Peritoneal Morphological Changes due to Pneumoperitoneum: The Effect of Intra-abdominal Pressure

Abstract

Introduction Carbon dioxide (CO₂) used in laparoscopy evokes local and systemic effects. This study was designed to evaluate the histopathologic morphologic changes due to CO₂ and air insufflation, at different pressure levels, on visceral and parietal peritoneum in rats.

Materials and Methods A total of 56 rats were object of the study, randomly divided into five groups. Pneumoperitoneum (PN) was maintained for 30 minutes, at a flow rate of 0.5 L/min and at a pressure of 10 and 6 mm Hg with CO₂ (group S1–S2, n = 32) and filtered air (group A1–A2, n = 16). Only anesthesia was performed in the fifth group (group C, n = 8). Peritoneal samples were obtained 24 hours later for blinded histological evaluation. A grading system was adopted to evaluate histological peritoneal changes (0, no change; 1, mild; 2, moderate; and 3, severe) such as mesothelial aspect, inflammatory response, edema, and hemorrhage. The score reflected the severity of damage and was calculated by the sum of the degree evaluated separately. Values were compared with the analysis of variance analysis.

Results CO₂ and air insufflation caused reactive mesothelial cells and peritoneal inflammation of different degrees depending on the level of intra-abdominal pressure (IAP) and type of gas. These modifications were absent in group C and were less evident in low pressure S2 group with respect to S1 and A1–A2 groups. The average values of histopathologic peritoneal score showed significant differences between S2 (11.5) versus S1 groups (16.83) with respect to A groups (A1 = 27.83; A2 = 20.5) and compared with the controls (C = 2.5).

Conclusions Our data confirm that PN affects the peritoneal integrity. The grades of morphological peritoneal changes are related to the level of IAP. Low CO₂ pressure causes minor peritoneal changes with respect to high pressure and air insufflation.

Keywords

laparoscopy - carbon dioxide - pneumoperitoneum - peritoneum - pressure

• References

• 1 Brokelman WJ, Lensvelt M, Borel Rinkes IH, Klinkenbijl JH, Reijnen MM. Peritoneal changes due to laparoscopic surgery. Surg Endosc 2011; 25 (1) 1-9
• 2 Neuhaus SJ, Watson DI, Ellis T, Lafullarde T, Jamieson GG, Russell WJ. Metabolic and immunologic consequences of laparoscopy with helium or carbon dioxide insufflation: a randomized clinical study. ANZ J Surg 2001; 71 (8) 447-452
• 3 Kuntz C, Wunsch A, Bödeker C , et al. Effect of pressure and gas type on intraabdominal, subcutaneous, and blood pH in laparoscopy. Surg Endosc 2000; 14 (4) 367-371
• 4 Ure BM, Niewold TA, Bax NM, Ham M, van der Zee DC, Essen GJ. Peritoneal, systemic, and distant organ inflammatory responses are reduced by a laparoscopic approach and carbon dioxide versus air. Surg Endosc 2002; 16 (5) 836-842
• 5 Kuebler JF, Vieten G, Shimotakahara A, Metzelder ML, Jesch NK, Ure BM. Acidification during carbon dioxide pneumoperitoneum is restricted to the gas-exposed peritoneal surface: effects of pressure, gas flow, and additional intraperitoneal fluids. J Laparoendosc Adv Surg Tech A 2006; 16 (6) 654-658
• 6 Papparella A, Noviello C, Romano M, Parmeggiani P, Paciello O, Papparella S. Local and systemic impact of pneumoperitoneum on prepuberal rats. Pediatr Surg Int 2007; 23 (5) 453-457
• 7 Volz J, Köster S, Spacek Z, Paweletz N. Characteristic alterations of the peritoneum after carbon dioxide pneumoperitoneum. Surg Endosc 1999; 13 (6) 611-614
• 8 Suematsu T, Hirabayashi Y, Shiraishi N, Adachi Y, Kitamura H, Kitano S. Morphology of the murine peritoneum after pneumoperitoneum vs laparotomy. Surg Endosc 2001; 15 (9) 954-958
• 9 Liu Y, Hou QX. [Effect of carbon dioxide pneumoperitoneum during laparoscopic surgery on morphology of peritoneum]. Zhonghua Yi Xue Za Zhi 2006; 86 (3) 164-166
• 10 Avital S, Itah R, Szomstein S , et al. Correlation of CO2 pneumoperitoneal pressures between rodents and humans. Surg Endosc 2009; 23 (1) 50-54
• 11 Papparella A, DeLuca FG, Oyer CE, Pinar H, Stonestreet BS. Ischemia-reperfusion injury in the intestines of newborn pigs. Pediatr Res 1997; 42 (2) 180-188
• 12 Du J, Yu PW, Tang B. Application of stereology to study the effects of pneumoperitoneum on peritoneum. Surg Endosc 2011; 25 (2) 619-627
• 13 Schaeff B, Paolucci V, Henze A, Encke A. Electron microscopical changes to pneumoperitoneum after laparoscopic operations. Surg Endosc 1998; 12: o36 (Abstract)
• 14 Bertram P, Tietze L, Hoopmann M, Treutner KH, Mittermayer C, Schumpelick V. Intraperitoneal transplantation of isologous mesothelial cells for prevention of adhesions. Eur J Surg 1999; 165 (7) 705-709
• 15 Schilling MK, Redaelli C, Krähenbühl L, Signer C, Büchler MW. Splanchnic microcirculatory changes during CO2 laparoscopy. J Am Coll Surg 1997; 184 (4) 378-382
• 16 Molinas CR, Binda MM, Carmeliet P, Koninckx PR. Role of vascular endothelial growth factor receptor 1 in basal adhesion formation and in carbon dioxide pneumoperitoneum-enhanced adhesion formation after laparoscopic surgery in mice. Fertil Steril 2004; 82 (Suppl. 03) 1149-1153
• 17 Bourdel N, Matsuzaki S, Bazin JE, Pouly JL, Mage G, Canis M. Peritoneal tissue-oxygen tension during a carbon dioxide pneumoperitoneum in a mouse laparoscopic model with controlled respiratory support. Hum Reprod 2007; 22 (4) 1149-1155
• 18 Neuhaus SJ, Watson DI. Pneumoperitoneum and peritoneal surface changes: a review. Surg Endosc 2004; 18 (9) 1316-1322
• 19 Wong YT, Shah PC, Birkett DH, Brams DM. Carbon dioxide pneumoperitoneum causes severe peritoneal acidosis, unaltered by heating, humidification, or bicarbonate in a porcine model. Surg Endosc 2004; 18 (10) 1498-1503