Both open and laparoscopy surgery trigger specific traumatic effects related with removing tumors or with surgical treatment of other diseases of the abdominal cavity (Table ). On the basis of literature it is suggested that open surgery results in more additional traumatic effects due to the following conditions and complications [16
Open and laparoscopy surgery-related factors and consequences of the surgical treatment of diseases in the abdominal and pelvic cavities
extension of the laparotomy incision of the abdominal wall to get access to the operated organ;
tissue drying due to open abdomen and prolonged surgery;
direct hand-manipulations, handling of the abdominal organs and tissue;
accumulation of foreign bodies - small pieces of surgical materials, tampons, plugs, napkins, suture materials
severe tissue ischemia related with ligation and suturing as well as extension of the laparotomy incision of the abdominal wall;
the possibility of bacterial contamination, which cannot be excluded.
However, laparoscopic surgery entails other, specific effects due to the use of gas media to extend the abdomen. From this, a large body of literature has sprung studying the pathophysiologic mechanisms of CO2
-pneumoperitoneum induced systemic alterations such as respiratory, cardiovascular and blood gas, acid base parameters changes, as well as local disturbances in the peritoneal cavity such as decreased peritoneal pH and blood circulatory deteriorations with mesothelial hypoxemia during laparoscopic surgery [24
]. The discussion has polarised: some claim these changes have a crucial impact on postsurgical complications such as adhesion formation and port-site cancer metastasis [30
] others say these changes have no or little impact on postsurgical complications [16
Recently, these two approaches have been systematically compared in malignant conditions in several meta-analyses. The mean operative time for LS was significantly longer but the postoperative hospital stay was shorter in comparison with those undergoing laparotomy in a meta-analysis of 2940 patients with splenectomy drawn from a large amount of publications [19
]. Subsequently, it was concluded that laparoscopy is associated with a significant reduction in splenectomy-related morbidity, primarily as a function of fewer complications (pulmonary, wound, and infectious). In another meta-analysis of randomized controlled trials of LS versus laparotomy in patients with endometrial cancer, LS was associated with fewer postoperative complications, lower transfusion incidence, less blood loss, longer operation time, and shorter hospital stay [9
]. Moreover, no significant differences in terms of recurrence and survival were found. Subsequently, LS was thought to be a better choice than OS if it is performed by suitably specialized surgeons in selected patients. Recently, quite striking contrasting findings were presented by Leroy et al [8
] with reports of increased conversion rates and a laparoscopic colectomy risk in obese patients (BMI > 30 kg/m2
). It was concluded that LS for left colon resections is as feasible and at least as safe in non-obese patients and the benefits of the laparoscopic approach depending on the implementation of a highly standardized surgical technique.
Most of these tissue traumatic factors are reduced or excluded during laparoscopy with the subsequent beneficial outcome. Due to the fast recovery after surgery, less morbidity, decreased pain etc, laparoscopy is now also being applied in the treatment of malignant but curable conditions resulting in equally beneficial results in the short-time follow-up for patients with malignant cancers.
More pronounced residual peritoneal tissue inflammatory reaction parameters were registered after open surgery, as compared with LS. There were no significant interactions in peritoneal tissue inflammatory reaction parameters, but highly significant differences were observed between the open surgery and LS groups (p < 0.0001) with regard to both treatment and time factors by two-way ANOVA with source of variation and Bonferroni post-tests. The differences in peritoneal tissue inflammatory reaction changes between the open surgery 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.
We found adhesion free wounds in approximately 20.0 and 31.0% cases after creation of open surgery and LS conditions respectively. There were no significant differences between these values by unpaired t test (p > 0.05). However, larger adhesion size (41.67 ± 33.63) was observed after open surgery 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 open surgery and LS with significant differences by unpaired two-tail t test (p = 0.03). Subsequently, a severe peritoneal tissue inflammatory reaction arose, due to the larger size of the postoperative adhesions in the open surgery group than those observed in the LS group respectively: 2.4 ± 1.55 and 1.31 ± 1.35 scores with the upper-lower 95% confidential limits from 3.26 to 1.54 and from 2.03 to 0.59 (the two-tailed p = 0.03).
Since excess CO2
is immediately eliminated through the lungs (Figure ) by increased breathing, in our opinion CO2
is the most convenient physiological gas. Our results did not support the impact of CO2
-pneumoperitoneum as a co-factor in postsurgical adhesion formation. We found severe peritoneal tissue inflammatory reaction due to surgical trauma resulting from the significantly larger size of postoperative adhesions in the open surgery group. Surprisingly, these observations are in accordance with results published by our colleagues from KULeuven [35
Figure 4 The pathways of CO2 insufflation, diffusion, circulation; and elimination during laparoscopy with CO2 pneumoperitoneum and its pathological effects. 1 - CO2 insufflation set up (including CO2 balloon and CO2 insufflator); 2 - increased tension of free (more ...)