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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1562_Библиотеки_им_академика_М_И_Перельмана.pdf
Small Intestinal Submucosa Biomaterial …
231
Figure 2. Photomicrograph of SIS hernia-repair material implanted into a ZDSD diabetic rat. There is a
robust fibrovascular response and lack of any evident residual implanted material. Slide stained with
hematoxylin & eosin, magnified 40X.
Figure 3. Photomicrograph of trichrome-stained SIS hernia-repair material implanted into a ZDSD
diabetic rat. The blue stain demonstrates rich deposition of collagen as part of the incorporation of the
SIS into host tissue. Magnified 40X.
With more than one million implants used in patients worldwide every year, the ability of
implanted materials to provide strong reinforcement to the abdominal wall in a manner
similar to normal host tissue is of great importance. SIS mimics the host extracellular matrix,
providing a scaffold for in-growth of cells. The state of cell differentiation and functionality is
defined, in part, by the connection of the cells to the extracellular matrix [Streuli, 1999]. As a
decellularized natural material, is flexible and mechanically strong, with a structure consisting
of a network of cross-linked collagen I, III and IV [Hodde, 2002].
Beyond simply providing a mechanical structure for cell attachment, SIS is also rich in a
variety of bioactive molecules, including fibronectin, glycosaminoglycans, and growth
factors. These molecules all serve to stimulate angiogenesis, and facilitate migration, cell
attachment, and cell proliferation [Yang et al., 2010]. Interestingly, as implanted SIS is
degraded, small molecular weight peptides are released which recruit endothelial cells [Li et
al., 2004]. Likely, the robust angiogenic response associated with SIS implantation aids in
tissue repair, as the cells populating and remodeling the SIS are metabolically active and
Mark A. Suckow, William R. Wolter, Susan M. LaBadie-Suckow et al.
232
benefit from the nutrients supplied via the blood. Typically, complete degradation of the
implanted SIS and replacement with host tissue occurs by three months [Gilbert et al., 2007a;
Gilbert et al., 2007b].
CONCLUSION
Adequate repair of abdominal hernia requires that any implanted materials be
biocompatible, flexible, non-abrasive, and be sufficiently strong to reinforce the injured body
wall. This is particularly true when surgical herniorraphy is performed in diabetic patients due
to complications associated with impaired healing. Porcine SIS has been demonstrated to be a
safe, biocompatible material used in a variety of clinical tissue repair procedures, including
hernia repair. Further, SIS has been demonstrated to inhibit bacterial growth when compared
to synthetic mesh materials and, therefore, has particular value when used in infected fields.
We have demonstrated in a diabetic rat model that SIS can be used for repair of ventral
abdominal hernia, and that, following implantation, there is robust ingrowth of host
fibrovascular tissue into the SIS scaffold. Further, the ultimate tensile strength of the repaired
tissue approximates that of human lineaalba. SIS is a safe, effective hernia repair material that
offers significant advantage for herniorrhaphy in diabetic patients.
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In: Hernias ISBN: 978-1-62948-441-9
Editor: Mark A. Suckow © 2014 Nova Science Publishers, Inc.
Chapter 16
ARTERIAL BLOOD GAS CHANGES IN PATIENTS
UNDERGOING INGUINAL, UMBILICAL AND
POSTOPERATIVE HERNIA REPAIR SURGERY
Efthimia Tsounaki
*
General Hospital Patision, Athens, Greece
ABSTRACT
Abdominal wall hernia repair surgery is one of the most common procedures
performed worldwide. Apart from aesthetics, the hernia repair also leads to an increase of
the intra-abdominal pressure in the immediate postoperative period, which tends to get
normalized in the later postoperative period. The aim of this chapter is to study the
arterial blood gas changes that occur due to the intra-abdominal pressure difference and
its consequent effects on the respiratory mechanics, given the fact that all other
parameters are standardized. Arterial blood gas changes were studied preoperatively, on
the 1
st
and 8
th
postoperative day in 50 patients with inguinal hernia, 36 patients with
umbilical hernia and 30 patients with postoperative hernia that underwent abdominal wall
hernia repair surgery (116 patients, 62 men and 54 women). All the patients in this study
had hernias of medium or large size (containing omentum and part of intestine). Patients
also were normothermic, experienced no significant blood loss during the operation and,
thus, were in no need of blood transfusion. Further, all patients were similarly
anesthetized, received post-operative analgesics, and experienced relatively pain-free
recovery as assessed by a standard numeric scale. Patients with respiratory system and
cardiovascular diseases were excluded. Statistical analysis used for measurements of
blood gas changes was the paired samples t-test and the normality of the distributions
was checked with Kolmogorof – Smirnov test. The results demonstrated that on the 1
st
postoperative day pH increased (0.36%), pO
2
increased (1.18%), pCO
2
decreased
(8.96%), HCO
3
decreased (2.78%), oxygen saturation (SaO
2
) increased (0.19%), and base
excess (BE) decreased (1.16%). By the 8
th
postoperative day, pH increased (0.35%), pO
2
increased (4.31%), pCO
2
increased (7.01%), HCO
3
decreased (1.11%), SaO
2
increased
(0.82%), and BE increased (30.2%). The changes observed between the 1
st
and 8
th
postoperative days were that the pH had no noticeable change; pO
2
increased (3.1%);
*
Corresponding author: e-mail: etsounaki@gmail.com.
Efthimia Tsounaki
236
pCO
2
increased (2.14%); HCO
3
increased (1.72%), SaO
2
increased (0.63%); and BE
increased (31.73%).
Keywords: Abdominal hernia repair, arterial blood gas changes, inguinal hernia, umbilical
hernia, postoperative hernia
INTRODUCTION
In enlarged hernias of the abdominal wall, particularly in cases in which there is
significant protrusion of an organ, the intra-abdominal pressure is lower in comparison with
the pressure in the absence of hernia. Due to the fact that hernias gradually increase in size,
the body adapts itself and functions with lower values of intra-abdominal pressure. When the
patient undergoes hernia repair and the protruding organ is returned within the peritoneal
cavity, an increase in intraperitoneal pressure is anticipated and the body will need some time
period in order to adapt to, and compensate for, the change in intraperitoneal pressure
postoperatively [Gilbert, 1989; Nyhus and Condon, 1989; Skandalakis et al.; 1989, Nyhus et
al., 1991; Abrahamson, 1998]. This fact leads to respective changes in respiratory function
which are reflected in the arterial blood gases [Bartlett, 1980; Weibel, 1983]. The aim of this
chapter is to describe the arterial blood gases’ changes in patients undergoing abdominal
hernia (inguinal, umbilical and postoperative) repair surgery.
Experimental Approach
To evaluate changes in arterial blood gas parameters following hernia repair surgery, 116
patients (62 men and 54 women) were studied. Among them, 50 patients had inguinal hernia
(37 men and 13 women), 36 patients had umbilical hernia (15 men and 21 women), and 30
patients had postoperative hernia following surgery for other reasons (10 men and 20
women). Furthermore, 31 patients underwent to emergency surgery (13 men and 18 women),
and 85 patients were operated electively (49 men and 36 women). Hernia sac content was
omentum and intestine. All patients were under general anesthesia with endotracheal
intubation during surgery, and all had hernias of medium or large size (containing omentum
and part of the intestine). Patients were all normothermic during sampling, and the use of
analgesics and fluids was standardized, with each patient receiving fentanyl (100-150 μg/Kg),
tramadol (100 mg, three doses), lornoxicam (16 mg/day), and paracetamole (3 g/day for the
1
st
postoperative day). Pain was scored using a subjective scale (0=no pain, 10=severe pain),
and no patients reported severe pain (score range was 0-3). There was minimal blood loss
during surgery, and no patient required transfusion during the surgery or postoperatively. A
standard anesthetic regimen was used for all patients and consisted of induction with propofol
(2 mg/Kg), maintenance with sevoflurane, muscle relaxation with rokourone (0.6 mg/Kg for
intubation and 0.5 mg/Kg for maintenance). Muscle relaxation was reversed at the conclusion
of surgery with sugamadex (4mg/Kg) and odacetron (4 mg) was administered to reduce
postoperative nausea.
Arterial blood samples were obtained from the radial artery of patients using a 26G
needle in a 2.5ml heparinized syringe, and analysis was done using a Roche OMNI-S blood
Arterial Blood Gas Changes in Patients Undergoing Inguinal, Umbilical …
237
gas analyzer (Roche Holding AG, Basel, Switzerland). Sampling was performed
preoperatively the day before surgery (11.00-12.00 a.m.); the 1
st
postoperative day (8.00-9.00
a.m.); and the 8
th
postoperative day when patients came for follow-up evaluation and suture
removal (10.00-12.00 a.m.), and this was standardized for all patients. Patients suffering from
severe respiratory diseases were excluded from the study, as well as patients with
compromised cardiovascular function (i. e., under treatment for heart failure, arrhythmias and
coronary syndromes), in order to avoid skewing of data due to such clinical conditions. As a
result, the patients participating in this research fall under ASA1 and ASA2 categories under
the physical status classification system of the American Society of Anesthesiologists [2010].
Parameters recorded were: arterial blood gases (pH, pO
2
, pCO
2
, HCO
3
, SaO
2
, and BE),
gender, age, previous surgeries, history of disease (diabetes, hypertension, alcohol abuse),
hernia size, and the emergency status of the hernia repair surgery. Statistical analysis used for
measurements of blood gas changes was paired samples t-test and the normality of the
distributions was checked with Kolmogorof – Smirnov test.
RESULTS
Three comparisons of arterial blood gases were performed, as follows: 1) preoperatively
versus 1
st
postoperative day; 2) preoperatively versus 8
th
postoperative day; and 3) 1
st
postoperative day versus 8
th
postoperative day. The change in pH value ranged from
statistically highly significant at the level of 0.1% to statistically non-significant at the level
of 10%, demonstrating a mean increase, from pre-operative levels, of 0.36% at the 1
st
postoperative day and an increase of 0.35% at the 8
th
postoperative day (Tables 1, 2).
Table 1. pH values
Hernia Type
Sex
Preoperative
1
st
postoperative day
8
th
postoperative day
Value
SD
Value
SD
Value
SD
Inguinal hernia
Men
7.4135
0.0283
7.4572
0.0357
7.4541
0.0336
Women
7.453
0.0361
7.4844
0.0471
7.462
0.038
Total
7.4332
0.0316
7.4708
0.0403
7.458
0.0346
Umbilical hernia
Men
7.423
0.0353
7.4283
0.0529
7.4332
0.0371
Women
7.4252
0.0394
7.453
0.0504
7.4667
0.0474
Total
7.4241
0.0373
7.4406
0.0522
7.4499
0.046
Postoperative
hernia
Men
7.4287
0.0286
7.4774
0.0437
7.4558
0.0475
Women
7.42995
0.0365
7.4683
0.0629
7.4803
0.0536
Total
7.4293
0.0336
7.4725
0.0566
7.468
0.05236
Table 2. pH t-test values
Hernia type
Preoperative – 1
st
postoperative day
Preoperative – 8
th
postoperative day
1
st
- 8
th
postoperative
day
Inguinal hernia
<0.0005
0.000104
0.108925
Umbilical hernia
0.0123254
0.000899
0.349037
Postoperative hernia
0.000192
<0.0005
0.944269
Efthimia Tsounaki
238
Changes in pH
Changes in pH value were statistically very significant at the level of 0.1% (P<0.001) in
the following measurements:
Preoperatively versus 1
st
postoperative day and preoperatively versus 8
th
postoperative day in inguinal hernias;
Preoperatively versus 8
th
postoperative day in umbilical hernias; and
Preoperatively versus 1
st
postoperative day in postoperative hernias.
Changes in pH value were statistically significant at the level of 1% (P<0.01)
preoperatively versus the 1
st
postoperative day for umbilical hernias. These results
demonstrate that pH changed more significantly following surgery to repair postoperative
hernias. Following repair of in inguinal hernias, pH increased 0.51% on the 1
st
postoperative
day and 0.34% by the 8
th
postoperative day in comparison with the preoperative day; and pH
decreased 0.17% on the 8
th
postoperative day in comparison with the 1
st
postoperative day.
Following repair of umbilical hernias, pH increased 0.23% on the 1
st
postoperative day and
0.34% by the 8
th
postoperative day in comparison with the preoperative day; and increased
1.12% by the 8
th
postoperative day in comparison with the 1
st
postoperative day
(Figures 1, 2).
Figure 1. pH values in patients undergoing abdominal hernia repair.
Figure 2. pH values in patients undergoing abdominal hernia repair (men and women).
Arterial Blood Gas Changes in Patients Undergoing Inguinal, Umbilical …
239
Changes in pO
2
The changes in pO
2
values ranged from statistically non-significant at the level of 10% to
statistically highly significant at the level of 0.1%, with an increase of 1.18% by the 1
st
postoperative day, 4.31% by the 8
th
postoperative day, and an increase of 3.09% between the
1
st
and 8
th
postoperative days (Table 3, 4).
Change in pO
2
value was statistically very significant (P<0.001) between 1
st
and 8
th
postoperative days following surgery for repair of umbilical hernia.
Changes in pO
2
value were statistically significant (P<0.05) with respect to the following
measurements:
Preoperatively versus the 8th postoperative day following surgical repair of inguinal,
postoperative and umbilical hernias; and
For the 1
st
versus 8
th
postoperative days following repair of inguinal hernias.
These data demonstrate that pO
2
changes increased considerably following repair of
postoperative hernias, with an increase of 5.62% by the 1
st
postoperative day and 4.14% by
the 8
th
postoperative day, though pO
2
decreased by 1.38% by the 8
th
postoperative day in
comparison with the 1
st
postoperative day, indicating moderation of the change. Following
umbilical hernia repair, pO
2
increased 5.95% by the 8
th
postoperative day in comparison with
the preoperative day, and increased 5.87% by the 8
th
postoperative. Data for patients who
underwent inguinal hernia repair demonstrated an increase of 1.99% by the 1
st
postoperative
day and 4.31% by the 8
th
postoperative day in comparison with the preoperative day, and an
increase of 2.35% on the 8
th
postoperative day in comparison with the 1
st
postoperative day
(Figures 3, 4).
Table 3. pO
2
values (mmHg)
Hernia type
Sex
Preoperative
1
st
postoperative day
8
th
postoperative day
Value
SD
Value
SD
Value
SD
Inguinal
hernia
Men
82.8054
10.596
81.0567
13.043
84.6837
13.31
Women
79.2384
10.63
84.0769
7.872
84.2538
7.452
Total
81.0219
10.614
82.5668
11.914
84.4687
11.99
Umbilical
hernia
Men
85.05714
5.482
81.619
9.6
87.8238
8.416
Women
85.68
10.028
89.3866
13.82
93.093
8.916
Total
85.3685
8.342
85.5028
12.692
90.4584
8.983
Postoperative
hernia
Men
82.99
7.816
88.33
6.063
85.49
6.953
Women
82.135
11.707
86.075
12.028
86.46
8.969
Total
82.5625
10.436
87.2025
10.362
85.975
8.242
Table 4. pO
2
t-test values
Hernia type
Preoperative – 1
st
postoperative day
Preoperative – 8
th
postoperative day
1
st
- 8
th
postoperative day
Inguinal hernia
0.980572
0.039874
0.034619
Umbilical hernia
0.84388
0.013505
0.000792
Postoperative hernia
0.034734
0.030752
0.687126
Efthimia Tsounaki
240
Figure 3. pO
2
values in patients undergoing abdominal hernia repair.
Figure 4. pO
2
values in patients undergoing abdominal hernia repair (men and women).
Changes in pCO
2
Changes in pCO
2
values ranged from statistically non-significant at the level of 10% to
statistically highly significant at the level of 0.1%, with a reduction of 8.96% by the 1
st
postoperative day, and an increase of 7.01% by the 8
th
postoperative day. Between the 1
st
and
8
th
postoperative days, pCO
2
increased by 2.14% (Tables 5, 6).
Changes in pCO
2
value were statistically very significant (P<0.001) with respect to the
following parameters:
Preoperatively versus the 1
st
postoperative day following repair of inguinal,
postoperative and umbilical hernias;
Preoperatively versus the 8
th
postoperative day following repair of inguinal,
postoperative and umbilical hernias; and
The 1
st
versus 8
th
postoperative day following repair of postoperative hernias.