Le pronostic de la carcinose péritonéale (CP) s’est nettement amélioré et son traitement permet aujourd’hui chez certains patients sélectionnés d’atteindre des survies prolongées. L’un des facteurs pronostics majeurs est l’étendue de la CP, évaluée par l’Indice de carcinose péritonéale (PCI). La prise en charge de la CP doit évoluer vers un double objectif : une évaluation précise du caractère chirurgicalement totalement extirpable des lésions (possibilité d’une CCR complète) et une détection la plus précoce possible de la maladie. Or sur ces deux objectifs, nos examens d’imagerie sont régulièrement mis en défaut, et ce n’est souvent qu’on moment de la laparotomie qu’une évaluation précise de la CP est possible.Dans ce projet nous nous sommes intéressés à l’apport potentiel de deux nouvelles technologies dans l’exploration de la CP : l’endoscopie péritonéale souple et la chromoendoscopie virtuelle.Dans la première partie de cette thèse, nous présentons notre technique d’exploration péritonéale par monotrocart (SILPE) au cours de laquelle nous réalisons en plus de l’endoscopie rigide, une endoscopie souple. Nous avons montré que cette technique est sûre et faisable. Dans une série de 183 SILPE, cette procédure a pu être réalisée dans 90,2% des cas. Cinq complications post-opératoires ont été observées (3%). La valeur prédictive positive de la SILPE pour prédire une CCR complète était de 79,5%. Le PCI était de 9,7±7,5 lors de la SILPE et de 13,5±9,6 lors de la laparotomie (p<0,0001). Le nombre de régions explorées était 13,0±0,3 en laparotomie et 12,2±1,6 en SILPE (p<0,0001). Le nombre de régions envahies était 6,9±4,5 en laparotomie et 5,4±3,8 en SILPE (p<0,0001). La sensibilité globale de la SILPE dans la détection de la CP dans les différentes régions était de 75%, avec une spécificité de 97%, soit une précision de 85%. Dans la deuxième partie de cette thèse, nous avons étudié l’apport de la chromoendoscopie virtuelle dans l’exploration de la cavité péritonéale et la détection de la CP.Nous sommes partis de l’hypothèse que le péritoine, comme tout autre organe soumis à un processus métastatique, subit des modifications selon le principe de la niche métastatique, pouvant être détectées par cette technologie. Le FICE est un système de chromoendoscopie virtuelle, qui contient 10 réglages différents permettant d’obtenir 10 images virtuelles, construites à partir d’images ayant des longueurs d’ondes réduites différentes. Nous avons d’abord mené une étude de faisabilité clinique au cours de laquelle des endoscopies péritonéales avec le système FICE étaient réalisées. Grâce à un système d’évaluation par deux questionnaires, nous avons déterminés les trois canaux du FICE adaptés à l’exploration du péritoine (canaux 2, 6 et 9). Pour la luminosité, la LB a été jugée meilleure (p<0,0001). En ce qui concerne la qualité du contraste, l’architecture vasculaire, la différentiation des organes, et la détection des nodules de CP, le canal 2 du FICE était jugé supérieur (p<0,0001). Dans un 2ème travail, nous avons créé un modèle murin de CP naissante. Les souris ont été opérées puis sacrifiées à des dates différentes. L’intervention consistait en une endoscopie péritonéale souple, au cours de laquelle les nodules de CP étaient pris en photo en LB et en FICE. 935 images correspondant à 85 nodules ont été analysées. Nous avons ensuite décomposé chaque image endoscopique en ces trois composantes élémentaires R-G-B. Nous avons par la suite comparé les contrastes obtenues avec ces différentes longueurs d’ondes. Nous avons pu ainsi déterminer la longueur d’onde du spectre de la LB qui donnait le meilleur contraste entre nodule de CP et péritoine avoisinant. Il s’agit de la lumière monochromatique à 460 nm (p<0,0001), avec un contraste moyen à 0,240±0,151. Ces résultats ont fait l’objet d’un dépôt de brevet via InsermTransfert. / The prognosis of peritoneal carcinomatosis (PC) has improved and today, its treatment could lead to long-term survivals in some selected patients. One of the major prognosis factors of this condition is the extent of the disease measured in terms of Peritoneal cancer index (PCI). The management of PC has to evolve towards two main goals: first an accurate evaluation of the disease burden in order to recognize the patients amenable to complete cytoreduction (CCR), and second an early detection of the disease. Unfortunately, current imaging methods strongly lack sensitivity in determining small tumor nodules, and it is often only at the time of laparotomy that an accurate evaluation of the PCI is possible.In this work, we have studied the potential role of two new techniques in the evaluation of PC: peritoneal flexible endoscopy and virtual chromoendoscopy.In the first part of the thesis, we present our technique of single incision laparoscopic peritoneal exploration (SILPE), in which we perform a peritoneoscopy with both a rigid endoscope and a flexible endoscope. Through a series a 183 SILPE, we showed that this technique is safe and feasible. The SILPE procedure was successful in 90.2% of the cases. Five postoperative complications were observed (3%). The positive predictive value of SILPE to predict CCR was 79.5%. The PCI was 9.7±7.5 at the time of SILPE, and 13.5±9.6 at the time of laparotomy (p<0.0001). The number of the regions explored by SILPE was 12.2±1.6, and by laparotomy 13.0±0.3 (p<0.0001). The number of affected regions was 5.4±3.8 at the time of SILPE and 6.9±4.5 at the time of laparotomy (p<0.0001). The overall sensitivity of SILPE in the detection of PC in the different regions was 75%, with a specificity of 97%, thus an accuracy rate of 85%. In the second part of this thesis, we have studied the role of virtual chromoendoscopy in the peritoneal exploration and PC detection. We started from the hypothesis that, as any organ subject to a metastatic process, the peritoneum would change according to the theory of the metastatic niche, changes that could be detected by this technology. FICE is a virtual chromoendoscopy system that is merchandised with 10 factory-determined presets, built from different reduced single-wavelength images. We have first carried out a feasibility study in human in which peritoneal endoscopies using the FICE system were performed. Thanks to an evaluation plan based on two questionnaires, we have determined the three FICE channels suitable for peritoneal exploration (channels 2, 6, and 9). For brightness, white light endoscopy was judged superior to all FICE channels (p<0.0001). FICE Channel 2 was superior to white light endoscopy and other FICE channels, in terms of contrast, visualization of vascular architecture, differentiation between organs, and detection of PC (p<0.0001). In a second study, we created a murine model of an incipient PC. Mice had peritoneal explorations with FICE at different times. For each PC nodule detected, one white light endoscopy and 10 FICE images were recorded. 935 images corresponding to 85 nodules were analyzed. Each image was then divided into its elementary red, green and blue band images. Therefore, we compared the contrasts obtained with each wavelength. Thus, we’ve determined the wavelength of the white light specter that provides the highest contrast between PC nodule and background peritoneum. It was the monochromatic light with a wavelength at 460 nm (p<0.0001), with a mean contrast value of 0.240±0.151. A patent via InsermTransfert has been filed.

INTRODUÇÃO: Cerca de 20% da população é portadora de colelitíase, sendo esta afecção a principal causa abdominal de internação hospitalar em países desenvolvidos. Considerando-se que somente nos Estados Unidos são realizadas cerca 700.000 colecistectomias a cada ano, pode-se estimar a importância do problema para a saúde pública. A diminuição do número de incisões tem o potencial de reduzir o trauma cirúrgico e oferecer melhor resultado estético. OBJETIVOS: Descrever técnica de colecistectomia laparoscópica com duas incisões (CL2i) utilizando apenas material convencional, sem aumentar complicações, nem tempo operatório, oferecendo a mesma segurança da colecistectomia videolaparoscópica convencional. MÉTODO: Série prospectiva de casos consecutivos, comparada a outra série histórica de casos operados pela técnica laparoscópica convencional (CLC). A CL2i foi realizada com 3 portais em 2 incisões, sendo dois na incisão umbilical e outro no epigástrio. Foram operados 72 pacientes (36 em cada grupo) pelo mesmo cirurgião. RESULTADOS: Não houve diferença estatística entre os grupos quanto sexo, média de idade, índice de massa corpórea (IMC) e tempo de internação. Os procedimentos foram classificados pelo cirurgião de acordo com o grau de dificuldade e não houve diferença entre as séries (p < 0,05). Ocorreram complicações menores em 5,6% (n = 2) procedimentos em cada grupo. Não houve diferença entre as médias de tempo operatório (p= 0,989), que foram de 49 (IC95% 42 a 56) min na CLC e 40 (IC95% 35 a 44) min na CL2i. Não houve necessidade de portais adicionais em nenhum caso, nem de conversão para cirurgia aberta. CONCLUSÕES: A técnica de colecistectomia laparoscópica com duas incisões (CL2i) é factível, segura e com bom resultado estético, permitindo operar utilizando apenas instrumental laparoscópico convencional, sem aumentar tempo operatório ou risco de complicações / INTRODUCTION: About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health. Decreasing the number of incisions can reduce surgical trauma and offer better aesthetic results. OBJECTIVE: To describe a two-incision laparoscopic cholecystectomy technique (TILC) using only conventional material, without increasing complications, nor operative time, offering the same safety as conventional laparoscopic cholecystectomy. METHOD: A consecutive and prospective case series, compared to another historical series operated by conventional laparoscopy cholecystectomy (LC). The TILC was performed with 3 trocars in 2 incisions, two trocars in umbilical incision and one in epigastrium. A total of 72 patients were operated on by the same surgeon (36 in each group). RESULTS: There were no significant differences between groups for gender, mean age, body mass index (BMI) or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and there was no difference between the series (p < 0.05). There were minor complications in 5.6% (n = 2) procedures in each group. There were no differences between means of operative time (p = 0.989), which were 49 (95% CI 42 to 56) min in LC and 40 (CI 95% 35 to 44) min in TILC. There was no need for additional portals in any case, nor for conversion to open surgery. CONCLUSIONS: Two-incision laparoscopic cholecystectomy (TILC) is feasible, safe and with good aesthetic result, using the same instruments of LC, without increasing operative time or complications

INTRODUÇÃO: Cerca de 20% da população é portadora de colelitíase, sendo esta afecção a principal causa abdominal de internação hospitalar em países desenvolvidos. Considerando-se que somente nos Estados Unidos são realizadas cerca 700.000 colecistectomias a cada ano, pode-se estimar a importância do problema para a saúde pública. A diminuição do número de incisões tem o potencial de reduzir o trauma cirúrgico e oferecer melhor resultado estético. OBJETIVOS: Descrever técnica de colecistectomia laparoscópica com duas incisões (CL2i) utilizando apenas material convencional, sem aumentar complicações, nem tempo operatório, oferecendo a mesma segurança da colecistectomia videolaparoscópica convencional. MÉTODO: Série prospectiva de casos consecutivos, comparada a outra série histórica de casos operados pela técnica laparoscópica convencional (CLC). A CL2i foi realizada com 3 portais em 2 incisões, sendo dois na incisão umbilical e outro no epigástrio. Foram operados 72 pacientes (36 em cada grupo) pelo mesmo cirurgião. RESULTADOS: Não houve diferença estatística entre os grupos quanto sexo, média de idade, índice de massa corpórea (IMC) e tempo de internação. Os procedimentos foram classificados pelo cirurgião de acordo com o grau de dificuldade e não houve diferença entre as séries (p < 0,05). Ocorreram complicações menores em 5,6% (n = 2) procedimentos em cada grupo. Não houve diferença entre as médias de tempo operatório (p= 0,989), que foram de 49 (IC95% 42 a 56) min na CLC e 40 (IC95% 35 a 44) min na CL2i. Não houve necessidade de portais adicionais em nenhum caso, nem de conversão para cirurgia aberta. CONCLUSÕES: A técnica de colecistectomia laparoscópica com duas incisões (CL2i) é factível, segura e com bom resultado estético, permitindo operar utilizando apenas instrumental laparoscópico convencional, sem aumentar tempo operatório ou risco de complicações / INTRODUCTION: About 20% of the population has cholelithiasis and this is the main abdominal cause of hospitalization in developed countries. Considering that only in the United States about 700,000 cholecystectomies are done each year, it is possible to estimate the importance of the problem for public health. Decreasing the number of incisions can reduce surgical trauma and offer better aesthetic results. OBJECTIVE: To describe a two-incision laparoscopic cholecystectomy technique (TILC) using only conventional material, without increasing complications, nor operative time, offering the same safety as conventional laparoscopic cholecystectomy. METHOD: A consecutive and prospective case series, compared to another historical series operated by conventional laparoscopy cholecystectomy (LC). The TILC was performed with 3 trocars in 2 incisions, two trocars in umbilical incision and one in epigastrium. A total of 72 patients were operated on by the same surgeon (36 in each group). RESULTS: There were no significant differences between groups for gender, mean age, body mass index (BMI) or length of hospital stay. The procedures were classified by the surgeon according to surgical difficulty and there was no difference between the series (p < 0.05). There were minor complications in 5.6% (n = 2) procedures in each group. There were no differences between means of operative time (p = 0.989), which were 49 (95% CI 42 to 56) min in LC and 40 (CI 95% 35 to 44) min in TILC. There was no need for additional portals in any case, nor for conversion to open surgery. CONCLUSIONS: Two-incision laparoscopic cholecystectomy (TILC) is feasible, safe and with good aesthetic result, using the same instruments of LC, without increasing operative time or complications