The Acute Surgical Trauma And Stress Research Of The Laparoscopic VS. Open Hepatectomy

Part 1The clinical research of the laparoscopic VS open hepatectomyObjective To evaluate the clinical application value of the laparoscopic hepatectomyby prospectively comparing with the open procedure.Methods From July 2007 to October 2008,a total of 65 left hepatectomy cases in ourlaparoscopic center were prospectively adopted in our research,in which 35 cases werein the laparoscopic hepatectomy group and the other 30 cases were in the openhepatectomy group,all the operations were done by the same surgeon group.Therewere no statistical difference between the two groups in the age,sex,height,weight,BMI,preoperative ASA scores and the history of the abdominal surgery(P＞0.05).Allthe cases were introduced the general anesthesia and trachea cannula.The purpose wasto compare the two groups'clinical outcomes of the operative time,hepatectomy time,hemorrhage volume,urine volume,postoperative time of the passage of the gas,fluiddiet-intaken,out-of-bed activity,hospital stay,the surgical complication,thepathological results and the drainage volume during 7 days after the operation.TheVAS scores during 3 days postoperatively,the dose of the analgesic drug consumption,the postoperative liver function,blood coagulation function and the hemoglobinchanging were also evalued and compared between two groups.Results All the operations were successfully proceeded.There were 18 cases ofsemihepatectomy(51.4%)and 17 cases of the left lateral hepatectomy(48.6%)in thelaparoscopic group.The open group included 14 cases of semihepatectomy(46.7 %)and 16 cases of the left lateral hepatectomy(53.3%).There were no statistical differencebetween two groups in the operative time,hepatectomy time,the left hepatectomyconstitution,urine volume(P＞0.05).The hemorrhage volume of the laparoscopic groupwas much less than the open one(P＜0.01),also were the postoperative time of thepassage of the gas,fluid diet-intaken and out-of-bed activity(P＜0.01).But there were nodifferences in the postoperative hospital stay and the surgical complications betweentwo groups(P＞0.05).The drinage volume on the third postoperative day was muchless in the laparoscopic group(P＜0.01).The VAS scores during 3 days after operationwere much less in the laparoscopic group than in the open's(P＜0.01),though theaverage and the total comsumption of the pethidine were no difference(P＞0.05).Thelevel of theγ-glutamyl transpeptidase on the 5th day postoperative,Alkalinephosphatase on the 1st day postoperative and triglyceride on the 3rd,5th dayspostoperative were higher in the open group than in the laparoscopic one(P＜0.05),Thelevel of the plasma protein on the 1st,3rd,5th postoperative days(P＜0.01)and thealbumin level on the 3rd,5th,7th days after the operation were lower in the open group(P＜0.05).The PT were much longer during the 1st and 3rd days after operation(P＜0.01),so as the APTT on the postoperative 5th day(P＜0.05).Fibrinogen level the1st day after operation was higher in the open group.There was no difference of thehemoglobin level between two groups pre and pro-peratively(P＞0.05).Conclusion Not only that it will not increasing the operative time,hepatectomy timeand the risk of the surgical complications,but also reducing the hemorrhage volume andpain feeling postoperatively which will bring a faster recovery by the laparoscopic lefthepatectomy.The internal environmental balance such as the liver function and theblood coagulation function were preserved better by the laparoscopic procedure. Part 2Comparison the inflammatory stress and oxidative stressbetween the laparoscopic and open hepatectomyObjective To investigate the influence of the laparoscopic and open hepatectomy onthe irflammatory stress and oxidative stress.Method There were 65 cases done left hepatectomy during July,2007 to October,2008,in which 35 cases were prospectively into the laparoscopic group,while other 30cases were in the open group,all the operations were done by the same surgeon group.Compare the change of the WBC,NE%,IL-6,IL-10,TNF-α,CRP,SAA,HSP70,Cortisol,insulin,insulin resistance index and the SIRS frequency during 7days afteroperation.It also included oxidative stress markers such as MDA,NO,TAC.Results There were no statistical difference of the WBC and NE% level between twogroups(P＞0.05).The 12 hours,1 day and 3 day postoperative IL-6 level was higher inthe open group,also was the 1st day,3rd day,and 5th day after operation the TNF-αlevel(P＜0.05),while the IL-10 level had no difference between two groups(P＞0.05).Acute phase proteins such as CRP and SAA were higher in the open groupon the 1,3,5 days after the operation(P＜0.05),while the protective protein was higherin the laparoscopic group on the 1st,3rd days postoperation(P＜0.05).The incidence rateof SIRS was higher on the lt,5 days postoperatively,furthermore,the duration of thepostoperative SIRS was also higher in the open's(P＜0.05).The Cortisol level wasobserved lower in the laparoscopic group 12 hours after operation(P＜0.05).Bloodglucos,insulin and insulin resistance index were higher in the open one 12hours,1 dayand 3 day after operation.The laparoscopic group of the MDA level was higher in the 3,12 hours after operation,but on the 1,2,and 3 days the open group was higher(P＜0.01).There was no difference of the NO level between two groups.The TAC level of theopen group was higher in the 3,12 hour after operation.Conclusion The level of inflammatory factor such as IL-6,IL-10,TNF-αand theacute phase protein as CRP,SAA,HSP70 were lower in the laparoseopic group whichindicates that the laparoscopic left hepatectomy was a less inflammatory stress.That the cortisol,insulin and insulin resistance index were higher in the open one was a evidenceof less substance metabolic disorder by laparoscopic procedure.Though the oxidativestress level was higher in the laparoscopic group,the regression was also faster than theopen's and it will not develop consistant harmful effect.Part 3Comparison the immune function between the laparoscopic andopen hepatectomyObjective To investigate the influence of the laparoscopic and the open hepatectomyon the immune function.Method Experimental group was 35 cases for laparoscopic left hepatectomy duringJune 2007 to October 2008 in the Sir Run Run Shaw Hospital.Meanwhile the controlgroup was 30 cases for open procedure at the same centre,all the operations were doneby the same surgeon group.The levels of the cases' peripheral blood CD3,CD4,CD8,NK,CD 14 and HLA-DR were cheek out by the flow cytometry before operation,1,3,5,7days after it.Results The expression of CD3 level was higher in the laparoscopic group on the 3rdday after the operation than open group(P＜0.05),while the higher expression period ofCD4 level was 1 st,3rd,5th,7th days comparing with the open group after the surgery(P＜0.05).There was no difference between the two groups in CD8 level.TheCD4/CD8 level was higher after the operation in the laparoscopic group(P＜0.05),especially on the postoperative 5th day(P＜0.01).In the open group,the CD4/CD8 levelwas lower afer the operation and was upswing to the preoperative level on thepostoperative 5th day.The laparoscopic group had a higher level of CD4/CD8 on the1 st day after operation(P＜0.05).The NK level was stable in the laparoscopic group,while it was minimum point on the 3rd day after operation in the open group(P＜0.01),the laparoscopic group has a higher level of it on the 5th,7th day after operationcomparing with the open one(P＜0.05).The level of CD14 had reached its peak on the posroperative on 5th day in the laparoscopic group,when it had got its lowest point onthe 3rd postoperative day in the open's.On the postoperative 3rd,5th day laparoscopicgroup had a higher level of CD14 than the open group(P＜0.05).The minimum level ofthe HLA-DR was on the 1st day after operation in the laparoscopic group(P＜0.01),while the time of the open group was on the 5th day and on the same day thelaparoscopic group had a higher group of it(P＜0.05).The level of the CD14~+/HLA-DR~+had reached its lowest point on thelst day after the operation in the laparoscopic'(P＜0.01),meanwhile the time of the open one was on the 3rd day.There were nodifference between two groups on the CD14+/HLA-DR+level(P＞0.05).Conclusion The postoperative recovery of the CD3,CD4 and HLA-DR were faster inthe laparoscopic group than the open one which means that the supression of theimmune function was slighter in the laparoscopic group and was concidence with theother reported laparoscopic results.The CD4,CD4/CD8 and CD14 levels was enhancedafter operation and it made a key role in the postoperative infection resistance and thetumor immunity watching.Part 4The expression apoptosis protein of the Caspase-3 on the earlystage after the laparoscopic or open hepatectomyObjective To compare the Caspase-3 apoptosis protein expression in the early stageafter operation between the laparoscopic and open groups.Method 35 cases for laparoscopic left hepatectomy and 30 cases for open procedurewas adopted in,all the operations were done by the same surgeon group.The liverspecimen about 2x2cm and lcm from the incisal margin was fetched for HE staining,immunohistochemisty staining and Western Blotting for analysis the Caspase-3apoptosis protein expression. Results The expression of the caspase-3 apoptosis protein was higher in thelaparoscopic group when compared with the open one on the early postoperative stagewhich was concordance with the Western Blotting result.Conclusion The pormotion of the apoptosis was more obvious in the laparoscopicgroup,but when associated with the little change of the liver function postoperatively,itseems that the apoptosis had no notable effect which may be because of thelaparoscopic micro-trauma and then the fast recovery of the cell.