The Effect Of Laparoscopy And Carbon Dioxide Pneumoperitoneum On Intra-Abdominal Infection

[ Objective ] Laparoscopy is widespread in clinical use.But whether the use of laparoscopy is safe in intra-abdominal infection diseases is unsure.This topic used animal and clinical experiment to study the effect of CO₂ pneumoperitoneum and laparoscopy on bacterial peritonitis,including bacterial translocation,immune function and infective complication.[ Methods ] Animal study:Thirty New Zealand white rabbits were injected by Escherichia coli into abdominal cavities and thirty rabbits were injected by bacteroides fragilis, so as to establish two animal models of intra-abdominal infection.And each model was divided into laparotomy group, pneumoperitoneum group, control group.In laparotomy group,the rabbits' abdomen were open with median incision for 30 min; In CO₂ pneumoperitoneum group,the rabbits' skins were put open by 0.5cm incision in middle abdomen,and were punctured by needle, the pressure of CO₂ pneumoperitoneum was maintained in 10 mmHg for 30min;In control group,the rabbits were injected by bacteria only.Before and 1, 2, 4, 7d after sugery, the peripheral arterial blood and peritoneal fluid were obtained for bacterial culture, serum IL-1, IL-6, TNF- α , CRP levels were measured via ELISA.And the total number of WBC, neutrophils and lymphocytes in blood were measured.Seven days after surgery, the animals were put to death and dissected to check the incision and abdominal infections.The tissues of liver, kidney, lung and spleen were obtained for bacterial culture. All samples were divided into two parts for aerobic and anaerobic bacterial culture.The samples were inoculated into blood agar plates and the anaerobic samples were put into anaerobic bags.Then the samples were cultured in 37℃ constant temperature oven.After 48-72h,some bacterial colonies were made into smear and stained by Gram staining. In microscope,the bacterial body forms wereobserved.The bacterial species were guessed with bacterial body forms and were confirmed by biochemical tests.Clinical study: 31 patients with acute appendicitis,including 16 patients in laparotomy group and 15 patients in laparoscopy group.In laparotomy group,the patients' abdomen were put open with 4-5cm McBurney incision.And then the appendix was cut off.The abdominal drainage-tube was used in severe peritonitis.In laparoscopy group,the operation was made by three-hole meathod and the pneumoperitoneum pressure was maintained in 10 mmHg. The appendix was cut off with the help of of laparoscope. The appendix was made pathological examination after operation.The abdominal pus was obtained for bacterial culture in operation.Before and Id-. 3d after sugery,the peripheral blood were obtained for aerobic and anaerobic bacterial culture; TNF- a levels in serum were measured by ratenephelometry;CRP levels were measured by radioimmunoassay ; Total number of WBC\ neutrophils and lymphocytes in blood were measured by auto-blood cell analysis system.Five days after surgery,the incisions were checked and intra-abdominal abscess were checked by ultrasound imaging.[Results] Animal study:In two bacterial model,the incidence rates of bacteremia were higher in laparotomy group and pneumoperitoneum group than control group, but there were no significant difference between laparotomy and pneumoperitoneum group.In E.coli pneumoperitoneum group,there were lots of bacteroides fragilis and enterococcus faecalis in blood and peritoneal fluid culture,more than laparotomy group. Seven days after operation,visceral baterial translocation occurred in each group,majored in liver and kidney,but there were no significant difference among three groups.The incidence rate of incision infection in pneumoperitoneum group was lower than that in laparotomy group.The abdominal abscesses occurred in each groups after operation, but there were no significant difference among three groups.The majority of abscesses were inter-intestinal abscesses,then the abdominal wall abscesses.The change of inflammatory factors in E.coli group and in bacteroides fragilis group was almost in the same mannenThe inflammatory factors in laparotomy group were significantly higher than pneumoperitoneum group; The inflammatory factors in pneumoperitoneum group increased slowly and restored quickly. The IL-6 level in laparotomy group increased to maximum at 1 day after operation then decreased gradually. The IL-6 level in laparotomy group was significantly higher than that in pneumoperitoneum group at 1 and 2 daysafter operation.The TNF- a level in laparotomy group increased significantly at 1 day after operation and reached to maximum at 2 days,then decreased gradually. The TNF- a level in laparotomy group was significantly higher than that in pneumoperitoneum group at 1 to 7 days after operation. The IL-1 level in laparotomy group increased to maximum at 1 day after operation and then decreased gradually,but was still higher than normal level 7 days after operation. The IL-1 level in laparotomy group was significantly higher than that in pneumoperitoneum group and control group at 1 to 7 days after operation. The CRP level in laparotomy group increased significantly at 1 day after operation and reached to maximum at 2 days,then decreased gradually. The CRP level in laparotomy group was significantly higher than that in pneumoperitoneum group and control group at 1 to 7 days after operation. In two bacterial model, the total number of WBC and neutrophils in laparotomy group were significantly higher than those in pneumoperitoneum group at 1 day after operation, then decreased gradually to normal level at 4 days after operation. The number of lymphocytes in laparotomy group were significantly lower than those in pneumoperitoneum group at 1 day after operation,and restored slowly at 4 days after operation.Clinical study:The incidence rates of positive bacteremia were high both in laparotomy group and laparoscopy group before operation,but there were no significant difference between two groups.The incidence rate of positive bacteremia in laparoscopy group was lower than that in laparotomy group at 1 and 4 days after operation, but there were no significant difference between two groups.In laparotomy group,the species of aerobic bacteria in blood culture were more than anaerobic bacteria.But in laparoscopy group, the majority of bacteria in blood culture were anaerobic bacteria. The incidence rates of postoperative incision infections and intra-abdominal abscess were lower in laparoscopy group than laparotomy group. The CRP and TNF- a levels in laparotomy group increased to maximum at 1 day after operation . The CRP and TNF- a levels in laparotomy group were significantly higher than those in laparoscopy group at 1 day after operation. The inflammatory factors in pneumoperitoneum group increased slowly and restored quickly. The total number of WBC and neutrophils in laparotomy group increased to maximum and significantly higher than those in laparoscopy group at 1 day after operation. The number of lymphocytes in laparotomy group were significantly lower than those in pneumoperitoneum group at 1 day after operation,and restored to normal level at 3 days afteroperation.[ Conclusions 1 This topic used animal and clinical experiment to study the effect of CO2 pneumoperitoneum and laparoscopy on intra-abdominal infection,and drew the next conclusions:CD In animal model of E. coli and bacteroides fragilis infection, CO2 pneumoperitoneum can cause bacteremia and visceral bacterial translocation,but the incidence rate was not higher than that in laparotomy.In pneumoperitoneum group, the incidence rate of incision infection was lower,the immune function was affected more slightly and restored more quickly after operation than that in laparotomy group. The total numbers of WBC and neutrophils in laparoscopy group increased more slowly and restored more quickly than those in laparotomy group. The lymphocytes in laparoscopy group were suppressed more slightly.(2) In clinical study of acute peritonitis, the incidence rates of bacteremian incision infections and abdominal abscesses in CO2 pneumoperitoneum and laparoscopy group were lower than those in laparotomy group.The levels of inflammatory factors and WBC\ neutrophils in laparoscopy group increased more slowly and restored more quickly. The lymphocytes in laparoscopy group were suppressed more slightly and the immune function was affected slightly and restored quickly.(3) In animal and clinical study,we all finded that CO2 pneumoperitoneum suppressed the growth of aerobic bacteria and promoted the growth of anaerobic bacteria. After laparoscopy, the anaerobic bacterial culture is necessary and sensitive antibiotics are ought to use to prevent the anaerobic infection.In short,the use of CO2 pneumoperitoneum and laparoscopy is safe in acute peritonitis...