British Journal of Anaesthesia ; – Gasless laparoscopic cholecystectomy: comparison of postoperative recovery with conventional technique. This interesting treatise begins with a well-done historical review of laparoscopy. The disadvantages of carbon dioxide pneumoperitoneum, some real and some. PDF | On Dec 1, , L Angelini and others published Gasless laparoscopy.

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The diagnosis of acute abdomen in the emergency setting, still remains a challenging problem. In these cases timely diagnosis and management is of great importance, while the anesthetic risk is high. The combination of the risk of an open laparotomy and the relative high likelihood of negative findings when performed, creates the need for a better approach.

The alternative actually exists since when Eruheim made the first gasless laparoscopy. The aim of this study is to put back into the spotlight, gasless laparoscopy in the differential vasless of acute abdomen and to underline the advantages of this simple, cheap and very useful technique, especially in patients that require prompt diagnosis and laaparoscopy relative or absolute contraindications to general anesthesia or pneumoperitoneum.

This study included 49 patients that were managed with laparodcopy laparoscopy for the diagnosis of acute abdomen, from to Two techniques were used: With both techniques used, sample of the intraperitoneal fluid or biopsy could be obtained.

The gasless technique for laparoscopy is an extremely useful mean of diagnosis in emergency conditions, or for patients with contraindications to undergo laparoscopy by pneumoperitoneum. Requiring only local or regional anesthesia, this technique could easily find application in diagnosis and treatment, while avoiding unnecessary laparotomies.

Hippokratialaparocsopy 1: The differential diagnosis of acute abdomen remains a complex clinical issue because, on one hand the patient involved could be already compromised and the time available for diagnosis limited, and on the other hand due to frequent lack laparoscopyy diagnostic means [computed tomography CTmagnetic resonance imaging MRIultrasonography US ].

In such cases, diagnostic laparoscopy may solve the differential diagnostic problem. There are, however, patients where pneumoperitoneum is contraindicated head trauma, brain tumors, etc. In these patients, gasless laparoscopy could be a valuable alternative. Gasless laparoscopy is the laparoscopic procedure in which, instead of pneumoperitoneum, the operational space in the abdomen is created by various mechanical means that raise the abdominal wall.

The method is not novel, but is currently revalorized in the above described context, and used more frequently. The idea of gasless laparoscopy belongs to Eruheim who described it in In Muhe achieved the first laparoscopic cholecystectomy without pneumoperitoneum. Currently, this technique is used in emergency surgery, especially in debilitated patients and in gynecological cases with uncertain diagnosis. Three hospitals were included in this study: Hospital of Obstetrics and Gynecology laparosocpy.

Sbarcea” of Brasov, Children’s Hospital of Brasov and Emergency Hospital Roman, where 49 gasless laparoscopic procedures were performed during the period For these 49 procedures, two methods were used: Laparolift can be performed in many ways by instruments that, while fixed to the operating gzsless, raise lxparoscopy abdominal wall 1. We chose a sui-generis alternative, in which an incision is made about 2 cm from the base of the navel, the abdominal wall is afterwards raised with two Kocher clamps and the laparoscope is introduced in the abdominal cavity.

Then, the balloon is inflated and a 3. Regarding the anesthesia used in gasless laparoscopy, it can be either regional or local laparoscipy. The study included 32 women and 17 men aged years, including the following age groups: The indications for the procedures are summarized in Table 1. In total, gasless laparoscopy was performed in 22 patients using the abdominal wall lifting method gaasless in 27 patients using the LapVision system.


Final diagnoses were established in 41 patients and are presented in detail in Figure 1while in eight patients no obvious cause was identified or existed. Of these eight cases without diagnosis, five involved multiple gqsless with symptoms of acute abdomen, in which we lapatoscopy not identify any pathological findings by gasless laparoscopy.

The other three cases involved intense abdominal pain, in older patients, with lapsroscopy neurological and cardiological problems, in whom mesenteric ischemia was suspected, but was eventually excluded, without revealing though any obvious cause for the pain. Treatment followed in each case, depended on the diagnosis and is presented on Table 2. Based on our experience and local guidelines applied, gasless laparoscopy paparoscopy currently in use in our institutions only for diagnostic purposes and this results in managing these cases either with gas laparoscopy or with laparotomy.

It is though under consideration, once our experience is advanced, to use this method for therapeutic applications in the future. Regarding the eight patients in which laparoscopy was inconclusive: The use of gasless laparoscopy has a number of advantages resulting from the lack of side effects and complications caused by the creation of pneumoperitoneum by CO 2 2.

Lapatoscopy the issue of gasless laparoscopic surgery, the available studies in the literature are relatively few and the largest series published are comparable to ours. In a larger study, Paolucci et al 1 studied the gasless method in a group of 54 patients that underwent laparoscopic surgery achieving: This author and others 1 – 6 used exclusively the laparolift method, with the LapVision variant not being mentioned.

An interesting study by Koivusalo et alshowed that gasless versus classical laparoscopy offers advantages laparoscopyy terms of postoperative recovery: Also a study of Ge et al, in cases of appendectomies performed by gasless laparoscopy showed significantly decreased hospital costs 8. Both gasless systems have the advantage of avoiding general anesthesia, requiring only local or regional anesthesia. Also, both allow the use of any ordinary tools for aspiration and drainage, making the technique cheap and easy to implement.

LapVision system has the additional advantage that it does not exert traction on the abdominal wall 9 which results in reduced pain, its flexible trocar can be left in place for drainage, or for the possibility of an easy second look laparoscopy, and additionally the system allows the performance of biopsies through the biopsy channel attached to the trocar. Gasless laparoscopy performed gaasless both methods has some disadvantages as well.

First of all, the view is somewhat inadequate, especially in the lateral and inferior quadrants.

Distension of the abdominal wall with the laparolift method is in a pyramid like shape that creates the effect of a tent and most importantly, can be painful In the obese patients or those with a thick abdominal wall, achieving gasless laparoscopy is difficult. Complications related to the blind insertion of the Veress needle and the first trocar can theoretically be avoided, since the open approach technique is used instead. It has to be mentioned though that neither this technique is free of complications.

Thus in gasless laparoscopy, all described entry related complications can occur. Post-operative complications are commonly related to the abdominal incision and are similar to the complications of classic surgery: In our study, there were five cases of infection at the site of the incision three cases of pelviperitonitis and two of perforated ulcer and one case of parietal hematoma.


All cases gaslews incision infections were managed by antibiotics and local treatment, while the hematoma was managed by drainage. Also, in our study two intraoperative complications occurred, that involved bleeding after hepatic biopsy with the LapVision system.

They were managed conservatively, with drainage and good post-operative outcomes. Specific to the laparolift system, increased post-operative pain of the anterior abdominal wall was lapqroscopy, caused by the mechanical lift. Especially in six cases treated this way, the postoperative pain was very intense and high doses of painkillers were required. In two of these patients, pain was reported at the trocar site 3 weeks after surgery.

Patients with acute abdomen, traumatic or not, where diagnosis is uncertain, in the setting of 13 In these patients, diagnostic gasless laparoscopy that identifies hemoperitoneum should be followed by laparotomy. Gasless laparoscopy is a useful method for the differential diagnosis of acute abdomen causes in cases of extreme graveness laparosclpy urgency.

Use of this technique, allows clarification of the diagnosis and also acquisition of the necessary information to determine the appropriate therapeutic approach. In this way unnecessary laparotomies can be avoided.

Another advantage is that this method uses only local or regional anesthesia, which makes it possible to be performed lzparoscopy, even on the emergency department setting.

Gasless Laparoscopy With Conventional Instruments: The Next Phase in Minimally Invasive Surgery

In addition, the simplicity of the method makes it economically feasible. National Center for Biotechnology InformationU. Journal List Hippokratia v. Author information Copyright and License information Disclaimer. CopyrightHippokratio General Hospital of Thessaloniki. Laparoscopy, gasless laparoscopy, emergency, contraindications.

Introduction The differential diagnosis of acute abdomen remains a complex clinical issue because, on one hand the patient involved could be already compromised and the time available for diagnosis limited, and on the other hand due to frequent lack of diagnostic means [computed tomography CTmagnetic resonance imaging MRIultrasonography US ].

Material and Methods Three hospitals were included in this study: Table 1 Indications for gasless laparoscopy and number of cases for each indication. Open in a separate window. Number of cases diagnosed by gasless laparoscopy as distributed based on their diagnosis.

Table 2 Treatment based on diagnosis made by gasless diagnostic laparoscopy. In parentheses is the number of cases.

Gasless laparoscopy in abdominal surgery.

Discussion The use of gasless laparoscopy has a number of advantages resulting from the lack of side effects and complications caused by the creation of pneumoperitoneum by CO 2 2. Basically, the target patients for this type of investigation are: Critical patients with major anesthetic risk, 2. Conclusions Gasless laparoscopy is a useful method for the differential diagnosis of acute abdomen causes in cases of extreme graveness and urgency.

Conflict of interest The authors declare no conflict of interest. Gasless laparoscopy in abdominal surgery. Low-pressure pneumoperitoneum laparoscopic surgery. Hypercarbia during carbon dioxide insufflation for therapeutic laparoscopy: Gasless laparoscopic technique of wide excizion for gastric gastrointestinal stromal tumor versus open method.

Gasless laparoscopy in abdominal surgery.

World J Surg Oncol. The gasless laparoscopic cholecystectomy. Endosc Surg Allied Technol. Randomized comparison of conventional and gasless laparoscoyp cholecystectomy: A randomized comparison of gasless laparoscopic appendectomy and conventional laparoscopic appendectomy. World J Emerg Surg.

Paolucci V, Schaeff B. Paolucci V, Schaeff B eds. Laparoscopia gasless in chirurgia e ginecologia.