ABSTRACT
CO2-insufflation and electrocoagulation were advanced as causative factors of postsurgical adhesions. We assumed that severe tissue reaction due to electrocoagulation might obscure CO2-insufflation impact on adhesion formation. Therefore, the purpose of this study was to evaluate the effects and interactions of surgical trauma and CO2-insufflation on adhesion formation. Prospective-randomized study with 60 rats, equally divided into 3 groups. In the control group, the sidewall adhesion model was induced by monopolar coagulation of the uterine horn and ipsilateral parietal peritoneum and by mechanical damaging - in the opposite side through open laparoscopy without CO2-insufflation. In two other groups, CO2 was insufflated for 60 min at 15 cm of water, either before or after the sidewall model-induction. Parameters of sidewall and lesion site adhesions of parietal peritoneum and uterine horns were evaluated by scoring system and analyzed by two-way ANOVA with Bonferroni posttests, one-way ANOVA Student-Newman-Keuls multiple comparisons test, as well as by two-tailed unpaired Mann-Whitney test. Monopolar coagulation significantly increased peritoneal lesion site adhesion scores, as compared with the scores for mechanical damaging (p=0.0001). Visceral peritoneal lesion sites were more predisposed to adhesion formation than parietal peritoneal lesion sites (p=0.0009), whereas CO2 did not affect parameters of either sidewall or peritoneal lesion site adhesions, regardless of the insufflation mode (p>0.05). The data suggest that both surgical trauma and peritoneal lesion sites had a substantial impact on adhesion formation, whereas CO2 did not interfere with adhesion parameters irrespective of its insufflation mode. These findings may improve our insights into adhesion formation pathophysiology and open new perspectives in developing future adhesion prevention strategies.
ABSTRACT
BACKGROUND: Many factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions. METHODS: A prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO2 insufflation at the 10 cm of water. TIR was evaluated at the 24th, 72nd, 120th and 168th hour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests. RESULTS: More pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24th and 72nd; p < 0.01--120th and p < 0.001--168th hrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group. CONCLUSIONS: MIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO2 insufflation however, led to moderate inflammation and less adhesion formation.
