Experimental And Clinical Research Of Two-site Infant Laparoscopic Pyeloplasty With Different CO₂ Pneumoperitoneum Pressure

Part one: The influence of different CO2 pneumoperitoneum pressures on acid-base balance in infant laparoscopic pyeloplastyPurpose: To investigate the influence of different CO2 pneumoperitoneum pressures on acid-base balance in infant laparoscopic pyeloplasty.Methods: This study adopted randomized controlled trial method of prospective cases.40 patients with infant hydronephrosis who accepted laparoscopic pyeloplasty were selected. The patients were randomly divided into low pneumoperitoneum pressure group (LP group, pneumoperitoneum pressure of 6mmHg) and high pneumoperitoneum pressure group (HP group, pneumoperitoneum pressure of 9mmHg) according to pneumoperitoneum pressures. All the surgeries were completed by the same surgical team, and it took laparoscopic pyeloplasty through two-part method as the only surgical method. There were no obvious statistical differences among age, sex, sides, hydronephrosis and body mass index etc basic information of two groups of cases (P>0.05). Arterial blood gas analysis were analyzed at 5 minutes before pneumoperitoneum. 5 and 30 minutes after pneumoperitoneum and 30minutes after operation respectively.Results: 1. During the pneumoperitoneum, pH of both groups decreased and HP group decreased lower than LP group (P<0.05). 5minutes after pneumoperitoneum,pH of HP group was lower than 7.35, while LP group was within normal range; 30 minutes after pneumoperitoneum, pH of the two groups decreased significantly and lower than 7.35; 30 minutes after the release of pneumopentoneum, pH of LP group returned to the normal range but which of HP group was significantly lower (P<0.05).2. Arterial pressure of carbon dioxide of two groups increased after pneumoperitoneum,and at each time point, HP group was significantly higher than that of LP group (P<0.05). 5 minutes after creation of pneumoperitoneum, arterial pressure of carbon dioxide of HP group was significantly increased and higher than 45mmHg, arterial pressure of carbon dioxide of LP group was significantly higher than pre-pneumoperitoneum but lower than 45mmHg; 30 minutes after pneumoperitoneum, arterial pressure of carbon dioxide of the two groups were both higher than 45 mmHg. 30 minutes after the end of pneumoperitoneum, arterial pressure of carbon dioxide of LP group returned to the level of pre-pneumoperitoneum and HP group was significantly higher(P<0.05). 3. Arterial oxygen saturation, pulse oxygen saturation of the two groups didn't change significantly at every time points(P>0.05). 4.The change of actual base excess and standard base excess of both groups was not significantly at every time points.Conclusion : In infant laparoscopic pyeloplasty, both 9 and 6 mmHg CO2 pneumoperitoneum pressures can cause hypercapnia, and 9mmHg pneumoperitoneum pressures have higher effect on acid-base balance than 6mmHg.Part two: The influence of different CO2 pneumoperitoneum pressures on cytokine and humoral immunity in infant laparoscopic pyeloplastyObjective: To compare the influence of different CO2 pneumoperitoneum pressures on cytokine and humoral immunity in infant laparoscopic pyeloplasty.Methods: This study adopted randomized controlled trial method of prospective cases.40 patients with infant hydronephrosis who accepted laparoscopic pyeloplasty were selected. The patients were randomly divided into low pneumoperitoneum pressure group (LP group, pneumoperitoneum pressure of 6mmHg) and high pneumoperitoneum pressure group (HP group, pneumoperitoneum pressure of 9mmHg) according to pneumoperitoneum pressures. All the surgeries were completed by the same surgical team, and it took laparoscopic pyeloplasty through two-site method as the only surgical method. There were no obvious statistical differences among basic information (age, sex, sides, hydronephrosis and body mass index etc) of two groups (P>0.05) . Blood was collected preoperatively 5minutes before pneumoperitoneum 30minutes after pneumoperitoneum and 12 hours after operation IL-6, IL-1 and TNF-? were determined by ELISA method, IgA, IgG, IgM, C3, C4 were determined by rate nephelometry.Results: 1.Two groups in the reaction parameters have obvious change in cytokine levels. The value of intraoperative and postoperative indexes were higher than preoperative, and the preoperative values were significantly higher than preoperative(P<0.05). The parameters of 12 hours after operation were decreased and tended to preoperative level. The humoral immune parameters were no significant differences between the two groups in preoperative, intraoperative and postoperative (P>0.05).2. Preoperative cytokine levels between the 2 groups were not significantly different(P>0.05); Intraoperative cytokine levels of HP group was higher than LP group(P<0.05); No significant difference was found in postoperative cytokine levels between two groups (P>0.05). The humoral immune parameters were no significant difference between the two groups in preoperative, intraoperative and postoperative(P>0.05).Conclusion : In infant laparoscopic pyeloplasty, 9mmHg CO2 pneumoperitoneum pressures have higher effect on cytokine levels than 6mmHg. Both 9 and 6 mmHg CO2 pneumoperitoneum pressures have no significant effect on humoral immunity.Part three: The influence of different CO2 pneumoperitoneum pressures on oxidative stress in infant laparoscopic pyeloplastyObjective: To investigate the influence of different CO2 pneumoperitoneum pressures on oxidative stress in infant laparoscopic pyeloplasty.Methods: This study adopted randomized controlled trial method of prospective cases.40 patients with infant hydronephrosis who accepted laparoscopic pyeloplasty were selected. The patients were randomly divided into low pneumoperitoneum pressure group (LP group, pneumoperitoneum pressure of 6mmHg) and high pneumoperitoneum pressure group (HP group, pneumoperitoneum pressure of 9mmHg) according to pneumoperitoneum pressures. All the surgeries were completed by the same surgical team, and it took laparoscopic pyeloplasty through two-part method as the only surgical method. There were no obvious statistical differences among age, sex, sides, hydronephrosis and body mass index etc basic information of two groups of cases (P>0.05). compare the levels of serum malondialdehyde (MDA),superoxide dismutase (SOD)and total antioxidant capability (T-AOC) before operation,at the end of operation and 24h after operation.Results: 1. levels of MDA in 2 groups after operation were significantly higher than preoperative (group LP, P<0.05, group HP P<0.05); 24 hours after operation in LP group recovered to the preoperative level (LP group P>0.05), while the level of MDA in group HP with preoperative ratio is still at a high level (P<0.05). The serum MDA level of HP group was significantly higher than that of group LP (P<0.05) only at the end of operation, and there was no significant difference in serum MDA level between the 2 groups before and 24h after operation (P>0.05).2. The level of SOD,T-AOC in 2 groups were significantly decreased (P<0.05) at the end of operation; postoperative SOD levels in 24 hours of the 2 groups were recovered to the preoperative level in LP(group P>0.05, HP group P>0.05), and the T-AOC levels in 2 groups before operation and the ratio is still at a low level (LP group P<0.05, HP group P<0.05).The SOD level of HP group was significantly lower than that of LP group at the end of operation (P<0.05); Before and after 24 hours, SOD levels were no statistically significant difference between the 2 groups (P>0.05); The T-AOC levels in preoperative, postoperative and postoperative 24 hours there was no significant difference between the 2 groups (P>0.05).Conclusion: In infant laparoscopic pyeloplasty, 9mmHg CO2 pneumoperitoneum pressure caused greater oxidative stress damage than 6mmHg, but the damage basically restored 24 hours after operation.Part Four: The clinical research and surgical techniques of two-site infant laparoscopic pyeloplasty with Different CO2 pneumoperitoneum pressurePurpose: This study explored the perioperative period indexes and prognostic influence of laparoscopic pyeloplasty through two-part method under different CO2 pneumoperitoneum pressures, and summarized the experience and skills of laparoscopic pyeloplasty through two-site method.Method: This study adopted randomized controlled trial method of prospective cases and selected 60 patients with infant hydronephrosis who accepted laparoscopic pyeloplasty in pediatric surgery of Qilu Hospital of Shangdong University. According to the different pneumoperitoneum pressures during operation, the patients were randomly divided into low pneumoperitoneum pressure group (LP group,pneumoperitoneum pressure of 6mmHg) and high pneumoperitoneum pressure group(HP group, pneumoperitoneum pressure of 9mmHg). All the surgeries were completed by the same surgical team, and it took laparoscopic pyeloplasty through two-site method as the only surgical method. There were no obvious statistical differences among age, sex, sides, hydronephrosis and body mass index etc basic information of two groups of cases (P>0.05). And compare with the general operation time, phase operation time (according to operation process, it can be divided into: 1.Separation and exposure phase; 2. Pelvis clipping phase; 3. Pelvis shaping phase),intraoperative blood loss, length of stay, postoperative complications and prognosis etc clinical indexes. Statistical analysis software SPSS 19.0 was used to compare with the data. And this study also adopted t test to compare with measurement data and X2 test to use for enumeration data group. P<0.05 stood there was statistical significance.Results: All the surgeries were successfully completed with peritoneoscope. The general operation time (118.7±20.2min) and operation time (63.4±16.5 min) of pelvis shaping phase of LP Group extended comparing with HP Group (107.6±18.7min) and(52.7±17.9 min); there were no statistical differences on the operation time of"separation and exposure phase" and "pelvis shaping phase" between two groups(P>0.05). And there were no statistical differences on intraoperative blood loss, length of stay, postoperative complications and long-term follow-up etc information between two groups (P>0.05).Conclusions:1. Laparoscopic pyeloplasty through two-site method under low pneumoperitoneum pressure (6mmHg) can obtain the same effect with high pneumoperitoneum pressure(9mmHg). Although it can lengthen the operation time to some extent, it can decrease the non-surgical damage of CO2 pneumoperitoneum to infant's body.2. Laparoscopic surgery skills (pelvis hanging skill, double J tubes laying skill with pneumoperitoneum needle's assistance,pelvis clipping skill) can enlarge the operation view, simplify surgical procedures and make laparoscopic surgery to infant under low pneumoperitoneum pressure possible.3. Laparoscopic Pyeloureteroplasty through two-site method is safe and reliable to cure hydronephrosis of infant. The cosmetology is good, and it has no special device requirements. Therefore it is worth being popularized to a wider range.