Vol.:(0123456789)
1 3
Surgical Endoscopy (2018) 32:3215–3224
https://doi.org/10.1007/s00464-018-6039-x
Impact of valve-less vs. standard insufflation on pneumoperitoneum
volume, inflammation, and peritoneal physiology in a laparoscopic
sigmoid resection experimental model
Michele Diana
1,2,3,4
· Eric Noll
5
· Andras Legnèr
2
· Seong‑Ho Kong
2,6
· Yu‑Yin Liu
1
· Luigi Schiraldi
1
·
Francesco Marchegiani
2
· Jordan Bano
1
· Bernard Geny
3
· Anne‑Laure Charles
3
· Bernard Dallemagne
1
·
Véronique Lindner
7
· Didier Mutter
4
· Pierre Diemunsch
5
· Jacques Marescaux
1,2
Received: 24 July 2017 / Accepted: 3 January 2018 / Published online: 12 January 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract
Background Standard insufflators compensate for intra-abdominal pressure variations with pressure spikes. Our aim was
to evaluate the impact of a stable, low-pressure pneumoperitoneum induced by a valve-less insufflator, on working space,
hemodynamics, inflammation, and peritoneal physiology, in a model of laparoscopic sigmoid resection.
Materials and methods Twelve pigs (47 ± 3.3 kg) were equipped for invasive hemodynamic monitoring and randomly
assigned to Standard (n = 6) vs. valve-less (n = 6) insufflation. Animals were positioned in a 30° Trendelenburg on a CT scan
bed. A low-pressure pneumoperitoneum (8 mmHg) was started and duration was set for 180 min. Abdominal CT scans were
performed, under neuromuscular blockade, before, immediately after, and 1 and 3 h after insufflation. Pneumoperitoneum
volumes were calculated on 3D reconstructed CT scans. After creation of a mesenteric window, capillary blood was obtained
by puncturing the sigmoid serosa and local lactatemia (mmol/L) was measured using a handheld analyzer. Surgical resection
was performed according to the level of lactates, in order to standardize bowel stump perfusion. IL-1 and IL-6 (ng/mL) were
measured repeatedly. The peritoneum was sampled close to the surgical site and distantly for the oxygraphic assessment of
mitochondrial respiration. A pathologist applied a semi-quantitative score to evaluate the anastomosis.
Results Mean arterial pressure, pulse, body temperature, oximetry, systemic lactatemia, and local lactates were similar.
IL-6 was lower in the valve-less group, reaching a statistically significant difference after 3 h of insufflation (64.85 ± 32.5
vs. 133.95 ± 59.73; p = 0.038) and 48 h (77.53 ± 68.4 vs. 190.74 ± 140.79; p = 0.029). Peritoneal mitochondrial respiration
was significantly increased after the survival period, with no difference among the groups. The anastomoses in the valve-less
group demonstrated a lower acute (p = 0.04) inflammatory infiltration. The mean anterior posterior thickness was slightly,
yet significantly higher in the valve-less group, on all post-insufflation CT scans.
Conclusions Valve-less insufflation achieved a slightly higher working space and a lower systemic and localized inflamma-
tory response in this experimental setting.
Keywords Valve-less insufflator · Stable pneumoperitoneum · Peritoneal mitochondrial respiration rate · Capillary lactates ·
Metabolism-guided bowel resection
and Other Interventional Techniques
This study was presented at the 24th International Congress of the
EAES, June 15–18, 2016, in Amsterdam, Netherlands.
* Michele Diana
michele.diana@ircad.fr
1
IRCAD, Research Institute Against Cancer of the Digestive
System, Strasbourg, France
2
Institute for Image-Guided Surgery, IHU-Strasbourg, 1, place
de l’Hôpital, 67091 Strasbourg, France
3
Physiology Institute, EA3072 Mitochondria and Oxidative
Stress, University of Strasbourg, Strasbourg, France
4
Department of General, Digestive and Endocrine Surgery,
University Hospital of Strasbourg, Strasbourg, France
5
Anesthesiology Department, University Hospital
of Strasbourg, Strasbourg, France
6
Department of Surgery, Seoul National University Hospital,
Seoul, South Korea
7
Pathology Department, University Hospital of Strasbourg,
Strasbourg, France
@Phil_Robichaud
@deepthiw
@JoseServera