Colecistectomia laparoscópica utilizando dispositivo selante de vasos e modificação da técnica utilizando nó extracorpóreo em coelhos: estudo experimental
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Data
2021-08-31
Autores
Wittmaack, Monica Carolina Nery [UNESP]
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Universidade Estadual Paulista (Unesp)
Resumo
As cirurgias laparoscópicas possuem vantagens conhecidas sendo amplamente utilizada na medicina humana, havendo tendência muito grande de redução dos procedimentos cirúrgicos abertos. Contudo, na medicina veterinária, esse avanço nas videocirurgias não ocorre da mesma maneira. As cirurgias minimamente invasivas ainda estão restritas a alguns centros, havendo poucas pesquisas que buscam o avanço das técnicas em pequenos animais. A colecistectomia laparoscópica (CL) é técnica cirúrgica minimamente invasiva recente na medicina veterinária. Estudos randomizados in vivo que avaliam diferentes métodos de divulsão e ligadura do trato biliar extra-hepático por laparoscopia comprovam benefícios aos pacientes. Sendo assim, o objetivo deste estudo randomizado foi relatar as complicações e os resultados perioperatórios de coelhos submetidos a três técnicas diferentes de CL. 30 coelhos foram divididos em 3 grupos. Grupo A (n = 10): técnica de CL iniciando-se pelo fundo da vesícula biliar (VB) em direção ao ducto cístico (Retrógada) pelo instrumento de dissecção Hook e aplicação de nó extracorpóreo para ligadura de ducto cístico. Grupo B (n = 10): técnica de CL convencional por pinça Maryland bipolar para dissecção da VB e Dispositivo Selante de Vasos (DSV- LigaSure ™) para selagem do ducto cístico. Grupo C (n = 10): técnica de CL convencional com utilização de DSV para dissecção da VB e DSV para selagem de ducto cístico. Os dados dos procedimentos cirúrgicos foram coletados e analisados (taxa de perfuração da VB, sangramento dos tecidos adjacentes à VB, tempo para dissecção da VB e tempo total de cirurgia). A função hepática: AST, ALT, FA, BT, BD, GGT e fibrinogênio foi avaliada no pré-operatório e nos dias 3,7 15 após a cirurgia. Avaliações ultrassonográficas seriadas foram realizadas no período pós-operatório a fim de se verificar ausência de extravasamento de bile e peritonite biliar. Alterações abdominais macroscópicas foram verificadas aos quinze dias de pós-operatório por meio da necropsia e o grau de aderências pós-operatórias foi classificado de 0 a 4. Amostras de fígado para avaliação histopatológica foram coletadas de todos os animais. Foi avaliada a presença de siderófagos e utilizada uma escala de 1 a 4 para o grau de fibrose, necrose e células gigantes. O grupo A apresentou um tempo de dissecção da VB maior do que os grupos B e C. A perfuração do VB e sangramento dos tecidos adjacentes ao VB foram semelhantes entre os grupos testados. Os níveis de GGT e ALP aumentaram (p≤0,05) no dia 3 pós-operatório no grupo A. No 15º dia pós-operatório, as enzimas voltaram aos valores pré-operatórios. A mediana de células gigantes, necrose, fibrose e proporção de siderofagos não foram influenciadas pelas técnicas de CL. Conclui-se que elevações transitórias em enzimas hepatocelulares de coelhos após CL podem ser uma observação benigna e podem não ter quaisquer características clínicas. O grupo A teve um escore de adesão maior do que os grupos B e C e foi associado à técnica menos previsível. A CL pode ser realizada por meio de diferentes técnicas, embora o uso de DSV seja altamente recomendado.
Laparoscopic cholecystectomy (LC) has become the gold standard management option for benign gallbladder (GB) disease and cholelithiasis. The aim of this randomized study was to evaluate the intraoperative complications and perioperative outcome of rabbits undergoing 3 different techniques of LC. In this study, we compared the effect of different LC techniques on changes in liver function tests (LFTs). And finally, we investigated and compared the degree of postoperative adhesions and histopathological changes of the liver bed after LC techniques. Methods:30 white male New Zealand rabbits were divided into 3 groups. Group A (n=10) Fundus-first dome-down technique by Hook dissecting instrument and Roeder Slipknot applied for Cystic Duct Ligation. The GB was dissected free from the liver bed starting at the fundus toward the GB neck using Hook electrocautery (Karl–Storz 36 cm length). The cystic duct and cystic artery were ligated using extracorporeally Roeder slipknot - extracorporeal slipknot (Roeder knot). Group B (n=10) Conventional technique by Maryland dissecting forceps for GB dissection and Electrothermal Bipolar Vessel Sealing (EVBS) for Cystic duct seal. Rabbits underwent conventional technique using Bipolar Maryland dissecting forceps (maryland–36 cm length) and the EVBS LigaSure™ Maryland Jaw 5mm-23cm (Medtronic, Dublin, Ireland) for Cystic duct seal. Group C conventional technique by Electrothermal Bipolar Vessel Sealing (EBVS) for GB dissection and EVBS for cystic duct seal. Rabbits who underwent conventional technique dissection of the gallbladder by the LigaSure™ Maryland Jaw 5mm-23cm (Medtronic, Dublin, Ireland) and LigaSure™ for cystic duct seal. The surgical procedure data were collected and analyzed (GB perforation rate, time to GB bed dissection and length of surgery, bleeding from tissues adjacent to gallbladder)Blood samples were obtained pre-operatively and on day 3, 7 and day 15 after surgery to compare liver enzyme alterations (aspartate transaminase [AST], alanine transaminase [ALT], alkaline phosphatase [ALP], bilirubin, direct bilirubin, total protein, albumin; gamma-glutamyl transferase (GGT), fibrinogen.The necropsy analysis was performed 15 days after surgery, and the degree of postoperative adhesions was classified from 0 to 4. Liver samples for histological examination were taken from all groups. The presence of vi siderophages was evaluated and a scale from 1 to 4 was used for the degree of fibrosis, necrosis and giant cells. Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. GGT and ALP levels increased (p≤0.05) on day 3 post-operatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. The median of giant cells, Necrosis, Fibrosis and proportion of Siderophags were not influenced by the CL techniques. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. LC can be performed using different techniques, although the use of EBVS is highly recommended.
Laparoscopic cholecystectomy (LC) has become the gold standard management option for benign gallbladder (GB) disease and cholelithiasis. The aim of this randomized study was to evaluate the intraoperative complications and perioperative outcome of rabbits undergoing 3 different techniques of LC. In this study, we compared the effect of different LC techniques on changes in liver function tests (LFTs). And finally, we investigated and compared the degree of postoperative adhesions and histopathological changes of the liver bed after LC techniques. Methods:30 white male New Zealand rabbits were divided into 3 groups. Group A (n=10) Fundus-first dome-down technique by Hook dissecting instrument and Roeder Slipknot applied for Cystic Duct Ligation. The GB was dissected free from the liver bed starting at the fundus toward the GB neck using Hook electrocautery (Karl–Storz 36 cm length). The cystic duct and cystic artery were ligated using extracorporeally Roeder slipknot - extracorporeal slipknot (Roeder knot). Group B (n=10) Conventional technique by Maryland dissecting forceps for GB dissection and Electrothermal Bipolar Vessel Sealing (EVBS) for Cystic duct seal. Rabbits underwent conventional technique using Bipolar Maryland dissecting forceps (maryland–36 cm length) and the EVBS LigaSure™ Maryland Jaw 5mm-23cm (Medtronic, Dublin, Ireland) for Cystic duct seal. Group C conventional technique by Electrothermal Bipolar Vessel Sealing (EBVS) for GB dissection and EVBS for cystic duct seal. Rabbits who underwent conventional technique dissection of the gallbladder by the LigaSure™ Maryland Jaw 5mm-23cm (Medtronic, Dublin, Ireland) and LigaSure™ for cystic duct seal. The surgical procedure data were collected and analyzed (GB perforation rate, time to GB bed dissection and length of surgery, bleeding from tissues adjacent to gallbladder)Blood samples were obtained pre-operatively and on day 3, 7 and day 15 after surgery to compare liver enzyme alterations (aspartate transaminase [AST], alanine transaminase [ALT], alkaline phosphatase [ALP], bilirubin, direct bilirubin, total protein, albumin; gamma-glutamyl transferase (GGT), fibrinogen.The necropsy analysis was performed 15 days after surgery, and the degree of postoperative adhesions was classified from 0 to 4. Liver samples for histological examination were taken from all groups. The presence of vi siderophages was evaluated and a scale from 1 to 4 was used for the degree of fibrosis, necrosis and giant cells. Group A presented a longer GB dissection time than groups B and C. GB perforation and bleeding from tissues adjacent to GB were similar among tested groups. GGT and ALP levels increased (p≤0.05) on day 3 post-operatively in group A. By the 15th postoperative day, the enzymes returned to the preoperative values. The median of giant cells, Necrosis, Fibrosis and proportion of Siderophags were not influenced by the CL techniques. Transient elevation of hepatic transaminases occurred after LC in all groups. Group A had a higher adherence score than groups B and C and was associated with the least predictable technique. LC can be performed using different techniques, although the use of EBVS is highly recommended.
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Palavras-chave
Vias biliares, Cirurgia laparoscópica, Cirurgia