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Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 5-7

Gasless laparoscopy and the working space in minimally invasive surgery

Director, Max Institute of Laparoscopy, Endoscopy and Bariatric Surgery, Max Super Specialty Hospital, Saket, New Delhi, India

Date of Submission06-Jan-2021
Date of Acceptance18-Jan-2021
Date of Web Publication19-Feb-2021

Correspondence Address:
Dr. Vandana Soni
Director, Max Institute of Laparoscopic, Endoscopic and Bariatric Surgery, Max Hospital, Saket, New Delhi - 110 017
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/cmrp.cmrp_2_21

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How to cite this article:
Soni V. Gasless laparoscopy and the working space in minimally invasive surgery. Curr Med Res Pract 2021;11:5-7

How to cite this URL:
Soni V. Gasless laparoscopy and the working space in minimally invasive surgery. Curr Med Res Pract [serial online] 2021 [cited 2022 Oct 1];11:5-7. Available from: http://www.cmrpjournal.org/text.asp?2021/11/1/5/309914

An essential prerequisite of an interventional procedure is a working space. Human's inquisitiveness has, since long, led to exploring body cavities where access to a space could be gained. The 19th century saw the evolution of natural orifice endoscopy; nearly every accessible cavity was explored, be it the bladder, the tracheobronchial tree and the upper and lower gastrointestinal tract.[1],[2] A century passed before the technology was applied for examining the abdominal cavity, air was the medium used to distend the abdominal cavity for examination.[3] The ease, simplicity and safety of the method laid the foundation for pneumoperitoneum as a means for work space creation. Eight decades later, the technology unfolded into the ‘minimally invasive surgery’ (MIS) revolution.[2] Carbon dioxide (CO2) gas emerged as the preferred medium for insufflation of the abdominal cavity, fulfilling nearly all criteria of an ideal insufflation agent. The rigorous application of MIS to surgical therapeutics, especially the unprecedented success in laparoscopic cholecystectomy, revealed, in addition to the accrued benefits, the adverse effects of CO2 pneumoperitoneum on human physiology.[4],[5],[6] Once the adverse effects of pneumoperitoneum were known, the surgeons started looking for alternative safer options of laparoscopy without using carboperitoneum.

The concept of gasless laparoscopy took root in the early 90s of the last century. Kitano et al. in 1992 reported a U-shaped retractor for lifting the anterior abdominal wall as an alternative to pneumoperitoneum for surgical site access. They cited poor vision, two-dimensional perspective with prolonged surgical time, presence of smoke interfering with clear vision (a likely cause of increased bile duct injuries) and cardiac distress due to prolonged CO2 insufflation and increased intra-abdominal pressure (IAP) in patients with compromised cardiopulmonary status as a reason for the alternate approach.[7] Smith et al. reported using a fan-shaped abdominal wall lift (AWL) system in 1993, concluding an adequate exposure with added advantage of using conventional surgical instruments.[8] Several other reasons cited for preferring gasless approach were penetrating injuries, vascular and visceral due to Veress needle, potential for CO2 embolism, deep vein thrombosis and thromboembolism, high cost of laparoscopic instruments and valved trocars and the need for availability of CO2. Another approach employed a combination of AWL and low pressure insufflation to combine the advantages offered by both.[9] The IAP was maintained at 3–7 mmHg. The adverse effects of pneumoperitoneum seen at 12–14 mmHg did not occur at such low pressures. It appeared that safer alternatives to classic pneumoperitoneum were evolving and would soon be available to surgeons for their higher risk patients, especially ASA III and ASA IV. However, history does not corroborate this development. Despite the initial volume of work reported on these systems, they never posed a challenge to conventional pneumoperitoneum as the preferred option of performing MIS. Several disadvantages offset the growing popularity of gasless laparoscopy, and these include lack of panoramic view of the cavity, limited exposure of surgical site, inability to create space in muscular patients (high basal muscle tone) and obese patients (heavy anterior abdominal wall), difficult manipulation of instruments, pain at site of AWL device placement and prolonged surgical time. A plethora of AWL devices available are testament to the lack of a universally acceptable design.

Several randomized controlled trials (RCTs) comparing pneumoperitoneum to gasless AWL failed to demonstrate a clear advantage of the latter over the former. Although it has been consistently demonstrated that cardiopulmonary derangements do not occur with gasless AWL, none of the trials had significant representations of patients recommended to benefit from gasless procedures, and most patients studied belonged to ASA I and II. The same has been substantiated by a systematic review from the Cochrane database which notes the high risk of bias in the studied RCTs, with no difference in the serious adverse events between the two approaches; the operating time was found to be significantly longer with AWL; none of the RCTs commented on quality of life and pain in the immediate post-operative period and no difference was observed in the duration of hospital stay. It concluded that AWL with or without pneumoperitoneum did not offer an advantage over pneumoperitoneum in any of the patient-oriented outcomes for laparoscopic cholecystectomy in people with low anaesthetic risk and did not favour its routine application. It also questioned the safety of AWL and recommended more research be done on the topic with future trials ensuring adequate blinded assessment and including people at higher anaesthetic risk.[10]

Another perspective of pursuing gasless AWL is the desire to make this technology available in low-resource regions. Even today, there are regions in the world where the cost of conventional laparoscopy precludes its routine applicability in surgical practice.[11] However, a study on improving surgical care in Mongolia does elucidate that the process of providing laparoscopic surgical expertise to the local population led to an overall improvement in surgical care of the country.[12] Some avid proponents of gasless AWL have published large number (~400) of assorted procedures with equipment modification, making it safer and more reliable for use even in the remotest of rural areas.[13] However, this enthusiasm is yet to catch the collective imagination of the larger surgical community. The world over MIS is synonymous with carboperitoneum, especially with inexpensive medical grade CO2 being easily and abundantly available.

Literature is replete with studies comparing the cost of conventional laparoscopy with open and robotic approaches for various surgical procedures. However, what is conspicuously absent is a study evaluating the cost difference of AWL to conventional laparoscopy.

With time and experience, the initial reservations of CO2 pneumoperitoneum and raised IAP have been laid to rest. The improved intra-operative haemodynamic and hypercarbia monitoring available to the anaesthesiologists has helped them in mitigating the effects of carboperitoneum early.[14] Patients with compromised cardiopulmonary status stand to benefit the most with these advances. The physiological changes are reversed on releasing CO2 and have not been documented to have long-term sequelae. Increasing technical expertise has made it possible to perform therapeutic laparoscopy at low IAPs and with a shorter operative time.[15],[16] Judicious use of disposables, careful maintenance and care of reusable instruments and indigenisation can significantly bring down the cost of conventional laparoscopy.[17],[18]

The most pronounced difference between carboperitoneum and gasless AWL remains the working space. The versatility of pneumoperitoneum remains its unique selling point (USP); the comfort of a large working space with anatomical cues provides comfort and satisfaction to the average surgeon which as yet remains unmatched in gasless laparoscopy. Maybe in time, an innovation will overcome this handicap to add to the popularity of gasless laparoscopy, till then gasless AWL remains confined to just a handful of centres globally.

  References Top

Litynski GS. Endoscopic surgery: The history, the pioneers. World J Surg 1999;23:745-53.  Back to cited text no. 1
Kelley WE Jr. The evolution of laparoscopy and the revolution in surgery in the decade of the 1990s. JSLS 2008;12:351-7.  Back to cited text no. 2
Litynski GS, Paolucci V. Origin of laparoscopy: Coincidence or surgical interdisciplinary thought? World J Surg 1998;22:899-902.  Back to cited text no. 3
Galizia G, Prizio G, Lieto E, Castellano P, Pelosio L, Imperatore V, et al. Hemodynamic and pulmonary changes during open, carbon dioxide pneumoperitoneum and abdominal wall-lifting cholecystectomy. A prospective, randomized study. Surg Endosc 2001;15:477-83.  Back to cited text no. 4
Wittgen CM, Andrus CH, Fitzgerald SD, Baudendistel LJ, Dahms TE, Kaminski DL. Analysis of the hemodynamic and ventilatory effects of laparoscopic cholecystectomy. Arch Surg 1991;126:997-1000.  Back to cited text no. 5
Liu SY, Leighton T, Davis I, Klein S, Lippmann M, Bongard F. Prospective analysis of cardiopulmonary responses to laparoscopic cholecystectomy. J Laparoendosc Surg 1991;1:241-6.  Back to cited text no. 6
Kitano S, Tomikawa M, Iso Y, Iwata S, Gondo K, Moriyama M, et al. A safe and simple method to maintain a clear field of vision during laparoscopic cholecystectomy. Surg Endosc 1992;6:197-8.  Back to cited text no. 7
Smith RS, Fry WR, Tsoi EK, Henderson VJ, Hirvela ER, Koehler RH, et al. Gasless laparoscopy and conventional instruments. The next phase of minimally invasive surgery. Arch Surg 1993;128:1102-7.  Back to cited text no. 8
Alijani A, Cuschieri A. Abdominal wall lift systems in laparoscopic surgery: Gasless and low-pressure systems. Semin Laparosc Surg 2001;8:53-62.  Back to cited text no. 9
Gurusamy KS, Koti R, Davidson BR. Abdominal lift for laparoscopic cholecystectomy. Cochrane Database Syst Rev. 2013 Aug 31;(8):CD006574. doi: 10.1002/14651858.CD006574.pub4. PMID: 23996298.  Back to cited text no. 10
Silverstein A, Costas-Chavarri A, Gakwaya MR, Lule J, Mukhopadhyay S, Meara JG, et al. Laparoscopic versus open cholecystectomy: A cost-effectiveness analysis at Rwanda Military Hospital. World J Surg 2017;41:1225-33.  Back to cited text no. 11
Price R, Sergelen O, Unursaikhan C. Improving surgical care in Mongolia: A model for sustainable development. World J Surg 2013;37:1492-9.  Back to cited text no. 12
Gnanaraj J, Rhodes M. Laparoscopic surgery in middle- and low-income countries: Gasless lift laparoscopic surgery. Surg Endosc 2016;30:2151-4.  Back to cited text no. 13
Jo YY, Kwak HJ. What is the proper ventilation strategy during laparoscopic surgery? Korean J Anesthesiol 2017;70:596-600.  Back to cited text no. 14
Ott DE. Abdominal Compliance and Laparoscopy: A Review. JSLS. 2019 Jan-Mar;23(1):e2018.00080. doi: 10.4293/JSLS.2018.00080. PMID: 30828242; PMCID: PMC6383692.  Back to cited text no. 15
Raval AD, Deshpande S, Koufopoulou M, Rabar S, Neupane B, Iheanacho I, et al. The impact of intra-abdominal pressure on perioperative outcomes in laparoscopic cholecystectomy: A systematic review and network meta-analysis of randomized controlled trials. Surg Endosc 2020;34:2878-90.  Back to cited text no. 16
Pontarelli EM, Grinberg GG, Isaacs RS, Morris JP, Ajayi O, Yenumula PR. Regional cost analysis for laparoscopic cholecystectomy. Surg Endosc 2019;33:2339-44.  Back to cited text no. 17
Grimes KL, Scott C, McHenry CR. Cost variation and opportunities for cost reduction for laparoscopic cholecystectomy. Surgery 2018;163:617-21.  Back to cited text no. 18


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