Authors: Maria Mercedes Binda
Publish Date: 2015/04/25
Volume: 292, Issue: 5, Pages: 955-971
Abstract
The peritoneum is the serous membrane that covers the abdominal cavity and most of the intraabdominal organs It is a very delicate layer highly susceptible to damage and it is not designed to cope with variable conditions such as the dry and cold carbon dioxide CO2 during laparoscopic surgery The aim of this review was to evaluate the effects caused by insufflating dry and cold gas into the abdominal cavity after laparoscopic surgeryInsufflating dry and cold CO2 into the abdomen causes peritoneal damage postoperative pain hypothermia and postoperative adhesions Using humidified and warm gas prevents pain after surgery With regard to hypothermia due to desiccation it can be fully prevented using humidified and warm gas Results relating to the patient recovery are still controversialThe use of humidified and warm insufflation gas offers a significant clinical benefit to the patient creating a more physiologic peritoneal environment and reducing the postoperative pain and hypothermia In animal models although humidified and warm gas reduces postoperative adhesions humidified gas at 32 °C reduced them even more It is clear that humidified gas should be used during laparoscopic surgery however a question remains unanswered to achieve even greater clinical benefit to the patient at what temperature should the humidified gas be when insufflated into the abdomen More clinical trials should be performed to resolve this queryThe peritoneum is the serous membrane that forms the lining of the abdominal cavity and it covers most of the intraabdominal organs It is composed of a single layer of mesothelium generally 25–3 µm thick supported by a thin layer of connective tissue 1 With a surface area of some 14000 cm2 in adults 2 almost equal to that of the skin this membrane may be the largest organ in humans Its function is to diminish the friction among abdominal viscera enabling their free movement It also walls off infection and serves as a reservoir of fat especially in the omentum It contains two distinct layers of collagen and it is one of the most richly vascularised of all organs The membrane comprises very large amounts of mucopolysaccharides or glycosaminoglycans and just beneath its surface there is an elastin layer that gives the peritoneum mobility The surface lining of the peritoneum consists of highly differentiated mesothelial cells 3Mesothelial cells are predominantly flattened squamouslike approximately 25 μm in diameter with the cytoplasm raised over a central round or oval nucleus 4 Long microvilli are projected from the apical surface of the mesothelial cells 1 They have welldeveloped celltocell junctional complexes including tight junctions adherent junctions gap junctions and desmosomes Tight junctions in particular are crucial for the development of cell surface polarity and the establishment and maintenance of a semipermeable diffusion barrier 4 They secrete glycosaminoglycans proteoglycans and phospholipids to provide a slippery nonadhesive glycocalyx that protects the serosal surface from abrasion infection and tumour dissemination In addition mesothelial cells can synthesise cytokines chemokines growth factors and matrix components that regulate inflammation initiate cell proliferation differentiation and migration and mediate tissue repair 5 Providing scaffolding for the mesothelial cells are connective tissue proteins and abundant vascular channels deliver oxygen and other nutrients to them Interspersed among the connective tissue there are extremely poorly differentiated and epithelioidlike cells similar to fibroblasts These cells can undergo a variety of differentiation changes after exposure to injury or other types of stimuli perhaps becoming mesothelial cells during peritoneal repair 3In summary the peritoneal surface has a very important function in the abdominal cavity ie to diminish the friction wall off infection and to enable the secretion of cytokines However it is a very delicate layer and therefore highly susceptible to being damagedLaparoscopy induces less direct trauma because of gentle tissue handling meticulous haemostasis constant irrigation the use of microsurgical instruments and the smaller operative field This procedure has been associated with less postoperative pain less systemic immunological depression less wound infection fewer complications faster bowel recovery shorter hospital stays and earlier return to normal activities however the operating times can be longer in comparison to those in open surgery 6 7 8 9 10 11
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