Effect of Pneumoperitoneum on Human Ovary
Condition: Reperfusion Injury
MeSH terms: Pneumoperitoneum; Reperfusion Injury
Study type: Interventional

Summary: 
      Laparoscopic surgery has played a pivotal role in all surgical fields in modern medicine. It
      has some well known advantages over open surgery. For this reason laparoscopic surgery is
      know the first choice for many surgical procedures, even in gynecology. On the other hand,
      despite the advantages of laparoscopy carbon dioxide (CO2) pneumoperitoneum is not free from
      side effects. Experimental studies and limited clinical studies showed that pneumoperitoneum
      leads to a decrease in the blood flow to intra-abdominal organs during laparoscopic surgery.
      This is also known as ischemia, leads to the production of free O2 radicals. The desufflation
      of the abdominal cavity at the end of the procedure reduces the increased abdominal pressure
      and increase the perfusion of intra-abdominal organs. However this will not stop the
      production of free radicals. This reperfusion period even exaggerate the release of free
      radicals. This phenomenon is called as ischemia/reperfusion (I/R) model that leads to release
      of various free radicals, which are the most important mediators of oxidative tissue injury
      and consequential organ dysfunction. Recently both oxidative tissue injury and consequential
      dysfunction have been shown in ovarian tissue in experimental animal studies. But the data
      related to human ovary is still scarce. Thus the aim of the study is to evaluate the effect
      of I/R injury related to CO2 pneumoperitoneum on human ovary.
    

Detailed description: 
      Twenty patients at premenopausal period and with an indication of hysterectomy with benign
      uterine pathology were included in the study.

      Patients were randomly assigned to open hysterectomy (group 1) and laparoscopic assisted
      vaginal hysterectomy (group 2).

      In all patients, surgeries were performed under endotracheal general anesthesia with
      mechanical ventilation. Under the general anesthesia Arterial blood gas, airway pressure,
      dynamic pulmonary compliance, peripheral pulse-oximetry, end tidal carbon dioxide pressure
      level (set at between 35 and 45 mm/hg), blood pressure, and cardiac rhythm were monitored
      continuously during the surgery. All patients received a single dose of cefazolin sodium as a
      prophylactic antibiotic. Low molecular weight heparin was not given the patients.

      Surgery in Group 1 (open hysterectomy) After the induction of the anesthesia and before the
      skin incision first venous blood sample was collected. Abdominal access was performed with
      Pfannenstiel incision. One of the ovaries was excised at the initial step. Contralateral
      utero-ovarian ligament and bilateral round ligaments were then ligated and transected. After
      the identification of the anterior and posterior leaves of the broad ligament, bladder flap
      was developed and bladder was moved off the lower uterine segment. Bilateral vascular uterine
      pedicles, and sacro uterine ligaments were ligated and transected. After performing
      circumferential colpotomy vaginal cuff was closed. At the final step, before closing the
      abdominal incision contralateral ovary was excised. Both ovaries were macroscopically
      evaluated by an expert pathologist immediately after their excision. Before the preparation
      of the ovaries for histopathological evaluation, 1 cm3 piece of each ovary was excised for
      biochemical evaluation of the malondialdehyde (MDA) level. Second blood sample was collected
      immediately after the skin closure.

      Surgery in Group 2 (LAVH) After the induction of the general anesthesia and before skin
      incision first venous blood sample was collected from the patients. This blood sample was
      reflected the baseline status. After umbilical skin incision was made, pneumoperitoneum was
      created via veress needle using a nonheated (room temperature) and dry CO2. A 10 mm trocar
      was then inserted into the abdominal cavity through umbilical incision for optic system.
      Three 5 mm ancillary trocars were then inserted under direct vision. Two were in lower
      abdominal quadrants and one on the left side of the umbilicus. Intraabdominal pressure (IAP)
      pressure was set at 14 mmHg and maintained. Immediately after the port placement one of the
      ovaries was excised in a few minutes. Surgery was continued with ligating and transecting
      contralateral utero-ovarian ligament and bilateral round ligaments. (Contralateral
      infundibulopelvic ligament (IP), which contains the main vascular supply of the ovary, was
      not ligated and transected at this step, ligating and transecting of the IP was performed at
      the end of the procedure.) Anterior and posterior leaves of the broad ligaments were then
      identified and bladder flap was developed and the bladder was mobilized off the lower uterine
      segment. At this point pneumoperitoneum was released and the surgical team performed the rest
      of the procedure vaginally. Before releasing the pneumoperitoneum second blood sample was
      collected to reflecting the ischemic status. Circumferential colpotomy was performed and
      bilateral sacro-uterine ligaments and uterine vascular pedicles were ligated and transected
      vaginally. Vaginal cuff was closed vaginally. At this point pneumoperitoneum was achieved
      again to excise the contralateral ovary in a few minutes. Before pneumoperitoneum was
      performed again third blood sample was collected to represent the reperfusion status. Both
      ovaries were macroscopically evaluated by an expert pathologist immediately after their
      excision. Before the preparation of the ovaries for histopathological evaluation, 1 cm3 piece
      of each ovary was excised for biochemical evaluation of the malondialdehyde (MDA) level. In
      this group, the first excised ovary represented the baseline status, and the other ovary
      (excised at the end of the procedure) was exposed to the ischemia and reperfusion condition
      and represented the I/R status.

      Plasma MDA and 8-hydroxy-2' -deoxyguanosine (8OHdG) was measured as a marker of oxidative
      stress. Ovarian tissue MDA level was also measured as a marker of tissue oxidative stress.
      Besides, ovarian histopathological examination was performed to score the oxidative stress.
    

Intervention name(s): open hysterectomy; laparoscopic assisted vaginal hysterectomy
Intervention type(s): Procedure; Procedure
Intervention description(s): Hysterectomy with laparotomy incision.; Hysterectomy with laparoscopic assisstance.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Single (Investigator)
Primary purpose: Screening