Severe inflammatory reaction induced by peritoneal trauma is the key driving mechanism of postoperative adhesion formation

Abstract

BackgroundMany factors have been put forward as a driving mechanism of surgery-triggered adhesion formation (AF). In this study, we underline the key role of specific surgical trauma related with open surgery (OS) and laparoscopic (LS) conditions in postoperative AF and we aimed to study peritoneal tissue inflammatory reaction (TIR), remodelling specific complications of open surgery (OS) versus LS and subsequently evaluating AF induced by these conditions.MethodsA prospective randomized study was done in 80 anaesthetised female Wistar rats divided equally into 2 groups. Specific traumatic OS conditions were induced by midline incision line (MIL) extension and tissue drying and specific LS conditions were remodelled by intraperitoneal CO2 insufflation at the 10 cm of water. TIR was evaluated at the 24th, 72nd, 120th and 168th hour by scoring scale. Statistical analysis was performed by the non-parametric t test and two-way ANOVA using Bonferroni post-tests.ResultsMore pronounced residual TIR was registered after OS than after LS. There were no significant TIR interactions though highly significant differences were observed between the OS and LS groups (p < 0.0001) with regard to surgical and time factors. The TIR change differences between the OS and LS groups were pronounced with postoperative time p < 0.05 at the 24th and 72nd; p < 0.01 - 120th and p < 0.001 - 168th hrs. Adhesion free wounds were observed in 20.0 and 31.0% of cases after creation of OS and LS conditions respectively; with no significant differences between these values (p > 0.05). However larger adhesion size (41.67 ± 33.63) was observed after OS in comparison with LS (20.31 ± 16.38). The upper-lower 95% confidential limits ranged from 60.29 to 23.04 and from 29.04 to 11.59 respectively after OS and LS groups with significant differences (p = 0.03). Analogous changes were observed in adhesion severity values. Subsequently, severe TIR parameters were followed by larger sizes of severe postoperative adhesions in the OS group than those observed in the LS group.ConclusionsMIL extension and tissue drying seem to be the key factors in the pathogenesis of adhesion formation, triggering severe inflammatory reactions of the peritoneal tissue surrounding the MIL resulting in local and systemic consequences. CO2 insufflation however, led to moderate inflammation and less adhesion formation.

Effects of hypoxia on the expression of inflammatory markers IL-6 and TNF-a in human normal peritoneal and adhesion fibroblasts

“…Pelvic adhesions may form in response to intraperitoneal inflammatory processes, as a result of tissue handling, introduction of foreign bodies, tissue dryness, and size of the midline incision [Corona et al 2011;Pismensky et al 2011;ten Broek et al 2011]. Trauma to the peritoneal surface is known to decrease tissue plasminogen activator Figure 1.…”

“…Injury of the peritoneum leads to an inflammatory response consisting of hyperemia, fluid exudation, recruitment of floating mesothelial cells, and release of white blood cells and platelets into the cavity peritoneal [Corona et al 2011;diZerega 1997;Pismensky et al 2011;ten Broek et al 2011]. Injury to the mesothelial cell layer exposes the underlying connective tissue to the peritoneal fluid.…”

A Modified Sidewall Adhesion Model: Hypothesis-Building and Testing Tool for a Surgical Experimental Research

“…The key points of postsurgical adhesions includes firstly the fixation of the intra-peritoneal structures to the parietal and/or visceral peritoneum, keeping them attached longer than in physiological wound healing [2] and secondly the initiation of excessive healing, caused by inflammation [3], which in turn may be triggered by surgical factors [4].…”

“…In our experimental researches we aimed to study an impact of surgical trauma and CO 2 -insufflation on adhesion formation [3,10] to demonstrate the developing of research questions, the building of a hypothesis, and the setting of goals and the elaboration of a study design as well as the interpretation of results.…”

“…Previously we demonstrated key steps of surgical research, namely the selection of the research questions, hypothesis building to set goals as well as the elaboration of a study design and interpretation of results based on our experimental studies and a systematic review of literature [10]. In our experimental researches we aimed to study an impact of surgical trauma and CO 2 -insufflation on adhesion formation [3,10] to demonstrate the developing of research questions, the building of a hypothesis, and the setting of goals and the elaboration of a study design as well as the interpretation of results.…”