Effect Of Gynecologic Laparoscopic Surgery On Oxidative Stress And Balance Of Th1/Th2 Cells And Research Of Its Clinical Application

Laparoscopic surgery has been gaining rapid development in gynecologic clinic because of its minimal trauma. It can replace most of the conventional gynecologic laparotomy for surgeries ranging from simple surgery of ectopic pregnancy to hysterectomy. Over the past decade laparoscopic surgery has become integral to general surgical practice, with the advantages over open surgery of less postoperative pain, earlier rehabilitate to normal activities and better cosmetic outcomes demonstrated for a range of procedures.This study includes basic and clinic reaearches.The objective of basic research is to evaluate the effect of laparoscopic surgery on oxidative stress and TH1/TH2 balance in patients with uterine myomas. The part of clinical researches have been done to explore the techniques and application of laparoscopic surgey in gynecologic department.Part I Basic research1. Effect of laparoscopic surgery on status of oxidative stressBackground: Creation of pneumoperitoneum created to facilitate laparoscopy is associated with splanchnic perfusion,ischemia/reperfusion (I/R) injury,and oxidative stress.The induction of the pneumoperitoneum increases intraabdominal pressure, followed by splanchnic ischemia,whereas its deflation normalizes IAP and splanchnic blood flow. This procedure appears to represent an ischemia-reperfusion I/R model in human. There are few researches on serum malondialdehyde (MDA) changes during laparoscopic surgery. Few research involves protein oxidation. We studied the changes of MDA, advanced oxidation protein products (AOPP) and antioxidation system in laparoscopic surgery.Objective: To evaluate the effect of laparoscopic surgery on oxidative stress in patients with uterinemyomas.Subjects: :Forty women with uterine myomas, aged from 22 to 35 years with a mean of 29.25 + 6.52years , were divided into two groups of 20 in each Intervention of laparoscopic or abdominalmyomectomy was conducted.Methods:1. Blood samples: vein blood samples were taken preoperatively,5 min after deflation of the pneumoperitoneum or at the end of surgery,and 24 h postoperatively respectively.2. Assay procedures: Serum malondialdehyde (MDA),representing lipid peroxidation level,was analyzed by thiobarbituric acid reaction.The concentration of advanced oxidation protein products (AOPP) was determined by spectal analysis with absorbance at 340nm in acidic condition. The activity of glutathione peroxidase (GPx) in serum was measured by spectrophotometry. antioxidant activity (AOA )was measured by inhibiting the production of thiobarbituric acid reative substance assay (TBARS).Results:In laparoscopic surgery, plasma AOPP> MDA level increased significantly at the early postoperation compared with that of the preoperation (P=0.000, J°=0.000) ,and recovered to the normal level at 24 h postoperation (P=0.865,P=0.200); GPx,AOA decreased significantly at the early postopeation (P=0.000, P=0.000) ,andGPx recovered at 24 h postoperation (P=0.110),but AOA was still lower(P=0.002). In open surgery, plasma AOPP> MDA level had a slight increase at the early postoperation compared with that of the preoperation (P=0.678,P=0.188) and continued to increase at 24 h postoperation (P=0.013, P=0.002) ; GPx and AOA decreased a little at the early postoperation (P=0.23 l,P=0.428)and continued to decrease at 24 h postoperation(P=0.000, P=0.001). Compared with open surgery, plasma AOPP ,MDA level in laparoscopic group was significantly lower (P=0.002, P=0.047 ) , and GPx was significantly higher (P=0.000) at 24h postoperation,but AOA was at the same level(P=0.331). Conclusion:1. Free radicals were generated at the end of a laparoscopic procedures, possibly as a result of an I/R phenomenon induced by the inflation and deflation of the pneumoperitoneum.,But in postsurgery .oxidation stress disappear sooner in laparoscopic surgery than open surgery.2. Laparoscopic surgery may descend serum antioxidative capacity. AOA was still lower 24hpostsurgery without complement.2. Effect of laparoscopic surgery on the balance of TH1/Th2 cells in patients with uterine myomasIt seems likely that surgery is associated with significant suppression of postoperative immune function; the degree to which this occurs and its duration are determined by the magnitude of the initial surgical insult. Following conventional open surgery, immunological function in general is depressed with adverse alterations in cytokine levels and changes in the function of cellular components of the systemic immune response. The usual physiological reaction to injury,surgical or non-srugical,is an early rise in serum stress hormone levels together with a decrease in cellular immune response. The latter manifests following reduction of lymphocyte and macrophage interaction are decreased activity of natural killer(NK) cells, decreased lymphocyte and neutrophil chemotaxis,and a reduction in delayed-type hypersensitivity (DTH) responses. Therefore, the overall immune response to surgery in general is reflected mainly in terms of alteration in cytokine functions and the cellular messenger system.IH 8 is a Thl cell promoting cytokine, and inhibits IL-10. IL-10 is a Th2 cell promoting cytokine, and it inhibits the function of Thl cell.Objective:To investigate the immunological influences of laparoscopic surgery on TH1/TH2 balance in patients with uterine myomas., the count of the Th subsets,Thl/Th2 ratio.the serum level of EL-18 and IL-10 in 20 patients submitted to laparoscopic surgery and 20 patients undergoing conventional open surgery(abdominal myomectomy) were evaluated preoperatively as well as 2, 24, 48 hours postoperatively.Subjects: .-Forty women with uterine myomas, aged from 22 to 35 years with a mean of 29.25+6.52 years.were divided into two groups of 20 in each.The patients ranged in age from 22 to 35 years, with a mean age of 29.25 + 6.52 years.Intervention:Laparoscopic or open surgery . Methods:1. Samples: vein blood samples were respectively taken preoperatively, 2 h postsurgeryly, 24 h postsurgeryly, 48 h postsurgeryly.2. Assay procedures:The count of the Th subsets,was detected by flow cemetery.The levels ofIL-18,IL-10 were detected by ELISA.Results:The level of Thl cell, IL-18,and the Thl/Th2 ratio decreased significantly (laparoscopic group: P<0.05, P<0.0l, P<0.05; open group: P<0.01, P<0.0l, P<0.01) .while Th2cell,IL-10 rose significantly (laparoscopic group: P<0.01, P<0.01; open group: P<0.0l, P<0.01) 2 hour postoperatively in both groups. The indexes of laparoscopic surgery group resumed to the preoperative levels 24h postsurgery, but the changes sustained in laparotomy group till 48h postoperatively. Conclusion:1. Laparoscopic surgery had fewer influences on Thl/Th2 balance postoperatively and was more advantageous than open surgery.2. Surgery stress may influence IL18, IL-10 levels.The Thl/Th2 balance shift was in correlation with IL-18/IL-10 dynamic changes.Part II. Clinical research of laparoscopic surgery in gynecologyMost complications of laparoscopy arise during the establishment of the pneumoperitoneum with Veress needle and the insertion of the first laparoscopic trocars into the abdominal cavity. The Veress needle technique seems to be associated with a high risk of vascular and visceral injuries. The most common technique for laparoscopy involves the blind infraumbilical insertion of a Veress needle and insufflation of a carbon dioxide (CO2) pneumoperitoneum followed by insertion of a sharp 10-mm trocar into the peritoneal cavity. One of the most serious complications of this technique is injury to the major retroperitoneal vessels. The state of vascular complications has been reported to occur at a frequency of 0.1 to 6.4 per 1000 cases receiving laparoscopies. It was reported that 76.5% of major vascular injuries occurred during the set-up phase of laparoscopy and 84.6% occurred secondary to insertion of the primary trocar.Heterotopic pregnancy (HP)is rare but dangerous in clinic. It became more and more common following widespread applications of assisted reproductive technique(ART). The immediate diagnosisand proper treatment were crucial. The successful removal of the ectopic pregnancy while keeping the intrauterine pregnancy to go on was required.Interstitial pregnancies constitute 2-4% of all ectopic pregnancies. It usually ruptures later than other tubal pregnancies. It may cause catastrophic hemorrhage and the mortality rate of interstitial pregnancy is 2—2.5% due to interstitial pregnancy.lt is imperative that the interstitial pregnancy be diagnosed early and treated properly.. Conventional treatment of interstitial pregnancy has been corneal resection by laparotomy. Laparoscopic technique was applied for the diagnosis and treatment of the interstitial pregnancy. The feasibility and safety of laparoscopy were evaluated in this study.1. Clinical study on the inserting site and supraumbilical direct trocar insertion without priorpneumoperitoneum method in gynecological laparoscopy.Objective: To study the feasibility and safety of supraumbilical direct trocar insertion in gynecologiclaparoscopy.Subjects: 240 patients undergoing gynecologic laparoscopy were randomly divided into two groups:experimental group( supraumbilical direct trocar insertion), and control group (classic subumbilicalVeress needle technique).Methods:1. The widths of linea alba were compared between 10mm supraumbilicus and 10mm infraumbilicus with abdominal CT scanning of 30 female patients. Abodominal wall thicknesses were also compared between 10mm supraumbilicus and 10mm infraumbilicus.2. Experimental group: supraumbilical direct trocar insertion. Control group: classic laparoscopy(subumbilical )Veress needle technique.Results:The width of linea alba of 10mm supraumbilicus is wider than that of 10mm infraumbilicus (/^O.OlXAbodominal wall of 10mm supraumbilicus is thicker than 10mm infraumbilicusC/^O.Ol).Expreimental group: technique succeeded into abdominal cavity immediately without any complication occurring, whereas 17 cases were punctured two times, and two cases subcutaneous emphysema occurred in control group. Minor complications were nil in experimental group. The latter group consisted of 17 cases of extra-peretoneal insufflation, 2 cases of subcutaneous emphysema and 2 cases of minor complication. Major complications were nil in both groups.Conclusion: Supraumbilicus is the ideal inserting site of the first entry. Supraumbilical direct tracar insertion without pneumoperitoneum is more feasible with less complications compared with traditional infraumblicucal Veress needle insertion method. 2. Laparoscopic treatment of heterotopic pregnancy.Objective: To study the effectiveness and safety of the laparoscopic treatment for the heterotopicpregnancy.Methods: 5 cases of heterotopic pregnancy, were applied the laparoscopic treatment. The laparoscopicsurgery were performed after definite laparoscopic diagnosis were made.Results: All cases of ectopic pregnancy were diagnosed under laparoscope and treated withlaparoscopic surgery. The ectopic pregnancies were cured while the intrauterine pregnancies wereretained successfully. One case of corneal heterotopic pregnancy was treated with laparoscopic surgerysuccessfully. 5 cases of heterotopic pregnancy had full-term delivery.Conclusion: Laparoscopic surgery treatment of heteroscopic pregnancy is safe and feasible, noabortion was found postsurgery in 5 cases of patients. The intrauterine gestation continued withfull-term delivery. We reported a case of cornual heterotopic pregnancy case which was successfullytreated with laparoscopy.Keywords: Laparoscopy; Heterotopic pregnancy; Cornual heterotopic pregnancy3. laparoscopic treatment of interstitial pregnancyObjective:To study the feasibility and safety of laparoscopy for treatment of in interstitial pregnancy.Subjects: 14 cases of high-suspicious interstitial pregnancies, with elevated HCG level but no signs ofthe locality of the pregnancy, were undertaken the diagnostic laparoscopy and the interstitial pregnancywas confirmed immediately.Methods: Three kinds of laparoscopic technique were applied respectively.Results: Patients with interstitial pregnancy were diagnosed immediately and taken laparoscopicsurgery successfully.Conclusion: Laparoscopic surgery treatment of Interstitial pregnancy was feasible. The method ofcornual coagulation first before resection was the best LS method of all.