Effects Of Laparoscopic Surgery With Carbon Dioxide Pneumoperitoneum On Coagulation And Fibrinolysis System

Objective: To observe the changes of coagulation and fibrinolysis system in patients undergoing laparoscopic (LH) and open hysterectomy (OH),under total intravenous anaesthesia of target-controlled infusion of remifentanil in combination with propofol,and assess the risk rate of deep vein thrombosis,by detecting the concentration of specific molecule markers.Methods: To choice thirty patients,who were submitted to laparoscopic hysterectomy group(observe group),and other thirty patients,who were submitted to open hysterectomy group(contrast group).All patients were classified as grade I or II,according to the American Society of Anesthesiologists (ASA) grading system, heart function grade I or II,age 40⁵0 years, body mass index 18.5²3kg/m2. No high risk factors of thrombogenesis (obesity, hypertension, coronary heart disease, diabetes and other diseases). Blood pressure,heart rate,pulse oxygen,temperature and end-tidal carbon dioxide partial pressure were monitored conventionally in the operation. Bathing abdominal cavity used warmed-brine. To maintain the temperature at 25℃in the operating room.This procedure of either group was performed under genenal anesthesia with Trendelenburg position.The time of operation was claimed between 2³h.The bleeding amount was less than 400ml, no blood transfusion. During Perioperative the patients were not given coagulant drugs.The two groups of patients used midazolam (5mg) and atropine (0.5mg) by intramuscular injection 30 minutes before operation. Induction of anesthesia used target-controlled infusion of remifentanil (4ng/ml), intravenous injection of midazolam (0.1mg/kg) ,propofol (1mg/kg), vecuronium (0.1mg/kg), then tracheal intubation and assisted ventilation. Tidal volume (8¹0ml/kg), respiratory frequency (12¹4times/min).Using target-controlled infusion of remifentanil (4⁸ng/ml) plus propofol (2⁴μg/ml), according to the changes of blood pressure and heart rate at any time,adjusted the dose of durgs to make sure intraoperative hemodynamic stability.Readjusting the respiratory parameters of anesthesia machine, to make sure the index of PETCO₂ always in 30³5 mmHg.Observe Group(LH) used the pneumoperitoneum be filling with CO₂, the pressure maintained at 12 mmHg.The quantity and type of infusion in the two groups were approximately same.Venous blood samples for determination of coagulation and fibrinolytic parameters were collected preoperatively 1h and at 24h and 72h postoperatively.The following parameters were measured:1.platelet granular membrane protein 140 (GMP-140) , 2.tissue plasminogen activator(t-PA),3.plasminogen activator inhibitor-1(PAI-1).GMP-140 also called P-selectin, was found in the plateletα-granule and Weibel–Palade body membrane of endothelial cells, which was expressed on the platelet surface membrane and shed into the plasma on platelet activation. Platelet activation had an important role in the process of thrombogenesis. the plasma level of GMP-140 could reflec the degree of platelet activation directly,was the specific molecular markers of platelet activation.t-PA and PAI-1 were important components of fibrinolysis system. The value of them played an important role in the formation of thrombus. t-PA could convert plasminogen into plasmin,which can eliminate fibrin, and played an important role in dissolving the thrombus. PAI-1 was the inhibitor of t-PA,which could result in the generation of activatory plasmin reduction and lead to the obstacle of fibrin degradation, in favor of thrombogenesis. Under normal circumstances, fibrin was lysed rapidly by the fibrinolysis system. t-PA/PAI-1 could reflect the activity of fibrinolysis system.Once the value of t-PA decreased or the value of PAI increased ,disturbing the equilibrium between coagulation and fibrinolysis meight lead to thrombosis.Results: 1.The comparison of LH and OH, the concentration of specific molecule markers (GMP-140, t-PA, PAI-1),which reflecting the activity of coagulation and fibrinolysis system, have no statistical difference(P>0.05). 2.The change of GMP-140:In both groups, the concentration of GMP-140 at T2 was significantly higher than at T₁(P<0.01), the concentration at T3 restored to closely at T₁.3.The change of t-PA: In both groups, the concentration of t-PA at T2 was higher than at T₁(P<0.01), the concentration at T3 restored to nearly at T₁.4.The change of PAI-1: In both groups, the concentration of PAI-1 at T2 was higher than at T₁(P<0.05), the concentration at T3 restored to nearly at T₁.5.The change of t-PA /PAI-1: In both groups, the concentration of t-PA /PAI-1 at T2 was higher than at T₁(P<0.05), the concentration at T3 restored to nearly at T₁.Conclusion: Using total intravenous anaesthesia of target-controlled infusion of remifentanil in combination with propofol,the activation of coagulation and fibrinolysis system between LH and OH is similar,The laparoscopic surgery of carbon dioxide Pneumoperitoneum did not enhance the risk rate of DVT,by detecting the concentration of specific molecule markers.