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Copyright ©The Author(s) 1999. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Dec 15, 1999; 5(6): 544-546
Published online Dec 15, 1999. doi: 10.3748/wjg.v5.i6.544
Study on incisional implantation of tumor cells by carbon dioxide pneumo peritoneum in gastric cancer of a murine model
Hao Wang, Min-Hua Zheng, Hao-Bo Zhang, Jian Zhu, Jian-Rong He, Ai-Guo Lu, Yu-Bao Ji, Min-Jun Zhang, Yu Jiang, Bao-Ming Yu, Hong-Wei Li
Hao Wang, Min-Hua Zheng, Hao-Bo Zhang, Jian Zhu, Jian-Rong He, Ai-Guo Lu, Yu-Bao Ji, Min-Jun Zhang, Yu Jiang, Bao-Ming Yu, Hong-Wei Li, Department of Surgery, Ruijin Hospital of Shanghai Second Medical Univer sity, Shanghai 200025, China Shanghai Institute of Digestive Surgery, Shanghai 200025, China
Hao Wang, male, born in 1972-09 in Nanyan, Henan Province, Han nationality, graduated from Shanghai Second Medical University as a postgraduat e in 1998, majoring in colorectal oncology and laparoscopy, having 20 papers published.
Author contributions: All authors contributed equally to the work.
Supported by the Shanghai Technological Development Founds, No. 98QMB1405
Correspondence to: Dr. Hao Wang, Department of Surgery, Ruijin H ospital of Shanghai Second Medical University, 197 Ruijin Er Road, Shanghai 2000 25, China.
Telephone: +86-21-64370045 Fax: +86-21-64333548
Received: July 18, 1999
Revised: August 12, 1999
Accepted: September 18, 1999
Published online: December 15, 1999

Key Words: stomach neoplasms, colonic neoplasms, cell movement, carbon dioxide pneumoperitoneum, murine model


Port-site recurrence after laparoscopic tumor surgery is a frequent complication in cancer operations, such as gallbladder, stomach, ovary and colon[1-5]. The incidence of port-site recurrence after laparoscopic colectomy ranged from 1.1% to 6.3%, in contrast to a 0.68% tumor wound recurrence rate in patients undergoing curative open colectomy[6-8]. The possible mechanisms proposed were: (1) contaminated laparoscopic instruments passing in and out of the port frequently; (2) increased exfoliated cancer cells from laparoscopic manipulation; (3) adhered tumor cells by pneumoperitoneum[9-12]. Some experiment sreported that desufflation related to seeding of port wounds via a stable suspension of tumor cells in CO2 gas was an unlikely cause of port tumors, some supported a direct intraperitoneal seeding of exfoliated tumor cells as its etiology and the instruments passing in and out of the port may play an important role in local recurrence[13-15]. The colon tumor cells were more common since laparoscopic colectomy was wildly performed.

The purpose of this study was to determine whether CO2 pneumoperitoneum could increase tumor implants in the port site.


A 5 mm laparoscopic port ( 5 mm trocar ) was inserted in the left iliac fossa and Veress needle was placed in the right iliac fossa, below which was the injecti on site of malignant cells. Then the right iliac fossa port was used for insufflation, and another was used for desufflation, through the same collection device. Laparoflator was made in Germany ( laparoflator electronic 3509 WEST GmbH).

Colon cancer cell line LoVo and gastric cancer cell line SGC-7901 (from Shanghai Institute of Digestive Surgery) were suspended in liquid culture media and divided into 2 groups: (1) the liquid tumor cell suspension contained 1 million cells in 1 mL volume (109 cells/L); (2) the liquid tumor cell suspension co ntained 10 thousand cells in 1mL volume (107 cells/L). The concentrati on of cells was calculated with a hemocytometer (Fischer Scientific, Pittsburg, PA) and then appropriately diluted to achieve the final concentration. Liquid culture media were RPMI 1640 containing 10 percent fetal bovine serum. Cell viability control culture and cell viability of each tumor cell preparation were determined to be greater than 95 percent by trypan blue exclusion. Continuous flow of CO2 was allowed by leaving the outflow port opened during insufflation, intraperitoneal pressure was maintained at the desired level via constant insufflation during co ntinuous flow studies.


Male Sprague-Dawley rats (250 g-350 g, from Shanghai Experimental A minal Center ) were anesthetized with 25 g/L sodium barbitone (1 μL/g). Abdomens were shaved and prepared with bromo-geramine. Animals then received a right lower quadrant intraperitoneal injection of 1 mL of a suspension of SGC-7901 gastric cancer cells or LoVo colon cancer cells (107/L, 109/L), respectively. Veress needle and 5mm trocar were placed in the abdomen and served as port sites. There were 4 pairs of groups for LoVo or SGC-7901 (4 rats for each group): (1) continuous pneumo of 2 kPa (5 min) at gas flow of 5 L/min for 5 min with (107/L, 109 /L) cells injected; (2) continuous flow (5 L/min ) of CO2 with ( 107/L, 109/L ) cells injected, maintaining a pressure of 4 kPa for 5 min inside the peritoneal cavity; (3) continuous flow (5 L/min) of CO2 with (107/L, 109/L) cells injected, maintaining a pressure of 2 kPa inside the peritoneal cavity for 60 min; and (4) continuous flow (5 L/min) of CO2 with ( 107/L, 109/L ) cells injected, maintaining a pressure of 4 kPa for 60 min inside the peritoneal cavity. At the end of the experiments, a peritoneal washing sample was cultured as a cell viability control. All collection dishes were incubated at 37 °C and 50 mL/L CO2 concentration for one week, then detected under microscopy to demonstrate whether tumor cells existed or not.


Continuous CO2 pneumoperitoneum with different number of cell injection in LoVo & SGC-7901 cell line were shown in Tables 1 and 2, respectively. After one week of incubation, in the group of 5 L/min, continuous CO2 flow of 4 kPa for 60min with 109 /L SGC-7901 cell injected, it demonstrated tumor growth in 3 of 4 dishes when compared with the same experimental condition in LoVo cell. All 4 peritoneal washing samples also showed tumor growth, whereas other dishes showed none.

Table 1 Results in continuous flow pneumo with LoVo cell injection.
Cell numberNo. of ratsPressure (kPa)Duration (min)Tumor growth
Table 2 Results in continuous flow pneumo with SGC7901 cell injection.
Cell numberNo. of ratsPressure (kPa)Duration (min)Tumor growth

Laparoscopic surgery has been carried out nationwide in patients with cancer of the gastrointestinal tract despite relatively high incidence of port site recurrence after curative resection[1,7]. Several clinical reports have proposed that recurrence may be caused by direct implantation of the tumor cells, whereas the proof is still uncertain. Many experimental studies of colon carried out more than those in gastric cancer[16].

Our design was to evaluate and compare the incidence of port site recurrence by direct seeding of either colon or gastric cancer cells. We injected LoVo cells into the mice and found none of the 32 mice had tumor growth in the dishes, but when injected SGC-7901 cells into the mice with 109/L SGC901 cells and pneumoperitoneum pressure 4 kPa for 60 min, 3 out of 4 dishes showed tumor cells growth. The gastric cancer cell line SGC-7901 was more likely to cause port-site recurrence than colon cancer LoVo cell line. This may partly be due to the difference of tumor metastatic behavior. It had been reported that the capacity of gastric cancer cell implantation in the peritoneum was much easier than that of the colon cancer cells[18,19]. Our finding corroborated the above conclusion. The pneumoperitoneum pressure in the abdominal cavity and its duration played an important role in the development of port-site recurrence of gastric cancer cells.

The mechanism for tumor cell port-site implantation may be explained as follow: (1) tumor cell exfoliation by surgical manipulation of the tumor; (2) contaminated laparoscopic instruments frequently passing in and out of the ports; (3) tumor cell viability, number of cells, duration, pneumoperitoneum pressure and the metastatic nature of tumor cells; (4) surgery induced immuno-suppression facilitating tumor growth at the port-site wounds[13,20]. Thus significant effort should be strived for to prevent tumor growth in the port wound. It has been suggested that all instruments should be routinely wiped on withdrawal from a port with a cytotoxic agent (povidone-iodine) and a similar agent flushing the laparoscopic port before withdrawl. The external aspect of the port should be sprayed and wound liberally irrigated with a cytotoxic agent[17].


Edited by Xie-Ning Wu

Proofread by Qi-Hong Miao

1.  Alexander RJ, Jaques BC, Mitchell KG. Laparoscopically assisted colectomy and wound recurrence. Lancet. 1993;341:249-250.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 161]  [Cited by in F6Publishing: 25]  [Article Influence: 5.8]  [Reference Citation Analysis (0)]
2.  Drouard F, Delamarre J, Capron JP. Cutaneous seeding of gallbladder cancer after laparoscopic cholecystectomy. N Engl J Med. 1991;325:1316.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 44]  [Cited by in F6Publishing: 18]  [Article Influence: 1.5]  [Reference Citation Analysis (0)]
3.  Cava A, Román J, González Quintela A, Martín F, Aramburo P. Subcutaneous metastasis following laparoscopy in gastric adenocarcinoma. Eur J Surg Oncol. 1990;16:63-67.  [PubMed]  [DOI]  [Cited in This Article: ]
4.  Clair DG, Lautz DB, Brooks DC. Rapid development of umbilical metastases after laparoscopic cholecystectomy for unsuspected gallbladder carcinoma. Surgery. 1993;113:355-358.  [PubMed]  [DOI]  [Cited in This Article: ]
5.  Gleeson NC, Nicosia SV, Mark JE, Hoffman MS, Cavanagh D. Abdominal wall metastases from ovarian cancer after laparoscopy. Am J Obstet Gynecol. 1993;169:522-523.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 123]  [Cited by in F6Publishing: 2]  [Article Influence: 4.4]  [Reference Citation Analysis (0)]
6.  Ramos JM, Gupta S, Anthone GJ, Ortega AE, Simons AJ, Beart RW. Laparoscopy and colon cancer. Is the port site at risk A preliminary report. Arch Surg. 1994;129:897-899; discussion 900.  [PubMed]  [DOI]  [Cited in This Article: ]
7.  Vukasin P, Ortega AE, Greene FL, Steele GD, Simons AJ, Anthone GJ, Weston LA, Beart RW. Wound recurrence following laparoscopic colon cancer resection. Results of the American Society of Colon and Rectal Surgeons Laparoscopic Registry. Dis Colon Rectum. 1996;39:S20-S23.  [PubMed]  [DOI]  [Cited in This Article: ]
8.  Hughes ES, McDermott FT, Polglase AL, Johnson WR. Tumor recurrence in the abdominal wall scar tissue after large-bowel cancer surgery. Dis Colon Rectum. 1983;26:571-572.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 225]  [Cited by in F6Publishing: 23]  [Article Influence: 5.9]  [Reference Citation Analysis (0)]
9.  Nduka CC, Monson JR, Menzies-Gow N, Darzi A. Abdominal wall metastases following laparoscopy. Br J Surg. 1994;81:648-652.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 275]  [Cited by in F6Publishing: 169]  [Article Influence: 10.2]  [Reference Citation Analysis (0)]
10.  Fusco MA, Paluzzi MW. Abdominal wall recurrence after laparoscopic-assisted colectomy for adenocarcinoma of the colon. Report of a case. Dis Colon Rectum. 1993;36:858-861.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 149]  [Cited by in F6Publishing: 16]  [Article Influence: 5.3]  [Reference Citation Analysis (0)]
11.  Cirocco WC, Schwartzman A, Golub RW. Abdominal wall recurrence after laparoscopic colectomy for colon cancer. Surgery. 1994;116:842-846.  [PubMed]  [DOI]  [Cited in This Article: ]
12.  Umpleby HC, Fermor B, Symes MO, Williamson RC. Viability of exfoliated colorectal carcinoma cells. Br J Surg. 1984;71:659-663.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 297]  [Cited by in F6Publishing: 172]  [Article Influence: 8.0]  [Reference Citation Analysis (0)]
13.  Iwanaka T, Arya G, Ziegler MM. Mechanism and prevention of port-site tumor recurrence after laparoscopy in a murine model. J Pediatr Surg. 1998;33:457-461.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 69]  [Cited by in F6Publishing: 11]  [Article Influence: 3.0]  [Reference Citation Analysis (0)]
14.  Whelan RL, Sellers GJ, Allendorf JD, Laird D, Bessler MD, Nowygrod R, Treat MR. Trocar site recurrence is unlikely to result from aerosolization of tumor cells. Dis Colon Rectum. 1996;39:S7-13.  [PubMed]  [DOI]  [Cited in This Article: ]
15.  Allardyce R, Morreau P, Bagshaw P. Tumor cell distribution following laparoscopic colectomy in a porcine model. Dis Colon Rectum. 1996;39:S47-S52.  [PubMed]  [DOI]  [Cited in This Article: ]
16.  Hubens G, Pauwels M, Hubens A, Vermeulen P, Van Marck E, Eyskens E. The influence of a pneumoperitoneum on the peritoneal implantation of free intraperitoneal colon cancer cells. Surg Endosc. 1996;10:809-812.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 63]  [Cited by in F6Publishing: 4]  [Article Influence: 2.5]  [Reference Citation Analysis (0)]
17.  Hewett PJ, Thomas WM, King G, Eaton M. Intraperitoneal cell movement during abdominal carbon dioxide insufflation and laparoscopy. An in vivo model. Dis Colon Rectum. 1996;39:S62-S66.  [PubMed]  [DOI]  [Cited in This Article: ]
18.  Asao T, Nagamachi Y, Morinaga N, Shitara Y, Takenoshita S, Yazawa S. Fucosyltransferase of the peritoneum contributed to the adhesion of cancer cells to the mesothelium. Cancer. 1995;75:1539-1544.  [PubMed]  [DOI]  [Cited in This Article: ]
19.  Asao T, Yazawa S, Kudo S, Takenoshita S, Nagamachi Y. A novel ex vivo method for assaying adhesion of cancer cells to the peritoneum. Cancer Lett. 1994;78:57-62.  [PubMed]  [DOI]  [Cited in This Article: ]  [Cited by in Crossref: 16]  [Cited by in F6Publishing: 3]  [Article Influence: 0.6]  [Reference Citation Analysis (0)]
20.  Murthy SM, Goldschmidt RA, Rao LN, Ammirati M, Buchmann T, Scanlon EF. The influence of surgical trauma on experimental metastasis. Cancer. 1989;64:2035-2044.  [PubMed]  [DOI]  [Cited in This Article: ]