Page 6 - World Journal of Laparoscopic Surgery
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Ricardo Jordão Duarte et al
In most protocols, the SA technique is performed such as housing, medications and assessments of other
through a single 2.5 cm incision that passes through the inflammation foci, e.g. lungs require larger technical and
skin, aponeurosis and muscles, called the port or access financial resources, in addition to imposing postoperative
point. A trocar is placed on the access point, allowing suffering on the animals.
instruments such as the optic and two to four clamps Nakano et al (2007) observed increased IL4, 3 hours
to be introduced into the body. This differs from lapa after laparotomy in rats, confirming that the sampling
roscopy, which is performed through a 1.0 cm incision time used in the present study was sufficient to evalu
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in the abdominal wall, usually in the umbilical region, ate IL4. In a study on IL4 and IL10, Shapenko et al
and two or three, 5 or 10 mm incisions in the abdominal considering that these markers have anti-inflammatory
wall, called ports or access points, where the trocars will action in animals, demonstrated that they are suitable for
be placed. Many video laparoscopic procedures use two studies in humans. 17,18 The reduction of IL4 might have
10 mm access points (one umbilical and one in the iliac resulted from the minor trauma caused by the access
fossa) and two 5 mm access points (one in the region of the points in the present study. In support of this hypothesis,
xiphoid appendix and the other in the hypochondrium), the reduction observed in the SA group (0.151 to 0.129 =
so this setting was used for the present study. The SA 0.022) was lower than the reduction observed in group 2
technique imposes a space restriction between the hands (0.218 to 0.118 = 0.100). This effect may warrant investiga
of the surgeons when they manipulate surgical clamps, tion in future studies. Kimura et al (2006), who studied the
making the procedure considerably more difficult than kinetics of IL4, IL6, IL8 and IL10, observed increases
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CL. Therefore, the benefit to the patient depends on the in all these markers except for IL4.
experience of the surgeon. 14 IL6 has been used as a marker of response to surgical
To evaluate only the inflammatory response triggered trauma by several authors. 911 Shenkin et al demonstrated
by the access points, pneumoperitoneum was not used variations in the IL6 level 90 minutes after skin incision,
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because the gas used in SA or CL surgery may influence reaching a peak level at 4 hours. Cruickshank et al found
the inflammatory response markers (ILs, TNFa and increased IL6 after 2 to 4 hours in several procedures,
CRP). 1013 Some studies have evaluated the differences demonstrating a correlation between IL6 and tissue
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between SA and video laparoscopy but included the trauma.
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entire surgical procedure. However, each surgery may A study by Hao et al (2012), which analyzed the inflam-
have different variables, such as the dissection length, matory response promoted by LESS and by CL in a
bleeding and infections, which could modify the results. procedure for treating varicocele in children, did not
The present study evaluated only the trauma resulting observe significant differences between the two proce
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from the access points. Recently, a study with a design dures regarding IL6 or TNFa. Matsumoto et al (2005),
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similar to ours was published. However, the author used who compared laparoscopic nephrectomy, handassisted
pneumoperitoneum for 1 hour after the access points laparoscopy (insertion of a hand into the abdomen
were placed, which could influence the IL levels. 1012 through a minimal incision) and the open technique,
In the present study, we used healthy pigs as an measured the inflammatory response in pigs by analyz
animal model, all from a farm in a nearby town. The ing peritoneal IL6 and plasma TNFa, showing that the
town is approximately 1 hour away from the lab, and the laparoscopic technique had weaker inflammatory effects
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pigs were brought to the lab on the day of the procedure. than handassisted or open surgery. Ypsilantis et al (2012)
This decision may have influenced the results because conducted a study of IL6, IL8, TNFa and CRP in 20 pigs,
of the possibility that the transportation was traumatic aiming to evaluate the inflammatory responses to LESS
for the animals. However, blood samples were collected and CL. The pigs were divided into four groups: SA with
from both groups at T0, immediately after anesthesia and pneumoperitoneum for 1 hour; CL with pneumoperito
intubation. Four pigs per day arrived on different days, neum; only pneumoperitoneum; and only anesthesia.
and two pigs went to each group randomly, to minimize The analysis of IL6, IL8, TNFa and CRP did not show
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the influence of the temperature each day and variations differences between the various procedures. Wang et al
in travel time. Ideally, the animals should be kept longer (2009) compared open pyeloplasty with laparoscopic
in the lab before the procedures, but this was not possi pyeloplasty in children, analyzing IL6, IL8, IL10, TNF
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ble because of a municipal law that forbids maintaining and CRP. They found that, in both groups, IL6 was
these animals in the city. This was also the reason why higher after 4 hours, and IL6 and CRP were higher in
the study time was set to 4 hours; ideally, the inflamma open surgery.
tory response should be monitored for longer periods, IL-8 has also been used in studies on the inflammatory
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such as days or weeks. Furthermore, ideal conditions, response to surgical trauma. This IL has the ability to
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