritoneal macrophages were less impaired. In addition, the systemic stress response, as determined from the delayed-type hypersensitivity response and leukocyte antigen expression by lymphocytes, is preserved after laparo-scopic surgery, but is weaker than after conventional surgery. The authors concluded

Reduction of pneumoperitoneum pressure, should be applied in patients with renal dysfunction or those receiving treatment with angiotensin II receptor 1 blockers or angiotensin converting enzyme inhibitors.

Gasless laparoscopic surgery had less effect on cardiopulmonary function than pneumoperitoneum.

Several studies have revealed that gas-less laparoscopic surgery is comparable to or better than pneumoperitoneum with respect to postoperative recovery. Some randomized trials have indicated that gasless laparoscopic surgery has less effect on neuroendocrine or hepatic function.

that intraperitoneal carbon dioxide insufflation attenuates peritoneal immunity, but laparoscopic surgery is associated with less systemic stress than open surgery.

Renal Function

In 1996, Chiu et al. reported that carbon dioxide pneumoperitoneum reduced the urine output and induced electrolyte abnormalities (71). Subsequent investigations showed that the urine output was reduced because pneumoperitoneum compressed the kidneys, thereby reducing blood flow in the renal cortex (72,73).

Reduction of pneumoperitoneum pressure, should be applied in patients with renal dysfunction or those receiving treatment with angiotensin IIreceptor 1 blockers or angiotensin converting enzyme inhibitors (74,75).

The effect on renal function of live donor nephrectomy with carbon dioxide pneumoperitoneum has been often reported as well. From the results of animal studies, Hazebroek et al. reported that pneumoperitoneum caused transient renal dysfunction, but had little effect on the kidney after transplantation (76-78). Abreu et al. reviewed 100 consecutive cases of laparoscopic live donor nephrectomy and concluded that carbon dioxide pneumoperitoneum had no effect on post-transplant kidney function (79).

Miscellaneous Effects

Other studies have revealed the following results: gasless laparoscopic surgery had less effect on respiratory function and causes fewer postoperative adhesions because of lower peritoneal oxidative stress than carbon dioxide pneumoperitoneum (80,81); gasless laparoscopic surgery does not stimulate bacterial growth (82); and gasless laparoscopic surgery is more appropriate for patients with head injury because it does not increase intracranial pressure (83,84).

Clinical Studies

Since 1996, a number of randomized controlled trials have been performed to compare abdominal wall lifting with carbon dioxide pneumoperitoneum. Gasless laparoscopic surgery had less effect on cardiopulmonary function than pneumoperitoneum.

Major studies on laparoscopic cholecystectomy are listed in Table 1 (45,85-90). Most investigators have reported that gasless laparoscopic surgery provides a small working space and is more technically difficult and time consuming. However, some investigators have found that the difference in operating time compared with pneumoperitoneum becomes negligible as surgeons increase their familiarity with the technique.

Several studies have revealed that gasless laparoscopic surgery is comparable to or better than pneumoperitoneum with respect to postoperative recovery. Some randomized trials have indicated that gasless laparoscopic surgery has less effect on neuroendocrine or hepatic function (91,92).

The randomized controlled trials performed in obstetrics and gynecology patients provided slightly different results from those on cholecystectomy patients (93-97). Many authors have concluded that gasless laparoscopic surgery was most appropriate for patients with serious cardiopulmonary dysfunction because it had little effect on car-diopulmonary function, but that it would be necessary to improve the lifting devices before gasless surgery became popular because it only provided a small working space, was more technically difficult, and often had to be switched to carbon dioxide pneumoperitoneum.

TABLE 1 ■ Comparison of Gasless Laparoscopic Cholecystectomy with Pneumoperitoneum

Author

Adverse effects Surgical Operative

No. of pts. (cardiopulmonary) procedure time Convalescence

Nagai H (85)a Koivusalo AM Vezakis (86)b Larsen JF (87)

144 26 36 50 34 95 40

Same

Same Fast Same Same

Low Same Low

Difficult Difficult Same Difficult Difficult

Long Same Same Long

Ortiz-Oshiro E (88)

Low Low

Fast Fast aA prospective nonrandomized multicenter study in Japan. bGasless versus low pressure pneumoperitoneum.

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