Addition of nitrous oxide to the carbon dioxide pneumoperitoneum strongly decreases adhesion formation and the dose-dependent adhesiogenic effect of blood in a laparoscopic mouse model

Corona, Roberta; Binda, María Mercedes; Mailova, Karina; Verguts, Jasper; Koninckx, Philippe

doi:10.1016/j.fertnstert.2013.08.049

Cited by 27 publications

(31 citation statements)

References 35 publications

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“…The severity of this acute inflammation can be decreased by adding more than 5% of N 2 O [22,23] to the CO 2 pneumoperitoneum, by cooling [24,25] the peritoneal cavity, by preventing desiccation [21], by decreasing blood or fibrin deposition [22] and by the addition of dexamethasone [26]. The addition of some 4% of O 2 to the CO 2 pneumoperitoneum, restoring a partial oxygen pressure of 28 mm of Hg [18,27] is beneficial when used alone but has no additive effect when more than 5% N 2 O is used.…”

Section: Discussionmentioning

confidence: 99%

Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery

et al. 2013

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BackgroundTo translate the concept of full-conditioning (FC) from animal experiments to the human, and to evaluate the efficacy for adhesion prevention. FC consisted of decreasing acute inflammation by 86% CO2+ 10% N2O + 4% O2 for the pneumoperitoneum, cooling of the peritoneal cavity, humidification, heparinized rinsing solution and 5 mg of dexamethasone as demonstrated in animal models.MethodsA randomized controlled trial (RCT: NCT01344486) comparing standard laparoscopy with full conditioning together with a barrier in a 2/3 ratio in 44 women undergoing deep endometriosis surgery at KULeuven. The primary aim was reduction of adhesions. Secondary aims were CO2 resorption, postoperative pain and recovery. Randomization was performed after signing informed consent. Adhesion scoring during second look laparoscopy and pain scoring were done blindly.ResultsIn the FC group (n = 16) adhesions were completely prevented in 12/16 women whereas in the control group (n = 11) all women had severe adhesions (P < 0.0005). Also the area, density and severity of adhesions were less. (P <0.001). In the control group, severity, density and area of adhesions were strongly interrelated (P = 0.0001 for all areas) suggesting a common enhancing factor. In the FC group CO2 resorption (P < 0.001), postoperative pain (P < 0.001), and CRP concentrations (P < 0.01) were lower while clinical recovery was faster (P < 0.0001) and time to first flatus (P < 0.002) shorter.In conclusionThis translational research confirms in the human the efficacy of FC in reducing CO2 resorption and adhesions with in addition less postoperative pain, lower postoperative CRP concentrations and an accelerated recovery.

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Section: Discussionmentioning

confidence: 99%

Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery

et al. 2013

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“…Adhesions at opposing surgical lesions are known to be enhanced by 60 min of CO 2 PP, by desiccation (using a 23 ml/min flow of dry CO 2 , obtained by placing a 26-gauge needle in the abdomen under 15 mmHg pressure) and a higher body temperature (at 37 °C induced in a heated chamber on a homeothermic pillow) [16, 21]. Adhesions were reduced by adding 10 % N 2 O to the CO 2 [18], the mechanism of which is unknown, although it is the single most effective treatment, and by adding 4 % of oxygen to prevent the mesothelial hypoxia of pure CO 2 [15], at a lower body temperature of 32 °C [16, 21], and finally, by preventing desiccation using humidified gas [16, 19]. …”

Section: Methodsmentioning

confidence: 99%

“…This acute inflammation is the net result of detrimental and beneficial factors. The duration of mesothelial hypoxia caused by CO 2 PP [14], the duration of hyperoxia [15], the severity of desiccation [16], mechanical trauma [17], and bleeding [18] have all been identified as detrimental factors, whereas the addition of 4 % O 2 [15] and 10 % nitrous oxide (N 2 O) to the CO 2 PP [18], the use of humidified gas [16, 19], and a lower PP temperature [20, 21] have all been identified as beneficial factors. Although the relationship between acute inflammation and peritoneal cell retraction and bulging, which exposes the basal membrane, is demonstrated only for the duration of CO 2 pneumoperitoneum, we assume that the same holds true for other factors investigated for adhesion formation and for CO 2 resorption.…”

Section: Introductionmentioning

confidence: 99%

Conditioning of the abdominal cavity reduces tumor implantation in a laparoscopic mouse model

Binda

Corona²,

Amant

et al. 2014

Surg Today

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PurposeThe addition of 4 % O2 and 10 % N2O to the CO2 pneumoperitoneum (PP), together with slight cooling and humidification (conditioning), contributes to reducing adhesions by preventing mesothelial damage. We investigated the effect of peritoneal damage during laparoscopy on tumor implantation.MethodsIn Experiment 1, different tumor cell concentrations were injected into control mice without PP and into mice with 60-min dry CO2PP (mesothelial damage). In Experiment 2, tumor cells were injected into control mice (group I) and in mice with mesothelial damage (group II). In groups III to VI, mesothelial damage was decreased by adding humidification, humidification + 10 % N2O, humidification + 10 % N2O + 4 % O2, and conditioning, respectively.ResultsIn Experiment 1, the tumors increased with the number of cells injected and with mesothelial damage in the abdominal cavity (p = 0.018) and abdominal wall (p < 0.0001). Experiment 2 confirmed that 60 min of dry CO2PP increased the number of tumors in the abdominal cavity and wall (p = 0.026 and p = 0.003, respectively). The number of tumors was decreased in the abdominal cavity by conditioning (p = 0.030) and in the abdominal wall using humidified CO2 (p = 0.032) or conditioning (p = 0.026).ConclusionsTumor implantation was enhanced by peritoneal damage (60 min of dry CO2PP and desiccation), but this was prevented by conditioning. If confirmed in humans, conditioning would become important for oncologic surgery.

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“…Animal experiments however showed that leaving blood in the abdominal cavity after surgery is a risk factor for adhesion formation [46]. It therefore is advised to clean the abdominal cavity with saline or Ringer's lactate.…”

Section: Bloodmentioning

confidence: 99%

Belgian consensus on adhesion prevention in hysteroscopy and laparoscopy

Verguts

Bosteels

Roberta³

et al. 2015

Gynecol Surg

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Intrauterine and intraabdominal adhesions are a major cause for infertility. The most recent investigations have demonstrated the potential of intraperitoneal adhesion barriers combined with good surgical technique to reduce adhesion formation. For intrauterine adhesions we suggest to minimize unipolar and bipolar instrumentation whenever possible. We advocate the use of estrogens for 10 days after adhesiolysis: 2dd two tablets of estradiol 2 mg. Instillation of Hyalobarrier Gel Endo actually is not reimbursed but may have a beneficial effect after myomectomy or adhesiolysis. Concerning laparoscopic and laparotomic prevention of adhesion also, meticulous surgical technique is of the utmost importance. Residual blood should be avoided by careful hemostasis and rinsing with Ringer's lactate with heparin. Preferably braided sutures are not to be left in the abdominal cavity. We advise to avoid unipolar and bipolar cauterization when possible and to replace with ultrasonic or laser energy. The use of floatation barriers does not seem to add substantial benefit in the prevention of adhesions. Gel barriers (Hyalobarrier Gel Endo® or Intercoat®) are proven to have a significant effect on adhesion prevention. As for sheets, there is enough evidence that they prevent adhesions. The use of NSAID in the prevention of pain and/or corticosteroids in the prevention of postoperative nausea is already mainstay after surgery and can be further endorsed in the prevention of adhesions.

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Addition of nitrous oxide to the carbon dioxide pneumoperitoneum strongly decreases adhesion formation and the dose-dependent adhesiogenic effect of blood in a laparoscopic mouse model

Cited by 27 publications

References 35 publications

Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery

Peritoneal full-conditioning reduces postoperative adhesions and pain: a randomised controlled trial in deep endometriosis surgery

Conditioning of the abdominal cavity reduces tumor implantation in a laparoscopic mouse model

Belgian consensus on adhesion prevention in hysteroscopy and laparoscopy

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