Page 15 - Journal of WALS

WJOLS

Immunological Response of Postcholecystectomy: SILS vs NOTES

release of basal TNF-α. This significant reversible inhibition of of the skin. Fewer than 7% of afferent nerves entering the spinal
TNF and IL-1 demonstrated in macrophages incubated in carbon cord project to the viscera, and only a small fraction of these
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dioxide are not seen with helium or air. 22 transmit sensory input to the central nervous system. These
Most studies on NOTES have been performed with room innervations, however, sparse spread to several segments of
air to establish pneumoperitoneum. Insufflation of air through the cord precluding the prospect of spinal/epidural anesthesia.
the flexible endoscopes used in performing NOTES currently is Studies are needed to evaluate the impact of somatic and visceral
not pressure controlled. The flow rate used in the typical pain in the context of the overall immunological profile of these
laparoscopy insufflators is higher. To date there is no novel procedures in cholecystectomy. In contrast to
randomized study that fully investigates the extent of immune conventional laparoscopy there is a reduction of shoulder tip
responses following this advanced endoscopic procedures to pain from irritation of the diaphragm caused by trapped carbon
know if physiology of pneumoperitoneum will behave in a similar dioxide following single incision laparoscopy. The paucity of
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way to the much studied carbon dioxide induced pneumo- large population study for transluminal surgery commonly
peritoneum of laparoscopy. performed using room air for pneumoperitoneum is a limitation
to understanding differences in pain induced immune
DISCUSSION responses.

The evolutionary arc from open to laparoscopic and now no- Anesthetic considerations play a role in the multifactorial
scar cholecystectomy has facilitated improvement in patient adverse immune response following surgery. Nonspecific
recovery, cosmetic results and reduced pain medication. The defenses both cellular and humoral responses with anesthetic
wide acceptance of these novel therapies has fueled huge agents produce a combination of direct and indirect effects.
investment of time, effort and funds by researchers to indeed These have significant impact on the function and regulation
achieve a no-scar surgery. At present, it is advised that NOTES of immune response. Longer operating time means longer
should be performed by a complementary team of a skilled exposure to anesthetic agents and pneumoperitoneum with
therapeutic endoscopist and a laparoscopic surgeon, in view strong potentials for immune status alteration. Technical
of the complex tasks required for its performance. Approach to difficulties and a shortage of proper equipment lead to longer
the peritoneum in this experimental extension of conventional operating time in NOTES. Better equipment and adequate
flexible endoscopy is via the stomach, colon, bladder and vagina. training and experience are likely to shorten operating time.
Laparoscopic instruments are often inserted through one or
two abdominal ports to assist in the procedure (hybrid NOTES). CONCLUSION
In its pure form the transvaginal approach is used, thus making Minimal access techniques of single incision laparoscopy (SILS)
the procedure applicable to only women evoking among other
issues ethical considerations. Patient acceptance between SILS and natural orifice transluminal endoscopic surgery (NOTES)
and NOTES is in favor of the former. are novel techniques in the surgical removal of the gallbladder.
Compared to open surgery they have a more favorable immune
Infection rate is an important issue for consideration.
Contamination of the peritoneal cavity by enteric contents may response. There is limited immunological data available
render NOTES more immunologically invasive than previously comparing NOTES and SILS postcholecystectomy. Further large
thought with possible increased risk of infection. Few cases of randomized studies are needed to ascribe immunological
intraperitoneal abscesses have been observed in some advantage between these novel techniques.
laboratory works though surgical measures of sterilization of REFERENCES
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